Paediatrics Flashcards
1
Q
How do you calculate body weight for infants
A
(Age in months +9) /2
2
Q
How do you calculate body weight for children
A
(Age +4) x 2
3
Q
What is the expected MAP in a neonate
A
Gestation in weeks eg at term =40
4
Q
What is expected SBP for >1 yr old?
A
80 + (age in yrs x 2)
5
Q
What is the maintainence fluid rate?
A
4 , 2 , 1 (4ml/kg/hr for first 10, 2 ml/kg/hr for next 10, 1ml/kg/hr for rest)
6
Q
What is the blood volume of a child and an infant?
A
Child = 70ml/kg, infant = 80ml/kg
7
Q
What is the dose to replace blood volume?
A
4ml/kg of PRBC increases Hb by 10
8
Q
How do you calculate allowable blood loss?
A
(Initial Hb - Final Hb)/intial Hb x estimated blood volume
9
Q
How to estimate ETT size
A
Age/4 + 4 uncuffed
Age/4 + 3.5 cuffed
10
Q
How to calculate ETT length at lips and nose?
A
Lips: ETT size x 3
Nose: ETT size x 4
11
Q
How to calculate suction catheter size
A
2 x ETT size
12
Q
How do you calculate LMA size?
A
1 = up to 5kg
1.5 = 5 to 10
2 = 10-20 kg
2.5 = 20 - 30
3 = 30 - 50
4 = 50 - 70
5 = 70+
13
Q
How much charge for paeds defib?
A
4J/kg
14
Q
How do you calculate TBSA?
A
9% per limb, 20% for head
15
Q
What is the parkland formula?
A
4mls/kg x TBSA % = fluid over first 24hrs. 50% in first 8 hrs, 50% in next 16
16
Q
Difference in neonatal and adult airway?
A
- Head is large and short neck
- Small mouth, large tounge
- Narrow nasal passage
- Larynx is anterior
- Long and floppy epiglottis
- Short trachea
17
Q
What factors precipitate apneoeas with neonates?
A
-GA
- Hypothermia
- Hypoglycaemia
- Anaemia
- Sepsis
- Seizures
18
Q
Advantages of cuffed tubes
A
- Reduced leak -> less pollution of OR and can do low flow (environmentally friendly)
- Less re-intubations due to ETT not fitting
- Better titration of ventilation volumes as nil leak
- No increase in post op stidor if cuff is monitored
19
Q
Whats the ideal breathing system?
A
-simple
-safe
- delivers correct accurate gas mixture
- allows ventilation in all ages
- efficent
- Sturdy, light, small, cheap
20
Q
Mapelson circuits
A
Semi-open circuit. Single limb with APL valve. FGF > MV to prevent rebreathing.
Mapelson D = bain circuit
Mapelson F = T piece circuit
21
Q
Difference in pre-oxygenation in children
A
May be poorly tolerated due to anxiety/refusal
May need parents/distraction techniques to enable
May need premedications as well
IV induction may require N20 or may need Gas induction
22
Q
Describe difference in positoning between neonate/infant and adult
A
In neonate/child optimal position is head neutral or slightly extended
Sometimes needs a towel under the shoulders
23
Q
Describe the difference in intubation in children vs adult
A
Consider use of Miller blade in neonates as epiglottis large and floppy
May require BURP
24
Q
What are indications for nasal intubation?
A
Patient: Trismus, syndromic with little oral cavity
Surgical: ENT/dental for surgical access
Anaesthetic: AFOI
25
What are features of a difficult airway in children?
- Mid face hypoplasia
- Mandibular hypoplasia
- Restricted movement of TMJ
- Limited cervical movement
- Limited mouth opening
- Macroglossia
- Micro/retrognathia
26
How do you assess for difficult airway?
- Signs on history of airway obstruction eg. Hx of apneoa episodes,
snoring, noisy breathing, increased work of breathing
- Review dentition, mouth opening, neck mobility, facial abnormalities
27
What syndromes are associated with difficult airway?
-Pierre- Robin sequence
- Mucopolysaccaridoses
- Treacher Collins
- Down’s syndrome
- Beckwith- Wiedemann syndrome
- Goldenhar syndrome
28
What are features of trisomy 21 airways?
