8. Pediatric Considerations

Question 1

Pediatric Considerations
• Management of a pediatric patient presents a unique set of challenges for the provider.
• One must understand the anatomic and physiologic differences in children at their various stages of development, and how that applies to their management.
• Pediatric health care is not merely the application of ____ medical principles to smaller patients.

Answer 1

adult

Question 2

Pediatric Considerations
• A thorough examination of the child is essential for identifying and predicting not only physiological, but also psychological and emotional problems that the child may encounter intraoperatively and postoperatively.
• The examination of a child should begin as soon as the patient ____ the room.

Answer 2

enters

Question 3

Pediatric Considerations
• Preliminary screening and history taking should include the patient’s age and weight, a general medical history, allergies, medications, past surgical history, previous hospitalizations, and a review of systems.
• Evaluation of the child’s ____ may indicate the necessity for closer evaluation.

Answer 3

growth and weight

Question 4

Pediatric Considerations
• Attention must be given to medical conditions such as ____ (reduced cardiac reserve), ____ disease (potential for bronchospasm), and ____ (potential for aspiration).
• Patients with musculoskeletal disease (kyphosis or scoliosis) may have restrictive ____ abnormalities.

Answer 4

congenital heart disease
reactive airway
gastroesophageal reflux
pulmonary

Question 5

Children Aren’t Just Small Adults

Anatomic/Physiologic Considerations
• Although differences in size are apparent, differences in body proportions are not as obvious but just as significant.
• The child’s larger body surface area translates to greater ____ loss (hypothermia), and increased ____ requirements (hypovolemia).
• ____ is more prominent (risk of airway obstruction in supine position).

Answer 5

heat
fluid
occiput

Question 6

Children Aren’t Just Small Adults
Respiratory
• The foremost concern is that the surgical site (the oral cavity) is in close proximity to the pharynx, thereby rendering the patient susceptible to ____ obstruction and irritation.
• There are anatomic differences unique to the ____that increase the risk of airway obstruction.

Answer 6

airway

pediatric upper airway

Question 7

Children Aren’t Just Small Adults
Respiratory – The Airway

Nasopharyngeal Airway: The nares are relatively ____, and more ____ of breathing is needed to overcome their resistance. Conditions such as ____ and increased ____ due to upper respiratory tract infections can increase the obstruction further.

Answer 7

narrow
work
choanal atresia
secretions

Question 8

Children Aren’t Just Small Adults
Respiratory – The Airway

Oropharyngeal Airway: Children have relative ____ with a smaller ____ compared with adults. ____ teeth may be present, which pose a risk for aspiration. Additionally, ____ tissues increase to their maximum size between the ages of 4 and 10 years, resulting in large tonsils and adenoids that may obstruct the airway.

Answer 8

macroglossia
mandible
loose
lymphoid

Question 9

Children Aren’t Just Small Adults
Respiratory – The Airway

Laryngeal Airway: The glottis is placed more ____ in children compared with adults (____ in infants and C5 in adults). The epiglottis also is ____, narrower, and at a more ____ angle.

These anatomic considerations make visualization of the glottis more difficult during laryngoscopy. In children younger than 10 years of age, the narrowest part of the airway is the ____ rather than the ____ (as in adults). The larynx itself is ____-shaped until approximately 8 years of age

Answer 9

cephalad
C3 to C4
shorter
acute

cricoid ring
glottis
cone

Question 10

Children Aren’t Just Small Adults

Respiratory
• Chest wall and diaphragm are more compliant in ____ than adults (rib cage will ____ inward during inspiration).
• The ribs are more ____ and oriented at ____ angles to the vertebrae.
• Coupled with underdeveloped intercostal muscles that cannot elevate the horizontal ribs efficiently, children tend to use ____ and ____ breathing.

Answer 10

children
move
horizontal
right
abdominal
diaphragmatic

Question 11

Children Aren’t Just Small Adults

Respiratory
• The Functional residual capacity (FRC) is the volume of gas in the lung after a normal ____.
• Children have a relatively ____ FRC compared to an adult.
• The FRC provides a ____ reserve.

