PICU Flashcards
what are the 3 P’s for airways
Position
Patency
Protection (GCS)
Name 3 situations where you would NOT intubate
mediastinal mass
known difficult airway
upper airway obstruction
* ask anesthesia/ENT
what does DOPE stand for
Displacement
Obstruction
Pneumothorax
Equipment failure
when do you perform needle decompression?
If there is a tension pneumothorax (signs of hemodynamic instability)
what is a normal Aa (PAO2- PaO2) difference?
<10
>10 think V/Q mismatch
what are 5 main causes of hypoxemia
Low FiO2 Hypoventilation VQ mismatch= most common Shunting impaired alveolar-capillary diffusion
what 3 things shift your oxygen dissociation curve to the right
decrease pH
increased temp
increased DPG
*SHIFTS RIGHT TO RELEASE OXYGEN TO THE BLOOD
What 3 things shift your oxygen dissociation curve to the left
increased pH
decreased temp
decreased DPG
what is the equation for minute ventilation
minute ventilation= TV x RR
what is the equation for alveolar ventilation
minute ventilation - deadspace
what are 3 things you can adjust to fix your CO2
TV
RR
deadspace
what is normal TV for healthy lungs
6-10mL/kg
5 risk factors found on history for fatal asthma
previous attack with rapid/severe deterioration previous PICU admission previous mechanical ventilation syncope/seizure during an attack denial/non-compliance depression or other psychiatric disorder dysfunctional family
what are 3 main factors with asthma that lead to V/Q mismatch
mucous plugging
airway inflammation
bronchoconstriction
List severe asthma warning signs (7)
cyanosis, PaO2 <70 in 40% oxygen absent breath sounds marked expiratory wheeze maximal accessory muscle use altered level of consciousness inability to speak marked pulses paradoxus (can see on sat probe)
what is pulsus paradoxus
exaggeration of the normal inspiratory drop in systolic BP: normal <5mmHg
but >10mmHg in pulsus paradoxus
what are the treatment options for status asthmaticus
oxygen Ventolin (continous nebs or IV ventolin) steroids (IV 2mg/kg then 1mg/kg q6h) Mg sulfate- ALL KIDS SICK ENOUGH TO GET ADMITTED SHOULD GET MG SULFATE BiPAP
why do we not want to intubate status asthmaticus?
> 50% morbidity/mortality during severe asthma occurs during or immediately after intubation
what is the equation for oxygen delivery
delivery of oxygen= CO x CaO2
CaO2= (Hb x sat x 1.34) + (PaO2x 0.003)
CO =?
HR x SV
SV= preload, after load, contractility
what does a low venous sat suggest? high venous sat?
increased oxygen consumption (pain, hyperthermia, shivering) or
decreased oxygen delivery (poor cardiac output, low Hb, low PaO2)
HIGH:
decreased oxygen consumption (anesthesia, hypothermia) or
increased oxygen delivery (high cardiac output, high PaO2, high Hb +/- poor oxygen utilization)
what inotrope is used for warm shock?
norepinephrine
what inotrope is used for cold shock?
epinephrine
is shock defined by blood pressure?
NO
SHOCK IS NOT DEFINED BY BLOOD PRESSURE
failure of delivery of oxygen and substrates to meet the metabolic demand of the tissue beds
what are the 5 types of shock
hypovolemic- dehydration, hemorrhagic
distributive- anaphylactic, septic, spinal
cardiogenic- duct dependent lesion, myocarditis
obstructive- PE, tension pneumothorax, tamponade
dissociate- CO, cyanide
If a patient presents in shock when should you give antibiotics?
