Unit 11 PEDIATRICS Flashcards
(89 cards)
1
Q
When compared to epiglotittis which is more likely to occur with Laryngotracheobronchitis (croup)? Onset
A
Gradual 24-72 hours
2
Q
When compared to epiglotitis , which is more likely to occur with Laryngotracheobronchitis (croup)? Age group
A
Less than 2 years
3
Q
Age of onset usually of epiglotitis?
A
2-6 years
4
Q
Onset of epiglotitis rapid or gradual?
A
rapid < 24 hours
5
Q
Regions affected by epiglottitis and croup. How do these present on a lateral neck x-ray?
A
Croup is LARYNGEAL STRUCTURES
Epiglotittis is SUPRAGLOTTIC STRUCTURES>
6
Q
Lateral Neck Xray for Epiglotittis will show ________ and it is associated with the _____sign
A
Swollen Epiglotittis THUMB SIGN
7
Q
Lateral Neck Xray for CROUP will show ________ and it is associated with the _____sign. SSC
A
Subglottic narrowing (Steeple sign)
SSC
8
Q
Discuss the clinical presentation and treatment of epiglottitis. 4 Ds
A
Clinical Presentation:
High fever
Tripod position helps breathing
4 D’s: drooling, dysphonia, dyspnea, dysphagia
9
Q
Treatment of EPIGLOTTITIS
A
O2
Urgent airway management –> Tracheal intubation or tracheostomy
ABX if bacterial
Intubation with spontaneous ventilation. CPAP 10-15 cm H2) minimizes airway collapse
10
Q
Who must be present when intubating a child with Epiglotitis?
A
ENT surgeon. Post op ICU care needed.
11
Q
3 bacteria implicated with croup
A
H. PARAinfluenzae
influenza A or B
RSV
12
Q
4 Bacteria implicated with Epiglotittis
A
H. influenzae
Streptococci
Pneumococci
Staphylococci
13
Q
Clinical presentation of Croup?
A
Mild inspiratory wheezes
BARKING COUGH
Mild fever
14
Q
Treatment of Croup
A
Oxygen
Racemic Epinephrine
Corticosteroids
humidification
Fluids
15
Q
Fever for epiglottitis is
A
High
16
Q
Tripoid position helps the patient with
A
Epiglottitis
17
Q
What are the 4 Ds of Epiglottitis?
Drooling HoPP
A
Drooling
Dysphonia
Dyspnea
Dysphagia
18
Q
When comparing croup with Epiglotittis : intubation is rarely required with
A
CROUP
19
Q
When inducing the patient with EPIGLOTTIS : what type of ventilation is necessary?
A
Spontaneous ventilation with RR with CPAP 10-15 cm H2O prevents airway collapse
20
Q
What is the dose and concentration of racemic epineprhine? what about dilution?
A
0.5ml of 2.25% solution ; diluted in 2.5ml of 0.9% NaCL
21
Q
What are the 2 cornerstone treatments for POST INTUBATION Croup?
A
Racemic Epinephrine 0.5 ml of 2.25
Dexamethasone 0.25 -0.5mg/kg IV
22
Q
Other name for post intubation croup is
A
Postintubation LARYNGEAL EDEMA
23
Q
Post intubation croup (Post intubation laryngeal edema) is more common in what type of population?
A
Small children
24
Q
What is the most common cause of Post intubation croup (aka. Post intubation laryngeal edema)
A
ETT that is too large.
Rigid Bronchoscopy
25
The tracheal mucosa perfusion pressure is
25cm H2O
26
The tracheal mucosa perfusion pressure is 25 cm H2O. Using an ETT that is too large or injecting an excessive amount of air into the cuff does what?
reduces tracheal perfusion → edema → ↓ subglottic airway diameter → ↑work of breathing.
27
The patient presents with Postintubation laryngeal edema presents with HBS
Hoarseness
Barky cough, and/or
Sstridor. I
28
When does postintubation laryngeal edema typically occurs?
Typically occurs within 30 - 60 minutes following extubation.
29
Treatment: Best treatment of posintubation laryngeal edema is
The best treatment is prevention!
30
Post-intubation laryngeal edema can occur with cuffed or uncuffed endotracheal tubes, but the key point is to maintain an
air leak < 25 cm H2O. If you are using a cuffed ETT, then you should use a manometer to intermittently measure cuff pressure.
31
4 top Risk Factors for Post croup laryngeal edema
Age < 4 years
ETT is too large
ETT cuff volume is too high (too much air was injected or N2O was used during the procedure)
Traumatic or multiple intubation attempts (one reason not to use an uncuffed tube)
Prolonged intubation
32
Unlike laryngotracheobronchitis (infectious croup), post-intubation croup is not
infectious. Therefore, antibiotics are not indicated.
