General Inpatient Supportive Care

Question 1

ABCs of medicine

Answer 1

1. Airway
2. Breathing
3. Cardiovascular stability

In that exact order of importance. This is the order in which you assess a critically ill individual.

Question 2

Ventilation in the case of diaphragmatic hernia

Answer 2

This is somewhat of a special case

Intubation here must be endotracheal, not just bag and mask. Bag and mask will also ventilate the gut, which in the case of diaphragmatic hernia is going to limit the thoracic volume available for ventilation.

Question 3

Classic presentation of choanal atresia

Answer 3

• Aka nasal septum
• Infant is dusky and cyanotic, struggles to breathe when at rest. But, when they start crying, they become pink again.
• This is because babies are generally obligate nose breathers, except when they are crying.
• Intubate with endotracheal tube until surgery may be performed to repair obstruction

Question 4

When a baby’s HR is < 60 despite PPV and 100% oxygen, the next step is. . .

Answer 4

. . . chest compressions

Do compressions for 30 seconds, then give epinephrine

Question 5

In an infant with RDS of the newborn, the degree of tachypnea often precludes ___

Answer 5

In an infant with RDS of the newborn, the degree of tachypnea often precludes oral feeding

NG tube is usually required

Question 6

Parkland fluid for burns

Answer 6

• 50% in first 8 hours
• 50% in next 16 hours
• Parkland formula:
  
  • % body surface area covered by 2nd or 3rd degree burns x 4 x body weight in kg

Question 7

Rule of 9’s (child vs adult)

Answer 7

Question 8

Routine ultrasounds in Beckwith-Wiedemann patients

Answer 8

Since these patients at at increased risk for abdominal tumors (hepatoblastoma, Wilm’s tumor, neuroblastoma), serial abdominal ultrasounds with view of the kidneys are recommended every 2-3 months until 4 years of age.

Question 9

If you cannot obtain venous access in an infant, what is the next type of access to try?

Answer 9

Intraosseous line in the proximal tibia

Question 10

Crystalloid of choice for ongoing fluid losses in the setting of burn in a child (> 1 month - 18 years)

Answer 10

• LR + dextrose is the fluid of choice
• 4,2,1 rule:
  
  • 4 mL/kg/hour for the first 10 kg
  • • 2 mL/kg/hour for the next 10 kg
  • • 1 mL/kg/hour for the remaining weight
• In children < 14, Parkland’s formula is:
  
  • 3 mL x % of TBSA affected (by 2nd and 3rd degree) x body weight in kg

Question 11

Modified Parkland’s formula

Answer 11

• Used to guide initial fluid therapy in the setting of burns
• Formula:
  
  • Vol. of LR to be administered in 24 h = x mL x % TBSA (2nd or 3rd degree) x body weight in kg
  • Where x = 2 for > 14 y.o. and x = 3 for < 14 y.o.
• x used to be 4 for adults, but this was more than necessary and often precipitated heart failure. Kids tolerate fluids well, so no change needed there.
• Administer half of this volume in first 8 hours, and the rest over the subsequent 16 hours

Question 12

Holliday-Segar method

Answer 12

• For approximating daily maintenance fluids for a child
• 100 mL/day for the first 10 kg
• 50 mL/day for the next 10 kg
• 20 mL/day for each kg thereafter

Question 13

4-2-1 rule

Answer 13

• Method for approximating hourly maintenance fluids in a child
• 4 mL/kr/hr for the first 10 kg
• 2 mL/kg/hr for the next 10 kg
• 1 mL/kg/hr for each kg thereafter

Question 14

Optimal maintenance fluids in infants vs children vs adolescents and adults to maintain electrolyte balance

Answer 14

• Infants: 1/4 NS with 10% dextrose and 20 mEq/L KCl
• Children: 1/4 NS with 5% dextrose and 20 mEq/L KCl
• Adolescents and adults: 1/2 NS with 5% dextrose and 20 mEq/L KCl

Question 15

Three goals of fluid management

Answer 15

1. Achieve and maintain adquate hydration
   
   • Achieved through fluid and sodium
2. Maintain electrolyte homeostasis
   
   • Achieved through adding 20 mEq/L KCl
3. Prevent catabolism
   
   • Achieved through adding dextrose

Question 16

Hypotension in children vs adults

Answer 16

• In adults, mild hypotension is a sensitive indicator of dehydration
• In children, hypotension is a late sign that is quite ominous.
• You should not think that a child is not dehydrated just because they are not hypotensive.

