Apex- Peds Flashcards
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
- age < 2
- onset 24-72hrs
- steeple sign
Generally speaking, what is usually bacterial vs viral:
epiglottitis (supraglottisis) or laryngotracheobronchitis (croup)
Epiglottis - bacterial (worse)
laryngotracheobronchitis - viral (usually)
Age affected of epiglottitis (supraglottis) vs laryngotracheobronchitis (croup)
epi = 2-6
laryngotracheobronchtiis (croup) < 2yo
onset of epiglottitis vs laryngotracheobronchitis
epi < 24hrs - rapid (bacterial)
laryngotracheobronchitis - gradual (24-72hr) (viral)
region affected in epiglottitis vs laryngotracheobronchitis
epiglottitis - supraglottic structures (above the cords- epiglottis, vallecula, aretenoids, aryepiglottic folds)
croup - laryngeal structures below the vocal cords
What is Thumb’s sign indicitative of?
what kind of xray?
swollen epiglottis (epiglottitis/supraglottitis)
lateral xray
What is Steeple sign indicitave of?
what kind of xray?
subglottic narrowing seen in laryngotracheobronchitis (croup)
frontal xray
T/F - tripod position helps breathing with croup
false - epiglottitis
maybe changes upper airway resistance? idk
think epiglottitis is 2-6yo - they are the ones who can prob assume this position anyway
Which one has a high grade vs low grade fever
epiglottitis vs croup
high grade - epi (bacterial, fast onset, worse)
low grade - croup (more gradual onset, younger)
What are the 4 D’s apart of ?
Epiglottis
Drooling
Dyspnea
Dysphonia
Dysphagia
clinical presentation of croup (5)
Low-grade fever
Inspiratory stidor
Vocal hoarseness
Barking cough
Rectractions - suprasternal, substernal, intercostal
LIVBR
Treatment for epiglottitis
vs treatment for croup
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
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
B. 0.5ml of a 2.25% solution
0-20kg = 0.25mLs
20-40kg = 0.5mL
>40kg = 0.75mL
Airleak should be less than what to decrease risk of postintubation laryngeal edema
<25cm H20
(tracheal perfusion pressure is 25cm h20, any pressure greater than this reduces tracheal perfusion > edema > reduced supglottic airway diameter > increased wob)
Most common risk factor for postintubation laryngeal edema
using too large of an ETT
maybe this is why matt always uses 7.5 for guys
Why do u want to be careful not to use too big of an ett?
post-intubation laryngeal edema
What 5 things can increase the risk for postintubation laryngeal edema?
-using ETT thats too big (most common)
-cuff pressure to ohigh
-trauma from multiple attempts
-prolonged intubation
-age <4 (more common in small kids)
someone has postintubation larygneal edema- now what?
cool and humidified o2
dexamethasone
and racemic epi (weight dependent)
s/s of post intubation croup
when does it typically occur?
hoarseness
barky cough
stridor
30-60 mins following extubation
T/F- trisomy 21 increase risk of post intubation croup
true
How many mLs of what % Racemic epi solution for:
0-20kg
20-40kg
> 40kg
what are you diluting it with and how much?
2.25% racemic epi
0-20kg: 0.25mL
20-40kg: 0.5mL
>40kg: 0.75mL
dilute with 2.5mL of NSS (each dose)
How much decadron would you give for post-intubation croup
how long does it take to achieve the max effect?
0.25-0.5mg/kg IV
4-6hrs
what is heliox?
how does it work?
when would you use it?
mixture of helium and o2
improves laminar airflow by reducing reynolds number
croup
t/f: antibiotics are indicated for post-intubation croup
false
unlike laryngotracheobronchitis (infecious coup); post intubation croup is not infectious
how long should patients be aboverved for after racemic epi tx is complete?
minimum of 4 hours
What age is postintubation laryngeal edema most often seen?
<4yo
How long do most clinicians postpone a procedure for kids with an active URI
why
2-4 weeks after onset of symptoms
active or recent hx increases risk of pulm complications
When would you cancel a snotty kid? (6)
- purulent nasal discharge
- temp > 38
- lethargy
- persistent cough
- poor appetite
- wheezing and rales that don’t clear with cough
if you have to use an ETT in a kid with a recent URI, how should you proceed?
use a smaller size than normal
t/f - pretreating a kid with a recent URI with inhaled bronchodilator or glyco does NOT provide a clear benefit
True
What is the best volatile agent for a kid with a recent URI?
