How does adding N2O to Sevo affect the MAC in Adults vs Kids 1-3 years old?

Adults: N2O decreases MAC Proportionately Kids (1-3): N2O decreases MAC by only 25%

Pediatric Pharmacology & Trauma - Quiz 4 Flashcards by Donny Le

How is Drug Absorption in the Neonate different from Infants, Children, & Adults?

Less Acidic pH

Slower Gastric Emptying & Transit

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What influences IV Drug Distribution?

Protein Binding

RBC Binding

Tissue Volumes, Solubility, & Blood Flow

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What are the characteristics of Protein Binding in the Neonate?

Less Plasma Proteins & Less Protein Affinity = Larger Volume Distribution

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What is the Physiologic Nadir of Hemoglobin?

When infants have anemia 3-6 months after birth where fetal Hgb is eliminated & a slow production of RBCs begin

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Why might the Neonate need more Higher per kg drug doses than the Child or Adult?

Neonates have more tissue volume –>

Total Body Water

ECF

Blood Volume

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Why are many drug concentrations higher in the Infant’s Brain than the Adult’s Brain?

Immature BBB = Easier Lipid Drug Diffusion

Rate of Entry = Blood FLow

Infant Brain gets a lot of Cardiac Ouput

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How does the Neonate’s smaller Muscle Mass & Fat stores affect drug distribution?

Less Uptake to Inactive Sites & Higher Plasma Volumes of the Drug

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Why is Postnatal age more important in regards to the Ability to Metabolize Drugs?

Drug metabolism develops to the same degree in the same time period after birth

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What are some examples of R>L Shunt?

Tetralogy of Fallot

Transposition of Great Arteries

Tricuspid Atresia

Total Anomalous Pulm. Venous Return

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At what age does the Renal Clearance of drugs reach Adult Values?

3 Months of Age

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Since Tidal Volume is constant througout life, what Respiratory aspect contributes to Infants having a more rapid Uptake of Inhaled Anesthetics?

Infants have higher Alveolar Ventilation in relation to FRC of 5:1 versus 1.4:1 for Adults

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Which Inhaled Anesthetics have more effect on Shunting?

Insoluble Agents - Sevo & N₂O

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How does R>L Shunting affect Inhaled Anesthetic Uptake?

Slow On & Slow Off

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How does L>R Shunting affect Inhaled Anesthetic Uptake?

Depends on Shunt Size

Small (<50%) = No change

Large (>80%) = Faster Uptake

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What are some examples of L>R Shunts?

Atrial Septal Defect

Ventricular Septal Defect

Patent Ductus Arteriosus

Blalock-Taussig

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What is the relationship b/t MAC and Age?

MAC increases the 1st month of life, then starts to decrease after 6 months of life

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How does the Neonate’s response to pain develop?

Reponse to pain diminshed in first week of life & matures rapidly in first few months

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Why do Infants have Bradycardia, Hypotension, and Cardiac Arrest more than Adults during Induction?

Increased CV Sensitivity

Over-Pressuring of Gas

Limited Baroreceptor Reflex (Gas worsens this)

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What are the CV affects of Halothane?

Dose-Dependent Cardiac Depression

↓PVR

Act as CC-Blocker

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What are the initial signs of Halothane Overdose?

Bradycardia

Hypotension

Muffled Heart Tones

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What are the CV Effects of Isoflurane?

Direct Negative Inotrope
(but less than Halothane)

↓↓↓PVR

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Why isn’t Isoflurane used for Inhaled Induction?

Pungent Smell & Airway Irritation

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Why might Sevo be used rather than Isoflurane or Halothane?

Less Soluble –> Rapid Wash In

More CV Stable w/ less Dysrhythmias

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How does adding N₂O to Sevo affect the MAC in Adults vs Kids 1-3 years old?

Adults: N₂O decreases MAC Proportionately

Kids (1-3): N₂O decreases MAC by only 25%

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Why is Desflurane not used for Kids?

Pungent Airway Irritant ↑Laryngospasm Risk Emergence Delirium CV Stable, but ↓SVR

What is the Inhaled Induction Method w/ Sevo?

