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High Yield Facts for the Final FRCA > Paediatrics > Flashcards

Paediatrics Flashcards

1
Q

What features may be seen in a baby with congenital diaphragmatic hernia?

A

Respiratory distress
Scaphoid abdomen

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2
Q

What would you see on a chest xray in a child with congenital diaphragmatic hernia?

A

Abdominal organs in the thoracic cavity

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3
Q

Which genetic conditions are associated with congenital diaphragmatic hernia?

A

Trisomy 13
Trisomy 18
Trisomy 21
CHARGE syndrome
Fryn syndrome
Cornelia de Lange syndrome

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4
Q

Which structural cardiac abnormalities are seen most commonly in patients with congenital diaphragmatic hernia?

A

Ventricular septal defect
Atrial septal defect
Coarctation of the aorta
Hypoplastic left heart

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5
Q

Which features correlate with a poor prognosis in congenital diaphragmatic hernia?

A

Large hernia
Bilateral hernia
Cardiac anomalies
Chromosomal anomalies
Severe pulmonary hypertension
Low birth weight
Low APGAR score at five minutes
Small contralateral lung

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6
Q

What pharmacological options are useful in patients with congenital diaphragmatic hernia?

A

Neuromuscular blockers to improve chest wall compliance in ventilated patients

Inotropes and vasopressors if haemodynamically unstable

Prostaglandins to maintain ductus arteriosus and reduce right heart strain

Prostacyclin or sildenafil to reduce pulmonary hypertension

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7
Q

What are the requirements of the CDH Euro-Consortium guidelines, for a congential diaphragmatic hernia patient to be deemed fit for surgical correction?

A

Lactate less than 3mmol/litre

Normalised mean arterial pressure

Adequate urine output of >1ml/kg/hour

Preductal oxygen saturations of 85-95% on less than 50% oxygen

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8
Q

A 6 week old girl presents with projectile vomiting immediately after feeding. Which of the following increases the risk of pyloric stenosis?

  1. Male gender
  2. Afro-Carribean ethnicity
  3. Pre-term delivery
  4. Maternal C.difficile infection
  5. Ventoux delivery
A
  1. Male Gender (4:1)

The risk factors for pyloric stenosis are as follows:
- Male gender
- White ethnicity
- Term delivery
- First-born child
- Caesarean section
- Bottle feeding

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9
Q

Which of the following is the most common complication of corrective surgery for oesophageal atresia?

  1. Gastro-oesophageal reflux
  2. Oesophageal stricture
  3. Tracheomalacia
  4. Anastomotic leak
  5. Post-operative pneumonia
A

GORD affects around 40-50% of patients

Anastomotic leak 10-20%, and half of these develop a stricture

Tracheomalacial and post-operative pneumonia are recognised complications but are rarer

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10
Q

A four year old child presents to the emergency department with a two day history of fever and drowsiness, and is now tachycardic and hypotensive. She has been given 600ml of fluid so far with no significant response. What should be done next?

  1. Rapid sequence induction and intubation
  2. Dopexamine 10mcg/kg/min
  3. Phenylephrine 0.5mg/min
  4. Fluid bolus 20ml/kg
  5. Noradrenaline 0.1mcg/kg/min
A
  1. Fluid bolus 20ml/kg

This child’s weight is estimated at 16kg, making a 20ml/kg bolus 320ml.

This means the child has had two boluses so far, and can have a third as part of sepsis management prior to starting vasopressors.

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11
Q

What is the incidence of congenital tracheoesophageal fistula?

A

1 in 3000 live births

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12
Q

What congenital abnormalities are associated with tracheoesophageal fistula?

A
  • Cardiac
    • Vertebral
    • Anorectal
    • Urogenital
    • Laryngo-trachial
    • Palatal
    • Musculoskeletal
    • Gastrointestinal
    • Renal
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13
Q

What chromosomal abnormalities are associated with tracheoesophageal fistula?

A

Holt-Oram syndrome
Pierre-Robin syndrome
Trisomy 18
Trisomy 21
Polysplenia
DiGeorge syndrome

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14
Q

What are the important aspects of induction and intubation with regards to tracheoesophageal fistula?

