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FFICM > Obs & Paeds > Flashcards

Obs & Paeds Flashcards

1
Q

Obstetric critical care admissions

A

83% postnatal
Haemorrhage, sepsis, pre-eclampsia commonest
Antepartum - covid, respiratory failure

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2
Q

Fetal considerations in maternal critical care

A

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

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3
Q

Risks of imaging

A

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

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4
Q

pharmacological concerns

A
  1. teratogenicity 1st trimester - AEDs, warfarin, ACE, antibiotics (trimethoprim, tetracyclines)
  2. Analgesics - NSAIDs - closure of DA, avoid after 30/40, codeine unreidvtable breastfeeding, opioids neonatal resp depression and withdrawal
  3. sedatives - depressant effect on fetus at delivery
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5
Q

Hypertensive disease in pregnancy

A

10% pregnancies
neonatal and maternal morbidity and mortality

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6
Q

gestation hypertension / PIH

A

> 140/90 after 20/40
- aim for < 135/85
- methyldopa
- labetalol
- nifedipine
- Ix for PET
160/110
- admit to hospital

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7
Q

PET

A

> 140 / 90
20/40
Organ dysfunction
- proteinuria (PCR > 30mg/mmol) / 2+
- creatinine > 90
- headache
- ALT 2x ULN
- platelets < 150
- IUGR

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8
Q

Severe PET features

A

> 160 / 110
Pulmonary oedema
Eclamptic seizures
RUQ pain
HELLP
platelet < 100
severe headache, visual disturbance

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9
Q

PET pathophysiogy

A

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

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10
Q

PET MX

A
  • 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)
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11
Q

PET Complications

A
  • eclamptic seizures
  • severe organ dysfunction - liver, renal, DIC
  • hypertensive emergencies - aortopathy, ACS, ICH
  • fluid leak - pulmonary oedema
  • fetal compromise - IUGR, death, preterm birth
  • PPH
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12
Q

PET admission to critical care

A
  • 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

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13
Q

Major obstetric haemorrhage

A

9% perinatal deaths (50% worldwide)

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14
Q

Classification

A

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

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15
Q

WHO maternal sepsis

A

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.

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16
Q

Common causes maternal sepsis

A

Direct
- Genital tract infection - Group A strep
- endometritis - e.coli
indirect
- urinary tract infection
- respiratory
- meningitis
- covid

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17
Q

risk factors maternal sepsis

A

patient
- immunocompromise - medications, diabetes
- ivdu
- strep colonised
pregnancy / delivery related
- IUD
- pph
- instrumentation
- prolonged labour
- PROM
- retained products
- trauma
- c-section

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18
Q

Management priorities in maternal sepsis

A

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

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19
Q

AFE

A

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

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20
Q

AFE presentation

A
  • 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

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21
Q

risk factors for AFE

A

advanced age, eclampsia, multiple pregnancy, male fetus, induction, oxytopicin, c-section

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22
Q

Causes of maternal cardiac arrest

A

Hypoxia
- PE
- AFE
- Pulmonary oedema
Hypovolaemia
- Haemorrhage
- Sepsis
Hypo/hyperkalaemia
hypothermia rare
toxins - LAST
Tamponade: aortic dissection
Thrombosis: AFE, PE
Tension

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23
Q

Alterations in ALS for maternal cardiac arrest

A
  • left uterine displacement
  • perimortem cesarean - within 5 mins
    Specific drugs
  • MgSO4 for eclampsia
  • calcium for magnesium toxicitiy
  • thrombolysis
  • intralipid
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24
Q

MBRACCE 2019-21

A

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

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25
Q

bronchiolotis

A

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

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26
Q

risk factors in bronchiolitis

A
  • chronic lung disease
  • prematurity
  • cardiac comorbidity
  • < 6 weeks of age
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27
Q

Mx bronchiolotis

A
  • 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
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28
Q

How might a child with congenital heart disease present to hospital?

A
  • cardiac arrest
  • respiratory failure
  • shock
  • failure to thrive
  • cyanosis
29
Q

Fontan circulation

A

single functional ventricle e.g. pulmonary atresia, hypo plastic left heart
4-12 mo cavopulmonary connection
5 year completion - IVC connection to PA

30
Q

CHD presentations to intensivist

A
  • 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
31
Q

Management principles in congenital heart disease

A
  • 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.