* Start w/ O2/N2O @ 2L/4L * Then Sevo @ 8% until Deep enough for IV

When does separation anxiety begin, warranting the use of Pre-Op Versed?

\> 9 months

What is the pediatric dose for Oral Versed?

0.5 - 1 mg/kg 15-30 min. Onset

What is the pediatric dose for Intranasal Versed?

0.2 - 0.3 mg/kg Onset: 1 min Peak @ 10 min.

What is the pediatric dose for IV Versed?

0.1 mg/kg

What is dose of Thiopental for Neonates?

3 mg/kg

What is Thiopental dose for Infants & Children?

5 - 7 mg/kg

What is the Thiopental dose for Adults?

3 -5 mg/kg up to 10 mg/kg d/t rapid redistribution

What is the ED₅₀ for Propofol in Infants?

3 mg/kg

What is the ED₅₀ of Propofol for Older Children?

2.4 mg/kg

What is the Pediatric dose for IV Ketamine?

2 mg/kg

What is the Pediatric dose for IM Ketamine?

3-6 mg/kg

Ketamine has potent analgesic properties for skin, muscle, and bone, but NOT for what?

Viscera

What should be given along with Ketamine for its side effects?

Antisialogogue - for increased salivation & Versed - for hallucinations

How do Neonates respond to Narcotics?

More Sensitive More Toxic Respiratory Depression

What is the Pediatric dose for Morphine?

0.05 - 0.1 mg/kg

Morphine has a longer half life in Neonates, what is the Elimination half-life?

Up to 14 hours

How much Protein Binding of Morphine is there in the Neonate vs. the Adult?

**Neonate**: 18-22% **Adult**: 30-35%

What is the Pediatric dose for Fentanyl?

1 - 5 mcg/kg

What is the concern when giving Fentanyl to _Premature_ Infants?

Clearance is Markedly Reduced | (Up to 32 Hour Half-Life)

What is the Pediatric Infusion Dose for Remifentanil?

0.02 - 2 mcg/kg/min Onset: 1 min Half-Life: 9 min

Why is a Bolus IV Dose of Remifentanil rarely used?

Profound Bradycardia & Asystole

Why are Anticholinergics used in the Pediatric Population?

**Protect Against Cholinergic Challenge - Prevent Bradycardia** Inhibit Secretions

Why is Bradycardia such a big concern in the Pediatric Population?

Neonates are born w/ a fully developed PNS The SNS does NOT fully develop until 3-6 months of age

What is the Pediatric dose for Atropine?

10 - 20 mcg/kg Onset: 1 min Duration: 30 - 60 min

What is the main reason why Atropine is used in Pediatrics?

Prevent Bradycardia \> Antisiologogue effects

Does Atropine cross the Blood Brain Barrier?

Yes

What is the Pediatric Dose for Glycopyrrolate?

10 - 20 mcg/kg Onset: 2-3 min Duration 30 - 60 min

What is the Induction Infant Dose for Succinylcholine?

2.2 mg/kg

What is usually given before Sux administration in Pediatrics?

Atropine - to contest profound bradycardia from Sux

What are the age related differences that change the dosing of Sux?

Cholinesterase Activity Receptor Sensitivity Volume of Distribution

When is Sux contraindicated because of its large potassium release?

Neuro Conditions Muscular Dystrophies Myotonia Burns MH

What is the Pediatric Induction dose of Rocuronium?

* 0.6 mg/kg * Onset: 1.5 min * Duration: * Infants \< 10 months: 45 min * Kids 1-5 yrs.: 25 min

What is the Pediatric Cisatracurium Dose?

0.1 - 0.2 mg/kg Onset: Dose-Dependent 2-3 min Duration 30-45 min

How do Neostigmine & Edrophonium work?

Inhibits acetylcholinesterase, increasing ACh which competes w/ NDNMB

What is the Pediatric Neostigmine Dose?

35 - 70 mcg/kg Given w/ Atropine & Robinul Must have 2/4 twitches for it to work

How does Neostigmine compare to Edrophonium?

Neostigmine is more potent, but slower onset

What is the Pediatric Dose for Edrophonium?

