Apex- Peds Flashcards

1
Q

Compared to epiglottitis, which findings are MORE likely to occur with laryngotracheobronchitis? (select 3)

-age < 2yo usually affected
-high fver
-tripod position
-steeple sign
-onset 24- 72hrs
-more likely to require anesthesia for urgent airway control

A
  • age < 2
  • onset 24-72hrs
  • steeple sign
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2
Q

Generally speaking, what is usually bacterial vs viral:

epiglottitis (supraglottisis) or laryngotracheobronchitis (croup)

A

Epiglottis - bacterial (worse)
laryngotracheobronchitis - viral (usually)

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3
Q

Age affected of epiglottitis (supraglottis) vs laryngotracheobronchitis (croup)

A

epi = 2-6
laryngotracheobronchtiis (croup) < 2yo

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4
Q

onset of epiglottitis vs laryngotracheobronchitis

A

epi < 24hrs - rapid (bacterial)
laryngotracheobronchitis - gradual (24-72hr) (viral)

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5
Q

region affected in epiglottitis vs laryngotracheobronchitis

A

epiglottitis - supraglottic structures (above the cords- epiglottis, vallecula, aretenoids, aryepiglottic folds)

croup - laryngeal structures below the vocal cords

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6
Q

What is Thumb’s sign indicitative of?

what kind of xray?

A

swollen epiglottis (epiglottitis/supraglottitis)

lateral xray

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7
Q

What is Steeple sign indicitave of?

what kind of xray?

A

subglottic narrowing seen in laryngotracheobronchitis (croup)

frontal xray

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8
Q

T/F - tripod position helps breathing with croup

A

false - epiglottitis

maybe changes upper airway resistance? idk
think epiglottitis is 2-6yo - they are the ones who can prob assume this position anyway

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9
Q

Which one has a high grade vs low grade fever

epiglottitis vs croup

A

high grade - epi (bacterial, fast onset, worse)

low grade - croup (more gradual onset, younger)

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10
Q

What are the 4 D’s apart of ?

A

Epiglottis

Drooling
Dyspnea
Dysphonia
Dysphagia

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11
Q

clinical presentation of croup (5)

A

Low-grade fever
Inspiratory stidor
Vocal hoarseness
Barking cough
Rectractions - suprasternal, substernal, intercostal

LIVBR

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12
Q

Treatment for epiglottitis

vs treatment for croup

A

o2
urgent airway management
ENT surgeon must be present
-tracheal lintubation vs tracheostomy
-induction with spontaenous RR –> CPAP 10-15cm H20 prevents airway collapse
-abx and postop ICU care

humidified o2
racemic epi
corticosteroids
IVF
-intubation rarely required

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13
Q

When diluted into 2.5mL of 0.9% sodium chloride, what is the MOST appropriate dose of racemic epi to administer to a 30kg child with post-intubation croup?

A. 0.5mL of a 0.25% soluation
B. 0.5 mL of a 2.25% soluation
C. 5mL of a 0.25% soluation
D. 5mL of a 2.25% soluation

A

B. 0.5ml of a 2.25% solution

0-20kg = 0.25mLs
20-40kg = 0.5mL
>40kg = 0.75mL

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14
Q

Airleak should be less than what to decrease risk of postintubation laryngeal edema

A

<25cm H20

(tracheal perfusion pressure is 25cm h20, any pressure greater than this reduces tracheal perfusion > edema > reduced supglottic airway diameter > increased wob)

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15
Q

Most common risk factor for postintubation laryngeal edema

A

using too large of an ETT

maybe this is why matt always uses 7.5 for guys

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16
Q

Why do u want to be careful not to use too big of an ett?

A

post-intubation laryngeal edema

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17
Q

What 5 things can increase the risk for postintubation laryngeal edema?

A

-using ETT thats too big (most common)
-cuff pressure to ohigh
-trauma from multiple attempts
-prolonged intubation
-age <4 (more common in small kids)

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18
Q

someone has postintubation larygneal edema- now what?

A

cool and humidified o2
dexamethasone
and racemic epi (weight dependent)

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19
Q

s/s of post intubation croup

when does it typically occur?

A

hoarseness
barky cough
stridor

30-60 mins following extubation

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20
Q

T/F- trisomy 21 increase risk of post intubation croup

A

true

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21
Q

How many mLs of what % Racemic epi solution for:

0-20kg
20-40kg
> 40kg

what are you diluting it with and how much?

A

2.25% racemic epi

0-20kg: 0.25mL
20-40kg: 0.5mL
>40kg: 0.75mL

dilute with 2.5mL of NSS (each dose)

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22
Q

How much decadron would you give for post-intubation croup

how long does it take to achieve the max effect?

