PICU Bri

Question 1

Airway

Answer 1

patent (stridor, obstruction)

protected (awake, breathing)

Question 2

Breathing

Answer 2

RR, sats, WOB, A/E

Question 3

Circulation

Answer 3

HR/BP/pulses CRT

Question 4

Disability:

Answer 4

GCS, pupils, materializing signs, glucose

Question 5

Exposure

Answer 5

undress the patient, temp

Question 6

Resus station

Answer 6

PPE
call for help, bring to resus room
monitors
O2
set of vitals
ABCDE
RN on PIV - if can't get in 5 minutes and child in shock, IO

Question 7

8 year old in MVC, TBI. moaning, will not open his eyes, and flexes to pain

Answer 7

moaning - 2 verbal
won’t open eyes - 1
flexes to pain - 3

total = 6

decerebrate - NO BRAIN, extension is bad (weird)

Question 8

Cushing’s Triad

Answer 8

hypertension
bradycardia
abnormal breathing

Question 9

Monro-Kellie Doctrine

Answer 9

skull is fixed
if any of the compartments increases, the others can only decrease so much
if have a mass, increase in the space taken by the parenchyma, critical volume is where the ICP goes up

Question 10

Evidence based TBI management - doesn’t mater what got you there

Guidelines for severe TBI

Answer 10

Normal - O2 sats, pCO2 (35-40 mmhg), BP >5th percentile, temperature (no hyperthermia, DO not COOL (trial shows that it is bad))
Avoid: hypoglycemia, seizures
Treat elevated ICP +/- impending herniation with hyperosmolar therapy
over 50% have an episode of hypotension/hypoglycemia

Question 11

TBI management in PICU

Answer 11

ICP probe if GCS 20 for 5 minutes then (NORMAL ICP IS s triad, blown pupil)

ICP probe only in trauma

Question 12

7 year old with CP involved in MVA and presents with GCS of 4, ICU x 1 week with no improvement despite aggressive management. Parents approach you regarding the withdrawal of treatment because of his underlying disability Which of the following is try:

Answer 12

not brain dead - because he has a GCS of 4

To be brain dead you need to have a GCS 3

Question 13

Pediatric Brain death CLINICAL DIAGNOSIS

Answer 13

1) established aetiology capable of causing neurological injury in absence of reversible conditions
2) no confounders including:
- unresuscitated shock
- hypothermia (temp t do the above tests: MRA or CTA (nothing about EEG anymore)

Canadian guidelines are different from american

Question 14

Who can perform neurological determination of death?

Answer 14

any licensed physician with the requisite knowledge and skill

Question 15

Differences in kids

Answer 15

> 1 year old, same as adults

>30 day and < 30 days: minimum time from birth 48 hours, 2 exams separated by at least 24 hours

Question 16

Procedural sedation for ortho, what are the 4 pieces of equipment you would want next to you ? 3 effects of ketamine?

Answer 16

Equipment: O2, suction, oral airway, BMV, airway cart, IV fluid
Ketamine: causes release of endogenous catecholamines: tachycardia, HTN, amnesia, analgesia, bronchorrhea, bronchodilation
ketamine good for hemodynamic unstable, no longer a problem for increased ICP

Question 17

meds for intubation for kid with increased ICP

Answer 17

ketamine - maintains HR and BP
if hypertensive then use fentanyl with midaz
don’t use proposal, drops your BP
fentanyl most HD stable for the opioids

Question 18

neuromuscular blockage

Answer 18

increases the chance of success in 1st attempt

always use it unless there is a reason not to (i.e. mediastinal mass)

Question 19

SIDe effects of depolarizing NM blockade (ie succ)

Answer 19

hyper K - worse in renal failure, rhabdo
malignant hyperthermia
Neuromuscular disease - can cause worsening of symptoms in MD

Question 20

Non depoolarizing - ie roc

Answer 20

blocks the receptor

less side effects but lasts up to one hour

Question 21

3 month old with fever, HR 180, BP 50/30, unwell with poor pulses and delayed CRTI. How is this infants cardiac output compared to usual? What about SVR? What would be your IV doers

Answer 21

1. CO decreased
2. SVR increased
3. 20 cc/kg NS push

Question 22

best indicator of early hypovolemic shock in 3 year old

Answer 22

tachycardia is the first sign

Question 23

oxygen delivery

Answer 23

cardiac output x arterial O2 content

Question 24

Why do we need O2

anaerobic metabolism is not good

Answer 24

glycolysis
decreased ATP = failure of energy dependent processes
increased lactate = acidosis - cells don’t like->death

Question 25

Shock types

Answer 25

1) distributie 2) cardiogenic 3) hypovolemic 4) neurogenic

Question 26

Clinical markers of perfusion

Answer 26

1. CRT 2. pulses 3. HR and BP 4. u/o

Question 27

Lab markers

Answer 27

lactate mixed venous acid-base

Question 28

Septic Shock

Answer 28

warm shock cold shock: cold, poor pulses, increased after load, lower cardiac output has to do with how many vasodilator cytokines vs vasoconstriction warm shock - toxic shock is most common - S. aureus/GAS, warm, cash cap refill, wide PP loss of auto regulation usually vasoconstrict/vasodilate based on demand

