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Pediatrics > H1. Emergency > Flashcards

H1. Emergency Flashcards

1
Q

In emergency, where to take pulses? (Infants/children)

A

Infants: Brachial artery
Children: Carotid/femoral artery

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2
Q

Capillary refill ranges (3)

A

Normal <2s
Delayed 2-5s
Suggested shock >5s

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3
Q

Formula to determine hypotension

A

Systolic BP < 70 + 2xage

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4
Q

Bradycardia HR, requiring chest compression?

A

HR < 60

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5
Q

End tidal CO2 indicating inadequate chest compression?

A

< 20mmHg

Normal range 35-45

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6
Q

In resuscitation, chest compression depth (Infant/Prepubertal/Adol•Adults)

A

*1/3 AP diameter of the chest

Infant: 1.5 inch (4 cm)
Prepubertal: 2 inch (5 cm)
Adol•Adult: 2 - 2.5 inch (6 cm)

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7
Q

In resuscitation, chest compression rate?

A

100 - 120 / minute

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8
Q

In resuscitation, chest compression/ventilation ratio, method for chest compression?
(Infant•prepubertal, 2 or 1 rescuers)

A

Infant•prepubertal:
when 2 rescuers, 15:2 with two thumbs
when 1 rescuers, 30:2 with two fingers

(Adults: 30:2 when 1 or 2 rescuers)

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9
Q

Location of chest compression? (Infant/prepubertal/adult)

A

Infant: 1 fingerbreadth below the intermammary line
Prepub: 2 fingerbreadths below the intermammary line
Adult: Lower half of the sternum

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10
Q

In resuscitation, what kind of fluid should be used?

A

Isotonic crystalloids (Normal saline or lactated Ringer’s solution)

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11
Q

In resuscitation, how much fluid should be given?

A

20 ml/kg boluses each within 5 min for a total of 60 ml/kg in the first 15 min
(Check for hepatomegaly after each bolus)

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12
Q

In resuscitation, when known or suspected cardiac insufficiency, how much fluid should be given?

A

5 - 10 ml/kg

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13
Q

Types of shock (4)

A

Hypovolemic
Cardiogenic
Distributive
Obstructive

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14
Q

Causes of cardiogenic shock? (4)

A

Congenital heart disease
Myocarditis
Cardiomyopathy
Arrhythmia

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15
Q

Causes of distributive shock? (3)

A

Sepsis
Anaphylaxis
Neurogenic

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16
Q

Causes of obstructive shock? (3)

A

Pulmonary embolus
Cardiac tamponade
Tension pneumothorax

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17
Q

Stridor vs wheezing, sound differences?

A

Stridor: single pitch
Wheezing: musical

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18
Q

Stridor vs wheezing, which respiratory cycle?

A

Stridor: inspiratory
Wheezing: expiratory

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19
Q

Stridor vs wheezing, which airway obstructed?

A

Stridor: large airway with severe obstruction
Wheezing: any size of airway

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20
Q

Single-pitched, inspiratory, severe large airway obstruction.

Stridor vs wheezing?

A

Stridor

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21
Q

Musical, expiratory, obstruction of airway of any size?

Stridor vs wheezing?

A

Wheezing

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22
Q

Sellick maneuver?

A

Cricoid pressure to minimize gastric inflation and aspiration
Excessive use could obstruct the trachea

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23
Q

Cricoid pressure to minimize gastric inflation and aspiration
Excessive use could obstruct the trachea

Name of the maneuver?

A

Sellick maneuver

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24
Q

In conscious patients, what airway is used?

Nasal vs oral airway?

A

Nasal airway

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25
Q

In unconscious patients, what airway is used?

Nasal vs oral airway?

A

Oral airway

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26
Q

How to measure the length of oral airway?

A

From corner of mouth to mandibular angle

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27
Q

How to measure the length of nasal airway?

A

From tip of nose to tragus of ear

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28
Q

Laryngeal mask airway, pro(1) and con(1)?

A

Pro: simple (no laryngoscopy needed), especially in difficult airways
Con: does NOT prevent aspiration

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29
Q

Formula to determine the size of endotracheal tube? (Cuffed/uncuffed)

A

Cuffed: age/4 + 3.5

Uncuffed: age/4 + 4

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30
Q

When cuffed endotracheal tube is preferred? (4)

A

Poor lung compliance
High airway resistance
Glottic air leak
Between age 1-2

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31
Q

Formula to determine depth of endotracheal tube (ETT) insertion?

