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Oral Boards > Peds > Flashcards

Peds Flashcards

1
Q

Management of foreign body aspiration

A

Inhalation induction w/ spontaneous ventilation
TIVA

PPV with RSI places patient at risk for distal migration of foreign object –> difficulty with extraction, hyperinflation, PTX

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2
Q

Management of airway edema/stridor

A 
Decadron 0.5-1.5mg/kg
Humidifed O2
Racemic epi (alpha-agonist)
- monitor for 3 hours
Check for cuff leak
Rule out obstruction, bronchospasm, residual foreign body
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3
Q

Anti-emetic contraindicated in peds

A

Phenergan <2 y/o resp depression

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4
Q

Associated anomalies with TEF

A

VACTERL

  • vertebral
  • anal
  • cardiac
  • TEF
  • renal
  • limb
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5
Q

Management of TEF

A

suction in blind pouch
elevate HOB
ventilate lungs without ventilating fistula leading to abdominal distention
ETT –> right mainstem –> slowly withdraw to b/l breath sounds to be distal to fistula
Sedated and relaxed until anastomosis heals, also risk of apnea

If unable to ventilate initially, stop
Surgeon perform gastrostomy to decompress —> intubate as above

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6
Q

Complications from TEF repair

A 
anastomotic leaks
stricture
GERD
feeding issues
esophageal dysmotility

recurrent aspiration, PNA
reactive airway

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7
Q

Electrolyte abnormality with pyloric stenosis

A

hypoK
hypoCl
Metabolic alkalosis

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8
Q

How would you rehydrate a patient with pyloric stenosis

A

NaCl until normal diuresis resumes
1/2 NaCl w/ K, dextrose

Remember to continue dextrose after surgery d/t depleted glycogen stores

LR - lactate —> bicarb worsens alkalosis

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9
Q

Induction of pyloric stenosis patient

A

OG to decompress stomach as much as possible - supine, lateral, prone positions
Pretreat with atropine 0.02mg/kg
Pre-O2
RSI with cricoid pressure and roc

inc dose of Sux d/t inc Vd (2-3mg/kg)

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10
Q

Pathogenesis and complications of CDH

A

Atelectasis from abdominal contents compressing developing lung –>

  • Pulmonary hypoplasia
  • Hypoxia
  • Pulmonary HTN –> persistent fetal circulation –> R–L SHUNT through PDA, PFO –> worsening hypoxia, hypercarbia, acidosis and further worsening pulm HTN
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11
Q

What promotes extra-pulmonary R –> L shunt?

A 
#1 is pulmonary HTN
Inc PVR inc de-oxy blood through PDA/PFO
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12
Q

Tx for pulmonary HTN

A 
avoid inc PVR (hypoxia, acidosis)
avoid stress catecholamines (sedated, paralyzed)
avoid 100% O2
Give NO
HFOV
ECMO
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13
Q

DDX for hypoxia and hypotension in CDH

A

PTX of contralateral lung (vigorous re-inflation of hypo plastic lung)
Severe pulmonary HTN
Compression of great vessels (difference in pulse Ox)
Blood loss
Dec venous return from IVC compression once contents return to abdomen - surgeon relieve pressure and close abdomen later

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14
Q

PDA concerns

A

H&P to evaluate current resp, cardio and fluid status
ABG, H&H, lytes, coag and type and cross

IVH - indomethicin (PG inhibitor) contraindicated
Pulm - compliance, pulm HTN
NEC - blood shunted away from systemic to pulmonary
Renal and hepatic function
Electrolytes
Glucose levels
Temp

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15
Q

Dx of PDA

A

Dx

  • bounding pulses
  • widened pulse pressure
  • CHF, dec breath sounds, rales, S3
  • ECHO - inc shunt, Pulm blood flow and dilation of LA
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16
Q

Monitors for PDA

A

A-line - right upper in case of Left subclavian clamping following torn PDA

Pulse-ox right hand and lower extremities

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17
Q

Post-PDA ligation concerns

A

Systemic HTN and inc LV afterload

  • persistent vasodilator like nitro
  • severe LV dysfunction then ionotrope like dopamine

Recurrent laryngeal nerve palsy
Phrenic nerve injury
Chest wall deformities

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18
Q

What are ductal dependent conditions

A

HLHS
AS
Interrupted aortic arch
Coarctation of aorta

TOF
Tricuspid atresia
Pulmonic stenosis
Transposition

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19
Q

Anomalies in TOF

A

RV outflow tract obstruction
VSD
Overrising aorta
RVH

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20
Q

Management of Tet spell

A

Imbalance in right sided heart pressures and dec SVR

Inc SVR by tucking knees to chest +/- Neo
Inc depth of anesthesia with ketamine
Hyperventilating with 100% O2
Fluid bolus
Beta blocker to reduce infundibular spasm

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21
Q

Induction w/ TOF

A

100% O2
Ketamine, fent, roc

Maintenence w/ fent +/- ketamine +/- N2O <50% to avoid inc PVR, hypoxia

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22
Q

Airway considerations with CHARGE syndrome

A

Cleft lip
Micrognathia
Laryngomalacia
Subglottic stenosis

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23
Q

Would you get an echo prior to surgery for patient with CHARGE syndrome?