Answer 11

expiration
lower
pulmonary oxygen

Question 12

Children Aren’t Just Small Adults

Respiratory
• Because children have a ____ metabolic demand (oxygen consumption), the ____ FRC results in a more ____ desaturation of hemoglobin during periods of respiratory depression.

Answer 12

higher
decreased
rapid

Question 13

Children Aren’t Just Small Adults

Cardiovascular
• The pediatric cardiovascular system has some significant ____ compared with that of the adult.

Answer 13

differences

Question 14

Children Aren’t Just Small Adults
Cardiovascular
• Cardiac Output: Cardiac output (volume of blood being pumped by the heart per minute) is dependent on ____ and ____.

• The pediatric heart has less ____ than that of the adult, with minimal ability to alter ____. Thus, pediatric cardiac output is largely dependent on ____.

Answer 14

heart rate
stroke volume

compliance
stroke volume
heart rate

Question 15

Children Aren’t Just Small Adults

Cardiovascular
• Blood Pressure: Blood pressure is the product of ____ and ____.
• The pediatric patient has less ability to alter ____; therefore, blood pressure is largely dependent on ____.
• A bradycardia with resultant decreased cardiac output thus results in a decrease in ____ since the child cannot compensate by increasing peripheral vascular resistance.

Answer 15

cardiac output
peripheral vascular resistance
peripheral vascular resistance
heart rate
blood pressure

Question 16

Children Aren’t Just Small Adults

Cardiovascular
• ‘Innocent murmurs’ are heard in up to ____% of normal pediatric patients at some point during childhood.
• The cause of these murmurs is usually ____ blood flow through any of the great vessels.

Answer 16

50

turbulent

Question 17

Children Aren’t Just Small Adults

Cardiovascular
• Features that commonly identify innocent murmurs include those that are ____ and of ____ duration and low intensity, and those that occur early in systole.
• All ____ murmurs are pathologic

Answer 17

crescendo-decrescendo
short
diastolic

Question 18

Pediatric Anesthesia
• Invasive diagnostic and minor surgical procedures on pediatric patients outside the traditional operating room setting have ____ in the last decade.
• As a consequence of this change and the increased awareness of the importance of providing analgesia and anxiolysis, the need for ____ for has also markedly increased.
• Sedation of pediatric patients has serious associated ____, such as hypoventilation, apnea, airway obstruction, laryngospasm, and cardiopulmonary impairment.

Answer 18

increased
sedation
risks

Question 19

Anesthetic Considerations
What is sedation?
• In 2002, the American Society of Anesthesiologists published “Practice Guidelines for Sedation and Analgesia by Nonanesthesiologists.”
• In 2006, the American Academy of Pediatrics and the American Academy of Pediatric Dentistry developed “Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures: An Update”
• The following levels of sedation were agreed upon: ____, Moderate, ____, and General.

Answer 19

minimal

deep

Question 20

Anesthetic Considerations
What is sedation?

most important = ____
where will see major issues
something simple as a jaw thrust = deep sedation airway automatically brings you to ____

Answer 20

airway

deep

Question 21

Anesthetic Considerations

Rescue
• Because sedation and general anesthesia are a ____, it is not always possible to predict how an individual will respond.
• Practitioners intending to produce a given level of sedation should be able to diagnose and manage the physiologic consequences (____) for patients whose level of sedation becomes deeper than initially intended.

Answer 21

continuum

rescue

Question 22

Anesthetic Considerations

Goals of sedation
• Guard the patient’s ____
• Minimize physical discomfort and pain.
• Control ____, minimize psychological trauma, and maximize the potential for amnesia.
• Control ____ and/or movement to allow the safe completion of the procedure.
• Return the patient to a state in which safe ____ from medical supervision.

Answer 22

safety and welfare
anxiety
behavior
discharge

Question 23

Anesthetic Considerations

Pediatric sedation
• The sedation of ____ is different from the sedation of adults.
• Sedation in children is often administered to control ____ so that procedures can be completed safely, often, children younger than 6 years and those with developmental delay require ____ levels of sedation to gain control of their behavior.
• Children in this age group are particularly ____ to the sedating medication’s effects on respiratory drive, patency of the airway, and
protective reflexes.

