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ACP Study > Pediatric CPGs > Flashcards

Pediatric CPGs Flashcards

1
Q

What is the maximum age for which the Broselow tape and associated pediatric calculations are typically designed?

A

Up to 12 years

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2
Q

What are the criteria under BCEHS CPGs for a patient to be considered pediatric

A
  • Age ≤ 12 years (i.e. 13 years + 1 second = adult)
  • No signs of puberty (i.e. signs of puberty = adult)

These criteria do not apply to matters of consent, only clinical practice

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3
Q

Which patients are appropriate for use of the Pedi-Mate

A

Patients with weight 10-40 lbs. (5-18kg)

Corresponds to children 6mths - 4 yrs

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4
Q

What are the three components of the Pediatric Assessment Triangle (PAT)?

A
  • General Appearance
  • Work of Breathing
  • Circulation to the Skin
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5
Q

What is the most common precipitating factor in cardiac arrest in the pediatric population?

A

Respiratory compromise

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6
Q

List up to 12 signs of respiratory distress in pediatrics

A
  • Rapid or slow respirations
  • Nasal flaring
  • Retractions
  • Accessory muscle use
  • Pale appearance
  • Decreased breath sounds
  • Mottled skin
  • Grunting
  • Stridor
  • Wheezing
  • Cyanosis
  • Bradycardia
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7
Q

A mandatory step in the assessment of any pediatric patient with the potential of respiratory distress is:

A

expose the chest

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8
Q

Qualitative indicators of shock are _________ (more/less) sensitive than quantitative measures in pediatrics

Qualitative measures include skin color changes, changes in mentation, falcidity, etc.

A

MORE!

  • Hypotension is a LATE and extremely ominous sign of decompensation in chlidren
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9
Q

List up to seven indicators of shock in pediatrics

A
  • Tachycardia/bradycardia
  • Pale/cool/mottled skin
  • Capillary refill > 2 seconds
  • Narrowing pulse pressure
  • Tachypnea
  • Relative flaccidity
  • Change in level of consciousness (LOC) – especially failure to recognize/respond to carer(s)
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10
Q

A child may lose up to _____% of their blood volume before becoming hypotensive in shock

A

25%

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11
Q

What are three strategies for estimating ETT size in children?

A
  • Compare to child’s little finger
  • Compare to child’s nare
  • Use formula
    • (age/4 + 4) = uncuffed tube size
    • (age/4 + 3) = cuffed tube size
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12
Q

What are rough guidelines for laryngoscope blade size in children?

A
  • <1yrs = #1 straight blade (miller)
  • 1-4yrs = #2 blade
  • >4 yrs = #3 blade
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13
Q

An SBP <90 is often used as a rough indicator of shock/hypoperfusion in adults. What values of SBP are used to indicate shock in pediatrics?

A
  • Neonates (0-28 days)
    • <60mmHg
  • Infants (1-12 months)
    • <70mmHg
  • Children (1-10 yrs)
    • < 70 mmHg + (2x age in years)
    • Ex: 5yr old = 70 + (2 x 5) = 80mmHg
  • Children/adolescents (10+ years)
    • <90mm Hg
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14
Q

What is the primary cause of cardiac dysfunction in the majority of pediatric cases?

A

repiratory failure

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15
Q

What are the CPG-accepted age ranges for neonates, infants, and children?

A
  • Neonates (0-28 days)
  • Infants (29 days - 1 year) / (1-12 months)
  • Children (1 - 12 years)
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16
Q

Sinus arrhythmia is _______ (more/less) pronounced in pediatrics than adults

A

Sinus arrhythmia is more pronounced

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17
Q

Describe sinus arrhythmia in children

A
  • Marked variation in HR with respiratory cycle
  • HR increases with inhalation and decreases with exhalation
  • more pronounced in children than adults
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18
Q

What is the significance of a tachycardia >180bpm in a child or >220bpm in an infant/neonate.

A

tachycardias at these rates are unlikely to be sinus or compensatory in nature. Primary cardiac intervention is likely required

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19
Q

A child with stable WCT ________ (should/shouldn’t) receive cardioversion in the field

A

shouldn’t

Wide complex tachycardia (QRS > 0.08 seconds) in a conscious pediatric patient with adequate perfusion and a heart rate > 150 bpm is probably in stable ventricular tachycardia and requires support with oxygen, continuous cardiac monitoring, and conveyance to ED, with equipment for electrical cardioversion immediately available

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20
Q

Describe treatment for pediatric patients with bradycardia <60bpm and signs of poor perfusion

(Signs of poor perfusion include cyanosis, mottling, decreased LOC, and lethargy)

A
  • Ensure maximal oxygenation and bag-valve mask ventilation is provided
  • If heart rate remains < 60 bpm for 30 seconds of effective oxygenation and ventilation, begin chest compressions
  • Epinephrine 0.01 mg/kg IV/IO is indicated for bradycardia unresolved by oxygenation, ventilation, and chest compressions
  • Atropine or TC pacing may be appropriate under certain conditions
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21
Q

Is it reasonable to provide chest compressions to an 8-year-old with a pulse?

