Chapter 10 - Paediatrics Flashcards
Several anatomical features of children affect airway assessment and management - name them.
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
What is the correct formula to calculate the ETT depth (in cm) in pediatrics?
The appropriate ETT x 3
Example: size 4.0 x 3 = 12
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?
< 30 mmHg is considered safe
Describe a simple technique to gauge the ETT size needed for pediatric patients
Approximate the diameter of the child’s external nares OR
Use the diameter of the tip of the smallest finger
What are the dosages for the following drugs used in pediatric RSI / Drug Assisted Intubation
- Atropine
- Etomidate
- Midazolam
- Succinylcholine
- Rocuronium
- Vecuronium
- 0.1 - 0.5mg
- Hypovoleamia 0.1 mg.kg and 0.3mg.kg
- 0.1 mg.kg for both
- 2mg.kg <10kg and 1mg.kg >10kg
- 0.6mg.kg
- 0.1mg.kg
Can’t intubate can’t ventilate - what next?
Rescue airway device -
LMA
Intubating LMA
Surgical cricthyroidotomy (needle-jet insufflation)
List the common causes of deterioration in an intubated patient.
“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
In pediatrics, what is the normal
- Breathe rate?
- Tidal volume
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
In cases of tension pneumothorax, how would you perform a needle decompression?
14-18 gauge over the needle catheter is inserted just above the 3rd rib in the midclavicular line
In children, up to a 30% decrease in circulating blood is needed for a drop in SBP.
Which signs are early features of hypovoleamia?
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
What is the formula to calculate the
- 1 mean normal SBP
- Lower limit normal SBP
- Diastolic BP
- 90mmHg + twice child’s age in years
- 70mmHg + twice child’s age in years
- 2/3 SBP
Name the methods used to estimate a child’s weight
1 - ask the caregiver
2 - length based resuscitation tape
3 - weight formula - (2 x age in years) + 10
What are the values for the estimated blood volume for
- Infant 0-12 months
- Child 1-3 years
- Child older than 3 years
- 80ml.kg
- 75ml.kg
- 70ml.kg
If peripheral venous access is unsuccessful after 2 attempts - what would be the next step?
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)
What is the lethal triad in trauma?
Hypothermia
Acidosis
Trauma-induced coagulopathy
What is the initial fluid resuscitation strategy recommendations for injured children?
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
What is the massive transfusion protocol for injured children?
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
Indications for diagnostic peritoneal lavage (DPL)
NOTE - only the surgeon who will ultimate treat the child should perform a DPL
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
Discuss the pitfalls of DPL
Limited to diagnosing injuries of intra-abdominal viscera only
Retroperitoneal organs cannot be assessed
Procedure interferes with subsequent abdominal examinations and imaging
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?
5 and 11 years