Answer 23

children
behavior
deep
vulnerable

Question 24

Anesthetic Considerations
Pediatric sedation
• Drugs with long ____ of action (chloral hydrate, intramuscular pentobarbital) will require longer periods of ____ even after the child achieves currently used ____ and discharge criteria.
• This is particularly important for infants and toddlers transported in ____ who are at risk of re-sedation after discharge because of residual prolonged drug effects with the potential for airway ____.

Answer 24

durations
observation
car safety seats
obstruction

Question 25

Anesthetic Considerations
• Patients who are in ASA classes I and II are frequently considered ____ candidates for minimal, moderate, or deep sedation.
• Children in ASA classes ____, children with ____ needs, and those with anatomic airway ____ or extreme tonsillar hypertrophy present issues that require additional and individual consideration.

Answer 25

appropriate
III and IV
special
abnormalities

Question 26

Anesthetic Considerations
Responsible adult
• The pediatric patient must be ____ to and from the treatment facility by a parent, legal guardian, or other responsible person (if consent has already been obtained).
• It is preferable to have ____ or more adults accompany children who are still in car safety seats if transportation to and from a treatment facility is provided by one of the adult.

Answer 26

accompanied

2

Question 27

Anesthetic Considerations

Facilities
• The practitioner must have immediately available facilities, personnel, and equipment to manage emergency and rescue situations.
• The most common complications of sedation involve compromise of the ____ or depressed ____ resulting in airway obstruction, hypoventilation, hypoxemia, and apnea.
• Hypotension and cardiopulmonary arrest may occur, usually from inadequate recognition and treatment of respiratory compromise.
• Other rare complications may also include ____ and allergic reactions.
• Facilities that provide pediatric sedation should monitor for, and be prepared to treat, such complications.

Answer 27

airway
respirations
seizures

Question 28

Anesthetic Considerations

• fasting guidelines are different for kids
• depends on what they’ve had (ex: breast milk vs infant formula sticks around more)
• the point = don’t want anything in stomach when ____ = preventing aspiration
• ____ is not allowed because stimulates gastric contents

Answer 28

intubated

chewing gum

Question 29

Anesthetic Considerations

SOAP-ME

S (\_\_\_\_)
O (\_\_\_\_)
A (\_\_\_\_)
P (\_\_\_\_)
M (\_\_\_\_)
E (\_\_\_\_)

Look at the definitions!

Answer 29

suction
oxygen
airway
pharmacy
monitors
equipment

Question 30

Anesthetic Considerations
Immobilization devices
• Immobilization devices such as ____ boards must be applied in such a way as to avoid airway obstruction or chest restriction.

Answer 30

papoose

Question 31

Anesthetic Considerations
Procedure
• During the procedure: the monitoring is the ____ for the adult and pediatric patient: Heart rate, ECG, oxygen saturation, respiratory rate, end- tidal CO2.
• It is important to obtain a baseline ____ if using medications that can cause malignant hyperthermia.
• Other adjuncts such as a pre-cordial stethoscope can be helpful.

Answer 31

same

temperature

Question 32

Anesthetic Consideration

• want back to ____
• • heart rate, bp, cognition, o2 saturations without supplemental o2 before sending home
• issue: common sense for us bc we’re thinking about this but a lot of times in office you have assistant who isn’t thinking > discharge are ____ and ____

Answer 32

normal
criteria
written

Question 33

Anesthetic Considerations

Oral (Enteral) Sedation
• Oral sedation is a valuable, although not entirely effective, technique. Failure rates of up to ____% are to be expected if one is seeking ____ sedation via this route.
• One of its major advantages is the fact that there is no need for the use of a ____ (in contrast to IM and IV techniques) or of a ____ (as needed for inhalation sedation) to produce a clinical effect.

Answer 33

50
moderate
needle
nasal hood

Question 34

Anesthetic Considerations

Oral (Enteral) Sedation
• There are several disadvantages as well. The most significant of which is the lack of ____ over medication.
• ____ is not possible via these routes of drug administration; therefore the risk of ____ is increased.

