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PICU > PICU Bri > Flashcards

PICU Bri Flashcards

1
Q

Airway

A

patent (stridor, obstruction)

protected (awake, breathing)

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2
Q

Breathing

A

RR, sats, WOB, A/E

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3
Q

Circulation

A

HR/BP/pulses CRT

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4
Q

Disability:

A

GCS, pupils, materializing signs, glucose

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5
Q

Exposure

A

undress the patient, temp

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6
Q

Resus station

A 
PPE
call for help, bring to resus room
monitors
O2
set of vitals
ABCDE
RN on PIV - if can't get in 5 minutes and child in shock, IO
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7
Q

8 year old in MVC, TBI. moaning, will not open his eyes, and flexes to pain

A

moaning - 2 verbal
won’t open eyes - 1
flexes to pain - 3

total = 6

decerebrate - NO BRAIN, extension is bad (weird)

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8
Q

Cushing’s Triad

A

hypertension
bradycardia
abnormal breathing

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9
Q

Monro-Kellie Doctrine

A

skull is fixed
if any of the compartments increases, the others can only decrease so much
if have a mass, increase in the space taken by the parenchyma, critical volume is where the ICP goes up

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10
Q

Evidence based TBI management - doesn’t mater what got you there

Guidelines for severe TBI

A

Normal - O2 sats, pCO2 (35-40 mmhg), BP >5th percentile, temperature (no hyperthermia, DO not COOL (trial shows that it is bad))
Avoid: hypoglycemia, seizures
Treat elevated ICP +/- impending herniation with hyperosmolar therapy
over 50% have an episode of hypotension/hypoglycemia

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11
Q

TBI management in PICU

A

ICP probe if GCS 20 for 5 minutes then (NORMAL ICP IS s triad, blown pupil)

ICP probe only in trauma

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12
Q

7 year old with CP involved in MVA and presents with GCS of 4, ICU x 1 week with no improvement despite aggressive management. Parents approach you regarding the withdrawal of treatment because of his underlying disability Which of the following is try:

A

not brain dead - because he has a GCS of 4

To be brain dead you need to have a GCS 3

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13
Q

Pediatric Brain death CLINICAL DIAGNOSIS

A

1) established aetiology capable of causing neurological injury in absence of reversible conditions
2) no confounders including:
- unresuscitated shock
- hypothermia (temp t do the above tests: MRA or CTA (nothing about EEG anymore)

Canadian guidelines are different from american

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14
Q

Who can perform neurological determination of death?

A

any licensed physician with the requisite knowledge and skill

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15
Q

Differences in kids

A

> 1 year old, same as adults

>30 day and < 30 days: minimum time from birth 48 hours, 2 exams separated by at least 24 hours

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16
Q

Procedural sedation for ortho, what are the 4 pieces of equipment you would want next to you ? 3 effects of ketamine?

A

Equipment: O2, suction, oral airway, BMV, airway cart, IV fluid
Ketamine: causes release of endogenous catecholamines: tachycardia, HTN, amnesia, analgesia, bronchorrhea, bronchodilation
ketamine good for hemodynamic unstable, no longer a problem for increased ICP

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17
Q

meds for intubation for kid with increased ICP

A

ketamine - maintains HR and BP
if hypertensive then use fentanyl with midaz
don’t use proposal, drops your BP
fentanyl most HD stable for the opioids

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18
Q

neuromuscular blockage

A

increases the chance of success in 1st attempt

always use it unless there is a reason not to (i.e. mediastinal mass)

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19
Q

SIDe effects of depolarizing NM blockade (ie succ)

A

hyper K - worse in renal failure, rhabdo
malignant hyperthermia
Neuromuscular disease - can cause worsening of symptoms in MD

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20
Q

Non depoolarizing - ie roc

A

blocks the receptor

less side effects but lasts up to one hour

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21
Q

3 month old with fever, HR 180, BP 50/30, unwell with poor pulses and delayed CRTI. How is this infants cardiac output compared to usual? What about SVR? What would be your IV doers

A
  1. CO decreased
  2. SVR increased
  3. 20 cc/kg NS push
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22
Q

best indicator of early hypovolemic shock in 3 year old

A

tachycardia is the first sign

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23
Q

oxygen delivery

A

cardiac output x arterial O2 content

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24
Q

Why do we need O2

anaerobic metabolism is not good

A

glycolysis
decreased ATP = failure of energy dependent processes
increased lactate = acidosis - cells don’t like->death

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25
Q

Shock types

A

1) distributie
2) cardiogenic
3) hypovolemic
4) neurogenic

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26
Q

Clinical markers of perfusion

A
  1. CRT
  2. pulses
  3. HR and BP
  4. u/o
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27
Q