A
  • Avoid facemask ventilation to prevent insufflation of the stomach
  • Gaseous induction
  • Suction of upper oesophageal pouch
  • Topicalisation of the airway
  • Maintenance of spontaneous ventilation
  • Use of flexible bronchoscope to ensure tube beyond fistula site
  • Muscle relaxant only once tube sited correctly
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15
Q

What are the haematological differences between neonates and adults?

A
  • Foetal haemoglobin has higher oxygen affinity
    • Higher red cell mass
      • Hb 180-200g/l is typical
    • Reduced platelet function
    • Reduced vitamin k dependent clotting factors
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16
Q

What are the cardiovascular differences between neonates and adults?

A
  • Cardiac output is rate dependent, with minimal ability to increase stroke volume
    • Less compliant myocardium
    • Dominant parasympathetic tone, with predisposition to bradycardia
    • Increased blood volume per kg than adult patients
    • Circulation in transition from foetal to adult
      • Severe hypoxia and acidosis can result in re-opening of ductus arteriosus
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17
Q

What are the respiratory differences between neonates and adults?

A
  • Respiratory
    • Ventilation is mainly diaphragmatic
    • Prone to diaphragmatic splinting by abdomen
    • Smaller Functional residual capacity with faster desaturation
    • Fixed tidal volume
    • Closing volume greater than functional residual capacity
    • Respiratory muscles tire quickly
    • Fewer alveoli
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18
Q

What are the airway differences in the neonate?

A

Large head with prominent occiput
Short neck
Large tongue and anterior larynx at level of C3-C4
Long, floppy U-shaped epiglottis
Preferential nasal breathers
Funnel shaped airway narrowest at cricoid cartilage

19
Q

What are the effects of hypothermia in the neonate?

A
  • Respiratory depression
  • Acidosis
  • Bradycardia
  • Platelet dysfunction
  • Reduced drug clearance and metabolism
  • Increased risk of infection
20
Q

Why are neonates more at risk of hypothermia?

A
  • Higher surface area to volume ratio
  • Less subcutaneous tissue
  • Poor shivering ability
  • Poor vasoconstriction
  • Thermogenesis by brown fat has enormous oxygen requirement
21
Q

What clinical signs are suggestive of severe dehydration in a child?

A
  • Drowsiness
  • Sunken anterior fontanelle
  • Weak rapid pulse
  • Rapid respiratory rate
  • Low urine output
  • Dry mucous membranes
22
Q

What examination findings would suggest pyloric stenosis?

A
  • Visible peristalsis
  • ‘Olive’ shaped mass in epigastrium, approximately 2-3cm in size
23
Q

Which hormones are released in response to severe dehydration?

A
  • ADH is released from the posterior pituitary as a direct response to increased serum osmolarity
  • Renin is released from the kidney as a response to hypoperfusion of the macula densa, or in reponse to reduced tubular flow rate
  • Aldosterone is released as an indirect response (via renin), and causes fluid and sodium retention in exchange for hydrogen and potassium ions. This produces acidic urine, with a metabolic alkalosis and hypokalaemia
24
Q

What treatment should be started immediately after delivery of a neonate with known Transposition of the Great Arteries?

A

Prostaglandin E2 infusion

This will maintain patency of the ductus arteriosus, upon which the circulation is dependent prior to definitive surgical correction

25
Q

What are the normal physiological parameters for a seven year old child?

A

Weight approx 22kg
Respiratory rate 20-25
Heart rate 80-120
SBP 90-110
Urine output 1ml/kg/hour

26
Q

What are the common causes of neonatal sepsis?

A

Group B strep
Listeria
E Coli
Staph Aureus
HSV
Candida

27
Q

What are the weight-based doses in children for:

Atropine
IM suxamethonium
Adrenaline
Ketamine

A

Atropine = 20mcg/kg

IM suxamethonium = 3-4mg/kg

Adrenaline = 10mcg/kg or 0.1ml/kg of 1:10000

Ketamine = 0.5-2mg/kg

28
Q

How should you manage fluid resuscitation in a septic child?