○ Short neck
○ Macroglossia
○ Mid-face and mandibular hypoplasia
○ Atlanto-axial instability
○ Tonsillar/adenoid hypertrophy
○ Congenital subglottic/tracheal stenosis (consider half size down of ETT)
29
What are airway features of Beckwith-Weidemann syndrome?
- Omphalocele, macroglossia, organomeagly and gigantism
- Often have OSA
- Organomeagly means cephalad displacement of diaphragm and reduced FRC (and higher risk of endobronchial intubation)
- Main issues are:
○ Maxillary hypoplasia
Macroglossia
30
What are the airway features of Pierre Robin sequence
- Triad of:
○ Micrognathia
○ Glossoptosis (Posterior displacement of the tongue into the pharynx)
○ U or V shaped cleft palate
- Main issues are the mandibular hypoplasia and posterior displacement of the tongue causing upper airway obstruction
- Intubation tends to get easier as they age as everything grows larger and opens up
31
What are the airway features of Treacher collins syndrome?
- Due to a genetic mutation
- Issues are:
○ Maxillary, mandibular and zygomatic hypoplasia
○ High arched cleft palate
○ Small mouth opening
○ Abnormal TMJ
- Tends to get harder with age due to decreased mandibular growth
Can be hard BMV but often easy LMA insertion
32
What are the airway features of Goldenhar syndrome?
- Underdevelopment of eye, ear, nose, soft palate, lip and mandible
- Can be difficult maintaining a seal with facial asymmetry
- Can have difficult intubation due to mandibular hypoplasia, tracheal deviation and limited neck mobility
33
What are the airway features of mucopolysaccharises?
- Lysosomal storage disorders leads to accumulation of mucopolysaccharides
- Difficult BMV and intubation
- Features:
○ Macoglossia
○ Thickened airway mucosa
○ Hypertrophy of adenoids and tonsils
○ Hypoplastic mandible
○ Reduced TMJ and neck movement
Narrowed short trachea
34
Which syndrome's airways improve with age?
o Pierre robin – micrognathia (jaw size increases)
o Goldenhar – asymmetrical micrognathia (jaw size increases)
35
Which syndromes airways worsen with age?
o Treacher Collins (micrognathia, small mouth, funnel shaped larynx)
o Apert (midface anomalies, cervical fusion)
o Hunter and Hurler (mucopolysaccharides in tongue and larynx)
o Beckwith-Wiedemann (macroglossia)
o Freeman-Sheldon syndrome (circumoral fibrosis and microstomia)
o Fibrodysplasia ossificans
36
What are preop, intra and post op causes of peri-operative upper airway obstruction?
Pre op - OSA, epiglottis, anaphylaxis, croup, laryngomalacia
Intra op - Laryngospasm, lack of airway mx
Post op - stridor, post intubation croup, laryngeal oedema, laryngospasm
37
What are clinical features of upper airway obstruction?
- Stridor
- Hypoxia
- Tracheal tug, abdominal discordance
- Voice changes
38
What is management of airway oedema?
- Dexamethasone 0.3mg/kg
- Nebulised adrenaline 0.5mg/kg
- Head up positioning
- Reintubation
39
What is laryngospasm?
Reflexive contraction of the glottis and supraglottic laryngeal adductor muscles
40
What causes laryngospasm?
Secretions or blood hitting vocal cords
Painful stimulus without adequate anaesthesia
41
What are risk factors for laryngospasm?
Patient factors:
- Younger age
- Recent URTI/irritable airways
- Passive smoking
- Asthma
Surgical factors:
- Surgery involving airway
- Blood/secretions in upper airway
Anaesthetic factors:
- Inhalational rather than TIVA
- ETT > LMA
- Light anaesthesia during instrumentation
42
What is the Mx of laryngospasm?
Remove stimulus
100% O2
PEEP
Propofol (2mg/kg)
Paralysis
43
What are causes of critical airway obstruction?
Intra- Luminal: Foreign body, stenosis, haemangiomas/cysts in airway
Lumen: trachobronchitis, laryngospasm, tracheomalacia
Extra-luminal: Tumour, epiglottis, laryngomalacia, vocal cord palsy
44
What is laryngomalacia?
Collapse of supraglottic structures on inspiration that closes glottis
45
What is tracheomalcia?
