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Fall 20' Anatomy III MO > PEDS Exam 3 > Flashcards

PEDS Exam 3 Flashcards

1
Q

Oxygenated blood from placenta enters through the?

A

umbilical vein

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2
Q

Most of the blood bypass fetal liver via the?

A

ductus venosus

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3
Q

Most of the blood bypass fetal liver via the ductus venosus and mix with deoxygenated blood in?

A

inferior vena cava

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4
Q

What does the foramen ovale do?

A

shunts blood from right atrium (increased pressure) directly into left atrium (decreased pressure).

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5
Q

Why is blood shunted away from the fetal lungs?

A

increased resistance in the lungs

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6
Q

What does the ductus arteriosus do?

A

connects pulmonary artery directly to the aorta.

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7
Q

How does deoxygenated blood return to the placenta?

A

via the umbilical arteries

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8
Q

Preductal vs post ductal?

A

Preductal is the blood before the hole of the ductus arteriosus and post ductal is after. Preductal is oxygenated and post ductal is low oxygen blood.

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9
Q

Which childhood issue below is improved with aerosolized racemic epinephrine?
croup, epiglottitis, tracheitis?

A

croup

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10
Q

thumbprint sign on lateral neck film describes?

A

epiglottitis

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11
Q

subglottic narrowing describes?

A

tracheitis

also croup if steeple sign is present in AP neck films

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12
Q

what causes epiglottitis?

A

Haemophilus influenzae B

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13
Q

what causes croup?

A

Parainfluenza virus

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14
Q

what causes tracheitis?

A

Staphylococcus aureus

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15
Q

high grade fever, inspiratory strider, cyanosis and drooling, what is most likely being described?

A

acute epiglottitis

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16
Q

what do you want to avoid doing if a kid is suspected or confirmed to have epiglottitis?

A

avoid laryngoscopy unless in the OR ready to intubate with a physician present who can take over if need be and also be ready to trach.

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17
Q

how will you induce a child with acute epiglottis?

A

inhalation induction in sitting position, use smaller tube size.

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18
Q

treatments for acute epiglottitis?

A

ET and antibiotics are life-saving
Ampicillin
Vaccination

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19
Q

Does laryngotracheal bronchitis require intubation?

A

usually no

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20
Q

low grade fever, barking cough, 4 month old what is described?

A

laryngotracheal bronchitis

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21
Q

treatment for laryngotracheal bronchitis?

A

Oxygen and mist therapy
Nebulized epi
IV dex
Intubate if signs of respiratory depression appear

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22
Q

if blood enters the right ventricle, where does it go from there?

A

into the pulmonary artery but bc the pulmonary resistance is so high it is then shunted through the ductus arteriosus and into the aorta

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23
Q

how many umbilical arteries exist? What is the function?

A

2, return deoxygenated blood from fetal internal iliac arteries to placenta

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24
Q

How many umbilical veins exist? what is the function?

A

1, supplies oxygenated blood from placenta to fetus

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25
Q

Blood in the umbilical vein is how much saturated with oxygen?

A

80%

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26
Q

The umbilical arteries have high or low O2 saturation?

A

low

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27
Q

Name the three important shunts that are present in the fetal circulation?

A

ductus venosus
foramen ovale
ductus arteriosus

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28
Q

how does the ductus venosus work?

A

Blood entering the fetus through umbilical vein is conducted via the ductus venosus into IVC to bypass the liver

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29
Q

How does the foramen ovale work?

A

Most oxygenated blood reaching the heart via the IVC is diverted through foramen ovale and pumped out the aorta to head and body

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30
Q

How does the ductus arteriosus work?

A

Deoxygenated blood from the SVC is expelled into the pulmonary artery and ductus arteriosus to the lower body of the fetus

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31
Q

explain what occurs at birth and with the first breath to change the fetal circulation?

A

at birth the infant takes a deep breath and this decreases resistance in pulmonary vasculature causing an increase in left atrial pressure vs right atrial pressure, formen ovale closes.
increased oxygen from respiration and decrease in prostaglandins due to placental separation causes closure of ductus arteriosus.

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32
Q

once the formen ovale closes what is it called?

A

fossa ovalis

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33
Q

What helps close the PDA?

A

INDOMETHACIN

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34
Q

What keeps the PDA open?

