Module 12 Flashcards
Week 12 Anesthesia III – Pediatrics
Chapter 39: Pediatric Trauma - buns - noods
- As you read the chapter, please be certain to review the following topics:
- Fasting duration
- Blood product transfusion
- Cervical spine injuries
- Review table 39.7 (medications); figures 39.6 and 39.7 (trauma/shock and head injury)
Pediatric Trauma
- Injuries are the most common cause of death within the US for children older than 1 year of age.
- ______(1) injuries are the leading cause of death among children.
- Most traumatic injuries in children result from
- MVA
- Falls
- Nonaccidental trauma
- Drowning
- Extremes of temperature
Trauma Scoring Systems
Glasgow Coma Scale (GCS) and the modified GCS
Pediatric Trauma Score (PTS)
ABCs of Resuscitation
A = ______(2)
B = ______(3)
C = ______(4)
D = ______(5)
E = ______(6)
Answers:
1. Head
2. Airway with cervical spinal control
3. Breathing & Ventilation (O2 & SaO2)
4. Circulation with hemorrhage control
5. Disability and neurologic control
6. Exposure & environmental control
Surveys
- Primary survey – incorporates the “______(1)” and life-threatening injuries are identified and treated
- Secondary survey – other injuries that contribute to significantly to illness and deaths are identified and treatment is instituted
- ATLS course (Advanced Trauma Life Support)
- SAMPLE Report
SYMPTOMS
ALLERGIES
MEDICATIONS
PAST MEDICAL HISTORY
LAST MEAL
EVENTS LEADING TO INJURY
Preoperative Evaluation
- Vital signs
- Airway/cervical spine evaluation
- Planned surgical procedure
- List of known injuries
- Management since arrival
- Relevant laboratory/imaging results
-Past medical/surgical history/family history - Allergies/current medications
- Fasting time
Primary Survey THINK ABCDEs!
- Airway
- Breathing
- Circulation and Access
- Disability (Neurologic Assessment)
- Exposure
Criteria for Early Intubation
Cardiac arrest
- Clinical signs of shock
- Hypoxia
- Hypercarbia
- Signs of developing ______(2)
- Head injury with ______(3) in mental status
- Burn injury with airway involvement
- Combativeness
- Chest trauma with ______(4)
- ABC’s
- airway obstruction
- decrease
- dyspnea
Fasting Duration
- It is common to consider all trauma patients at risk for ______(1) regardless of the ______(2) of last ______(3) intake.
- ______(4) gastric emptying & distention
- Major injury
- At time of injury, considered “time zero”
- Pain
- Anxiety
- ______(5)
Fluid Resuscitation
- Goal is to maintain ______(6) in the presence of ongoing blood loss and/or third-spacing
- Colloids, such as ______(7) albumin
- PRBCs, FFP, Platelets and Cryoprecipitate and Factor ______(8)
- aspiration
- time
- oral
- Delayed
- Opioids
- normovolemia
- 5%
- VIIA
Blood Product Transfusion
- Be sure you can recall the dosages and indications for each of the following:
- PRBCs
- FFP
- Platelets
- Cryoprecipitate
- Factor VIIA
Fluid Management
- Consider isotonic solutions
- Avoid _______(1) solutions
- especially when concerned with CNS injury
- Monitor blood glucose
- Per current literature, blood glucose should be maintained less than _______(2)
- depending upon your facility protocol
Vascular Access
- Establish _______(3) access ASAP!
- Intraosseous (IO) access if _______(4) cannot be established
Answers:
1. dextrose-containing
2. 130-200
3. IV
4. IV
Neuro
Induction
- Rapid sequence induction
- Consider hemodynamic status
- If less than ______(a) volume deficit (normotensive), then consider propofol & Sch or _______(1)
- If _______(b) blood loss (normotensive and HR <110), then consider Ketamine (______(c) mg/kg) or Etomidate (0.2 - 0.3 mg/kg) and Sch
- If your patient has > ______(d)% blood loss (hypotensive, ______(e), respiratory distress, anuria, cold extremities) then you must be _______(2) with the aforementioned agents because of hemodynamic instability!
Specific Injuries
- Head injuries
- _______(3) spine injuries
- Facial trauma
- Dog bites (______(f) of all bites > ______(g) years of age)
- Soft-tissue neck trauma
- Chest trauma
- Abdominal trauma
- Lawnmower related injuries
- Skeletal injuries
- _______(4)
Answers:
1. Rocuronium
2. extremely cautious
3. Cervical
4. Abuse
a. 10%
b. 10-20%
c. 1-2
d. 25%
e. tachycardia
f. 68%
g. 5
Head Injuries
- Traumatic Brain Injury (TBI) is the leading cause of morbidity and mortality resulting from trauma in children.
- Results in life long disability and significant expense.