Airway collapse during expiration due to insufficent rigidity of the cartilagionus framework of the trachea-bronchial tree (usually within first 12 months of life)
46
How do you use fibreoptic intubation in children?
- If old enough would use AFOI like in adults --> upper airway topicalisation
- If younger i.e <12, would use spont vent gas induction, asleep fibreoptic intubation with topicalisation as you go (insertion of LMA if I thought maintaining a patent airway was difficult then use bronch with airway exchange catheter or ETT loaded)
- Smaller scopes have nil suction channel (2.2mm or 2.5mm), whilst paeds scopes usually OD of 3.5 - 4mm
47
What are the differences in pain in children compared to adults?
- May not be able to communicate pain with language
- May need a pain assessment tool which changes as they grow
eg Face pain scale, numeric pain scale, FLACC scale (face, legs, activity, cry, consolability)
- Assessment of pain includes distractability
48
What are the doses of morphine infusions in childrens
Usually run ~10mcg/kg/hr
49
What is the dose of normal ketamine infusions ?
0.1-0.4 mg/kg/hr
50
What is the rate of epidurals in children?
0.1-0.3mls/kg/hr 0.2% ropivacaine +/- 2mcg/ml fentanyl
51
What are the important psychological and social factors in acute pain management in kids?
- children with psychological/behavioural difficulties are unlikely to report pain --> may need other tools to assess pain
- Children from poorer backgrounds less likely to understand goals of treatment or side effects --> may need closer observation
- Children with neglect/NAI/abuse less likely to trust and interact and report pain
52
What are the requirements for pain management in day case paeds anaesthesia?
- child must return quickly to oral intake
- pain must be controlled by oral route
- have sufficient supply of analgesia to last them at least another day
53
What are the requirements for day case anaesthesia in children?
- Low risk procedure (not airway, quick return to oral intake)
- Low risk patient
- Low risk parent
- Stable anaesthesia and post op period (nil PONV, passed urine, nil bleeding, vitals NAD)
54
What factors decide the route of opioids in children eg infusion vs PCA vs PRN
Patient - prior opioid use, ability to use a PCA, ability to report pain
Surgical - Severity of post op pain, ability for post op oral use/absorption
Anaesthetic - use of intra-op regional eg block, use of multi-modal analgesia, use of ketamine infusion (may change need for opioids)
55
When might regional be beneficial in children?
- Lower abdominal surgery in non-ambulant or small children caudal is effective and low risk
- Bilateral large orthopaedic surgeries of lower limb epidurals are effective for intra and post op analgesia (dose is 0.1-0.2ml/kg/hr or 2-4mg/kg/hr)
- Penile block for circumcision and hypospadias repair
- wound catheters for extensive surgical wounds
56
What is a normal PCA dosing?
Morphine: 50mcg/kg bolus with Q5min lockout +/- infusion 0-40mcg/kg/hr
Fentanyl: 0.6mcg/kg bolus with Q5min lockout +/- infusion 0 - 1.2mcg/kg/hr
57
What monitoring is required for PCA in children?
- Sedation score, RR, HR, pain and vomiting assessed Q1H
- Continous pulse O2 if sedated, hx of OSA, hypoxia, concurrent sedating agents/infusion
58
What are the risks of neonates receiving opioids?
- High risk of apnoeas, resp depression and hypoxia
- Should be on continous sats monitoring
59
What are the clinical implications for anaesthetising premature babies?
- Risk of resp distress syndome of prematurity
- Higher risk of apnoeas (brainstem immaturity) --> need post op monitoring
- PDA (left to right shunt), anaemia of prematurity
- Risk of hypoglycaemia (Q1H BSL)
60
What are implications for asthma in anaesthetising children?
- Thorough preop assessment for triggers and current resp function
- Intra op aim to prevent bronchospasm, use LMA if possible
61
What are clinical implications of OSA?
- Pre op thorough history, avoid oversedating with premeds
- Avoid opioids intraop
- Post op extubate awake and may need overnight monitoring if severe OSA
62
What are clinical implications of cystic fibrosis?
- Pre op need PFTs
- Intraop aim for minimally invasive airway
- Post op need regular analgesia and regular physio
63
What are clinical implications of quinsy?