A

Prostaglandins E1 and E2

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35
Q

What is the PaCO2 and PaO2 of fetal blood?

A 
PaCO2 = 48 mmHg
PaO2 =   30 mmHg (+10 increase if mother is on 100% O2)
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36
Q

When does the ductus arteriosus close?

A

2-3 weeks

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37
Q

when does the foramen ovale close?

A

takes months to close

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38
Q

**What occurs if the fetus has hypoxia or acidosis in the first few days?

A

ultimately pulmonary hypertension

NEEDS MORE DETAILS

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39
Q

List the three cyanotic defects?

A

They all start with a T
Tetrology of Fallot
Transpostion of great vessel
Truncus

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40
Q

Acyanotic defects are?

A 
VSD
ASD
PDA
Pulmonary stenosis
Aortic stenosis
Coarctation of aorta
Atrioventricular septal defect
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41
Q

What types of shunts always results in a decrease in arterial PO2 bc of admixture of venous blood with arterial blood?

A

right to left shunts

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42
Q

How can you estimate the magnitude of the right to left shunt?

A

the patient breathes 100% O2 and measuring the degree of dilution of oxygenated arterial blood by non-oxygenated shunted (venous) blood

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43
Q

what type of shunt is more common and why?

A

left to right shunts, bc pressures are higher on the left side of the heart

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44
Q

what percentage of the cardiac output normally bypasses the lungs resulting in a physiologic shunt?

A

2%

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45
Q

In certain cardiac abnormalities what percentage of blood may bypass the lungs?

A

up to 50%

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46
Q

what type of shunt is TOF?

A

?

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47
Q

What is Eisenmenger’s syndrome?

A

When a left to right shunt becomes so bad that it reverses into a right to left shunt due to an increase in pulmonary hypertension.

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48
Q

What type of shunt does NOT result in decrease in arterial PO2?

A

left to right shunt. Instead PO2 will be elevated on the right side of the heart because there has been admixture of arterial blood with venous blood. (left side of the heart mixing blood with the right means more oxygen in the right side)

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49
Q

What type of shunts result in blue babies?

A

R to L shunts

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50
Q

What type of shunts result in blue kids?

A

L to R shunts

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51
Q

early cyanosis is what type of shunt?

A

right to left

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52
Q

late cyanosis is what type of shunt?

A

left to right

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53
Q

examples of right to left shunts also known as early cyanosis or blue babies

A
  1. Tetralogy of Fallot (MCC of early cyanosis)
  2. Transposition of great vessels
  3. Truncus arteriosus
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54
Q

examples of left to right shunts also known as late cyanosis or blue kids?

A
  1. VSD (MC congenital cardiac anomaly)
  2. ASD
  3. PDA (close with indomethacin)
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55
Q

most common types of left to right shunt?

A

VSD then ASD then PDA

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56
Q

late cyanosis due to a left to right shunt reversing into a right to left shunt will have what two symptoms?

A

clubbing and polycythemia

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57
Q

What is occurring with an atrial septal defect?

A

LA shunts blood into the RA which increases work on the right side of the heart leading the RVH. (right ventricle is receiving more blood and working harder)

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58
Q

what would you want to avoid with ASD?

A

avoid increases in SVR because this may worsen the L to R shunting

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59
Q

is childhood ASD symptomatic or no symptoms?

A

no symptoms

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60
Q

Complications of ASD?

A

Pulmonary HTN if age greater than 20 years.

Eisenmenger disease

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61
Q

What is the most common congenital heart disease?

A

VSD

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62
Q

VSD, how does this shunt start and how does it usually end up?

A

starts as a left to right shunt but with increased pulmonary resistance it turns into a right to left shunt and now the patient becomes cyanotic.

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63
Q

pulmonary resistance increases what 3 things?

A

hypoxia, hypercarbia, and hypothermia.

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64
Q

small VSD have no symptoms but large defects can cause what?

A

Pulmonary HTN
Growth failure
CHF
Infection

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65
Q

Physical findings with VSD?

A

Midsystolic harsh blowing murmur

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66
Q

What is coarctation of aorta?

A

Mechanical obstruction ‘kink’ between proximal and distal aorta, usually after the origin of left subclavian artery

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67
Q

Does coarctation of aorta cause increase or decrease in LV afterload?

A

increase

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68
Q

male to female ratio with coarctation of aorta

A

2:1

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69
Q

physical findings with coarctation of arota?