0.5 - 1 mg/kg Given w/ Atropine Must have at least 3/4 twitches for it to work

What is the Sugammadex dose?

2 mg/kg - Shallow Block after T2 4mg/kg - Deep Block w/ 1-2 Post-Tetanic

What are the first signs of LA Toxicity in Infants & Children?

Dysrhythmias or CV Collapse

What are the common Local Anesthetics used in Pediatrics?

Lidocaine Bupivacine Ropivacaine For Caudal Blocks & Local/Intra-Tracheal Infiltration

What is the Max Lidocaine Dose w/ & w/o Epi

**W/O Epi**: 5 mg/kg **W/ Epi**: 7 mg/kg

What is the Max dose for Bupivacaine?

2.5 mg/kg

What is the Max dose for Ropivacaine?

0.5 - 1 mL/kg | (2.5 mg/kg)

What is the Max dose for Epinephrine?

2 - 3 mcg/kg/dose Can re-dose after 30 min

Other than its sedative and analgesic effects, what drug can also be used to treat SVT?

Precedex

What is the dose for Precedex?

Bolus: 0.25 - 1 mcg/kg Infusion: 0.2 - 1 mcg/kg/hr

What is Tranexamic Acid?

Antifibrinolytic - Blocks Lysin Binding site and prevents Plasminogen converting to Plasmin & Anti-Inflammatory

How does TXA compare to Amicar?

TXA is 10x more potent

What is the dose for TXA?

Loading: 30 mg/kg Infusion: 10 mg/kg/hr

What are the Primary Causes of Pediatric Death or Long Term Disability?

Traumatic Brain Injury - 70% Thoracic Injury - 20% Abd. Injury - 10%

What are the Categories of Pediatric Trauma?

Blunt - 90% Penetrating - 10% Burns

What is included in the Primary Survey?

* Airway * Breathing * Circulation * Disability - Assess Neuro * Expose - Remove clothes for visual exam

What is included in the Secondary Survey?

Head to Toe History Labs Imaging

The pediatric Larynx & Glottic Opening is more _____ compared to adults

The pediatric Larynx & Glottic Opening is more **CEPHALAD** compared to adults

Due to their big head & lack of neck muscles, what should be placed on a child who comes in as a trauma?

Head & Neck Protection - C-Collar Assume C-Spine Injury

How should Intubation be done w/ a C-Spine Injury?

Avoid Head & Chin Maneuvers Use MILS Direct Laryngoscopy w/ RSI Video Assist

What should be avoided whenever there is a Head Injury or Basilar Skull Fracture?

Nasal Instrumentation

What are signs & symptoms of a Basilar Skull Fracture?

Rhinorrhea Otorrhea PeriOrbital Ecchymosis

What does Crepitus indicate & how should this patient be intubated?

Tracheal/Bronchial Interruption Use Awake Fiberoptic Intubation

For a Difficult Airway in Pediatric Trauma, what meds should and should NOT be given?

Propofol Remifentanil Inhaled Induction **w/** Spont. Ventilation Avoid NMBs until Airway Secured

What is an early sign of Shock?

Tachycardia - can be an early sign of Hypovolemia & Hemorrhagic shock

How much total blood volume can be loss before there is ever any sign of hypotension?

Late Sign 25 - 35% of Total Blood Volume or _~ 20 mL/kg

Other than Tachycardia, what are other signs of Shock & Inadequate Peripheral Perfusion?

Delayed Cap. Refill Weak Pulses Mottling Cyanosis Impaired LOC

In the setting of Shock, what does Bradycardia indicate?

Hypoxemia Impending Arrest ↑ICP

What are signs & symptoms of a \<20% Pediatric Blood Loss?

Tachycardia Weak Pulses Cool Touch ↓Urine Output w/ ↑Specific Gravity Irritable

What are signs & symptoms of a 25% Pediatric Blood Loss?

Same as w/ \< 20%, but with Cold Extremities Cyanosis/Mottling Confusion Lethargy

What are signs & symptoms of a 40% Pediatric Blood Loss?

Frank Hypotension Bradycardia Pale No Urine Output Comatose

What is the initial Fluid Bolus for Pediatric Volume Resuscitation?

