Chapter 10 - Paediatrics

Question 1

Several anatomical features of children affect airway assessment and management - name them.

Answer 1

Tongue and tonsils relatively larger

Funnel shaped larynx - accumulation of secretion in retropharyngeal area

Larynx and vocal cords are more cephalad and anterior in the neck

Shorter trachea - 5cm in infants and 7cm by 18mo

Question 2

What is the correct formula to calculate the ETT depth (in cm) in pediatrics?

Answer 2

The appropriate ETT x 3

Example: size 4.0 x 3 = 12

Question 3

In infants an uncuffed ETT is used as the cricoid ring forms a natural seal.

In infants and a children a cuffed ETT may be used.

What is the ideal cuff pressure measurement?

Answer 3

< 30 mmHg is considered safe

Question 4

Describe a simple technique to gauge the ETT size needed for pediatric patients

Answer 4

Approximate the diameter of the child’s external nares OR

Use the diameter of the tip of the smallest finger

Question 5

What are the dosages for the following drugs used in pediatric RSI / Drug Assisted Intubation

1. 1. Atropine
2. 2. Etomidate
3. 3. Midazolam
4. 4. Succinylcholine
5. 5. Rocuronium
6. 6. Vecuronium

Answer 5

1. 1. 0.1 - 0.5mg
2. 2. Hypovoleamia 0.1 mg.kg and 0.3mg.kg
3. 3. 0.1 mg.kg for both
4. 4. 2mg.kg <10kg and 1mg.kg >10kg
5. 5. 0.6mg.kg
6. 6. 0.1mg.kg

Question 6

Can’t intubate can’t ventilate - what next?

Answer 6

Rescue airway device -

LMA
Intubating LMA
Surgical cricthyroidotomy (needle-jet insufflation)

Question 7

List the common causes of deterioration in an intubated patient.

Answer 7

“Don’t be DOPE”

D- Dislodgement due to short trachea

O- Obstruction - if secretions then suction, if tube kinks then replace ETT

P- Pneumothorax - can develop Tension pneumothorax related to positive pressure ventilation - decompress

E- Equipment failure - ensure that your equipment is well maintained and properly functioning - have backup equipment

Question 8

In pediatrics, what is the normal

1. 1. Breathe rate?
2. 2. Tidal volume

Answer 8

1.1.
Infants - 30-40

Older children - 15-20

1.2.

Infants and children 4-6 ml.kg
Occasionally higher tidal volumes of 6-8 ml.kg (as high as 10) during assisted ventilation

Question 9

In cases of tension pneumothorax, how would you perform a needle decompression?

Answer 9

14-18 gauge over the needle catheter is inserted just above the 3rd rib in the midclavicular line

Question 10

In children, up to a 30% decrease in circulating blood is needed for a drop in SBP.

Which signs are early features of hypovoleamia?

Answer 10

Tachycardia
Poor skin perfusion

Weakening of peripheral pulses
Narowing of pulse pressures to < 20mmHg
Skin mottling (which substitutes for clammy skin in infants and young children) 
Cool extremities
Decreased LOC
Dulled response to pain

Question 11

What is the formula to calculate the

1. 1 mean normal SBP
2. 2. Lower limit normal SBP
3. 3. Diastolic BP

Answer 11

1. 1. 90mmHg + twice child’s age in years
2. 2. 70mmHg + twice child’s age in years
3. 3. 2/3 SBP

Question 12

Name the methods used to estimate a child’s weight

Answer 12

1 - ask the caregiver

2 - length based resuscitation tape

3 - weight formula - (2 x age in years) + 10

Question 13

What are the values for the estimated blood volume for

1. 1. Infant 0-12 months
2. 2. Child 1-3 years
3. 3. Child older than 3 years

Answer 13

1. 1. 80ml.kg
2. 2. 75ml.kg
3. 3. 70ml.kg

Question 14

If peripheral venous access is unsuccessful after 2 attempts - what would be the next step?

Answer 14

Intraosseous infusion via bone-marrow needle

18G in infants
15G in young children OR

Insertion of femoral venous line of appropriate size using Seldinger technique

If this fails THEN

Venous cut down (last resort)

Question 15

What is the lethal triad in trauma?

Answer 15

Hypothermia
Acidosis
Trauma-induced coagulopathy

Question 16

What is the initial fluid resuscitation strategy recommendations for injured children?

Answer 16

Initial fluid bolus of 20ml.kg with crystalloid solution followed by 1-2 further bolus depending on the child’s physiological response

If evidence of ongoing bleeding after 2-3rd bolus THEN

10ml.kg of packed red blood cells may be given

Question 17

What is the massive transfusion protocol for injured children?

Answer 17

Intial 10-20ml.kg bolus with isotonic crystalloid fluids FOLLOWED BY

10-20ml.kg packed red blood cells PLUS

10-20ml.kg FFPs and platelets

Question 18

Indications for diagnostic peritoneal lavage (DPL)

NOTE - only the surgeon who will ultimate treat the child should perform a DPL

Answer 18

Children with suspected intra-abdominal bleeding

Haemodynamic abnormalities AND
Cannot safely be transported to CT scan
CT scan and FAST not readily available AND
Presence of blood will lead to immediate operative intervention

Question 19

Discuss the pitfalls of DPL

Answer 19

Limited to diagnosing injuries of intra-abdominal viscera only
Retroperitoneal organs cannot be assessed
Procedure interferes with subsequent abdominal examinations and imaging

Question 20

Basilar odontoid synchondrosis (where the odontoid process meets C2 VB) appears as a radiolucent area at the base of the dense on X-ray in children less than 5 years.

Apical odontoid epiphysis appear as separations on the odontoid X-ray - between which ages?

Answer 20

5 and 11 years