A

ETT size * 3

ETT size; cuffed: age/4 + 3.5, uncuffed: age/4 + 4

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32
Q

How to measure nasogastric tube length?

A

From nose to angle of jaw to xiphoid

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33
Q

In rapid sequence intubation (RSI),

what’s the purpose?

A

To induce immediate unresponsiveness and muscular relaxation to reduce aspiration risk

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34
Q

Rapid sequence intubation (RSI) indications? (2)

A

High aspiration risk:
Intact gag reflex
‘Full’ stomach ( <4-6 hours from last meal)

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35
Q

In rapid sequence intubation (RSI),

How long is pre-oxygenation recommended in children/adults?

A

Children: minimum 3 minutes
Adults: 3 minutes

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36
Q

In rapid sequence intubation (RSI),

How is pre-oxygenation administered?

A

Non-rebreather mask at 100% oxygen without positive pressure ventilation unless patient’s effort is inadequate

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37
Q

In rapid sequence intubation (RSI),

Why is pre-oxygenation longer in children?

A

Less oxygen/respiratory reserve than adults
Due to higher oxygen consumption
lower functional residual capacity
(Adults: 3min, children >3 min)

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38
Q

Steps for rapid sequence intubation (7)

A
  1. Preparation
    (SOAP-ME;
    Suction, Oxygen, Airway supplies, Pharmacology, Monitoring Equipment)
  2. Pre-oxygenation for minimum 3 minutes

+/- 3. Atropine if at risk for bradycardia (e.g. using succinylcholine)

+/- 4. Cricoid pressure (Sellick maneuver)

  1. Adjunct (Atropine, lidocaine)
  2. Sedative (Thiopental, ketamine, midazolam, fentanyl, etomidate, propofol)
  3. Paralytic (Succinylcholine, vecuronium, rocuronium)
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39
Q

Atropine, mechanism of action? (2)

A

Anticholinergic (= vagolytic, inhibition of parasympathetic system)
Competitive antagonist of the muscarinic receptors (M1,2,3,4,5)

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40
Q

In rapid sequence intubation,

Dosage of atropine?

A

0.02 mg/kg IV/IO

Adult 0.5-1.0 mg/kg, max 3 mg

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41
Q

In rapid sequence intubation,

Effects of atropine? (2)

A

Prevents bradycardia

Reduces oral secretion

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42
Q

In rapid sequence intubation,

Side effects of atropine? (2)

A 
Tachycardia
Pupil dilatation (eliminates the ability to examine neurologic responses i.e. pupil reflexes)
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43
Q

In rapid sequence intubation,

Indications of atropine?

A

High risk of bradycardia (e.g. using succinylcholine)

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44
Q

Lidocaine, mechanism of action?

A

Inactivates the fast voltage-gated Na+ channel in the neuronal cell membrane to prolong action potential of neurons

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45
Q

In rapid sequence intubation,

Dosage of lidocaine?

A

1 mg/kg IV/IO (max 100 mg/dose)

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46
Q

In rapid sequence intubation,

Effects of lidocaine? (3)

A

Blunts ICP spike,
Reduces gag/cough reflexes
Controls arrhythmia

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47
Q

In rapid sequence intubation,

Indications of lidocaine as adjunct? (4)

A

Shock
Arrhythmia
Increased ICP
Status asthmaticus

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48
Q

In rapid sequence intubation,

Drug of choice for adjunct? (2)

A

Atropine

Lidocaine

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49
Q

In rapid sequence intubation,

Drug of choice for sedatives? (6)

A 
Thiopental (Barbiturate)
Ketamine (NMDA antagonist)
Midazolam (Benzodiazepine)
Fentanyl (Opiate)
Etomidate (Imidazole, hypnotic)
Propofol (Sedative, hypnotic)
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50
Q

Thiopental, class of drug?

A

Ultrashort-acting barbiturate

Sedatives

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51
Q

Brand names for thiopental? (2)

A

Pentothal

Trapanal

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52
Q

In rapid sequence intubation,

Dosages for normotensive / hypotensive patients?

