Structured Approach To The Sick Child Flashcards
T or F: the most common cause of cardiac arrest in children is secondary to cardiac arrhythmia
F. Rarely due to cardiac arrhythmia. Most commonly sequelae of hypoxaemia and/or shock with associated organ damage & dysfunction
Average weights for M or F children at:
1) Birth
2) 1 year
3) 2 years
4) 5 years
5) 10 years
6) 14 years
1) Birth 3.5kg
2) 1 year 9-10kg
3) 2 years 12kg
4) 5 years 18kg
5) 10 years 31kg
6) 14 years 50kg
Normal resp rate range at:
1) Birth - 3 months
2) 3 months
3) 6-12 months
4) 18 months
5) 2-7 years
6) 8-11 years
7) 12 years - adult
1) 25-50
2) 25-45
3) 20-40
4) 20-35
5) 20-30
6) 15-25
7) 12-24
Normal HR range for:
1) Birth - 1 month
2) 3 months
3) 6 -12 months
4) 18 months
5) 2 years
6) 3 years
7) 4 - 5 years
8) 6-7 years
9) 8 - 11 years
10) 14 years
1) 120 - 170
2) 115 - 160
3) 110 - 160
4) 100 - 155
5) 100 - 150
6) 90 - 140
7) 80 - 135
8) 80 - 130
9) 70 - 120
10) 60 - 110
Normal systolic BP range for:
1) Birth - 6 months
2) 12 - 18 months
3) 2 - 4 years
4) 5 - 11 years
5) 12 years - adult
1) 80-90
2) 85-95
3) 85-100
4) 90-110
5) 100-120
Name - anatomical features that need to be taken into account when managing a child’s airway?
- Large occiput + short neck (in young child)
- can result in neck flex ion and airway narrowing when laid supine - Small face + mandible
- Teeth or orthodontic appliances can be loose
- Large tongue
- tends to obstruct airway in unconscious child
- can impede laryngoscope view - Floor of mouth easily compressible
- need to pay attention when positioning fingers on jaw
Why is an infant < 6 months old at greater risk of airway compromise when they have an URTI compared to older children?
Infants < 6 months are primarily nasal breathers, so narrow nasal passages are easily obstructed by mucus secretions in URTI
How does the shape of the epiglottis in children differ from adults?
Horseshoe shaped and projects posteriorly at 45 degrees (can make intubation more difficult)
How does the position of the larynx in children differ from adults and how does this affect intubation?
Larynx is high & anterior
- sits at level of 2nd + 3rd cervical vertebrae in children, but 5th + 6th cervical vertebrae in adults
Can often be easier to intubate children with straight blade laryngoscope
Name 3 differences affecting a child’s breathing compared to adults?
- Small upper and lower airways
- greater resistance to airflow due to smaller radius of airways
- therefore more easily obstructed - Horizontal ribs
- ribs are more horizontal compared to adults so contribute less to chest expansion - Diaphragmatic breathing
- infants mainly rely on diaphragmatic breathing
- therefore tire more easily as they have fewer Type 1 muscle fibres (highly oxidative, fatigue resistant fibres)
What is a child’s circulating blood volume?
70-80 ml / kg
How does the body surface area to weight ratio differ with increasing age?
BSA to weight ratio decreases with increasing age.
- Means that smaller children with a higher ratio lose heat more rapidly and are relatively more prone to developing hypothermia
Why do infants desaturate more rapidly than adults?
Combination of:
- high metabolic rate and oxygen consumption
- low lung volumes
- limited respiratory reserve
How does the oxygen dissociation curve appear at birth?
Shifted to the left with reduced P50.
- Because 70% of baby’s Hb is HbF
What is cardiac output principally related to in infants: HR or SV?
HR - stroke volume in infants is relatively fixed
Explain the standardised triage scale
1 - RED - immediate care - max time to clinician 0 min
2 - ORANGE - very urgent care - max time to clinician 10 min
3 - YELLOW - urgent care - max time to clinician 60 min
4 - GREEN - standard care - max time to clinician 240 min
5 - BLUE - non-urgent care - max time to clinician N/A
What are the 5 steps in the triage system?
