Critically Ill (AJHP 10/1/19)

Question 1

Most septic events in peds are caused by

Answer 1

respiratory infections

Question 2

SIRS Criteria

Answer 2

Leukocytosis (>12,000)
Leukopenia (<4,000)
>10% immature neutrophils (aka bands)
At least one vital sign instability 
(ex. Temp, HR, RR, BP)

Question 3

Peds patient often compensate in shock and will have normal BP +/- adequate issue perfusion at first so you should

Answer 3

begin fluid resuscitation when other SIRS symptoms are present even if the patient has a normal blood pressure. THey will compensate with increased HR to maintain CO but will progress to hypotension when compensation becomes inadequate and can result in cardiac arrest

Question 4

Fluid resuscitation

Answer 4

20mL/kg (max 1 L/dose) of isotonic fluids up to 60 mL/kg within 30 min of shock identification

Question 5

Warm shock

Answer 5

vasodilation with decrease in SVR and increase in CO

Pink extremeities, bounding pulses and flash capillary refill

often adolescents

Norepinephrine 0.05 mcg/kg/min recommended to vasoconstrict and increase SVR

Question 6

Cold shock

Answer 6

Vasoconstriction is wincrease in SVR and decrease in CO

mottled extremities, weak pulses and delayed capillary refill

epinephrine 0.05 mcg/kg/min to increase CO via B1 receptor

Question 7

Steroids in peds shock

Answer 7

Limited evidence of benefit but considered after pressor if pt as known/risk of adrenal insufficiency

hydrocortisone 1mg/kg/dose q6hr OR 25mg/m2/dose q6hr have both been studied

Max 50mg q6hr

May check random cortisol conc prior with total cortisol of <10mcg/dL or free cortisol <2mcg/dL indicated insufficientcy

Question 8

Atropine

Answer 8

may pretreat before RSI to prevent vagal bradycardia

Vagal nerve anatomically close to trachea in kids

IV: 0.02 mg/kg

Question 9

Ketamine

Answer 9

Peds studies - decrease or no change in ICP so it is a sedative option for RSI in traumatic brain injury peds

Question 10

Avoid which paralytic in peds

Answer 10

Succinylcholine

boxed warning against use in undiagnosed skeletal muscle myopathy because risk of hyperkalemia, rhabdo, arrhythmias and cardiac arrest

Question 11

RSI Premeds

Answer 11

Fentanyl (Pain) 30-60min
IV/IN: 2mcg/kg
*Chest wall rigidity risk esp with rapid admin or small pt

Atropine (Prevent Vagal)