33
How long should the patient should be observed after recemic epinephrine?
The patient should be observed for a minimum of four hours after the racemic epinephrine treatment is complete.
34
Maximum effect of dexamethasone requires?
Dexamethasone 0.25 - 0.5 mg/kg IV (maximum effect requires 4-6 hours)
35
What put a child with an INCREASED RISK OF RESPIRATORY TRACT INFECTION?
A child with an active or recent history of respiratory tract infection is at increased risk of pulmonary complications.
36
Children with URI : In addition to increased airway reactivity (bronchospasm), these children are more likely to experience
laryngospasm, mucous plugging in the airway, atelectasis, desaturation events, and post-operative hypoxemia.
37
What is the most common cause of URI
Viral infection
38
How long do you wait after the child has had URI
Most clinicians wait 2 - 4 weeks after onset of symptoms, although the risk of pulmonary complications can persist for up to 6 - 8 weeks.
39
Good reasons to cancel surgery for children with upper respiratory symptoms
Purulent nasal discharge
Fever > 38C or > 100.4F
Lethargy
Persistent cough
Poor appetite
Wheezing and rales that do not clear with cough
Child less than 1 year.
40
Mechanical irritation (ETT use) increases the risk of
Dexamethasone 0.25 - 0.5 mg/kg will reduce the risk of post-intubation croup.
bronchospasm 10-fold!
41
With children with URI, If an ETT must be used, then use a
smaller size than normal because these children are at higher risk of post-intubation croup.
42
Ensure what before instrumenting the airway with child at risk for pulmonary complications?
a deep plane of anesthesia
43
This anesthetic attenuates airway reactivity and may reduce the risk of bronchospasm.
Propofol
44
The best volatile agent, because it is non-pungent.
Sevoflurane
45
Pretreatment for children or child at risk for pulmonary complications.
inhaled bronchodilator (albuterol or ipratropium) or glycopyrrolate does not provide a clear benefit.
46
Foreign body aspiration can also occur with seeds, hotdogs, or nearly anything else. Since food is radiolucent, it can be more difficult to diagnose. The foreign body most commonly lodges in the
right bronchus.
47
Over 60 percent of children with foreign body aspiration FBA present with the CLASSIC TRIAD -->
Cough
Wheezing
Decreased breath sounds on the affected side (usually the right).
48
Supraglottic obstruction →
Infraglottic obstruction →
Stridor (SS)
Wheezing (IW)
49
Airway obstruction significant enough to impair gas exchange can quickly progress to
hypoxemia, cyanosis, altered mental status, cardiac arrest and death.
50
Surgical Considerations for Foreign Body ASPIRATION: What is the "gold standard" procedure to retrieve the foreign body.
Rigid bronchoscopy
51
Other options besides RIGID Bronch for foreign body aspiration include
flexible bronchoscopy or thoracotomy
52
Most significant concerns for Foreign body aspiration ?
Airway obstruction is the most significant concern, so weigh the pros and cons of observing NPO guidelines.
53
Best induction way for a child with foreign body aspiration is?
A sevoflurane induction with spontaneous ventilation is usually best.
54
Foreign body aspiration and PPV?
Positive pressure ventilation can push the foreign body deeper into the bronchial tree, increasing the difficulty of its retrieval.
55
The anesthesia circuit can be connected to the_____. How is that helpful? what problem can it present? What is the best maintenance technique?
port on the rigid bronchoscope. It can be used to provide oxygen and volatile agent during the procedure. It can also be used to provide gentle PPV breaths if required.The problem with this approach is the leak around the bronchoscope. You can compensate for this with a high FGF and increasing the vaporizer output. It can be difficult to maintain a sufficient level of anesthesia if a lot of the gas is escaping around the bronchoscope.If the patient coughs or bucks, the foreign body can move distally. This isn't good. For these reasons, TIVA is probably the best maintenance technique.
56
Complications of Rigid Bronchoscopy
Laryngospasm
Bradycardia during scope insertion
Post-intubation croup
Pneumothorax
57
Patients may not improve immediately after the foreign body is removed why?
due to residual lung inflammation
58
Congenital conditions associated with Macroglossia?What are the implications?
