Obs & Paeds Flashcards
Obstetric critical care admissions
83% postnatal
Haemorrhage, sepsis, pre-eclampsia commonest
Antepartum - covid, respiratory failure
Fetal considerations in maternal critical care
monitoring
- obstetric and midwifery teams
- CTG / auscultation / dopplers as indicated
Delivery
- timing decided by MDT
- mother may benefit if intractable hypoxia
- lung maturation with steroids 24-34 weeks
resuscitation
- specialised equipment
teratogencity
- imaging risks
- drug risks 1st trimester
Risks of imaging
fetus maximum risk 10 - 17 weeks from ionising radiation (microcephaly, developmental delay)
iodine - fetal thyroid risk worse with age
mother CTPA - risk of breast cancer. V/Q increased risk to fetus
pharmacological concerns
- teratogenicity 1st trimester - AEDs, warfarin, ACE, antibiotics (trimethoprim, tetracyclines)
- Analgesics - NSAIDs - closure of DA, avoid after 30/40, codeine unreidvtable breastfeeding, opioids neonatal resp depression and withdrawal
- sedatives - depressant effect on fetus at delivery
Hypertensive disease in pregnancy
10% pregnancies
neonatal and maternal morbidity and mortality
gestation hypertension / PIH
> 140/90 after 20/40
- aim for < 135/85
- methyldopa
- labetalol
- nifedipine
- Ix for PET
160/110
- admit to hospital
PET
> 140 / 90
20/40
Organ dysfunction
- proteinuria (PCR > 30mg/mmol) / 2+
- creatinine > 90
- headache
- ALT 2x ULN
- platelets < 150
- IUGR
Severe PET features
> 160 / 110
Pulmonary oedema
Eclamptic seizures
RUQ pain
HELLP
platelet < 100
severe headache, visual disturbance
PET pathophysiogy
complex multi-system disease associated with endothelial dysfunction
abnormal placentation, relative placental hypoxia
- inflammatory factors
decrease proangiogenic (VEGF)
increase antiangiogenic
increased vascular tone and permeability
PET MX
- BP control - methyldopa, labetalol, nifedipine
- labetalol 200mg 12hrly increased to 2.4g/24hr
- IV bolus 20mg then commence infusion
- Aim for < 135/95
- MgSo4 seizure or severe. 4g bolus then 1g/hr. tendon reflexes. toxicity - calcium.
- MAGPIE - lower risk of eclampsia
- consideration of invasive monitoring
- monitoring for end organ complications - U+E / LFT / Coag studies
- If severe –> delivery. dependent on gestation, severity
- careful fluid balance (1ml/kg/hr)
PET Complications
- eclamptic seizures
- severe organ dysfunction - liver, renal, DIC
- hypertensive emergencies - aortopathy, ACS, ICH
- fluid leak - pulmonary oedema
- fetal compromise - IUGR, death, preterm birth
- PPH
PET admission to critical care
- features of severe disease
- pulm oedema requiring respiratory support
- severe hypertension requiring IV
- eclamptic seizures
- strict fluid balance, severe ologuria
- severe coagulopathy needing mx
- Bleeding / PPH
considerations
- difficult airway
- hypertensive response to laryngoscopy
- risk of pulmonary oedema - restrictive balance, GTN
Major obstetric haemorrhage
9% perinatal deaths (50% worldwide)
Classification
Antepartum 24/40 - delivery
- abruption, praaevia, trauma, accreta, rupture
Postpartum
- primary - 24hrs
- secondary 24hrs-12 weeks - infection
- minor 500-1L
- major > 1L. moderate 1L-2L. severe > 2L
WHO maternal sepsis
life threatening organ dysfunction resulting from infection during pregnancy, childbirth, post-abortion or postpartum period
leading cause of maternal morbidity and mortality worldwide. UK 11% deaths.
