Emergencies in pediatric anesthesia

Question 1

Risk factors for cardiac arrest include

Answer 1

Cardiac surgery, infants less than 1 month of age, ASA >3, prematurity, congenital heart disease, emergency procedures*****

Question 2

From 1998-2004, the following reasons were attributed to intraoperative pediatric mortality:

Answer 2

38% <1 year of age
18-28% were “medication-related”-
Heart disease (aortic stenosis, cardiomyopathy, & single ventricle account for 75% arrests)- 54% arrested in a general OR

Question 3

Declining use of _______ which was associated with bradycardia & myocardial depression.

Answer 3

halothane

Question 4

Medication related causes of cardiac arrest during anethesia include

Answer 4

anesthetic overdose or relative OD of inhalational or IV agent
succinylcholine-induce dysrhythmia
neostigmine-induced dysrhythmia
medication "swap"
drug reactions
unintended IV inject of LA
high spinal
LAST
inadequate reversal of paralytic agent
opioid-induced respiratory depression

Question 5

Cardiovascular related causes of cardiac arrest during anesthesia include

Answer 5

hypovolemia**
hemorrhage**
inadequate volume administration**
hyperkalemia caused by succinylcholine, rapid or large volume of transfusion, reperfusion, K+ administration, renal insufficiency 
hypocalcemia from citrate toxicity
hypoglycemia
vagal episodes
CVC- dysthymia's, hemorrhage, tamponade
embolism (air, clot, fat)
MH
hypothermia
myocardial infarction
sepsis, adrenal insufficiency

Question 6

Respiratory causes of cardiac arrest during anesthesia include

Answer 6

inadequate oxygenation/ventilation
inability to ventilate (laryngospasm, bronchospasm, mass)
ETT misplacement, kink, plug, accidental removal
difficult airway anatomy
residual NMB
aspiration
pneumothorax

Question 7

Other factors related to cardiac arrest in anesthesia include

Answer 7

lack of vigilance
ignorance
failure to apply knowledge
unknown etiology
surgical technique
patient factors

Question 8

Asystole outside of hospital is associated with

Answer 8

poor ROSC & survival

-often due to prolonged hypoxia and represents a terminal rhythm

Question 9

Asystole in the operating room, is more likely an

Answer 9

initial rhythm in response to vagal stimulation

-more likely to be reversed and associated with good prognosis in the OR

Question 10

Vagal stimulation can be due to

Answer 10

trigeminal nerve
insufflation
eyes

Question 11

Vagal stimulation can be treated with

Answer 11

glyco
epi
atropine
& carotid massage

Question 12

Prolonged arrest leads to

Answer 12

lengthy low-flow intervals
inadequate perfusion
myocardial & cerebral injury

Question 13

The need for more than ______ minutes of CPR is a predictor of mortality

Answer 13

15

Question 14

Up to _____ hours of CPR has been reported in anesthesia-related events with a good outcome

Answer 14

3

Question 15

____ minutes after failed resuscitation of reversible conditions, ECMO should be activated

Answer 15

10

Question 16

Perioperative cardiopulmonary arrest is the result of

Answer 16

arrest during inhalation induction (25%)- laryngospasm, agent OD, depressed myocardial function
arrest during craniofacial or spine surgery- hypovolemia/blood loss, VAE
hyperkalemia- rapid RBC transfusion
VP shunt malfunction- increased ICP
LAST
Anaphylaxis

Question 17

Describe the dose of IV lipids for LAST treatment.

Answer 17

1.5 mL/kg of 20% lipid emulsion over 1 minute, followed by an infusion of 0.25 mL/kg/min. for 10 minutes

Question 18

The steps to treating CPR include

Answer 18

1. recognize the need
2. know how to perform
3. vascular access
4. medications for CPR
5. teamwork
6. documentation
7. post resuscitation care
8. selfcare post a critical incident

Question 19

Chest compression should begin at

Answer 19

<60 bpm**

Question 20

Checking for a pulse in the newborn should occur at the

Answer 20

umbilical artery

Question 21

Checking for a pulse in the infant should occur at the

Answer 21

brachial artery

Question 22

Checking for a pulse in the child should occur at the

Answer 22

carotid

Question 23

When initiating CPR, it is important to also remember to

Answer 23

administer 100% fiO2
cease all anesthetic administrations
allow for chest recoil
switch compression provider every 2 minutes

Question 24

Medications that can be administered through an ETT include

Answer 24

NAVEL:
naloxone
atropine
vasopressin 
epinephrine
lidocaine

Question 25

Intubation of the trachea during CPR in the OR is recommended and includes:

Answer 25

adequate ventilation
trained anesthesia providers place ETTs rapidly with minimal interruptions to compressions
check for correct placement

Question 26

A______ puts patients at greater risk for aspiration during CPR

Answer 26

an unprotected airway (mask, laryngeal mask ventilation, etc.)

Question 27

Defibrillation is used for the following rhythms:

Answer 27

vfib & vtach
at 2-4 J/kg
up to 10 J/kg

Question 28

Cardioversion is used for the following rhythms:

Answer 28

synchronized with R wave
afib, aflutter, or SVT
0.5-1J/kg up to 2 J/kg

Question 29

Attempts to obtain peripheral venous access should be limited to

Answer 29

90 seconds

if unsuccessful consider IO, femoral vein access, drug administration through ETT

Question 30

Each drug should be flushed with

Answer 30

0.25 mL/kg normal saline (5 mL infants, 10 mL children)

Question 31

The preferred site for placement of an IO needle in a child is

Answer 31

the anterior tibia

Question 32

Titration of FiO2 after ROSC is generally aimed at

Answer 32

pulse oximetry levels of 94 to 99%

Question 33

Care after ROSC, includes assessing for

Answer 33

rebound of arrest (i.e. hyperkalemia treatment, needle decompression of tension pneumo)

Question 34

Care after ROSC includes

Answer 34

assess for ETT and line displacements during the arrest

accurate reporting to surgery team, family, ICU team

Question 35

After ROSC, it is important to avoid

Answer 35

hyperthermia, hyperglycemia, & seizures