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Pharm Final review > Peds week 2 > Flashcards

Peds week 2 Flashcards

1
Q

When do deciduous teeth erupt?

A

At 6 months and begin shedding between 5-8 yrs.

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2
Q

Epiglottis is ______, ______, and at a more _____ angle from the trachea making it more difficult to lift

A

Epiglottis is narrower, longer, and at a more acute angle from the trachea making it more difficult to lift

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3
Q

The narrowest part of the pediatric airway is:

A

The cricoid cartilage. In adults it is at the vocal chords

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4
Q

The pediatric larynx is at:

A

C3-4

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5
Q

The adult larynx is at:

A

C4-5

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6
Q

What shape is the pediatric airway?

A

Funnel shaped

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7
Q

Length of the trachea (vocal cords to carina) in neonates and children up to one year of age is ___cm or ___

A

Length of the trachea (vocal cords to carina) in neonates and children up to one year of age is 5-9 cm or 2-2.5 inches

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8
Q

DO NOT ____ THE ETT once you go through the vocal cords

A

DO NOT BURY THE ETT once you go through the vocal cords

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9
Q

Do NOT overextend…keep the head ______

A

Do NOT overextend…keep the head parallel

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10
Q

The epiglottis is ____ shaped

A

omega

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11
Q

True/False: It is more difficult to lift an infants epiglottis with a laryngoscopic blade

A

True

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12
Q

A small decrease in airway size (edema from inflammation or trauma) results in what?

A

a large increase in resistance to flow

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13
Q

Infants are _____ ______ breathers until 3-5 months of age because?

A

Infants are obligate nasal breathers until 3-5 months of age because the major source of resistance to airflow is the lower airways

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14
Q

What can occlusion of the nares can cause?

A

complete airway obstruction

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15
Q

Overcoming the resistance of the nares accounts for only ___% of the work of breathing for infants as compared to ___% in adults

A

Overcoming the resistance of the nares accounts for only 25% of the work of breathing for infants as compared to 60% in adults

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16
Q

What kind of breathing do children under 6 months of age rely on?

A

diaphragmatic breathing

Thorax is weak and unstable

Diaphragm contains a smaller percentage of Type 1 (slow twitch, fatigue-resistant) muscle fibers

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17
Q

Ribcage/intercostal muscle contribution to ventilation is ___to___%

By 9 months of age, ribcage contribution increases to ___%

A

Ribcage/intercostal muscle contribution to ventilation is 20-40%

By 9 months of age, ribcage contribution increases to 50%

By 12 months of age, chest wall is stable and resists inward recoil of lungs

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18
Q

FRC is ____

A

FRC is small (not functional)

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19
Q

Infant respiratory rate is ____

A

30-50

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20
Q

Infants tidal volume is ___

A

7

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21
Q

Infants dead space is ____

A
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22
Q

Alveolar ventilation is _____

A

100-150

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23
Q

Functional residual capacity is ____

A

27-30

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24
Q

Oxygen consumption is ___

A

7-9

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25
Q

Anesthesia reduces FRC by causing ____ ____ ____ and impaired intercostal and diaphragm activity

A

peripheral airway collapse

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26
Q

ETT Size (mm ID) =

A

age in years +16 / 4

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27
Q

There should be an audible air leak around the tube at a pressure between ___-___ cm H20 (we typically go with 20 cm H2o)

A

There should be an audible air leak around the tube at a pressure between 15-25 cm H20 (we typically go with 20 cm H2o)

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28
Q

What is the biggest factor for post operative croup?

A

caused by excessive tube size

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29
Q

Is cuffed ETT is always a half size smaller?

A

Yep

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30
Q

Is percussion and auscultation is of limited usefulness in small children?

