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21 Cards in this Set
- Front
- Back
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Physiology of metabolism
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-pedi body surface area to volume ratio if four times that of an adult
-heat production is only one and a half times as high -greater risk for accidental hypothermia -pedi muscle tone and nervous system may yet be underdeveloped and immature and as a result cannot effectively induce muscular shivering as an effective mechanism for thermogenesis. -also have smaller amount of adipose and contributes to additional difficulty in maintaining core body temp -pedi 02 consumption occurs at almost twice the rate of an adult |
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Anatomical differences
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-Pedi lung tissue is more fragile than adult
-The mediastinum is more mobile in a pedi -The liver of a pedi is proportionally larger -The rib cage is more elastic and flexible -Skull bones are softer and separated by cartilage until 5 years of age -The anterior fontanelle will typically close between 12 and 18 months, and the posterior should close around 2 months of age |
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Anatomical differences cont
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-the bones are not yet completely calcified and tend to be flexible, causing a relative inability to support the lungs when intrathoracic pressure becomes more negative during heightened ventilation attempts
-Pedi’s have smaller Vt as their lungs are physically smaller than adults -Hepatic flow rates are the same or better than adults as they have not developed liver disease or CAD yet -the pedi myocardium can only increase the heart rate efficiently in an attempt to improve CO -HR should be viewed as a significant clinical marker when monitoring CO -A child who is not responding to therapy consider temperature -Obtunded, bradycardiac, hypotensive kids are commonly cold -Fussy, irritable, tachypnic, tachycardic kids are hot |
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General info
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-Reyes syndrome has been associated with fever in children and aspirin administration as not recommended
-Pedi’s with acute blood loss will not demonstrate hypotension until approximately 25% loss of circulating blood volume -Heart rate is the best indicator of compensation and adequate resuscitation of fluid losses -Pedi’s have relatively little ability to change their contractility and thus stroke volume -To improve CO pedi’s rely almost exclusively on increased heart rate -Infants will commonly present with a subtle seizure which presents with repetitive mouth or tongue movements, bicycling of the lower extremities, eye deviations and repetitive blinking -Scaphoid abdomen think of diaphragmatic hernia, most common form occurs at left posterolateral region -Choanal atresia is a birth defect in which the posterior nasal passage is obstructed by tissue. -Infants being nose breathers they will have difficulty with anything requiring them to breath via their nose -Tasks such as feeding/suckling and sleeping are problematic |
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Pedi airway
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-the pedi tongue is larger than an adults in relationship to the amount of free space in the oropharynx
-the larynx is higher than an adults, the higher the larynx is the more anterior the glottic opening, -The vocal cords have a lower point of attachment -The narrowest part of the airway is the cricoid cartilage vs the vocal cords in the adult -the pedi epiglottis is larger, not as well supported by its cartilaginous structure and more U shaped, making it difficult to manipulate during intubation -pedi intubation should be performed using a straight blade, because it directly lifts the epiglottis -Duchennes muscular dystrophy is a form of muscular disorder in which an increase in the production of immature acetylcholine (ACh) receptors occurs -Administration of Succs would promote a massive lethal release of K extracellularly -Suction the newborn with staining if they are brisk -Bulbe syringe suction the mouth first then nose |
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Fluids
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-Fluid resuscitation >1 yr give 20ml / kg; <1 yr give 10ml / kg
-Use NS for resuscitation -Neo maintenance D10 80ml/kg/24hr Pedi maintenance fluid rates: use D5 1/2 NS (D5/0.45% NS) -Use 4/2/1 formula -Calculate the pt’s weight in kilos -for the first 10kgs administer 4ml/kg/hr -for the second 10kgs administer and additional 2ml/kg/hr -and for every kg over 20 administer an additional 1ml/kg/hr -anything above 20kg will automatically receive 60ml, just add the rest ex -Pt weight is 25kg -4ml/kg/hr for first 10kg = 4ml X 10kg = 40ml/hr -2ml/kg/hr for second 10kg = 2ml X 10kg = 20ml/hr -1ml/kg/hr for every kg over 20 = 1ml X 05kg = 5ml/hr -Total maintenance-25kg = 65ml/hr |
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ECG
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Cardioversion is 0.5 – 1.0 j/kg and repeat at 2 j/kg
Defibrillate at 2 j/kg and repeat at 4 j/kg |