A

0.25-0.5mg/kg IV

4-6hrs

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23
Q

what is heliox?

how does it work?

when would you use it?

A

mixture of helium and o2

improves laminar airflow by reducing reynolds number

croup

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24
Q

t/f: antibiotics are indicated for post-intubation croup

A

false

unlike laryngotracheobronchitis (infecious coup); post intubation croup is not infectious

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25
Q

how long should patients be aboverved for after racemic epi tx is complete?

A

minimum of 4 hours

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26
Q

What age is postintubation laryngeal edema most often seen?

A

<4yo

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27
Q

How long do most clinicians postpone a procedure for kids with an active URI

why

A

2-4 weeks after onset of symptoms

active or recent hx increases risk of pulm complications

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28
Q

When would you cancel a snotty kid? (6)

A
  1. purulent nasal discharge
  2. temp > 38
  3. lethargy
  4. persistent cough
  5. poor appetite
  6. wheezing and rales that don’t clear with cough
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29
Q

if you have to use an ETT in a kid with a recent URI, how should you proceed?

A

use a smaller size than normal

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30
Q

t/f - pretreating a kid with a recent URI with inhaled bronchodilator or glyco does NOT provide a clear benefit

A

True

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31
Q

What is the best volatile agent for a kid with a recent URI?

A

SEVO

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32
Q

How long can the risk of pulmonary complications persist for after the onset of URI symptoms

A

6-8 weeks but clinicans will wait 2-4

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33
Q

T/F- a snotty kid that was a previous preemie is reason enough to cancel an elective case

A

true

or <1yo

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34
Q

Mechanical irritation (ETT use) increases the risk of bronchospasm by how much in snotty kids?

A

10 fold

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35
Q

snotty kids that are cleared for surgery- considerations

5

A

use least irritating airway
if ett is needed, downsize
decadron 0.25-0.5mg/kg to reduce risk of post-intubation croup
ensure deep lane of anesthesia before instrumenting airway
sevo

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36
Q

a 3yo kid aspirated a peanut and comes in for rigid bronchoscopy. What is the MOST important anesthetic consideration for this patient?

A. inhalational induction
B. observing NPO guidelines
C. Positive pressure ventilation
D. Rocuronium

A

A. inhalational induction

*goals = prevening complete airway obstruction and preventing it from moving distally in the airway (which PPV would do)

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37
Q

Classic triad of foreign body aspiration

A

cough
wheezing
decreased breath sounds on affected side (usually right)

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38
Q

in kids with a foreign body aspiration, what would stridor vs wheezing indicate?

A

stridor = supraglottic obstruction
wheezing = subglottic obstruction

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39
Q

gold standard procedure to retrieve foreign body from the airway?

A

rigid bronchoscopy

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40
Q

Best maintenance technique for foreign body aspiration removal with rigid bronch

anesthesia

A

TIVA

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41
Q

“What can happen during rigid bronchoscopy that you need to be aware of” (4)

A
  1. laryngospasm
  2. bradycardia during scope insertion
  3. PTX
  4. post-intubation croup
42
Q

What should you do after rigid bronch for foreign body removal if the patient doesnt immediately improve afterward?

A

observe- can be normal due to residual lung inflammation

43
Q

Why is it best to maintain spontaneous ventilation throughout a rigid bronchoscopy?

A

bc it maintains laminar flow and reduces risk of foriegn body moving distally

44
Q

can the anesthesia circuit be connected to the port on the rigid bronchoscope to deliver o2 and voliatle agents during the procedure?

A

yes…you can also deliver breaths if needed

-

45
Q

Induction, maintenance main goals with rigid bronchosocopy for foreign body remvoal?

A

induction- sevo with spontaneous respirations
matinenance- avoid PPV, TIVA (gases leak out around the rigid bronch)
*no coughing or bucking - object can move distally

46
Q

If using sevo during a rigid bronchoscope and it’s leaking out around the scope, it can dilute the concentration of volatile anesthetic, making it difficult to maintain a sufficent level of anesthesia.

How can you compensate for this leak?

A

by increases FGF and vaporizer output

(although TIVA is prob best)

47
Q

What congenital condition is associated with macroglossia?

A. Glucose-6 dehydrogenase deficiency
B. Klippel-Feil
C. Treacher Collins
D. Trisomy 21

probelm?

A

D.

risk of upper airway obstruction

47
Q

What congenital condition is associated with macroglossia?

A. Glucose-6 dehydrogenase deficiency
B. Klippel-Feil
C. Treacher Collins
D. Trisomy 21

probelm?