A

Yep. Limited usefulness

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31
Q

URI within the past 2-6 weeks =

A

significant risk of bronchospasm

32
Q

Canceled Cases:

A

Wheezing
Green nasal drainage
Fever

33
Q

Laryngospasm

A

Stimulation in stage 2

Sustained tight closure of the vocal cords during light planes of anesthesia (creates a state of central disinhibition)

Stimulation of the superior laryngeal nerve, not the recurrent laryngeal nerve

Contraction of the adductor muscles of the larynx (lateral cricoarytenoids, thyroarytenoids, and cricoarytenoids)

34
Q

Causes of laryngospasm

A

Inhalation of volatile agents

Excessive secretions in the airway

Presence of URI (hyper-irritable)

Manipulation of the airway (intubation, extubation)

Stimulation of the visceral nerve endings in the pelvis, abdomen, and thorax

35
Q

Treatment for laryngospasm

A

Remove irritating stimulus (suction)

Remove debris from airway

Deepen anesthesia as appropriate

100% O2 via tight fitting face mask

*Sustained positive airway pressure (30-40 cm H2O)

Manual forward displacement of the mandible

If airway maneuvers fail – atropine, succinylcholine, and consider intubation

Succinylcholine 0.4mg/kg IV
4mg/kg IM
Atropine 20mcg/kg IM/IV

36
Q

Post Intubation Laryngeal Edema

A

Potential complication of intubation in all children but incidence is greatest in children ages 1-4

37
Q

Causes of post-intubation laryngeal edema

A

Mechanical trauma to the airway during intubation

Placement of a tube that produces a tight fit (no leak up to 40 cm H2O)

38
Q

Treatment for post intubation laryngeal edema

A

Humidification of inspired gases

Aerosolized racemic epinephrine 0.5ml of 2.25% solution in 2-3 ml saline –

vasoconstriction of capillaries in subglottic mucosa

Re-intubation

Tracheostomy

39
Q

Epiglottitis

A

Rare cause of infectious upper airway obstruction in children

Etiology – haemophilus influenzae type B

Occurs in children 3-6 yrs.

Pathology – systemic septicemic process with local erythema and edema most marked in the epiglottis, aryepiglottic folds, and supraglottic connective tissue

40
Q

Symptoms of epiglottitis

A

Rapid clinical progression of symptoms, <24 hrs.

Dysphagia, dysphonia, drooling, inspiratory stridor, distress

High fever, >39°C

41
Q

Treatment for epiglottitis

A

O2
Urgent intubation of the trachea under general anesthesia – NEED to be in the OR

Antibiotics, antipyretics
Fluids

42
Q

Anesthetic Management for epiglottitis

A

Transfer the child to the OR – do nothing to upset or agitate the child

Smooth, controlled inhalation induction with sevoflurane, child in a sitting position, CPAP applied to the circuit

Obtain IV access, administer atropine

Achieve Stage III, do no precipitate laryngospasm
ENT HAS TO BE PRESENT

Place the child supine, intubate the trachea with a small ETT a size and ½ smaller

MAINTAIN SPONTANEOUS VENTILATION

Through direct laryngoscopy by the ENT surgeon to confirm diagnosis

43
Q

Anesthetic implications with epiglottitis

A

Expect a slow induction due to the partially obstructed airway

Inflammation of the airway may enhance irritability and increase the potential for coughing, breathholding, and laryngospam

CV depressant effects of inhalation agent magnified r/t hypovolemia

Rigid ventilating bronchoscope and surgical airway equipment must be available

With severe obstruction and mucosal swelling, identification of supraglottic structures may be difficult

May choose to replace oral tube with nasal tube intubated for 48-96 hrs.

44
Q

Recovery of epiglottitis

A

Extubation considered when temp and white count fall

Resolution of the swelling signaled by audible leak around ETT

Extubation only after direct laryngoscopy in the OR under GA to confirm that swelling of epiglottis has resolved

45
Q

How can you tell if epiglottitis swelling has resolved?

A

by audible leak around ETT

46
Q

Laryngotracheobronchitis(croup, subglottic infection)

A

Accounts for 90% of infectious upper airway obstruction in children

Etiology – parainfluenzae virus type 1 and 2, influenzae A, respiratory syncytial virus

Occurs in children <2 years of age

Pathology – mucosal and submucosal edema within the circoid ring (decreased luminal size)

47
Q

Laryngotracheobronchitis

A

Gradual onset and progression of symptoms, 24-72 hrs.