Question 29

Shock:

Answer 29

``` recognize shock, O2, PIV 20 cc/kg/ NS x 3, 2nd PIV, start ABx, correct low BG and Ca cold shock = dopamine warm shock = norepi if catecholamine resistant = steroids ```

Question 30

causes of cardiogenic shock

Answer 30

``` cardiomyopathy viral myocarditis post bypass coronary artery anomalies arrythmias etc signs and symptoms: cold shock+ poor perfusion + heart failure (Hepatomegaly, pulmonary/peripheral edema) ```

Question 31

where spinal cord injury for neurogenic shock

Answer 31

T1 to L2 | inappropriately nomal HR but hypotensive , treatment is vasopressors

Question 32

Boy collapses at school. paramedic arrive and intubate, get IV access and use AED to defibrillate for wide complex tachycardia then continue CPR. On arrival you would:

Answer 32

1) defibrillate 2J/kg 2) defrillate 4J/kg 3) epi 1:10000 IV 4) continue CPR x 5 minutes if using a manual defibrillator, then restart fresh at 2J/kg

Question 33

if PEA or systole

Answer 33

don't give a damn about your debrillator, you only have CPR and epi

Question 34

management shock as soon as you can

Answer 34

CPR x 2 minutes, shock again THEN EPI (with the second shock) once first epi then every 3-5 minutes after that 15:2 no advanced airway, no need to coodinate once intubated epi dose: 0.01 mg/kg 1:10000 IV (going right to veins, vs muscle need more dose) **we don't know if epi helps in arrest if you haven't intubated need to co-ordinate (but not 1st priority if getting ventilation)

Question 35

unconscious person

Answer 35

check pulse first | CAB

Question 36

3 things you can tell the team to ensure good quality CPR

Answer 36

1. push fast 2. push deep 3. minimize interruptions 4. allow full chest recoil 5. switch people 6. no leaning (use a stool)

Question 37

unstable SVT

Answer 37

synchronized cardioversion or adenosine (if have IV present) 0.5-1J/kg is the cardioversion dose give them fentanyl first

Question 38

SVT

Answer 38

stable - vagal, adenosine | unstable - cardiovert or adenosine

Question 39

Wide complex tachy

Answer 39

unstable - pulseless arrest | stable - talk to cardiology

Question 40

bradycardia HR<60 and compromised

Answer 40

usual ABCs most commonly bradycardia is from hypoxia if persists then start CPR, then give epi and atropine if continues then do TC pacing

Question 41

What is the does for anaphylaxis

Answer 41

1:1000 IM anterolateral thigh | don't do it IV

Question 42

if respiratory compromise

Answer 42

wheezing - ventolin other - intubate if need more than 3 IM epi then give infusion H1/H2 antagonists, genadryl, ranitidine, steroids (prednisone)

Question 43

tidal volume

Answer 43

regular breathing

Question 44

functional residual capacity

Answer 44

lung still open, what is left

Question 45

maximum inspiration

Answer 45

inspiratory reserve volume and expiratory reserve volume , total lung capacity without residual volume is your vital capacity

Question 46

Where is breathing controlled

Answer 46

respiratory centres in brain signals fo diaphram and heart C345 diaphragm alive

Question 47

ventilation CO2 clearance depends on what

Answer 47

minute ventilation | tidal volume x rr

Question 48

5 year old 3 days of fluA with high ver, stridor and severe resp distress. First step in management? 2 likely organisms?

Answer 48

ABCs then secure airway | staph aureus, GAS

Question 49

Symptoms of upper airway obstruction depends on where the obstruction is

Answer 49

negative intrathoracic pressure - collapses on inspiration , get symptoms of expiratory stridor extrathoracic obstruction - should have collapse on inspiration

Question 50

Upper airway obstruction

Answer 50

epiglottitis, bacterial tracheitis, croup, RPA, foreign body, airway anomaly if in distress secure the airway don't give them sedatives or paralytics consults anaesthesia or ENT

Question 51

causes of hypercapnea

Answer 51

hypoventlation obstructive lung disease (asthma, OSA) neuromuscular disease

Question 52

Respiratory acidosis

Answer 52

resp failure bad vent settings 1:10 rule for acute resp acidosis, as you compensate closer to 3-4

Question 53

metabolic alkalosis

Answer 53

vomiting | lasix/Bartters

Question 54

respiratory alkalosis

Answer 54

secondary to something else | incorrect vent

Question 55

Indications for intubation

Answer 55

1. CNS: cannot protect airway (GCS <8, no airway reflexes), loss of control of breathing 2. Resp: upper airway obstruction, hypoxemia, hypercapnea, severe WOB despite max medical tx 3. CVS: hemodynamic instability, to decreased metabolic demand 4) logistics: transport, procedures - small pneumo need a chest tube

