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APLS > Seriously ill Child > Flashcards

Seriously ill Child Flashcards

1
Q

In the primary assessment of the sick child, what are the 3 aspects of breathing that should be assessed?

A
  1. EFFORT
    - RR, recessions, insp or exp noises, grunting, accessory muscle use, nasal flaring, gasping
  2. EFFICACY
    - degree of chest expansion, auscultation, sats measurement
  3. EFFECT (on other organs)
    - HR, skin colour, mental status
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2
Q

Name the 3 circumstances where an increased effort in breathing will not be present despite failure of the respiratory system?

A
  1. If severe respiratory problems have been present for a prolonged time, fatigue develops
  2. In presence of cerebral depression e.g. raised ICP, encephalopathy, poisoning. Depresses the respiratory drive
  3. Concurrent neuromuscular disease
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3
Q

T or F: central cyanosis is an early consequence of hypoxia

A

False.
Late sign, only occurs when SpO2 is < 70%
Note if child is anaemic may not be present at all

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4
Q

Aspects used to assess cardiovascular status in the primary assessment of the sick child?

A

Heart rate
Pulse volume
Cap refill

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5
Q

Pre-terminal cardiovascular signs?

A

Hypotension
Rapidly falling heart rate

Associated with poor systemic perfusion

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6
Q

Effect of cardiac inadequacy on the respiratory system?

A

increased respiratory rate, but wont have recessions

incr in RR is caused by the metabolic acidosis from circulatory failure

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7
Q

Systemic effects of cardiac inadequacy?

A
  • mottled pale skin
  • drop in urine output
  • drop in mental status (poor cerebral perfusion)
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8
Q

Decorticate posturing

A

flexed arms, extended legs

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9
Q

Decerebrate posturing

A

extended arms, extended legs

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10
Q

What is Cheyne-Stokes breathing pattern

A

an abnormal pattern of breathing characterized by progressively deeper, and sometimes faster, breathing followed by a gradual decrease that results in an apnoea. The pattern repeats, with each cycle usually taking 30 seconds to 2 minutes.

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11
Q

What is Cushing’s response and what does it mean

A

Systemic hypertension with sinus bradycardia

Indicates compression of the medulla oblongata caused by herniation of of the cerebellar tonsils through the foramen magnum

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12
Q

Fluid bolus in children if inadequate circulation

A

20mg/kg (crystalloid)

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13
Q

Signs of raised ICP

A

decreasing conscious level
asymmetrical pupils
abnormal posturing
abnormal ocular motor reflexes

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14
Q

Difference between acidaemia/alkalaemia and acidosis/alkalosis

A

acidaemia + alkalaemia represent the acidity of the blood outwith the normal range.
acidosis + alkalosis refer to the underlying processes that result in the acidaemia/alkalaemia

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15
Q

What is the carbonic acid reaction

A

CO2 + H2O – H2CO3 – H + HCO3

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16
Q

T or F: bicarbonate crosses the BBB.

What does this mean for CSF & serum levels of bicarbonate

A

False. Cannot cross. Secreted in the CSF as it is produced in the choroid plexus

CSF bicarbonate levels approximate serum levels some hours previously

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17
Q

T or F: CO2 crosses the BBB

What does this mean for CSF & serum levels of CO2

A

True.

CSF CO2 and serum CO2 are essentially equivalent concurrently

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18
Q

Rewrite the carbonic acid reaction, expressed as the concentration of hydrogen ions

A

[H+] = K x ( [CO2] / [HCO3] )

where K is the dissociation constant

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19
Q

Henderson-Hasselbach equation

A

pH = pK + log ( [HCO3] / PCO2 )

where pK is approx 6.1

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20
Q

How does the pH of CSF contribute to the respiratory drive

A

pH of CSF is a major contributor to the respiratory drive

If CSF becomes acidotic then there is increased respiratory drive to exhale CO2

Reverse also true

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21
Q

What is the role of bicarbonate

A

To act as an electrical buffer to accommodate other electrolyte changes

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22
Q

What cation has the greatest impact on the concentration of [HCO3] if it changes

A

Na

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23
Q

What anion has the greatest impact on the concentration of [HCO3] if it changes

A

Cl-

24
Q

What is the anion gap

A

Incorporates all the other anions/cations for which measurements aren’t usually available in order to provide wider context for acid-base balance

25
Q

Anion gap calculation

A

AG = (Na + K) - (HCO3 + Cl)

26
Q

What cations/anions are incorporated into the anion gap

A

Alb (- ve)
Phos (- ve)
Xa (unmeasured weak acids) (- ve)
Lactate (- ve)

Ca (+ ve)
Mg (+ ve)

27
Q

Why are Ca and Mg not routinely included in the anion gap calculation

A

The concentrations of these are small and vary minimally

28
Q

Which anion can be included into the anion gap to expand the calculation and why is this done

A

Albumin

Forms a large component of the normal anion gap & can vary dramatically in acute injury or illness, so if not included it could mask the severity of the acidotic process

29
Q

What is the anion gap calculation with albumin included and why is it like this

A

AG = (Na + K) - (HCO3 + Cl) + 0.25x(42-Alb)

0.25 because albumin is only slightly charged so add a quarter of the albumin deficit to remain realistic

30
Q

What is base excess and what does it tell us in practice

A

The amount of acid or base that needs to be added to a blood sample in order to return the pH to 7.40 at a temp of 37C at a PCO2 of 5.3kPa

It removes the respiratory component and allows us to quantify the metabolic components of. The acid-base abnormality

31
Q

Fluid requirement in a well, normal child

A

First 10kg - 100ml/kg (per day) or 4ml/kg (per hour)
Second 10kg - 50ml/kg (per day) or 2ml/kg (per hour)
Subsequent kg - 20ml/kg (per day) or 1ml/kg (per hour)

