Chapter 5 Circulation Flashcards
How does acidosis affect myocardial contractility and the affect of catecholamines?
Decreases myocardial contractility
Decreased effective of catecholamines
What are the 5 categories of shock?
Hypovolaemic
Distributive
Cardigenic
Obstructive
Dissociative
What are some features of toxic shock syndrome?
Generalised erythema
Conjunctivitis
Mucositis
What urine output is the target in children?
1ml/kg/hr
You have given multiple fluid boluses, you are considering a furthe fluid bolus and are thinking about using albumin, is there much evidence for this?
Not very good evidence but still worth considering if you’ve already given 20ml/kg of crystaloid
What patients might you consider more judicious fluid boluses (5-10ml/kg)
cardiogenic shock
Raised ICP
After how much fluid should you consider starting inotropes?
20ml/kg
After how many fluid boluses in the setting of shock would you consider intubation to reduce energy demand of the child?
40ml/kg
What antibiotic do you give for septicaemia without clear cause?
Age < 2 months
Ampicillin (aged dependent if < 1 month) (if < 1 month 50mg/kg IV ever 6 hours max 2g
PLUS
Gentamycin (if < 1 month age dependent dosing) (>1 month 7.5mg/kg IV once daily max 320mg)
Age > 2 months
Ceftriaxone 100mg/kg IV once daily max 4 g daily
or cefotaxime 50mg/kg IV 6 hourly max 2g /dose
In shock from haemorrhage, after what volume of crystaloid resuscitation should you consider activation of massive transfusion protocol?
5-10ml/kg of crystaloids if there is no response to this
What joules do you use for cardioversion for shock secondary to a tacycarrhythmia?
1st shock: 1J/kg
2nd shock: 2J/kg
3rd shock 2J/kg
Is adenosine acceptable to use in a shocked child from SVT?
Yes, if you can give it as quickly as you can delivery and shock + provide sedation for the shock (often it is quicker to use adenosine)
What is the dose of adrenaline for shock secondary to anaphylaxis?
10microg/kg IM
True or false, hypoglycaemia can mimick compensated shock?
true
What are the main causes of heart failure in an older child?
Myocarditis
Cardiomyopathy
What are the causes of shock in trauma?
Haemorrage (no. 1)
Tension pneumothorax
Haemothorax
Tamponade
Spinal cord transection
In gastroenteritis with shock, what fluid bolus should you give and how many does it usually take to restore adequate circulatory volume
20ml/kg
Repeat if needed
Two boluses is usually enough
When should you start NG feeds in gastroenteritis with shock?
Immediately , can start concurrently with IV fluid boluses. Speeds up recovery.
Aim to restart normal normal feeding with feeding within 4-6 hours
In severe gastroenteritis, a child may convulse due to hyponatraemia. How much and how fast can you given Na+ replacement?
3% 3ml/kg over 15-30 minutes
Until Na 125mmol/L OR when seizure terminates
In asymptomatic hyponatramia, what is the maximum rate of correction per day you want to achieve?
Increase Na+ no more than 8 -12 mmol/L/day
In young children with diarrhoea and vomiting, what are the other gut pathologies other than gastroenteritis that can present this way?
Volvulus
Intersusspection
Appendicitis
Get an XRAY or USS to investigate these
Can sepsis and toxic shock syndrome mimick an acute abdomen?
Yes, give antibiotics early
After how many fluid boluses should you definitely consider inotropes and or intubation if not already done?
3rd 20ml/kg fluid bolus
Definitely inotropes, strongly consider intubation to reduce oxygen demand and prevent pulmonary oedema
What is it important to place a urinary catheter in shocked patients?
To monitor fluid status/renal perfusion
What organism is responsible for the majority of infant and child septicaemia
Neisseria meningitidis
What organisms frequently infect very young children/infants?
Group A and streptococcal
Gram negative rods from urosepsis
This is why amoxycilin and gentamycin is used in sepsis of young childre
A maculopapular rash may prodcede a purpuric one in meningococcal septicaemia. True or false?
True
How may toxic shock syndrome appear in a child?
High ever
Diffuse erythema or scarlantiform rash
Subcutaneous oedema
Desquamation
Mucosal hyperaemia (strawberry tongue)
Vomiting
Watery diarrhoea
+ possible source of infection: wound, pneuomonia, osteomyelitsi
In a 24 hourp period, how many ml/kg may be needed to treat septic shock?
200ml/kg i.e 2.5 x the blood volume
What antibiotic covers listeria in what age group should you add this on when covering for sepsis
Penicillins - benzylpenicillin or amoxycilin
Age < 3 months
Do the third generation cephalosporins (ceftriaxone/cefotaxime) have good staphylococcal cover?
No, add on specific staphyloccal covered if worried about toxic shock
When should you use cefotaxime over ceftiaxone?
Premature or jaundiced infants
In hypoalbuminaemia
If calcium infusion is needed
What antibiotic do you use to cover hospital aquired sepsis or neutropaenic sepsis?
Piptaz
What antibiotic covered extended spectrum beta lactamase producers?
Meropenem
If a vascular access device has been used for more than 48 hours, what antibiotic should you add on?
Vancomycin
Before you give hydrocortisone for refractory shock or suspected adrenal insufficency, what blood test should you order
Cortisol
What is the dose of dopamine for shock in children?
10 microg/kg/min
If a child has signs of hypodynamic shock with high systemic vascuar resistance (cold extermities) what inotrope would you use first
1) Adrenaline or dopamine OR
2) Noradrenaline
1) Adrenaline or dopamine
In a child with hyperdynamic shock with low systemic vascular resistance (warm peripheries) what inotrope might you consider first?