A

YES!

In a pediatric patient with a HR < 60 bpm coupled with poor perfusion, CPR is indicated. Ensure maximal oxygenation and bag-valve mask ventilation is provided. If heart rate remains < 60 bpm for 30 seconds of effective oxygenation and ventilation, begin chest compressions. Signs of poor perfusion include cyanosis, mottling, decreased LOC, and lethargy.

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22
Q

When should CPR be initiated in a bradycardic, pediatric patient with a pulse?

A
  • After 30 seconds of attempts to optimize oxygenation/ventilation with no improvement in condition
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23
Q

Describe treatment of unstable NCT in pediatric patients

A
  • Vagal Maneuver
  • Adenosine
    • (do not use if patient is prescribed carbamazepine or dipyramidole)
  • Synchronized Cardioversion
    • initial at 1J/kg, repeat at 2 J/k

This differs from management in adults, where unstable NCT is treated with urgent PSA and cardioversion

24
Q

Describe treatment of unstable WCT in pediatric patients

A
  • Vagal maneuver
  • Synchronized cardioversion
    • Initial at 0.5 – 1 J/kg, repeat at 2 J/kg
25
Q

Is atropine indicated for unstable bradycardia in pediatric patients?

A

Yes!

Only if increased vagal tone suspected

26
Q

Describe a general approach to the management of Bradycardia in Pediatric patients

A
  • Asymptomatic: no treatment required
    • Consider crystalloid bolus if no cardiac history
  • Unstable bradycardia
    • EPINEPHrine
    • Atropine – if increased vagal tone suspected
      • CliniCall consultation required prior to repeat dose Q 3-5 min to a maximum total dose of 0.4 mg/kg or 1 mg, whichever is less
    • Transcutaneous pacing
      • CliniCall consultation required prior to pacing
  • In a pediatric patient with a HR < 60 bpm coupled with poor perfusion, CPR is indicated
27
Q

The sudden, unexplained appearance of respiratory symptoms (such as apnea), change in colour or muscle tone, and/or altered responsiveness in a young child/infant is known as a _________

A

BRUE (Brief Resolved Unexplained Event)

or

ALTE (Apparent Life Threatening Event)

28
Q

A BRUE/ALTE is most likely to occur during which period in a child’s life?

A

Events typically occur in children < 1 year with peak incidence at 10 to 12 weeks.

29
Q

Describe general principles of IV fluid administration in children

A
  • Fluid may be given in 5-10mL/kg boluses, to a maximum total of 20mL/kg
  • Maintenance infusions may be calculated using the 4-2-1 rule:
    • 4 mL/kg/hr for the first 10 kg of weight
    • 2 mL/kg/hr for the next 10 kg
    • 1 mL/kg/hr for each kilogram thereafter
30
Q

The initial signs of shock are often ________ (subtle/obvious) in children/infants.

A

The initial signs of shock may be subtle in children and infants as their compensatory mechanisms are very effective.

31
Q

When is shock considered to be compensated in pediatric patients?

A

As long as the compensatory mechanisms are able to maintain a systolic BP within an age-appropriate normal range, the shock is considered compensated.

32
Q

What is the particular significance of classic signs of shock (tachycardia, hypotension, pallor, cold extremities, ALOC) in children?

A

These are signs of decompensated shock, cardiopulmonary arrest may be imminent

33
Q

What are the 3 primary components of the pediatric assessment triangle?

A
  • Appearance
  • Work of Breathing
  • Circulation to Skin
34
Q

What are the components of the TICLS acronym, and when is this acronym used?

A

TICLS is an acronym used to systematically assess the “appearance” component of the pediatric assessment triangle.

  • Tone
    • Vigorous to limp
    • Normal children of all ages, including newborns should have Muscle tone
  • Interactiveness
    • Engaged to unintererested
  • Consolability
    • Content to unconsolable
  • Look or gaze
    • Gaze follows to glassy eyed stare
  • Speech or cry
    • Spontaneous speech to wimper
35
Q

What are the four classic abnormal findings in the “work of breathing” component of the pediatric assessment triangle?

A
  • Abnormal airway sounds
    • Grunting
    • Stridor
    • Wheezing
  • Abnormal positioning
    • Tripod position
    • Sniffing
    • Head Tilt (consider Retropharyngeal Abscess, Epiglottitis)
  • Intercostal or neck retractions (or head bobbing in infants)
  • Nasal Flaring
36
Q

What are the three classic abnormal findings in the “circulation to skin” component of the pediatric assessment triangle?

A
  • Pallor
  • Mottling
  • Cyanosis
37
Q

What are the four major categories of respiratory disorders in children?

A
  • upper airway obstructions
    • ex: foreign body, tissue swelling (croup/epiglottitis/anaphylaxis), subglottic stenosis from previous intubation trauma, tumour
  • lower airway obstructions
    • ex: foreign bodies, bronchial swelling or constriction
  • lower airway restrictive pathology
    • ex: pulmonary edema, toxic exposure, allergic reactions, infiltration, inflammation, abdominal structures pushing on lung tissue
  • disordered control of breathing
    • ex: increased intracranial pressure, neuromuscular disease, and some poisonings and overdoses
38
Q

Continuous salbutamol administration is associated with which electrolyte imbalance?

