FINAL EXAM Flashcards
What are (8) common examples of trauma incidences in pediatrics?
Near drowning
Lawn mower accidents
Riding Accidents
Motor Vehicle Accidents
All-terrain vehicle accidents
Amish-Buggy Accidents
Burns
Dog bites
What are the major toxic effects of LA?
CV and CNS
LA crosses the BBB readily
Because of the lower/higher threshold for cardiac toxicity with bupivicaine, cardiac and CNS toxicity may occur virtually simultaneously in infants and children
Lower
What can happen if under GETA and having LA toxicity?
GETA with volatile anesthetics may obscure the signs of CNS toxicity until devastating CV effects are apparent.
CNS and CV signs of toxicity include what? 8 things?
- Circumpolar paresthesia
- Lightheadedness
- Tinnitus
- Slurred speech
- Muscle twitching
- Seizures
- Respiratory depression/arrest
- Ventricular arrhythmias/ cardiac arrest
What 3 channels does bupivacaine have a particular affinity for?
What effect does this have on resuscitative efforts?
Na
K
Ca
Makes resuscitation effort difficult after toxic dose of bupivicaine
Bupivicaine is highly bound to plasma proteins (a1- acid glycoprotein) and concentration of albumin and a1 acid glycoproteins are less/more in neonates which increases/decreases free (unbound) fraction of the LA that produces toxicity.
Less
Increased
After the accidental injection of large intravascular dose of bupivacaine, the progression from prodromal signs to CV collapse is slow and progressive. T/F?
False, it’s rapid
What is the resuscitation for toxic reactions of LA?
ABC
Patent airway, supplemental oxygen, reestablishing circulation and normal cardiac rhythm.
What can you give to terminate or prevent seizure activity?
Versed 0.05-0.2 mg/kg
Thiopental 2-3mg/kg
If they go into cardiac arrest from LA toxicity what should you give?
CARDIAC ARREST -> THINK INTRALIPIDS
Treatment of toxic reactions: Lipid sink hypothesis.
What is the mechanism of action of this mechanism?
1.5ml/kg of 20% IV lipid emulsion have shown to be effective for resuscitation of cardiac arrest due to bupivacaine toxicity.
The mechanism is not entirely understood, suspect that it binds free fractions of bupivicaine
What are the doses that can be repeated for LAST?
Yes dose can be repeated (max 3mL/kg) followe by a maintenence infusion rate of 0.25 mL/kg/min until circulation is restored.
Can propofol be used as a substitute for intralipid for resuscitation from bupivacaine Toxicity?
No
What should supportive treatment include for toxic reactions to LA?
IV fluid loading 10-0 mL/kg of isotonic crystalloid
Peripheral vasopressors (phenylephrine, norepinephrine)
Anti arrhythmic drugs
Phenytoin
ECMO
Where is the conus medullary in neonates/infants?
In neonates/infants up to 1 year it is located at L3 vs adults L1
Where is lumbar puncture for SAB in neonates/infants performed?
L4-L5 and L5-S1 to avoid going into spinal cord
Where does the tip of the SC end in the neonate?
L3
When does the tip of the SC achieve the normal adult position (L1-L2)?
1 year of age
Neonatal sacrum is narrower/wider and flatter/more pointy than in adults.
What does this do to your approach to the subarachnoid space?
Narrower and flatter
The approach to the subarachnoid space from the caudal canal is much more likely, so the needle must not be advanced deeply in neonates.
When is a caudal block contraindicated?
The presence of a deep sacral dimple may be associated with spina bifida occulta and greatly increasing the probability of dural puncture.
CSF volume as a percentage of body weight is less in infants and young children than in adults. T/F?
False, greater
Why do children require larger doses of LA for surgical anesthesia comparatively with a subarachnoid block in infants and young children?
The fact that CSF as a percentage of body weight is greater in young children than in adults.
The CSF turnover rate is considerably greater in infants and children, accounting in part for the much briefer duration of SAB agent compared with adults. T/F?
True
Anatomic differences necessitate meticulous attention to detail to achieve successful and uncomplicated spinal and epidural anesthesia. T/F?
