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Paediatrics Flashcards

1
Q

Preterm

A

< 37 weeks post conceptual age

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2
Q

Low birth weight

A

Less than 2.5kg

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3
Q

Very low birth weight

A

Less than 1.5kg

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4
Q

Extremely low birth weight

A

Less than 1Kg

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5
Q

Infant

A

1 month - 1 year

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6
Q

Which studies are the neonatal survival rates derived from?

A

EPICure and EPICure 2 Studies

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7
Q

What is the morbidity and mortality for < 23 weeks

A

Negligible survival. Appropriate to not attempt resuscitation as standard.

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8
Q

What is the morbidity and mortality for 23 - 23+6?

A

80% mortality
54% survivors have moderate to severe disability
Reasonable to not attempt resuscitation but decision made with family

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9
Q

What is the morbidity and mortality for 24 - 24+6?

A

66% Mortality
Half remaining have moderate to severe disability
Resuscitation is generally considered appropriate unless there are other antenatally diagnosed conditions that would further impair survival

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10
Q

What is the morbidity and mortality for > 25 weeks?

A

33% Mortality
Resuscitate as standard

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11
Q

When does surfactant secretion begin?

A

24-26th week

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12
Q

When does alveolar development begin?

A

From 32nd week

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13
Q

What are the cut off ages for 24 hour postoperative apnoea monitoring in neonates?

A

Up to 60th PC week if born preterm
Up to 44th PC week if born term

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14
Q

How commonly is a patent ductus arteriosus seen in preterm neonates?

A

Up to 50% of extreme preterms

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15
Q

Describe the physiological complications of a PDA

A

Excessive pulmonary blood flow
Low systemic pressures
Myocardial failure
Inability to wean from mechanical ventilation
Sequela of low DBP e.g. NEC

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16
Q

List cardiorespiratory complications of ex-premature neonates

A

Bronchopulmonary dysplasia
Tracheomalacia (from long term ETT placement)
Subpglottic stenosis
Persistent pulmonary hypertension of the newborn (PPHN)

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17
Q

Neonate

A

Less than 1 month (44 weeks PCA)

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18
Q

Paediatric defibrillation energy

A

4 J/Kg

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19
Q

Paediatric cardiac arrest adrenaline dose

A

10 mcg/kg (20 mcg/kg neonate)

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20
Q

Infant estimated weight

A

(Months/2) + 4 in Kg

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21
Q

Child weight estimate

A

Weight in kg = 2 x (age in years + 4)
OR new Luscombe (age x 3) + 4

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22
Q

Uncuffed tube size

A

Age/4 + 4

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23
Q

Cuffed tube size

A

Age/4 + 3.5

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24
Q

Oral ETT length

A

Age/2 + 12

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25
Q

Nasal ETT length

A

Age/2 + 15

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26
Q

LMA size for less than 5 Kg

A

1

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27
Q

LMA size for 5 - 10 Kg

A

1.5

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28
Q

LMA size for 10 - 20 Kg

A

2

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29
Q

LMA size for 20 - 30 Kg

A

2.5

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30
Q

LMA size for 30 - 50 Kg

A

3

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31
Q

Normal obs for infant

A

RR 30 - 40
HR 110 - 160
SBP 70 - 90

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32
Q

Normal obs for child 1 - 3

A

RR 25 - 35
HR 100 - 150
SBP 80 - 90

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33
Q

Normal obs for child 3 - 6

A

RR 25 - 30
HR 95 - 140
SBP 80 - 100

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34
Q

Normal obs for child 6 - 13

A

RR 20 - 25
HR 80 - 120
SBP 90 - 110

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35
Q

Normal obs for child 13 - 17

A

RR 15 - 20
HR 60 - 100
SBP 100 - 120

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36
Q

Propofol dose

A

1 - 4 mg/kg

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37
Q

Thiopentone dose

A

4 - 7 mg/kg

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38
Q

Ketamine dose

A

2 mg/kg IV
10mg/kg IM

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39
Q

Fentanyl dose

A

1 - 2 mcg/kg

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40
Q

Morphine dose

A

0.1 mg/kg

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41
Q

Alfentanil dose

A

30 - 50 mcg/kg

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42
Q

Paracetamol dose

A

PO: 15 mg/kg (neonate 20mg/kg)

IV:
Neonate 32 weeks-term: 7.5mg/kg every 8h
Neonate + child up to 10kg: 10mg/kg every 4-6h, max 30mg/kg
Child 10-50kg: 15mg/kg every 4-6h, max 60mg/kg
Child 50kg+: 1g every 4-6h, max 4g

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43
Q

Ibuprofen dose

A

5 mg/kg

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44
Q

Codeine dose

A

Under 12: avoid
Over 12: 1 mg/kg (30-60mg)

