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GOSH > Notes from Handbook > Flashcards

Notes from Handbook Flashcards

1
Q

What is the difference between stridor and stertor?

A

Stridor is caused by turbulent air flow in or below the larynx
Stertor is caused by turbulent air flow above the larynx (IE pharynx, nasopharynx, soft palate)

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2
Q

When may stertor occur relating to neurological conditions?

A

In the post ictal phase following a tonic clonic seizure

Vagal or hypoglossal nerve damage e.g. Stroke, tumour

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3
Q

Why is I&V often used in seriously ill kids even without an ‘at risk’ airway? 3 reasons

A

To reduce metabolic demands of body
To maintain tight control over physiology e.g. For neuroprotection
When anticipating progression of illness e.g. Pulmonary oedema

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4
Q

What is the triad of Pierre-Robin sequence?

A

Cleft palate
Retrognathia
Glossoptosis

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5
Q

What is retrognathia?

A

Abnormal positioning of the maxilla or (usually) mandible - ‘overbite’

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6
Q

What is glossoptosis?

A

Airway obstruction caused by backwards displacement of the tongue base

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7
Q

How does the Pierre Robin sequence arise?

A

Micro/retrognathia causes glossoptosis, causing upper airway obstruction and usually cleft palate (failure of fusion of hard palate)

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8
Q

What is Stickler Syndrome?

A

Hereditary progressive arthro-ophthalmopathy
CTD of collagen causing ‘flattened’ facial appearance (Pierre Robin), eye problems, hearing problems and infections, arthritis

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9
Q

How is Stickler Syndrome inherited?

A

AD

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10
Q

Eye problems associated with Stickler Syndrome?

A 
High myopia
Ocular hypertension and glaucoma
Cataract
Retinal detachment
Classical vitreous findings
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11
Q

How do you size a Guedel airway?

A

From middle of lips to angle of jaw

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12
Q

When are nasopharyngeal tubes particularly useful?

A

For upper airway anomalies

Tolerated in awake patients

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13
Q

2 contraindications to nasopharyngeal tube use?

A

Base of skull fracture (suspected)

Coagulopathies

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14
Q

3 methods of NIV?

A

Optiflow
Facial BiPAP
Nasal CPAP

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15
Q

When is NIV used?

A

Often first for kids in need of respiratory support e.g. Bronchiolitis
As alternative to invasive ventilation when that is high risk e.g. Oncology patients

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16
Q

Examples of conditions requiring long term NIV?

A 
Neuromuscular e.g. DMD, SMA
Neurodisability e.g. Recurrent aspiration, poor inspiratory reserve, scoliosis/chest shape abnormalities
Obstructive sleep apnoea
Central hypoventilation
Craniofacial abnormalities 
Airway malacia
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17
Q

What is the first step in intubation?

A

Establishing a secure airway

ETT (nasal or oral) or Tracheostomy

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18
Q

What is stertor?

A

Heavy snoring/gasping respiratory sound caused by partial airway obstruction above the level of the larynx

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19
Q

What is PIP?

A

Peak Inspiratory Pressure

The highest level of pressure applied during inspiration measured in cmH2O

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20
Q

What is PEEP?

A

Peak End Expiratory Pressure
The pressure applied to the lungs during and after expiration until PIP kicks back in; needed to maintain small airway and alveolar patency

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21
Q

What is delta P/ the distending pressure?

A

PIP - PEEP Determines tidal volume, which varies based on lung compliance

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22
Q

What limit is applied to the size of breaths made by ventilation in order to avoid lung barotrauma?

A

Less than 7 ml/kg/breath

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23
Q

What are the 2 broad types of ventilation?

A

Pressure control, where PIP and PEEP are set

Volume control, where volume control and PEEP are set

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24
Q

What does tidal volume depend on in pressure limited/controlled ventilation?

A

Patient’s lung compliance

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25
Q

What varies in volume limited/volume control ventilation?

A

PIP - we set tidal volume and PEEP, and changes in patient’s lung compliance are managed by the ventilator changing the PIP

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26
Q

4 modes of ventilation (how and when breaths are provided or supported)?

