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Pediatrics > Final > Flashcards

Final Flashcards

1
Q

Cardiac and CNS toxicity may occur virtually simultaneously in infants and children due to

A

Lower threshold for cardiac toxicity with bupivacaine

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2
Q

CNS and CV signs of LA toxicity include

A

Circumpolar numbness

Paresthesias

Lightheaded

Tinnitus
Seizure

Respiratory depression/arrest

Ventricular arrhythmia

Cardiac arrest

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3
Q

Why is resuscitation effort after bupivacaine toxic dose difficult

A

Bupivacaine has affinity for Na, K, and Ca channels

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4
Q

Bupivacaine is highly bound to plasma proteins specifically what 2 proteins

A

Alpha 1 acid glycoprotein

Albumin

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5
Q

Lower levels of plasma proteins leads to what with bupivacaine

A

Increased free (unbound) fraction of LA that produces toxicity

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6
Q

After accidental injection of large IV dose of bupivacaine progression from prod royal signs to CV collapse timeline

A

May be rapid

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7
Q

To terminate seizure activity what drugs given

A

Midazolam 0.05-0.2 mg/kg

Thiopental 2-3mg/kg

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8
Q

If cardiac arrest from LAST think

Treatment of choice

A

Intralipids

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9
Q

Dose of intralipids

A

1.5ml/kg of 20% IV lipid emulsion

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10
Q

Max dose of intralipids

A

3ml/kg

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11
Q

Maintenance infusion rate of intralipids

When stop?

A

0.25 ml/kg/min

Until circulation restored

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12
Q

Is propofol recommended as substitute for intralipids for LAST

A

No

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13
Q

Supportive treatment of LAST with intralipids

A

IVF 10-20ml/kg isotonic

Vasopressors (NE or neo)

Antiarrythmic

Phenytoin

ECMO

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14
Q

Conus medularis is located where in peds

Adults

A

L3 in peds up to 1 yr old

L1 adults

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15
Q

Lumbar puncture for SAB/spinal in neonates and infants is performed at what level

A

L4-L5

L5-S1

Avoid needle injury to SC

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16
Q

Tip of spinal cord in neonate ends at what level

When achieves normal adult position of L1-L2

A

L3

1 year of age

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17
Q

Neonatal sacrum differences from adults

A

Narrower and flatter

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18
Q

LP in older child may be performed where

A

L2-L3

L3-L4

L4-L5

L5-S1

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19
Q

At birth spinal cord ends at what level

A

L3

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20
Q

LP in infant may be performed at what levels

A

L4-L5

L5-S1

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21
Q

Presence of deep sacral dimple may be associated with

A

Spina Bifida Occulta

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22
Q

Presence of deep sacral dimple implications with caudal anesthesia

A

Greatly increases probability of dural puncture

Caudal block contraindicated

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23
Q

CSF volume as percentage of body weight in infants/young children compared to adults

A

Greater in infants/young children

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24
Q

CSF turnover rate for infants and children compared to adults

A

Greater turnover rate

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25
Q

Greater turnover rate of CSF in peds results in what changes in SAB

A

Much briefer duration compared to adults

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26
Q

SAB and epidural in infants and small children has what hemodynamic effect

A

Hemodynamically stable even when reaches upper thoracic levels

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27
Q

Why clinically significant BP changes do not occur in young children with SAB and epidural