History of URI progressing to hoarse cry or barking cough

Low grade fever <39ºC

48
Q

Treatment for laryngotracheobronchitis

A

O2 with cool aqueous mist

Aerosolized racemic epi (vasoconstriction of capillaries in subglottic mucosa, Beta adrenergic bronchodilatory effect) Albuterol

Corticosteroids. Stabilize cell membrane integrity, decrease release of inflammatory mediators

Antipyretics

Intubation of the trachea is RARE unless exhaustion occurs

49
Q

Foreign Body Aspiration

A

Most frequent site is right mainstem

Cough, wheezing, decreased
air entry into affected lung, URI, pneumonia

50
Q

Treatment of Foreign Body Aspiration

A

Laryngoscopic or endoscopic removal

Best to remove object within 24 hrs.

Risks of leaving the foreign object:
-Migration of the aspirated material
-Pneumonia
-Residual pulmonary disease

51
Q

Anesthetic Management for airway obstruction

A

Induction technique will depend on severity of airway obstruction:

With airway obstruction, inhalation of volatile agent in O2 maintaining spontaneous ventilation

Without airway obstruction, IV induction with standard agents

52
Q

After anesthetic management for airway obstruction continued..

A

Achieve Stage III of anesthesia, perform direct laryngoscopy for the purpose of anesthetizing the vocal cords to prevent laryngospasm – lidocaine 1% 1-2 mg/kg

With airway obstruction, avoid NDNMBs: Positive pressure ventilation may contribute to migration of the aspirated material

Narrow bronchoscope creates high resistance to gas flow
Typically there is a large gas leak around the bronchoscope

53
Q

Anesthetic Management continued

A

Maintenance – O2, IH agent

Skeletal muscle paralysis may be required for removal if the aspirate object is too large to pass through the moving vocal cords – succs, cisatracurium

Emergence – pt. may or may not be intubated after removal of the foreign body

Post-op – aerosolized racemic epi, corticosteroids to reduce subglottic edema

54
Q

Foreign body aspiration complications

A

Airway obstruction

Fragmentation of the foreign body

Arterial hypoxemia

Hypercarbia

Subglottic edema from trauma to the tracheobronchial tree – foreign body, instrumentation

55
Q

Tonsillectomy and Adenoidectomy implications

A

Upper airway obstruction

Massive hypertrophy

Chronic upper respiratory infections

Obstructive sleep apnea

56
Q

Anesthetic management for Tonsillectomy and Adenoidectomy

A

Pre-medication oral or intranasal midazolam

IH induction with sevoflurane

Intubation – deep (sevoflurane + propofol 1-2mg/kg) or with short acting NDNMB

Analgesia – MSO4 0.1mg/kg or Fentanyl 1-2mcg/kg (Obstructive sleep apnea cut meds to ½ dose)

Steroid –dexamethasone 0.3-1mg/kg

Emergence – extubate when child fully awake…don’t need to

57
Q

Post-tonsillectomy Bleeding

A

Bleeding that continues or recurs after tonsillectomy and requires surgical intervention (packing or suturing)

Early: Incidence 0.2-2%
*Within first 24 hrs. 99% within first 6 hrs.

Secondary/Delayed
Incidence 0.1-3%
24 hrs. up to 2-3 wks. post-op, peak - day 7

58
Q

Post-tonsillectomy Bleeding risk populations

A

Older pts.