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Trauma
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-Common injury patterns seen in children struck by vehicle is called Wadell triad
-Injuries to the lower extremities as the child turns to face the vehicle in fear with the bumper striking the legs, the child then folds over the hood causing chest and abd injuries. Finally the child is then knocked away from the vehicle striking the head upon landing. -Largest cause of pediatric traumatic deaths are motor vehicle crashes -Of all the child abuse cases the most commonly injured system is the skin and the most common system injured causing death is head injuries -Spiral fractures in the arms are typical of twisting type forces and most common with child abuse related extremity fractures |
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Vent management
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-Infants are typically pressure ventilated for safety purposes
-Older than 1yr of age volume ventilation is common -The safest mode is SIMV as varying levels of sedation or paralysis occurs -With pressure a peak pressure and a PEEP must be set -Common setting are 20/5, where 20 is peak pressure the vent will deliver before terminating the breath and 5 is PEEP -Frequency (F) or rate should be set at normal or manipulated based on disease -Inspiratory time (IT) typically set at 0.5sec or greater to allow for adequate time to provide sufficient Vt before the PIP reaches the pressure limit -Fi02 typically set at 100% -When pressure ventilating Vt must be monitored closely to assure adequate Ve |
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Congenital disease
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-Trisomy – 21 (downs syndrome) is associated with ventriculoseptal defect (VSD) accompanied by aortic stenosis and PDA’s
-VSD is the most common form of congenital heart defect -Auscultation of the heart will reveal and audible systolic murmur -The louder the murmur the smaller the VSD -The small size of the VSD that increased turbulence is created as blood moves through it -Congenital heart lesions are categorized into cyanotic lesions and acyanotic lesions -Cyanotic lesions are those in which blood being sent down the aorta has somehow bypassed the lungs and been adequately oxygenated -Acyanotic lesions have abnormal blood flow but there is adequate mixing of oxygenated and unoxygenated blood prior to entering the systemic circulation |
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Ventriculo septal defect (VSD) an Acyanotic Lesion
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-Is a defect in the ventricular septum, the wall dividing the left and right ventricles of the heart.
-Causes a pathognomonic holo- or pansystolic murmur -The size of the VSD will determine much of the symptomology -Left to right shunt -Blood moves from higher pressure left ventricle to lower pressure right ventricle -Heart becomes overloaded leading to pulmonary congestion and CHF symptoms and right ventricular hypertrophy |
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Cyanotic lesions (baby blue syndrome)
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-Are PDA dependant, it allows blood to enter the pulmonary circuit from the aorta
-Tetrology of Fallot (TOF) -Four defects; a VSD, pulmonary stenosis, an overriding or right shifted aorta and right ventricular hypertrophy -An overriding aorta receives blood from the rt ventricle and lt ventricle and reduces the amount of oxygen in the blood -Eventually a predominantly right to left shunt occurs -The primary goal when transporting a pt with a cyanotic lesion is to avoid any therapy that might promote pulmonary hypertension be it via coughing, straining, pain, acidosis -A blalock-taussing shunt (BT shunt) involve placing a shunt between the subclavian artery and the pulmonary artery -The shunt will rob some of the affected limb of blood flow, avoid procedures such as IV access and BP cuffs |
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Acyanotic lesions
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-Patent ductus arteriosus (PDA) is failure of the PDA to close up upon birth
-PDA, the aorta and pulmonary artery are connected via the ductus arteriosus -Typically develop symptoms around day 3 post delivery -Can result in CHF form blood entering the pulmonary circuit from the aorta -Can be essential to survival in some defects like TOF HLHS -Indomethacin is used when attempting to close a persistent PDA -0.2 mg/kg followe by 0.1 mg/kg 12 hrs after first dose and repeated 24 hrs after second dose -0.2 mg/kg q 12 hrs for three doses -Indomethacin is a prostaglandin synthesis inhibitor -Prostaglandin (PGE1) is used to maintain a PDA -Side effects include apnea, bradycardia, hypotension -Oxygen is the best stimulus to prompt closure of the ductus arteriosus, if the pt is PDA dependent because of other disorders, you may receive direction not to administer oxygen. -Order might be given not to let Sp02 exceed 90% |
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Coarctation of the aorta (COA)
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-results in blood flow to the left subclavian that may be significantly less than the right.