A

Weak or absent femoral pulse. Always compare radial and femoral pulse

Upper extremity hypertension; lower extremity hypotension

Cold extremities, claudication with exercise, leg fatigue

Rib notching, “3” sign

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70
Q

with coarctation of aorta are most patients symptomatic or asymptomatic?

A

most are asymptomatic, ten percent can have CHF in infancy

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71
Q

What are the four treatments for coarctation of aorta ?

A

Resection
Patch
End to end repair
Balloon

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72
Q

if a patient has VSD what should you avoid during repair?

A

Arrhythmia

RV dysfunction

Pulmonary vascular obstructive disease

Paradoxical embolus

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73
Q

EKG of a person with coarctation of aorta?

A

normal or LVH

74
Q

what is a patent ductus arteriosus?

A

persistence of connection between pulmonary artery and aorta.

75
Q

patent ductus arteriosus would cause what kind of shunt?

A

left to right shunt

76
Q

what is the issue with a patent ductus arteriosus?

A

blood flow from aorta to pulmonary artery.

additional blood is re oxygenated in the lungs and returns to the LA and LV leading to increased work load and causing LVH

77
Q

what type of murmur is present with PDA

A

Continuous murmur “machinery”

78
Q

if you have a small defect with PDA you have no symptoms but if you have a large defect then what symptoms will a person have?

A

CHF
delayed growth
infections

79
Q

Treatment for PDA

A

surgical ligation

COX-1,COX-2 inhibtors and indomethacin “medical ligation”

80
Q

** preductal and postductal anatomical locations and difference

A

3%

81
Q

What four abnormalities are present in TOF

A

Narrowing of pulmonary valve

thickening of wall of right ventricle

displacement of aorta over ventricular septal defect

ventricular septal defect

82
Q

TOF results in what type of oxygenation to the body?

A

insufficiently oxygenated blood pumped to the body

83
Q

Pulmonary blood flow is decreased, the RV is hypertrophied, and deoxygenated blood enters the aorta.
What does this describe?

A

TOF

84
Q

Boot shaped heart happens with what CHD?

A

TOF

85
Q

MC congenital heart dz causing cyanosis?

A

TOF

86
Q

Four features of TOF?

A

Pulmonary stenosis – RV outflow obstruction
Overriding aorta (aorta comes out both from left ventricle and right ventricle ( BIG AORTA)
Large VSD
Right ventricular hypertrophy

87
Q

Right ventricular outflow obstruction (pulmonary stenosis) plus VSD results in ?

A

ejection of mixed blood into the aorta

88
Q

clinical presentation of TOF?

A

CYANOSIS
Squatting
Dyspnea
Hypercyanotic and hypoxic spells (TET spells)

89
Q

what does squatting with TOF do?

A

A position that increases systemic vascular resistance and aortic pressure, which decreases right-to-left ventricular shunting and thus increases arterial O2saturation.

90
Q

during feeding or crying a babies PO2 can drop to below 50, what is this known as?

A

TET spells, will be unresponsive to supplemental oxygen

91
Q

physical examination of a person with TOF will reveal?

A

RV heave

harsh systolic ejection murmur

92
Q

what does squatting do for a TOF pt?

A

tries to decrease the shunt so lungs can get more blood

93
Q

what do you see when the kid has a TET spell?

A

hands and feet can turn blue as well as lips and places on face.

94
Q

Conditions that increase right to left shunt

A

increased pulmonary vascular resistance or decreased SVR

acidosis

hypercarbia

hypotension

95
Q

Treatment for TOF kid?

A

For symptomatic patient , PGE1 infusion

ForTETspells, knee-chest positioning, calming, O2, and vasoconstrictors

96
Q

Surgery options for TOF

A

Blalock-Taussing shunt; connects subclavian artery to pulmonary artery
Closing VSD
Resecting obstruction

97
Q

Anesthetic management of TOF kid?

A

maintain intravascular volume and SVR

avoid increases in pulmonary vascular resistance (N2O)

Ketamine is used bc it maintains or increases SVR and therefore does not aggravate R to L shunt

VA and histamine releasing drugs decrease SVR and increase the shunt

Phenylephrine increases SVR and decreases shunt

98
Q

**Why do you want to keep the duct open in TOF or create a ductus?

A

by connecting subclavian artery and pulmonary artery leads to more blood to lungs as less blood is going because of pulmonary stenosis

99
Q

What is Tricuspid atresia?