A

PNS stronger than SNS

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28
Q

What position is patient placed into for caudal epidural

A

Lateral decubitus position

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29
Q

Palpate what for caudal epidural

A

Cornu of sacral hiatus

Found at the beginning of the crease of the buttocks

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30
Q

Appropriate insertion site of caudal epidural

A

Slightly more caudal from palpate sacral Cornu

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31
Q

What size IV cath for caudal block

A

22G

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32
Q

Needle direction initially for caudal block

A

45 degrees cephalad bevel down

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33
Q

Needle passes through what ligament for caudal block

A

Sacrococcygeal ligament

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34
Q

What space is caudal block placed into

A

Caudal canal

Continuous with epidural space

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35
Q

If bone is encountered before sacrococcygeal ligament do what

A

Withdraw several mm

Decrease angle to 30 degrees

Gently advance

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36
Q

As advance needle for caudal block what adjustments to angle

A

Decreased angle and nearly parallel to plane of child’s back

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37
Q

Intraosseous injeciton of LA results in what uptake

A

Very rapid uptake

Similar to direct IV injection

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38
Q

Drug dose for epidural blockade to a given dermatome level depends on what

A

Volume not concentration

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39
Q

Concentration of LA for epidural should be based on what

A

Desired density of block

Risk of toxicity

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40
Q

Where does spinal cord end in neonate

A

Lower border of L3

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41
Q

Neonate is undergoing surgical procedure with spinal. What would indicate high or total spinal?

A

Decreasing sat is earliest sign

Respiratory insufficiency rather than hypotension

CV markers stable bc PNS dominant

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42
Q

What is maximum dose of 0.25% bupivacaine that should be used for pediatric caudal anesthesia

How long anesthesia provided

A

1 ml/kg up to max of 25ml

Provides 3-6 hours for procedures below the diaphragm

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43
Q

Appropriate volume for pediatric epidural blood patch

Awake

Anesthetized

A

Awake- stop when child feels discomfort or pressure

Anesthetized- max 0.3ml/kg

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44
Q

Leading cause of death an disability in peds

A

Injuries

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45
Q

Up to 40% of polytrauma patients die as a result of what

A

Circulatory shock from acute blood loss

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46
Q

Besides surgical control of hemorrhage what is crucial for survival

A

Adequate volume resuscitation with blood products and IVF

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47
Q

Most common cause of death from injury for victims of all ages

A

Traumatic brain injury

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48
Q

Major threat to children in US

A

Vehicular trauma

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49
Q

Initial management and definitive care of child with traumatic head injury is focused on

A

Optimizing cerebral perfusion

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50
Q

Why optimize cerebral perfusion

A

Minimize extension of injury

Maximize recovery of damaged neuron

Managing extracranial injury simultaneously

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51
Q

Primary goals in management of peds trauma pt (9)