A

Yes
Cardiac defects, often complex like TOF

C - coloboma of the eye
H - heart (TOF, DORV, ASD, VSD, Right aortic arch)
A - atresia of choanae
R - reatrded growth
G - genital anomalies
E - ear abnormalities
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24
Q

Difference between Treacher-Collins and Pierre Robin

A

Both known for micrognathia and difficult airways
Both have cardiac defects

Pierre robin has glossoptosis
Treacher-collins = more congenial defects

Neck prepped, difficult airway, sedate spontaneous fiber optic

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25
Q

Speed of IV induction with TOF

A

Faster due to right to left shunt

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26
Q

How would you induce patient with pyloric stenosis

A

Assuming hypoCl, hypoK metabolic alkalosis is fixed
Decompress to stomach lateral, supine prone NG/OG
100%O2
Atropine
RSI prop and roc

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27
Q

Emergent tonsil rebleed, how would you induce?

A

Full stomach due to blood

If unstable RSI with cricoid, ketamine, roc

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28
Q

Pre-op considerations with Down

A

Airway - macroglossia, subglottic stenosis
GI - duodenal atresia - full stomach
Cardiac - cardiac defects
Neuro - AA subluxation, maintain neutral
Resp - obstructive disease, snoring, apnea

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29
Q

What is a Cobb angle and when is surgery recommended?

A

Measure of severity of scolisis
Angle of perpendicular lines from upper cephalad and lower caudad vertebral bodies

> 10 = abnormal
40-50 = surgery
Pulmonary dysfunction = 60-65
Pulm HTN = 70

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30
Q

Concerns with DMD

A

Macroglossia —> difficult intubation
Diminished laryngeal reflexes
Delayed gastric emptying

Cardiac - loss of myocardial tissue —> dysrhythmia, MVP, cardiomyopathy, RVH and RV failure

Contractures - positioning
HyperK and rhabdo with volatile

Induction

  • GI PPx + cricoid
  • DI equipment, ketamine preserves reflexes and spont vent if difficult
31
Q

Considerations with scoliosis surgery? What monitors would you use?

A

Prone Positioning

  • head and neck neutral
  • no compression on eyes
  • arms <90
  • padding joints
  • avoid abdominal compression –> venous congestion
  • restrictions in ROM of joints

Wake up test - recall, extubation, pain, air embolism with vigorous inhalation

Monitors:

  • A-line
  • Precordial Doppler
  • CVC for venous air embolism
  • SSEPs + MEPs (inc sensitivity w false negatives w SSEPs)
32
Q

Unable to open mouth following sux administration, what is your Ddx?

A

Masseter muscle rigidity vs. myotonic syndrome vs. MH vs. TMJ

MMR may suggest susceptibility for MH
Cancel case and monitor for 24 hours for myoglobinuria, generalized rigidity, hypermetabolism

Assuming presence of dantrolene could proceed after frank risk benefit discussion or if they returned in 1 week - non-triggering anesthetic. No PPx dantrolene as nausea, vomiting common

33
Q

Concerns with prematurity

A

IVH
Retinopathy of prematurity

Respiratory distress syndrome
Persistent pulm HTN
Apneic spells
BPD

NEC

Impaired glucose reg
Hypothermia

34
Q

Intra-op fluid management with peds patient

A

4ml/kg/hr dextrose fluid
Replace insensible losses with NS 6-8ml/kg/hr
Ml:ml of EBL and keep HCT >35% (dec risk of NEC, ischemia, better would healing)

35
Q

Concerns with prematurity

A

IVH
Retinopathy of prematurity

Respiratory distress syndrome
Persistent pulm HTN
Apneic spells
BPD

NEC

Impaired glucose reg
Hypothermia

36
Q

Initial treatment in neonate with flaring, dec breath sounds on left, scaphoid abdomen?