A

D.

risk of upper airway obstruction

48
Q

Conditions with large tongues

mneumonic

A

Beckwith Syndrome
Trisomy 21

“Big Tongue”

49
Q

Conditions with small/underdeveloped mandible

mneumonic

another name for small/underdeveloped mandible

A

Pierre Robin
Goldenhar
Treacher Collins
Cri du Chat

Please Get That Chin

MicroGnathia

50
Q

What is micrognathia?

A

a small/underdeveloped chin

please get that chin
pierre, golden, treacher, cri du chat

51
Q

C-Spine Anomaly conditions

mneumonic

A

Klippel Feil
Treacher Collins
Golden Har

kids try gold (to fix thier spines)

52
Q

4 anesthetic considrations for cleft lip and palate

A
  1. airway obstruction
  2. difficult laryngoscopy
  3. difficult mask ventilation
  4. aspiration
53
Q

risk with the dingman-dott mouth retractor

A

it can reduce venous drainage and cause tongue engorgement, increasing the risk of post-extubation airway obstruction

54
Q

What condition

4 main things associated with it
A

Pierre Robin

  1. small/underdeveloped mandible
  2. a tongue that falls back and downward (glossoptosis)
  3. cleft palate
  4. neonates often require intubation
55
Q

Which condition is associated with a cleft palate

A

pierre robin

56
Q

what is glossoptosis

what condition is it associated with

A

a tongue that falls back and downward

pierre robin

57
Q

t/f- kids with klippel-fiel often require intubation as neonates

A

false - pierre robin

58
Q

what condition is associated with choanal atresia and what is that?

A

treacher collins

nasal airway blocked by tissue

59
Q

what condition is associated with a small mouth? (2)

A

treacher collins & downs

60
Q

what condition?

4 things associated with it

A

Treacher collins

  1. small mouth
  2. small/under developed manidble
  3. (small) nasal passages - blocked by tissue (choanal atresia)
  4. ocular and auricular anomalies
61
Q

which condition is associated with ocular and auricular anomalies

A

treacher collins

62
Q

4 major things associated with trisomy 21

A
  1. small mouth
  2. large tongue
  3. atlantoaxial instability
  4. small subglottic diameter (subglottic stenosis)
63
Q

What is klippel-fiel?

A

a congenital fusion of the cervical vertebrae > neck rigidity

64
Q

2 big things with goldenhar

A
  1. small/underdeveloped mandible (Please Get That Chin)
  2. C-Spine abnormality (Kids Try Gold)
65
Q

3 things associated with cri du chat

A
  1. Small/underdeveloped mandible (Please Get That Chin)
  2. Laryngomalcia
  3. Stridor
66
Q

T/F- Cleft lip and palate are commonly asssociated with other genetic disorders

A

true

67
Q

when is cleft lip repair done vs cleft palate ?

A

cleft lip - 1 month
cleft palate - 1 year

68
Q

What is the MOST common cardaic anamaly associated with Down syndrome?

A. AV septal defect
B. 1st degree heart block
C. Bicuspid aortic valve
D. Single ventricle

A

A. ASD

69
Q

What % of infants with down syndrome have co-exisisting cardiac disease?

most common vs 2nd most common

A

50%

most common = atrioventricular septal defect (AV-SD)
2nd most common = ventricular septal defect (VSD)

70
Q

T/F- Trisomy 21 is the most common chromosomal disorder

A

True

71
Q

Why are pt’s with Down syndrome at increased risk for difficult ventilation AND intubation?

A

small mouth, big tongue
high, arched palate
midface hypoplasia (difficult seal)
A-O instability (difficult sniffing position)
subglottic stenosis (difficult intubation)
OSA (difficult BMV)

72
Q

other than difficult ventilation and intubation risk, what 3 other concerns are you on the lookout for ? (Down’s syndrome)

A
  1. co-exisiting congenital heart disease
  2. low muscle tone and GERD (aspiration)
  3. intellectual disability
73
Q

Our genetic makeup consists of how many pairs of chromosomes?

how is downs different?

A

23 pairs

additional 3rd copy of chromosome 21 (TRIsomy 21)

23 birthday
23 generations of bronchioles
23 pairs of chromosomes
2-3 months = dilutional anemia
2-3 months = highest mac
2-3cm of water mandatory minimum PEEP for standing bellows vent

2.2mm = smallest fiberoptic bronchoscope & can be used in ett as small as 3.0

74
Q

T/F- older moms are more likely to give birth to a child with Down Syndrome

A

True

75
Q

T/F- Down syndrome affects nearly every organ system

A

True

76
Q

T/F- Downs kids hsould have a preop c-spine xray before anesthesia

A

True!

atlantoaxial instability - avoid neck flexion during laryngoscopy

77
Q

why should you use a smaller ETT in downs kids??