Answer 34

control
titration
oversedation

Question 35

Anesthetic Considerations

Oral (Enteral) Sedation
• In the past, it was common to have the parent or guardian administer the medication at home before departing for the office, however there have been numerous cases where a parent has inadvertently ____ the patient with administration errors.
• These medications should be given by the clinician approximately ____ hour prior to the procedure and the patient should be observed by their ____ with staff check-ins.

Answer 35

oversedated
1
parent

Question 36

Anesthetic Considerations
Oral (Enteral) Sedation
• Drugs that have an unpleasant taste or odor may be ____. Orange juice, apple sauce, and Tylenol elixir are commonly used to mask the taste but they may have an adverse effect on ____.
• The medications most frequently administered orally in dentistry are ____, hydroxyzine (Atarax, Vistaril), ____ (Valium), and midazolam (Versed).

Answer 36

mixed
absorption
chloral hydrate
diazepam

Question 37

Anesthetic Considerations
Oral (Enteral) Sedation

• My preference: Oral Midazolam
-Midazolam is a ____ which is a ____ receptor agonist which causes sedative hypnotic, anxiolytic, anticonvulsant, and
anterograde amnesia.
-The recommended dosage of oral midazolam is____ mg/kg (maximum dose ____ mg) as a ____ dose before treatment.

-Flumazenil: Competitive ____ – in ____ situations.

Answer 37

benzodiazepine
GABA
0.5
20
single
antagonist
emergency

Question 38

Anesthetic Considerations

Intramuscular (Parenteral) Sedation
• The major advantage is the decreased need for patient ____. To administer a drug via these routes the patient merely need be restrained for a moment during the injection.
• The most significant disadvantage is the lack of ____ over medication. ____ is not possible via these routes of drug administration; therefore the risk of ____ is increased.
• The patients fear of the ____ is also a disadvantage.

Answer 38

cooperation
control
titration
oversedation
injection

Question 39

Anesthetic Considerations
Intramuscular (Parenteral) Sedation
• The medications most frequently administered intramuscularly in dentistry are: ____ (Versed) and ____.

Answer 39

midazolam

ketamine

Question 40

Anesthetic Considerations

Intramuscular (Parenteral) Sedation

• My preference: ____

• Ketamine is a ____ receptor antagonist which causes a trance like state providing pain ____, sedation, and amnesia. It stimulates the cardiovascular system, and respiratory drive and causes ____.
• The recommended dosage of intramuscular ketamine is ____ mg/kg as a ____ dose before treatment. It will take effect in ____ min. and last ____ min. *There is no ____ agent.

Answer 40

IM keatmine
NMDA
relief
bronchodilation

2-4
single
5
25
reversal

Question 41

Anesthetic Considerations

Intravenous (Parenteral) Sedation
• ____ administration of medication is the most reliable and safest technique to obtain all levels of sedation.
• The most significant advantage is the ability to ____ the medication. ____ of onset and ability to rapidly ____ medications are other advantages.
• The only significant disadvantage is the need for
placement of an ____ which can be challenging in a non-compliant patient.

Answer 41

intravenous
titrate
speed
reverse
intravenous

Question 42

Anesthetic Considerations

Intravenous (Parenteral) Sedation
• The medications most frequently administered intravascularly in dentistry are: ____, fentanyl, ____ and ketamine.

Answer 42

midazolam

propofol

Question 43

Anesthetic Considerations

Intravenous (Parenteral) Sedation
• My preference: Midazolam, Fentanyl, Propofol.
-Midazolam: Previously discussed.
-Fentanyl: ____ acting ____. Causes analgesia, sedation. Watch for respiratory ____, bradycardia, nausea, and chest wall rigidity. Reverse with ____ (0.4 mg).
-Propofol: Depresses ____ activating system. Causes sedation. Watch for ____ depression. No ____.

Answer 43

short
opate
depression
naloxone
reticular
respiratory
reversal

Question 44

Anesthetic Considerations

General Anesthesia
• Performed in the hospital by an ____. This involves a combination of ____ and ____ medications to produce a general anesthetic. A ____ is generally given and an endotracheal tube is placed.
• Induction can be ____, IM or inhalational (sevoflurane) and anesthesia is generally maintained with ____ agents (sevoflurane/ desflurane).

