10. Paediatrics Flashcards
1. Assess 2 day old baby Surgery testicular Torsion 39/40 After uneventful pregnancy / Delivery Baby is average weight Correct Dose of IV paracetamol
A. 3.5 mg B. 10 mg C. 15 mg D. 26 mg E. 53 mg
D. 26 mg
Average neonate weight
3.5 kg
Paed dose IV paracetamol
Paediatric dose IV Paracetamol
15mg/kg 10-33kg
<10kg
Dose reduction to 7.5mg/kg
Increased risk toxicity
Altered PK of developing organs
MHRA Guidance & Safe Anaesthesia Liaison Group
Anaesthetise 4yo exploration groin
No relevant PMH
No Prev GA
IV induction
LMA 2
SV - O2/Air/ Sevo on Ayre’s T piece.
Give 2mg IV mophine
30 min into operation
Rising FiCO2
Other parameters normal range
Cause:
A. Hypoventilation 2nd to Opioid B. MH C. Soda lime exhaustion D. FGF low E. FGF hih
D, FGF too low
Answer to 2
The question asks about rising fractional inspired CO2
Answers A and B would cause a rise in the
end tidal CO 2 only.
The weight of a four-
year- old child can be estimated at 7 or 8 kg.
The correct dose of morphine is 0.1–0.2 mg/
kg so in this case an appropriate dose has been
given.
Soda lime is not used with an Ayre’s T
piece.
The fresh gas flow (FGF) when using this breathing system must be at least two or three times the
minute ventilation of the patient to prevent rebreathing and a rise of inspired CO 2
. Having a gas
flow that is higher than required is safe with no detrimental side effects for the patient but cost/
waste/
air pollution become relevant
FGF when using Ayres T Piece
The fresh gas flow (FGF) when using this breathing system must be at least two or three times the
minute ventilation of the patient to prevent rebreathing and a rise of inspired CO 2
3.
You anaesthetize a seven-
year- old boy for manipulation of forearm
fracture. On attaching the electrocardiogram (ECG) you notice multiple round bruises of different ages all over his torso. You are concerned the child may have suffered non-
accidental injury. It is 10 pm. The best action you should take is:
A. Notify your Consultant B. Phone the on- call social worker C. Phone the police D. Phone the court E. Notify the hospital- designated child protection doctor
E. Notify the hospital- designated child protection doctor
Answer to 3
The anaesthetist has a duty of care to act upon any concerns they have regarding child safety and
should ensure they are familiar with the local child protection policies within their organization.
Every organization has designated child protection doctors, nurses, and midwives with whom
serious concerns can be raised and discussed either formally or informally.
This is commonly the Consultant Paediatrician on call who can ensure the issue is managed by the child protection team if deemed necessary
You perform an inguinal nerve block on a seven-
year- old child for operative management of undescended testis on the same side. The safest way to avoid inadvertent intravascular injection
is:
A. Monitor closely with ECG, non- invasive blood pressure (NIBP), and pulse oximetry
B. Using local anaesthetic with adrenaline (epinephrine)
C. Regular aspiration during injection
D. Using a nerve stimulator to guide placement
E. Observing the maximum safe dosage as per the child’s weight
C. Regular aspiration during injection
Answer to 4
Note this is not a question about local anaesthetic toxicity, it is specifically about accidental
intravascular injection, which is only one of the causes of local anaesthetic toxicity
Regular aspiration during injection (answer C) is the only one which allows early detection of accidental intravascular injection.
Monitoring as in option A would detect it but not avoid it; adrenaline (epinephrine) would increase the safe dosage and show a tachycardia but not protect
against IV injection.
D and E may prevent toxicity resulting from an excessive dose of local anaesthetic but not specifically due to intravenous injection
5.
Lidocaine 2% spray to the vocal cords may reduce the incidence of laryngospasm following tonsillectomy. Which best describes the pharmacodynamics of this?
A. It blocks the recurrent laryngeal nerves bilaterally
B. It blocks sympathetic efferents
C. It blocks parasympathetic afferents
D. It paralyses the smooth muscle of the
larynx
E. It blocks superior recurrent laryngeal
nerve
C.