- DIfficult mouth opening
- May present with stridor and upper airway obstruction
- Potentially difficult airway although issue is above the level of the larynx, so should be able to intubate once anaesthetised
64
What are the clinical implications of croup?
- Larynx, trachea, bronchi are involved and become oedematous, worse with anxiety
- Intubation is usually straightforward but trachea may be narrower than usually
65
What are the clinical implications of epiglottitis?
- Acute life threatening infection called by HiB or staph/strep
- Usually 2-3 yrs old
- Rapid onset of fever, kid sitting forward with drooling saliva
- Have ENT in theatre
- IV preop with EMLA, avoid causing laryngospasm due to pain
- Inhalational induction in the upright position, then move to supine when asleep
- Intubation may be very difficult due to abnormal anatomy
66
What are the clinical implications of trisomy 21?
- Difficult airway (large tounge, small upper airways, atlanto-axial instability)
- Pre op exclude heart disease
- Post op careful extubation with low threshold for guedel
67
What are the clinical implications of cerebral palsy?
- Risk of epilepsy
- High risk of resp pathology
- Potentially difficult airway as poor dentition, poor positioning and TMJ dysfunction
- Often have oesphageal dysmotility and spasm, risk of aspiration and inadequate fasting
68
What is the criteria for muscular dystrophies?
-Primary myopathies
- Genetic basis
- Progressive course
- Degneration and death of muscle fibres at some stage
69
What are the clinical implications of muscular dystrophies?
- Most common two are Duchenne's and becker type (less severe)
- Risk of Anaesthetic induced rhabdomyolsis due to volatile or sux so use propofol based
- Non-depolarising muscle relaxants should be used with caution, prolonged onset and duration
- Some rarer forms are mitochondrial in origin, can have high risk of propofol infusion syndrome
70
What are useful preop Ix for myopathies
Bloods: K, Lactate (higher in mitochondrial disease), CK (higher in duchene's or becker)
TTE: evaluate for cardiomyopathy
71
What is a cardiac shunt?
abnormal flow between cardiac chambers that results in mixing of blood
72
What are acyanotic shunts?
-Left to right shunts eg ASD, VSD, PDA (however if large and unrepaired can cause cardiac failure, pulm hypertension and reversal of shunt aka eisenmengers)
- Obstructive lesions eg AS, coarctation or pulmonary stenosis
73
What are cyanotic lesions?
-Tetralogy of fallot
- Transposition of the great arteries
- Single ventricle pathologies
74
What is the end product of a fontan's procedure?
- Single ventricle pumps blood systemically
- Pulmonary circulation is filled by passive venous return
- Often a valve between IVC and atrium in case pulmonary pressures are too high
75
What are the implications for anaesthesia for a fontan's patient?
- Preload dependent (lose preload, lose pulmonary circulation then lose CO)
- Poorly respond to changes in PaO2 and PaCO2 as that changes Pulm vasc resistance
- PEEP and IPPV is poorly tolerated due to changes in VR
- Risk of VTE and are often anticoagulated
76
What are the features of tetralogy of fallot?
* RV outflow obstruction (usually infundibular /valular)
* Large sub-aortic VSD
* Over-riding aorta
* RV hypertrophy in response to RVOT obstruction and hypoplastic pulmonary artery
77
What are the anaesthetic aims for tetralogy of fallot?
- Maintain preload as impaired pulm flow
- Duct dependent (ductus arteriosis to allow CO to flow back from aorta into pulm circulation)
- Avoid high FiO2, target normal MAP, normal temp and CO2, accept lower Sats of PaO2 due to mixing in VSD
78
What are causes of anterior mediastinal masses in paeds?
- Variety of malignancies such as T Cell ALL, NHL or hodgkins lymphoma
79
What are the concerns with anterior mediastinal masses?
-If large enough can compress trachea/bronchus as well as great vessels and cause either airway or vascular obstruction
80
What preop Ix are useful with mediastinal masses?
CXR or CT to assess location and spread of mass
TTE to assess for great vessel compression
81
What is the anaesthetic approach to anterior mediastinal masses?