Down Syndrome (Trisomy 21)
59
Trisomy 21 (Down Syndrome)
Large tongue
Atlantoaxial instability
Small subglottic diameter (subglottic stenosis)
Small mouth
60
Large TONGUE disorder (BIG TONGUE)
B T
Beckwith
Trisomy 21
61
Small underdeveloped Mandible : PGTC
Please Get that chin
Pierre Robin
Goldenhar
Treacher Collins
Cri du chat
62
Klippel-Feil implications
Congenital fusion of cervical vertebrae → neck rigidity
63
Goldenhar Implications
Small / underdeveloped mandible
Cervical spine abnormality
64
A tongue that falls back and downwards (glossoptosis) is seen with
Pierre Robin
65
Cleft palate
Neonate often requires intubation
Pierre Robin
66
Dingman-Dott mouth retractor can cause what?
reduce venous drainage and cause tongue engorgement. This increases the risk of post-extubation airway obstruction.
67
Cleft lip repair is typically performed at
~ 1 month of age.
68
Cleft palate repair is typically performed at
~ 12 months of age.
69
Cleft Lip and palate implications?
Airway obstruction
Difficult laryngoscopy
Difficult mask ventilation if there are additional craniofacial abnormalities
Aspiration
70
Cervical spine anormalies: Kids Try Gold
Klipper Feil
Trisomy 21
Goldenhar
71
Cri du Chat : anormalies.
Small / underdeveloped mandible
Laryngomalacia
Stridor
72
Most common cardiac anormalies associated with Down syndrome ?
Atrioventricular septal defect. (endocardial cushion defect)
73
% of infants with Down syndrome with cardiac defects?
50%
74
2nd common cardiac anormalies associated with down syndrome is
Ventricular septal defect.
75
Our genetic make-up consists of 23 chromosomal pairs. What is trisomy 21?
Small mouth
Large tongue
Palate is narrow with a high arch
Midface hypoplasia
Atlantoaxial instability
- C1 & C2 subluxation
- Avoid neck flexion during laryngoscopy
- Child should receive cervical x-ray screening between 3-5 years of age
Subglottic stenosis
- Increased risk of postintubation croup
- Use a smaller ETT
Obstructive sleep apnea
Chronic pulmonary infection
Bradycardia is very common during sevoflurane induction (tx = anticholinergic)
Low levels of circulating catecholamines
Other
Intellectual disability
Epilepsy
Strabismus
Low muscle tone (hypotonia)
Hyperflexible joints (careful with positioning)
GERD
Thyroid disease
Increased incidence of leukemia
Trisomy 21 (Down syndrome) results from the addition of a 3rd copy of chromosome 21.
76
Most common chromosomal disorder.
Trisomy 21
77
More likely to give birth to a child with Down syndrome.
Older mothers
78
While Down syndrome affects nearly
every organ system
79
The patient with Down syndrome is at risk for
difficult ventilation and intubation.
80
AIRWAY PROBLEMS with Children with Down syndrome
Small mouth
Large tongue
Palate is narrow with a high arch
Midface hypoplasia
Atlantoaxial instability
C1 & C2 subluxation
81
Palate with Down syndrome?
Narrow , HIGH ARCH
82
Avoid this with Trisomy 21? when chould children receive cervical xray screening?
- Avoid neck flexion during laryngoscopy
- Child should receive cervical x-ray screening between 3-5 years of age
83
Trisomy 21 and Induction?
Bradycardia is very common during sevoflurane induction (tx = anticholinergic)
Low levels of circulating catecholamines
84
Respiratory implications for children with trisomy 21
Subglottic stenosis
- Increased risk of postintubation croup
- Use a smaller ETT
Obstructive sleep apnea
Chronic pulmonary infection
85
CHARGE Association:
C – Coloboma (a hole in one of the eye structures)
H – Heart defects
A – Choanal atresia (back of nasal passage is obstructed)
R – Retardation of growth and development
G – Genitourinary problems
E – Ear anomalies
86
You might also see this called DiGeorge syndrome or 22q11.2 gene deletion syndrome.
C – Cardiac defects
A – Abnormal face
T – Thymic hypoplasia
C – Cleft palate
H – Hypocalcemia (due to hypoparathyroidism)
22 – 22q11.2 gene deletion (the cause of the syndrome)
87
What are the unique anesthetic considerations for the patient with DiGeorge syndrome?
Hypocalcemia is common (remember hyperventilation, albumin, and citrated blood products lower free Ca+2 in the blood).
If the thymus is absent, the child is at high risk for infection. Treatment consists of thymus transplant or mature T cell infusion. Transfusion of leukocyte-depleted irradiated blood is best.
88
3 interventions that lower Ca2+ in blood
Albumin
Citrated blood products
Hyperventilation.
89
Associated with Cardiac defects? VACTERL
V- Vertebral Defects
A- Imperforated anus
C- Cardiac anomalies
T- TEF
E - Esophageal atresia
R - Renal dysplasia
L - Limb anomalies.