- Adequate venous drainage (_______(1), heads up position)
- Adequate oxygenation
- Avoidance of hypotension
- +/- Maintenance of slight _______(2) (PaCO2 of _______(3))
- Monitor ICP (intraventricular catheters and _______(4)) and CBF (______(5))
- Remember that fontanelles allow for expansion to a _______(6)!
Answers:
1. 30 degree
2. hypocarbia
3. 35 to 38
4. subarachnoid bolts
5. SVO2
6. point
Neurotrauma
Box 22-2 Predictors of Poor Outcome after Traumatic Brain Injury in Children
- Age < _______(1) years
- Cardiopulmonary resuscitation needed
- Multiple trauma
- Hypoxia (PaO2 < _______(2) mm Hg)
- Hyperventilation (PaCO2 < _______(3) mm Hg)
- Hyperglycemia (glucose > _______(4) mg/dL)
- Hyperthermia (temperature > _______(5) °C)
- Hypotension (systolic blood pressure < _______(6) percentile for age)
- Intracranial hypertension (intracranial pressure > _______(7) mm Hg)
- Poor rehabilitation
Child Abuse
- Laws mandating the report of suspected abuse and neglect exist in all 50 states
Healthcare workers have a duty to report!
- In order to recognize child abuse, anesthesia providers must acknowledge that victimization occurs in all segments of society and must be considered as part of a differential diagnosis
Answers:
1. 4
2. 60
3. 35
4. 250
5. 38
6. 5th
7. 20
Chapter 36: Burn Injuries -Propofol Papi
Please be certain to review the following topics:
- Burn-wound assessment
- Neuromuscular relaxants
- Volume resuscitation
Anesthesia For Burn Injuries
- Children younger than 5 years of age account for _______(1) of all burns with most children burned in their homes.
- Mortality rates from burn injuries have declined over the past decades but almost 1100 children still die from fire and burn injuries each year.
Burn-Wound Assessment
- Injury _______(2), size and _______(3) are the three components that contribute to the overall severity of burn wounds.
- May be caused by _______(4), chemical, electrical, _______(5) and radiologic sources.
- Burn wounds are _______(6) (evolve over time).
Answers:
1. 19%
2. depth
3. location
4. thermal
5. ultraviolet
6. dynamic
Burn Injury
Pathophysiology
- Mediators released from burn areas activate _______(1) and _______(2) inflammatory responses.
- Abnormal _______(3) values may persist for years after injury.
- _______(4) are detected immediately after the burn, correlate with burn size, and are predictive of multiorgan failure.
- Shortly after injury massive fluid volumes shift from the _______(5) compartment to burned tissues and nonburned areas resulting in _______(6).
- Systemic BP is initially maintained by _______(7) secondary to an outpouring of ______(8.a) and ADH.
- Days 1-4 of a _______(8.b.) size burn will result in an albumin loss equal to twice the total body plasma content through the wound.
- Changes in vascular integrity result in widespread _______(8.c.).
- Mortality increases when 3 or more organ systems fail.
- ______(9.a) failure occurs in the first 5 days primarily
- Cardiac and _______(9.b.) failure in first 3 weeks
- _______(10) failure as the duration of hospital stay continues
Answers:
1. local
2. systemic
3. cytokine
4. Endotoxins
5. vascular
6. hemoconcentration
7. vasoconstriction
8.a. catecholamines
8.b. moderate
8.c. edema
9.a. Respiratory
9.b renal
10. Hepatic
Anesthesia for Burn Injuries
Cardiac
- CO is _______(1) immediately after an injury.
- _______(2) are used to improve CO while avoiding volume overload acutely.
- 3-5 days post injury, children are _______(3).
- CO may increase 2-3 fold and persists for weeks to months.
- Some children may develop a reversible _______(4) and hypertension.
Pulmonary
- ______(a) airway injury is usually a _______(5) insult.
- ______(b) airway injury is usually chemical or toxic insult.
- Overall effect is _______(6), bronchial swelling, alveolar destruction, exudation of protein, loss of surfactant, loss of bronchial lining and ciliary function, bronchospasm leading to ______(c) pneumonia.
- Mortality from inhalation injury is 16%
- Carbon ______(d) binds well to hemoglobin, replacing oxygen molecules
- Oxygen molecules can not be transported causing _______(7)
- ______(e) shift of oxyhemoglobin curve
- Peak airway _______(8) occurs between 12 and 24 hours
Answers:
1. reduced
2. Inotropes
3. hypermetabolic
4. cardiomyopathy
5. thermal
6. necrotizing bronchitis
7. hypoxemia
8. edema
a. upper
b. lower
c. bronchopulmonary
d. monoxide
e. Leftward
Burn Injuries
Indicators of Lower Airway Injury
- Victim extricated from an _______(1) environment
- Burns noted on face, lips, _______(2), or intraoral cavities
- Carbon _______(3) in mouth, nose, sputum
- Stridor or hoarseness
- Dyspnea, retractions, or nasal flaring
- _______(4)
- Carbon ______(a) levels confirmed by co-______(b) on the ABG
Renal
- Acute tubular necrosis may result from _______(5), hemoglobinuria, hypoxemia, hypotension, inhaled toxins.