Lab markers

A

lactate
mixed venous
acid-base

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28
Q

Septic Shock

A

warm shock
cold shock: cold, poor pulses, increased after load, lower cardiac output
has to do with how many vasodilator cytokines vs vasoconstriction
warm shock - toxic shock is most common - S. aureus/GAS, warm, cash cap refill, wide PP
loss of auto regulation
usually vasoconstrict/vasodilate based on demand

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29
Q

Shock:

A 
recognize shock, O2, PIV
20 cc/kg/ NS x 3, 2nd PIV, start ABx, correct low BG and Ca
cold shock = dopamine
warm shock = norepi
if catecholamine resistant = steroids
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30
Q

causes of cardiogenic shock

A 
cardiomyopathy
viral myocarditis
post bypass
coronary artery anomalies
arrythmias etc
signs and symptoms: cold shock+ poor perfusion + heart failure (Hepatomegaly, pulmonary/peripheral edema)
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31
Q

where spinal cord injury for neurogenic shock

A

T1 to L2

inappropriately nomal HR but hypotensive , treatment is vasopressors

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32
Q

Boy collapses at school. paramedic arrive and intubate, get IV access and use AED to defibrillate for wide complex tachycardia then continue CPR. On arrival you would:

A

1) defibrillate 2J/kg
2) defrillate 4J/kg
3) epi 1:10000 IV
4) continue CPR x 5 minutes

if using a manual defibrillator, then restart fresh at 2J/kg

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33
Q

if PEA or systole

A

don’t give a damn about your debrillator, you only have CPR and epi

34
Q

management shock as soon as you can

A

CPR x 2 minutes, shock again THEN EPI (with the second shock)
once first epi then every 3-5 minutes after that
15:2 no advanced airway, no need to coodinate once intubated
epi dose: 0.01 mg/kg 1:10000 IV (going right to veins, vs muscle need more dose)
**we don’t know if epi helps in arrest
if you haven’t intubated need to co-ordinate (but not 1st priority if getting ventilation)

35
Q

unconscious person

A

check pulse first

CAB

36
Q

3 things you can tell the team to ensure good quality CPR

A
  1. push fast
  2. push deep
  3. minimize interruptions
  4. allow full chest recoil
  5. switch people
  6. no leaning (use a stool)
37
Q

unstable SVT

A

synchronized cardioversion or adenosine (if have IV present)
0.5-1J/kg is the cardioversion dose
give them fentanyl first

38
Q

SVT

A

stable - vagal, adenosine

unstable - cardiovert or adenosine

39
Q

Wide complex tachy

A

unstable - pulseless arrest

stable - talk to cardiology

40
Q

bradycardia HR<60 and compromised

A

usual ABCs
most commonly bradycardia is from hypoxia
if persists then start CPR, then give epi and atropine
if continues then do TC pacing

41
Q

What is the does for anaphylaxis

A

1:1000 IM anterolateral thigh

don’t do it IV

42
Q

if respiratory compromise

A

wheezing - ventolin
other - intubate
if need more than 3 IM epi then give infusion
H1/H2 antagonists, genadryl, ranitidine, steroids (prednisone)

43
Q

tidal volume

A

regular breathing

44
Q

functional residual capacity

A

lung still open, what is left

45
Q

maximum inspiration

A

inspiratory reserve volume and expiratory reserve volume , total lung capacity without residual volume is your vital capacity

46
Q

Where is breathing controlled

A

respiratory centres in brain
signals fo diaphram and heart
C345 diaphragm alive

47
Q

ventilation CO2 clearance depends on what

A

minute ventilation

tidal volume x rr

48
Q

5 year old 3 days of fluA with high ver, stridor and severe resp distress. First step in management? 2 likely organisms?

A

ABCs then secure airway

staph aureus, GAS

49
Q

Symptoms of upper airway obstruction depends on where the obstruction is

A

negative intrathoracic pressure - collapses on inspiration , get symptoms of expiratory stridor
extrathoracic obstruction - should have collapse on inspiration

50
Q

Upper airway obstruction

A

epiglottitis, bacterial tracheitis, croup, RPA, foreign body, airway anomaly
if in distress secure the airway
don’t give them sedatives or paralytics
consults anaesthesia or ENT

51
Q

causes of hypercapnea

A

hypoventlation
obstructive lung disease (asthma, OSA)
neuromuscular disease

52
Q

Respiratory acidosis

A

resp failure
bad vent settings
1:10 rule for acute resp acidosis, as you compensate closer to 3-4

53
Q

metabolic alkalosis

A

vomiting

lasix/Bartters

54
Q

respiratory alkalosis

A

secondary to something else

incorrect vent

55
Q

Indications for intubation

A
  1. CNS: cannot protect airway (GCS <8, no airway reflexes), loss of control of breathing
  2. Resp: upper airway obstruction, hypoxemia, hypercapnea, severe WOB despite max medical tx
  3. CVS: hemodynamic instability, to decreased metabolic demand
    4) logistics: transport, procedures
    - small pneumo need a chest tube
56
Q

pneumonic for intubation 7Ps

A

1) prepare
2) pre O2
3) premedicate -include atropine if <1 year old
4) paralysis
5) pressure on cricoid carilage (only if RSI)
6) placement of ETT (4+ age/4, depth = ETT size x 3)
7) post intubation care

