Paediatrics Flashcards
Examples of obstruction which may lead to decompensated respiratory failure in children ?
Foreign body aspiration
Asthma
Croup
Examples of respiratory depression which may lead to decompensated respiratory failure in children ?
Convulsions
Poisoning
Raised ICP
How are paediatric oropharyngeal airways measured ?
Midpoint of incisor to angle of mandible
How are paediatric oropharyngeal airways measured ?
Lateral edge of nostril to Tragus of ear
Airway signs of anaphylaxis?
Stridor
Wheeze
Circulatory signs of anaphylaxis?
Hypotension
Tachycardia
Response to anaphylaxis in children
- call anaesthetist to secure airway
- remove allergen
- high flow oxygen
- adrenaline IM
- IV hydrocortisone
- salbutamol NEB
- IV chlorphenamine (antihistamine)
Characteristic signs if epiglottitis (paediatrics)
Drooling
Quiet
Septic appearance
Response for epiglottitis emergency
- DO NOT ENDANGER AIRWAY
- call anaesthetist early
- once secured and anaesthetised start broad spec antibiotics e.g. Amoxicillin or 3rd gen cephalosporins (ceftotaxime)
Observations in type 2 respiratory failure
paO2
Causes of type 1 respiratory failure in children?
- pneumonia
- pleural effusion
- pneumothorax
- pulmonary oedema
Causes of type 2 respiratory failure in children?
- severe asthma with exhaustion
- reduced consciousness
- exhaustion
Normal heart rate in infants ?
110-160 Bpm
Normal heart rate in younger children ?
140-95 Bpm
Normal heart rate in older children ?
120-80 Bpm
At what age does paediatric heart rate reach same as in adults ?
12 years
Normal Systolic BP in infants ?
70-90 mmHg
Normal Systolic BP in young children ?
80-100 mmHg
Normal Systolic BP in older children ?
90-110 mmHg
3 main areas to survey in recognition of circulatory problems for pRRAPID
- vitals e.g. HR, pulse Vol, BP
- skin and mucous membrane perfusion
- organ perfusion e.g. Mental status, urine output, effect on breathing
Define shock
Generalised state of tissue hypoperfusion leading to inadequate supply of nutrients I.e. Oxygen and glucose to the tissues
Name 5 types of shock?
- hypovolaemic
- distributive
- cardiogenic
- obstructive
- neurogenic
How is distributive shock different to other types ?
Occurs despite normal output of the heart
When does hypovolaemic shock occur ?
When lose more than 20% blood volume e.g. Trauma
Pathology of distributive shock ?
Vessels less responsive to vasoconstrictive agents
Septic or anaphylactic shock
Mechanism of cardiogenic shock ?
Pump failure of the heart, deceased output = reduced end organ perfusion
E.g. PE, cardiac tamponade
When does neurogenic shock occur ?
Loss of vascular tone normally supported by sympathetic nervous system I.e. CNS disruption/ injury
How much given in fluid bolus to children?
20ml/kg
Outline sepsis 6 pathway for response to sepsis in children
- Oxygen
- IV/Access and take blood
- IV/IO antibiotics
- Fluid resus (20ml/kg) saline 0.9%
- Senior help
- Inotropic support e.g. Adrenaline or dopamine
In children what are the 2 main causes of decompensated respiratory failure ?
Obstruction and respiratory depression
Classic presentation of PROM
Popping sensation and watery discharge
At what week of gestation is surfactant produced?
33
What does PPROM stand for ?
Preterm prelabour rupture of membranes
What percentage of pregnancies does PPROM occur in ?
2%
Of suspected PROM what is done to make diagnosis ?
- look for amniotic fluid leaking from cervix and pooling in vagina
- pad checks
What should be monitored in PROM/PPROM scenarios ?
- foetal heart rate
- maternal temperature
- if maternal fever check bloods
Risk factors for PROM?
- smoking
- previous preterm delivery
- vaginal bleeding during pregnancy
- associated With lower genital tract infections
How is PPROM managed ? (<37 weeks)
- Delay delivery using tocolytic agents for 48hrs if possible
- antenatal steroids (lung maturation, decrease risk of IVH)
- council parents
- prepare for delivery
How is PROM managed ? (>37 weeks)
Induce delivery if foetal distress or ascending infection
- monitor foetal HR and maternal temp
What is the earliest sign of ascending infection in PROM?
Foetal tachycardia and slight elevation in maternal temperature
3 most common causes of mortality in PPROM
- immaturity
- sepsis
- pulmonary hypoplasia
4 respiratory problems in low birthweight infants?
- RDS (74%)
- pneumothorax (5%)
- apnoea/bradycardia/desaturations
- bronchopulmonary dysplasia (chronic lung disease)
Appearance of RDS on CXR ?
Ground glass appearance
RDS is rare in full term babies, which group of full term babies are at increased risk ?
Those born to diabetic mothers
How does RDS present ?
- Cyanosis
- tachypnoea > 60
- increased work of breathing
- expiratory grunt
- present within 4hrs of birth
How common is RDS ? (All births and prem)
1% all births
50% 26-28 weeks
How is RDS treated ?