It blocks parasympathetic afferents
How + Why Does Laryngospasm occur
Laryngospasm occurs by
contraction of the intrinsic muscles
of the larynx,
specifically the adductors.
It is usually triggered by a peri- glottic stimulus mediated via the Vagus nerve.
How does Lidocaine prevent laryngospasm
What is the supply to the Larynx
Lidocaine will block the afferent pathway
to prevent the reflex efferent response of glottic closure.
The larynx is supplied by the
superior laryngeal nerve
above the vocal cords
and the recurrent laryngeal nerve
below the vocal cords.
Both are branches of the vagal nerve
and both would need to be
blocked to prevent the efferent arc of the reflex
- A ten-month- old infant presents for elective herniotomies under GA. He appears well though routine examination reveals a soft systolic murmur; the rest of the examination is normal. The most appropriate action to take is:
A. Postpone surgery and obtain an urgent cardiac echocardiogram
B. Postpone surgery and refer the child cardiologist for investigation
C. Assume this is an innocent murmur and proceed
D. Proceed with anaesthesia giving antibiotic
cover
E. Proceed with surgery under local anaesthesia
B. Postpone surgery and refer the child cardiologist for investigation
Investigation of murmurs
The surgery is elective and non- urgent. Most murmurs are innocent murmurs, with less than 1%signifying congenital heart disease and most congenital heart disease is diagnosed before the age of three months.
But, any child who is less than one year old should be thoroughly investigated by Paediatric Cardiologists as presentation may be slower and/ or later.
You are in a restaurant when a mother frantically calls for assistance with her three- year- old daughter who appears to be choking. The child is conscious, and appears to be coughing but no noise is made. What is
the most appropriate immediate action?
A. Continue to encourage coughing
B. Deliver five back blows
C. Call for help (999) and deliver five abdominal thrusts
D. Perform a finger sweep under direct vision to dislodge the object
E. Place the child in the recovery position
B. Deliver five back blows
BLS choking
From the 2015 Paediatric BLS choking guidelines,
if there is an ineffective cough in a conscious
child (no noise, cannot vocalize, cyanosed) then five back blows should be immediately delivered
followed by five abdominal thrusts (use chest thrusts in an infant to avoid solid organ damage).
If the child were to become unconscious, the airway should be opened and anything visible could be
removed, followed by commencing basic life support
You anaesthetize a 6- year- old child for adenotonsillectomy. After the Boyle– Davis gag has been positioned, you notice the patient’s abdomen
moving excessively. You diagnose partial airway obstruction, confirmed by capnography. What is most likely to be the cause of this?
A. The LMA has moved
B. The LMA is too small
C. The Boyle– Davis gag is too small
D. The depth of anaesthesia is insufficient
E. The child has aspirated gastric contents
A. The LMA has moved
LMA answer
The LMA is most likely to have moved:
this is common during the move from anaesthetic room to theatre plus transfer of patient onto table.
If not in the correct position the LMA will be obstructed
when the Boyle– Davis gag is fully opened.
Insertion of the gag is a time when vigilance is specifically required to confirm the airway remains patent post insertion.
An LMA which is too small should not cause obstruction in this way (although may not establish the
best airway) and the Boyle– Davis gag used should the smallest possible to do the job
Depth of anaesthesia can be reduced during transfer but should be confirmed as adequate before
giving the surgeon permission to begin. Aspiration is less likely in a fasted child for an elective
procedure
A nine- year- old boy with mild learning difficulties and an incarcerated inguinal hernia requires surgical repair. He is refusing medication and topical local anaesthetic. The parents are hyper- anxious. Which of the following is the most appropriate action?
A. Wait until child is calm before anaesthetizing
him
B. Restrain with parental consent and attempt gas induction
C. Restrain with parental consent, give midazolam 0.5 mg/ kg orally and wait 20 min
D. Give IM ketamine 5 mg/ kg and wait 5 min
E. Restrain with parental consent and apply topical local anaesthetic cream to
hands
D. Give IM ketamine 5 mg/ kg and wait 5 min