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45
Q

Atracurium dose

A

0.3-0.6 mg/kg
(0.3-0.5 mg/kg neonates)

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46
Q

Rocuronium dose

A

1 mg/kg

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47
Q

Suxamethonium dose

A

Neonate + infant: 2mg/kg
Child + adult: 1mg/kg

IM: 4mg/kg

48
Q

Ondansetron dose

A

0.1 mg/kg

49
Q

Dexamethasone dose

A

0.1 mg/kg

50
Q

Neostigmine (2.5mg/ml) / Glycopyrrolate (0.5mg/ml) dose

A

0.02 mL/kg
max 2ml
1 amp per 50 kg

51
Q

Sugammadex dose

A

16 mg/kg immediate
4 mg/kg - TOF 1-2
2 mg/kg - TOF 2-4

52
Q

Atropine dose

A

20 mcg/kg

53
Q

Adrenaline dose

A

10 mcg/kg (0.1ml/kg of 1:10,000)
Neonate: 20mcg/kg (0.2ml/kg of 1:10,000)

Anaphylaxis: IV 0.01ml/kg of 1:10,000
IM use 1:1000
Up to 6 months - 100-150 mcg
6 months-6 years: 150mcg
6 years-12 years: 300mcg
12 years-adult: 500mcg

54
Q

Phenylephrine dose

A

1 mcg/kg

55
Q

Amiodarone dose

A

5 mg/kg

56
Q

Naloxone dose

A

100 mcg/kg (2mg in older than 5)

57
Q

Tranexamic acid dose

A

15 mg/kg (max 1 g)

58
Q

Co-amoxiclav dose

A

30 mg/kg

59
Q

Cefuroxime dose

A

20 mg/kg

60
Q

Metronidazole dose

A

7.5 mg/kg

61
Q

Flucloxacillin dose

A

25 mg/kg

62
Q

Gentamicin dose

A

1 - 2 mg/kg

63
Q

Diclofenac dose

A

1 mg/kg

64
Q

Midazolam dose

A

0.1 mg/kg

65
Q

Oramorph dose

A

0.1-0.2mg/kg

66
Q

Adenosine dose

A

100 mcg/kg then double (until max 12g reached)

67
Q

Noradrenaline infusion

A

0.01 - 0.5 mcg/kg/min (start at 0.1)

68
Q

Adrenaline infusion

A

0.01 - 0.5 mcg/kg/min (start at 0.1)

69
Q

Morphine infusion

A

10 - 40 mcg/kg/hour (start at 20)

70
Q

Midazolam infusion

A

0.1 mg/kg/min

71
Q

Calculate SBP based on age

A

80 + (Age x 2)

72
Q

Define status epilepticus

A

Seizures lasting >5 mins or 2 or more seizures without recovery

73
Q

First line seizure management

A

2x benzo doses:
Lorazepam 0.1 mg/kg IV
Diazepam 0.5 mg/kg PR
Midazolam 0.5mg/kg buccal

74
Q

Second line seizure management

A

Phenytoin 20 mg/kg (rate 50mg/min)
Sodium valproate 40 mg/kg
Levetiracetam 60mg/kg

75
Q

Third line seizure management

A

Another second line agent

76
Q

Fourth line seizure management

A

Phenobarbital 15 mg/kg
GA - propofol/thio/midaz

77
Q

Common pitfalls in paediatric sedation (7)

A

Inexperience
Too much sedation (verbal endpoints different)
Too little sedation
Poor timing
Non-fasting
Dose errors
Hyperactive delirium (e.g. katamine)

78
Q

What causes cleft palate

A

Defective palatal growth and fusion in 1st trimester

79
Q

Incidence of pyloric stenosis

A

1:3-400 live births
4:1 male:female (85% male)

80
Q

What is pyloric stenosis?

A

Congenital hypertrophy of the pylorus muscle causing obstruction of gastric emptying

This results in projectile non-bilious vomiting after feeds, usually at 1 month of age

81
Q

Electrolytes in pyloric stenosis?