32
Q

Approximate urine & stool losses

A

Urine 30ml/kg/day or 1-2ml/kg/hr

Stool 0-10ml/kg/day

33
Q

Consequence of hypernatraemia

A

Brain damage - the brain shrinks as a result of intracellular dehydration and blood vessels can tear or clot up

34
Q

Consequence of hypernatraemia that is too rapidly corrected

A

Cerebral oedema

Convulsions

35
Q

Consequence of hyponatraemia that is too rapidly corrected

A

Demyelination

Permanent brain injury

36
Q

Principles of Rx of hypernatraemia

A
  1. Treat shock first
  2. Calculate maintenance fluid and estimate fluid deficit
  3. Lower serum Na at rate no higher than 0.5mmol/h
  4. Check other electrolytes
  5. Monitor electrolytes frequently
  6. Clinical assess hydration and weigh frequently

Use isotonic saline e.g. 0.9% NaCl or 0.9% NaCl with 5% glucose

37
Q

Causes of hypernatraemia

A

Excessive Na intake e.g. iatrogenic poisoning, NAI
Excessive water loss e.g. diabetes insipidus, diarrhoea

Or combo of both e.g. children with gastroenteritis given excessive sodium in rehydration fluid

38
Q

Causes of hyponatraemia

A

Excess water intake or retention
Excessive Na loss

Or combo of both

39
Q

Rx of hyponatraemia if child is fitting

A

Needs rapid partial correction of Na to stop the fitting

4ml/kg of 3% NaCl over 15 mins
- will raise serum Na by approx 3 mmol and usually stops the seizures

40
Q

Rx of hyponatraemia if child asymptomatic

A

If due to excessive water intake or retention - fluid restrict to 50% of intake requirements

41
Q

Principles of Rx of hyponatraemia

A
  1. If fitting use hypertonic (3%) NaCl at 4ml/kg
  2. Calculate maintenance fluid and estimate fluid deficit
  3. Raise serum Na at rate no higher than 0.5mmol/h
  4. Check other electrolytes
  5. Monitor electrolytes frequently
  6. Clinical assess hydration and weigh frequently
42
Q

Is Na mainly extracellular or intracelluar ion

A

Extracellular

43
Q

Is K mainly extracellular or intracellular ion

A

Intracellular

44
Q

Causes of hypokalaemia

A 
Diarrhoea 
Alkalosis 
Volume depletion 
Primary hyperaldosteronism 
Diuretic abuse
45
Q

Causes of hyperkalaemia

A 
Renal failure 
Acidosis
Adrenal insufficiency 
Cell lysis 
Excessive potassium intake
46
Q

What is the underlying mechanism of hypokalaemia in patients who are alkalotic or receiving insulin or salbutamol?

A

Total body potassium depletion hasn’t occurred, there has been redistribution of potassium into cells

Therefore management of underlying cause is indicated

47
Q

Drugs causing hyperkalaemia

A

ACEI
ARBS
B blockers

48
Q

Management of hyperkalaemia if > 6 or abnormal ECG

A
  1. Stabilise cardiac membrane
    - calcium gluconate or calcium chloride
  2. Shift K into cells
    - Glucose/insulin infusion AND neb salbutamol
    (Consider sodium bicarb if pH <7.2)
  3. Remove K from the body
    - Furosemide or Ca resonium

(Consider dialysis if appropriate)

49
Q

Before using sodium bicarb in a hyperkalaemic patient, what other electrolyte should be checked and why

A

Calcium

Hyperkalaemia can be accompanied my marked hypocalcaemia, esp in prfound sepsis or renal failure
Giving Na bicarb in hypocalcaemia can provoke hypocalcaemic crisis - tetany, convulsions, hypotension, arrhythmias

50
Q

Causes of hypocalcaemia

A

Can be part of any severe illness

Specific conditions:

  • severe rickets
  • hypoparathyroidism
  • pancreatitis
  • rhabdomyolysis
  • acute and chronic renal failure
51
Q

Causes of hypercalcaemia

A
  • hyperparathyroidism
  • hypervitaminosis A or D
  • idiopathic hypercalcaemia of infancy
  • malignancy
  • thiazide diuretic abuse
  • skeletal disorders
52
Q

Symptoms of hypercalcaemia

A 
long standing anorexia 
malaise 
weight loss 
failure to thrive
vomiting
53
Q

Pathophysiology of DKA

A

Relative or absolute lack of insulin
Therefore inability to metabolise glucose
Leads to hyperglycaemia and osmotic diuresis

No insulin, so fat is used as source of energy, leading to production of large quantities of ketones and metabolic acidosis

Initial compensation of the acidosis by hyperventilation & a respiratory alkalosis.
As it progresses, there is a combo of acidosis, hyperosmolality and dehydration, leading to coma

54
Q

Rx of DKA

A
  1. ABCDE

Principles of DKA Mx:

  1. Only give fluid bolus if signs of shock
  2. Rehydrate with 48 hours of replacement fluid - use ‘reduced volume’ calculations (large volumes of fluid replacement can precipitate cerebral oedema)
  3. Replace insulin - start IV insulin infusion 1-2 hours after beginning IV fluids
  4. PICU involvement if considering use of inotropes if signs of hypotensive shock
55
Q

Major complications of DKA

A

Cerebral oedema

  • avoid by slow normalisation of osmolality and hydration
  • monitor for headache, recurrence of vomiting, irritability, reduced GCS, inappropriate bradycardia, high BP

Cardiac dysrhythmias
- usually 2y to electrolyte disturbances

Pulm oedema
- careful fluid replacement required

Acute renal failure

APLS (4 decks)

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