ideally within the first hour
what are 4 sides effects of prostaglandin E1 (6)
apnea fever flushing (vasodilation) tachycardia hypotension seizure-like activity
inotropes: alpha- subtype 1
norepinephrine, high dose epinephrine
increase SVR, afterload
inotropes:
B-1
B2
low dose epinephrine (<0.3), dopamine (5-10)
increase HR and contractility
bronchodilation, peripheral vasodilation
V-2 receptor (vasopressin)
vasoconstriction of the capillaries and small arterioles
restores catecholamine sensitivity
*3rd line
what is the compression to ventilation ratio for 2 person CPR
15:2
what is the treatment for low glucose in trauma room
5ml/kg IV dextrose 10%
what are the treatment option for status epilepticus
give benzodiazepines within the first 5 minutes (lorazepam, diazepam or midazolam)
IV lorazepam 0.1mg/kg (max 4 mg) or IV midazolam 0.1mg/kg
IV fosphenytoin 20mg/kg over 20 min
IV phenobarbital 20mg/kg over 20 min
if no resolution then IV midazolam
consult neuro
what is the equation for CPP
MAP-ICP
what is the treatment for high ICP? how does it work?
3% NS
- decreases osmolar swelling
- decreases cellular swelling by decreased reuptake of glutamate
- plasma volume expansion
- restoration of cellular resting membrane potential and cell volume
- decreases inflammation by inhibiting post traumatic action of leukocytes
what is primary injury and secondary injury for TBI
primary injury- damage to brain tissue or vasculature that occurs immediately on impact of mechanical force
secondary injury- neuronal injury as a result of the pathological processes that are initiated as the body response to primary injury
(ex: edema and abnormal blood flow regulation)
what is the goal when we are treating patients with TBI
prevent secondary injury**
consider ICP probe for monitoring in all salvageable patients with a severe TBI (GCS 3-8) and an abnormal CT scan (hemaotmas, contusions swelling, herniation, compressed basal cisterns)
what are the key management principals for TBI patient
Keep CPP >40 maintain sats >92 and normal CO2 maintain normotension maintain normothermia maintain normal sodium and glucose keep well sedated +/- muscle relaxed treat ICP >20 x 5 minutes (HOB up, analgesia, sedation, IV 3% saline 5/kg, ensure normal CO2 and O2 and BP, collar not too tight)
what is Cushing’s triad?
decreased HR, increased BP, abnormal RR
altered LOC
pupillary changes
* transtentorial= most common herniation will see unilateral pupillary fixation
what is the treatment for herniation (4)
elevated HOB >30 degrees
hyperventilate
sedatives, analgesia +/- NMB
IV 3% saline PUSH (5mL/kg) and repeat as needed
what are risk factors for cerebral edema with DKA
new onset age <5 initial pH <7.1 high urea initial corrected Na >145 failure of Na to rise as glucose decreases bicarbonate use
what is brain death
irreversible loss of all brain activity
what is required for brain death in newborns <30 days and >36 weeks gestation
2 full exams with apnea tests with >/=24h interval between exam
MUST be >48 h after birth
* key here is exams must be separated by 24 hours*
brain death exam in infants: >=30 days and <1 year
full SEPERATE exams must be performed but NO fixed interval
brain death exam in children >1 year old to adults
still need two physicians but can perform exams including apnea testing CONCURRENTLY
- if examined separately then the apnea test must be repeated
in the setting of hypoxic-encephalopathy injury when can the exam be completed?
≥ 24 hour post injury
ex: arrest or pt hung themselves
what is the definition of a positive apnea test (3)
PaCO2 ≥ 60mmHg AND is 20mmHg greater than pre-apnea value
AND pH ≤ 7.28
AND patient remained apneic (respiratory reflex is absent)
what must be seen on ancillary testing for brain death? when do you do ancillary testing for brain death?
