Pediatric Anes. Pt. 3 (Exam 4 Final) Flashcards
1
Q
What nerve is primarily involved in the hyper-responsive reflex seen in laryngospasm?
A. Recurrent laryngeal nerve
B. Phrenic nerve
C. Superior laryngeal nerve
D. Glossopharyngeal nerve
A
C. Superior laryngeal nerve
Anesthetic Emergency!
Slide 4
2
Q
Which of the following is TRUE about laryngospasm in pediatric patients?
A. It is less common than in adults
B. It only occurs during intubation
C. It is typically self-limiting and non-emergent
D. It may cause negative pressure pulmonary edema
A
D. It may cause negative pressure pulmonary edema
Which can lead to cardia arrest 💔
There is a greater percent of patients in the pediatric world that will have laryngospasm than adults
slide 4
3
Q
Which patient is MOST at risk for developing laryngospasm?
A. Adult patient undergoing orthopedic surgery
B. Pediatric patient with recent URI undergoing tonsillectomy
C. Pediatric patient with no URI undergoing foot surgery
D. Adult patient with GERD undergoing ENT procedure
A
B. Pediatric patient with recent URI undergoing tonsillectomy
slide 4
4
Q
Which of the following statements best explains why pediatric patients have increased incidence of laryngospasm?
A. They require higher concentrations of volatile anesthetics
B. They have a stronger sympathetic response
C. They more frequently undergo surgeries without paralysis
D. They have longer vocal cords
A
C. They more frequently undergo surgeries without paralysis
slide 4
5
Q
What is the estimated incidence of laryngospasm in the pediatric population?
A. 0.5%
B. 1.7%
C. 5.0%
D. 10%
A
B. 1.7%
…up to 25% in procedures like ENT procedures, tonsils, and adenoids where
we’re really interfering in the airway.
Slide 4
6
Q
Patients exposed to __________ in their home environment are at increased risk for laryngospasm.
A. pets
B. mold
C. gluten
D. secondhand smoke
A
D. secondhand smoke
slide 5
7
Q
Laryngospasm is more likely to occur during which phase of anesthesia?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
A
B. Stage II (Excitement)
slide 5
8
Q
Which of the following are preoperative risk factors for laryngospasm? (Select 3)
A. GERD
B. 3rd phase of inhalation induction
C. Recent upper respiratory infection
D. Mechanical irritants
E. Use of NMBD
A
A. GERD
C. Recent upper respiratory infection
D. Mechanical irritants (oropharyngeal secretions)
slide 5
9
Q
Which of the following is the BEST way to prevent laryngospasm during extubation?
Select 2
A. Extubate while the patient is in Stage II
B. Administer midazolam prior to extubation
C. Extubate while the patient is fully awake
D. Perform oral suctioning after extubation
E. Extubate while deeply anesthetized
A
C. Extubate while the patient is fully awake
E. Extubate while deeply anesthetized
slide 6
10
Q
Which medication can be used topically or intravenously to reduce sensory input to the larynx before extubation?
A. Propofol
B. Succinylcholine
C. Lidocaine
D. Epinephrine
A
C. Lidocaine
Supresses laryngeal nerve activity
slide 6
11
Q
What is the purpose of administering 100% oxygen for 3–5 minutes prior to extubation?
A. Increase end-tidal CO₂
B. Promote muscle relaxation
C. Prolong anesthesia
D. Provide oxygen reserve
A
D. Provide oxygen reserve in case of airway obstruction
slide 6
12
Q
Which of the following is a correct method to reduce airway irritation before extubation?
A. Suction the oral pharynx prior to extubation
B. Increase tidal volume prior to extubation
C. Administer naloxone
D. Delay emergence with sevoflurane
A
A. Suction the oral pharynx prior to extubation
slide 6
13
Q
Incomplete Airway obstruction
What is the first step in managing an incomplete airway obstruction following extubation?
A. Administer succinylcholine
B. Perform laryngoscopy
C. Apply gentle positive pressure
D. Give atropine
A
C. Apply gentle positive pressure with 100% oxygen
a lil’ CPAP action
slide 7
14
Q
Which of the following should be eliminated early in laryngospasm treatment?
A. Inhaled anesthetic
B. Oxygenation
C. Noxious stimuli
D. Intravenous fluids
A
C. Noxious stimuli
SUCTION the airway, don’t touch the patient
slide 7
15
Q
If a patient with incomplete laryngospasm improves after suctioning and CPAP, what is the appropriate next step?
A. Administer succinylcholine
B. Deepen anesthesia
C. Resume anesthetic and stabilize
D. Reintubate immediately
A
C. Resume anesthetic and stabilize
slide 7
16
Q
If there is no improvement with laryngospasm after trying CPAP and 100% O2. Which IV anesthetic is commonly used to deepen anesthesia?
A. Etomidate
B. Midazolam
C. Ketamine
D. Propofol
A
D. Propofol
…turn up your gas or propofol.. I’ll still give a small dose of propofol, maybe like half a milligram or less per kilo.
slide 7
17
Q
Which drug combination is appropriate when a patient has no improvement after deepening anesthesia during laryngospasm?
A. Ketamine + glycopyrrolate
B. Midazolam + atropine
C. Succinylcholine + atropine
D. Rocuronium + naloxone
A
C. Succinylcholine + atropine
Ventilate with 100% O2 and intubate if needed
slide 7
18
Q
Complete Airway obstruction
Which of the following is a unique first-line maneuver for treating complete airway obstruction due to laryngospasm?
A. CPAP with nasal cannula
B. Laryngospasm notch pressure
C. Cricoid pressure
D. Needle decompression
A
B. Laryngospasm notch pressure
“a little more aggressive and a little faster with our treatment and management of a laryngospasm.”
slide 8
19
Q
Which steps are appropriate initial management for a complete airway obstruction? (Select 3)
A. Administer 100% O₂
B. Flutter the bag
C. Administer atropine alone
D. Spray the airway with lidocaine
E. Listen and watch for oxygen entry
A
A. Administer 100% O₂
B. Flutter the bag
E. Listen and watch for oxygen entry
Fluttering the bag - When you apply positive pressure using a mask and anesthesia bag (like the reservoir bag on your circuit), you squeeze the bag gently and then let go, repeatedly. You’re gently cycling small breaths of 100% oxygen into the patient.