Presence of inflammation, infection

Pre-op ingestion of ASA, NSAIDS – inhibition of platelet function

Coagulopathy

Patients that have had strep multiple times

59
Q

Post-tonsillectomy Bleeding prevention

A

Careful dissection in tonsilar capsule

Meticulous hemostasis

Avoid surgery during/immediately after acute inflammation, infection

Avoid blind vigorous suctioning

Avoid use of NSAIDS

60
Q

Post-tonsillectomy bleeding symptoms

A

Frequent swallowing
The kid will throw up blood
Tonsil bleed is an RSI
Need to know hemoglobin and urine specific gravity (how dehydrated) 1.010-1.015

61
Q

Post-tonsillectomy Bleeding clinical presentation

A

Hypovolemia
Anemia
Agitation
Shock
Stomach full of blood
Active bleeding (poor visualization of glottis)

62
Q

Post-tonsillectomy Bleeding preop evaluation

A

Assessment of volume status:
BP (orthostatic changes), HR, urine output, mucus membranes, skin turgor, sensorium
Labs, H/H, urine specific gravity/osmolality
E
stablish IV access-rehydration or transfusion must begin immediately

SEND for BLOOD

63
Q

Post-tonsillectomy Bleeding management

A

2 Suctions AT THE HEAD OF THE BED!!! In case the one clots

64
Q

Choanal Atresia

A

Occlusion of one or both posterior nares

Atresia is partially or totally bony in 90% of cases

Freq. association craniosynostosis

Since neonates are obligatory nose breathers, bilat. choanal atresia causes suffocation if the mouth is not kept open (oral airway or large rubber nipple secured in the mouth)

Unilateral atresia may go undiagnosed for months or years; is eventually diagnosed due to the presence of intractable unilateral nasal drainage

Surgical correction or tracheostomy must be performed within the first few days of life

65
Q

Anesthetic Management of choanal atresia

A
66
Q

Anesthetic Management of choanal atresia

A

Awake intubation with oral RAE tube

Maintenance – O2/N20/IH, NDNMB may be used, opioids for analgesia

Emergence – wide awake for extubation

Post op – partial or intermittent airway obstruction may persist for some time, so the infant must be observed with appropriate monitoring until airway patency is assured

Stents are place – baby will transfer to ICU

66
Q

IV Induction: Advantageous because…

A

Asleep without going through Stage 2
Risk of Laryngospasm very low

67
Q

Stages chart

A
68
Q

anatomical differences between pediatric and adult airways

A
69
Q

Anesthetic Management of choanal atresia

A

Awake intubation with oral RAE tube

Maintenance – O2/N20/IH, NDNMB may be used, opioids for analgesia

Emergence – wide awake for extubation

Post op – partial or intermittent airway obstruction may persist for some time, so the infant must be observed with appropriate monitoring until airway patency is assured

Stents are place – baby will transfer to ICU

70
Q

Anesthetic Management of choanal atresia

A

Awake intubation with oral RAE tube

Maintenance – O2/N20/IH, NDNMB may be used, opioids for analgesia

Emergence – wide awake for extubation

Post op – partial or intermittent airway obstruction may persist for some time, so the infant must be observed with appropriate monitoring until airway patency is assured

Stents are place – baby will transfer to ICU

71
Q

Laryngospasm dose of succs

A

Succinylcholine 4mg/kg IM 0.4 mg/kg IV

Positive pressure 40 mm Hg – This is the reason you bring the mask and oral airway with every child –
and why you transport with O2 in the event of spasm
the kid has been oxygenated prior to event rather than starting at room air

72
Q

Opioid doses for peds

A

½ the dose for fatigued children

½ the dose for children with OSA

Narcan o.5 mcg/kg

73
Q

Anesthetic Management of choanal atresia

A

Awake intubation with oral RAE tube

Maintenance – O2/N20/IH, NDNMB may be used, opioids for analgesia

Emergence – wide awake for extubation

Post op – partial or intermittent airway obstruction may persist for some time, so the infant must be observed with appropriate monitoring until airway patency is assured

Stents are place – baby will transfer to ICU

73
Q

Nausea/Vomiting

A

Zofran 0.1-0.5mg/kg

74
Q

Anesthetic Management of choanal atresia

A

Awake intubation with oral RAE tube

Maintenance – O2/N20/IH, NDNMB may be used, opioids for analgesia

Emergence – wide awake for extubation

Post op – partial or intermittent airway obstruction may persist for some time, so the infant must be observed with appropriate monitoring until airway patency is assured

Stents are place – baby will transfer to ICU

Pharm Final review (24 decks)

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