- Avoid GA if possible, biopsy under local anaesthetic
- Consider preop steroids to shrink size of lesion
- IV access in lower extermity as SVC may be compressed
- Spont vent GA
- Avoid loss of intrathoracic pressure i.e muscle relaxants
- Induce in sitting position
- IPPV can help maintain patent airway
- Have plan for loss of ventilation i.e turn lateral or prone, Rigid Bronch, ECMO
82
When is a safe time to delay surgery post URTI?
unlikely to improve more than 2 weeks post symptoms
83
What are risk factors for children with URTIs and anaesthesia?
Patient:
- Asthma
- Passive smoking
- Productive cough/high fever/irritable/wheeze
- Less than 1 yr old
Anaesthetic:
- Type of airway instrumentation
- Seniority of anaesthetist
- Inhalational induction (propofol safer)
Surgery: airway surgery
84
What are reassuring features of a child with an undiagnosed murmur?
- Asymptomatic with normal exercise tolerance, over 1
- Continous venous hum, soft early systolic with no thrill
- Nil variation with posture
- Normal ECG
85
What are exam findings that are concerncing in a child with undiagnosed murmur?
- Diastolic, pansystolic, late systolic
- Variable/harsh quality
- Thrill
- Variation with posture eg HOCM
- Symptomatic child
86
What features require further Ix for a child with an undiagnosed murmur?
- All infants <1 yr old
- Concerning symptoms on history i.e failure to thrive, tachypnoea, reduced exercise fatigue
- Hx of congential syndrome
87
What are clinical features of a critically ill child?
- Fatigue, tiredness, not resisting examination or procedures eg IV insertion
A: Signs of airway obstruction
B: Tachypnoea/resp failure
C: Pale dusky, reduced cap refill
88
How do you assess blood loss in children?
- Pulse (tachy, brady is sign of imminent death)
- Cap refill (press on sternum for 5s then release. <2 is normal)
- Skin colour and temp
- Blood pressure (hypotension is a late sign)
- Agitation/decreased conscious state
- Decreased urinary output
89
What is the fluid resuscitation for acute blood loss in children?
1. 20mls/kg bolus of crystalloid and reassess
2. Repeat 20mls/kg bolus
3. PRBC:
4ml/kg increases Hb by 10.
10mls/kg increases it by 30
90
How can you calculate fluid deficits in children?
- Weight loss
- Clinical signs eg thirst, dry mucous membranes, Vitals, irritability, lethargy
- Lab investigations
91
What percentage fluid deficit correlates with what severity in infants and children?
Infants: Mild 5%, Moderate 10%, Severe 15%
Children: Mild 3%, Moderate 6%, Severe 9%
92
How do you manage replacing a fluid deficit?
- Volume (mls) needed = % deficit x body weight (kg) x 10
- Then replace this volume either with 10-20ml/kg boluses in unwell or if more stable 1/2 of deficit over 1-2hrs then the rest over several hours
93
What are your vascular access options in a shocked child?
- IO
- CVC
- Direct cannulation of EJV
- Cutdown onto long saphenous vein
- Saggital sinus cannulation
94
What is the commonest cause of cardiac arrest?
- Resp cause
- Hypoxia can cause severe bradycardia and asystole
95
What is the dose of amiodarone in cardiac arrest?
5mg/kg
96
What dose of adrenaline do you give down an ETT in a cardiac arrest if unable to gain IV access?
100mcg/kg
97
What is the management of aspiration in a child?
- Mild aspiration is usually fine without intervention
- If 2hrs post aspiration pt is asymptomatic, CXR NAD and SpO2 normal nil need for ICU
- If there is particulate matter, or more severe refer to ICU
- Steroid and antibiotics are not indicated in the management
98
What is the management of bronchospasm?
- 100% oxygen
- Deepen anaesthesia
- Confirm ETT placement, exclude circuit/airway obstruction
- Salbutamol 6-8 puffs
- Long exp phase and tolerate hypercapnia
- IV adrenaline or salbutamol bolus/infusion as needed
- IV steroids (hydrocort)
- Consider magnesium, aminophylline, ipratropium
99
What are the types of post-tonsillectomy haemorrhage?
- Primary (within 24hrs of surgery)
- Secondary (up to 28 days post op)
100
What are the assessments of a child with post-tonsillectomy haemorrhage?
- Blood loss may be underestimated (swallowed blood)
- Assess fluid status by vitals, cap refill, urine output
101
What are possible problems with a post tonsillectomy haemorrhage patient presenting to theatre?