A

For the normotensive, 3-5 mg/kg IV/IO

For the hypotensive, 1-2 mg/kg IV/IO

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53
Q

In rapid sequence intubation,

Effects of thiopental? (2)

A

Decrease O2 consumption Decrease cerebral blood flow

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54
Q

In rapid sequence intubation,

Side effects of thiopental? (4)

A

Vasodilatation
Myocardial depression
May increase oral secretion
Cause bronchospasm/laryngospasm (not to be used for asthma)

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55
Q

In rapid sequence intubation,

Indications for thiopental?

A

Drug of choice for increased ICP

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56
Q

In rapid sequence intubation,

What’s DOC for IICP?

A

Thiopental

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57
Q

Thiopental, mechanism of action?

A

Ultrashort-acting barbiturate (GABA agonist; potentiate inhibitory neurons)

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58
Q

Ketamine, class of drug?

A

NMDA receptor antagonist

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59
Q

Ketamine, mechanism of action?

A

NMDA R antagonist in neurons; inhibits action potential of neurons
(NMDA R = inotropic R = ligand gated ion channel)

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60
Q

In rapid sequence intubation,

Dosage of ketamine? IV/IM

A

1-2 mg/kg IV/IO

4-10 mg/kg IM (only drug available for IM)

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61
Q

In rapid sequence intubation, which sedative drug is available for IM?

A

Ketamine

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62
Q

In rapid sequence intubation,

Effects of ketamine? (2)

A

Bronchodilation

Catecholamine release may benefit hemodynamically unstable patients

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63
Q

In rapid sequence intubation,

Side effects of ketamine?

A

May increase BP, HR
May increase oral secretions
May cause laryngo

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64
Q

In rapid sequence intubation,

Drug of choice for asthma?

A

Ketamine

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65
Q

In rapid sequence intubation,

Indication for ketamine?

A

Drug of choice for asthma

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66
Q

Midazolam, class of drug?

A

Short-acting bezodiazepine

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67
Q

Midazolam, mechanism of action?

A

Short-acting benzodiazepine (Increase GABA neurotransmitter)

68
Q

Brand name for midazolam?

A

Versed

69
Q

In rapid sequence intubation,

Dosage of midazolam and max total?

A

0.05 - 0.1 mg/kg IV/IO

Max total dose of 10 mg

70
Q

In rapid sequence intubation,

Effects of midazolam? (2)

A

Amnestic

Anticonvulsant properties

71
Q

In rapid sequence intubation,

Side effects of midazolam? (3)

A

Respiratory depression/apnea
Hypotension
Myocardial depression

72
Q

In rapid sequence intubation,

Indication of midazolam?

A

Mild shock

73
Q

Fentanyl, class of drug?

A

Opiate

74
Q

Fentanyl, brand names for transdermal/oral transmucosal/injection?

A

Duragesic (Transdermal)
Actiq (Oral transmucosal)
Sublimaze (Injection)

75
Q

In rapid sequence intubation,

Dosage of fentanyl?

A

1-3 mcg/kg IV/IO

Fentanyl dosage is in mcg/kg not mg/kg, mg = 1,000 mcg

76
Q

In rapid sequence intubation,

Effects of fentanyl?

A

Fewest hemodynamic effects of all opiates

77
Q

In rapid sequence intubation,

Side effects of fentanyl? (2)

A

Chest wall rigidity with high dose or rapid administration

Cannot use with MAOIs

78
Q

In rapid sequence intubation,

Indication of fentanyl?

A

Shock

79
Q

Etomidate, class of drug?

A

Imidazole/hypnotic

80
Q

Brand names for etomidate? (2)

A

Amidate

Hypnomidate

81
Q

Benefits of etomidate compared to propofol (2)

A

Minimal histamine release

Stable hemodynamic profile

82
Q

Propofol benefits compared to etomidate

A

Rapid onset

83
Q

In rapid sequence intubation,

Dosage of etomidate?

A

0.2-0.3 mg/kg IV/IO

84
Q

In rapid sequence intubation,

Effects of etomidate? (2)

A

Cardiovascular neutral

Decrease ICP

85
Q

In rapid sequence intubation,

Side effects of etomidate?

A

Exacerbates adrenal insufficiency by inhibiting 11-beta-hydroxylase

86
Q

In rapid sequence intubation,

Indication of etomidate?