- _______(6) retention is common ______(c) days post injury followed by ______(d).
Hepatic
- The liver may be damaged by hypoxemia, hypoperfusion, drug toxicity, sepsis, _______(7) response to burns, blood transfusion, ______(e) injury
Answers:
1. enclosed
2. nares
3. debris
4. Hypoxia
5. myoglobinuria
6. Fluid
7. hypermetabolic
a. monoxide
b. oximetry
c. 3-5
d. diuresis
e. reperfusion
Burn Injuries
CNS
- Chemicals inhaled may be neurotoxic, hypoxic _______(1)CNS?, sepsis, hyponatremia, hypovolemia all contribute to CNS dysfunction.
Hematology
- _______(2) HCT?
- Hemolytic anemia
- _______(3) pltls?
- _______(4) complication?
Gastrointestinal
- Gastric stasis
- Intestinal ileus
- _stress______(5)
Answers:
1. encephalopathy
2. Hemoconcentration
3. Thrombocytopenia
4. DIC
5. ulcers
Burn Injuries
Metabolic
- Altered ______(a) responses
- Impaired _______(1) control
- Impaired _______(2) control and increased potential for infection due to loss of skin integrity.
- Increased use of glucose, fat, protein leads to greater ______(b) demand and ______(c) production.
- Hypocalcemia, hypophosphatemia, hypermagnesemia
- _______(3) trauma
“Hyperdynamic” State
- The hyperdynamic, hypercatabolic response is related
- TBSA burned
- the duration of time patients are exposed to elevated levels of catecholamines and stress hormones.
- Strategies used to ameliorate the hypermetabolic response include
- early surgical intervention
- _______(4)
- nutritional support to replenish catabolic losses
- pharmacological agents such as ______(d)
- Early excision and grafting of burn eschar attenuates the hypermetabolic response by preventing further _______(5)
Answers:
1. glucose
2. temperature
3. Psychiatric
4. Normothermia
5. net protein loss, catabolism, and the development of sepsis
a. hormone
b. O2
C. CO2
d. insulin and β-antagonists
Burn Injuries
Neuromuscular blockade
- In the context of acute burns, there is an increased risk of severe _______(1).
- Excessive SCh-induced potassium efflux may be observed as early as ______(a) hours post-injury and for up to ______(b) years.
- In general, SCh okay within < _______(2) hours of burn injury; avoid if > 24 hours and for at least 18 months after burn injury.
- Nondepolarizing agents: ↑dose frequency and requirements (_______(3)) during hyperdynamic phase, reversal agent requirements are unchanged.
- Consider _______(4) (up to ______(c) mg/kg) for rapid-sequence induction if > 24 hours after burn injury.
General Anesthetics
- Intravenous agents
- ______(e) dose requirements during early phase.
- ______(f) requirements during the hyperdynamic phase of injury.
- Inhalation agents
- ______(g)MAC during early phase of burn injury
- ______(h) MAC during hyperdynamic phase of burn injury
Answers:
1. hyperkalemia
2. 24
3. 2- to 5-fold
4. rocuronium
a. 12
b. 2
c. 1.2
e. Decreased
f. Increased
g. Decreased
h. Increased
Burn Injuries
Volume Resuscitation
- The most widely accepted fluid protocols are the Parkland and Brooke formulas. (mostly for adults)
- Infants weighing less than _______(1) should have hourly maintenance fluid requirements calculated and then added to the Parkland or Brooke formula.
- Make example qs
- Fluid therapy is goal directed.
- Individualized for BP, CO, and HR
- Restrict _______(2) containing solutions at all times.
- As patients become hemodynamically stable, give _______(3), prevent rebound hypoglycemia
- Parkland Memorial Hospital (Dallas, TX)
- Recommends _______(4) mL/kg of crystalloid x the percentage of burn
- Administer ½ of the volume in first 8 hours
- Administer remainder over the next 16 hours
- No _______(5) per parkland formula
- Brooke Army Medical Center at Fort Sam Houston (San Antonio, TX)
- Recommends BOTH _______(6) mL/kg of crystalloid and a.___ mL/kg of colloids x the percentage of burn
- Administer ½ of the volume in first 8 hours
- Administer remainder over the next 16 hours
- Clinical Endpoints for Volume Resuscitation
- Normothermia
- Age-appropriate hemodynamics
- Sustained urine output (_______(7); _______(8) glucose or protein)
- Minimal systemic acidosis
- Check ABGs
Answers:
1. 10kg
2. glucose
3. TPN
4. 4
5. colloids
6. 1.5
a.0.45
7. 0.5-1 mL/kg/hr
8. negative