A

Avoid PPV (distends intrathoracic viscera)
Intubate neonate (inhalational)
NG/OG for gastric decompression
Vent settings to correct hypoxia, hypercarbia while avoiding high airway pressures (C/L PTX risk)
Muscle relaxation (reduce O2 consumption)
Sedation (dec catecholamine induced inc in PVR)
Get ABG, CXR, ECHO

37
Q

FiO2 to use in neonates

A

O2 to avoid hypoxemia which can lead to acidosis and inc PVR
Avoid high O2 to avoid retrolental fibroplasia (ROP)

SpO2 goal >87-95%
PaO2 50-80mmHg

38
Q

Cyanotic after induction (75% on foot), but hand 95% cause?

A

Normal pre-ductal + low post-ductal = significant R–>L shunt through PDA

Tx = 100% O2, ventilation adequate + inc SVR and dec PVR

39
Q

Markers of stability for pyloric stenosis patient pre-op

A 
Good urine output 1-2ml/kg/hr
pH 7.3-7.5
Na >130
K >3
Cl >85
40
Q

Is inhalation induction in kids slower or faster than adults?

A

faster d/t higher MV:FRC and inc BF to vessel-rich organs

41
Q

What are the risk factors for post-op apnea in premature infants?

A 
low gestational AGE (<50 weeks)
chronic lung disease
hx of apnea/brady spells
congenital anomalies
sepsis
anemia
alkalosis
narcotic use
42
Q

How does PDA closure normally occur?

A

Initiation of ventilation + inc arterial O2 + dec PVR

Hypoxia d/t RD –> no bradykinin to induce closure. Thinner less responsive muscular layer in pre-me
Dec PG following separation from placenta

43
Q

Factor predisposing to PDA

A

Prematurity
RDS/hypoxia –> low bradykinin = can’t close PDA
Acidosis

44
Q

Describe respiratory distress syndrome of the newborn

A

Occurs in premature infants 2/2 insufficient surfactant production

Tachypnea, tachycardia, retractions, rales, cyanosis

45
Q

Risk factors for retinopathy of prematurity

A 
Prematurity (esp <32wks until 44 weeks)
Low birth weight (<1,500g)
mechanical vent
RDS
hyperoxia/hypoxia
acidosis/infection
anemia
bradycardia
46
Q

Transfusion threshold for premature infant

A

Hct 30%

47
Q

How do you calculate maximum allowable blood loss

A

Preme 95ml/kg

ABL = [EBV x (Hi-Hf)] / Hi

48
Q

Desaturation and bradycardia during PDA ligation dissection, what would you do?

A

100% O2 manually ventilate
Surgical retraction –> hypoxemia, inc shunt and bradycardia
Release traction, assess value status and consider atropine

49
Q

When do most tonsillectomy re-bleeds occur?

A

75% in first 6 hours

Remaining majority within 24 hours

50
Q

Risk factors for emergence delirium?

A 
Pre-op anxiety/underlying temperment
Young age (1-5yrs)
Post-op pain
Use of less soluble volatiles (sevo, des)
Prolonged surgical duration

Cannot be reliably prevented

  • attempt by reducing pre-op anxiety
  • pain control
  • recover in quiet , stress free environment
51
Q

Omphalocele vs. gastroschisis

A

Omphalocele - at umbilicus, membranous covering, assoc congenital defects (CDH, Trisomy 21, extrophy of bladder, cardiac)

Gastroschisis - lateral to umbilibcus, exposed viscera, abnormal bowel function

52
Q

How would you prepare neonate for omphalocele repair?

A
  1. address resp insufficiency (pre-me, lung hypoplasia)
  2. cover viscera with sterile soaked gauze, wrap in plastic
  3. Prevent infection
  4. Maintain normothermia
  5. IV access
  6. Replace fluid loss with LR and 5% albumin, lytes, acid-base
  7. decompress stomach (aspiration risk)
  8. delay until baby stabilized and complete assessment for congenital abnormalities can be performed
53
Q

What is Beckwith-Wiedmann syndrome?

A

Disorder assoc with omphalocele

  • macrosomia
  • macroglossia (potential DI)
  • hypoglycemia
  • polycythemia
54
Q

What monitors would you use for omphalocele repair?

A

In addition to standard AS monitors

  • a-line d/t potential for significant fluid loss and monitor acid-base balance
  • closely monitor airway pressure during reduction of abdominal viscera
  • pulse ox lower extremity to monitor lower extremity circulation with inc abdominal pressure, delay closing
55
Q

Why would a neonate with a PDA have LA enlargement on ECHO?

A

PDA shunts blood from systemic to pulmonary circulation which when large can increase blood flow 3-4x normal –> overload of pulmonary vasculature and left heart

56
Q

How would you maintain anesthesia for PDA ligation?