A

Patients with severe shock, especially cardiac patients

Do not use routinely in patients with septic shock

87
Q

Propofol, mechanism of action? (3)

A

Potentiation of GABA R activity
Na+ channel blocker
Endocannabinoid system

88
Q

Brand names of propofol? (2)

A

Diprivan

Propoven

89
Q

In rapid sequence intubation,

Dosage of propofol?

A

2 mg/kg IV/IO

90
Q

In rapid sequence intubation,

Effects of propofol? (4)

A

Extremely quick onset (15-30s)
Short duration (5-10 min)
Blood pressure lowering
Good antiemetic

91
Q

In rapid sequence intubation,

Side effects of propofol?

A

Hypotension
Profound myocardial depression
Contraindicated patients with egg allergy

92
Q

In rapid sequence intubation,

Indication of propofol

A

Induction for general anesthesia

93
Q

In rapid sequence intubation,

Drug of choice for paralytics? (3)

A

Succinylcholine
Vecuronium
Rocuronium

94
Q

Neuromuscular blockers

Drugs for depolarizing vs nondepolarizing?

A

Depolarizing: succinylcholine
Nondepolarizing: vecuronium, rocuronium

95
Q

Neuromuscular blockers: depolarizing vs nondepolarizing

Initial excitatory response?

A

Depolarizing (succinylcholine): Transient fasciculation

Nondepolarizing (vecuronium, rocuronium): none

96
Q

Neuromuscular blockers: depolarizing vs nondepolarizing

Reactions to cholinesterase?

A

Depolarizing (succinylcholine): not reversed

Nondepolarizing (vecuronium, rocuronium): reversed

97
Q

In rapid sequence intubation,
Dosage of succinylcholine?
(IV/IO, IM)

A

1-2 mg/kg IV/IO

2-4 mg/kg IM

98
Q

In rapid sequence intubation,

Drug available for IM?

A

Succinylcholine

99
Q

In rapid sequence intubation,

Advantages of succinylcholine? (2)

A 
Quick onset (30-60s)
Short duration (3-6min)
Make it an ideal paralytic
100
Q

In rapid sequence intubation,

Disadvantages of succinylcholine?

A

Irreversible (Non-competitive Ach R agonist)

9077

101
Q

Contraindications for succinylcholine (6)

A
  1. Burns
  2. Massive trauma/muscle injury
  3. Neuromuscular disease
  4. Myopathies
  5. Eye injuries
  6. Renal insufficiency
102
Q

In rapid sequence intubation,

Dosage of vecuronium?

A

0.1 mg/kg IV/IO

103
Q

Brand names of succinylcholine? (2)

A

Quelicine

Anectine

104
Q

Brand name of vecuronium?

A

Norcuron

105
Q

Brand names of rocuronium? (2)

A

Zemuron

Esmeron

106
Q

In rapid sequence intubation,

Advantages of vecuronium? (2)

A

Onset 70-120s

Cardiovascular neutral

107
Q

In rapid sequence intubation,

Disadvantages of vecuronium? (2)

A

Longer duration 30-90min

Must wait 30-45 min to reverse with glycopyrrolate and neostigmine

108
Q

In rapid sequence intubation,

Indications for vecuronium? (2)

A

When succinylcholine contraindicated

When longer term paralysis desired

109
Q

In rapid sequence intubation,

Dosages of rocuronium?

A

0.6 -1.2 mg/kg IV/IO

110
Q

In rapid sequence intubation,

Advantages of rocuronium? (3)

A

Quicker onset (30-60s)
Shorter acting than vecuronium (duration 30-60 min; may reverse in 30 min with glycopyrrolate and neostigmine)
Cardiovascular neutral

111
Q

What class of glycopyrrolate and neostigmine?

A

Anticholinergic drugs

Reverse nondepolarizing neuromuscular blockers

112
Q

Brand name of glycopyrrolate?

A

Robinol

113
Q

Brand name of neostigmine

A

Bloxiverz

114
Q

Brand name of vecuronium?

A

Norcuron

115
Q

Brand names of rocuronium? (2)

A

Zemuron

Esmeron

116
Q

In rapid sequence intubation,

Advantages of vecuronium? (2)

A

Onset 70-120s

Cardiovascular neutral

117
Q

In rapid sequence intubation,

Disadvantages of vecuronium? (2)

A

Longer duration 30-90min

Must wait 30-45 min to reverse with glycopyrrolate and neostigmine

118
Q

In rapid sequence intubation,

Indications for vecuronium? (2)

A

When succinylcholine contraindicated

When longer term paralysis desired

119
Q

In rapid sequence intubation,

Dosages of rocuronium?