absence of intracranial blood flow
should be completed when any of the minimum clinical criteria cannot be completed OR if unresolved confounding factors exist
ex: MR angiography, CT angiography, radionuclide angiography, xenon CT
NOT EEG
what are the minimum clinical criteria for brain death
bilateral absence of motor responses (EXCLUDING spinal reflexes)
bilateral absence of pupillary responses to light (pupils ≥ 3mm)
bilateral absence of corneal responses
bilateral absence of oculovestibular responses
absent gag reflex
absent cough reflex
cough, gag, corneal, pupillary, oculovestibular, motor
A 6 week old child is found pulseless by parent. What would be the recommended compression to ventilation ratio awaiting EMS?
synchronous 30:2
A 6 week old child is found pulseless. EMS intubates the child prior to transport to the emergency department. What would be the correct compression to ventilation ratio for two rescuers?
asynchronous 100:10
what are key features for high quality CPR
Compressions: lower sternum at nipple line, on a firm surface, 1/3 anterior diameter of the chest (4cm infant; 5cm child), 100-120 times per minute, allowing for full chest recoil
Rotate compressors q2 minutes with <5s pause during this change, <10s pause for pulse changes
Bradycardia
Drug and electricity
Drug- epinephrine, atropine
Electricity- transcutaneous pacing
SVT
Drug and electricity
If that doesn’t work what other 2 drugs can be used?
adenosine 0.1mg/kg (max 6 mg)
second dose 0.2mg.kg (max 12mg)
synchronized cardio version 0.5J/kg-1J/kg
procainamide and amiodarone
wide complex tachycardia
Drug and electricity
Drug- adenosine, amiodarone, procainamide
do not use adenosine for WPW
synchronized cardio version 0.5J/kg- 1J/kg
VF with no pulse
Drug and electricity
Drug- epinephrine 0.01mg/kg
then *amiodarone, lidocaine (faster return of ROSC)
electricity- shock 2-4J/kg, max 10J
pulseless, 6 week old child has wide-complex tachycardia on EMS monitor, defibrillated x 1 and on arrival continues to receive CPR, what is the next step in your management?
shock, shock then epi
shock 4 J/kg now, epinephrine 0.01mg/kg (0.1mg/mL) once CPR resumed
ROSC: target oxygen saturation?
ROSC: target oxygen saturation 94-99%
when can you use a pediatric dose attenuator?
up to 25kg or 8 yo
why is etomidate not recommended for intubation in sepsis?
adrenal suppression
is cricoid pressure recommended during intubation?
Insufficient evidence to recommend cricoid pressure to prevent aspiration during intubation
List 3 things that changed in the 2015 PALS guidelines
20ml/kg bolus then reassess patient
ROSC: 94-99%
No routine pre-intubation use of atropine in infants or children
With shock refractory VF or pulseless VT can use either lidocaine or amiodarone
If comatose after out of hospital cardiac arrest, its reasonable to maintain 5d of normothermia (36.5-37.5C)
3 broad indications for intubation
- Patient can’t ventilate or oxygenate or impending failure
- Need to decrease metabolic demand or regulate physiology
- Reduction of LV afterload
what medications are used for intubation of a newborn infant? why is atropine used?
atropine- Indicated for neonatal intubations to prevent bradycardia related to vagal response (succinylcholine also causes bradycardia)
fetanyl
succinylcholine
ETT size <1
1-2
>2
<1: 3.0
1-2: 3.5
>2: age/4 + 4 (-0.5 if cuffed)
How can you confirm ETT position
Look for bilateral chest movement and listen for equal breath sounds
Listen for gastric inflation over stomach
Check exhaled carbon dioxide with CO2 detector or capnography
check oxygen saturation with a pulse oximeter
In hospital: perform a chest x-ray to verify that the tube is in the mid trachea
What would you do with your ventilator is you want to increase CO2 clearance?
Increase PIP and ventilator rates if you want to increase CO 2 clearance
what would you do with your ventilator if you want to improve oxygenation?
Increase PEEP and FiO2 if you need to improve oxygenation
Called to ED to assess patient described as developing shock. What vital sign abnormality might you except as a first sign of shock?
tachycardia
What is shock?