A

Missing Tricuspid valve

Blood can flow out of right atrium only via PFO or ASD

PDA is necessary for blood to flow from LV into pulmonary circulation

100
Q

What is needed for survival with Tricuspid atresia?

A

PGE1 is needed for survival

101
Q

Treatment of Tricuspid atresia?

A

Septostomy

B.T. shunt

Fontan procedure
-Anastomosis of right atrium with right pulmonary artery

Glen shunt
-SVC to pulmonary artery

Heart transplant

102
Q

What is shown on EKG with Truncus arteriosus

A

biventricular hypertrophy

103
Q

what is truncus arteriosus

A

Conotruncal separation does not occur, one trunk

104
Q

when pulmonary resistance falls with truncus arteriosus what occurs

A

increased flow to the lungs leading to CHF, tachypnea

105
Q

What is the treatment for Truncus arteriosus?

A

surgery, close VSD with trunk in LV, connect RV and pulmonary artery

106
Q

What is transposition of Great Vessels ?

A

Right ventricle is connected to aorta and LV is connected to pulmonary artery

107
Q

What must someone with TGV have to survive?

A

mixing of blood, thus they must have an ASD, VSD, PDA

they must also have PGE1 infusion

108
Q

On chest X ray what shape will the heart of someone with TGV have?

A

egg shaped heart

109
Q

what is the surgery for TGV?

A

atrial septostomy if no connection, whole atrial switch in neonatal period

110
Q

**TAPVR, what is it?

A

Pulmonary veins lead to RA instead of going to left atrium, even the coronary sinus go to the RA.

111
Q

snowman shaped heart indicates what CHD?

A

TAPVR

112
Q

What is hypoplastic left heart syndrome?

A

Hypoplasia of left ventricle, mitral valve and ascending aorta

mixing of pulmonary and systemic blood in single ventricle

113
Q

if you have an increase or decrease in pulmonary vascular resistance with Hypoplastic LH syndrome what will happen?

A

cardiovascular collapse

114
Q

systemic flow is depended on PDA in hypoplastic left heart syndrome, what keeps the duct open?

A

PG-E1 infusion to keep the duct open

115
Q

prematurity is defined as birth before how many weeks and what weight?

A

37 weeks and less than 1000 g

116
Q

prematurity complication can include?

A 
Hyaline membrane disease
Apneic spells
Bronchopulmonary dysplasia
Respiratory distress syndrome
PDA
Retinopathy
117
Q

Anesthetic considerations with premature babies?

A

Avoid excessive inspired O2

Risk of post-anesthetic apnea

118
Q

Congenital diaphragmatic hernia, what is it?

A

gut herniates into thorax through hole in diaphragm

119
Q

what issue can a congenital diaphragmatic hernia cause?

A

hypoxia due to right to left shunt, resulting from persistent fetal circulation

Scaphoid abdomen
Bowel sound in chest
Pulmonary hypoplasia & hypertension
Severe retractions

120
Q

Treatment for Congenital diaphragmatic hernia

A 
Stabilization  
Postductal PCO2 < 65mmHg and preductal O2 saturation >85%
ECMO is useful 
Surgical decompression 
Intrauterine surgery
121
Q

Anesthetic considerations for congenital diaphragmatic hernia?

A 
NG tube
Avoid high pressure PPV
Pre-oxygenation
decreased conc. of VA, muscle relaxant
Nitrous oxide (N2O) is contraindicated 
High risk of pneumothorax,  avoid barotrauma 
-Chest tube
122
Q

Most common type of tracheoesophageal fistula?

A

Type IIIB is most common

123
Q

What is tracheoesophageal fistula? How do you know a child may have it?

A

Esophagus is a blind pouch attached by a fistula to the trachea.

Presents with increased oral secretions and respiratory distress.
cyanosis, chocking, and coughing with feedings - 3c’s

124
Q

Other defects may be present, what is VATER syndrome?

A 
Vertebral defect
Anal atresia
TE fistula
Esophageal atresia
Radial dysplasia
125
Q

if you put an NG tube down a kid with TF what will it show?

A

NG tube coiled in esophagus

126
Q

TF is associated with what amount of fluid in utero?

A

polyhydramnios

127
Q

what is oligohydramnios?