A

hypokalemia

39
Q

Describe pediatric salbutamol dosing by MDI and nebulizer

A
  • MDI
    • < 10 kg: not indicated
    • 10-20 kg: 5 x 100 mcg per course; may repeat up to 3 times
    • > 20 kg: 10 x 100 mcg per course; may repeat up to 3 times
  • Nebulizer
    • Via nebulizer
    • Age < 1 year: 2.5 mg
    • Age ≥ 1 year: 5 mg
40
Q

Describe treatment options for pediatric patients with severe bronchoconstriction and hypoxemia refractory to Salbutamol and supplemental oxygen.

A
  • IM Epinephrine
    • 0.01 mg/kg IM to a maximum of 0.5 mg
  • MDI Ipratropium
    • Dosing not specified, contact clinicall
  • Magnesium sulfate
    • 50 mg/kg IV/IO infused over 15 minutes
  • Procedural Sedation or Anesthesia Induction, in anticipation of;
  • Endotracheal Intubation
41
Q

Nebulized epinephrine is indicated for use in __________ (croup/epiglottitis/both)

A

Croup only!

Nebulized epinephrine is not indicated for epiglottitis.

42
Q

The “three Ds” of epiglottitis are:

A
  • Drooling
  • Dysphagia
  • Distressed breathing
43
Q

With regards to croup and epiglottitis, which is associated with an abrupt vs a gradual onset?

A

Epiglottitis generally has an abrupt onset, while the onset of croup is slower and is generally associated with a prodromal history of viral symptoms

44
Q

Differentiate between classic findings of croup and epiglottitis in terms of onset, common symptoms, infectious agent, and typical age of patients

A
  • Onset
    • Croup: gradual with viral prodrome
    • Epiglottitis: abrupt
  • Common symptoms
    • Croup: barking cough +/- stridor, fever, nasal congestion
    • Epiglottitis: drooling, dysphagia, and distressed breathing. Coughing is rare. tripod/sniffing is common
  • Infectious agent
    • Croup: usually viral
    • Epiglottitis: usually bacterial, but may be viral or fungal
  • Typical age
    • Croup: 6 months to 3 years (very uncommon past 6 years)
    • Epiglottitis: 2 to 6 years (although increasingly common in adults)
45
Q

Is the presence or absence of fever an effective tool in differentiating between croup and epiglottitis?

A

No!

Fever may be present in either, and may be mild or severe in either case!

46
Q

Inflammation from croup which spreads to the entire respiratory tract is known as:

A

laryngotracheobronchitis

47
Q

Epiglottitis is increasingly rare due to routine ___________ vaccination in childhood. Vaccination status should therefore be confirmed when assessing for upper airway disease.

A

Haemophilus influenzae type B (Hib)

48
Q

Describe epinephrine dosing in pediatric patients with croup

A
  • 5 mg by nebulizer mask
  • If under 1 year of age: 0.5 mg/kg to a maximum of 5 mg
  • Total volume of fluid in nebulizer mask should be 5 mL
49
Q

Is acetaminopohen indicated for antipyresis in croup/epiglottitis? If so, describe dosing

A

yes!

  • < 30 kg: 15 mg/kg PO (use liquid preparation)
  • 30-50 kg: 500 mg PO (may use liquid preparation or tablets, depending on patient ability)
  • > 50 kg: 500-1,000 mg PO
  • May repeat once after 4 hours
  • 24 hour maximum: 75 mg/kg or 1 g
  • Do not exceed 5 doses in 24 hours in patients < 12 years of age
50
Q

At what age do children most commonly present with febrile seizures?

A

between six months and five years

51
Q

How is status epilepticus defined in children?

A

As it is in adults – a series of two or more seizures without a recovery of consciousness in between, or a seizure lasting longer than five minutes

Patients who continue to seize on arrival of paramedics or EMRs/FRs should generally be considered as being in status epilepticus.

52
Q

The leading cause of death in children is:

A

trauma

53
Q

children have a _________ (higher/lower) risk of C-spine injury compared to adults

A

Higher!

Children are at higher risk for cervical spine injury because of their larger, heavier heads, and weakly developed spine and neck muscles.

54
Q

The preferred choices for analgesia in pediatric trauma are:

A

opiates/ketamine

Nitrous oxide is less effective but can also be used due to license level, unless contraindications exist.

55
Q

Children are _______ (more/less) likely to die from isolated pelvic fractures than adults

A

Less!

Unlike adults, children rarely die from isolated pelvic fractures. If hemodynamic instability exists in what appears to be an isolated pelvic fracture, look for other causes of blood loss.

56
Q

What are target values for SBP for children requiring fluid resuscitation?

A
  • < 28 days; > 60 mmHg
  • 1-12 months; > 70 mmHg
  • 1-10 years; > 70 mmHg + (2x age in years)
  • 10 years to adulthood; > 90 mmHg
57
Q
A

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