- Hypovolaemia
- Aspiration
- Potentially difficult airway (risk of airway oedema and blood in airway)
102
What is your approach to a post-tonsillectomy haemorrhage anaesthetic?
-Pre op: assess prior anaesthetic chart and airway, assess blood loss, resuscitate with fluid, check Hb, Cross match
Intra-op: two suckers, ETTs including half size down, suction NGT at end of case, modified RSI with as much pre-oxygenation as possible
- Post op: extubate awake, extended stay in recovery
103
What are signs of a gas embolism?
- Hypotension, tachycardia, raised CVP, ECG abnormalities, decrease in CO2
104
What is the management of a gas embolism?
- Call for help
- Prevent further entrainment
- Hyperventilate with 100% O2, avoid N20
- Head down, left lateral (in neuro) so operative site is below heart to increase venous pressure and keep air in the Right atrium
- Aspirate the CVC if in place
- Adrenaline for haemodynamic support
- Consider hyperbaric if stable post resuscitation within 6hrs)
105
What is the presentation of fat embolism?
- Triad of:
1. Neurological abnormalities - confusion, drowsiness, lethargy, convulsions
2. Resp failure - hypoxia, dyspnoea, tachypnoea
3. Petechial rash, fever
106
What is the management of fat embolism?
-Cardiopulmonary support
107
What is normal ICP in neonates and infants?
0-6 mmHg
108
What is the normal ICP in children and adults?
13-15mmHg
109
What is the management of raised ICP?
Positioning: Head up 30 degrees, avoid neck obstruction, Ensure ETT not obstructed
Physiological: Drain CSF, control temp, maintain low normal CO2, avoid hyponatraemia, avoid hypovolaemia, maintain normal PO2
Pharmacological: adequate sedation - consider thiopentone, paralysis, osmotherapy eg mannitol 20% 0.25-0.5g/kg, steroids if tumour
Surgical: Drain anything collecting, decompressive craniectomy
110
What are the target CPPs in different ages?
Infant: > 40mmHg (therefore aim MAP 46 if normal ICP)
Child (1-10): 50mmHg (MAP 65)
Adult (>10): 50 - 70mmHg (MAP 65-85)
111
What is the management of local anaesthetic toxicity?
- Stop giving LA
- Call for help
- Manage airway
- Commence CPR if circulatory arrest
- ALS, amiodarone can be useful for resistant VF (5mg/kg)
- Intralipid 1.5mls/kg bolus, infusion of 15ml/kg/hr
112
What is the management of malignant hyperthermia?
- Call for help, can ask for MH cards
- Turn off volatiles and change to propofol
- A, B , C managment
- Hyperventilate with 100% oxygen
- Dantrolene 2.5mg/kg up to 4 boluses
- Active cooling
- Gain arterial and CVC access, monitoring for hyperkalamia, acidosis and arrhythmias
113
What are the three stages of the pathophysiology of pyloric stenosis?
1. Hypocholoraemic, hypokalaemic, hyponatraemic metabolic alkalosis with dehydration and alkaline urine
- Gastric outlet obstruction causes loss of HCl, water, and Na, K
- HCO3 formed during HCl production enters plasma, net gain, less food getting through to duodenum so less release of pancreatic HCO3 --> alkalosis
- Kidneys cannot excrete all HCO3 as need a negatively charge ion to come back in with Na and Cl has been lost
2. Potassium depletion and paradoxical acidic urine
- Aldosterone is stimualted, Na reabsorption in exchange for K --> hypokalaemia
- Kidney maximises Na reabsorption by exchanging it for H+ --> paradoxical aciduria (worsening alkalosis)
3. Shock, lactic acidosis and starvation ketosis
114
What is the most useful Ix for pyloric stenosis?
- Serum chloride, > 90 is mild, <85 is severe
- Serum Bicarb, mild <35, severe >42
115
What is the management of pyloric stenosis rehydration?
- Correct volume and electrolytes
- Need NaCl and potassium
- Happy when Cl > 100, Na >132, K > 3.2
116
What is the normal fluid requirement of a neonate?
150ml/kg/day or 6.5mls/kg/hr
117
What is the guiding principle of transporting a critically ill patient?
the level of care provided during transport must aim to at least equal that at the
point of referral and must prepare the patient for admission to the receiving service
118
What are the major principles of transporting critically ill patients?
