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39 Cards in this Set

  • Front
  • Back
1) What is the #1 cause of airway obstruction?
2) Other causes?
3) Why does a muscle relaxant block an airway?
4) What is the proper position for a kid's head to decrease airway resistance?
5) What naturally causes the kid's head to roll forward?
1) Patient soft tissues (tongue, tonsils and adenoids)
2) Foreign object, operator pressure on submental, patient chin on chest, fluids like water and blood
3) Relaxes the submental muscle, the tongue naturally falls back
4) Head extension "sniffing position"
5) Occiput
1) According to Litman et al, children who receive sedation with oral midazolam and 50% N2O inhalation may exhibit clinically significant airway obstruction, especially in the presence of enlarged ___
2) Presedation evaluations should routinely include questions concerning the presence of ___ and ____ should be assessed during exam of mouth and airways
3) Why should you re-think suing passive restraints in patients receiving tranquilizing agents?
4) What is the proper term for papoose nowadays?
5) What are the sizes?
6) What does the AAPD say about the papoose board?
1) Tonsils
2) Nighttime snoring, tonsil size
3) Can't monitor respirations, blocks coughing to clear airway
4) "Protective stabilization"
5) Regular, large, extra large (>12)
6) Can cause physical/psychological harm, loss of dignity, patient rights. We don't know if this child will be psychologically damaged
1) What did Vargas find about dentists' views of papoose and success of sedation?
2) Should you cut with or without water in sedation? Why?
3) Sequence of water aspiration in a sedated, supine child?
4) How do you protect the airway from fluids?
5) 2 useful purposes of the Yankauer suction tip? Why is it nice to use?
6) **What bad thing can posterior pharyngeal irritation cause?
1) Restraint w/ sedation doesn't necessarily imply that it's adequate or unacceptable, management style has a role in how one makes use of sedation and defines success
2) Without - fluid accumulation in the posterior pharynx = common cause of HbO2 desaturation episodes
3) Water accumulates in posterior pharynx, breath holding as a protective reflex, kid attempts to swallow (ineffective - supine position, rubber dam), takes deep breath + aspirates => laryngospams => coughing inhibited by papoose board
4) Minimize water use during tooth prep, suction diligently, palatal pack/change when saturated, LIGATED rubber dams (no slit dam)
5) Can use when you hear gurgling breath sounds, physical stimulation tests depth of sedation (protective reflexes). Wraps around posterior pharynx nicely
6) Vagal stimulation with resultant bradycardia!!
1) Best things to use for observation? What do you look for?
2) What's better, manual or electronic monitoring?
3) What is the false positive rate of traditional monitoring? Electronic?
4) In Croswell's study, what was better at picking up respiratory compromise - capnography or pulse ox?
5) What is the hierarchy of monitors for different levels of sedation?
1) Eyes and ears - look for breathing effort (depth, rate, chest rocking), noises, cyanosis and responsiveness
2) Manual - electronic has too many false positives
3) 73%, 88% - however, the more sensitive method of detecting potentially harmful episode of respiratory compromise far outweighs any relative inconvenience caused by false positives
4) Capnography
5) PPCBET - pre-trach steth, pulse ox, capnograph, blood pressure, ECG, temperature
Personnel needed, monitoring equipment, monitoring/info, frequency recorded for:

1) Minimal sedation?
2) Moderate sedation?
3) Deep sedation?
4) GA?
1) 2, only clinical observation, unless moderately sedated, skin color, resp. effort, continual observation
2) 2, BPC, PO, Capno or PC, HR, RR, BP, SaO2, q15 minutes
3) 3, BPC, PO, Capno/PC, ECG. HR, RR, BP, SaO2, ETCO2, ECG. q5 minutes
4) 3, BPC, PO, Capno/PC, ECG, Temp. HR, RR, BP, SaO2, ETCO2, Temp. q5 minutes
1) "Ventilatory function must be continuously monitored by ____ and ___, and perhaps ___, because _____ and _______ are the msot common causes of serious sedation-related problems in children"
2) Survival rate following respiratory arrest? Survival rate following cardiopulmonary arrest? Will an AED work well on a child?
3) What is the most important system to closely monitor? Monitoring must include what 2 things, and how are they different, and how do you monitor them?)
1) Observation, auscultation, capnography. Respiratory depression, airway obstruction
2) ~75%, ~5%. AED will NOT work well on a child because children don't have recognizable shockable rhythms
3) Respiratory system. Ventilation (movement of air into and out of the lungs - monitor patency of airway, depth, and frequency of respiration). Oxygenation - circulation of O2 to metabolically active tissues (brain, heart - monitor HR, hemoglobin oxygen saturation, BP)
1) How do children's respiration rates and functional reserves compare to adults?
2) 6 ways in which airway anatomy is different in children than adults?
3) How does the pediatric airway look?
1) Breath faster, smaller FRC.
2) My Little Toddler's Head Looks Undersized - Mandible less developed, Larynx (vocal cords) more superior and anterior, Tongue and epiglottis larger, Head to body size ratio is larger, prominent occiput, Lymphoid tissue (tonsils and adenoids) enlarged, Upper airway's smallest portion is at level of cricoid cartilage (below the vocal cords)
3) Narrow, with increased airway resistance and susceptibility to obstruction
1) What do you look for for signs of ventilation? Oxygenation?
2) Between what 3 initial things do you have ventilation and oxygenation covered?
3) What are the remaining items for monitoring and what do they observe?
4) Besides O2, CO2, BP, EKG, Temp, and airway patency, what is the last thing you monitor?
5) What sound dominates on a pre-cordial steth? Pre-tracheal?
6) What is the correct location for a pre-tracheal steth? Why do we place it here? What is the stethoscope we use? What are the comfortable and cheap earpieces we can use?
7) Tether free stethoscopes?
1) Chest rise. Cyanosis
2) Eyes, Pretracheal steth (airway patency/sounds, indicates ventilation), Pulse ox (O2 Sat, HR - indicates oxygenation)
3) Capnograph (end tidal CO2, indicates ventilation), BP/ECG/Temp (oxygenation)
4) Consciousness/responsiveness (behaior rating scale, BIS monitor)
5) Heart sound. Airway sound.
6) Suprasternal notch - no interference from bone. Wenger type chest piece (child size, heavy weight - attached by 3M double-stick discs). Soft ear monoaural
7) Radiotelemetry, blue tooth, piezo chest piece w/ built-in mic that amplifies breath sounds and suppresses room noise, or speaker
What is blocked and what is the cause if you hear:

1) Snoring
2) Gurgling
3) "Seal barking"
4) Stridor
5) Crowing
6) Wheezing
7) What are the only two expiratory sounds?
1) Partial pharyngeal blockage by tongue, tonsils, foreign body
2) Partial pharyngeal blockage by fluids (water, blood, saliva)
3) Partial pharyngeal blockage by laryngeal edema (croup) - EXPIRATORY
4) Partial tracheal blockage by foreign body, scarring, stenosis, malacia
5) Partial laryngospasm (aspiration)
6) Parital bronchospasm (asthma) - EXPIRATORY
7) Seal barking, wheezing
1) What are the 9 signs of respiratory distress?
2) Is respiratory obstruction the same as respiratory depression?
3) What is the definition of respiratory obstruction?
4) Definition of respiratory depression?
5) Inspiratory obstructed airway means the (upper/lower) airway is obstructed
6) Expiratory airway means (upper/lower) airway is obstructed
7) What is easier to manage, upper or lower obstruction?
1) FAST 'TACCS - Flaring nostrils, Agitation, Sweating, Tachycardia, Tachpnea, Abnormal breath sounds, Cyanosis, Coughing, Sit-Up
2) No, but can exist simultaneously
3) Physical obstruction with known cause
4) Drug induced state that affects medulla oblongota, allows increased CO2, decreased respiration
5) Upper
6) Lower
7) Upper (most often just repositioning)
1) What are 3 main signs of upper airway obstruction?
1) Prolonged inspiration
2) Chest retractions/spasms ("rocking horse" motion between chest and diaphragm, sternal retraction)
3) Abnormal breath sounds (snoring, stridor, crowing, coughing)
7 causes of upper respiratory obstructions?
Allergies To Little CATS

