Gastrointestinal & Pain/Sedation Flashcards
1
Q
Pain will be present with passive extension or flexion of the right lower extremity
A
Psoas Sign
2
Q
Pain present with internal rotation of the right thigh
A
Obturator sign
3
Q
Pain reported in the right lower quadrant with palpation of the left lower quadrant
A
Rovsing Sign
4
Q
Antibiotic coverage targeted toward what bacterial flora in appendix
A
- E. coli
- Strep. milleri
- Anaerobes
- P. aeruginosa
5
Q
Differential diagnoses for abdominal masses
A
- Organomegaly
- Constipation
- Umbilical hernia
- Benign cystic lesion (choledochal cyst, polycystic kidney disease, duplication cyst, cystic teratoma)
- Neuroblastoma
- Wilms tumor
- Hepatoblastoma
6
Q
Most common extracranial tumor in children, age at presentation is 18 months, with the prevalence greatest in children <4 years
A
Neuroblastoma
7
Q
Most common renal tumor and the 5th most common pediatric malignancy, with a common presentation age of 1-5 years
A
Wilms tumor
8
Q
Most common malignant tumor of liver with a mean age at diagnosis 1 year, occurring in the right lobe of liver and associated with extreme prematurity, low birth weight, Beckwith-Wiedemann syndrome, Gardner syndrome, and familial adenomatous polyposis disease
A
Hepatoblastoma
9
Q
Absence or obstruction (due to fibrosis) of the biliary tree, leading to intrahepatic bile duct obstruction and proliferation
A
Biliary Atresia
10
Q
- Obstruction of bile flow from liver due to inflammatory process
- Fibrosis or scarring obliterates the ducts and prevent bile from being transported from liver to GI tract
- Resultant cirrhosis and eventual development of liver failure
A
Pathophysiology of biliary atresia
11
Q
Physical exam findings of biliary atresia
A
Jaundice, acholic stool, dark urine
12
Q
Management of Biliary Atresia
A
- Kasai procedure
- Nutrition (130-150% recommended daily allowance and 150kcal/kg/day)
- Treatment of cholestasis (actigal, questran, phenobarbital)
- Treatment of portal hypertension
- Liver transplantation
13
Q
Most common indication for liver transplantation
A
Biliary Atresia
14
Q
Pain on deep inspiration when the inflamed gallbladder is palpated
A
Murphy sign
15
Q
Five Types of Esophageal Atresia
A
Type A: EA w/out fistula
Type B: EA w/ proximal fistula
Type C: EA with distal fistula; most common type
Type D: EA w/ proximal and distal fistula
Type E: Tracheoesophageal fistula w/out atresia
16
Q
- Newborn with excessive oral secretions, drooling, accompanied by coughing, choking, or sneezing
- Feeding can cause cyanosis, choking, emesis
A
clinical presentation of EA
17
Q
- Obstruction of proximal duodenum secondary to failure of recanalization
- Associated with T21
A
Duodenal Atresia
18
Q
Bilious emesis in the first hours of life
A
clinical presentation of duodenal atresia
19
Q
Abdominal radiograph with a double bubble sign representing the stomach and proximal duodenum
A
diagnostic evaluation of duodenal atresia
20
Q
Antidiarrheal medications often contain aspirin, which contributes to Reye syndrome and show be avoided. True or False
A
True
21
Q
Reasons for upper GI bleeding
A
- Ulcers (gastric or dodenal)
- Helicobacter pylori
- Esophageal varices
- Liver disease
22
Q
Reasons for lower GI bleeding
A
- Infectious colitis
- Colonic polyps
- Allergic colitis/milk-protein enteropathy
- Anal fissure
- IBD (Crohn, UC)
- Ischemia (intussusception, obstruction)
- Meckel diverticulum
23
Q
- Hematemesis/bright red blood from GT
- coffee-ground emesis/output from gastric tube
A
clinical presentations of upper GI bleeding
24
Q
- Melena: hemoccult positive stool with black, tarry appearance
- Hematochezia (painful vs painless)
A
clinical presentations of lower GI bleeding
25
- metabolism of glucose, lipid, nitrogen, drugs, toxins
- synthesis of albumin and coagulation factors
- formation of bile and bile acids
Functions of the liver
26
Hepatitis A
fecal-oral; common in child care centers; contaminated food/water
27
Hepatitis B
blood, saliva, semen, transplacental; infants especially susceptible
28
Hepatitis C
mother to infant, blood, saliva, semen
29
Labs that can help distinguish if source is liver or other muscle/tissue etiology
- Fractionated alkaline phosphatase
- GGT
30
Rapid decrease in AST/ALT with increased coagulation and bilirubin suggests worsening hepatic failure. True or False.
