Acute Care/PEM/Drug&Hazardous Flashcards
Name 4 risk factors for ICU admission and death in asthma.
- Previous life threatening events, admissions to PICU, intubation
- Hospitalizations or ED visits for asthma in the last year
- Deterioration while on, or recently after stopping systemic steroids
- Using >1 canister of salbutamol/month
- Lack of an asthma action plan or poor adherence to treatment
- Comorbidities (ex. food allergy, obesity)
- Low SES, psycosocial concerns
What factors are included in PRAM scoring?
Oxygen saturation (0-2 95/92-94/<92), suprasternal retraction (0 or 2: absent/present), scalene contraction (0 or 2: absent/present), AE (0-3, N/dec to base/dec at apex/minimal or absent), wheezing (0-3: absent/exp/insp/audible w/o steth or silent chest)
What is the FEV1 for mild/moderate/severe asthma exacerbation?
Mild: >70%
Moderate: 50-70%
Severe: <50%
Are chest x-rays indicated in asthma exacerbations?
Not typical ones. May be useful to exclude complications (PTX, PNA) or other pathology. In absence of suggestive clinical features, CXRs increase the risk of over diagnosis of PNA.
What are the 5 pillars of asthma exacerbation medical management?
Treatment of acute asthma includes:
- Treatment of hypoxemia
- Administration of bronchodilators: inhaled short-acting beta2-agonists ± ipratropium bromide
- Administration of corticosteroids
- Assessment of response
- Consideration of other treatments, including transfer to a tertiary facility
Which patients may have a better and more prolonged bronchodilator effect with asthma treatment?
In patients having a severe asthma attack, the continuous administration of nebulized beta2-agonists may have a better and more prolonged bronchodilator effect compared with intermittent therapy
What are the side effects of salbutamol?
Tachycardia, hyperglycemia, hypokalemia
-Increased lactate can be seen w/ increased salbutamol causing hyperventilation
When are corticosteroids indicated in an asthma exacerbation?
Children who have a modto severe asthma exacshould receive systemic steroids as part of initial treatment. This medication should be administered as early as feasible, ideally by mouth, and within the first hour of arrival. Steroids appear to reduce the need for hospitalization, risk for relapse after initial treatment and may also facilitate an earlier discharge from the hospital.
Which astham exac patients should receive IV magnesium sulphate?
IV magnesium sulphate should be considered for patients with incomplete response to conventional therapy during the first 1 to 2 h. Need CRM when given b/c causes hypotension and bradycardia.
When is heliox used for asthma exacerbation?
Using a helium-oxygen gas mixture is generally reserved for children in a PICU setting, with severe exacerbation, who have failed to improve despite maximal therapy.
When should a patient with asthma exacerbation be considered for PICU admission?
A patient in severe distress fails to improve after the initial 1 to 2 h of therapy (i.e., persisting PRAM of 8 to 12). Call a tertiary care paediatric ED and/or PICU specialist to discuss patient management and transport. Intermittent inhaled or continuous nebulized salbutamol and ipratropium (if not already given) and IV magnesium sulfate should be administered while awaiting transport.
Name 2 indications for ICS in children/youth with asthma exac.
- Presenting with symptoms or waking up due to asthma 2 times per month or more, or
- Presenting with moderate or severe exacerbations and have required oral steroids within the last 12 months
Name 2 indications for ICS in preschoolers with asthma exac.
- Persistent symptoms ≥8 days per month
- Moderate or severe exacerbations requiring PO steroids at presentation
When is LET contraindicated?
Patients <3 months old, on mucosal surfaces and in large, deep or contaminated wounds,
When providing analgesia for suture placement, you first apply LET. Unfortunately, your patient is still complaining of pain. What is your next step?
- Local infiltration with lidocaine or a nerve block
- Anxiolysis/sedation with IN midazolam, nitrous oxide
A child with a fracture has moderate to severe pain and needs to go to x-ray. They have already been given ibuprofen, what else can you give?
IN fentanyl 1mcg/kg to 2mcg/kg to maximum of 100mcg
Why is codeine no longer recommended for pain management?
- Prodrug that is metabolized to morphine and 3 main types of phenotypes including rapid metabolizers who have had adverse outcomes inc. death (also can be ineffective for some)
- Risk for toxicity/safety essentially
What is the recommendation for dosing adjustment when changing IV morphine to PO?
When changing IV morphine to oral, it is necessary to multiply the dose by three to compensate for its relatively low bioavailability.
What is the recommended opioid to be used?
Morphine (over tramadol, oxycodone, codeine, etc.)
What is required for procedural sedation to be performed?
- Immediate availability of a clinician with advanced airway skills and competent in resuscitation and stabilization of the critically ill paediatric patient.
- An additional health care provider (HCP) to assist the clinician administering sedation.
- Continuous physiologic monitoring with pulse oximetry and non-invasive blood pressure measurements. ECG and end-tidal capnography should be available when using intravenous (IV) sedation.
- Immediate availability of emergency equipment and rescue medications.
- Adequate post-sedation monitoring capabilities, including overnight admission if necessary.
What ASA classes are considered appropriate for procedural sedation?
ASA I and ASA II
Name 3 anatomic differences of the pediatric airway which may pose challenges for clinicians inexperienced in managing pediatric airways.
- Large occiput and tongue
- Floppy epiglottis
- Anterior and cephalad larnyx
- Narrow subglottic airway
A child requires procedural sedation. What factors should prompt an anesthesia consultation?
- ASA class III-V
- Symptoms of acute illness ex. URTI
- Active chronic conditions ex. asthma
- Infants less than 6 months of age
- Difficult airway, CV/resp disease
- Preterm infants (at risk of post anestheic apneas until 60 wks post conceptual age)
- Obese patients
- Hx of OSA or increased risk of airway obstruction post sedation