A

0.6 -1.2 mg/kg IV/IO

120
Q

In rapid sequence intubation,

Advantages of rocuronium? (3)

A

Quicker onset (30-60s)
Shorter acting than vecuronium (duration 30-60 min; may reverse in 30 min with glycopyrrolate and neostigmine)
Cardiovascular neutral

121
Q

What class of glycopyrrolate and neostigmine?

A

Anticholinergic drugs

Reverse nondepolarizing neuromuscular blockers

122
Q

Brand name of glycopyrrolate?

A

Robinol

123
Q

After endotracheal tube intubation,

What can signify acute respiratory failure (4)

A 
DOPE
Displacement of the ETT
Obstruction
Pneumothorax
Equipment failure
124
Q

In resuscitation,

Mouth-to-mouth or mouth-to-nose breathing duration/volume per breath?

A

1 sec/breath

Adequate volume to cause chest rise

125
Q

In resuscitation,

Mouth-to-mouth or mouth-to-nose breathing rate for newborns?

A

One breath for every three chest compression

126
Q

In resuscitation,

Mouth-to-mouth or mouth-to-nose breathing for infants/children with one rescuer?

A

Two breaths after 30 compressions

127
Q

In resuscitation,

Mouth-to-mouth or mouth-to-nose breathing for infants/children with two rescuer?

A

Two breaths after 15 compressions

128
Q

In resuscitation,

Bag-mask ventilation rate in infants/children?

A

Infants: 30 breaths/min
Children: 20 breaths/min

129
Q

Definition of anaphylaxis (4)

A
  1. A rapid onset
  2. immunoglobulin (Ig) E-mediated
  3. systemic allergic reaction
  4. involving multiple organ systems, including two or more of the followings:
    A. Cutaneous/mucosal (flushing, urticaria, pruritus, angioedema)
    B. Respiratory (laryngeal edema, bronchospasm, dyspnea, wheezing, stridor, hypoxemia)
    C. Gastrointestinal (vomiting, diarrhea, nausea, abdominal pain)
    D. Circulatory (tachycardia, hypotension, syncope)
130
Q

Organ systems and symptoms involved in anaphylaxis and its percentage(4)

A

A. Cutaneous/mucosal (flushing, urticaria, pruritus, angioedema) ~90%
B. Respiratory (laryngeal edema, bronchospasm, dyspnea, wheezing, stridor, hypoxemia) ~ 70%
C. Gastrointestinal (vomiting, diarrhea, nausea, abdominal pain) ~40-50%
D. Circulatory (tachycardia, hypotension, syncope) ~30-40%

131
Q

Anaphylaxis initial reaction onset and recurring time

A

Initial reaction may be delayed for several hours
AND
Symptoms may recur up to 72 hours after initial recovery

132
Q

Anaphylaxis management steps (9)

A
  1. Remove stop exposure to precipitating antigen
  2. Epinephrine IM/SQ
  3. Establish airway
  4. Obtain IV access, fluid or cardiac inotropes
  5. Histamine-1 receptor antagonist (dyphenhydramine) or histamine-2 receptor antagonist (ranitidine)
  6. Corticosteroid
  7. Albuterol (for bronchospasm or wheezing)
  8. Racemic epinephrine (for upper respiratory obstruction)
  9. Should be discharged with Epi-pen
133
Q

In anaphylaxis,

Dosage of epinephrine

A

0.01 mg/kg IM/SQ

134
Q

Sites of epinephrine IM/SQ in case of anaphylaxis

A

Lateral aspect of thigh, owing to its vascularity

135
Q

Histamine receptor antagonists used for anaphylaxis and dosages

A

Histamine0

136
Q

Brand name of diphenhydramine

A

Benadryl

137
Q

Brand name of ranitidine

A

Zantac

138
Q

Dosage of diphenhydramine (Benadryl) for anaphylaxis (max)

A

1-2 mg/kg IM/IV or PO

Max 50 mg

139
Q

What phase of the allergic response that can be helped by corticosteroids?

A

Late phase

140
Q

Corticosteroids dosages for anaphylaxis?