Common causes maternal sepsis
Direct
- Genital tract infection - Group A strep
- endometritis - e.coli
indirect
- urinary tract infection
- respiratory
- meningitis
- covid
risk factors maternal sepsis
patient
- immunocompromise - medications, diabetes
- ivdu
- strep colonised
pregnancy / delivery related
- IUD
- pph
- instrumentation
- prolonged labour
- PROM
- retained products
- trauma
- c-section
Management priorities in maternal sepsis
prevention - vaccination, abx for instrumentation, management of PROM
cvs support - left lateral displacement fluid management
surgical source control - wound infection, ERPC, delivery of fetus
considerations re. delivery - source, severity, gestation age, fetal wellbeing, state of labour, parity
AFE
exposure of fetal antigens or amniotic fluid substances to maternal circulation leads to sudden catastrophic immune activation
2 phases
- initial entry of substances leads to pulmonary hypertension, RV failure, microvascular damage, hypotension
- LV failure, endothelial activation, capillary leak, DIC
high mortality, neurological injury
AFE presentation
- fetal distress
- sudden profound maternal collapse
- cardiac arrest
- hypotension
- pulmonary oedema, ards, hypoxia
- seizures
- dic
clinical diagnosis, confirmation postmortem only
acute hypotension, cardiac arrest, hypoxia, coagulopathy, haemorrhage in absence of other explanation
DDX anaphylaxis, PE, MI, sepsis, LAST, major haemrrhage
risk factors for AFE
advanced age, eclampsia, multiple pregnancy, male fetus, induction, oxytopicin, c-section
Causes of maternal cardiac arrest
Hypoxia
- PE
- AFE
- Pulmonary oedema
Hypovolaemia
- Haemorrhage
- Sepsis
Hypo/hyperkalaemia
hypothermia rare
toxins - LAST
Tamponade: aortic dissection
Thrombosis: AFE, PE
Tension
Alterations in ALS for maternal cardiac arrest
- left uterine displacement
- perimortem cesarean - within 5 mins
Specific drugs - MgSO4 for eclampsia
- calcium for magnesium toxicitiy
- thrombolysis
- intralipid
MBRACCE 2019-21
Indirect causes
1. covid-19
2. Cardiac disease
3. Neurological
4. Sepsis
5. Psychiatric
Direct causes
1. Thrombosis
2. Haemorrhage
3. Psychiatric
4. Sepsis
5. PET
6. AFE
Direct = resulting from obstetric complications of the pregnant state, including interventions, omissions, treatment
Indirect = resulting from previous existing disease or disease that developed during pregnancy, not due to direct obstetric causes but aggravated by physiological changes of pregnancy
bronchiolotis
respiratory infection, children under 2 (3-6mo)
clinical diagnosis
coryza, fever, wheeze, cough, crepitations
varying respiratory failure
DDx pneumonia, croup, asthma, viral wheeze
Severe disease
- FiO2 > 0.5 to maintain 95%
- severe recessions
- tachypnoea, tachycardia, apnoeas
Life threatening
- Sats < 88% despite HF / CPAP
- respiratory acidosis
- apnoeas requiring FMV, exhaustion, grunting
risk factors in bronchiolitis
- chronic lung disease
- prematurity
- cardiac comorbidity
- < 6 weeks of age
Mx bronchiolotis
- clear nasal secretions
- respiratory support - humidified O2, CPAP, BIPAP
- hydration / NG feed
- gastric decompression
- invasive ventilation
- deteriorating severe disease
- respiratory acidosis, hypoxia on NIV
ICU complciations
- secondary bacterial infection
- mucous plugging
- bronchospasm
- bradycardia
- hyponatraemia
How might a child with congenital heart disease present to hospital?
- cardiac arrest
- respiratory failure
- shock
- failure to thrive
- cyanosis
Fontan circulation
single functional ventricle e.g. pulmonary atresia, hypo plastic left heart
4-12 mo cavopulmonary connection
5 year completion - IVC connection to PA
CHD presentations to intensivist
- severe cyanosis - TGA, pulmonary atresia, obstructed TAPVD
- cardiac failure - left outflow obstruction.- severe AS, coarctation, hypo plastic left heart. may present when DA closes. cold pale weak pulses, hepatomegaly
Management principles in congenital heart disease
- reduce O2 demand - IPPV
- correct acidosis, hypoxia, hypercarbia
- prostaglandins for duct patency
- inotropes
- dw cardiac centre
patients surviving to adulthood and may present to adult critical care.
Cyanotic lesions
Likely if PaO2 doesn’t rise 20kPa after 10 mins 100% O2
obstruction to pulmonary flow - ToF, pulmonary stenosis
Pulmonary and systemic circulations in parallel - TGA
Complete mixing of systemic and pulmonary blood - single ventricle, truncus arteriosis
pulmonary venous abnormalities - TAPR
intubation and early prostaglandin
Non-cyanotic lesions
- septal defects - left –> right shunt
- left sided obstruction - coarctation, AS lead to pulmonary oedema. systemic circulation from RV through DA.
