Unit 11 - Pediatrics Flashcards
typical cause of epiglottitis
bacteria
typical cause of croup
virus
- H. parainfluenzae
- Respiratory syncytial virus
- Influenza viruses type A & B
typical age group affected by epiglottitis
2-6 yo
typical age group affected by croup
< 2 yrs
onset of epiglottitis
rapid ( < 24 H)
onset of croup
gradual (24-72 hours)
bacterial infection assoc with croup
Mycoplasma pneumonia
region of airway affected in epiglottitis
Supraglottic structures (supraglottis)
* Epiglottis
* Vallecula
* Arytenoids
* Aryepiglottic folds
region of airway affected by croup
Laryngeal structures below the vocal cords
neck xray findings in epiglottitis vs. croup
epiglottitis: thumb sign (swollen epiglottis)
croup: steeple sign (subglottic narrowing)
s/s epiglottitis
High-grade fever
The tripod position helps breathing
4 D’s:
* Drooling
* Dyspnea
* Dysphonia
* Dysphagia
s/s croup
- Low-grade fever
- Barking cough
- Vocal hoarseness
- Inspiratory stridor
- Retractions: suprasternal, substernal, or intercostal
treatment of epiglottitis
- Oxygen
- Urgent airway management
- Antibiotics if bacterial
- Induction with spontaneous RR
- CPAP 10 - 15 cm H2O prevents airway collapse
- ENT surgeon must be present
treatment of croup
- Oxygen
- Racemic epinephrine
- Corticosteroids
- Humidification
- Fluids
- Intubation rarely required
most common cause of postop laryngeal edema
ETT that is too large
tracheal mucosa perfusion pressure
25 cm H2O
s/s post-intubation laryngeal edema
hoarseness, a barky cough, and stridor
typical onset of post-intubation laryngeal edema
30 - 60 minutes following extubation
risks for Postintubation Laryngeal Edema
- Age < 4 years
- ETT is too large
- ETT cuff volume is too high
- traumatic or multiple intubation attempts (one reason not to use an uncuffed tube)
- prolonged intubation
- coughing (cuff rubs against the tracheal mucosa)
- head or neck surgery
- head repositioning during surgery
- history of infectious or post-intubation croup
- trisomy 21
- upper respiratory tract infection?
key to preventing Postintubation Laryngeal Edema
maintain an air leak < 25 cm H2O
preferred treatment for post-intubation laryngeal edema
Racemic epinephrine
dilution of racemic epi
2.25% racemic epi diluted in NS
0-25 kg = 0.25 mL epi, 2.5 mL NS
20-40 kg = 0.5 mL epi, 2.5 mL NS
>40 kg = 0.74 mL epi, 2.5 mL NS
treatments for croup
- racemic epi
- Cool and humidified oxygen
- Dexamethasone 0.25 - 0.5 mg/kg IV (maximum effect requires 4 - 6 hours)
- Heliox
how long should patients be observed post-racemic epi admin
4 hours minimum
how long should elective surgery be delayed in pts with URI
2-4 weeks after onset of symptoms
risk of pulmonary complications can persist 6- 8 weeks
good reasons to cancel elective surgery in pt with URI
- purulent nasal discharge
- fever > 100.4
- lethargic
- persistent cough
- poor appetite
- wheezing/rales that dont clear with cough
- child < 1 yr or previous preemie
considerations for ETT use in pt with URI
- increases risk of bronchospasm 10 fold
- use a smaller ETT (higher risk post-intubation croup)
- 0.25-0.5 mg/kg decadron dec risk post extubation croup
- Pretreatment with an inhaled bronchodilator (albuterol or ipratropium) or glycopyrrolate does not provide a clear benefit
classic triad of foreign body aspiration
- cough
- wheezing
- decreased breath sounds on affected side
s/s supraglottic vs subglottic obstriction
- supraglottic = stridor
- subglottic = wheezing
gold standard procedure to retrieve foreign body
Rigid bronchoscopy
complications of rigid bronch to retrieve foreign body
- laryngospasm
- bradycardia during scope insertion
- post-intubation croup
- pneumothorax
best method of induction for foreign body aspiration
