Caring for Kids vs. Adults Flashcards
1
Q
Why do children deterioate rapidly
A
they have less of a phsyiological reserve
This is why early recongnition of a child in distress is essential
2
Q
Anatomical differences in children vs adults
A
These differences are most pronounced in infancy
- In summary, infants and toddlers (younger than 2 years) have higher anterior airways. Children older than 8 years have airways similar to adults. The age range of 2 to 8 years old marks a transition period, when the above-mentioned anatomical differences may have varying effects on airway management.
3
Q
What kind of breathing do infants do
A
Infants are considered to be obligated nose breather, meaning that they prefer to breath through their nose
4
Q
Anatomy of the Tongue in Children
A
- In children the tongue is large compared to the oral cavity especially in infancy making the tongue a natural airway obstructer
- An oral airway should be a first line of defense when beginning bag-mask ventilation on an unconscious child to avoid tissue airway obstruction.
5
Q
Tonsils and Adenoids in Children
A
- Children also have large tonsils and adenoids and large amounts of lymphoid tissue
- All of these are potential areas for swelling and can result in upper airway obstruction
- These can also be sources for bleeding during trauma or intubation, which will obstruct views and risk aspiration
6
Q
Epiglottitis of a Child
A
- Larger
- Less flexible
- Omega or U shaped
- Lies more horizontally compared to adults
- More susceptible to trauma
Can make visulization more difficult during intubation
7
Q
angle between the epiglottis and laryngeal opening in children
A
- The angle between the epiglottis and laryngeal opening is more acute in infants than in an adult, which makes blind nasal intubation difficult.
- Can make direct visualization difficult during intubation and blind nasal intubation
8
Q
The Glottis in Infancy
A
- In infancy, the glottis begins at the first cervical vertebrae (C1)
- As the thorax and trachea grow, the glottis moves to C3 to C4 by age 7 and is located at C5 to C6 in adulthood.
- This makes the glottis in children higher and more anterior than in adults.
- This will make visulization more difficult with intubation
9
Q
Cricoid Cartilage in Children
A
- The cricoid ring is the smallest portion of a child’s airway, whereas in adults the vocal cords are the smallest portion of the airway.
- An uncuffed endotracheal tube (ETT) provides an adequate seal in a small child because it fits snugly at the level of the cricoid ring.
- When using an uncuffed ETT, correct tube size is imperative because air can leak around an ETT that is too small, and tracheal damage can result from an ETT that is too large.
- Children have small cricothyroid membranes, and, in children younger than 3 years, it is virtually nonexistent. This means emergency surgical airway techniques such as needle cricothyrotomy and surgical cricothyrotomy are extremely difficult, if not impossible, in infants and small children.
10
Q
Trachea in a child
A
- Smaller and shorter making extubation easier
- More malleable meaning it is more susceptible to change in shape when under pressure making it easier to collapse
- Smaller diameter which will increase resistacne as well as easier to obstruct
- Increased inspiratory pressure during respiratory distress causes increased negative intrathoracic pressure and can lead to collapse of the extrathoracic trachea.
11
Q
Sniffing Position for Children
A
- With both adults and children, an effective way of opening the airway is to place the patient in the sniffing position, in which the patient’s head and chin are thrust slightly forward to keep the airway open.
- However, the occiput (back part of the skull) is larger in children and may cause flexion of the neck and inadvertent obstruction of the airway. To align the airway in an adult, a roll can be placed under the head. In children this is not needed, and infants may need a shoulder roll to achieve sniffing position.
12
Q
Cricothyroid Membrane in Children
A
Smaller, virtually non-existant in children, younger than 3 years old
Needle cricothyroid and surgical cricothyroid are difficult in infants and small children
13
Q
Thoracic Cage in Children
A
- An infant’s ribs and sternum are mostly cartilage, and the ribs lay more horizontally than do those of an adult. The thoracic cage thus offers little stability, and the chest wall will collapse with negative pressures.
- This makes retractions more pronounced in infants and most obvious in preterm infants. The cartilaginous ribs do, however, mean that closed-chest compressions from cardiopulmonary resuscitation do not usually cause rib fractures in children
- Ribs and sternum are mostly cartilage (infants)
Ribs lay more horizontal
* The thoracic cage offer little stability; the chest wall will collapse with negative pressure; retractions are more pronounced in infants
14
Q
Belly Breathers in Children
A
- Breathing for infants is mostly diaphragmatic, making them abdominal or “belly breathers.”
