Circulation, Seizures and Coma Flashcards
What are the 3 stages of shock
Compensated
Decompensated
Irreversible
Features of compensated shock?
Cold peripheries
tachycardia
elevated diastolic pressure
Agitation
reduced UO
Signs of uncompensated shock
Prolonged CRT
Cool peripheries
Low BP
Acidotic breathing
reduced UO
Main classes of shock
Hypovolaemia - including peritonitis and intussuception
Distributive - eg septic/anaphylaxis
Cardiogenic -
Obstructive -
Where does adrenaline come in during ABCDE assessment of anaphylaxis?
In A if signs of obstruction
What are the man ductus dependent syndromes in neonates? Treatment?
- duct dependent pulmonary circulation (critical pulmonary stenosis, pulmonary atresia, tricuspid atresia)
-present in the first few days of life with increasing cyanosis unresponsive to supplemental oxygen and signs of severe hypoxaemia with little respiratory distress before collapsing with cardiogenic shock. - Duct dependent systemic circulation (transposition of the great vessels, aortic stenosis, hypoplastic left heart, coarctation of the aorta)
-present in the first few days of life with an inability to feed, breathlessness, a grey appearance, and collapse with poor peripheral circulation and cardiogenic shock.
1) Assess ABC
2) Judicious use of oxygen
3) Intravenous prostaglandin E1
Name 4 causes of seizures in children
1) Febrile seizures
2) Epilepsy
3) Meningitis
4) Raised ICP
5) Hypoglycaemia
6) Electrolyte abnormalities eg hyponatremia
Seizure APLS algorithm ? Doses?
5 min - Midaz 0.15mg/kg (max 10mg)
5 min - Midaz 0.15mg/kg (max 10mg)
5 min - Levetiracetam 40mg/kg (max 3g) over 5 mins
OR Phenytoin 20mg/kg over 20 mins
+ICU / anaesthetics
5 min after infusion - the other one from above
OR phenobarbitone
5 min after infusion
RSI
What are the reversible causes of status in a kid? Emergency management of these
Systemic
-Hyponatraemia (<125mmol) - 3-5mls/kg of 3% NaCl
-Hypoglycaemia - 2-3mg/kg 10% glucose
-Hypertension -
Intracranial
-Infection - Cef + acyclovir
-Bleed
-Raised ICP
When would you not follow APLS algorithm for seizures
Compromised airway not responding to basic manoeuvres
Shock unresponsive to fluid resus
Raised ICP / trauma
Bar electrolytes and glucose what blood test should you send off in status
Ammonia
FBC
Buccal/nasal midaz and rectal diazapam dose in status
Buccal/nasal midaz - 0.3mg/kg (max 10mg)
Rectal diazepam - 0.5mg/kg
Kid with status on keppra usually at home. What dose of keppra can you give?
The full 40 mg/kg dose can be given even if the child is on regular maintenance levetiracetam.
Phenytoin dose in status and speed of infusion?
It is given at a dose of 20mg/kg infused at a rate of no faster than 1mg/kg/minute (20 minutes)
Phenobarbitone dose? More commonly used in?
Phenobarbitone is a second line anticonvulsant administered intravenously at a dose of 20 mg/kg.
It is more commonly used in neonates and infants.
Being a barbiturate it may cause respiratory depression and hypotension.
GCS score for children <4
GCS for kids 4-15
Same as adults
What is decorticate posturing.
flexed upper limbs and extended lower limbs.
Decorticate posturing indicates an insult to the brain in the areas of the cerebral hemispheres, internal capsule and thalamus
What is decerebrate posturing
extended upper limbs and extended lower limbs. It is sometimes referred to as extensor posturing.
Decerebrate posturing indicates brain stem pathology.
What are you worried about if a kid goes from decorticate to decerebrate posturing?
May indicate brain stem herniation.
Low GCS with
Small reactive pupils?
Pinpoint?
Fixed midsize?
Fixed dilated?
Unilateral dilated?
Emergency management of meningitis
Assess and manage ABCDE
IV antibiotics such as third generation cephalosporins
IV acyclovir if encephalitis is a possibility
Correct hypoglycaemia and any other electrolyte abnormalities
Consider steroids
What are the 2 main clinical syndromes that occur as ICP rises
Central syndrome - where the whole brain is pressed towards the foramen magnum and the cerebellar tonsils herniate through it. This is known as “coming”
Uncal syndrome - where the uncus is forced through the tentorial opening and compressed against the free edge of the tentorium. This leads to third nerve compression and an ipsilateral dilated pupil.
Emergency management of raised ICP
Intubation and ventilation to maintain a low normal C02 level
20 degrees head up position
Intravenous mannitol or hypertonic saline
Dexamethasone
Define sepsis
Sepsis is defined as proven or suspected infection in the presence of an abnormal heart rate, respiratory rate, temperature or white cell count. This is termed a systemic inflammatory response.