Noradrenaline if all you need is vasoconstriction.
Caution - watch for reflex bradycardia
What is the dose of adrenaline in shock?
0.05 to 2 microg/kg/min
In a septic shock, what PCR tests should you order for specific organisms?
PCR meningo/streptococcal
What takes precedence: treatment of shock or treatment or raised ICP?
Treat shock as a priority even at the compromised of further increasing the ICP
What is the dose of hydrocortisone for children for the following age groups?
1) < 6 months
2) 6 months to 6 years
3) 6 - 12 years
4) > 12 years
1) 25mg
2) 50mg
3) 100mg
4) 200mg
What is the bolus dose of IV adrenaline for anaphylaxis?
1 microg/kg IV
Dilute to 10ml to allow push over 1 min
What features suggest a cardiac cause of circulatory inadequacy?
Cyanosis not correcting with O2
Tachycardia out of proportion to respiratory difficulty
Raised JVP
Gallop heart rhythm
Enlarged hear on CXR
Enlarged liver
Absent femoral pulses
What are some duct-dependent pulmonary circulation diseases of the newborn and what is key feature that makes them stand out from duct dependent systemic circulatory disease?
Pulmonary atresia
Critical pulmonary stenosis
Tricuspid atresia
Tetralogy of fallot
Hypoxia, central cyanosis without much respiratory distress and doesn’t improve with O2
Name a few duct-dependent circulatory disease of the newborn and describe how they look different to duct-dependent pulmonary disease of the new born?
Coartication of the aorta
Critical aortic stenosis
Hypoplastic left heart syndrome
Interrupted aortic arch
Ash grey with severe metabolic acidosis and organ dysfunction
Poor urine output, decreased GCS
Pulses very difficult to feel, may feel difference between brachial and femoral pulses
Is transposition of the great vessels a pulmonary or systemic duct-dependent disease or something else?
It’s both!
What medication is use to reopen a closing ductus arteriosis?
Alprostadil (Prostaglandin E1)
What is the dose of alprostadil to reopen a closing ductus arteriosis?
10 (if not too sick) to 20 nanogram/kg/min (sick)
If no response in 1st hour increase to 50 nanogram/kg/min
In a child with suspected left sided obstruction being treated with alprostadil, what is your end goal?
palpable pulses and normal pH & lactate
For suspected right sided heart disease being treated with alprostadil, what is your end goal?
SpO2 75 - 85% and normal lactate
What side effect can you expect when using alprostadil?
Apnoeas - may need ventilatory support
Vasodilation - may need fluid bolus
Where should your sats probe be when suspecting duct-dependent shock?
Pre and post ductal blood should be monitored (left and right side)
In heart failure, what is the dose of frusemide?
0.5 to 1mg/kg IV
What colour will the urine be if anaemia is due to acute haemolysis?
brown
What are the most common causes of acute anaemia in children?
Sick cell disease
Haemolytic uraemic syndrome
Malaria
When giving a blood transfusion for severe anaemia, what drug might you have to use at the same time if the child is already showing signs of heart failure?
Frusemide 0.5 to 1mg/kg IV
What is the standard therapy for the various forms of sickle crisis?
O2 therapy
Rehydration
Antibiotics
Analgesia
In ml/kg what is the circulatory volume of a child?
80ml/kg
O- blood can be made available straight up and a full cross match takes about 60 minutes. What is the in-between option?
ABO resus matched blood. Only takes 15 minutes but better than O negative
What are the causes of bardycardia in children
Pre-terminal event in hypoxia or shock
Raised ICP
Conduction pathway damange post cardiac surgery
Congenital heart block
Long QT syndrome
What are the causes of tachyarrhythmias in children?
Re-entrant congenital pathway abnormalities (common)
Poisoning
Metabolic disturbance
After cardiac surgery
Cardiomyopathy
Long QT syndrome
What is the dose of atropine for bradycardia?
20mcg/kg (min dose 100mcg, max 600 mcg)
Can repeat, max total dose 1mg in child, 2mg in adolescent
How many joules for a sychnronised shock for VT
2J/kg
What is the dose of adenosine for treatment of SVT?
How is the dose diferent for a neonate?
100microg/kg up to 500 mcg/kg (max dose in neonate 300mcg/kg)
What is the push dose of adrenaline for bradycardia?
How do you give it?
10mcg/kg IV slowly titrate, don’t push it all at once
What is the dose of an adrenaline infusion for bradycardia?
0.05 to 2 microg/kg IV
If p waves are present in SVT, how are they different to normal p waves?
Usually inverted, odd morphology
How can you apply vagal manoevres to a young child?
Glove filled with ice to face
Dunk infants face in ice bath
What are the causes of VT in children?
Congenital heart disease or heart surgery
Myocarditis
Cardiomyopathy
Poisoning (TCA)
Renal disease (high K+)
Channelopathies (long QT)
What is the dose of amiodarone in a stable child in SVT
5mg/kg over 20 minutes, 30 minute in neonates
In cases of toxic VT (from overdose) what is the best option - amiodarone or DC shock
DC shock
What do you do if you are trying to give a synchronised shock for VT but it won’t deliver shock?
Take of the sync
What is the treatment of torsades de points VT?
DC cardioversion the IV magnesium 25 - 50mg/kg over a few minutes
What are your next steps for VT if you have tried giving a 2J/kg DC shock but that patient won’t cardiovert?
Increased to 4J/kg
Give amiodarone 5mg/kg over 20 min the trying shocking
Why should giving adenosine to a wide complex tachycardia (unsure if SVT with abberancy or VT but pt stable) be avoided or be very very cautious if doing so?
If its VT adenosine can increase the tachycardia and cause deterioration.
Give DC shock