A

subglottic stenosis- risk of postintubation croup

78
Q

What is endocardial cushion defect and who might have it

A

AV septal defect - downs kids

79
Q

Caution with downs kids and sevo induction

A

bradycardia is common - careflly stair step up sevo concentration to avoid profound bradycardia

*tx with anticholinergics

80
Q

VACTERL association

A

Vertebral defects
Anus imperforated
Cardiac anomalies
TEF
Esophageal atresia
Renal dysplasia
Limb anomalies

81
Q

CHARGE association

A

Colomba (hole in eye structure)
Heart defects
Atresia (ChoAnal)
Restriction of growth and development
Genitourinary problems
Ear anomilies

82
Q

CATCH 22

AKA

A

Cardiac defects
Abnormal face
Thymic hypoplasia
Cleft palate
Hypocalcemia
22q11.2 gene deletion (cause of the syndrome)

DiGeorge Syndrome

83
Q

What is DiGeorge Syndome caused by?

AKA?

A

deletion of gene 22q11.2

CATCH22

Cardiac defects
Abnormal face
Thymic hypoplasia
Cleft palate
Hypocalcemia
22q11.2 gene depletion

84
Q

3 things to avoid in a kid with DiGeorge syndrome

A

hyperventilation, albumin and citrated blood products

all of these lower ionized calcium concentrations in blood

these kids already have hypocalcemia at baseline

85
Q

3 key facts about DiGeorge Syndrome

A
  1. low calcium- avoid hyperventilation, albumin, and citrated blood
  2. high risk for infection if thymus is absent > tx w thymus trnasplant are mature T cell infusion
  3. need leukocyte-depleted irradiated blood
86
Q

What is the MOSt common coagulation disorder in children undergoing adenotonsillectomy?

A. Hemophilia A
B. Heparin-induced thrombocytopenia
C. Sickle cell disease
D. von Willebrand disease

A

D. Von Willebrand Disease

87
Q

Your doing tonsils and adenoids on a kids and you see DDAVP is ordered… what are your thoughts?

Risks with DDAVP

postop risks

A

kid probably has von willebrand disease (most common coag disorder in these patients )

risk of hyponatremia- decrease IVF maintenance to 1/2 calculated rate

postop bleeding, montior sodium

88
Q

2 indications for T&A’s

A

recurrent infections or nocturnal upper airway obstruction

89
Q

What is the most common cause of OSA in kids

A

adenotonsillar hypertrophy

90
Q

How much decadron to give to T&A patients and why?

A

1mg/kg up to 25mg

reduce postop airway swelling, pain, and PONV

analgesia via inhibition of periphearl phospholiapse > decreases pain reducing substances from COX and lipoxygenase pathways

91
Q

How do you decrease the risk of airway fire with T&A?

A

low fio2 (<40%) and avoid nitrous (supports combustion)

92
Q

kids with OSA undergoing adenotonsillectomy need to be admitted to the hospital for how long and why?

A

23 hours to be monitored for airway obstruction

93
Q

key anesthetic risks with postop tonsil bleeding

A

hypovolemia and aspiration
*volume resusitation and RSI

*Surgical emergency

94
Q

T/F- codeine is the drug of choice for postop pain in kids after T&A’s

A

false- risk of resp depression (FDA warning)

codeine = prodrug > body metabolizes it to morphine, kids are fast metabolizers

95
Q

how can you assess for VWD in kids presenting for T&A?

A

easy/frequent bruising
nose bleeds
family history of bleeding disorders

96
Q

How should you preoxygenate the bleeding tonsil patient?

A

left-lateral, head down position (helps drain blood from airway)

97
Q

What should you do after securing the airway of a bleeding tonsil?

A

pas OGT to decompress the stomach

98
Q

When do most post-tonsillectomy bleeds occur?

A

wtihin the first 6 hours of surgery (75%)

99
Q

A child with which condition is MOST likely to develop QT prolongation after blood products?

A. DigEorge Syndrome
B. CHARGE association
C. VACTERL association
D. Trisomy 21

A

A. DiGeorge Syndrome

these kids have hypocalcemia at baseline and citrated blood products reduce calcium further (bind it) , low caclium > prolonged QT

100
Q

What is the MOST common indication for liver transplantation in kids < 2yo:

A. Alpha-1 antitrypsin deficiency
B. Biliary atresia
C. Cystic fibrosis
D. Alagille syndrome

A

B. Billiary atresia

101
Q

Most common electrylyte abnormaility in the neonate:
A. Hypocalcemia
B. Hypoglycemia
C. Hypokalemia
D. Hyponatremia

A

B. hypoglycemia