Body’s inability to deliver adequate oxygen to meet metabolic demands of vital organs and tissues
Decrease aerobic and increased anaerobic cellular metabolism (that is where the lactate comes from)
what must be present to call it decompensated shock?
hypotension
what are 2 examples of hypovolemic shock?
clinical presentation
pathophysiology
diarrheal illness
hemorrhagic (burns, vomiting)
clinical: tachycardia, dry mucuous membranes, decreased urine out, orthostatic hypotension, perfusion (normal to impaired)
pathophysiology: decreased preload
what are 2 examples of cariogenic shock?
clinical presentation
pathophysiology
congenital heart disease
arrhythmias
clinical presentation: tachycardia, cool extremities, decreased urine output, delayed cap refill
pathophysiology: left ventricular failure, impaired myocardial function, decreased contractility
what are 2 examples of obstructive shock?
clinical presentation
pathyophysiology
pericardial tamponade
tension pneumothorax
PE
clinical presentation: tachycardia, cool extremities, decreased urine output, delayed cap refill
pathophysiology: reduced stroke volume
what are 2 examples of distributive shock
anaphylaxis
neurogenic shock- PRESENT WITH BRADYCARDIA
- the only one that presents differently*
clinical presentation: tachycardia or bradycardia, flash cap refill, bounding pulses, poor urine output, peripheral vasodilation, widened pulse pressure
pathophysiology: inadequate vasomotor tone
2 examples of septic shock
pathophysiology
bacterial
viral
fungal
pathophysiology: inadequate preload +/- impaired vascular tone +/- impaired contractility
how much blood loss is required before a patient will become hypotensive?
45%!
what inotrope is used for cold shock? warm shock?
cold shock- epinephrine
warm shock- norepinephrine
what is the first thing you should do for a patient you suspect has septic shock?
put them on oxygen!!
Ddx for altered level of consciousness
“DIMS”
D- drugs
I- infection
M- metabolic (electrolytes, uremia, IEM, ende)
S- structural (trauma, stroke, tumor), seizure, shock
what is the clinical criteria for anaphylaxis
- Acute onset of an illness with involvement of the skin and at least one of the following:
a. Respiratory compromise
b. Reduced BP or associated symptoms of end-organ dysfunction
- Two or more of the following that occur rapidly after exposure to a likely allergen for that patient:
a. Involvement of the skin-mucosal tissue
b. Respiratory compromise
c. Reduced BP or associated symptoms of end-organ dysfunction
d. Persistent gastrointestinal symptoms
- Reduced BP after exposure to a known allergen for that patient (minutes to hours)
a. Infants and children: low systolic BP (age specific) or greater than 30% decrease in systolic BP*
what is the principal of neurocritical care
Prevention of secondary injury is the principal of neurocritical care
Things that can worsen secondary brain injury:
Increased CSF pH/decreased CO2: vasoconstriction cerebral arterioles and can lead to inadequate perfusion and ischemia
Hyponatremia: worsen cerebral edema
Hypotension and hypertension: affect cerebral blood flow is cerebral autoregulation impaired by the injury
Hyperthermia increases cerebral metabolic demand
Hypoglycemia leads to neuronal apoptosis, seizures increase cerebral metabolic demand and can result in loss of airway control and hypoxemia
3 month old with bilateral subarchnoid hemorrhages and suspected abusive head injury. List signs they may have on physical exam
Bulging fontanelle Comatose or irritability (headache) Conning: hypertension, bradycardia, irregular respirations, signs of 6th or 3rd CN palsy Seizure Emesis
List 4 medical reasons why a brain-dead patient might not be a valid organ donor
severe untreated sepsis active disseminated TB active rabies active viral Hep B, C or CMV active extra cranial malignancy viral encephalitis acute or progressive neurological disorder active west nile virus
tetanus prophylaxis after minor wound?
all other wounds?