Duct dependent lesions
Duct dependent pulmonary circulation
- pulmonary atresia
- pulmonary stenosis
- tricuspid atresia
- Severe ToF
Duct dependent systemic circulation
- Severe AS
- Coarctation
- Hypoplastic left heart
Duct dependent pulmonary and systemic
- Transposition of great arteries
Suspect duct dependent lesions when
cyanosis
hypoxia despite O2
tachypnoea without lung pathology
Pulmonary oedema, pathological murur, absent femoral pulse, hepatomegaly, cardiogmegaly, lactic acidosis
100% O2 may result in excess flow through the lungs - pulmonary overcirculation. aim for pre and post ductal saturations 75-85%. pink and shocked.
balanced circulation - increase PVR or decrease SVR. avoid high O2, modest PEEP
prostaglandin side effects
apnoea
ypertherthermia
hypotension
5-100ng/kg/min. greater SE with high dose
DKA in children
HCO3 < 15 / pH < 7.30
Ketones > 3
Differences
- first presentation of diabetes
- susceptible to cerebral oedema
- glucose falls rapidly with rehydration - withhold insulin 1-2 hrs start 0.05units/kg/hr
- abdo pain common
Fluid management in paediatric DKA
shock - bolus 10ml/kg as needed
if not shocked consider 10ml/kg over 60 mins
replacement of deficit over 48hrs 0.9% + 20mmol KCL
- severe DKA = 10% dehydration
- mild-moderate = 5%
Add deficit to maintenance
maintenance fluid 10 / 50 / 20
cerebral oedema in DKA
early - headache, agitation, bradycardia, hypertension
late - reduced GCS, abnormal breathing pattern, palsies, posturing
3ml/kg 3% saline 0.5g/kg mannitol
reduce fluid
Neonatal life support
risks
fetal - < 37/40, congenital abnormalitiy
maternal - infection, PET, high BMI
intrapartum - em CS, GA, bleeding, breech vaginal delivery meconium, fetal compromise
NLS algorithm
First 60s
- delay cord clamping if possible
- assess colour, tone, breathing, HR
- open airway
- 5 inflation breaths (30cmH20) if gasping / not breathing
Ongoing
- reassess
- if no HR improvement look for chest movement
- if no chest movement use 2 person airway control
- repeat 5 breaths
- ventilate for 30s if HR < 60
- chest compressions 3:1 if HR < 60. fiO2 1.0
- reassess every 30s
32/40 + air
28-31/40 0.21 - 0.3
< 28/40 - 0.3
preductal sats (right hand) 65 - 85 -90 2-5-10mins
Bradycardia despite AB and CPR adrenaline IV 20mc/kg
review at 10mins
usually discontinue at 20mins
Therapeutic hypothermia
clinica, biochemical evidence of risk of hypoxic ischaemic encephalopathy - consider inducing hypothermia 33-34 degrees
Paediatric life support
5 rescue breaths
15:2
non-shockable - 10mcg/kg adrenaline
shockable 4J/kg
Paediatric arrhythmias
decompensation - reduced LOC, tachypnoea, BP < 5 gentile, CRT > 2
bradycardia - oxygenate. if vagal 20mcg/kg atropine. if not 10mcg/kg adrenaline
narrow complex tachycardia
- sinus tachycardia infant 180-220, child 160-180. treat precipitant (sepsis, hypovolaemia, pain)
- SVT infant > 220 child > 180 - adenosine 100-150mcg/kg, DCCV 1j/kg
broad complex tachycardia
- if conscious - sedate and DCCV
- unconscious - DCCV
- 2–> 4 j/k. amiodarone 5mg/kg before 3rd
Paediatric sepsis definition
life threatening organ dysfunction caused by dysregulated host response to infection
- severe sepsis 2 + SIRS criteria, confirmed or suspected invasive infection, cvs dysfunction, ARDS or 2+ other organ system dysfunction
- septic shock - severe infection leading to cvs hypotension, vasoactive medication, impaired perfusion
Paediatric SIRS
2 or more
1 must be abnormal temp or abnormal WCC
- temp > 38.5 or < 36
- WCC > 34 —> 11 1w —> 17
- HR > 2SD above normal (180 up to 1yr, 140 2-5, 130 6-12, 11 13-17
- RR > 2SD above normal
Paediatric organ dysfunction
resp
- P/F < 300
- need for invasive or non-invasive ventilation
CVS - despite 40ml/kg isotonic crystalloid
- hypotension BP < 2SD below normal
- vasoactive support
- acidosis, lactataemia, oliguria, CRT > 5s, core to peripheral temperature differential 3 degrees
Neuro
- GCS < 11
renal
- creatininee > 2x ULN
Hepatic
- bili > 4mg/dl (68)
haem
- platelets < 80, INR > 2
Other DDX in neonatal collapse
- cardiac
- trauma (NAI)
- metabolic
- surgical
Resusctivative measures in paediatric sepsis
- source control
- 40-60ml/kg fluid in 1st hour if shock or organ dysfunction
- adrenaline, NA first line vasoactive
- IV hydrocortisone in refractory instability
Extracorporeal support - RRT - fluid overload
- VV-ECMO severe pARDS
- VA-ECMO - refractory shock
Commonest injuries causing death in paediatrics
- RTC
- fall from height
- drowning
- burns
- poisoning
Injury prevention
Primary - speed limits, cycle lanes, child resistant medication containers
Secondary - seat belts, bike helmets
Tertiary - pressure to laceration, cold water to burns
Consideration of child injury patterns
Chest
- elastic tissues - high degree of force to fracture rib.