A

Methylprednisolone 2 mg/kg IV bolus
-> 2 mg/kg/day IV/IM q6hr
or
Prednisone 2 mg/kg PO qD

141
Q

Albuterol dosage for anaphylaxis? (> 30kg)

A

2.5 mg for <30 kg
5 mg for >30 mg
Every 15 min as needed

142
Q

How racemic epinephrine is used for anaphylaxis

A

Inhaled

0.5 mL of 2.25% solution

143
Q

When racemic epinephrine is used for anaphylaxis?

A

Upper airway obstruction

144
Q

With what patient of anaphylaxis should be discharged?

A

Epi-Pen (>30 kg)
Epi-Pen Junior (< 30kg)
Anaphylaxis action plan

145
Q

Common causes of respiratory emergencies? (4)

A
  1. Asthma
  2. Upper airway obstruction
    a) epiglottitis
    b) croup
    c) foreign body obstruction
146
Q

The hallmarks of upper/lower airway obstruction?

A

Upper airway obstruction: stridor

Lower airway obstruction: cough, wheeze, prolonged expiratory phase

147
Q

Asthma triad

A

Inflammation
Bronchospasm
Increased secretions

148
Q

Asthma assessment (7)

A
  1. Respiratory rate
  2. Work of breathing
  3. O2 saturation
  4. Heart rate
  5. Peak expiratory flow
  6. Alertness
  7. Color
149
Q

Asthma initial management (5)

A
  1. O2 to keep saturation >95%
  2. Inhaled b-agonisits (albuterol)
  3. Ipratropium bromide (atrovent)
  4. Steroids
  5. Consider epinephrine, terbutaline, magnesium sulfate
150
Q

Ipratropium bromide, mechanism of action?

A

Muscarinic acetylcholine antagonist

Medium-large airway dilatation

151
Q

Ipratropium bromide, brand name?

A

Atrovent

152
Q

For asthma, how to use steroid?

A

Mild to moderate:
prednisone/prednisolone 2mg/kg (max 60mg) PO qD for 5 days
or
dexamethasone 0.6 mg/kg (max 16 mg) qD for 2 days

Severe:
Methylprednisolone 2mg/kg IV/IM bolus, then 2 mg/kg/day divided q6h

153
Q

Systemic steroids require a minimum of _____ (time) to take effect

A

2-4 hours

154
Q

For asthma, drugs to consider if air movement still poor after initial treatment (3)

A

Epinephrine
Terbutaline
Magnesium sulfate

155
Q

For asthma, dosage of epinephrine?

A

0.01 mg/kg of 1:1000 SQ/IM (maximum dose 0.5mg)

156
Q

In asthma, effects of epinephrine? (3)

A

Bronchodilator
Vasopressor
Inotropic effects

157
Q

Terbutaline, mechanism of action?

A

b2-adrenergic receptor agonist
(“Reliever” inhaler for asthma,
tocolytics for preterm labor)

158
Q

Terbutaline, brand name?

A

Bricanyl

159
Q

When to consider IV terbutaline?

A

If no response to second dose of SQ terbutaline

160
Q

When using terbutaline for asthma, what to monitor? (4)

A

12-lead ECG
Cardiac enzymes
UA
Electrolytes

161
Q

For asthma, when to consider terbutaline? (2)

A

Severely ill patients

Patients who are uncooperative with inhaled beta agonists

162
Q

For asthma, dosages of magnesium sulfate?

A

25 to 75 mg/kg/dose IV or IM
(max 2g)
infused over 20 min

163
Q

For asthma, magnesium sulfate, mechanism of actions?

A

Smooth muscle relaxant; relieves bronchospasm

164
Q

Precautions to take when giving magnesium sulfate?

A

Many give a saline bolus prior to administration,

because hypotension may result

165
Q

For asthma, contraindications of magnesium sulfate? (2)

A

Significant hypotension

Renal insufficiency

165
Q

Asthma management:

A normalizing PCO2 is often a sign of ________.

A

Impending respiratory failure

During an asthma exacerbation there is air trapping and ventilation/perfusion mismatch, resulting in hypoxemia. Initially compensation occurs and hyperventilation causes the PCO2 to decrease. When further air trapping leads to decreased lung compliance and increased work of breathing, the PCO2 will begin to increase.

Pediatrics (24 decks)

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