Slide 8
20
Q
If you have suctioned and removed noxious stimulus and still no air movement is present and the patient has IV access, what is the appropriate next step?
A. Give IV propofol
B. Apply CPAP and wait
C. Administer IV succinylcholine with atropine
D. Attempt intubation first
E. Administer IM succinylcholine with atropine
A
C. Administer IV succinylcholine with atropine
If NO IV then use IM succinylcholine with atropine
Ventilate with 100% O2 and attempt intubation
Slide 8
21
Q
What is the appropriate airway action if succinylcholine and atropine are given but intubation fails?
Select 2
A. Administer naloxone
B. Repeat laryngoscopy
C. Start steroids
D. Suction stomach contents
E. Administer lidocaine spray
A
B. Repeat laryngoscopy
E. Administer lidocaine spray
Attempt intubation again and call for help EARLY (circulator nurse usually first)!
Slide 8
22
Q
Which of the following indicates a failed airway and should prompt consideration of cricothyrotomy or tracheostomy?
A. Bronchospasm unresponsive to albuterol
B. Two failed intubation attempts
C. ETCO₂ increase to 50 mmHg
D. Moderate inspiratory stridor
A
B. Two failed intubation attempts and no ventilation
START CPR
Slide 8
23
Q
If you have suctioned and removed noxious stimulus and air movement is present, what is the appropriate next step?
(Select 2)
A. Increase concetration of volatile anesthetic
B. Apply gentle positive pressure
C. CPR or cricothyrotomy
D. Decrease concetration of volatile anesthetic
E. Attempt intubation
A
A. Increase concetration of volatile anesthetic
D. Decrease concetration of volatile anesthetic
Slide 8
24
Q
Once air movement is present and you have increased or decreased your volatile anesthetic you are ok to spray with lidocaine and intubate again
A
False
You should apply gentle positive pressure to the airway and continue 100% oxygen
Slide 8
25
Where exactly is the laryngospasm notch where you apply pressure?
A. At the thyroid cartilage
B. Behind the angle of the mandible
C. Over the mastoid process
D. At the cricoid cartilage
B. Behind the angle of the mandible
## Footnote
slide 9
26
Which statement about succinylcholine dosing for IV treatment of laryngospasm is correct?
A. 0.1–0.3 mg/kg IV
B. 0.35–0.45 mg/kg IV
C. 0.25–0.5 mg/kg IV
D. 0.75–1.5 mg/kg IV
Answer: B. 0.25–0.5 mg/kg IV
C. 0.25–0.5 mg/kg IV
Up to 2mg/kg
"A lot of times just a small dose of succs will relax the vocal cords enough to start moving air."
## Footnote
slide 9
27
Which anticholinergic medication should be co-administered with **IV** succinylcholine to prevent bradycardia?
A. Glycopyrrolate
B. Epinephrine
C. Midazolam
D. Albuterol
A. Glycopyrrolate
..or Atropine IV 0.02mg/kg
## Footnote
slide 9
28
When using **IM** succinylcholine during a laryngospasm, what is the appropriate dosing range?
A. 1–2 mg/kg
B. 2–3 mg/kg
C. 3–4 mg/kg
D. 5–6 mg/kg
C. 3–4 mg/kg
Atropine IM - 0.04mg/kg
## Footnote
slide 9-10
29
# Bronchospasm
Which of the following best describes the pathophysiology of bronchospasm?
A. Disorder of skeletal muscle
B. Disorder of smooth muscle
C. Infection of alveolar tissue
D. Paralysis of the diaphragm
B. Disorder of smooth muscle
## Footnote
Slide 11
30
Which conditions increase a patient's risk of intraoperative bronchospasm? (Select 3)
A. Active asthma
B. Recent upper respiratory infection
C. Controlled hypothyroidism
D. History of anaphylaxis
E. Hypertension without airway disease
A. Active asthma
B. Recent upper respiratory infection
D. History of anaphylaxis
"...the risk factors are kids with asthma, upper respiratory infections, but also patients with **allergies** or a history of anaphylaxis, patients that have **ingested a foreign body or have pulmonary edema.**
## Footnote
slide 11
31
Which clinical signs are associated with bronchospasm during anesthesia? (Select 3)
A. Audible wheezing
B. Shark-fin capnography
C. Increased SPO2
D. Hypercapnia
E. Increased tidal volume
A. Audible wheezing
B. Shark-fin capnography - *Prominent slope on expiratory portion of ETCO2*
D. Hypercapnia (increased CO₂)
**Decreased SPO2**
"It's characterized by an expiratory wheeze, a prolonged expiration, increase in our
airway pressures. "
## Footnote
Side 11
32
Which of the following are appropriate first-line treatments for bronchospasm under anesthesia? (Select 3)
A. Deepen anesthesia with volatile agent
B. Administer succinylcholine
C. Remove stimulus
D. Switch to 100% FiO₂
E. Increase PEEP aggressively
A. Deepen anesthesia with volatile agent *or propofol*
C. Remove stimulus
D. Switch to 100% FiO₂
## Footnote
Slide 11
33
Which interventions are appropriate if bronchospasm if **air trapping** may be might be happening? (Select 3)
A. Decrease PEEP
B. Increase PEEP
C. Increase expiratory time
D. Decrease expiratory time
E. Beta agonists
F. Beta blockers
A. Decrease PEEP
C. Increase inspiratory time
E. Beta agonists (**albuterol**)
"Other treatment options are to decrease your PEEP and increase your expiratory time to minimize any air trapping they might be having."
"Other treatments will be **corticosteroids (fluticasone or budesonide)**, so some beta agonists like albuterol."