57
Q

equipment

A

1) mask
2) ETT
3) airway gadgets (oropharyngeal, LMA)
4) laryngoscope blade
5) stylet
6) suction catheter
7) syringe for cuff inflation

58
Q

confirm ETT placement

A

1) ausculation
2) direct laryngoscopy
3) detect CO2 - BEST
4) CXR - BEST
5) condensation in the ETT

59
Q

RSI - haven’t been fasted to higher risk of aspiration

A

preO2 before the BMV, want to limit the Positive pressure
minimize BMV as may distend stomach
Deep sedation and paralysis so increase chances of success
cricoid pressure to compress esophagus during laryngoscopy (controversial) BURP maneuver

60
Q

Questions about changing the vent settings

A 
Timing of the breath: synchronized, assist control, pressure support
pressure or volume
rate
PEEP
I/E time
61
Q

low sats vented patient

A

DOPE, increased FiO2 or PEEP (increases SA)

62
Q

high CO2 vented patient

A

increase minute vent with increased tidal volume or RR

63
Q

1 month old with RSV, 22/6 FiO2 40% RR35 . first gas 7.20/75/23/70. next step

A

increase rate

increase PIP

64
Q

12 year old old influenza pneumonia, sats 60% rule out new issues

A

increase the PEEP

65
Q

3 year old female in ED for 4 hours with asthma, got ventolin q30 minutes, moderate distress on FiO2 40%

A

MgSO4 - reduces ICU admission

may need to give fluid with it

66
Q

Status asthmaticus

A

failure to respond to initial bronchodilator

67
Q

RFs for ICU in asthma

A

prior ICU, h/o increased bronchodilator use with no improvement, asthma exacerbation despite recent steroids, frequent ED visits, sats <92% despite O2
may need some adjuncts
no evidence for IV ventolin (do inhaled continuous first always)

68
Q

ARDS

A

1) within 1 week of known clinical insult
2) bilateral lung opacities
3) not explained by CHF or fluid overload
P/F ratios with PEEP of at least 5
P/F ratios: mild 200-300, moderate 100-200, severe <100
Causes: sepsis, pneumonia, trauma, aspiration, TRALI
Tx: lung protective ventilation (high PEEP,low tidal volumes), early steroids, probing, ?NO, ?surfactant

69
Q

Status epilepticus

A

acute symptomatic
prolonged febrile seizure
remote
idiopathic
management : ABCDs include BG
benzo q5 min x 2 )midaz and ativan best in CPS statement
fosphenytoin 20 mg/kg > 1 year old or phenobarb 20 mg/kg
then the other
if still seizing 10 minutes post then intubate with RSI and start midaz infusion

70
Q

chance of 1st benzo stopping seizure

A

80% for first

20% for second

71
Q

Differential for coma

A

vindicate

72
Q

Burns

A

remove clothes and other exposures
ABCDEs 100% FIO2 and rapid trauma assessment (10% have other injuries)
wash burns with tepid water, flush chemical burns, cool minor burns with cool saline)
estimate % BSA involvement with partial /full thickness (don’t include 1st degree)
if >10% then at risk for SIRS response and fluid resuscitate with Parkland

73
Q

What is Parkland

A

4cc/kg/percent BSA + maintenance crystalloid (1/2 in first 8 hour, 1/2 in 16 hours)
best indicator for volume resus is u/o

74
Q

what concerns you about airway involvement in a burn patient?

A 
soot in nares
stridor
carbonaceous sputum
singed hair
closed space, any resp distress
intubate sooner rather than later if any respiratory involvement
75
Q

Criter for refer to burn center

A
  1. partial or full thickness burns
    >10% in pt 20% in other age groups

***get the rest from rbi slides

76
Q

Trauma

A

C spine collar very important
exposure is a big one
log roll them and check their back

77
Q

if bleeding then need to look for source as part of primary survey

A 
long bone fractures
splint them
put them in a binder
anything in abdomen that is suspicious
tachycardia/hypotension ->look for sources of bleeding on primary survey
secondary survey - full head to toe
78
Q

chest tube

A

ant axillary 5th intercostal

79
Q

tamponade

A

distended neck veins
good air entry
don’t get distracted by significant injuries
follow ABCDEs

80
Q

best predictor of good survival after drowning

A 
cardiopulmonary arrest 
(time for return of spontaneous circulation is the most important) 
quality CPR is the most importent if they are arrested; CPR at the scene is very important 
bad GCS when in hospital is less important 
electromechanical dissociation - PEA (a old word)

PICU (2 decks)

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