Answer 44

anesthesiologist
IV
inhalational
paralytic
IV
volatile

Question 45

Pediatric Emergency

Primary survey
• In any medical emergency the first step is to determine if the ____ is open, followed by evaluation of the ____, then ____.
• These are the ABCs of cardiopulmonary resuscitation – Often referred to as the ‘Primary Survey’

Answer 45

airway
breathing
circulation

Question 46

Primary Survey

Airway
• First check if the airway is open: “Hey! Are you okay?’ If there is a response – the airway is open.
• If no response, you must assess if the airway is ____.
• If the airway is not intact, you must correct this ____ moving on to further assessment.
• Common reasons for airway obstruction: ____ bodies, upper airway obstruction (sedated/unconscious patients), and ____ (sedated patients).

Answer 46

obstructed
before
foreign
laryngospasm

Question 47

Primary Survey
Breathing
• After the airway is confirmed to be intact, assess the patients breathing.
• In the pediatric patient, if air is moving, you must also asses the ‘____ of breathing.’
• Monitor the ____ and ____ of breathing (know the age appropriate respiratory rates).
• Hypercarbia and inadequate ventilation is often underappreciated.

Age
infant (birth-1)
Rate: ____

Toddler (1-3)
Rate: ____

Preschooler (3-6)
Rate: ____

School age (6-12)
Rate: \_\_\_\_

Adolescent (12-18)
Rate: ____

Answer 47

work
rate
depth

30-60
24-40
22-34
18-30
12-16

Question 48

Primary Survey
Breathing
• Signs of increased work of breathing:
Nasal ____ (widening of nostrils on inspiration)
Retractions of the ____ muscles of respiration

• Auscultation:
Wheezing - Course, whistling sound caused by narrowing of the ____ airway/bronchioles. Usually ____. {Ex: Asthma}

Stridor - ____ pitched breath sound from turbulent airflow in the ____ (upper airway). Usually ____. {Ex: Croup}

Answer 48

flaring
accessory

lower
expiratory

high
larynx
inspiratory

Question 49

Primary Survey

Circulation
• Understand the age appropriate heart rates.
• Most common reason for cardiac arrest: ____ (laryngospasm, etc.).
• Hypotension is a ____ finding correlating to a loss of 30% of blood volume.
• Monitor for poor ____ or confusion.
• Remember that pediatric blood pressure is
primarily maintained by ____

Age
Infant (birth-1)
Low: ____
High: ____

Toddler (1-3)
Low: ____
High: ____

Preschooler (3-6)
Low: ____
High: ____

School-age (6-12)
Low: ____
High: ____

Adolescent (12-18)
Low: ____
High: ____

Answer 49

respiratory arrest
late
perfusion
heart rate

100
160

90
150

80
140

70
120

60
100

Question 50

Primary Survey

Disability
• ____ is the most common scoring system used to describe the level of consciousness in a person following an injury.
• GCS is modified for children: ____ emphasis on verbal response.

Answer 50

glasgow coma scale

less

Question 51

Pediatric Emergency Scenarios

Basic Life Support
• When a patient experiences a respiratory arrest, cardiac arrest or obstructed airway, you need to act swiftly.
• Basic Life Support (BLS) refers to the care healthcare providers provide to patients who are experiencing respiratory arrest, cardiac arrest or airway obstruction. BLS includes ____ skills for performing high- quality cardiopulmonary resuscitation (CPR), using an automated external ____ (AED) and relieving an obstructed airway for patients of all ages.

Answer 51

psychomotor

defribillator

Question 52

Pediatric Emergency Scenarios
Basic Life Support
• Most child-related cardiac arrests occur as a result of a ____ event such as an exacerbation of asthma, an airway obstruction or a drowning. As such, ____ and appropriate ____ are important for a successful resuscitation.
• While it is rare in the professional setting to be alone with a child or infant, there is an important difference in the management of an adult vs. a pediatric patient.
• After determining that an adult is unresponsive and you are alone, you should immediately call for additional ____ and get an ____. With children, it is more important to provide 2 minutes of ____ before leaving them to ____ for help.