A

Continuous mechanical ventilation CMV
Synchronised Intermittent Mandatory Ventilation SIMV
Pressure support PS
High Frequency Oscillatory Ventilation HFOV

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27
Q

What 2 variables govern oxygenation levels?

A

Inspired oxygen concentration

Mean airway pressure (via altering surface area for gas exchange)

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28
Q

What 2 variables is CO2 clearance dependant on?

A

Tidal volume X respiratory rate (= minute volume, in L/min)

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29
Q

DOPES of causes of difficult ventilation or sudden deterioration?

A

Displaced ETT - auscultate and look at CO2
Obstructed ETT - secretions, plugs, clots, misplaced tube
Pneumothorax - percuss and auscultate… CXR
Equipment failure
Stomach - gas filled stomach (kid should always have NG tube in)

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30
Q

5 aims of anaesthesia in kids who are being ventilated?

A 
Achieve hypnosis
Achieve amnesia
Achieve haemodynamic stability
Adequate muscle relaxation
Facilitate treatment in ICU
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31
Q

5 examples of induction agents for anaesthesia?

A 
Ketamine
Thiopentone
Benzodiazepines 
Opioids
Propofol
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32
Q

How does ketamine work and therefore what is it useful for?

A

Sympathomimetic effects - good for the haemodynamically unstable or hypovolaemic
Also bronchodilator so useful in severe asthma
Analgesic

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33
Q

2 contraindications to ketamine use in kids?

A

Severe septic shock - paradoxical effect on hypotension

Raised intracranial pressure

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34
Q

What is thiopentone used for in kids?

A

Strong antiepileptic effects so good for rapid sequence induction in status

35
Q

Contraindication to thiopentone use?

A

Severe sepsis - hypotension

36
Q

What are benzodiazepines mostly used for in ICU?

A

Maintenance of anaesthesia e.g. Midazolam infusion

Or induction agents at higher dose alongside opioids

37
Q

What is the preferred maintenance drug for sedation in neonates? What is avoided?

A

Opioids best

Benzos are avoided

38
Q

What can Propofol cause in septic or hypovolaemic patients?

A

Myocardial depression and hypotension

39
Q

What is suxamethonium?

A

Depolarising agent used as a muscle relaxant

40
Q

How quickly does suxamethonium work?

A

About 30 seconds

41
Q

What is suxamethonium used for?

A

Rapidly securing airway after induction of anaesthesia - e.g. To prevent regurgitation of gastric contents

42
Q

Two examples of non-depolarising agents?

A

Vecuronium

Atracurium

43
Q

Which non-depolarising muscle relaxant is used at induction and as boluses for short procedures?

A

Atracurium

44
Q

When is the peak effect of a morphine bolus?

A

10 minutes

45
Q

When is fentanyl used for sedation and pain relief?

A

When pruritis is a big problem with morphine

Where morphine has not worked adequately

46
Q

How quickly does fentanyl work following a bolus?

A

Peak effect is at 2-3 minutes

47
Q

What is Chloral Hydrate?

A

Sedative and hypnotic

Used for pre-procedure sedation e.g. Prior to a CT scan on Paeds wards

48
Q

What drug is often used as a sedative and hypnotic prior to procedures e.g. a CT scan?

A

Chloral hydrate

49
Q

What is alimemazine?

A

Phenothiazine derivative used as a sedative, hypnotic, anti-emetic and anti-pruritic

50
Q

Side effects of alimemazine?

A

EPSEs - dystonia, tardive dyskinesia

51
Q

What is clonidine?

A

Central alpha-2 adrenergic agonist - a sympatholytic

Lower BP and cause bradycardia but little impact on respiratory drive so useful as a sedative

52
Q

What drug is useful to minimise side effects from opioid or benzo withdrawal?

A

Clonidine

53
Q

What is dexmedetomidine?

A

Specific central acting alpha-2 adrenergic receptor agonist with minimal respiratory depression

54
Q

2 examples of centrally acting alpha-2 adrenergic agonists used in sedation in kids?