True
In contrast to Older children and adults, subarachnoid and epidural blockade in infants and small children is characterized by ____________ __________, even when the level of the block reaches the upper thoracic dermatomes.
Hemodynamic stability
In infants the sympathetic/parasympathetic NS is stronger than the parasympathetic/sympathetic therefore, the HR appears to attenuated and clinically significant blood pressure changes do/do not occur in young infants after a SAB.
Parasympathetic
Sympathetic
Do not
Position of patient for caudal epidural
Lateral decubitus position with spine and shoulder in neutral curvature
What do you palate before performing caudal epidural?
Palate the coronau of sacral hiatus.
What are the cornau of the sacral hiatus?
Two bony ridges that are palpated, about 0.5-1cm apart and are often found just at the beginning of the crease of the buttocks
Where is the appropriate insertion spot in caudal epidural anesthesia?
The appropriate insertion spot is slightly more caudal form the palpated sacral corni
Caudal Epidural: how to perform?
Prep site with iodine, chlorohexadine and alcohol pads (wiped toward the buttocks)
Have prepared 22G IV catheter with a pig tail and LA filled syringe readily available
Done sterile gloves, palpated the injection site and insert the needle bevel facing downward- initially directed cephalad at a 45 degree angle
Needle advances through the skin until it “pops through the sacrococcygeal ligament into caudal canal, which is continguous with epidural space.
As needle is advanced the angle of the needle should be decreased and nearly parallel to the plane of the child’s back
IV catheter stays in place, while the needle is removed. The pigtail - syringe filled with LA will be attached
Once negative aspiration for both blood or CSF is confirmed test does of LA is administered
If neither hemodynamic nor ECG changes are evident after the test dose, the remainder of the dose of LA for a single shot caudal anesthesia should be slowly injected wth intermittent aspiration
Intraosseous injection of LA results in v rapid uptake (similar to direct IV injection)
Remove IV catheter, wipe off the size and place bandaid over it.
What do you do if encounter bone when doing caudal epidural anesthesia?
If bone is encountered before sacrococcygeal ligament, needle should be withdrawn several millimeters, the angle with the skin decreased (~30 degrees) and again gently advanced until ligament is pierced
The drug dose required for epidural blockade to a given dermatomal level depends on what?
The volume NOT CONCENTRATION of the LA and volume of the epidural space, which may change with age
The concentration of the LA should be based on what?
The desired density of the block and the risk of toxicity
Should the block be more dense/less dense for post op analgesia?
Less dense
Should block be more dense or less dense for intr op anesthesia?
More dense
MM
Where does the SC end in neonate?
Ends at the lower border of L3
MM
A neonate is underlying a surgical procedure with the use of a spinal blockade. What sign would indicate a “high” or “total” spinal?
Decreasing oxygen saturation is the earliest sign of a high or total spinal in the neonate
A high or total spinal, produced either with a primary spinal technique or secondary to an attempted epidural, presents as respiratory insufficiency rather than hypotension owning to a relatively immature sympathetic nervous system in the neonate.
Which an immature sympathetic nervous system, the cardiovascularparameters areremarkably stable in the neonate with a high or total spinal
MM
What is the max dose of 0.5% bupivacaine that should be sued for pediatric caudal anesthesia?
Bupivacaine (0.25%) at a volume of 1ml/kg up to a maximum of 25mL can provide 3-6 hours of anesthesia for surgical procedures below the level of the diaphragm
MM
What is the appropriate volume for pediatric epidural blood patch?
In the child who is awake, the practitioner should stop the blood infusion once th child feels discomfort of pressure in the back
In the anesthetized patient, no more than 0.3mL/kg of blood should be injected into the epidural space.
A baby’s head can weigh what percent of its total body weight?
1/4th of its total body weight
Why can the baby’s head fling out of control?
Because the neck muscles are weak and any violent shake will cause the head to fling out of control, because the baby’s head weighs 1/4th of its total body weight.
The impact of shaken baby syndrome can be up to 30 times the force of gravity and cause permanent or fatal damage to the baby. T/F?