Answer 52

hypoxic
ventilations
oxygenation

resources
AED
CPR
call

Question 53

• ventilation to compression ratio. in adults, ____ compressions to ____breaths. regardless of the amount of rescuers.

with kids: ____ with one rescuer bc its hard to switch back and forth. ____ with two rescuers (one breaths, and on compressions)

Answer 53

30
2
30:2
15:2

Question 54

Pediatric Emergency Scenarios
Aspiration/Choking

• ____ aspiration is a major cause of acute airway obstruction in infants and children.
• Many of the foreign objects will lodge at the ____.

Answer 54

foreign body

cricoid ring

Question 55

with kids that can stand > go for ____. kneeling behind them bc they are smaller and making a fist with one hand into the abdomen midline
- keep doing until dislodge, or if pt is unresponsive > ____

Answer 55

abdominal thrusts

CPR

Question 56

Pediatric Emergency Scenarios
Respiratory Arrest
• Every dental professional should be able to provide supplemental oxygen to a breathing patient and should have the equipment and training to provide ____ if the patient is not spontaneously breathing.
• Due to the anatomic and physiologic factors previously discussed – oxygen should be given in all pediatric ____.

Answer 56

positive pressure ventilation

emergencies

Question 57

Pediatric Emergency Scenarios
Respiratory Arrest
• If your patient has an open airway, and has a pulse but is not breathing -> you need to ____ for the patient.
• The easiest way to do this is with ____ ventilation.
• You must have the proper size mask and deliver adequate tidal volumes.
• Rescue breaths are given ____ (1s), every ____ seconds for adults and every ____ seconds for pediatric patients.
• Watch for visible chest rise.

Answer 57

breath
bag-mask
slowly
5-6
3

Question 58

Pediatric Emergency Scenarios

Asthma
• Acute management is no different that of an adult patient. However, children often present differently than adults.
• Common childhood asthma signs and symptoms include:
-Frequent, intermittent ____
-A whistling or wheezing sound when exhaling
-____ of breath
-Chest congestion or tightness
-____ pain, particularly in younger children
-Vomiting
-Being unable to ____
-Abdominal breathing

Answer 58

coughing
shortness
chest
talk

Question 59

Pediatric Emergency Scenarios
Asthma Exacerbation
1. Follow the Child’s ____ Plan, if Possible
Find out if the child has an individualized asthma action plan. If so, follow directions for giving medications. Consider activating EMS.
2. Give ____ Medicine
If the child has no asthma action plan but has an inhaler:
Give one puff of ____ with a spacer. Ask child to take ____ breaths from spacer. Give ____ more puffs, with ____ breaths between each. Wait ____ minutes. If there’s no improvement, give another ____ puffs. If the child doesn’t have an inhaler, use one from a first aid kit.
3. ____ Up
An emergency room doctor will check the severity of the attack and provide additional treatment. The child may be discharged home or hospitalized for further care, depending on response to treatment.

Answer 59

asthma
quick-relief
albuterol
four
three
four
four
four
follow

Question 60

Pediatric Emergency Scenarios

Anaphylaxis
• Anaphylaxis is an acute, potentially life-threatening syndrome with multisystemic manifestations due to the rapid release of inflammatory mediators.
• In children, foods can be a significant trigger for ____ (IgE)-mediated anaphylaxis. ____, eggs, ____, and soy (MEWS) as a group are the most common food allergens; however, ____ and fish are among the most potent.
• Other common triggers include ____ (in food and drugs), medications (antibiotics), insect venom (bee sting), and ____ substances (blood products).

Answer 60

immunoglobulin E
milk
wheat
peanuts
preservatives
bioactive

Question 61

Pediatric Emergency Scenarios
Anaphylaxis
• The ____ use of epinephrine is the most important step in managing anaphylaxis.
• Administration in the anterolateral ____ appears to provide superior absorption compared with deltoid and subcutaneous injections.
• There are no ____ for the use of epinephrine in treating anaphylaxis. Since delay in administration may lead to more severe cases, one should administer epinephrine when patients present with the possibility any allergic symptoms, whether mild or moderate in severity.