A

Clonidine

Dexmedetomidine

55
Q

What is the risk of giving Propofol via infusion in kids?

A

Propofol infusion syndrome - metabolic acidosis, hyperK, Hyperlipidaemia, rhabdomyolysis, organ failure

56
Q

What is the role of steroid use in severe sepsis?

A

Adjunct when BP remains low despite maximum IV inotrope infusion (inotrope unresponsive septic shock) - probably occult adrenal insufficiency contributing therefore exogenous steroids help

57
Q

Which steroid is often used as a post-op or post-chemo anti emetic?

A

Dexamethasone

58
Q

Which corticosteroid is only available PO?

A

Prednisolone

59
Q

Which catecholamine has the biggest effect on increasing systemic vascular resistance when given via central line?

A

Noradrenaline

60
Q

Which catecholamine has the strongest chronotropic and inotropic effect when given via central line?

A

Adrenaline

61
Q

What is milrinone? What effect does it have?

A

Phosphodiesterase inhibitor

Used to decrease systemic vascular resistance

62
Q

2 reasons why inotropes need to be given via central line? Exception?

A

To avoid tissue necrosis when extravasation occurs
To achieve adequate delivery into circulation
Dopamine is the exception

63
Q

What does central venous pressure measure?

A

Right atrial pressure; right ventricular end diastolic pressure

64
Q

What is IVH?

A

Intraventricular haemorrhage - often a comorbidity in neonates as any condition causing clotting abnormalities can contribute

65
Q

9 methods of supporting cerebral autoregulation to prevent secondary brain injury?

A

Positioning - head in midline, 30 degrees elevated
Normothermia
Normoglycaemia
Sedation
Noradrenaline vasopressor (to maintain CPP)
PCO2 control
Oxygenation over 10kPa
Electrolyte control (Na 140-145)
Phenytoin in severe injury to prevent seizures

66
Q

How do you work out fluid requirements for kids?

A

100mls/kg for first 10kg (up to 1L)
50mls/kg for next 10kgm(up to 500ml)
20mls/kg thereafter
Over 24 hours

67
Q

Max fluid for females and males per 24 hours?

A

2L/day for females

2.5L/day for males

68
Q

What fluid is used for maintenance on PICU?

A

0.45% NaCl + 5% glucose

69
Q

What fluid is used for maintenance in head injury or hyponatraemia?

A

0.9% saline

70
Q

What fluid is used for neonates?

A

10% glucose + electrolytes

71
Q

What fluid is used for raised ICP and how is it given?

A

3% NaCl - boluses

72
Q

What fluid is given in fluid resus and how?

A

4.5% HAS - boluses

73
Q

What is normal plasma osmolality?

A

290-310 mosmol/Kg

74
Q

How is plasma osmolality calculated?

A

2[Na] + 2[K] + [glucose] + [urea]

75
Q

4 indications to start renal replacement therapy?

A

Refractory hyperkalaemia
Fluid overload with anuria
Acidosis, uraemia, neurological impairment
Certain inborn errors of metabolism

76
Q

Which are the 2 most commonly used RRT methods on PICU?

A

Peritoneal dialysis

Continuous Veno-Venous Haemofiltration (CVVH)

77
Q

What equipment is needed for CVVH and who does this therefore limit use on?

A

Vascath (large cannula) - increasingly difficult the smaller the baby is and can also cause cardiovascular instability

78
Q

What is leukapheresis and what is it used for?

A

Separating white blood cells from whole blood

Useful for e.g. Reducing WCC in a kid with leukaemia

79
Q

What is the biggest risk of TPN use?

A

Central venous/long lines - infection and technical problems with line

80
Q

What type of feed is used for kids with cows milk protein intolerance, lactose intolerance, allergy or eczema?

A

Hydrolysed formula

81
Q

What is elemental formula used for?

A

Short bowel syndrome, CF, malabsorbative conditions

82
Q

What is Medium Chain Triglyceride feed used for?

A

Chylothorax

83
Q

What is Medium Chain Triglyceride feed and branched chain amino acids used for?

A

Liver disease

GOSH (6 decks)

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