- Clear co-ordination and communication
- Adequate training and staffing for staff providing transport
- Adequate monitoring, equipment , documentation, vehicle
- Adequate governance, eg education, training, auditing
119
What are the specific preparations for recieving a paediatric trauma?
pre arrival:
- ensure senior medical emergency staff available
- ensure department and other services eg radiology are available
- Delegate tasks to team members
- Check resus equipment
- prepare drugs and equipment appropriate for size of patient arriving if known or estimated
On arrival:
- primary survey
- collateral history
120
Outline the use of the Broselow tape in paediatric trauma
- uses childs height or length to estimate weight
- is laid next to child on the bed and measured
- this is then used to determine drug doses, equipement etc.
121
What are some differences between paediatric patients comapred with adults when it comes to trauma?
- due to reduced size trauma more likely to affect more organs
- more flexible skeleton means can have internal injuries without overlying skeletal injury
- larger head
- less fat so abdominal organs more at risk
- more likely to compensate well then suddenly deteriorate
122
What is Spinal cord injury without radiological abnormality (SCIWORA)
- Injury with objective cervical injury without radiological evidence of fractures or ligamentous injury
- Due to elasciticy of spinal cord
- stable injury
123
What is a tension pneumothorax?
- life threatening accumulation of air in the pleural space, compressing the lung on the side of the injury first then subsequently the other lung
- Ultimately impairs venous return and will compromise CO
124
What are the signs and sx of a pneumothorax?
- hypoxia
- dyspnoea
- tracheal shift
- Hypotension
- Decreased air entry/breath sounds on affected side
- Hyperresonance to percussion
125
What is the management of a tension pneumothorax?
- high flow oxygen
- Urgent needle thoracocentesis (2nd intercostal space MCL)
- Intercostal drain insertion
126
What are the signs of NAI?
- Injuries inconsistent with history
- child reporting harm
- multiple injuries
- Delayed presentation
- unusual injuries eg retinal haemorrahge, sudural haematoma
127
What is the initial assessment of a child with severe burns?
- Hx: events around burn, smoke inhalation, co-morbidities, allergies, other injuries
- Examination: Primary survey, specifically airway compromise (soot, singed, voice change), Ventialtory issues, circulation (depending on surface of burns may be shocked), conscious state
Ix:
128
What is the initial management of a burns patient?
- Immediate cooling
- Covering of burns with sterile non adhesive dressing
- Potent analgesia
- Airway managment if required
129
What are the types of inhalational injury in fires?
Due to aspiration of superheated gases, liqui
- Upper airway thermal injury:
130
What are the injuries from CO poisioning?
- HbCO forms and amount correlates with severity of toxicity and outcome
- Shifts OHDC to the left --> increased affinity for O2 so less released to tissues and tissue hypoxia
- Pulse O2 cannot differentiate between the two and will overestimate saturations
- Need a blood gas to identify amount of HbCO
131
How is CO posioning managed?
- 100% oxygen
- Ventilation if HbCO levels >25-30%
132
How is immediate fluid resuscitation determined for burns patients?
Parkland formula = 4mlgs/kg x %TBSA is 24hr volume of fluids required
Give 50% in the first 8 hours, 50% in the next 16hrs
- Maintainance fluids should be added for children under 30 kg, via the 4:2:1 rule
133
What is the pathophysiology of electrocution in children?
- Current passing through person disrupts normal electrical function of cells
- Depolarisation of muscle cells causes VF, asystole, arrythmias, skeletal muscle contraction
- Peripheral nerve injuries
- Myoglobinuria
- Compartment syndrome
134
What is the management of electrocution?
- Normal managment of trauma patient
- Look for compartment sydnrome or rhabdomyolysis hyperkalaemia
135
What is the presentation of drownings?
- resp/cardiac arrest
- Hypothermia
- may be assocaited trauma
136
What is the immediate mx of drownings?
- 100% oxygen
- early intubation
- decompress the stomach
- withhold resus drugs if temp <30
- Shock x 3 if VF is present but further defib attempts should be withheld until temp > 30
- Active rewarming to at least > 32 (remove wet clothes, dry patient, forced warm air blankets, warm IV fluids, gastric/bladder lavage)
137
What is the management of evenomation?