Answer 61

early
thigh
contraindications

Question 62

Special Patient Populations
Patient Scenarios – URI
• ____ is a common illness, and children often present for procedures with a current or recent URI.
• Children with current or recent URIs are at increased risk for perioperative respiratory adverse events, mostly related to airway hyperreactivity, including laryngospasm, bronchospasm, oxygen desaturation, cough, and breath-holding.
• Though most of these events are mild and easily treated, more significant events can occur.

Answer 62

upper respiratory infection (URI)

Question 63

Special Patient Populations
Patient Scenarios – URI
• Management of these infections is controversial, but for patients with only mild rhinorrhea and mild symptoms at the time of a minor procedure, most do not ____ anesthesia.
• For patients who present with fever ≥____°C or a ____ cough, or who are obviously ill, most postpone elective procedures until ____ weeks after symptoms subside.

Answer 63

postpone
38
wet
four

Question 64

Special Patient Populations
Patient Scenarios – Down Syndrome
• Down syndrome, or trisomy 21, is a common chromosomal disorder occurring at a rate of 1.5 per 1,000 live births and is usually characterized by mild to moderate developmental delay, cardiovascular abnormalities, and craniofacial abnormalities.
• Craniofacial abnormalities that have an impact on the management of these patients include ____, micrognathia, and a short ____, putting these patients at increased risk for ____ obstruction.

Answer 64

macroglossia
micrognathia
airway

Question 65

Special Patient Populations
Patient Scenarios – Down Syndrome
• **Atlantoaxial instability occurs in approximately ____% of patients with ____ syndrome, and airway maneuvers, such as neck ____ for airway opening or intubation, may induce a serious ____ injury (____ subluxation).
• ____ occurs in approximately 40% of these patients (endocardial cushion defect, ventricular septal defect, tetralogy of Fallot, patent ductus arteriosus, and atrial septal defect).

Answer 65

20
down
positioning
cervical
C1-2

Question 66

Special Patient Populations
Patient Scenarios – Cerebral Palsy
• Cerebral palsy is a group of neurologic disorders that are characterized by impaired control of ____. The clinical manifestations are variable and are dependent on the site and extent of injury.
• Associated medical conditions include ____ delay (> ____% of patients with cerebral palsy do not demonstrate mental impairment), speech abnormalities, ____, drooling, dysphagia, and ____ reflux.

Answer 66

movement
developmental
50
seizures
gastroesophageal

Question 67

Special Patient Populations
Patient Scenarios – Cerebral Palsy
• Several factors must be taken into consideration in treating these patients.
• The spasticity and lack of coordination can contribute to a ____. Anxiety can aggravate the involuntary movements. Severe contractures may make positioning the patient difficult. Contractures, which may result in scoliosis, can result in a ____ disorder. The patient’s ____ may necessitate ____ of the head.

Answer 67

hyperactive gag reflex
restrictive lung
hypotonia
stabilization

Question 68

Special Patient Populations
Patient Scenarios – Muscular Dystrophy
• Muscular dystrophy is a group of diseases of genetic origin, characterized by the progressive loss of ____ muscle function.
• Muscle weakness contributes to poor ____ function. Muscle weakness also contributes to obtunded laryngeal reflexes and an inability to clear tracheo-bronchial ____. Patients are at increased risk for ____.

Answer 68

skeletal
respiratory
secretions
aspiration

Question 69

Special Patient Populations
Patient Scenarios – Muscular Dystrophy
• Patients with muscular dystrophy may also have ____ disorders.
• These include degenerative cardiomyopathy, cardiac arrhythmias, and mitral valve prolapse.
• It is frequently difficult to assess cardiovascular function in these patients
because they are usually ____.

Answer 69

cardiovascular

wheelchair-bound

Question 70

Special Patient Populations
Patient Scenarios – Muscular Dystrophy
• In an emergency scenario, ____ is contraindicated because it can cause rhabdomyolysis with a resultant ____.
• Although all patients may have a slight increase in extracellular ____ after the administration of succinylcholine, the increase in a patient with muscular dystrophy can cause ____ cardiac arrest.
• The avoidance of ____ and volatile ____ agents is also recommended because of the increased malignant ____.

Answer 70

succinylcholine
hyperkalemia
potassium
hyperkalemic
succinylcholine
inhalational
hyperthermia