## Footnote
Slide 11
34
Which interventions are appropriate for treating **persistant** bronchospasm with no air movement after trying beta agonist and corticosteroids? (Select 2)
A. IV Epinephrine
B. Administer propofol
C. IV Magnesium
D. Administer succinylcholine
E. Nebulized Epinephrine
A. IV Epinephrine
C. IV Magnesium
## Footnote
Slide 11
35
What is an appropriate epinephrine dose for severe bronchospasm in an adult patient?
A. 0.1–0.2 micrograms/kg
B. 1–2 mg/kg
C. 5–10 micrograms/kg
D. 50–100 micrograms total
C. 5–10 micrograms/kg
"Epi is a great second line option for severe bronchospasm. If you *know* it's a bronchospasm and feel like it's pretty severe, you could even say it's a first line treatment."
## Footnote
Slide 11
36
What is the primary cause of post-extubation croup?
A. Infection of the alveoli
B. Hyperventilation postoperatively
C. Airway collapse during deep anesthesia
D. Edema in a narrow pediatric airway
D. Edema in a narrow pediatric airway
## Footnote
Slide 12
37
Which symptoms are most characteristic of post-extubation croup?
Select 2
A. Barking cough
B. Productive cough with thick sputum
C. Inspiratory stridor
D. Expiratory stridor
A. Barking cough
C. Inspiratory stridor
"Typically the patient will have a barking cough or sort of a hoarseness. They may have some inspiratory stridor and increased work of breathing."
## Footnote
Slide 12
38
Which of the following are risk factors for post-intubation croup? (Select 3)
A. Using too large of an ETT
B. Multiple direct laryngoscopy attempts
C. High FiO₂ for prolonged periods
D. Changing position during the case
E. Using too small of an ETT
A. Using too large of an ETT
B. Multiple direct laryngoscopy attempts
D. Changing position during the case
* Surgical time
* Age
* Upper airway infection
* Coughing on ETT
## Footnote
Slide 12
39
Which treatments are appropriate for managing post-extubation croup? (Select 3)
A. Hypertonic saline instillation
B. Nebulized racemic epinephrine
C. Immediate bronchoscopy
D. Supplemental O₂
E. IV Steroids
B. Nebulized racemic epinephrine
D. Supplemental O₂
E. Steroids
""You can also do **nebulized steroids.**
Typically with patients that **we know** are susceptible for post intubation or extubation croup, we'll go ahead and do a dose of 0.5mg/kg IV steroids.
## Footnote
slide 12
40
# True or False
Supplemental oxygen is cooled and humidified.
True
## Footnote
Slide12
41
Racemic epinephrine for croup is typically dosed at __________ mL/kg of a 2.25% solution.
A. 0.01
B. 0.05
C. 0.1
D. 0.5
B. 0.05
## Footnote
Slide 12
42
What precaution must be taken after giving racemic epinephrine for croup?
A. Repeat racemic epi immediately after 15 minutes
B. Administer hypertonic saline
C. Extubate the patient if breathing improves
D. Observe for rebound swelling after 4 hours
D. Observe for rebound swelling after 4
## Footnote
Slide 12
43
What is the best prevention strategy for post-extubation croup in pediatric patients?
A. Use a smaller-than-predicted ETT
B. Immediately inflate the ETT cuff to maximum volume
C. Verify a leak at before inflating the cuff
D. Routinely intubate without a cuffed tube
C. Verify a leak at before inflating the cuff
"...what you do is you typically turn your pop off valve to 20 cm and just hold and somebody will listen at the **tracheal
notch** and see if they hear an air leak.
And you'll inflate the balloon to make the leak go away. And so there's **no certain milliliters** that you put in a pediatric airway cuff."
## Footnote
Slide 12
44
In pediatric patients, which factor would most likely suggest a difficult airway?
A. A history of snoring or feeding difficulties
B. A history of abdominal surgery
C. A history of good bottle feeds
D. A history of eye infection
A. A history of snoring or feeding difficulties
## Footnote
slide 13
45
Which components are essential in assessing a pediatric airway during physical exam? (Select 3)
A. Mandible structure
B. Visual acuity
C. Palpation of liver size
D. Tongue size
E. Dental development
A. Mandible structure
D. Tongue size
E. Dental development
Face, Mouth, tongue, teeth, etc.
## Footnote
slide 13
46
Which syndromes are associated with a large tongue that can complicate airway management?
A. Pierre Robin and Goldenhar
B. Trisomy 21 and Beckwith-Wiedemann
C. Treacher Collins and Cri du Chat
D. Klippel-Feil and Goldenhar
B. Trisomy 21 and Beckwith-Wiedemann
"Remember: **B**ig **T**ongue"
"Both these kids have large tongues that can cause upper airway occlusion, so an **oral airway** might be helpful for them."
## Footnote
Slide 14
47
Which syndromes are associated with a small or underdeveloped mandible?
A. Trisomy 21 and Beckwith
B. Klippel-Feil and Trisomy 21
C. Pierre Robin and Treacher Collins
D. Beckwith and Cri du Chat
C. Pierre Robin and Treacher Collins
"Remember: **P**lease **G**et **T**hat **C**hin"
**P**ierre Robin Sequence
**G**oldenhar Syndrome
**T**reacher Collins Syndrome
**C**ri du Chat Syndrome
**"These are kids you definitely want to have a fiber optic or video scope nearby"**
## Footnote
Slide 14
48
Which syndromes are associated with **cervical spine** anomalies? (Select 3)
A. Beckwith-Wiedemann
B. Trisomy 21
C. Treacher Collins
D. Klippel-Feil
E. Goldenhar
F. Cri du Chat
B. Trisomy 21
D. Klippel-Feil
E. Goldenhar
"Remember: **K**ids **Tr**y **Gold**"
**K**lippel-Feil Syndrome
**Tri**somy 21 (Down Syndrome)
**Gold**enhar Syndrome
"...you want to be careful manipulating their necks. So again, having a video scope might help you intubate these patients without having to manipulate their head and neck as much."