A

not enough amniotic fluid

128
Q

What is a MUST to be performed for babies born with TF

A

surgical repair is a must, high risk aspiration

129
Q

Anesthesia considerations with Tracheoesophageal Fistula ?

A

Need frequent suction due to increased secretion
avoid PPV
awake intubation

130
Q

What is pyloric stenosis ?

A

Hypertrophy of pyloric smooth muscles

131
Q

palpable olive shaped mass describes?

A

pyloric stenosis

132
Q

pyloric stenosis causes?

A

projectile vomiting leading to metabolic alk. and shock

133
Q

the vomiting causes a loss of what electrolytes?

A

sodium, potassium, hydrogen, chloride

134
Q

what is paradoxic aciduria

A

trading off sodium with hydrogen

135
Q

when is pyloric stenosis noticed?

A

present in the first two weeks to four months

136
Q

what do you see on a barium study?

A

string sign

137
Q

Treatment for pyloric stenosis?

A

Correct dehydration
NaCl and K+ supplement
Avoid Ringers lactate as lactate is metabolized to bicarb by liver
Surgical correction

138
Q

Anesthetic consideration for pyloric stenosis?

A 
Fix fluid and lytes first
Suction
High risk of aspiration 
High risk of respiratory depression due to prolonged alkalosis
Awake intubation and rapid induction 
Urinary output 1-2 ml/kg/hour
139
Q

soar throat that leads to dysphagia that leads to obstruction describes?

A

acute epiglottitis

140
Q

Tell me what you know about acute epiglottitis ?

A 
Haemophilus influenzae type B
Edema of supraglottic structures
2-6 year of age
High grade fever
Inspiratory stridor
Tachypnea
SOB
Cyanosis
Drooling
Respiratory acidosis
141
Q

Treatment for acute epiglottitis?

A

ET and antibiotics are life-saving
Ampicillin
Vaccination

142
Q

Anesthetic considerations for acute epiglottitis?

A 
Lateral neck X-ray to determine extent of obstruction
Prepare for tracheostomy
Avoid laryngoscopy
Inhalation induction in sitting position
Intubation with smaller size tubes
143
Q

what size ETT do you want to use with acute epiglottitis and what type of induction do you want to perform?

A

smaller size ETT and inhalation

inhalation induction in sitting position

144
Q

symptoms of laryngotracheal bronchitis?

A

Low grade fever
Less air way obstruction than with AE
Barking cough

145
Q

what age group does laryngotracheal bronchitis typically effect?

A

3 months to 3 years

146
Q

treatment for laryngotracheal bronchitis?

A

oxygen and mist therapy
nebulized epi
IV dex
intubate if signs of resp. depression appear

147
Q

does racemic epinephrine help croup, epiglottitis, or tracheitis?

A

it only helps improve the strider of croup

148
Q

how long does it take croup to develop?

A

2-3 days

149
Q

how long does it take epiglottitis to develop?

A

rapid onset over hours

150
Q

how long does it take tracheitis to develop?

A

gradual onset

151
Q

Pierre-Robin Syndrome /Treacher-Collins Syndrome how are they for intubations and what intubation or extubation technique will you want to use?

A

very difficult intubation

use awake techniques

152
Q

characteristics of pierre robin syndrome?

A

Cleft palate

Small face and glottis

153
Q

Treacher collins syndrome characteristics

A

Small lower jaw
Absent or malformed ear
More severe than Pierre-Robins

154
Q

Congenital defects in abdominal wall leads to what?

A

external herniation of viscera

155
Q

how common is omphalocele and how common is gastroschisis?

A

Omphalocele 1:5000

Gastroschisis 1:15000

156
Q

omphalocele vs gastroschisis, what are the differences? ( sac and anomalies)

A

omphalocele have a hernia sac and is associated with other congenital anomalies such as Down’s syndrome.

gastroschisis does not have a hernia sac and is not associated with other congenital anomalies.

157
Q

Persistence of herniation of abdominal contents into umbilical cord, covered with peritoneum describes what congenital issue?

A

omphalocele

158
Q

Failure of lateral body folds to fuse leads to an extrusion of abdominal contents through abdominal folds what congenital issue is described?

A

Gastroschisis

159
Q

increased maternal alpha fetoprotein is associated with omphalocele or gastroschisis?