- Instability of the thoracic cage makes it difficult to increase minute ventilation by increasing thoracic volume. Infants must drop the diaphragm more to increase tidal volume, which increases WOB.
- To avoid increased WOB, infants usually increase respiratory rate to increase minute ventilation.
15
Q
Diaphragm in children
A
Main action for breathing in infants
Infants known as belly breather increase WOB when increasing tidal volume
16
Q
Mainstem Bronchus in Children
A
Right mainstem angle lower
Right mainstem intubation and right foreign body obstruction are more frequent
17
Q
Conducting Airway in Children
A
- At birth, the number of conducting airways is completely developed. However, airway diameter increases with lung growth.
- This explains the phenomenon of children “outgrowing” reactive airways disease. It is less likely that the swelling and smooth muscles are no longer reactive; rather, the degree of airway obstruction is less pronounced as a result of the increased airway diameter.
18
Q
Alveoli in Children
A
Fewer at birth increase in number during childhood
No pores of Kohn (infants)
Infants decompensate more rapidly during airway obstruction
More respiratory distress during alveolar disease
19
Q
Reasons for decreased FRC in Children
A
Larger heart in relation to thoracic cavity
Less elastic recoil
Abdomincal contents are larger and push up against diapgragm
Higher compliance
20
Q
basal oxygen consumption of children
A
- Furthermore, the basal oxygen consumption of children is twice that of adults: 6 mL O2/kg for children versus 3 mL O2/kg for adults.
- The clinical implication of lower pulmonary reserve and increased oxygen consumption is that children will desaturate more rapidly than will adults.
- Recommendations for airway management suggest that clinicians should be prepared to provide bag-mask ventilation with 1.0 FIO2 if a child’s oxygen saturation falls below 90%
21
Q
MAP in children
A
- Once blood pressure is obtained, the calculation to determine mean arterial blood pressure (MAP) is:
MAP = 1/3 systolic pressure + 2/3 diastolic pressure
- MAP is often used in the pediatric setting to evaluate blood pressure stability and effectiveness of cardiac inotropic and sympathomimetic therapies.
22
Q
Crying in Infants
A
- Crying can also increase WOB in an infant up to 32-fold (5), so it is imperative to try to keep young children in respiratory distress as calm as possible. Keeping them in a quiet, comfortable environment with familiar people will help alleviate anxiety and minimize additional respiratory distress.
23
Q
Breath Sounds in Infants
A
- Breath sounds may be more difficult to distinguish in very young children, and vocal noise transmissions are more common as a result of whining and crying during auscultation.
24
Q
Contraindication to ABG in Children
A
- These include a modified Allen’s test result indicating lack of collateral circulation (another extremity should be chosen) or a lesion or surgical shunt proximal to the patient on the same limb.
- If there is evidence of infection or peripheral vascular disease involving the selected limb, an alternate site should be selected.
- A coagulopathy or high-dose anticoagulation therapy such as heparin or Coumadin may be a relative contraindication for arterial puncture.
25
Q
ABG in Children
Heparin Dilution
A
- Because of the smaller sample size, neonatal and pediatric samples are more susceptible to liquid heparin dilution errors.
- Heparin has a lower pH than blood, so heparin will lower pH without affecting PaCO2. This will make the ABG results trend toward a metabolic acidosis.
- This is most common in umbilical line sampling in neonates if all heparin is not removed from the line prior to collecting the ABG sample.
- Comparing the current values of pH and calculated bicarbonate with previous ABG results should help reveal this error should it occur
26
Q
ABG in Children
Air in Sample
A
- An air bubble consists of room air, which has a PO2of158 mmHg and a PCO2 of approximately 0 mm Hg.
- PaCO2 in the blood will decrease as CO2 travels into the air bubble in an equilibrating manner because gases travel from areas of high pressure to areas of low pressure until they are equal.
- Room air will change the PaO2 in the arterial sample in an attempt to equilibrate but will raise it or lower it based on the blood sample’s starting PaO2.
- If the sample PaO2 is greater than 158 mm Hg, then oxygen will travel from the blood into the air sample and lower the PaO2 of the blood sample.
- If the sample PaO2 is less than 158 mm Hg, then addi- tional oxygen molecules will travel into the blood sample and increase measured PaO2.