A

Py lo ric stenosis - low K⁺ low Cl⁻ low Na⁺ metabolic alkalosis

82
Q

Metabolic resuscitation goals for pyloric stenosis prior to theatre

A

Cl⁻ >100
HCO₃⁻ <28

83
Q

Physiology of low potassium in pyloric stenosis (3)

A
  1. GI loss - vomiting leads to loss of water, sodium, potassium + hydrochloric acid → hypokalaemia, hypochloraemic metabolic acidosis
  2. Intracellular movement - buffering of intravascular alkalosis by movement of H⁺ out of cells in exchange for K⁺ into cells
  3. Renal loss - initially alkaline urine → hypovolaemia triggers aldosterone → retains sodium in exchange for urinary potassium loss + hydrogen in an attempt to restore blood volume - eventually acidic urine
84
Q

O₂consumption at rest (adult vs paed)

A

Adult 2-3 ml/kg/min
Paeds 6-8 ml/kg/min

85
Q

Closing volume of lung in paediatric patients

A

Within tidal breathing

86
Q

Level of the larynx

A

Neonate: C3-4
Child: C3-5
Adult: C5-6

87
Q

Narrowest part of paediatric airway

A

Cricoid ring (subglottic) - vs adults which is vocal cords

88
Q

Define laryngospasm

A

Upper airway obstruction secondary to partial or complete adduction of the vocal cords

Due to a primitive reflex to protect the airway from aspiration

89
Q

Patient risk factors for laryngospasm

A

Increased secretions
Anxiety (i.e. increased sympathetic stimulation)
Younger age
URTI
GORD
Asthma
Smoking
Obesity / OSA

90
Q

Anaesthetic risk factors for laryngospasm

A

LMA use
Light planes of anaesthesia
Desflurane / Isoflurane
Airway manipulation
Inexperience of anaesthetist

91
Q

Surgical risk factors for laryngospasm

A

ENT surgery
Blood in airway
Poor surgical timing - pain at light plane
Hypospadias repair

92
Q

Treatment of laryngospasm

A

Remove trigger
Ensuring a clear larynx
Open airway
CPAP with 100% oxygen
Consider propofol 0.5mg/kg bolus
Consider suxamethonium 0.1-2 mg/kg

93
Q

Methods to prevent laryngospasm

A

Clear communication on surgery start
Avoid moving in light planes
Meticulous suctioning

Pharmacological:
Mg²⁺ 15 mg/kg
Lidocaine 1.5 mg/kg IV
Lidocaine 4% spray to cords
Atropine premed - presumably to dry secretions

94
Q

What is viral croup?

A

Laryngotracheobronchitis
Responsible for 80% of acute stridor in children
Usually 2° to parainfluenza, can also be 2° to influenza A/B, RSV, rhinovirus.

95
Q

Assessment priorities when returning to theatre with a bleeding tonsil

A

Evaluate blood loss (usually underestimated)
Ensure IV access
Send blood for x-match
Resuscitate
Review anaesthetic chart
Airway
Dentition / Loose teeth
Review pt haemodynamics: CRT, UO, HR, RR, temperature
Recent food
Stridor or breathing difficulty
Recent opioid analgesia

96
Q

Perioperative priorities when returning to theatre with a bleeding tonsil

A

Equipment
Selection of laryngoscope blades
Smaller than expected tracheal tubes
2 suction catheters
Induced once the child is haemodynamically stable
PreO2and RSI with slight head-down positioning
Consider left lateral if bleeding is excessive
Fluid resuscitation and transfusion continue intraoperatively as necessary
Following haemostasis, a large-bore OG to emply stomach
Extubate the child fully awake in the recovery position
After operation, monitor closely for any recurrence of bleeding.

97
Q

Methods to decrease PONV in bleeding tonsils

A

OG/NG and thorough suctioning
Suctioning of blood from pharynx
Dual antiemetics -
* 0.15 mg/kg IV Dex
* 0.1 mg/kg IV ondansetron
Reduce BMV (stomach insufflation)
Reduce opiate analgesia (LA by surgeons)

98
Q

What are the clinical features of viral croup? (4)

A

Barking cough
Low-grade fever
Inspiratory stridor
Increased respiratory effort:
- Fatigue
- Hypoxia
- Hypercarbia

99
Q

Give an example of a croup scoring system and appropriate actions

A

Westley Croup Score:
Method of assessing the severity of croup in children
Comprises assessment of:
Chest wall retractions (0-3 points)
Stridor (0-2 points)
Cyanosis (0-5 points)
Level of consciousness (0-5 points)
What is heard on auscultation (0-2 points)

100
Q

Treatment options for viral croup

A

Humidified oxygen
Steroids
Dexamethasone 0.6 mg/kg IV/PO or
Beclomethasone 2 mg NEB
Nebulised Adrenaline: 0.5ml of 1/1000 (500mcg) diluted to 5 ml, repeated 30-60 minutes as needed
Heliox

101
Q

Describe the proceedure for intubation for a child with viral croup

A

Escort child to theatres
Minimal monitoring so as to not upset child
Inhalational induction with sevoflurane in 100% O₂
Maintain SV, apply CPAP via mapleson-F
Establish IV access ASAP following induction
Intubate once pupils are small and central
Oral intubation preferred (quicker)
Be prepared with a number of smaller uncuffed tubes
Consider exchange for nasal ETT once stable
Maintain sedation
Secure lines (consider arm splint)
Extubate once a leak is demonstrated

102
Q

What is epiglotitis?