- Identify the problem
- Gather and analyse information related to the solution
- seek discriminators to allow differentiation between patients
- life threat, pain, haemorrhage, conscious level, temperature - Evaluate all alternatives and select one for implementation
- Implement the selected alternative
- Monitor the implementation and evaluate outcomes
In which situation is the Alder Hey Triage Pain Score a useful tool?
When the child is experiencing anxiety associated with a sudden and unexpected presentation in pain that impedes self-assessment of pain
Elements of the Alder Hey Triage Pain Score
- Cry/voice
- Facial expression
- Posture
- Movement
- Colour
Scoring of Cry/Voice in the Alder Hey Triage Pain Score
0 - no crying, able to have normal conversation
1 - crying but is distractible, on direct questioning says it is painful
2 - inconsolable, crying persistently and complaining of pain
Scoring of Facial Expression in the Alder Hey Pain Triage Score
0 - normal
1 - short grimace < 50% of time
2 - long grimace > 50% of time
N.b. Grimace = open mouth,lips pulled back at corners, furrowed forehead
Scoring of Posture in the Alder Hey Pain Triage Score
0 - normal
1 - increased awareness of affected area, touching, rubbing, limping
2 - affected area held tense and defended e.g. non weight bearing
Scoring of Movement in the Alder Hey Pain Triage Score
0 - normal
1 - reduced or restless
2 - immobile or thrashing
Scoring of Colour in the Alder Hey Triage Pain Score
0 - normal
1 - pale
2- extreme pallor ‘green’
3 topical local anaesthetics used in paediatrics
- Ametop gel (tetracaine 4%)
- EMLA (lidocaine 2.5% and prilocaine 2.5%)
- Ethyl chloride spray
Ametop gel - how long does analgesic effect take + last
Analgesia achieved after 30-45 mins
Effect lasts for 4-6 hours after removal of gel
What age group should Ametop gel not be used
Where should Ametop gel not be used
< 1month old
Broken skin, mucus membranes, eyes or ears
2 infiltrative local anaesthetics used in paediatrics
Lidocaine 1% + Bupivacaine 0.25% or 0.5%
How long does lidocaine take to work and how long does it last
Onset within 2 mins
Effective for up to 2 hours
What is lidocaine often used with and why
Adrenaline - to prolong the duration of sensory blockade and limit toxicity by reducing absorption
When is Bupivacaine used for a local anaesthetic instead of lidocaine
When a longer sensory blockade is required e.g. femoral nerve block
How long does Bupivacaine take to have an effect and how long does it last
Onset within 15 mins
Lasts for up to 8 hours
How does paracetamol work
Inhibits cyclo-oxygenate in the CNS but not in other tissues, so producing analgesia without any anti-inflammatory effect
In which groups of children should NSAIDS be avoided
History of gastric ulceration, platelet abnormalities, dehydration or renal problems
CVS effects of IV morphine
Peripheral vasodilatation
Venous pooling
How do opiates cause respiratory depression
Reduce the sensitivity of brain-stem respiratory centres to hyperecarbia and hypoxia
Consequence of using oropharnygeal airway that is too large
Laryngospasm
When is a nasopharyngeal airway contraindicated
BOS #
What is the ideal duration for an intubation to take
< 30 secs
What is a possible advantage of using a straight blade laryngoscope rather than curved
Straight blade directly lifts the epiglottis so that it does not does not obscure the view of the vocal cords
T or F: uncuffed tubes are recommended rather than cuffed tubes in paediatrics
F. Previously thought this, however improvements in materials now means that it comes down to availability & preference
T or F. You shouldn’t hear any air leak when using an uncuffed ET tube.
F. You should hear an audible small leak when inflation is continued to pressures slightly over the max normal inflation pressure
What are the consequences of an uncuffed ET tube that is too large?