An alternative definition is: sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection.
Define septic shock
Septic shock is present when sepsis is accompanied by cardiovascular dysfunction. Hypotension is a late sign.
If there are signs of shock (+/- lactate is more than 2 mmol/l) and there are no signs of fluid overload treatment?
give 10 ml/kg of isotonic crystalloid. Assess the haemodynamic response at the bedside and repeat if there is evidence of improvement but still signs of shock.
Inotropes should be considered if no improvement after 20 ml/kg of fluid boluses.
Sepsis without access to pressors?
Surviving Sepsis campaign guidelines only recommend fluid boluses if there is evidence of both impaired perfusion and hypotension. In the absence of hypotension, maintenance fluid with vasoactive support (if available) is recommended.
[The FEAST (Fluid Expansion As Supportive Therapy) study was published in 2011 and showed that in a resource-limited setting in Africa, without access to intensive care, children with severe febrile illnesses and evidence of impaired perfusion who were treated with fluid boluses had a significantly increased mortality compared with controls.]
Sepsis in a neonate Abx choice?
CefotaximeIV 50 mg/kg
and
Amoxicillin
Antibiotic choice in septic kids >1m months
Cefotaxime IV 50 mg/kg
or
Ceftriaxone IV 50-100 mg/kg (4 gm MAX)
plus
Flucloxacillin IV 50 mg/kg
Cause of maculopapular rash in staph toxic shock
The rash is caused by a superantigen toxin (TSST-1) that results in polyclonal T cell activation.
Urine sample from a neonate in septic screen
A supra pubic aspirate of urine is a rapid, accurate and reliable way of obtaining an uncontaminated sample of urine from a neonate.
6m with septic shock, hypotension, fever and hypoglycaemia first fluid choice
2 mls/kg of 10% dextrose IV for hypoglycaemia first
Name 3 causes of decreased fluid intake in kids
Nausea and or vomiting
Painful oral lesions like primary herpes
Reduced consciousness
Sepsis
Name 3 causes of increased fluid intake by kids
Fever
Vomiting
Diarrhoea
Increased urine output, as in diabetes mellitus or insipidus
Third space losses
Gold standard for defining dehydration status in kids
Weight loss
Can you think of 5 signs on exam which would indicate >10% volume fluid loss
dehydration and no shock can be assumed to be 5-10% dehydrated; if shock is present, then greater than 10% dehydration has occurred.
When would you use NG rehydration? IV?
<3 and not tolerating oral
> 3 and not tolerating oral, or <3 failed on NG
Fluid of choice for kids resus
20mg/kg 0.9% Nacl + 5% dextrose
Hartmans
How to calculate maintenance fluids in kids
First 10kg - 100ml/kg
+10-20kg - 50ml/kg
>20kg - 20ml/kg
eg 30kg child = 1000+500+200
How to calculate deficit volume in kids
% dehydration x weight x 10
When might you be more cautious using lots of fluids in septic kids
Acute CNS conditions eg meningitis
Pulmonary conditions eg pneumonia, bronchiolitis
Both may cause ADH secretion
Maintenence fluid choice in kids
IV maintenance is sodium chloride 0.9% with glucose 5%.
Alternative maintenance fluid options include:
Plasma-Lyte 148 with glucose 5% (contains 5 mmol/L of potassium)
Hartmann’s with glucose 5%
How fast do you want to correct severe hypoNa
no more than 8 mmol per 24 hrs
Management of hyperkalemia algorithm? Doses?
Arrhythmia-> 0.1mmol/kg (0.5mls/kg 10%) Calcium
Salbutamol - 5-10mg neb
If still high:
pH < 7.35 - give bicarbonate 1mmol/kg (1ml/kg of 8.4%)
pH > 7.35 - insulin 0.05u/kg/hr + dextrose 5ml/kg 10%
Once falling
Resonium 1g/kg
tachycardia, prolonged capillary refill time, dry mucus membranes how dehydrated?
> 10%
Seizing with hypoNa fluid
3 mls/kg of 3% saline over 15-30 minutes will generally raise the sodium level enough (2-3 mmol/l)
HyperNa eg 165 + dehydrated child fluid choice? Na aim over 24 hrs?
Plasma-Lyte 148 or N.Saline (+/- 5% dextrose) to manage hypernatremic dehydration
Sodium levels should only be changed cautiously by 8-12 mmol/l in 24 hrs.
[Too rapid correction of hypernatraemia may lead to cerebral oedema and convulsions]
HyperK and acidotic rx?
Sodium bicarbonate (1mmol/kg IV)
Correction of the acidosis will shift potassium back into the cells
Fluid resus before pressors in hypovolemic shock
40mls/kg
Coma algorithm
Why dex in meningitis
Reduces long term learning development
Less hearing loss
Where do you check pre ductal sats / BP
Right arm