## Footnote
Slide 14
49
Why are neuromuscular blocking drugs (NMBDs) often avoided in patients with suspected difficult airways?
A. They cause laryngospasm
B. They can increase airway swelling
C. So we can wake them up quickly
D. They prolong recovery time
C. So we can wake them up quickly
"A lot of times we'll avoid muscle relaxant. That way if we need to wake them up
quickly, we don't have any muscle relaxant on board."
## Footnote
Slide 15
50
Which of the following are critical steps when preparing for a potentially difficult airway? (Select 3)
A. Maintain VC ventilation
B. Prepare multiple sizes of ETTs
C. External manipulation of the trachea
D. Administer succinylcholine immediately for induction
E. Plan for different induction techniques
B. Prepare multiple sizes of ETTs
C. External manipulation of the trachea
E. Plan for different induction techniques
* Maintain Spontaneous Ventilation (SV)
* Establish IV access
* Adjunct airway equipment like LMAs
"We have multiple sizes of pediatric equipment and nearby...you want to make sure to have two different size ET tubes, the size you need, a size smaller, stylets, oral airways of multiple sizes."
## Footnote
Side 15
51
In pediatric cases, after achieving a deep plane of anesthesia, ensure delivery of 100% __________ before proceeding with airway instrumentation.
A. nitrous oxide
B. FiO₂
C. air
D. helium
B. FiO₂
## Footnote
Slide 15
52
Which of the following should you consider if you anticipate a difficult pediatric airway during surgery?
A. Calling ENT for standby assistance
B. Administering muscle relaxants immediately
C. Using only one airway attempt before canceling the case
D. Planning to extubate deeply anesthetized
A. Calling ENT for standby assistance
"...having our pediatric ENT on standby, because if you need an emergent airway, you want the expert in the room"
## Footnote
Slide 15
53
What is the primary purpose of having a difficult airway algorithm readily available during airway management?
A. For rapid decision-making if intubation or ventilation fails
B. To help organize surgical case lists
C. To provide pharmacology references for emergency drugs
D. To document postoperative complications
A. For rapid decision-making if intubation or ventilation fails
## Footnote
Slide 15-16
54
During emergency airway management, what is the first maneuver to attempt after calling for help?
A. Perform tracheostomy immediately
B. Attempt Two-Person, Two-Hand mask ventilation
C. Insert an oral RAE tube
D. Start rigid bronchoscopy
B. Attempt Two-Person, Two-Hand mask ventilation
## Footnote
Slide 17
55
What is the peak age range for foreign body aspiration in children?
A. 2 months –5 years
B. 5 months - 4 years
C. 6 months–3 years
D. 1 month– 4 years
C. 6 months–3 years
## Footnote
Slide 18
56
Which symptoms may indicate a child has aspirated a foreign body? (Select 3)
A. Cough
B. Bucking
C. Wheezing
D. Increased tidal volume
E. Stridor
A. Cough
C. Wheezing
E. Stridor
## Footnote
Slide 18
57
If a foreign body is located **supraglottically**, the patient is most likely to present with __________.
A. Wheezing
B. Stridor
C. Decreased breath sounds
D. Productive cough
B. Stridor
## Footnote
slide 18
58
If a foreign body is located **subglottically**, the patient is most likely to present with __________.
A. Wheezing
B. Absent breath sounds
C. Stridor
D. Productive cough
A. Wheezing
## Footnote
sldie 18
59
Foreign bodies aspirated into the airway are most commonly found in the __________ main bronchus.
A. anterior
B. superior
C. left
D. right
D. right
"a lot of times when kids eat things it goes in their esophagus instead
of their airway. Usually it ends up going down into their right main bronchus and causes some air trapping"
## Footnote
slide 18
60
Which anesthesia considerations are important for rigid bronchoscopy for foreign body removal? (Select 3)
A. Maintain spontaneous ventilation
B. Maintain positive pressure ventilation
C. Give large boluses of narcotics
D. Consider using TIVA
E. Increase fresh gas flow
A. Maintain spontaneous ventilation
D. Consider using TIVA
E. Increase fresh gas flow
"we'll do a mask conduction still with just a very gentle slow induction, making sure we keep them spontaneously breathing, make sure we're not giving them too much positive pressure."
## Footnote
slide 18
61
Lithium button battery ingestion causes rapid damage by raising the tissue pH to around __________.
A. 5–6
B. 7–8
C. 10–11
D. 12–13
D. 12–13
Severly alkalotic
## Footnote
19
62
In cases of button battery ingestion, necrosis of tissue can begin within __________ minutes.
A. 5
B. 15
C. 45
D. 90
B. 15
## Footnote
slide19
63
What is the target timeframe for removal of a button battery after ingestion?
A. Within 2 hours
B. Within 6 hours
C. Within 24 hours
D. Wihtin 48 hours
A. Within 2 hours
## Footnote
slide 19
64
Which action by parents is encouraged prior to arrival in the hospital after suspected battery ingestion?
A. Give milk and toast
B. Give a weak acid
C. Force vomiting
D. Keep the child completely NPO
B. Give a weak acid **like honey, juice, or soda**
"these neutralize this alkalitic environment...it's noted to the anesthesia providers **we don't want to delay for NPO status**"
## Footnote
Slide 19
65
What is a lethal complication of button battery ingestion if not promptly managed?
A. Aspiration pneumonia
B. Pulmonary embolism
C. Pneumothorax
D. Aorto-esophageal fistula
D. Aorto-esophageal fistula with **massive hemorrhage**
## Footnote
Slide 19
66
What is the most common cause of epiglottitis in children?
A. Viral infection
B. Bacterial infection
C. Fungal infection
D. Allergic reaction
B. Bacterial infection
**Supra**glottica
## Footnote
Slide 20
67
Which symptom combination is most characteristic of epiglottitis?