<3 doses then give dTap, TDap
if other wound then give them TIG
> 3 doses: minor wound then give dTap if >10 years since last dose, all other wounds give dTap if >5 years since
TIG is not required if they have ever had 3 doses
other wound: dirt, feces, saliva, puncture wound
Tdap if >7 years
What is different for the examination of a neonate who is brain dead
must be > 36 weeks GA
assessment must also include occulocephalic and suck reflexes
must be at least 36 ℃
must be at least 48h old
and assessed by 2 physicians at least 24h apart
What is different with infants (30d-1 year) for brain death examination? what reflex is different?
What is different with infants (30d-1 year)? Assess the occulocephalic reflex instead of vestibulo-occular reflex, two full separate exams by different physicians
Following a submersion injury, how long after the injury must they be observed in hospital
they should be observed for 6-8 hours for signs of pulmonary edema
This patient remains in an unresponsive, comatose state. How long after the submersion injury would you wait to council parents that the child will not recover of full neurological function
72 hours best answer (or 48h)
what are some adjuvant therapies for asthma
epinephrine ketamine helix aminophylline mechanical ventilation
Ddx bronchiolitis
Asthma Other pulm infection Laryngotracheomalacia Foreign body GERD CHF Vascular ring Allergic reaction Cystic fibrosis Mediastinal mass Tracheoesophageal fistula
what groups are at higher risk of severe disease with bronchiolitis (4)
TABLE from CPS statement premature babies (<35 weeks) <3 months of age at presentation immunodeficiency hemodynamically significant cardiopulmonary disease
what are 6 reasons for admission to hospital with bronchiolitis
- Signs of severe respiratory distress (indrawing, grunting, respiratory rate >70)
- Supplemental O2 required to keep SpO2 >90%
- Dehydration o history of poor fluid intake
- Cyanosis or history of apnea
- Infant at risk for severe disease
- Family is unable to cope
what are the only 2 recommended treatments for bronchiolitis
hydration
oxygenation
what are 4 criteria prior to discharge from hospital for bronchiolitis?
- Tachypnea and work of breathing improved
- O2 sat >90% without supplemental O2 or stable fo home oxygen therapy
- Adequate oral feeding
- Education provided and appropriate follow-up arranged
Who should get Palivizumab
Hemodynamically significant CHD or CLD <12m at start of season
Preterm before GA30 at start of season
GA <36 now <6months in remote communities
Immunodeficiencies, T21, C.F., upper airway concerns, chronic pulm disease other than CLD should not be routinely offered
Consider for severe disease/home O2
Not recommended to continue if break through disease
Name 5 clinical conditions that are potentially responsive to HFNP therapy
- OSA
- Asthma
- Bronchiolitis
- Pneumonia or pneumonitis
- Heart failure
what are 3 benefits of HFNP
Higher FiO2
Some positive pressure
Humidification
what is considered mild croup? how do you treat mild croup?
without stridor or substantial chest wall indrawing at rest
- oral dex 0.6mg/kg
- Educate the parents (course of the illness, signs of respiratory distress, when to seek medical attention)
what is considered moderate croup? how do you treat moderate croup?
stridor or chest wall indrawing at rest without agitation
- oral dex 0.6mg/kg
- Observe
- if no improvement after 4 hours consider admission
what is considered severe croup? how do you treat?
stridor and indrawing of the chest associated with agitation or lethargy
- epi neb 5mL
- oral dex
- if cannot give oral dex consider budesonide nebulized with epi
how long after epi neb should a child be observed
2 hours
what are the criteria for admission for croup?
consider hospital admission if child received steroids 4 hours ago and has:
- continued moderate distress (without agitation or lethargy)
- stridor at rest
- chest wall indrawing
what is the main virus associated with croup?
parainfluenza
what is on the ddx for croup? (4)
bacterial tracheitis
foreign body
epiglottitis
hemangioma/anatomic variant
what would you do for impending failure with croup?
high conc O2 (NRB mask)
assist ventilation
administer IV/IM dex
ETT (smaller tube – half size smaller than predicted for age), prepare for surgical airway if needed
Besides epi and dex, what is one other treatment that can be considered for severe croup
heliox
what are some indications for dialysis in ICU (7)
Refractory volume overload Persistent hyperkalemia Severe, refractory metabolic acidosis Uremia Calcium/phosphorus imbalance Neurologic symptoms (Bad renal humours!) Certain toxins
what are some management options for hyperkalemia
ABCs!