- To avoid this, all air bubbles should be tapped to the end of the syringe and pushed out of the sample immediately after the sample is drawn.
27
Q
ABG in Children
Venous Admixture
A
- This is an error that will occur with puncture sampling, not with arterial line sampling.
- Peripheral venous blood has different PvO2, PvCO2, and pH values based on local metabolism, perfusion, and tissue and organ function.
- So there is no direct correlation between any venous sample and an arterial one.
- In general, however, lower PO2 and higher PCO2 values should be expected.
- A mixed venous blood sample taken from the right atrium or ventricle of the heart can be correlated with an ABG and then subsequent samples used to trend changes in acid-base status.
- Normal mixed venous blood gas values are pH = 7.38, PvCO2 = 48 mm Hg, and PvO2 = 40 mm Hg.
28
Q
ABG in Children
Temperature
A
- Patient hypothermia or hyperthermia will cause the measured blood gas results to be less accurate.
- This is because the electrodes in a blood gas analyzer are heated to normal body temperature.
- In general, every 2°C decrease in body temperature will cause a drop in PaCO2, causing a subsequent increase in pH of 0.03.
- Decrease in temperature will also cause a decrease in measured PaO2. The reverse is true for increases in body temperature.
29
Q
ABG in Children
Metabolism
A
- Blood continues to metabolize when it is outside of the body.
- If a sample is left at room temperature, pH will decrease, CO2 will increase, and PaO2 will decrease.
- Icing samples have been used historically but are not effective when samples are stored in plastic syringes; therefore, the current recommendation is to run a sample immediately after it is obtained
30
Q
Transcutaneous Monitoring
A
-
Transcutaneous monitoring electrochemically measures skin-surface PO2 and PCO2 by heating localized areas of the skin to induce hyper-perfusion.
- This provides a non-invasive estimate of arterial oxygen and carbon dioxide.
- To validate transcutaneous measurements, an arterial blood sample should be drawn and compared with transcutaneous readings taken at the same time.
- Validation should occur at initiation of monitoring and at regular intervals.
- Though transcutaneous monitoring is non-invasive, it is not without complications.
- In patients with poor skin integrity (e.g., extremely premature infants), tissue injury such as erythema, blisters, burns, and skin tears may occur at the measuring site
- Patients with adhesive allergies can also be at risk for complications from the electrodes.
31
Q
Capillary Blood Gas Sampling
A
- Arterialized capillary blood can provide a rough estimate of arterial blood values.
- The physiological principle is that there is little time for oxygen and carbon dioxide exchange in blood flowing through a dilated capillary bed, so the sample drawn has approximately the same acid-base balance as that in the arteries.
32
Q
False reading from a capillary blood sample can be the result of
A
- Inadequate warming of the site
- Clots within the sample tubing
- Excessive squeezing or “milking,” which causes contamination with venous blood and interstitial fluid
- Exposure of blood to air during sampling
33
Q
Why use a Miller Blade
A
- Because of the higher and more anterior glottic opening, floppy epiglottis, and large tongue in children younger than 3 years old, a straight (Miller) laryngoscope blade is recommended for these patients. It elevates the distensible airway and provides direct control of the epiglottis.
34
Q
Miller Blade Chosen By Wieght
A
- Size 0 Miller (straight): less than 3 kg
- Size 1 Miller: 6 to 11 kg
- Size 2 Miller: 12 to 31 kg
- Size 2 Macintosh (curved): 19 to 31 kg
- Size 3 Miller or Macintosh: greater than 31 kg
35
Q
for selecting ETT sizes for pediatric patients
A
- In neonates, ETTs are selected by either gestational age (when intubating at birth) or weight (once weight is known).
- Cuffless ETTs are preferred in infants.
- In children older than 1 year, selection of an ETT size should be based on the following calculation:
ETT size (mm) = (16 + age in years)/4
36
Q
determining depth placement of an ETT in child
A
- For any age child, depth can be calculated by multiplying the internal diameter of the ETT by 3. This gives the provider the desired depth of the ETT, measured at the lip.
- For infants, depth can be calculated by adding 6 to the weight in kilograms. This gives the provider the desired depth of the ETT, measured at the lip.
- During intubation, the provider passes the ETT through the vocal cords until one of the vocal cord markers is visualized at the level of the cords. The provider reads the number at the lip after intubation to document the correct depth.