A

A life-threatening emergency caused bybacterial infectionof the epiglottis, aryepiglottis, and arytenoids. Typically caused by Haemophilus influenzae type b (Hib), beta-haemolytic streptococci, staphylococci, or pneumococci. Vaccination against Hib has greatly reduced its incidence. Regardless, 10% of those with Hib epiglottitis had the vaccine.

103
Q

How can you clinically distinguish epiglotitis and croup?

A

Epiglottitis:
More toxic appearance
Slightly older children (2–6 yrs)
Abrupt onset of: high fever, sore throat, dysphagia, stridor, drooling
Speech muffled/lost
Absence of cough
Classically forward sitting, open mouth withdrooling
Unlikely to be relieved by adrenaline nebs

104
Q

Describe the proceedure for intubation for a child with epiglotitis

A

Escort child to theatres
Minimal monitoring so as to not upset child
Inhalational induction with sevoflurane in 100% O2
Maintain SV, apply CPAP via mapleson-F
Have ENT standing by for immediate surgical airway
Establish IV access ASAP following induction
Intubate once pupils are small and central
Oral intubation preferred (quicker)
Be prepared with a number of smaller uncuffed tubes
Consider exchange for nasal ETT once stable
Maintain sedation
Secure lines (consider arm splint)
Extubate once a leak is demonstrated

105
Q

What technique can you employ if you cannot visualise the airway during epiglotitis intubation?

A

Compress the chest slightly but suddenly
Bubbles appear at the laryngeal inlet
Intubate at the bubbles

106
Q

What is an appropriate dose of antibiotics for epiglotitis?

A

Extended spectrum cephalosporin
e.g. ceftriaxone 80 mg/kg/day max 4 g/day

107
Q

What is bacterial tracheitis?

A

An uncommon bacterial infection of the trachea. Most commonly 2° to: Staphylococcus aureus, Haemophilus influenzae, streptococci or Neisseria spp. Since the Hib vaccine, this has taken over as the leading cause of infective upper airway obstruction in children.

108
Q

What are the clinical features of bacterial tracheitis?

A

Midway between viral croup and bacterial epiglottitis
URTI 48 hours preceeding
Sudden deterioration in condition (8-10 hrs)
High fever
Respiratory distress
Copious purulent secretions
No dysphasia or drooling
Child can usually lie flat

109
Q

You are about to intubate a case of bacterial tracheitis. Any extra proceedures necessary?

A

Inhalation induction and set up as for epiglotitis
Bronchoscope ready to remove pus/debris from airway proior to intubation
In extremis, intubation must go first, but immediate bronchoscopy and a tube change is very likely

110
Q

Antibiotic treatment in bacterial tracheitis?

A

Ceftriaxone
Consider vancomycin if MRSA suspected

111
Q

Describe the proceedure for administering caudal anaesthesia.

A

CAMDEN
Left lateral position, knees drawn up to the chest
Landmarks:
Equilateral triangle formed between two posterior superior iliac spines and the sacral hiatus
Sacral hiatus palpable between between cornua
Needle (20-22g cannula) introduced slightly cranial (45°) through the hiatus
A pop is felt as the needle pierces the sacrococcygeal membrane
Aspirate to confirm the absence of blood/CSF
Inject local anaesthetic while feeling for inadvertent subcutaneous injection

112
Q

Calculate a childs blood volume

A

Preterm: 90-100 ml/kg
Neonate-3 months: 80-90 ml/kg
3 months+: 70 ml/kg

113
Q

Adrenaline in anaphylaxis dose

A

> 12 years - 500 mcg IM
6-12 years - 300 mcg IM
<6 years - 150 mcg IM
Can use IV at doses of 1mcg/kg

114
Q

Incidence, gender distribution and presentation of cleft palate?

A

1 in 1000 LB
Male preponderance
Left preponderance
Environmental/genetic factors
Typically 1st trimester

Presentation:
Visible defect
Difficulty latching while feeding
Respiratory distress and reflux during feeding
Speech problems, such as a nasal sound or difficulty being understood
Ear infections, which can lead to hearing loss if left untreated
Dental problems, such as cavities, missing teeth, or malformed teeth

115
Q

Cleft lip/palate disease associations

A

Pierre Robin
Treacher Collins
Downs
EtoH fetal syndrome

116
Q

What is the incidence of MH in children?

A
117
Q

Why are neonates prone to respiratory fatigue?

A

Disproportionately fewer Type 1 (oxidative) slow muscle fibres in the diaphragm

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