32
Q

Cyanotic lesions

A

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

33
Q

Non-cyanotic lesions

A
  • septal defects - left –> right shunt
  • left sided obstruction - coarctation, AS lead to pulmonary oedema. systemic circulation from RV through DA.
34
Q

Duct dependent lesions

A

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

35
Q

Suspect duct dependent lesions when

A

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

36
Q

prostaglandin side effects

A

apnoea
ypertherthermia
hypotension
5-100ng/kg/min. greater SE with high dose

37
Q

DKA in children

A

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

38
Q

Fluid management in paediatric DKA

A

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

39
Q

cerebral oedema in DKA

A

early - headache, agitation, bradycardia, hypertension
late - reduced GCS, abnormal breathing pattern, palsies, posturing
3ml/kg 3% saline 0.5g/kg mannitol
reduce fluid

40
Q

Neonatal life support

A

risks
fetal - < 37/40, congenital abnormalitiy
maternal - infection, PET, high BMI
intrapartum - em CS, GA, bleeding, breech vaginal delivery meconium, fetal compromise

41
Q

NLS algorithm

A

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

42
Q

Therapeutic hypothermia

A

clinica, biochemical evidence of risk of hypoxic ischaemic encephalopathy - consider inducing hypothermia 33-34 degrees

43
Q

Paediatric life support

A

5 rescue breaths
15:2
non-shockable - 10mcg/kg adrenaline
shockable 4J/kg

44
Q

Paediatric arrhythmias

A

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

45
Q

Paediatric sepsis definition

A

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

46
Q

Paediatric SIRS

A

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

47
Q

Paediatric organ dysfunction

A

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

48
Q

Other DDX in neonatal collapse

A
  • cardiac
  • trauma (NAI)
  • metabolic
  • surgical
49
Q

Resusctivative measures in paediatric sepsis

A
  • 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
50
Q

Commonest injuries causing death in paediatrics

A
  • RTC
  • fall from height
  • drowning
  • burns
  • poisoning
51
Q

Injury prevention

A

Primary - speed limits, cycle lanes, child resistant medication containers
Secondary - seat belts, bike helmets
Tertiary - pressure to laceration, cold water to burns

52
Q

Consideration of child injury patterns

A

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

53
Q

Presentations related to NAI

A
  • head injuries
  • long bone fractures, multiple
  • ruptured viscus
  • glove and stocking burns
  • suffocation
  • bruising in non-mobile infant, non-exposed areas
54
Q

Doses of resuscitative agents in paediatric trauma

A
  • 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

55
Q

GCS in children

A

< 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

56
Q

NICE paediatric CT head

A
  • 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
57
Q

paediatric inflammatory conditions

A
  • sepsis
  • toxic-shock
  • HLH
  • MAS
  • Kawasaki disease
  • PIMS-TS (paediatric multisystem inflammatory syndrome temporally associated with Sars Cov-2
58
Q

PIMS-TS

A

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

59
Q

Toxic shock syndrome

A

acute inflammatory multi system condition associated with exotoxin production from gram positive infections. early shock, rash, desquamation, fever

60
Q

TSS causes

A

Group A strep - strep progenies (burns, new fas) (TSLS)
Staph aureus - menstrual products, nasal packs, IUD, pneumonia

61
Q

TSS presentaiton

A

fever, malaise, rash
circulatory compromise
myocarditis
abdo pain

62
Q

TSS Ix

A

Blood cultures
MC/S any fluid
usual bloods
urine - haemoglobinuria
cxr - ards
staphylococcal antibody, streptococcal exotoxin

63
Q

TSS diagnosis

A

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

64
Q

TSS Mx

A

source control
- debridement
- antimicrobials + antitoxin
- ivig in streptococcal
- supportive care

65
Q

Paediatric DKA

A

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

66
Q

Fluid in Paediatric DKA

A

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

67
Q

Insulin in paediatric DKA

A
  • start 1-2 hours after fluid
  • 0.05 - 0.1 units/kg/hr
  • reduce rate when BM < 14
68
Q

Cerebral oedema in paediatric DKA

A

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

FFICM (14 decks)

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