spontaneous ventilation (use throughout procedure)
PPV can push FB deeper
compromising for leak when using rigid bronch
- increased FGF
- increased vaporizer output
TIVA with propofol prob best maintenance technique
airway concerns with Pierre Robin
- micrognathia or mandibular hypoplasia
- A tongue that falls back and downwards (glossoptosis)
- Cleft palate
airway concerns with treacher collins
- Small mouth
- Small/ underdeveloped mandible
- Nasal airway is blocked by tissue (choanal atresia - you won’t be able to pass a suction catheter past)
airway concerns with trisomy 21
risk difficult intubation and mask
* Small mouth, large tongue, palate high/narrow arch, midface hypoplasia
* Atlantoaxial instability (avoid neck flexion)
* Small subglottic diameter (subglottic stenosis) -use smaller ETT
airway concerns with Goldenhar
- Small/underdeveloped mandible
- Cervical spine abnormality
airway concerns with cri du chat
- Small/underdeveloped mandible
- Laryngomalacia, stridor
airway specific risks with cleft lip/palate
- Airway obstruction
- Difficult laryngoscopy
- Difficult mask ventilation if there are additional craniofacial abnormalities
- Aspiration
risks assoc with dingmann-dott mouth retractor for cleft lip/palate repair
can reduce venous drainage and cause tongue engorgement - increases the risk of post-extubation airway obstruction
when are cleft lip and palate surgeries typicallt performed
lip : ~ 1 mo
palate: ~ 12 mo
most common CHD in trisomy 21
AVSD
#2 = VSD
considerations for inhalation induction in trisomy 21 pts
bradycardia very common during induction with sevo
carefully increase sevo conc. during inhalation induction
VACTERL
Vertebral defects
Imperforated anus
Cardiac abnormalities
Tracheoesophageal fistula
Esophageal atresia
Renal dysplasia
Limb anomalies
CHARGE syndrome
Coloboma
Heart defects
choanal Atresia
Restriction of growth
Genitourinary problems
Ear anomalies
CATCH 22 syndrome (Aka digeorge)
Cardiac defects
Abnormal face
Thymic hypoplasia
Cleft palate
Hypocalcemia
22 – 22q11.2 gene deletion
why is hypocalcemia common with digeorge/catch 22
due to hypoparathyroidism
remember hyperventilation, albumin, and citrated blood products lower io
blood transfusion considerations in digeorge/catch 22
leukocyte-depleted irradiated blood is best
(high risk for infection if thymus is absent)
most common indication for peds T&A
nocturnal upper airway obstruction and sleep disordered breathing (with or without obstructive sleep apnea)
Also chronic and/or recurrent infections
considerations for kids with OSA undergoing T&A
- longer emergence
- should receive lower opioid dose intraop
- higher incidence of postop airway obstruction, prolonged O2 requirements
- admit to hospital for 23 hr obs
- no codeine postop
most common coagulation disorder in pts undergoing T&A
von willebrand disease
considerations for pts with von willebrand undergoing surgery
pts receiving DDAVP are at risk for hyponatermia
* Use isotonic crystalloids at 1/2 - 2/3 of the calculated maintenance values
* also monitor sodium postoperatively
when does primary post-tonsillectomy bleeding usually occur
within 24 hours
(surgical complication)
when do 75% of post-tonsillectomy bleeds occur
within first 6 hours of surgery
when does secondary post-tonsillectomy bleeding occur
5-10 days after surgery
scar covering tonsil bed contracts
suggested EBL when post-tonsillectomy bleed pt has dizziness and orthostatic hypotension
suggestive of a ≥ 20% loss of circulating volume
considerations for post-tonsillectomy bleed pts
- surgical emergency
- full stomach - RSI
- volume resuscitation before induction
- preoxygenate in left-lateral head down (helps blood drain)
- OGT after induction to decompress stomach