A. Barking cough and mild fever
B. Hoarseness, mild cough, nasal congestion
C. Drooling, dysphagia, high fever, dyspnea
D. Diarrhea, dehydration, high fever
C. Drooling, dysphagia, high fever, dyspnea
"the kids will sit in like a tripod sort of position with their head tilted forward because they are having a hard time breathing."
## Footnote
Slide 20
68
The onset of epiglottitis symptoms is usually __________.
A. rapid
B. gradual over days
C. intermittent
D. delayed by a week
Answer: B. rapid
A. rapid
## Footnote
Slide 20
69
What is the typical age group affected by epiglottitis?
A. Less than 2 years old
B. 2–6 years old
C. 5–8 years old
D. 8–12 years old
B. 2–6 years old
## Footnote
Slide 20
70
In managing epiglottitis, which considerations are critical?
(Select 3)
A. Ensure ENT surgeon is available
B. Oxygen administration
C. Steroids
D. Racemic Epi
E. Administer IV antibiotics
A. Ensure ENT surgeon is available
B. Oxygen administration
E. Administer intravenous antibiotics
## Footnote
Slide 20
71
Which clinical signs are more typical of croup? (Select 3)
A. Inspiratory stridor
B. Drooling
C. Barking cough
D. Mild fever
E. Severe dysphagia
A. Inspiratory stridor
C. Barking cough
D. Mild fever
## Footnote
slide20
72
The usual cause of croup in pediatric patient is a laryngeal __________________?
A. Bacterial infection
B. Parasitic infection
C. Fungal infection
D. Viral infection
D. Viral infection
## Footnote
Slide 20
73
What is the typical onset time for symptoms of croup?
A. Sudden, within minutes
B. Gradual, over 24–72 hours
C. Immediately following ingestion
D. Rapid, within 1 hour
B. Gradual, over 24–72 hours
## Footnote
Slide 20
74
What is the typical age group affected by croup?
A. Less than 2 years old
B. 2–6 years old
C. 5–8 years old
D. 8–12 years old
A. Less than 2 years old
## Footnote
Slide 20
75
In managing epiglottitis, which considerations are critical?
(Select 3)
A. Ensure ENT surgeon is available
B. Humidified oxygen
C. Steroids
D. Racemic Epi
E. Administer IV antibiotics
B. Humidified oxygen
C. Steroids
D. Racemic Epi
## Footnote
Slide 20
76
In pediatric anesthesia, children with autism often struggle most with which of the following?
A. Pain management
B. Changes in routine and sensitivity to stimuli
C. Postoperative nausea
D. Allergic reactions to anesthesia
B. Changes in routine and sensitivity to stimuli
## Footnote
Slide 23
77
Which factors are important to consider when preparing to anesthetize a child with autism? (Select 3)
A. Preoperative discussion with parents
B. Allowing parental presence during induction
C. Maintaining a highly stimulating environment
D. Using Child Life services for support
E. Not allowing parental presence during induction
A. Preoperative discussion with parents
B. Allowing parental presence during induction when appropriate
D. Using Child Life services for support
## Footnote
Slide 23
78
One key strategy for managing autistic patients is **premedication** and to __________ them with their parents in the PACU as soon as possible.
A. medicate
B. separate
C. reunite
D. discharge
C. reunite
## Footnote
Slide 23
79
What airway characteristics in Trisomy 21 contribute to difficult ventilation and intubation?
(Select 3)
A. Large mouth
B. Large tongue
C. Subglottic stenosis
D. Wide open vocal cords
E. Narrow high-arched palate
B. Large tongue
C. Subglottic stenosis
E. Narrow high-arched palate
## Footnote
Slide 24
80
Which features increase the risk of difficult ventilation in patients with Trisomy 21? (Select 3)
A. Small tongue
B. Atlantoaxial instability
C. Wide high-arched palate
D. Large tonsils and adenoids
E. Small mouth
B. Atlantoaxial instability
D. Large tonsils and adenoids
E. Small mouth
## Footnote
Slide 24
81
What are important anesthesia considerations for a Trisomy 21 patient? (Select 3)
A. Size down the endotracheal tube
B. Expect obstructive sleep apnea
C. Anticipate severe hypertension
D. Be cautious of chronic pulmonary infections
E. Increase neck extension aggressively during intubation
A. Size down the endotracheal tube
B. Expect obstructive sleep apnea
D. Be cautious of chronic pulmonary infections
## Footnote
Slide 24
82
What is the most common congenital heart defect seen in patients with Trisomy 21?
A. Tetralogy of Fallot (TOF)
B. Atrioventricular septal defect (AVSD)
C. Patent ductus arteriosus (PDA)
D. Ventricular septal defect (VSD)
B. Atrioventricular septal defect (AVSD)
## Footnote
Slide 25
83
What is the SECOND most common congenital heart defect seen in patients with Trisomy 21?
A. Tetralogy of Fallot (TOF)
B. Atrioventricular septal defect (AVSD)
C. Patent ductus arteriosus (PDA)
D. Ventricular septal defect (VSD)
D. Ventricular septal defect (VSD)
PDAs or tetralogy of flow are common as well..
## Footnote
Slide 25
84
What factors explain the bradycardia seen in Trisomy 21 patients during inhalational induction? (Select 2)
A. High sensitivity to volatile agents
B. Congenital pulmonary stenosis
C. Lower circulating catecholamines
D. Decreased vagal tone
A. High sensitivity to volatile agents
C. Lower circulating catecholamines
"Bradicardia is also very very common with these patients during an inhalation induction and this is **independent of them
having a heart condition**. Instead of just going straight to 8% sevo, we might dial it a little slower, maybe go to 4, 6, then 8"
## Footnote
Slide 25
85
What conditions are seen in Trisomy 21 patients when thinking about positioning considerations on the OR table:
(Choose 3)
A. Hypertonia
B. Hyperflexible joints
C. Diabetes mellitus
D. Hypotonia
E. Asthma
B. Hyperflexible joints
D. Hypotonia
"They have a lot of hypotonia hyperflexibility in their joints so you want to make sure they're well padded and well positioned so you're not hurting any joints."
