8. Pediatric Considerations Flashcards by J L

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.

adult

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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.

enters

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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.

growth and weight

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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.

congenital heart disease
reactive airway
gastroesophageal reflux
pulmonary

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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).

heat
fluid
occiput

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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.

airway

pediatric upper airway

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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.

narrow
work
choanal atresia
secretions

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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.

macroglossia
mandible
loose
lymphoid

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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

cephalad
C3 to C4
shorter
acute

cricoid ring
glottis
cone

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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.

children
move
horizontal
right
abdominal
diaphragmatic

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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.

expiration
lower
pulmonary oxygen

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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.

higher
decreased
rapid

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Children Aren’t Just Small Adults

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

differences

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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 ____.

heart rate
stroke volume

compliance
stroke volume
heart rate

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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.

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

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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.

turbulent

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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

crescendo-decrescendo
short
diastolic

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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.

increased
sedation
risks

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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.

minimal

deep

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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 ____

airway

deep

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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.

continuum

rescue

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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.

safety and welfare
anxiety
behavior
discharge

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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.

children
behavior
deep
vulnerable

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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 ____.

durations
observation
car safety seats
obstruction

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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.

appropriate III and IV special abnormalities

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.

accompanied | 2

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.

airway respirations seizures

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

intubated | chewing gum

Anesthetic Considerations SOAP-ME ``` S (____) O (____) A (____) P (____) M (____) E (____) ``` Look at the definitions!

``` suction oxygen airway pharmacy monitors equipment ```

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

papoose

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.

same | temperature

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 ____

normal criteria written

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.

50 moderate needle nasal hood

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.

control titration oversedation

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.

oversedated 1 parent

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).

mixed absorption chloral hydrate diazepam

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.

``` benzodiazepine GABA 0.5 20 single antagonist emergency ```

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.

``` cooperation control titration oversedation injection ```

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

midazolam | ketamine

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.

IM keatmine NMDA relief bronchodilation ``` 2-4 single 5 25 reversal ```

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.

``` intravenous titrate speed reverse intravenous ```

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

midazolam | propofol

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 ____.

``` short opate depression naloxone reticular respiratory reversal ```

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).

``` anesthesiologist IV inhalational paralytic IV volatile ```

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’

airway breathing circulation

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).

obstructed before foreign laryngospasm

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: ____

work rate depth ``` 30-60 24-40 22-34 18-30 12-16 ```

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}

flaring accessory lower expiratory high larynx inspiratory

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: ____

respiratory arrest late perfusion heart rate 100 160 90 150 80 140 70 120 60 100

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.

glasgow coma scale | less

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.

psychomotor | defribillator

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.

hypoxic ventilations oxygenation resources AED CPR call

- 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)

30 2 30:2 15:2

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 ____.

foreign body | cricoid ring

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 > ____

abdominal thrusts | CPR

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 ____.

positive pressure ventilation | emergencies

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.

``` breath bag-mask slowly 5-6 3 ```

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

coughing shortness chest talk

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.

``` asthma quick-relief albuterol four three four four four follow ```

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).

``` immunoglobulin E milk wheat peanuts preservatives bioactive ```

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.

early thigh contraindications

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.

upper respiratory infection (URI)

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.

postpone 38 wet four

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.

macroglossia micrognathia airway

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).

``` 20 down positioning cervical C1-2 ```

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.

``` movement developmental 50 seizures gastroesophageal ```

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.

hyperactive gag reflex restrictive lung hypotonia stabilization

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 ____.

skeletal respiratory secretions aspiration

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 ____.

cardiovascular | wheelchair-bound

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 ____.

``` succinylcholine hyperkalemia potassium hyperkalemic succinylcholine inhalational hyperthermia ```