SEVO
How long can the risk of pulmonary complications persist for after the onset of URI symptoms
6-8 weeks but clinicans will wait 2-4
T/F- a snotty kid that was a previous preemie is reason enough to cancel an elective case
true
or <1yo
Mechanical irritation (ETT use) increases the risk of bronchospasm by how much in snotty kids?
10 fold
snotty kids that are cleared for surgery- considerations
5
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
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. inhalational induction
*goals = prevening complete airway obstruction and preventing it from moving distally in the airway (which PPV would do)
Classic triad of foreign body aspiration
cough
wheezing
decreased breath sounds on affected side (usually right)
in kids with a foreign body aspiration, what would stridor vs wheezing indicate?
stridor = supraglottic obstruction
wheezing = subglottic obstruction
gold standard procedure to retrieve foreign body from the airway?
rigid bronchoscopy
Best maintenance technique for foreign body aspiration removal with rigid bronch
anesthesia
TIVA
“What can happen during rigid bronchoscopy that you need to be aware of” (4)
- laryngospasm
- bradycardia during scope insertion
- PTX
- post-intubation croup
What should you do after rigid bronch for foreign body removal if the patient doesnt immediately improve afterward?
observe- can be normal due to residual lung inflammation
Why is it best to maintain spontaneous ventilation throughout a rigid bronchoscopy?
bc it maintains laminar flow and reduces risk of foriegn body moving distally
can the anesthesia circuit be connected to the port on the rigid bronchoscope to deliver o2 and voliatle agents during the procedure?
yes…you can also deliver breaths if needed
-
Induction, maintenance main goals with rigid bronchosocopy for foreign body remvoal?
induction- sevo with spontaneous respirations
matinenance- avoid PPV, TIVA (gases leak out around the rigid bronch)
*no coughing or bucking - object can move distally
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?
by increases FGF and vaporizer output
(although TIVA is prob best)
What congenital condition is associated with macroglossia?
A. Glucose-6 dehydrogenase deficiency
B. Klippel-Feil
C. Treacher Collins
D. Trisomy 21
probelm?
D.
risk of upper airway obstruction
What congenital condition is associated with macroglossia?
A. Glucose-6 dehydrogenase deficiency
B. Klippel-Feil
C. Treacher Collins
D. Trisomy 21
probelm?
D.
risk of upper airway obstruction
Conditions with large tongues
mneumonic
Beckwith Syndrome
Trisomy 21
“Big Tongue”
Conditions with small/underdeveloped mandible
mneumonic
another name for small/underdeveloped mandible
Pierre Robin
Goldenhar
Treacher Collins
Cri du Chat
Please Get That Chin
MicroGnathia
What is micrognathia?
a small/underdeveloped chin
please get that chin
pierre, golden, treacher, cri du chat
C-Spine Anomaly conditions
mneumonic
Klippel Feil
Treacher Collins
Golden Har
kids try gold (to fix thier spines)
4 anesthetic considrations for cleft lip and palate
- airway obstruction
- difficult laryngoscopy
- difficult mask ventilation
- aspiration
risk with the dingman-dott mouth retractor
it can reduce venous drainage and cause tongue engorgement, increasing the risk of post-extubation airway obstruction
What condition
Pierre Robin
- small/underdeveloped mandible
- a tongue that falls back and downward (glossoptosis)
- cleft palate
- neonates often require intubation
Which condition is associated with a cleft palate
pierre robin
what is glossoptosis
what condition is it associated with
a tongue that falls back and downward
pierre robin
t/f- kids with klippel-fiel often require intubation as neonates
false - pierre robin
what condition is associated with choanal atresia and what is that?
treacher collins
nasal airway blocked by tissue
what condition is associated with a small mouth? (2)
treacher collins & downs
what condition?
4 things associated with it
Treacher collins
- small mouth
- small/under developed manidble
- (small) nasal passages - blocked by tissue (choanal atresia)
- ocular and auricular anomalies
which condition is associated with ocular and auricular anomalies
treacher collins
4 major things associated with trisomy 21
- small mouth
- large tongue
- atlantoaxial instability
- small subglottic diameter (subglottic stenosis)
What is klippel-fiel?
a congenital fusion of the cervical vertebrae > neck rigidity
2 big things with goldenhar
- small/underdeveloped mandible (Please Get That Chin)
- C-Spine abnormality (Kids Try Gold)
3 things associated with cri du chat
- Small/underdeveloped mandible (Please Get That Chin)
- Laryngomalcia
- Stridor
T/F- Cleft lip and palate are commonly asssociated with other genetic disorders
true
when is cleft lip repair done vs cleft palate ?