True
Because the damage form shaken baby syndrome is external, signs of danger can be seen easily. T/F?
False, damage is internal, signs of danger may not be seen until its too late.
Blood vessels that lea from the brain to the dura membrane are most susceptible to tearing since the subdural space between the brain and the skull is greater for for babies. T/F?
True
What happens when the nerves inside the brain sever from shaken baby syndrome?
The brain will swell, cutting off oxygen tot the brain in surviving babies- blindness and brain damage may also occur.
What is located in the brain stem and what happens if it is severed or damaged?
Vital sensors are located in the brain stem and if severed or damaged baby will experience respiratory problems and vomiting.
What nerve is often damaged in shaken baby syndrome and can cause retinal bleeding?
Optic nerve
Retinal hemorrhage (unilateral) has an incidence of ______% in SBS; if bilateral the incidence increases up to _____%.
50-80%
90%
What are s/sx of cerebral injury form SBS?
"Not acting right" Poor feeding Vomiting Irritability Lethargy Seizure Apnea Altered LOC Visual impairment (retinal hemorrhage) Unexplained infant death
The majority of patients who survive severe shaking will have some form of neurologic or mental disability, such as CP or mental retardation requiring lifelong medical care. T/F?
True
Definition of physical abuse?
Physical abuse is defined as physical, mental injury or sexual abuse of a child under the age of 18 years by a person who is responsible for the child’s welfare.
Definition of neglect?
Occurs when a care provider responsible for the child either deliberately or by extraordinary inattentiveness permits a child to suffer, or fails to provide conditions generally deemed essential for developing a child’s physical, intellectual or emotional capacities.
Children who are at risk for non accidental trauma?
Children born with physical or developmental disabilities
Children born to single parents who are themselves younger, lesser- educated with less/no prenatal care and children with a family history of violence or other abused siblings.
What age of children are at the highest risk for maltreatment and subsequent mortality?
3 years and younger
What does bruising form physical abuse look like?
Tends to be bilateral, widespread and on soft tissue areas (e.g. Inner thighs, axillary regions) that do not usually come in contact with hard surfaces on falling.
Multiple bruises with different colors, belt whips, finger and hand marks, burns from cigarette butts or hot iron, multiple fractures in different healing stages are s/s of abuse. T/F
True
Abuse by immersion of children in hot fluids presents how?
Usually present with bilateral burns or equal severity usually of palms or lower half of the body with sparing of the flexor creases because the child would be pulling up their legs to avoid the hot fluid
What should you do if you suspect a child is being abused?
Consult services of DCS and SW.
What is the top 5-6 leading causes of injury in children <1?
1) Unintentional suffocation
2) Homicide unspecified
3) Homicide specified
4) Unintentional MV Traffic
5) Undetermined suffocation
6) Unintentional drowning
What are the top 5 leading causes for children 1-4 years old?
1) Unintentional drowning
2) Unintentional MV traffic
3) Homicide unspecified
4) Unintentional suffocation
5) Unintentional fire/burn
What are the top 5 causes for children 5-9 leading cause of death?
1) unintentional MV traffic
2) Unintentional drowning
3) unintentional fire/burn
4) Homicide/firearm
5) unintentional other land transport
What are the top 5 leading causes of death for children 10-14?
1) unintentional MV traffic
2) suicide suffocation
3) suicide firearm
4) Homicide firearm
5) Unintentional drowning
What are the top 5 leading causes of death for children 15-24?
1) Unintentional MV traffic
2) Homicide fire arm
3) Unintentional poisoning
4) Suicide firearm
5) suicide Suffocation
__ remain the leading cause of DEATH and DISABILITY in the pediatric population.
Injuries
Up to __% of polytrauma patients die as a result of CIRCULATORY SHOCK from acute blood loss.
40%
Besides surgical control of hemorrhage, what is crucial for survival for polytrauma victims?
Adequate volume resuscitation with blood products and fluids
What is the MAJOR threat to children in the United States?
Vehicular trauma
What is the most common cause of death from injury for victims of all ages?
Traumatic brain injury