20 mL/kg of Warmed LR or NS

What is the next course of action for Pediatric Volume Resuscitation if the initial fluid bolus produces a transient or no response?

20 mL/kg Second Bolus of Warmed LR or NS Give Third Bolus if needed

How much Blood should be given for Pediatric Volume Resuscitation?

10 mL/kg

What might causes Persistent Shock even after Volume Resuscitation?

Long Bone & Pelvic Fractures Pericardial Effusion & Tamponade Tension Pneumo Intra-Abd. Injuries Intracranial Bleed

In Infants, what factor might cause Significant Unrecognized Blood Loss related to Intracranial Hemorrhage?

Expandable Fontanelle

Why are "FAST" Sonograms less valuable for smaller patients?

Less Free Fluid

What are the Primary & Secondary Neuro Surveys?

**Primary -** AVPU - Alert, Voice, Pain, Unresponsive **Secondary** - GCS - Intubate if \< 8

What are the different types of Facial Trauma?

Soft Tissue - Most common, falls Dental Facial Fractures - Least Common

What is the most common type of Facial Fracture?

Nasal \> Mandibular \> Maxillary

Sometimes there are Oral Lacerations & Impalement, what should be done before the object is removed?

Angiogram

Why are Pediatric Chest Injuries potentially Life Threatening?

Impairs Breathing & Circulation Monitor or Place Thoracotomy Tube

What are signs & symptoms of a Tension Pneumo?

↓Breath Sounds & Lung Compliance Tracheal Deviation Hypotension ↑PAP

How is a Tension Pneumo treated?

Needle Decompression @ 2nd ICS, Midclavicular

What causes an Open Pneumo?

Chest Wall Defect that equalizes pressures of the Pleural Space w/ Outside Environment

How is an Open Pneumo treated?

Cover w/ Occlusive Dressing + Tape on 3 Sides

What is the most common type of Abdominal Injuries?

Blunt Trauma - cause of 10% Trauma Deaths - treated w/ Medical Management rarely needing Surgery

What is almost always associated w/ Multi-System Trauma?

Traumatic Brain Injury

Why are Traumatic Brain Injuries the leading cause of Pediatric Death?

Big Head Weak Neck Thin Cranial Bones Less Myelinated Nerve Tissue

What are the Phases of Traumatic Brain Injury?

Primary Injury Secondary Injury - Cerebral & Systemic Response

What is the Goal in regards to Traumatic Brain Injuries?

Minimize Secondary Injury

Where is the Cervical Mobility in Children vs Adults?

**Children**: C2-3 **Adults:** C5-7

What characteristic of the Pediatric Spine decreases the incidence of Fractures?

Ligamentous Laxity

What are the Mechanisms of Lawnmower Injuries?

Lower Mower Stability Blade Contact Mower Layout, Function, & Controls Running/Backing Over

What type of Skeletal Injuries include Vascular Involvement?

Supracondylar Distal Humerus Fracture Distal Femur Proximal Tibia Displaced Pelvic Fracture Knee Dislocation

Which Induction Med is Neuro Protective and is a Profound Vasodilator?

Propofol

Which Induction Med has Hemodynamic Stability, Neuro Protective, and Suppresses the Adrenal Response?

Etomidate

What are the effects of using Ketamine for Induction?

Sympathetic Outflow ↑CBF Marked Hypotension Not Neuro Protective

How much Allowable Blood Loss can be replaced w/ _only_ cystalloids?

Up 40% ABL, except for pts w/ certain pre-existing conditions

What should be given along with PRBCs?

**Calcium** - citrate binds to calcium & inactivates it

When is FFP indicated?

Abnormal PT/PTT to replace Factors 2, 5, 8, 9, 10, 11, & AntiThrombi 3 & For kids who received \> 1 PRBC

How long does it take to thaw FFP and How long is it good for?

45 min to Thaw, Good for 24 hrs.

What is the Initial Pediatric dose for FFP?

10 - 15 mL/kg

Platelets are usually required _____ FFP

Platelets are usually required **BEFORE** FFP

How much will the Platelet count rise w/ 0.1 units/kg?

20,000

True or False: Platelets should be Refrigerated.

**FALSE**