Remove iatrogenic causes
Stabilize:
Calcium
Shift:
Sugar/insulin
Bicarb
Ventolin
Remove:
Furosemide
Dialysis
Confirm
Repeat tests
ECG
what are some causes of hyperkalemia? (4)
Renal failure
Iatrogenic
Acidosis
Aldosterone deficiencies
what is seen on EKG with a potassium >6? >7.5? >9
> 6: peaked T waves
7.5: long PR, wide QRS, tall T wave
9: absent p wave, sinusoidal wave
what are 4 causes of SIADH
stress
malignancy
infection
pain
what are the treatment options for HYPERnatremia(3)
free water replacement
volume expansion
DDAVP
How do you calculate your free water deficit?
Total body water x (Serum sodium – desired sodium)/desired sodium
= (0.6L/kg x Wt(kg)) x (Serum Sodium – desired sodium)/desired sodium
what is one cause you should think of for HYPERnatremia
Diabetes insipidus
what is the definition of fulminant hepatic failure? (3) KNOW THIS
INR > 1.5, uncorrectable by Vit K, with encephalopathy or INR > 2 uncorrectable by Vit K
Evidence of acute liver injury
No evidence of chronic liver disease
what is the Ddx for fulminant hepatic failure? (9)
Viral hepatitis Autoimmune HLH Idiopathic Toxins Metabollic Inherited Ischemic Neonatal hemochromatosis
Names signs/symptoms of potential airway burn? (9)
Facial burns Singed nasal hairs Mucosal sloughing /erosion Carbonaceous sputum Hoarse/absent voice Stridor Wheeze Respiratory distress Hypoxia
what is the parkland formula?
= 4mlx weight x BSA + maintenance
first half over 8 hours then next half over 16 hours
follow urine output as a guide for fluid resuscitation
how do you manage a patient with fulminant hepatic failure
watch for bleeding (increased INR) watch for clotting (strokes) monitor encephalopathy watch for cerebral edema** COMMON, call ICU seizures common
what is the treatment for CO poisoning
the half life of CO is 4-6 hours in 21% O2
with 100% O2 the half life is reduced to 45-60 minutes
consider hyperbaric if symptomatic, COHB >25-40%
* consider CO poisoning if they have cherry red lips, do carboxyhemoglobin level
what are two methods of vagal maneuver in an infant
rectal temp
knees to chest
how does adenosine work?
blocks AV node conduction
Pros and cons of succinylcholine
pros- fast onset and ofset
cons- muscle fasiculations/spasms can lead to pain, hyperkalemia
don’t use for increased ICP, rhabdomyolysis, burn patients, IOP (glaucoma)
what is the goal of peep
to prevent atelectasis
what is a typical tidal volume
7-10ml/kg (healthy lung)
what is the equation for minute ventilation
TV x RR
how much can gases expand on an airplane
up to 30%
blood loss or shock should receive supplementary oxygen, NG for ileus and chest tube for pneumothorax MUST be inserted first, Change ETT cuff from air to saline because of changes on the plane!
at what age can you start using verbal numerical rating scales for pain? what do you use for younger kids?
> 8 years old
Verbal numerical ratings are preferred and considered the gold standard; valid and reliable ratings can be obtained from children 8 yr and older.
3-7: use visual analog pain scale (drawings, graded color intensities)