- surfactant (curosurf) - get in before 1st breath
- intubation
- CPAP
- antenatal glucocorticoids if prem anticipated
Complications of RDS
- pneumothorax
- IVH
- delayed cognitive development
Management of hypotension in neonate ?
- IV bolus of 10ml/kg 0.9% saline
- inotropes e.g. Dopamine
- hydrocortisone IV QDS (sometimes)
How do IVH present in neo ages ?
- apnoeas
- reduced muscle tone
- lethargy
- seizures
- abnormal eye movements
- absent MOROS
How are IVH managed in neonates
Support I.e. Correct anaemias, hypotension, Acidosis
- ventilators support if deteriorate acutely
- longterm management if seizures, neuro delay etc
- limit handling keep baby calm
- stabilise BP
Outcomes of IVH in neonates ?
- hydrocephalus
- motor and cognitive deficits
Neuro developmental delay
Preventative measures for IVH in neonates ?
- antenatal steroids
- avoid birth trauma
Outline grading system for IVH in neonates
I - bleeding confined to germinal matrix
II - bleeding fills 10-50% ventricle
III - bleeding fills >50% ventricle
IV - bleeding into brain outside ventricles
Signs of IVH in neonates
- tense/bulging fontanelle
- neuro depression -> coma
- mild forms may have no signs or alternating symptomatic and asymptomatic periods
Most common cause of heart murmur in newborns ?
Patent ductus arteriosus
Where is the ductus arteriosus located ?
Connects pulmonary artery to proximal descending aorta just after left subclavian artery origin
What percentage of circulation passes through the lungs in utero ?
10%
Function of ductus arteriosus in utero?
Shunts blood away from unopened lungs
- 12-18h after delivery closes (functionally) and blood is directed to opened lungs
- anatomically closes after 2-3w
Define persistent patency of ductus arteriosus
Remains open beyond
- 3m in preterm babies
- 1y in term babies
Risk factors for patent ductus arteriosus
- asphyxia during delivery
- rubella infection during pregnancy
- genetic syndromes e.g. Trisomy 21, holt-oram syndrome
Presentation of ductus arteriosus in term baby
- SOB
- tachycardia
- bounding pulses
- continuous murmur
- feeding problems
- failure to thrive due to heart failure
- if small PDA = asymptomatic
What is likely cause if preterm baby with RDS does not improve after initial treatment or if improves and gets worse again and cannot be weaned off ventilator ?
Patent ductus arteriosus
Presentation of ductus arteriosus in preterm baby
Many classic signs not present:
- continuos murmur rarely heard
- bounding peripheral pulses
- hyperactive precordium
- tachycardia with or without gallop
What 3 conditions is Patent ductus arteriosus associated with ?
- chronic lung disease
- NEC
- IVH
Risk factors for NEC
- prem
- low birth weight
- blood transfusion
- PDA
- abx > 10d
- bottle fed
Mortality rate in NEC
50%
Presentation of NEC
- feeding intolerance
- classically preterm baby in first 2 weeks who showed initial progress in enteral feeds
- bilious aspirates/vom
- bloody stool
Management of NEC
- stop feeds to rest gut
- IV Abx - amp/gent or cefotaxime + metronidazole or clindamycin
- acute laparotomy
Appearance of NEC on AXR?
- intramural gas
- bowel wall thickening
- persistent bowel loops filled with gas
- overall gaseous distension
Define chronic lung disease in neonates
Aka bronchopulmonary dysplasia
Any baby with an oxygen requirement Beyond 28d if life
What causes chronic lung disease (BPD) in infants ?
- prem
- damaged caused by long term ventilation
Management of infantile chronic lung disease/ bronchopulmonary dysplasia
- continued ventilation with gradual weaning
- steroids
- nutrition
- diuretics/caffeine?
- immunisations
What is retinopathy of prematurity ?
Eye disease affecting premature infants
- abnormal proliferation of retinal blood vessels
- scarring of retina and possible detachment
- high oxygen is detrimental
Who is screened for retinopathy of prematurity ?
Babies <1500g or those born <31w
- first assessment around 6w
Treatment of retinopathy of prematurity ?
Laser ablation of the avascular retina
Define neonate
A baby term or preterm up to 28days old
Define term baby
Born between 37 and 42 weeks gestation
What is the Barlow manoeuvre?
Physical exam performed on infants to screen for developmental dysplasia of the hip
- adduct hip (towards midline) while applying light pressure on the knee, directing force posteriorly
- if hip is dislocatable = positive test
What is the Ortolani test?
Relocates hip dislocated during barlows
- flex hips and knees of supine infant to 90 degrees
- place anterior pressure on greater trochanter and abduct
- positive sign = distinct ‘clunk’ as femoral head relocates
What is the APGAR score ?
Score done 1 and 5 mins after birth A - appearance (skin colour) P - pulse (HR) G - grimace (reflexes) A - activity (tone) R - respiration (RR and effort)
2 points available for each part, score of 8-10 at 5 mins = norm
* at 1 min most newborns cyanosed
Average measurements of newborn ?
Head, length, weight
- head = 35cm
- length = ~ 50cm
- weight = 2.5-3.5kg (5.5-7.7lbs)