Damage to the mucousa at the level of the cricoid ring and subsequent oedema following extubation
T or F: You shouldn’t hear any air leak when using a cuffed ET tube
T
Name a situation where a cuffed tube may be preferred to an uncuffed tube
IF the child has stiff lungs e.g. bronchiolitis
Formula to estimate ET tube size in an emergency
Internal diameter (mm) = (age/4) + 4
If tracheal suction is required, what rule should be used for deciding size of suction catheter to use
Generally a suction catheter that’s French gauge is 2x the the internal diameter of the ET tube in my e.g. 3mm ET tube, 6 gauge suction catheter
Gold standard for monitoring during intubation
Capnometry
3 limits of cpanometry
- May be little or no Co2 in low or zero cardiac output states
- May not detect endobronchail intubation - suspect if asymmetrical chest movements following intubation, should be confirmed by auscultation
- If unfree ET tube is too small then lots of air will leak out from sides rather than go through tube, which generates falsely low readings
Mnemonic used for assessment of potential causes of airway,ventilator problems in intubated patients
D - displaced tube
O - obstructed tube ( blocked or kinked)
P - pneumothorax
E - equipment problems
Signs in displaced ET tube and management
Endobronchial - asymmetrical chest wall movements, unilateral breath sounds, falling sats. slightly withdraw ETT and re-auscultation
Oesophageal - no end tidal CO2. Remove ETT tube and prepare for re-intubation
Signs of obstructed ETT and management
Straighten tube, fix securely, suction full length of tube.
If not resolved remove ETT and mask ventilate whilst preparing for re-intubation
Signs of pneumothorax in ventilated patient and management
High peak ventilator pressures, rapid decline in sats and cardiac outpout. Needle decompression
In mouth to mask ventilation, what is the correct position for a shaped mask in 1. A child and 2. An infant
What head position should each be in
- Child - use the right way up
- Infant - use upside down
Neutral head position in infants
More extended in older children
In single person bag-mask ventilation technique, what is the correct positioning of the fingers to ensure adequate seal on mask & also effective airway manoeuvres
Thumb and 1st finger over the mask
3rd and 4th fingers doing chin lift
5th finger doing jaw thrust
Drugs used in intubation of child
Ketamine 1-2mg/kg Rocuronium 1mg/kg Adrenaline 0.1ml/kg of 1:10,000 Dilute adrenaline 1 microgram/kg/ml Sedation e.g. morphine and midazolam infusions
Formulas to calculate ETT size
Uncuffed (over 1 year): age/4 + 4
Cuffed (>3kg): age/4 + 3.5
Neonates under 3kg: 2.5, 3.0 or 3.5mm uncuffed tube
CXR position of a correctly placed ET tube
Mid-trachea at T1 level, or the midpoint between the tip of the clavicles and the carina
What is Rapid Sequence Induction (RSI)
A form of delivering emergency anaesthesia
- Pre-oxygenation with 100% o2 for at least 3min
- Induction of anaesthesia
- Cricoid pressure application. Aim to compress oesophagus against vertebral body behind, so preventing gastric content aspiration
- Administration of rapid acting muscle relaxant e.g. suxamethonium or rocuronium
- Intubation of trachea and release of cricoid pressure when successful intubation confirmed
Why is RSI best avoided in children
Little evidence that RSI reduces the risk of gastric aspiration, and RSI is associated with high incidence of hypoxia as it somewhat distorts the airway
Usual cuff pressure of an ET tube
20cm H20
Agent of choice for induction of anaesthesia in paeds crit care and why
Ketamine
Causes the least cardiovascular instability of all induction agents, because it stimulates endogenous catecholamine release
Dose of ketamine in anaesthesia induction
1 -2 mg /kg
Lower dose to be used in established circulatory shock
When is thiopentone used as the anaesthesia induction agent of choice?
To terminate a prolonged seizure
N.B. ketamine still a better choice if the seizure is associated with cardiovascular compromise
When is gas induction preferred as the anaesthesia induction agent of choice?
If there is an upper airway obstruction
T or F. Needle cricothyroidotomy should be used as 1st line surgical airway in all children
F.
Should NOT be used as 1st line in children under 5.
The cricothyroid membrane is difficult to palpate in children < 5 years, and almost impossible to feel in infants
1st line surgical airway in children < 5 years
< 1 year of age - emergency tracheostomy
Between 1 and 5 years - either emergency tracheostomy or surgical cricothryoidotomy, but online is the cricothyroid membrane can be correctly identified
Where is the cricothyroid membrane
Below the thyroid cartilage and above the cricoid cartilage
Monitoring a ventilated patient: which cause a sudden drop in expired CO2 and which cause gradual drop:
- Disconnection in breathing system
- Extubation
- Ventilator failure
- Cardiac arrest
- Inadequate external chest compressions
- Pulmonary embolism
- Sudden
- Sudden
- Sudden
- Gradual
- Gradual
- Gradual