A

Delivery of oxygen

Appropriate ventilation

Vital organ perfusion

Normothermia to mild hypothermia

Assure renal function

Neurological stability

Correct coagulopathies

Avoid overhydration

Meticulous mgmt of metabolic demands

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52
Q

In emergency and shortage of 0- blood boys can receive what type

A

B+

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53
Q

Prepare for trauma patient with what in regards to weight

A

Estimated weight

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54
Q

Lidocaine bolus and infusion

A

1mg/kg bolus

20-50mcg/kg/min infusion

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55
Q

Adenosine dose

A

100 mcg/kg rapid bolus
Max 6 mg

200mcg/kg second dose
Max 12 mg

56
Q

Amiodarone dose

A

5mg/kg

Max 300mg

VF and VT

57
Q

Procainamide dose

A

5-15 mg/kg over 30-60min

Then 20-80mcg/kg/min infusion

58
Q

Magnesium IV dose

A

25-50 mg/kg
Max 2 gm

Torsades

59
Q

Calcium chloride dose

A

10-20mg/kg

Central line. Slowly

Stronger. More Ca per ml

60
Q

Calcium gluconate dose

A

30-60mg/kg

PIV ok

61
Q

Epinephrine

Hypotension

Cardiac arrest

A

1 mcg/kg hypotension

10mcg/kg arrest

62
Q

Atropine max dose

Child

Adolescent

A

Child 1 mg

Adolescent 2 mg

63
Q

No time for type and cross what blood given

A

O PRBCs

AB platelets and plasma

64
Q

Women of childbearing potential should receive what type of blood

A

O negative RBC

65
Q

Men and women post-childbearing age could receive what type

A

0 positive PRBCs

66
Q

PRBCs 4 ml/kg increases Hgb bu how much

A

1g/dL

67
Q

What dose of PRBCs increases Hgb by 1 g/gL

A

4 ml/kg

68
Q

Platelet transfusion of what dose increases platelet count 50K-100K

A

5-10 ml/kg

69
Q

FFP transfusion of how much increases factor level by 15-20%

A

10-15ml/kg

70
Q

Platelet infusion of 5-10ml/kg will increases platelet count by how much

A

50,000-100,000

71
Q

FFP transfusion of 10-15ml/kg increases factor level by how much

A

15-20%

72
Q

Cryoprecipitate given to increase what level

A

Fibrinogen

73
Q

Cryo dose of 1-2 units/kg increases fibrinogen how much

A

60-100 mg/dL

74
Q

To increase fibrinogen by 60-100mg/DL dive how much cryo

A

1-2 units/kg

75
Q

Lethal trauma triad of death

A

Coagulopathy

Acidosis

Hypothermia

76
Q

How coagulopathy leads to acidosis

A

Increased lactic acid in blood

77
Q

How acidosis to hypothermia

A

Decreased heart performance

78
Q

Hypothermia to coagulopathy

A

Decreased coagulation

79
Q

Platelets should/should not be refrigerated

A

NOT

80
Q

If overt signs of bleeding present or more hemostatic challenging procedure imminent what platetlet level may be required

A

30,000 to 50,000/mm3

81
Q

Platelet should be give through what type of filter

A

Large-pore filters

> 150nm

82
Q

FFP contains what

A

All clotting factors and regulatory proteins

83
Q

What patients could benefit from higher FFP:RBC ratio of 1:1

A

Massively transfused patients

84
Q

Increased FFP transfusions to massively transfused patients associated with

A

Trend toward increased mortality

Increased risk of TRALI

85
Q

Rapid administration of FFP can cause

A

Citrate toxicity

86
Q

S/S hypochloremia

A

Hypotension and arrhythmias

87
Q

Citrate intoxication may be more likely in setting of

A

Hypothermia, liver disease/transplantation

More likely in pediatric patients

88
Q

Citrate is mainly metabolized where

A

Liver

89
Q

Citrate has what effect in blood stream

A

Binds calcium

90
Q

Cryoprecipitate contains what factors

A

Factor VIII

Von willebrand factor

Factor XIII

91
Q

Cryoprecipitate indicated for what

A

Factor XIII deficiency

Dysfibrinogenemia

Hypofibrinogenemia

92
Q

MABL formula

A

EBV X (Hct-maHct)
—————————-
Hct

Minimum accepted Hct (maHct)

93
Q

Cryoprecipitate contains how much factor VIII from original plasma unit

A

20-50%

94
Q

Formula for volume of PRBCs to be transfused

A

EBV X (desired Hct - current low Hct)
————————-
Hct of PRBCs- 60

95
Q

Hct of unit of PRBCs

A

60

96
Q

Child with severe pulmonary disease or cyanotic heart disease requires ___________ Hct than healthy child

A

Higher Hct

97
Q

Preterm infants may require _______ Hct

A

Greater

98
Q

Why do preterm infants require higher Hct

A

To prevent apnea

Reduce cardiac and respiratory work

Improve neurologic outcomes (possibly)

99
Q

If little potential for post op bleeding Hct level of _____ is acceptable in healthy infants put to 3 months

A

20-25%

100
Q

If little potential for post op bleeding what Hct is acceptable in older healthy children

> 3 months

A

20%

101
Q

Risk of spine injury in peds patient is increased when child is subjected to (2)

A

Inertial forces from falls

Chaotic rotary forces from MVA

102
Q

Any child with suspected neck injury should have

A

C spine precautions

103
Q

_________ should always be maintained when airway manipulation attempted in suspected neck injury

A

In line stabilization

104
Q

How many people may be required to intubate child with cervical fracture

Roles

A

4

1 for inline stabilization

1 to do intubation

1 for cricoid, hold ETT

1 to give drugs

105
Q

Initial management of severe brain injury must first focus on

A

Actual pathophysiologic process that occurred at point of impact

106
Q

Useful for initial and ongoing assessments of severity of CNS injury

A

GCS

Modified GCS for peds patients

107
Q

Regardless of whether brain injury due to trauma or secondary due to global hypoxia there is