Question 56

pneumonic for intubation 7Ps

Answer 56

1) prepare 2) pre O2 3) premedicate -include atropine if <1 year old 4) paralysis 5) pressure on cricoid carilage (only if RSI) 6) placement of ETT (4+ age/4, depth = ETT size x 3) 7) post intubation care

Question 57

equipment

Answer 57

1) mask 2) ETT 3) airway gadgets (oropharyngeal, LMA) 4) laryngoscope blade 5) stylet 6) suction catheter 7) syringe for cuff inflation

Question 58

confirm ETT placement

Answer 58

1) ausculation 2) direct laryngoscopy 3) detect CO2 - BEST 4) CXR - BEST 5) condensation in the ETT

Question 59

RSI - haven't been fasted to higher risk of aspiration

Answer 59

preO2 before the BMV, want to limit the Positive pressure minimize BMV as may distend stomach Deep sedation and paralysis so increase chances of success cricoid pressure to compress esophagus during laryngoscopy (controversial) BURP maneuver

Question 60

Questions about changing the vent settings

Answer 60

``` Timing of the breath: synchronized, assist control, pressure support pressure or volume rate PEEP I/E time ```

Question 61

low sats vented patient

Answer 61

DOPE, increased FiO2 or PEEP (increases SA)

Question 62

high CO2 vented patient

Answer 62

increase minute vent with increased tidal volume or RR

Question 63

1 month old with RSV, 22/6 FiO2 40% RR35 . first gas 7.20/75/23/70. next step

Answer 63

increase rate | increase PIP

Question 64

12 year old old influenza pneumonia, sats 60% rule out new issues

Answer 64

increase the PEEP

Question 65

3 year old female in ED for 4 hours with asthma, got ventolin q30 minutes, moderate distress on FiO2 40%

Answer 65

MgSO4 - reduces ICU admission | may need to give fluid with it

Question 66

Status asthmaticus

Answer 66

failure to respond to initial bronchodilator

Question 67

RFs for ICU in asthma

Answer 67

prior ICU, h/o increased bronchodilator use with no improvement, asthma exacerbation despite recent steroids, frequent ED visits, sats <92% despite O2 may need some adjuncts no evidence for IV ventolin (do inhaled continuous first always)

Question 68

ARDS

Answer 68

1) within 1 week of known clinical insult 2) bilateral lung opacities 3) not explained by CHF or fluid overload P/F ratios with PEEP of at least 5 P/F ratios: mild 200-300, moderate 100-200, severe <100 Causes: sepsis, pneumonia, trauma, aspiration, TRALI Tx: lung protective ventilation (high PEEP,low tidal volumes), early steroids, probing, ?NO, ?surfactant

Question 69

Status epilepticus

Answer 69

acute symptomatic prolonged febrile seizure remote idiopathic management : ABCDs include BG benzo q5 min x 2 )midaz and ativan best in CPS statement fosphenytoin 20 mg/kg > 1 year old or phenobarb 20 mg/kg then the other if still seizing 10 minutes post then intubate with RSI and start midaz infusion

Question 70

chance of 1st benzo stopping seizure

Answer 70

80% for first | 20% for second

Question 71

Differential for coma

Answer 71

vindicate

Question 72

Burns

Answer 72

remove clothes and other exposures ABCDEs 100% FIO2 and rapid trauma assessment (10% have other injuries) wash burns with tepid water, flush chemical burns, cool minor burns with cool saline) estimate % BSA involvement with partial /full thickness (don't include 1st degree) if >10% then at risk for SIRS response and fluid resuscitate with Parkland

Question 73

What is Parkland

Answer 73

4cc/kg/percent BSA + maintenance crystalloid (1/2 in first 8 hour, 1/2 in 16 hours) best indicator for volume resus is u/o

Question 74

what concerns you about airway involvement in a burn patient?

Answer 74

``` soot in nares stridor carbonaceous sputum singed hair closed space, any resp distress intubate sooner rather than later if any respiratory involvement ```

Question 75

Criter for refer to burn center

Answer 75

1. partial or full thickness burns >10% in pt 20% in other age groups ***get the rest from rbi slides

Question 76

Trauma

Answer 76

C spine collar very important exposure is a big one log roll them and check their back

Question 77

if bleeding then need to look for source as part of primary survey

Answer 77

``` long bone fractures splint them put them in a binder anything in abdomen that is suspicious tachycardia/hypotension ->look for sources of bleeding on primary survey secondary survey - full head to toe ```

Question 78

chest tube

Answer 78

ant axillary 5th intercostal

Question 79

tamponade

Answer 79

distended neck veins good air entry don't get distracted by significant injuries follow ABCDEs

Question 80

best predictor of good survival after drowning

Answer 80

``` cardiopulmonary arrest (time for return of spontaneous circulation is the most important) quality CPR is the most importent if they are arrested; CPR at the scene is very important bad GCS when in hospital is less important electromechanical dissociation - PEA (a old word) ```