- contusions common
Abdomen
- liver, spleen, bladder all more exposed
- less protection
Neuro
- single biggest cause of trauma death
- fontanelles / sutures may mitigate ICP rise
- prone to cerebral oedema
Limbs / spine
- extremity injury common but less likely to be life threatening
- pelvic fractures uncommon
- spinal cord injury in absence of fracture
Presentations related to NAI
- head injuries
- long bone fractures, multiple
- ruptured viscus
- glove and stocking burns
- suffocation
- bruising in non-mobile infant, non-exposed areas
Doses of resuscitative agents in paediatric trauma
- blood - 5ml/kg
- TXA - 15mg/kg
- crystalloid 10ml/kg
- 20ml/kg blood –> 10ml/kg platelets
- 0.1ml/kg 10% calcium chloride
transfusion targets
- platelets 50
- fibrinogen 1
- ica 1
- hb 80-120
GCS in children
< 4 - children’s GCS
E / M same as adult
V
5 - babbles, coos, alert to normal level
4 - less than usual words, irritable cry
3 - cries only to pain
2 - moans to pain
1 - nil to pain
preverbal - grimace response
NICE paediatric CT head
- GCS < 14 initial (< 15 if under 1)
- GCS < 15 at 2hrs
- suspected NAI
- seizure in absence of epilepsy
- suspected BOS fracture
- focal neurology
- suspected open / depressed fracture
- < 1 with > 5cm bruise, swelling, laceration
paediatric inflammatory conditions
- sepsis
- toxic-shock
- HLH
- MAS
- Kawasaki disease
- PIMS-TS (paediatric multisystem inflammatory syndrome temporally associated with Sars Cov-2
PIMS-TS
fever, oxygen requirement, hypotension
others
- mucous membrane changes
- lymphednopathy
- syncope
- confusion
- gi upset
High fibrinogen, CRP, d-dimer, ferritin
low albumin, lymphocytes
CXR - patchy infiltrates
Echo - myocarditis, valvulitis
Management
- treat as covid-19
- evaluate cardiac dysfunction
- empirical abx
- immunomodulation on discussion with MDT - IVIG if Kawasaki disease criteria fulfilled
Toxic shock syndrome
acute inflammatory multi system condition associated with exotoxin production from gram positive infections. early shock, rash, desquamation, fever
TSS causes
Group A strep - strep progenies (burns, new fas) (TSLS)
Staph aureus - menstrual products, nasal packs, IUD, pneumonia
TSS presentaiton
fever, malaise, rash
circulatory compromise
myocarditis
abdo pain
TSS Ix
Blood cultures
MC/S any fluid
usual bloods
urine - haemoglobinuria
cxr - ards
staphylococcal antibody, streptococcal exotoxin
TSS diagnosis
Probable: clinical case definition + isolation of GAS from non sterile site
confirmed : GAS from sterile site
clinical case definition
- hypotension
- 2+ organ involvement - renal, haem, liver, ards, generalised rash, soft tissue necrosis
Non-strep
- clinical + lab criteria
- lab includes negative cultures (apart from SA) negative serology for rocky mountain fever, lepto, measles
TSS Mx
source control
- debridement
- antimicrobials + antitoxin
- ivig in streptococcal
- supportive care
Paediatric DKA
Diagnosis same as adults
severity
pH < 7.1 - severe (10% dehydration)
pH < 7.2 - moderate (5% dehydration)
pH < 7.3 - mild (5% dehydration)
deaths
- cerebral oedema
- hypokalaemia
- inadequate fluid replacement
- aspiration pneumonia
Fluid in Paediatric DKA
Shocked - 10ml/kg bolus, repeat as needed
not shocked 10ml/kg over 30 mins
requirement = deficit + maintenance
maintenance = 100 / 50 / 20
deficit = according to severity 5 / 5/ 10%. replaced over 48 hours
n/saline + 40mmol KcL
switch to 5% dextrose when BM < 14
Insulin in paediatric DKA
- start 1-2 hours after fluid
- 0.05 - 0.1 units/kg/hr
- reduce rate when BM < 14
Cerebral oedema in paediatric DKA
headache / agitation / fall in HR / rise in BP
deterioration in consciousness, posturing, pupillary changes, breathing abnormalities
- 2.5ml/kg 3% saline or 0.5g/kg mannitol 20%
- fluid 1/2 maintenance