A

omphalocele

160
Q

Anesthetic considerations for omphalocele and gastroschisis?

A

NG decompression
Awake intubation
Nitrous oxide (N2O) is contraindicated ; avoid further distension
Muscle relaxation for reduction

161
Q

omphalocele and gastroschisis staged closure surgery requires intragastric pressure to be? peak pressures to be? and end tidal CO2 to be?

A

Intragastric pressure > 20 cm H2O
Peak inspiratory pressure > 35 cm H2O
End-tidal CO2 > 50 mmHg

162
Q

what will you replace third space lost with for omphalocele or gastroschisis ?

A

salt solution and five percent albumin

163
Q

how long will babies with omphalocele and gastroschisis stay intubated after surgery?

A

1-2 days post op

164
Q

What is Intestinal Malrotation and Volvulus ?

A

Abnormal rotation of the midgut around mesentery (SMA)

165
Q

what are the symptoms of intestinal malrotation and volvulus?

A

symptoms of acute or chronic bowel obstruction

166
Q

midgut volvulus can cut the blood supply and cause?

A

infarction

167
Q

midgut volvulus, is it a surgical emergency?

A

yes

168
Q

tell me some signs of midgut volvulus?

A

bilious vomiting
Progressive abdominal distension and tenderness
Metabolic acidosis
Bloody diarrhea is indicative of infarction

169
Q

Anesthetic consideration for intestinal malrotation and volvulus twist…

A

Preop stabilization, NG, fluid/lyte balance, antibiotics
Rush to OR
Preoxygenation , awake intubation, rapid induction

170
Q

bowl compartment syndrome may develop from intestinal malrotation and volvulus, which can cause?

A

impaired ventilation
obstruct venous return
impair renal functions
high mortality

171
Q

Patients with volvus?

A 
Hypovolumia
Poor tolerance to GA
Ketamine may be agent of choice
Fluid rescusitation
Blood products
172
Q

what is intussusception?

A

telescoping of a segment of bowl into itself

173
Q

what is the MC kind of bowel obstruction in first 2 years of life?

A

Intussusception

174
Q

Risk factors that increase having intussusception?

A

Meckel’s diverticulum, intestinal lymphoma, viral infection

175
Q

History and physical of a patient with intussusception may reveal?

A

Abrupt onset of abdominal pain in a health child
Colicky pain, vomiting, blood in stool “ current jelly stool”
Pallor , sweating
“Sausage-shape abdominal mass”

176
Q

treatment of intussusception would include?

A

Correct fluid and electrolyte
Air contrast enema is diagnostic and curative
Surgical resection

177
Q

cystic fibrosis, what is it and what does it cause?

A

Hereditary disease of exocrine glands of lungs and G.I.T

Most common recessive disorder in Caucasians [defective CFRT gene on chromosome 7]

Result from a defect in Cl- channels that is caused by mutation

Thick and sticky mucus builds up in lungs and intestine forming cysts.

Inability to clear secretions leading to bronchiectasis

Is associated with a deficiency of pancreatic enzymes resulting in malabsorption and steatorrhea

178
Q

Clinical presentation of Cystic fibrosis

A

increased RV, increased airway resistance, decreased VC, decreased expiratory flow rate
Recurrent resp. infections , pneumonias
Fat malabsorption leading to deficiency of A,D,E, K
Fluid and electrolyte imbalance due to malabsorption
Failure to thrive
Death in early adulthood

179
Q

How do you diagnose cystic fibrosis?

A

sweat chloride test is very increased

180
Q 
anesthetic considerations with cystic fibrosis? 
what drugs are controversial?
what type of induction?
type of anesthesia for intubation?
ect.
A

Anticholinergic drugs are controversial
Prolong inhalation induction
Deep anesthesia for intubation
Avoid hyperventilation; may  shallow postop respiration

Respiratory therapy
-Bronchodilators, incentive spirometry, postural drainage and proper antibiotics

181
Q

Scoliosis what is it and what all will it affect in a person ?

A

Lateral curvature of vertebra and deformity of rib cage
Affect cardiac and respiratory functions
Hypoxia due to V/Q mismatch
Restrictive disease with low lung volume
decreased chest compliance
increased PCO2 in severe disease
Pulmonary hypertension due to increased pulmonary vascular resistance leading to RVH

Fall 20' Anatomy III MO (5 decks)

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