Paediatric intensive care Flashcards
what do you think when a kid comes in with bradycardia?
hypoxia
what are some causes of a widened pulse pressure?
Sepsis anaphylaxis patent ductus arteriosus anaemia aortic regurgitation
what are some causes of a narrow pulse pressure?
aortic stenosis/coarctation
hypovolaemia (due to peripheral vasoconstriction)
pump failure (e.g. myocarditis/tamponade)
untreated sepsis
describe kussmaul breathing
effortless tachypnoea
why would you not intubate a patient with septic shock immediately to protect his airway?
because giving anaesthetic drugs will shut down his circulatory system
if you get to 40mls/kg fluid resuscitation to a shocked child and they are still in shock, what do you do?
call intensive care unit for advice!
give inotrope or vasopressor
what do we use as fluid maintenance therapy for a child?
Plasma-lyte
what is the most commonest cause of iron deficiency in kids
poor nutrition
how can cow’s milk cause iron deficiency?
poorly bioavailable iron
occult blood loss if there is an allergy to cow’s milk
often associated with poor diet
why do premature babies need iron supplements?
premature babies are at higher risk of iron deficiency because most of the hb transferred from the mother occurs during late gestation.
what is the issue with interpreting iron studies in an anaemic child?
ferritin may be normal or raised
so need to order a reticulocyte count along with full iron studies
how do you give iron supplementation and what advice do you give?
oral iron- take it with orange juice and on a full stomach; keep it safe and out of reach; brush teeth after giving iron to prevent staining of teeth
IV iron is now making a comeback
what are the acute effects of iron overdose in a child?
inflammation of the gastrointestinal tract- mucosal irritation
how can we tell if an iron deficient child is responding to iron supplementation?
increased reticulocytes within 72 hours
why might a child with beta thalassemia major present with concurrent haemosiderosis?
Blood transfusions are the mainstay treatment of beta thalassaemia major. In some countries, additional chelating agents are not available and so the excess iron from each transfusion accumulates
what are the indications for a blood transfusion?
when the patient is symptomatic for anaemia
- has co-morbidities
- decompensated deficit in oxygen delivery
- progressive anaemia/blood loss
What are the ways we can provide respiratory support to a sick child?
Low flow O2 High flow O2 (flow rate > respiratory flow rate) CPAP BiPAP Mechanical ventilation
what is the main difference between mechanical ventilation and bipap?
Bipap= spontaneous breathing
Mechanical ventilation= ventilator takes over breathing; requires a level of sedation; can use higher pressures than bipap as high pressures in bipap will cause gastric dilation as air goes down the oesophagus
what is the main mechanism by which CPAP helps respiratory failure?
increased recruitment of alveoli (functional residual capacity), enables greater oxygenation and hence reduced work of breathing
how might you tell if a CXR is over-exposed?
If you can see the intervertebral discs well on x-ray then over-exposed
what does ECMO stand for and what is the indication for its use?
extra-corporeal membrane oxygenation
for life-threatening reversible causes of cardiac/respiratory failure unresponsive to conventional management
think of it like an artificial lung/heart outside the body
when might we order a cranial ultrasound?
exclusively for preterm babies/neonates only.
looking through the fontanelle for signs of haemorrhage, leukomalacia, tumours, structural abnormalities, hydrocephalus
what is the flow rate of high flow oxygen therapy?
2L/kg/min for first 10kg, then additional 0.5L/kg/min for over kg > 12kg
what does FiO2 stand for?
fraction of inspired oxygen
what is the normal range for ICP?
0-15mmHg, upper limit= 20
what are some causes of hyponatremia in children?
Common:
GIT losses (diarrhoea)
Inappropriate fluid resus
Increased ADH states e.g. meningitis, sepsis, bronchiolitis etc
Less common:
Psychogenic polydipsia
Adrenal insufficiency
Renal tubular acidosis
what are the components of high flow oxygen therapy?
clinicians can titrate FiO2 and deliver O2 at a faster rate. But with faster rate of O2 delivery you need humidification. Thus humidification is an essential component of HF therapy
what is the most accurate way to obtain a temperature in a fever?
Rectal temperature
what is the main cation of intracellular fluid?
K+
what is the main cation of extracellular fluid?
Na+
what do we mean by fluid resuscitation?
fluid that replaces ongoing losses and existing deficit
what do we mean by fluid maintenance?
fluid that replaces insensible losses
what are the normal values of Na+ in the body?
135-145mmol/L
what are the normal values of K+ in the body?
3.5-5mmol/L
why are children at risk of hyponatremia?
children have larger brains and may have impaired adaptive mechanisms due to Na/K ATPase
what are the high risk groups for hyponatremia we need to consider when we are commencing IV fluid therapy in a child?
HIGH RISK GROUPS for hyponatremia:
• Neurological disease= meningitis
• Craniofacial/neurosurgical patients
• Neonates- have their own special fluids
Seriously unwell children with full maintenance fluids bc of stress response
these patients will need LESS maintenance fluids- so think 2/1/1 instead of 4/2/1 rule
why do we put dextrose in fluids for children?
prevents hypoglycaemia and ketosis prevents haemolysis (original role when hypotonic fluids were used, but now that we use isotonic fluids, it is mainly to prevent hypoglycaemia)
how do we manage hyponatremia in an otherwise ASYMPTOMATIC child?
careful fluid restriction and avoidance of hypotonic fluids
how do we manage hyponatremia in a SYMPTOMATIC child?
Notify ICU
ABC + resuscitation
Give 3% NaCL fluid boluses carefully, regularly monitor UEC
make sure to not correct the sodium too quickly!
How do we calculate the corrected (ie. Actual sodium) in the setting of hyperglycemia?
Corrected na = na + 0.3 (glucose - 5.5) mmol / litre