## Footnote
Slide 26
86
Which of the following are additional clinical considerations in patients with Trisomy 21?
(Select 3 answers)
A. Increased risk of GERD
B. Decreased risk of thyroid disease
C. Higher risk of varicella-zoster
D. Higher incidence of leukemia
E. Epilepsy
A. Increased risk of GERD
D. Higher incidence of leukemia
E. Epilepsy
## Footnote
Slide 26
87
Which of the following are additional clinical considerations in patients with Trisomy 21?
(Select 3 answers)
A. Long neck
B. Increased risk thyroid disease
C. Strabismus
D. Heat intolerance
E. Intellectual disabilities
B. Increased risk thyroid disease
C. Strabismus
E. Intellectual disabilities.
## Footnote
Slide 26
88
If a patient with developmental delays is uncooperative in taking PO midazolam, what is another option for premedication?
A. IM ketamine
B. IV propofol
C. Nitrous
D. IV fentanyl
A. IM ketamine
## Footnote
slide 26
89
What is the dose of IM ketamine you would give for preop medication?
A. 15-20mg/kg
B. 5-7mg/kg
C. 5-10mg/kg
D. 2-3mg/kg
C. 5-10mg/kg
## Footnote
slide 26
90
What is a risk factor with a dose of IM ketamine?
A. apnea
B. bradycardia
C. hypotension
D. increase oral secretions
D. increase oral secretions
increased risk of laryngospasm or bronchospasm during induction
## Footnote
slide 26
91
What is the most common cardiac anomaly associated with down syndrome?
A. Atrioventricular septal defect
B. first degree heart block
C. bicuspid aortic valve
D. single ventricle
A. Atrioventricular septal defect
## Footnote
slide 27
92
What does the VAC stand for in Vacterl association? (select 3)
A. Vomiting
B. Vertebral anomalies
C. Anal atresia
D. Cardiovascular anomalies
E. Anemia
F. Cerebral vascular events
B. Vertebral anomalies
C. Anal atresia
D. Cardiovascular anomalies
## Footnote
slide 28
93
What does the TERL stand for in VACTERL association (select 4)
A. Tracheoesophageal fistula
B. tracheal enlongation
C. esophageal atresia
D. eccentric movement
E. Renal and or radial anomalies
F. Limb defects
A. Tracheoesophageal fistula
C. esophageal atresia
E. Renal and or radial anomalies
F. Limb defects
## Footnote
slide 28
94
What is the cause thought to be for VACTERL (select 2)
A. gender
B. parental
C. enviromental
D. genetic
C. environmental
D. genetic
Exact cause is unknown but normally a combination of genetic and enviornmental
typically it will not be passed from parent to child
## Footnote
slide 28
95
How many characteristics with VACTERAL association patient typically have?
A. 3
B. 2
C. 4
D. 1
A. 3
## Footnote
slide 28
96
Which 2 symptoms are the most common of VACTERL
A. spine
B. cardiac
C. renal
D. tracheal
A. spinal
D. tracheal
Which affect about 70% of the children with VACTERL
## Footnote
slide 28
97
What does CHARGE syndrome stand for?
A. cardiac anomalies, heart defects, choanal atresia, respiratory obstruction, genitourinary problems, esophageal anomalies
B. coloboma, heart defects, choanal atresia, restriction of growth and development, genitourinary problems, ear anomalies
C. coloboma, heart defects, cardiac anomalies, restriction of growth and development, gastrointestinal problems, ear anomalies
D. coloboma, hearing difficulties, choanal atresia, restriction of growth and development, genitourinary problems, ear anomalies
B. coloboma(defect to the eye), heart defects, choanal atresia (blockage of nasal passage), restriction of growth and development, genitourinary problems, ear anomalies
## Footnote
slide 29
98
DiGeorge syndrome or ________ has 3 major symptoms which include?
A. Latch 55; abnormal face, thymoc hypoplasia, cleft palate
B. Catch 22; hypercalcemia, hypotension, absent thymus
C. Latch 55; Laryngospasm, hypotension, cleft palate
D. Catch 22; cardiac issues, hypocalcemia, absent thymus
D. Catch 22; cardiac issues, hypocalcemia, absent thymus
need irradiated blood if recieving blood products
## Footnote
slide 30
99
With Catch 22 the patient may also have______ and _______ (select 2)
A. hyperthyroidism
B. hyper-parathyroidism
C. cleft palate/lip
D. small ears/ hooded eyes
C. cleft palate/lip
D. small ears/ hooded eyes
## Footnote
slide 30
100
Patients with down syndrome, cerebral palsy, developmental delays, and severe autism are a common occurance in which procedures
A. hernia repair
B. dental restoration
C. spinal surgery
D. orthodedic surgery
B. dental restoration
Sometimes its just kids that really dont tolerate going to the dentist well. **These patients will almost always require premedication**
## Footnote
slide 32
101
What type of anesthesia plan will patients undergoing dental restoration need?
A. Nasal intubation
B. oral rae tube
C. Mask case
D. LMA
A. Nasal intubation with nasal rae tube
## Footnote
slide 32
102
# True or false
With dental restoration procedures, even if the patient has a clotting disorder you should proceed with nasal intubation
False;
if you're just unable to nasally intubate them because sometimes it can be challenging or if they have a bleeding disorder and it's not advised to instrument the nasal passage because passing the nasal tube can cause some bleeding of the adenoids and so if they have a **clotting disorder we don't really want to mess with their nasal passage.**
## Footnote
slide 32
103
# Put the following steps in order
Afrin nose spray
IV insertion
Mask induction
Nasal intubation
nasal dilation
securing tube
Mask induction
IV insertion
Afrin (oxymetazolin) nose spray
Dilation of nasal passaage
nasal intubation
securing tube
## Footnote
slide 33
104
_______ and ______ are important for dental restoration procedures.
A. suction well after extubation
B. antiemetics
C. thoat pack placed by CRNA
D. pain management
B. antiemetics
D. pain management
suction well BEFORE extubation
throat pack placed by DENTIST to keep the extra blood and irrigation that they're using from going into the airway
## Footnote
slide 33
105
What does strabismus repair surgery do?