- assess severity of patient illness specifically coagulopathy, neurotoxicity
- IV access and bloods
- Antivenom if directed by toxicologist (not weight based, don't need more than 1 and risk of anaphylaxis)
138
Describe methods to optomise the experience during the induction of anaesthesia in children
- Preinduction: minimise fasting, prepare equipment and drugs to minimise pauses, prepare environement to be non-threatening with posters toys etc
- Induction: Apply monitoring after induction, keep anxious child where they're settled i.e on lap, use of distraction techniques, parental presence, predmedications, N20
139
Describe the pharmacology of EMLA
-eutetic mixture of lignocaine 2.5% and prilocaine 2.5%
- Onset 45-60 min, duration 1-2hrs
- vasoconstricts
- risk of metheamoglobinaemia in neonates
140
Describe the pharmacology of angel cream
-Amethocaine 4%
- Onset 30min, duration 2-3 hrs
- Better penetration than EMLA
- Vasodilates and causes erythema
141
What is the difference between children and adults regarding TIVA?
- Children need larger doses to achieve the same plasma concentration due to increased plasma distribution to the peripheral compartments
- tend to have longer emergence due to higher dose and long context sensitive half time
142
What are the TCI models for children?
- Paedfusor: > 6mo or 5kg
- Kataria: > 3yrs or 15kg
- Marked inter-individual variability, with many assumptions in algorithms
143
What are the mechanisms of neurotoxicity due to general anaesthesia?
- NMDA antagonists and GABA agonists both trigger neuronal apoptosis in experimental infant animals
- Effects are dose dependent and time dependent
- Larger prospective trials showed in short anaesthetics no impact on young patients
144
Describe general fasting guidelines for paediatrics
Less than 6 months old - Breast milk 3 hrs, Formula milk 4 hrs
Older than 6 months - Food and formula 6 hrs, breast milk 4hrs, Clear fluids 1 hr
145
What are benefits of premeds?
- Reduces patient anxiety and cooperation
- Reduces parental anxiety
146
What are the disadvantages of premeds?
Slower wake up
Dysphoria in recovery
147
What are the doses for premeds?
Midazolam orally: 0.5mg/kg up to 20mg. Onset 15-20min
Clonidine: 4mcg/kg
Ketamine: 2-5mg/kg
148
What is emergence delirium?
Drug induced transient state of disorientation, irritation and diassociation after the end of anaesthesia, begins when child awakens usually lasts less than 30 minutes
149
What are risk factors for emergence delirium?
- Preschool age
- Short acting volatiles eg sevo
- Rapid awakening
- Pain
- Head and neck surgery
- Pre-op anxiety
- Child temperament
150
What can prevent emergence delirium?
- Propofol bolus at end of case (3mg/kg)
- Analgesia eg fentanyl 10min prior to emergence
- Clonidine 2mcg/kg
151
How do you manage emergence delirium?
-Exclude other causes eg hypoxia and pain
- Reassure parents
- Ensure child does not injure themselves
- Can sedate with propofol and wake up again
152
What are the physiological effects of pneumoperitoneum in children?
-proportional to intra-abdominal pressure
- Neonates keep pressure <6mmHg, infants and small children <10mmHg, larger children and adults is 10-15mmHg
- CO2 absorption is greater in paeds
- Resp effects: reduced FRC, atelectasis
- CVS effects: mechanical compression of splanchnic vessels, postural changes, increased sympathetic tone
153
What is the difference in temperature management in children compared to adults?
-Children are more prone to hypothermia
- Larger SA relative to BMR
- Lose more heat through their head
154
What are the ways heat is lost?
Radiation (40%) - head transfer by radiation between objects not in contact down a thermal gradient (electromagnetic waves)
Convection (30%) - transfer of heat to molecules of the surrounding medium
Evaporation (15%) - latent heat of vapourisation
Conduction 5% - heat exchange via direct contact
Respiration (10%)
155
What are the methods of maintaining heat?
- Forced air warmer
- Space blanket
- Warm blanket
- Warm fluids
- Warm environment
- Underbody warming mat
- Keep patient dry, minimise exposure
- HME filters maintaining heat and humidification
- cardiopulmonary bypass
- Abdo and bladder irrigation