-the aorta narrows in the area where the ductus arteriosus inserts. -Sp02 readings may be off on the left hand -Sp02 readings should come from the right side |
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Epiglottitis
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-Sudden onset of resp distress, fever, difficulty swallowing and drooling
-Occurs in children 3-7 yrs -Also will have a hoarse or muffled voice -Lateral neck x-ray will show a thumb print sign -Occurs because the usual slit like epiglottis has enlarged to resemble a thumb encroaching on the airway -if stridor becomes quieter, obstruction is likely to follow, and thus intubation should be expedited even further. |
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Croup-laryngotracheobronchitis
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-is a respiratory condition that is usually triggered by an acute viral infection of the upper airway.
-The infection leads to swelling inside the throat, which interferes with normal breathing and produces the classical symptoms of a "barking" cough, stridor, and hoarseness, difficult breathing which worsens at night, and a low grade fever -patient will be sick for 1-5 days before the onset of croup -rapid onset of a fever, sore throat, and unwillingness to eat or drink -the child with croup will have no difficulty in eating or drinking because the point of irritation is below the level of the glottis, and neither food nor fluid will cause direct irritation of the subglottic tissues -worsened by agitation of crying -Will show a steeple sign on a AP neck film -Refers to the steep like appearance of the airway as it narrows into the subglottic inflamed soft tissue -most common between 6 months and 5–6 years of age. It is almost never seen in teenagers or adults. -treat with humidified oxygen, have child remain calm, and not recommended to intubate -racemic epi stimulated vascular constriction, reduces swelling of airway tissues by vessel constriction in the edematous tissues -greatest complication associated with racemic epi is rebound swelling of the airways once epi has worn off |
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Glucose requirement
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-Neo: <50mg/dl D10 2ml/kg/5min
-Child:<60mg/dl D25 0.5g/kg -Adult:<70mg/dl D50 25g -at a greater risk for the development of acute hypoglycemia due to: -dec glycogen stores -inability to stimulate the release of stored glycogen from an immature liver -an increased metabolic rate -or a known hx of DM |
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COMMON RESUSCITATION MEDS:
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-Epinephrine 0.1 ml/kg 1:10,000 (1:1000ET) for cardiac arrest & bradycardia
-Adenosine 0.1 mg/kg for SVT 1st dose - .2 mg/kg 2nd dose -Naloxone 0.1 mg/kg for narcotic OD -Versed 0.1 mg/kg for seizure and sedation -Morphine Sulfate 0.1 – 0.2 mg/kg -Phenergan 0.25 mg/kg -Atropine 0.02 mg/kg as a second medication for bradycardia -D25 0.5 gm/kg for diabetic emergency -Lidocaine 1 mg/kg for VF arrest and VT -Benadryl 1mg/kg -Sodium Bicarbonate 1 mEq/kg for TCA OD -Fentanyl 0.5-1 mcg/kg -Amiodarone 5 mg/kg for tachycardia -Tylenol 10-15 mg/kg PO -Insulin 0.1u/kg/hr |
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General info cont
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-Birth to 1 month = 60 systolic
-1 month to 1 year = 70 systolic -1 year to 10 years = (age in yrs X 2) + 70 weight: -(age in years X 2) + 8 = wt in kg ET tube size are; -(age + 16)/4 -Premature neonates: 2.5 – 3.0 -Term neonates: 3.0 – 3.5 -3mos – 1yr: 3.5 – 4.0 -Older than 1yr: use (age + 16)/4 ETT depth is: -(age/2) + 12, tube size X 3 |
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STABLE-neonate
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Sugar:
-Neo: <50mg/dl D10 2ml/kg/5min -Child:<60mg/dl D25 0.5g/kg -Adult:<70mg/dl D50 25g Temp Airway BP: -Birth to 1 month = 60 systolic -1 month to 1 year = 70 systolic -1 year to 10 years = (age in yrs X 2) + 70 -Labs Emotional |
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DKA
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-BG >250mg/dl, pH <7.3, HC03 <15 mEql/L
IV fluids: 20ml/kg for shock when glucose reaches 250mg/dl change fluids to D5% / 0.45%NS and maintain BG between 150-250 Insulin: -IV regular insulin 0.1u/kg/hr -continue until acidosis clears, pH>7.3 and HC03>15 Potassium: -administer 1mEq/kg of KCL IV over 1 hour HC03: -<pH 7.0 after fluid bolus administer 2mEq/kg in NS over 1 hour |