True
31
Hepatitis Pearls
- Vaccination is available and part of the recommended immunization schedules for Hep A and B
- Diagnosis of Hep A does not lead to chronic infection
32
Unconjugated/indirect bilirubin levels suggest
hemolytic cause
- Physiologic (newborns): increased erythrocyte breakdown, enzyme deficiency, increased extrahepatic circulation
- Pathologic: infection, G6PD deficiency, ABO incompatibility, Gilbert syndrome
33
Conjugated/direct bilirubin levels suggest
hepatobiliary disease
- anatomic/obstruction: BA, choledochal cyst, gallstones/sludge, CF
- Infectious: sepsis, UTI, viral
- Metabolic/Genetic: Alagille syndrome, Down syndrome
34
Irreversible, bilirubin-induced brain dysfunction as a result of bilirubin deposition into gray matter of brain
Kernicterus
35
Hyperbilirubinemia Pearls
- Physiologic: total bilirubin e14mg/dL; resolves in 2 weeks
- Hyperbilirubinemia in children >2 weeks of age requires further investigation
- Direct bilirubin level e1.5mg/dL requires further evaluation
36
- nonmechanical obstruction of the intestines
- disruption of peristalsis that can be partial or complete, results in dilation of proximal intestines
Ileus
37
Management of Ileus
- bowel rest, NGT for decompression
- Postop pain management w/out narcotics
- Ambulation and time
38
inflammatory process that can affect any portion of the GI tract; most commonly affects the terminal ileum; inflammation is the entire lumen of the intestines
Crohn Disease
39
inflammatory process that affects the colon and rectum; inflammation is the mucosal layer of the intestinal wall
Ulcerative Colitis
40
feeling that you need to pass stools, even though your bowels are already empty
tenesmus
41
clinical presentation of Crohn disease
pain, diarrhea, weight loss, perirectal inflammation with fistula
42
clinical presentation of ulcerative colitis
bloody, watery diarrhea, weight loss, tenesmus, urgency
43
gold standard diagnosis of IBD
endoscopy of intestinal tract w/ bx and histology
44
Liver transplant management
- Immunosuppression therapy (tacrolimus)
- Ppx antibiotic/antiviral meds
- Close monitoring for infection
- Fluid management
- Anticoagulants (aspirin)
45
small bowel twists around the superior mesenteric artery, resulting in vascular compromise to large portions of the midgut
volvulus
46
asymptomatic anatomical variant that occurs as a result of incomplete rotation of the intestine during fetal development
malrotation
47
The diagnosis of malrotation can be made on plain films alone. True or False
False
48
Preferred study to evaluate the position of the ligament of Trietz in malrotation
Upper GI series
49
Purpose of the Ladd procedure is not to return the bowel to a normal configuration, which is anatomically impossible, but to minimize future risk of volvulus by widening the mesentery, and placing the bowel in a nonrotation position. True or False
True
50
Bilious vomiting in a neonate is highly suspicious for...
malrotation
51
most common congenital abnormality of the small intestine, caused by an incomplete obliteration of the omphalomesenteric duct
Meckel Diverticulum
52
Painless GI bleeding is the most common symptom of what GI disorder
Meckel Diverticulum
53
Gold standard for diagnosing Meckel diverticulum
Meckel scan or scintigraphy
54
Meckel Diverticulum Pearl
Although the hallmark of Meckel diverticulum is painless rectal bleeding, other symptoms may predominate. Bowel obstruction, appendicitis-like symptoms, or an acute abdomen with bleeding may represent a symptomatic Meckel diverticulum
55
Hallmark sign of necrotizing enterocolitis
pneumatosis intestinalis on abdominal radiograph
56
- Metabolic acidosis (dehydration)
or
- Metabolic alkalosis (vomiting)
- Hypochloremia, hypokalemia, hyperbilirubinemia
- Peristaltic waves across abdomen
- Olive-sized mass in RUQ
Pyloric Stenosis
57
Bowel resection that can lead to decreased cholecystokinin and gastric hypersecretion
Jejunal resection
58
Bowel resection that can lead to overgrowth of bacteria in small intestine
Ileocecal valve resection
59
Bowel resection that can lead to malabsorption, steatorrhea, secretory diarrhea, decreased transit time
Ileal resection
60
Bowel resection that can lead to increased gastric emptying
colonic resection
61
acute pain defined as either somatic (skin, bone, connective tissue) or visceral (internal organs)
nociceptive
62
pain due to nerve damage
neuropathic
63
pain due to the abnormal presence of, or inappropriate activation of, abnormal pain pathways within the nervous system
functional
64
short lived and occurs with an injury or near the injured tissue due to an adverse chemical, thermal, or mechanical stimulus
acute
65
any pain (nociceptive, neuropathic, or functional) that lasts longer than 1 month
chronic
66
state of sedation that provides anxiolysis