A. corrects misalignment to the extraocular muscles and re-establishes the visual axis
B. corrects color
C. corrects the lid of the eye to paralyze the muscles
D. corrects fixation
A. corrects misalignment to the extraocular muscles and re-establishes the visual axis
## Footnote
slide 34
106
What type on anesthetic is typically used for strabismus repair (select 2)
A. LMA, ET
B. inhalation
C. IV
D. MAC
A. LMA, ET
B. inhalation
## Footnote
slide 34
107
What is a risk for strabismus repair? (select 2)
A. hypertension
B. PONV
C. tachycardia
D. bradycardia
B. PONV
D. bradycardia- oculocardiac reflex
FIRST alert the surgeon so they can stop pressing on the eye might have to give some glyco
## Footnote
slide 34
108
Besides bradycardia, what does traction on the extraocular muscle cause? (select 2)
A. ventricular ectopy
B. tachycardia
C. AV block
D. junctional rythm
A. ventricular ectopy
C. AV block- it can even cause asystole
## Footnote
slide 35
109
The oculocardiac reflex will _______ with repeated stimulation
A. exaggerate
B. fatigue
C. remain unchanged
D. increase
B. fatigue
Ask surgeon to stop pulling on the muscle, they'll release the muscle the heart rate will come back and hopefully it won't happen again
## Footnote
slide 35
110
What is the first step in managing OCR?
A. turn down anesthesia
B. glycopyrolate
C.atropine
D. communication with surgeon
D. communication with surgeon
(this has been mentioned a lot just FYI)
## Footnote
slide 35
111
What 2 risk factors contribute to retinopathy of prematurity
A. increased birth weight
B. <30weeks gestation
C. <1000g birth weight
D. prolonged labor
B. <30weeks gestation
C. <1000g birth weight
## Footnote
slide 36
112
Retinopathy of prematurity is linked to _____
A. increased nutrition intake
B. lack of oxygen
C. decreased nutrition intake
D. liberal oxygen use
D. liberal oxygen use
"when you get patients from the NICU you'll notice they're almost never on 100% FiO2. They also set their parameters on their pulse ox lower than 100% being the high. If the patient gets usually greater than about 90% 95% on their pulse ox they will decrease the FiO2. They do not want their babies on 100% They don't like when we put their babies on 100% FiO2."
## Footnote
slide 36
113
When is retinal maturation is complete?
A. 44 weeks
B. 33weeks
C. 40 weeks
D. 28weeks
A. 44 weeks post conception
## Footnote
slide 36
114
What do you want oxygen saturation at for preemies?
A. 92-98%
B. 94-100%
C. 96-99%
D. 89-94%
D. 89-94%
## Footnote
slide 36
115
Where should you place the O2 probe?
A. left hand
B. right foot
C. right hand
D. left foor
C. right hand (preductal)
preductal O2 better correlates with O2 sats of retinal vessels
## Footnote
slide 36
116
What is a common procedure for children for OSA?
A. appenectomies
B. Tonsils and adneoids
C. hypoglossal nerve stimulator
D. ear tubes
B. Tonsils and adneoids
## Footnote
slide 37
117
What can OSA be caused by in children (select 4)
A. low birth weight
B. tonsillar hypertrophy
C. obesity
D. neuromusclar disease
E. craniofacial abnomalies
G. prematurity
B. tonsillar hypertrophy
C. obesity
D. neuromusclar disease
E. craniofacial abnomalies
## Footnote
slide 37
118
We would like to to be cautious with ________ and ______ due to not wanting to disrupt their normal breathing or worsen their apnea
A. inhalation inductin
B. propofol
C. titration of opioids
D. premedication
C. titration of opioids- monitor response and adjust dose accordingly
D. premedication
## Footnote
slide 37
119
How do we dose children with obesity
A. total body weight
B. ideal body weight
C. actual body weight
D. age
B. ideal body weight
"I just say go lighter than you normally would instead of giving one milligram per kilo of fentanyl I'll give half a milligram per kilo. It's also great if you can supplement with a non-opioid."
## Footnote
slide 37
120
What are 3 indications for Adenotonsillectomy? select 3
A. obstruction
B. acute infection
C. chronic infection
D. mass/lesion
E. redness
A. obstruction - OSA
C. Chronic infection
D. mass/lesion
## Footnote
slide 38
121
A patient coming in for adenotonsillectomy is at risk for _____
A.dehydration
B. infection
C. difficult IV access
D. reactive airway
D. reactive airway
## Footnote
slide 38
122
For an adenotonsillectomy what is especially important to assess preop (select 2)
A. bleeding disorder
B. airway
C. nutrition
D. neurological assessment
A. bleeding disorder- tonsils can bleed very easily and rebleed easily
B. airway
## Footnote
slide 38
123
What type of airway is typically used for a T&A?