A

Dec SVR with gas can dec L–R shunt but infants are often sick, hypovolemic so i would prefer to maintain with fentanyl with supplement N2O or ketamine.

57
Q

How would you extubate following pyloric stenosis repair

A

awake, lateral

58
Q

What post-op problems do you anticipate following repair of pyloric stenosis

A

aspiration
hypothermia
hypoglycemia (inadequate glycogen stores)
apnea

59
Q

What conditions produce cyanosis in the first year of life?

A 
TOF
Transposition (higher post-ductal SpO2)
Truncus arteriosus
Tricuspid atresia
Total anomalous return
60
Q

How would you induce a patient with epiglottis?

A

In OR with surgeon and DI equipment
Seated position
Inhalation w/ Sevo = avoid PPV

61
Q

Cause of inc A-a gradient in CDH

A

Hypoplastic lung tissue –> intrapulmonary shunt and persistent pulm HTN

Pulm HTN then causes extrapulmonary shunt through PFO and PDA

62
Q

Is there inc risk of hyperK or MH with CP?

A

No

High incidence of GERD

63
Q

Difference between child and adult airway

A

Narrowest: cricoid (peds) - VC (adult)

Location: C3,4,5 (peds) - C4,5,6 (adult)

Epiglottis : longer, stiffer

VC: anterior angle

Mucosa more vulnerable to trauma

64
Q

Unable to open mouth following sux administration, what would you do?

A

Suspect MMR

  1. attempt to mask
  2. call for help
  3. place nasal airway
  4. attempt nasal intubation
  5. perform trachestomy
  6. admit for 24 hour observation
  7. get MH labs
65
Q

A baby is born making no respiratory effort, grimaces with stimulation, flaccid muscle tone, acrocyanotic and HR of 80. What is the APGAR score?

A

3

A - appearance

  • normal color = 2
  • acrocyanosis = 1
  • blue/gray all over = 0

P - pulse

  • > 100 = 2
  • <100 = 1
  • absent = 0

G - grimace

  • pulls away, coughs = 2
  • grimace with stim = 1
  • absent = 0

A - activity

  • active, spontaneous movement = 2
  • flexion = 1
  • flaccid = 0

R - respirations

  • normal, good cry = 2
  • slow, irregular, weak = 1
  • absent = 0
66
Q

Newborn w/ weak resp effort ddx

A

Pre-E dec uteroplacental perfusion –> neonatal depression

Transient tachypnea of newborn - retained fetal lung fluid

magnesium toxicity

hypoglycemia

meconium aspiration

undiagnosed congenital anomaly - choanal atresia, subglottic stenosis, Pierre-Robin

67
Q

Is CDH repair an emergency surgery

A

No.

Should be medically optimized first

  • improving oxygenation to >90%
  • correcting acidosis
  • reduction R—>L shunt
  • inc pulmonary perfusion with lung protective ventilation
68
Q

Maintenance in CDH

A

Sevo, fent, vecuronium

Low dose Sevo as its effects dec SVR > dec PVR which could worsen R—>L shunt

69
Q

Would you use sux in TOF case?

A

No.

It’s not indicated for routine use in pediatrics

Histamine release would dec SVR and promote right to left shunting

70
Q

Given the risk of PION in prone spine surgery, would you agree to deliberate hypotension during this case?

A

I would employ deliberate hypotension because patient has no history of chronic HTN and there is no reliable evidence suggesting an association b/w deliberate hypotension and vision loss.

I would not completely dismiss theoretically risk as this could also place patient at risk for spinal cord or cerebral ischemia

Therefore I would

  • optimize end-organ perfusion by ensuring adequate oxygen carrying capacity (avoiding anemia and hypoxia)
  • monitoring CVP, urine output, EKG, MEPs and ABGs for acidosis
71
Q

What technique would you employ to produce deliberate hypotension?

A

Reduce to no lower than MAP 60 ensuring adequate intravascular volume, Hb of 7-8, and monitor for signs of end-organ dysfunction.

Remi
Na Nitroprusside
Esmolol

72
Q

Does a positive Babinski sign in a Down patient concern you?

A

Yes

Strongly suggests neurologic compromise, likely from atlantoaxial subluxation

Reschedule and have neurologist evaluate

73
Q

How would you induce a child with a retropharyngeal abscess?

A

Goals are to maintain spontaneous ventilation, avoid loss of airway, disruption of infection leading to aspiration or laryngospasm

Would prefer to have IV before induction to administer emergency medications but if excessive anxiety would proceed without.

Awake fiberoptic first choice, may prove impossible in pediatric patient.

Then inhalation induction and fiberoptic assisted laryngoscopy –> trach

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