minimal sedation
67
drug-induced depressed consciousness, but patient is able to respond purposefully to verbal commands or light physical stimulation
moderate sedation
68
drug-induced depressed consciousness from which patient is not easily aroused, and has partial or complete loss of protective reflexes
deep sedation
69
drug-induced loss of consciousness; patient is not arousable even to painful stimuli
general anesthesia
70
Sedatives (5)
Midazolam, lorazepam, diazepam, etomidate, pentobarbital
71
Midazolam (versed) uses and side effects
Uses: anxiolysis/amnesia, procedural sedation, mechanical ventilation
Side effects: hypotension, bradycardia, cardiac arrest, respiratory depression or arrest
72
Lorazepam (ativan) uses and side effects
Uses: sedation, procedural sedation, mechanical ventilation
Side effects: respiratory depression, apnea, bradycardia, and circulatory collapse; high dose/long-term use of parenteral formulation may result in toxicity (lactic acidosis, osmotic gap, and renal failure) as related to formulation with polyethylene glycol
73
diazepam (valium) uses and side effects
Uses: procedural sedation, sedation/anxiolysis
Side effects: sudden hypotension, cardiac arrest, laryngospasm, apnea or respiratory depression may result from rapid IV push
74
Pentobarbital uses and side effects
Uses: procedural sedation, hypnotic
Side effects: respiratory depression, apnea, laryngospasm, arrhythmias, bradycardia, hypotension, syncope, angioedema
75
Analgesics
Morphine, hydromorphone, fentanyl, methadone, dexmedetomidine, clonidine, ketamine, Propofol
76
Morphine, Hydromorphone, Fentanyl side effects
Respiratory depression, orthostatic hypotension, CNS depression, increased ICP, histamine release, chest wall rigidity (fentanyl)
77
Methadone side effects
Respiratory depression, prolonged QT or torsade de pointes, death, cardiac arrhythmias, increased ICP, histamine release
78
Dexmedetomidine (Precedex) uses and side effects
Uses: sedation (ICU/procedural)
Side effects: respiratory acidosis, pulmonary edema, bradycardia, sinus arrest, hypotension, and hypertension
79
Ketamine side effects
Respiratory depression, laryngospasm, hypersalivation, tachycardia, hypertension, hypotension, increased cerebral blood flow, postanesthetic delirium
80
Propofol side effects
Continuous infusion not recommended in pediatrics to risk of Propofol infusion syndrome (severe metabolic acidosis, hyperkalemia, lipemia, rhabdomyolysis, hepatomegaly, cardiac failure, kidney failure)
81
Neuromuscular Blocking Agents (5)
Succinylcholine, Cisatracurium, Pancuronium, Rocuronium, Vecuronium
82
Reversal agent for benzodiazepine
Flumazenil
83
Reversal agent for narcotics
Naloxone
84
Reversal agent for neuromuscular blocking agents
Neostigmine
85
Neostigmine side effects
Severe salivation (administer with atropine or glycopyrrolate)
86
Pre-procedure Fasting Guidelines
Clear liquids - 2hr
Human breast milk - 4hr
Infant formula or milk - 6hr
Solid - 8hr
87
Decrease in drug's effect over time or the need to increase the dose to achieve the same effect
Tolerance
88
Continued need for the drugs' administration to prevent withdrawal
Dependence
89
Constellation of physical symptoms that occurs when an opioid or benzodiazepine is abruptly discontinued in a patient who has developed tolerance
Withdrawal
90
Pediatric patient's receiving sedation and/or analgesic agents 5 days are at risk for withdrawal. True or False
True
91
Withdrawal is seen in 100% of pediatric patients receiving opioids or benzodiazepines for >9days and will require a slow sedation taper. True or False
True
92
Fentanyl, unlike morphine, is not associated with histamine release, making it useful in children with bronchospasm and those with hemodynamic instability. True or False
True
93
Which NMBA pharmacokinetics are independent of kidney and liver functions to reduce inadvertent prolongation of NMBA
Cisatracurium
94
Train of four (TOF)
Used to measure the degree of neuromuscular blockade with a nerve stimulator; assists in preventing complications of prolonged neuromuscular blockade and allows for minimal medication administration; facial and ulnar nerves are most commonly used for TOF evaluation
95
What is the desired number of elicited twitches in a TOF evaluation
at least 1/4
96
If chest wall rigidity occurs from administering fentanyl too fast, it is treated with...
narcotic antagonists or NMBAs
97
Four features of delirium
1) inattention and disturbance in consciousness
2) change in cognition (memory deficits, disorientation, language disturbances
3) acute onset
4) fluctuating course
98
Physical status classification scale was developed to assist in determining the status of patients prior to surgery, thus offering information on anesthesia risk
ASA (American Association of Anesthesiologist)