A. LMA
B. Mask (no airway)
C. oral RAE tube
D. nasal intubation
C. oral RAE tube
## Footnote
slide 39
124
What is the anesthetic plan for a T&A (select 2)
A. Inhalation with IV placment after
B. smooth induction and emergence
C. IV induction
D. Mask management
A. Inhalation with IV placment after
B. smooth induction and emergence
## Footnote
slide 39
125
What medications will we be giving to our T&A patient? (select 3)
A. succinycholine
B. analgesics
C. antiemetics
D. dexamethasone (0.5mg/kg)
B. analgesics
C. antiemetics
D. dexamethasone (0.5mg/kg)- because of airway swelling and PONV
## Footnote
slide 39
126
# True or false
You can do awake or deep extubation but deep extubations is at increase risk for laryngospasm so make sure you suction really well before extubation
true
## Footnote
slide 39
127
Most facilities for a T&A use morphine and fentanyl. However with the use of opioids there is an increased incidence for _____ and _______
A. laryngospasm
B. PONV
C. respiratory depression
D. pain
B. PONV
C. respiratory depression
tylenol is a great choice for these patients
## Footnote
slide 40
128
Which meds are controversial in T&A procedures
A. NSAIDS
B. albuterol
C. glycopyrolate
D. dexmedetomidine
A. NSAIDS - increased risk for bleeding
precedex is a good choice for these patients
## Footnote
slide 40
129
Primary bleeding for a T&A comes within ______ hours post op and secondary bleeding comes _____ days after surgery
A. 12-36; 4-6
B. 8-16; 8-10
C. 2-4; 5-8
D. 6-24; 5-10
D. 6-24; 5-10
## Footnote
slide 40
130
T&A is high risk for airway fire. In order to control airway fire it is best to keep FiO2 below _____ and avoid N2O
A. 20%
B. 30%
C. 50%
D. 21%
B. 30%
she said 35% during lecture but slide says 30%
## Footnote
slide 40
131
A post tonsillar bleed is a surgical emergency and the patient will be considered full stomach. The best anesthetic for these patients is an RSI or ________
A. nasal intubation
B. awake intubation
C. mask case
D. neuraxial anesthesia
B. awake intubation
## Footnote
slide 41
132
Considering a post tonsillar bleed patient had just been intubated, what should we consider in our anesthesia plan?
A. mask caase
B. nasal intubation
C. half size up on ETT
D. half size down on ETT
D. half size down on ETT
## Footnote
slide 41
133
Some possible considerations for anesthesia providers for a post tonsillar bleed include all the following except
A. large bore IV
B. IV fluids
C. Blood products
D. H&H
E. awake extubation
F. increase FiO2 during sugery
G. OGT
H. antiemetics
F. increase FiO2 during sugery
## Footnote
slide 41
134
# True or false
Cleft lip and palate is a defect in palatal growth in the first timester of pregnancy and is associated with things like pierroven, trisomy 21, fetal alcohol syndrome, but never just clept lip and palate. It will always be associated with a syndrome
False!
1/3 is associated with a disorder but it CAN be just cleft lip and palate
## Footnote
slide 43
135
When is cleft lip repaired?
A. 6-12 months
B. 3-6 months
C. 2-4 months
D. 1-3 months
B. 3-6 months
## Footnote
slide 43
136
When is cleft palate repaired?
A. 6-12 months
B. 3-6 months
C. 2-4 months
D. 1-3 months
A. 6-12 months
## Footnote
slide 43
137
When intubating a child with a cleft palate it is important to be careful to not go into the cleft palate so the patient could be considered to have
A. wide mouth opening
B. easy airway
C. enlongated soft palate
D. difficult airway
D. difficult airway
## Footnote
slide 43
138
Children coming in for a cleft palate/ lip repair will recieve a _________ anesthetic with a/an_________ tube
A. regional; Nasal RAE
B. regional; oral RAE
C. general; oral RAE
D. general; nasal RAE
C. general; oral RAE
## Footnote
slide 43
139
Patients with a cleft lip/palate will be at risk for post op obstruction and will require a
A. deep extubation
B. awake extubation
C. oral airway
D. avoid analgesics
B. awake extubation
a nasal trumpet to prevent any upper airway obstruction and you really want to avoid putting an oral airway in as well because the hard oral airway can can rub against the suture lines.
Analgesia is really important for these kids- acetaminophen and opioids are common
## Footnote
slide 43
140
Pyloric stenosis is an obstructive olive shaped lesion below the xiphoid process we commonly see in ________
A. second born males
B. second born females
C. firstborn males
D. firstborn females
C. firstborn males
## Footnote
slide 44
141
When is pyloric stenosis typically diagnosed
A. 2-12 weeks of age
B. 2-4 months of age
C. 6-12 months of age
D. 14-20 weeks of age
A. 2-12 weeks of age
## Footnote
slide 44
142
Common symptoms of pyloric stenosis include all the followign except
A. nonbilous postprandial emesis
B. palpable pylorus
C. diarrhea
D. visible peristatic waves
E projectile vomiting
C. diarrhea
often non-bilious because the bile
isn't able to get back up into the stomach
## Footnote
slide 44
143
What surgery is performed to correct pyloric stenosis
A. gastric bypass
B. pylomyotomy
C. hiatal repain
D. duodenectomy
B. pylomyotomy
commonly laproscopic
## Footnote
slide 44
144
With pyloric stenosis, all the following are anesthetic considerations except
A. acid base balance
B. hypovolemia
C. hypochloremic
D. hypokalemic metabolic acidosis
E. hypernatremia
F. full stomach
G. post op apnea
E. hypernatremia
HYPOnatremia
full stomach- RSI or awake intubation, extubate awake , suction stomach prior to induction until clear
## Footnote
slide 46
145
Inguinal hernias are prevalent in
A. children over the age of 6 months
B. infants born at 38 weeks
C. preterm neonates
D. late term neonates
C. preterm neonates
## Footnote
slide 47
146
Concerns for inguinal hernia repair include (select 2)
A. bilateral testicular injury
B. small bowel incarceration
C. large bowel incarceration
D. ipsilateral testicular injury
B. small bowel incarceration
D. ipsilateral testicular injury
## Footnote
slide 47
147
What is the typical anesthetic plan for patients undergoing inguinal hernia repair
A. mask case
B. spinal anesthesia
C. general with a caudal
D. mac witha caudal
C. general with a caudal
GETT or LMA
inhalation induction
We'll do an inhalation induction, place an LMA or ET tube, and then place the caudal. If they're a little bit older you could do a spinal. Typically we don't do the spinal. If the caudal doesn't work or they're too old for a caudal, they'll just inject a local at the site, but the spinal is an option.
## Footnote
slide 47
148
What is a post op concern for inguinal hernia repair
A. obstruction
B. PONV
C. pain
D. apnea
D. apnea
There's also concern for postop apnea with these patients because it's not super stimulating. A lot of times it's more prevalent in pre-term neonates, so again those patients are at risk for apnea.
## Footnote
slide 47