A

10ml/kg boluses of balanced crystalloid up to a maximum of 40-60ml/kg

Then intubation and commencement of vasopressors is required

29
Q

What factors might make for a difficult airway in Down syndrome?

A

Large tongue
Large tonsils
Large adenoids
Small chin
Atlanto-axial instability
Subglottic stenosis

30
Q

At what length should an endotracheal tube be secured in a child?

A

Oral = age/2 + 12
Nasal = age/2 +15

31
Q

How many rescue breaths should be given prior to starting CPR in paediatric cardiac arrest?

A

5

32
Q

What energy should be used for defibrillation in a paediatric cardiac arrest?

A

4J/kg

33
Q

What dose of adrenaline should be given in paediatric cardiac arrest?

A

0.1ml/kg of 1:10 000 adrenaline

or 10mcg per kilogram

34
Q

What are the peroperative fasting guidelines for elective procedures in children aged up to 16 years?

A

Clear fluids - 1hour
Breast milk - 4 hours
Solid food - 6 hours
Formula - 6 hours

35
Q

Which syndromes are associated with strabismus?

A
  • Down’s syndrome
  • Edward’s syndrome
  • Cri du Chat
  • Goldenhar
  • Treacher-Collins
  • Smith-Lemli-Opitz
  • Crouzon
  • Apert
  • Pfeiffer
36
Q

What are the features of an innocent paediatric murmur?

A

Soft
Early systolic
Sternal
Varies with position
No associated symptoms such as cyanosis or syncope

37
Q

What are the paediatric doses for the following?

Paracetamol
Ibuprofen
Glycopyrrolate
Ondansetron
Dexamethasone

A

Paracetamol - 15mg/kg

Ibuprofen - 5-10mg/kg

Glycopyrrolate - 4-8 microg/kg

Ondansetron - 0.1-0.15mg/kg

Dexamethasone - 0.15mg/kg

38
Q

What reflex causes bradicardia during strabismus surgery?

A

Oculocardiac reflex

Ophthalmic division of the trigeminal nerve afferent

Sensory nucleus in fourth ventricle

Vagus nerve efferent

Children with a positive oculocardiac reflex are more likely to develop post operative nausea and vomiting

39
Q

What factors would make a child inappropriate for day surgery?

A

Patient factors

  • Baby less than 1 month old
  • Premature baby less than 60 weeks post conception
  • Cardiac disease
  • Poorly controlled systemic disease
  • Active infection
  • Type I diabetes
  • Inborn errors of metabolism
  • Sickle cell disease

Social factors

  • Not safe to be cared for at home post-operatively
  • More than one hour away from hospital
  • No suitable transport
  • No telephone
  • Poor living conditions
40
Q

What is the 4-2-1 rule for paediatric fluid management?

A

Maintenance fluid requirement can be calculated as:

  • 4ml/kg for the first 10kg
  • 2ml/kg for the next 10kg
  • 1ml/kg thereafter

This gives you a value per hour.

So a 21kg child would need 40ml+20ml+1ml = 61ml per hour

41
Q

What are the risks of using a ‘native airway’ and sedation approach for paediatric endoscopy?

A

Apnoea
Laryngospasm
Aspiration

42
Q

How can patient positioning affect your airway management during endoscopy?

A

The lateral position helps a native airway to remain open
It may also reduce laryngospasm by helping secretions drain away from the vocal cords
Intubation is obviously going to be substantially harder in a lateral patient with a bite block and endoscope in the mouth, so clear communication with your endoscopist is essential

43
Q

What are the indications for intubation in paediatric endoscopy?

A

Less than a year old
Less than 10kg
Known airway issues
Obstructive sleep apnoea
Cardiac or respiratory co-morbidity
High risk of aspiration, including GORD or congenital oesophageal problems
Specific procedures (such as PEG tubes)

44
Q

What impact might residual gas in the stomach after endscopy have for a child?

A

Increased risk of post operative nausea and vomiting
Pain and discomfort
Diaphragmatic splinting and respiratory compromise

High Yield Facts for the Final FRCA (22 decks)

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