cleft lip - 1 month
cleft palate - 1 year
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. ASD
What % of infants with down syndrome have co-exisisting cardiac disease?
most common vs 2nd most common
50%
most common = atrioventricular septal defect (AV-SD)
2nd most common = ventricular septal defect (VSD)
T/F- Trisomy 21 is the most common chromosomal disorder
True
Why are pt’s with Down syndrome at increased risk for difficult ventilation AND intubation?
small mouth, big tongue
high, arched palate
midface hypoplasia (difficult seal)
A-O instability (difficult sniffing position)
subglottic stenosis (difficult intubation)
OSA (difficult BMV)
other than difficult ventilation and intubation risk, what 3 other concerns are you on the lookout for ? (Down’s syndrome)
- co-exisiting congenital heart disease
- low muscle tone and GERD (aspiration)
- intellectual disability
Our genetic makeup consists of how many pairs of chromosomes?
how is downs different?
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
T/F- older moms are more likely to give birth to a child with Down Syndrome
True
T/F- Down syndrome affects nearly every organ system
True
T/F- Downs kids hsould have a preop c-spine xray before anesthesia
True!
atlantoaxial instability - avoid neck flexion during laryngoscopy
why should you use a smaller ETT in downs kids??
subglottic stenosis- risk of postintubation croup
What is endocardial cushion defect and who might have it
AV septal defect - downs kids
Caution with downs kids and sevo induction
bradycardia is common - careflly stair step up sevo concentration to avoid profound bradycardia
*tx with anticholinergics
VACTERL association
Vertebral defects
Anus imperforated
Cardiac anomalies
TEF
Esophageal atresia
Renal dysplasia
Limb anomalies
CHARGE association
Colomba (hole in eye structure)
Heart defects
Atresia (ChoAnal)
Restriction of growth and development
Genitourinary problems
Ear anomilies
CATCH 22
AKA
Cardiac defects
Abnormal face
Thymic hypoplasia
Cleft palate
Hypocalcemia
22q11.2 gene deletion (cause of the syndrome)
DiGeorge Syndrome
What is DiGeorge Syndome caused by?
AKA?
deletion of gene 22q11.2
CATCH22
Cardiac defects
Abnormal face
Thymic hypoplasia
Cleft palate
Hypocalcemia
22q11.2 gene depletion
3 things to avoid in a kid with DiGeorge syndrome
hyperventilation, albumin and citrated blood products
all of these lower ionized calcium concentrations in blood
these kids already have hypocalcemia at baseline
3 key facts about DiGeorge Syndrome
- low calcium- avoid hyperventilation, albumin, and citrated blood
- high risk for infection if thymus is absent > tx w thymus trnasplant are mature T cell infusion
- need leukocyte-depleted irradiated blood
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
D. Von Willebrand Disease
Your doing tonsils and adenoids on a kids and you see DDAVP is ordered… what are your thoughts?
Risks with DDAVP
postop risks
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
2 indications for T&A’s
recurrent infections or nocturnal upper airway obstruction
What is the most common cause of OSA in kids
adenotonsillar hypertrophy
How much decadron to give to T&A patients and why?
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
How do you decrease the risk of airway fire with T&A?
low fio2 (<40%) and avoid nitrous (supports combustion)
kids with OSA undergoing adenotonsillectomy need to be admitted to the hospital for how long and why?
23 hours to be monitored for airway obstruction
key anesthetic risks with postop tonsil bleeding
hypovolemia and aspiration
*volume resusitation and RSI
*Surgical emergency
T/F- codeine is the drug of choice for postop pain in kids after T&A’s
false- risk of resp depression (FDA warning)
codeine = prodrug > body metabolizes it to morphine, kids are fast metabolizers
how can you assess for VWD in kids presenting for T&A?
easy/frequent bruising
nose bleeds
family history of bleeding disorders
How should you preoxygenate the bleeding tonsil patient?
left-lateral, head down position (helps drain blood from airway)
What should you do after securing the airway of a bleeding tonsil?
pas OGT to decompress the stomach
When do most post-tonsillectomy bleeds occur?
wtihin the first 6 hours of surgery (75%)
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. DiGeorge Syndrome
these kids have hypocalcemia at baseline and citrated blood products reduce calcium further (bind it) , low caclium > prolonged QT
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
B. Billiary atresia
Most common electrylyte abnormaility in the neonate:
A. Hypocalcemia
B. Hypoglycemia
C. Hypokalemia
D. Hyponatremia
B. hypoglycemia