Question 17

Capillary refill in a child

Answer 17

• >2 seconds is normal, but may still be dry
• 2-3 seconds is mildly dry
• >3 seconds is quite dry

Question 18

WHO recommendation for optimal oral rehydration therapy

Answer 18

• Indicated for mild-to-moderate dehydration
• 90 mEq/L Na, 20 mEq/L K, 20 g/L glucose

Question 19

Fluid bolus for severe dehydration

Answer 19

• Children in hypovolemic shock should receive 20 mL/kg IV boluses of isotonic fluid (NS or LR) until blood pressure normalizes

Question 20

Most children should have half of fluid deficit repleted over the first 8 hours and the other half over the next 24 hours. What is the exception to this case?

Answer 20

• Hypernatremic dehydration
  
  • These children are at risk of cerebral edema if fluids are repleted too quickly
  • Fluids should be replaced over 48-72 hours

Question 21

Ongoing loss replacement in dehydrated kids

Answer 21

• Ongoing losses (at least sensible losses) should be measured and repleted mL-for-mL with an electrolyte content comparable to what is being lost
  
  • 1/2 NS for GI losses
  • Dependent upon urine composition for renal losses

Question 22

IV fluids should not contain potassium UNTIL. . .

Answer 22

. . . the patient urinates

Question 23

Effects of glucose on serum Na

Answer 23

• Corrected sodium is:
  
  • Na_corrected = Na_observed - 0.016 x (100 - Glucose)

Question 24

Treatment of hyponatremia

Answer 24

• 1st line: Fluid restriction, correction of underlying pathology (renal disease, SIADH)
• Life-threatening scenarios: 3% hypertonic saline may be used cautiously. This is truly reserved for life-threatening complications such as intractable seizures.
• Serum sodium correction should not exceed 1-2 mEq/L/hr to avoid central pontine myelinolysis

Question 25

Neonatal hypermagnesemia

Answer 25

• May be seen in cases where mom was given large doses of magnesium for tocolysis or preeclampsia
• Baby will present with lethargy, muscle weakness, respiratory difficulty
• Treat w/ extra calcium to competitively antagonize magnesium. In severe cases or if renal failure is present, hemodialysis is indicated.

Question 26

Most reliable finding for metabolic acidosis on exam

Answer 26

Hyperpnea in the presence of normal oxygen saturation

Question 27

Treatment of metabolic acidosis

Answer 27

• Correction of the underlying abnorality
• Sodium bicarbonate therapy is reserved for VERY SEVERE cases, where pH < 7.00. It requires frequent monitoring of blood pH, sodium, potassium, and calcium.
  
  • As it may induce alkalosis (overcorrection), hypokalemia, hyponatremia, and hypocalcemia

Question 28

DDx for metabolic alkalosis

Answer 28

• Excessive vomiting
  
  • Pyloric stenosis
  • Bulimia
  • Hyperemesis gravidarum
• Loss through sweat
  
  • Pathognomonic feature of CF
• Chloride-wasting diarrhea
• Laxative abuse
• Iatrogenic
  
  • Loop diuretics and thiazides

Question 29

When correcting hypernatremia you are worried about ___. When correcting hyponatremia you are worried about ___.

Answer 29

When correcting hypernatremia you are worried about cerebral edema. When correcting hyponatremia you are worried about central pontine myelinolysis.

Question 30

Rate of decline of ESR, CRP, ferritin

Answer 30

• CRP declines w/in a day
• ESR declines w/in multiple days
• Ferritin can take weeks to months

Question 31

Ventilator-sparing agents

Answer 31

• CPAP
• BIPAP
• Helium