A

Immediate disruption of integrity of BBB

Results in cerebral edema and diminished neuronal oxygenation

108
Q

Modified GCS for peds

Verbal response rankings

A

5- babbles, coos

4- cries but inconsolable

3- persistent crying or screaming in pain

2- grunts or moans to pain

1- none

109
Q

Modified GCS is applicable to what patients

A

Eye opening and motor < 1 yr

Verbal response < 2 years

110
Q

Children with head trauma may have minimal neurologic abnormalities at time of initial evaluation, however

A

Increased ICP and neurologic deficits may progressively develop

111
Q

Increased ICP and neurologic deficits occur slowly in how many stages

A

2

112
Q

2 stages of brain injuries

A

Primary insult

Secondary insult

113
Q

Primary insult of deficit occurs when

Results from

A

Time of impact

Results from biomehcanical forces that disrupt cranium, neural tissue, and vasculature

114
Q

Secondary insult of neurologic deficit is

Results from

A

Parenchymal damage caused by sequence subsequent to primary insult

Results from hypotension, hypoxia, cerebral edema, or intracranial hypertension

115
Q

Ventilation of children with cerebral injury should maintain PaCO2

A

Between 35-40 mm Hg

116
Q

Avoid/do mild hyperventilation in patient with cerebral injury

A

AVOID

117
Q

Hyperventilation even mild should be avoided. Why?

A

Decreased blood flow to area surrounding injured area. Worsening flow to area

118
Q

Calming the brain involves

A

Immediate administration of opioids and benzos

Seizure prophylaxis

alters neuro exam

119
Q

What commonly given for seizure prophylaxis

A

Phenytoin

Phenobarbital

120
Q

____________ should be considered when caring for children with AMS, Sz, or associated trauma requiring surgery

A

Basilar skull fracture

121
Q

Findings associated with basilar skull fracture

A

Raccoon eyes

Retro auricular ecchymosis (battle sign)

Hemotympanum

Clear rhinorrhea

Otorrhea

122
Q

Avoid what in possible basilar skull fracture

A

nasal intubation

NG tube

123
Q

Acute subdural hematoma is most dangerous. Generally caused by what

A

Severe head injury

124
Q

S/S of acute subdural hematoma occur when

A

Immediately usually

125
Q

Due to rupture of usually veins between brain and dura

A

Subdural hematoma

126
Q

Rupture of blood vessel between dura and skull

A

Epidural hematoma

127
Q

Epidural hematoma

What BV usually rupture

A

Artery

128
Q

As epidural hematoma expands leads to what s/s

A

Loss of consciousness

Hemiparesis

Pupillary dilation

129
Q

Treatment of epidural hematoma

A

Prompt surgical evacuation

130
Q

Medical therapy with epidural hematoma should be aimed at

A

Decreasing ICP

131
Q

Acute subdural hematoma is almost always r/t

A

Trauma and frequently result of abuse

132
Q

Shaken baby syndrome leads to what

A

Acute subdural hematoma

133
Q

MOA of shaken baby syndrome

A

Infant so vigorously shaken that accelerating and decelerating rotational forces cause bridging veins to rupture

134
Q

Blood vessels most susceptible with shaken baby syndrome

A

BV leading from brain to dura

135
Q

In 50-80% of shaken baby syndrome what is presence

A

Unilateral retinal hemorrhage

136
Q

Any bruises in what areas must be suspect for abuse

A

Buttocks

Groin

Neck

Cheeks

137
Q

Age of children at highest risk for maltreatment and subsequent mortality

A

3 and under

Pediatrics (6 decks)

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