Mid-Semester Revision

Question 1

Airway Anatomical Differences

Answer 1

• Larger Occiput – need to raise head to maintain airway.
• Tongue is disproportionately large – more able to obstruct airway
• Larynx higher in neck and narrowest point is the cricoid (below vocal chords which is narrowest point in adult) so obstruction may lodge lower than in adult
• Vocal cords angled down – airway conical in shape
• Large floppy epiglottis
• Compressible floor of mouth – may obstruct airway with grip if not cautious
• Short soft trachea
• Loose teeth
• Small changes are proportionally more significant

Question 2

Breathing Anatomical Differences

Answer 2

• Diaphragmatic breathers (esp. small children).
• Diaphragmatic splinting – Abdominal Distension and obesity push the diaphragm into the thorax lead to increased work of breathing (CPR ventilation can cause abdominal distention)
• Compliant chest and horizontal ribs limit ability of thorax to increase tidal volume. Accommodate by increased RR
• Minute volume = rate dependant
• Lower proportion of type 1 muscle fibres
• Increased WOB leads to earlier fatigue
• Lower proportional lung surface area + increased basal metabolic rate = higher demand proportional to adult
• Decreased FRC (Functional Residual Capacity) = more likely to have alveolar collapse
• Higher RR also increases risk of inhaling airborne pathogens

Question 3

Circulation Anatomical Differences

Answer 3

• Limited ability to increase SV (stroke volume), especially at < 2 years of age o Rate dependent Cardiac Output - Impressive ability to maintain BP with vessel tone – vasoconstriction o Compensate well but BP can fall rapidly!! - Low total blood volume o 70/80mL/kg

Question 4

Body Surface Area Anatomical Differeces

Answer 4

• Proportionally larger than adults - Increased risk of excessive loss of heat and fluids. More quickly affected by toxins absorbed through the skin - Also thinner skin  increased absorption through skin

Question 5

Immune System Physiological Differences

Answer 5

• Immature immune system. Greater risk of infection through skin and inspiration. - Less hard immunity to infections.

Question 6

Key Physiological and Psychological Development milestones

Answer 6

6 months – rolling over 10 months – sitting alone 12 months – crawling 12 months – talking (at all) 18 months – walking 24 months – talking with basic sentences

Question 7

Drug Calculation Formula - APLS

Answer 7

Age < 1 year – (months + 8)/2 Age 1-5 – (Age x 2) + 8 Age >5 – (Age x 3) + 7

Question 8

Normal Vital Signs

Answer 8

Question 9

Formula for Calculating ETT size and depth of insertion

Answer 9

Size ETT (mm internal diameter) = Age/4 + 4

Length ETT (cm at lips) = Age/2 + 12

*If using cuffed ETT, use half a size smaller (0.5 mm)

Question 10

Endotracheal Intubation - Indications

Answer 10

Airway obstruction - airway trauma, foreign body, congenital malformation, infection

Respiratory failure - impaired gas exchange or respiratory pump failure

Inability of patient to protect airway

Question 11

Endotrachal Intubation - Equipment required

Answer 11

SOAPIM

Suction

Oxygen

Airway equipment - ETT, Laryngoscope, Bite block, BVM, Magill’s forceps, lubrication

Pharmacological agents

Intravenous access

Monitoring

Question 12

Endotrachal Intubation - Complications

Answer 12

Oesophageal intubation

Main bronchus intubation

Trauma to Oropharynx

Pneumothorax

Hypoxaemia

Damage to teeth or tongue

Damage to C-Spine

Question 13

Needle Thoracocentesis - Define

Answer 13

Process of rapidly intering pleural cavity to relieve threatening physiological derangement caused by accumulation of air in pleural cavity

• Temporary measure prior to intercostal catheter insertion

Question 14

Tension Pneumothorax - Signs and Symptoms

Answer 14

Signs

• _Tachypnoea
• _{Tracheal deviation}
• _{Resonance on percussion}
• _{Decreased breath sounds on affected side}
• _{Cardiac apex deviation on affected side}
• _{Hypoxia and Shock}
• _{Distendded neck veins}

Symptoms

• _SOB
• Pleuritic Pain
• Impending sense of doom

Question 15

Needle Thoracocentesis - Complications

Answer 15

• Pneumothorax (10-20% chance if patient does not have tension pneumothorax)
• Nerve bundle damage
• Kinking or dislodgement of catherter leading to re-accumulation of pneumothorax
• Damage to intrathoracic or intraabdomina structures (especially if abdomen distended)

Question 16

Needle Thoracocentesis - Proceedure

Answer 16

1. Identify the 2nd intercostal space in the mid-clavicular line on the side of the pneumothorax (the opposite side to the direction of tracheal deviation)
2. Swab the chest wall with antiseptic solution or alcohol wipe.
3. Attach the syringe to the cannula. Fluid in the cannula will assist in the identification of air bubbles.
4. Insert the cannula perpendicular to the chest wall, just above the rib space, aspirating all the time.
5. If air is aspirated remove the needle, leaving the plastic cannula in place.
6. Tape the cannula in place and proceed to chest drain insertion as soon as possible.

Question 17

IO access- Contraindications

Answer 17

• Recent fracture of bone to be used
• Osteogenesis imperfecta
• Osteoporosis

Question 18

IO access - sites

Answer 18

Tibia, femur, humerus

Question 19

IO access - complications

Answer 19

• Osteomuelitis
• Cellulitis and subcutaneous abscess
• Device not within correct space/in soft tissue of bone or through bone
• Fat embolization
• Fracture and damage to growth plate (avoid angling needle towards joint)
• Septicaemia or Bacteraemia

Question 20

Pelvic Fracture Epidemiology and Aetiology

Answer 20

Pelvic fractures are rare in paediatric patients

Common causes - MVA, fall from height, paedestrian/car collision

Question 21

Pelvic Binder - Procedure

Answer 21

1. Place folded bed sheet underneath the patient – between the iliac crests and greater trochanters.
2. Two team members should cross the sheet across the pubic symphysis and pull the sheet firmly so it tightly fits around and stabilises the pelvis.
3. A third person should clamp the sheet at the four points (away from laparotomy / angiograph access points).

Question 22

C-Spine Anatomical Difference

Answer 22

• Higher fulcrum of neck motion
• Larger occiuput à relative kyphosis when supine
• Weaker neck muscles
• Increased antoeror-posterior motion due to horizontal facet joints and ligament laxity
• Pseudosubluxation
• Greater cartilaginous component
• Presence of growth plates and tapered anterior vertebrae

Question 23

C-Spine Immobilisation - complications

Answer 23

• Airway compromise with bleeding, vomiting or aspiration due to supine position
• Worsening of cervical spine injury in uncooperative or struggling patient
• Hyperextension or flexion of neck
• Limited visualisation of shifted tachea, subcutaneous emphysema or expanding neck haematoma
• Impairment of vascular raining due to compression of external jugular veins

Question 24

C-Spine Injury - Physical Findings

Answer 24

• Midline cervical pain
• Traumatic torticollis
• Limitation of cervical motion
• Motor weakness
• Sensory changes
• Diaphragmatic breathing without retractions
• Hypotension without tachycardia
• Bowel or bladder dysfunction