1) Allergic reactions (angioedema/croup)
2) Tongue
3) Laryngospasm
4) Chin on chest
5) Aspiration (foreign body, oral/gastric fluids)
6) Tonsils/adenoids
7) Submental finger pressure
1) What kind of sounds do you get with upper airway obstruction?
2) What kind of sounds do you get with lower airway obstructions?
1) Turbulence
2) Turbulence + wheezing
1) 4 signs of lower respiratory obstruction?
2) 4 causes of lower respiratory obstruction?
1) GAWP - Grunting, Accessory chest muscle retraction, Wheezing, Prolonged expiration
2) BACS - Bronchospasm, Asthma/bronchitis, Chest constriction from tight passive restraint, Severe allergic reactions
1) T or F: children should receive supplemental oxygen for all levels of sedation?
2) What is a pulse-ox and how does it work? Where do you place it? Two types? What is more common with clipon device?
3) Adult hard shell clip-on pulse oximetry sensors can be adapted to what on a child?
4) Why shouldn't you put a BP cuff on the kid's arm during sedation?
1) T
2) Non-invasive photosensor (light emitting diode, measures wavelength absorption of red and infrared light by oxygenated Hb and deoxygenated Hb). Pulsating capillary bed (finger, toe, ear lobe). Re-usable clip-on, disposable tape-on. Motion artifacts.
3) Great toe
4) Can't see it with the papoose!
1) What is the definition of hypoxia?
2) Definition of hypoxemia?
3) What is the most likely cuase of hypoxemia during sedation?
1) Diminished oxygen in the tissue
2) Diminished oxygen in the blood
3) Respiratory obstruction or respiratory depression leading to hypoventilation leading to hypoxia
4 advantages of pulse ox:

1) What is the "gold standard" for detection of hypoxemia?
2) Does it provide continual or continuous monitoring?
3) How does it alert you of a desaturation event?
4) Perks?
5) Limitations - it evaluates ____, not ____. What's common? What can't it detect? What about real-time?
6) 7 things that can cause false alarms?
1) Pulse ox, a non-invasive photosensor
2) Continuous
3) Audible alarm, default setting at 90%, 5% decrease from baseline
4) Affordable
5) Oxygenation, not effectiveness of ventilation (CO2 elimination). False readings common. Can't detect methemoglobinemia. Not real-time! Delayed response of 20-30 seconds in response to hypoventilation, because of the peripheral location of sensor site
6) People Can't Ever Detect My Poor Pulse - Poor perfusion to peripheral capillary bed, Cold limbs, Excessive ambient light, Dark finger nail polish, Movement, Poor adaptation of oxisensor to site location, Placement of oxisensor on same limb as BP cuff, Cold limbs
Oxyhemoglobin Dissociation Curve:

1) At what oxyhemoglobin saturation % does hypoxemia occur? Cyanosis?
2) Is the oxyhemoglobin dissociation curve linear? Where is "the cliff"?
3) What does a shift to the right mean? (Affinity, CO2, temp, pH?)
4) What does a shift to the left mean?
5) What is SpO2 and PaO2? Do they directly correlate?
6) If kid becomes apneic, how much time do you have before the fall off the cliff?
7) Main cardiac warning sign of apnea?
1) 90%, 75%
2) No - it's curved. Cliff between 90% (hypoxemia) and 75% (cyanosis) - drops off quickly!
3) Decreased affinity - negative effect (increased PCo2, increased temperature, decrease pH)
4) Increased affinity - positive effect (decrease PCo2, decrease temperature, increased pH)
5) SpO2 = saturation (peripheral) of hemoglobin with oxygen. PaO2 = plasma saturation of oxygen. Don't correlate directly, but close enough to be a useful tool
6) 2 minutes
7) Tachycardia
1) Time interval for desturation (decrease from 99% to 90% SpO2) as measured by pulse ox to an apneic event is age related in children. What is the time for <2? 2-5 year olds? 6-10 year old?
2) What two things can cause more rapid desat in kids despite preoxygenation?
3) 6 steps of a desaturation event?
4) When heart rate is <___ BPM, you are in critical trouble
5) What is the most important factor in a desaturation event? What are the three categories of %s and what should you be thinking during each?
1) 1.5 minutes. 2 minutes. 3 minutes.
2) Reduced FRC, obesity
3) Hypoxia => hypercarbia => vagal response => bradycardia => decreased CO => hypotension
4) 60
5) Trending. 100-97% - not a big deal if sporadic or stable, adjust airway, crying, poor ox adaptation. 96-94%, why is this happening? Airway adjustment, cold limbs, poor perfusion, partial blockage, prolonged struggling. <93%, do something quickly!! open and clear airway (head tilt, chin lift, jaw thrust), positive pressure O2 and stimulate patient
CAPNOGRAPH:

1) T or F: it is a real-time monitor
2) What does it analyze, and what does it provide in response to the analysis?
3) It can detect ventilatory changes associated with what 3 things?
4) What is ETCO2 and what does it represent?
5) Set the apnea alarm with a ___ second delay. Why do we need the delay?
6) Draw a tidal breath waveform and explain what each point is. Where is end tidal CO2 measured?
7) When you have slower respirations, what will the peaks look like?
1) T
2) Respiratory depth and rate, provides numerical values and waveforms.
3) Hypoventilation, obstruction, apnea
4) End-tidal carbon dioxide, represents PaCO2. 15 second. You pause before you take the next breath - need the delay or else it'd always be going off
6) 1 - exhalation of dead space 2 - exhalation of lower airway 3 - exhalation of alveoli (plateau) 4 - inspiration. ETCO2 measured right before inspiration
7) Further apart
ETCO2:

1) Normal range?
2) Average increase during respiratory dperession?
3) Use of absolute values is questionable because?
4) ___ RR correlated with increased ETCO2
5) T or F: ETCO2 represents PaCO2 in the similar manner that SpO2 represents PaO2, and is thus used as an indicator of CO2 blood gas and is the purest measure of hypoventilation
6) What would you see in the waveform of a patient on opioids?
1) 35-42 mmHg
2) 7 mmHg
3) Open-system sampling
4) Decreased
5) T
6) Respiratory depression => elongation in wave form (starts to separate), wave would go HIGHER as carbon dioxide builds up
Respiratory depression description: explain what happens with the respiratory drave, rate, etc. and how it leads to an increase in ETCO2
1) Decreased respiratory drive =>
2) Decrease in respiration rate =>
3) Decrease in alveolar ventilation =>
4) Increase in PaCO2 (hypercapnia), increase in ETCO2
What is the sequence of events in vital signs during respiratory depression?
1) RR decrease
2) ETCO2 increase
3) HR increase
4) SpO2 decrease
What happens to SpO2, ETCO2, waveform (amplitude/width/#), and RR in the case of:

1) Hyperventilation
2) Bradypneic hypoventilation - what is this induced by?
3) Hypopneic hypoventilation - what is this induced by?
4) Bronchospasm - sounds?
5) Partial airway obstruction - sounds?
6) Complete airway obstruction or laryngospasm?
7) Apnea
1) Normal, decreased, decreased amplitude/width, increase #, increase
2) Normal, increased, increased amplitude and width, decrease #, wayyyy down (this is INDUCED BY OPIOIDS!)
3) Decrease, decrease, decreased amplitude, decrease (EVERYTHING decreases) - drug-induced by sedative and hypnotic agents
4) Normal or decreased/normal, increased or decreased (dependent on duration and severity of bronchospasm), curved waveform, RR normal, increased or decrease, wheezing.
5) Normal or decreased, normal, normal (altered in shape or height), variable, noisy breathing and/or inspiratory stridor
6) Normal or decreased (depending on duration), zero, absent, zero, chest wall movement and breath sounds present
7) Normal or decreased (depending on duration), zero, absent, zero, chest wall movement or breath sounds absent
Capnography - Key Factors
1) Measures concentration of ___, and ___
2) This determines the adequacy of _______
3) Can alert you to what two kinds of problems?
4) During GA, capnography confirms what kind of intubation, and rules out what kind of intubation?
5) Sensitive to what 3 things that could cause erroneous readings?
6) Alarm is set for apnea with a __ second delay
7) It has become the gold standard for monitoring when combined with?
1) Expired CO2, RR
2) Spontaneous ventilation
3) Airway compromise and ventilation problems
4) Confirms tracheal intubation, rules out esophageal intubation
5) Probe placement/mucous blockage, rate of sampling, patient behaviors (eg crying)
6) 15
7) Pulse ox
1) What are the effects of hyperventilation created by crying and panting?
2) What does gulping air lead to?
1) Crying/panting => decrease expired CO2 => increased plasma CO2 => decrease PaO2 => increased SPO2 => desturation
2) Vomiting, then aspiration
1) What is the tricky thing about using pulse ox only to monitor desats?
2) For intraoperative procedures, changes to what vitals are the last to occur?
3) How do you rapidly assess BP? How do you monitor BP?
1) Supplemental oxygen can make it look like you're still good with oxygen, even though you're apneic
2) Blood pressure (hypotension)
3) Palpation, manual auscultation. Monitor with automated unit
SYSTOLIC BP:
1) If carotid pulse is present, then SBP is at least _
2) If brachial pulse is present, SBP at least?
3) If radial pulse present, SBP at least?
4) Pulse ox becomes inaccurate when SPD goes below ___, if using toe sensor, or below ___ when using finger sensor
1) 60
2) 70
3) 80
4) 70, 80
Heart (Pulse) rate and CO

1) In children, stroke volume and cardiac output are ___ dependent
2) How does a HR of 150-200 affect kids? Adult?
3) In a manual BP cuff, where is the center of the dot placed?
4) Cuff should be palced at level of?
5) In kids, when is diastolic pressure best recorded?
1) RR (CO = HR x SV)
2) In kids, it's fine, can maintain CO with PR = 150-200. In adults, tachycardia prevents adequate filling due to shortness of diastole, reducing CO and causing hypotension
3) Over brachial artery
4) Heart
5) When Korotkoff sounds become muffled rather than disappear
Temperature:
__% increase in oxygen consumption with every increase in temp
1) 7%
What are the 3 levels of responsiveness in pediatric dental sedation?
1) Totally fine, awake, eyes always open, uninterrupted interactive ability
2) Minimally depressed consciousness, responds to verbal commands, eyes closed temporarily
3) Moderately depressed consciousness, asleep, responds to physical stimulation, requires airway maneuver occasionally
Behavior scales:

What 3 things does Houpt rate?
Sleep, movement, crying.

1) Sleep: 1 - fully awake, alert. 2 - drowsy, disoriented. 3 - asleep

2) Movement: 1 - violent, interrupts tx. 2 - continuous, makes tx hard. 3 - controllable, doesn't interfere with tx. 4 - none

3) Crying: 1 - hysterical, demands attention. 2: continuous, persistent that makes tx difficult. 3: intermittent, mild, does not interfere with tx. 4 - none
What 4 things does the OSU sedation scale rate?
Quiet, Crying, Struggling, Crying and Struggling
Review Michigan and Ramsey scales (pg 31). What move does the Ramsey scale use/
ok. Glabellar tap
1) What 4 things are required in a recovery facility?
2) What is the recovery position if they're sleeping? What is the biggest concern?
1) Quiet and comfy, portable oxygen with BACKUP, suction with BACKUP, pulse ox
2) Right hand side, pillow behind back, cross legs to stabilize. Vomiting + aspiration
AAPD Discharge Criteria?
PRATSCAPS

1) Presedation level achieved
2) Responsible adult available
3) Ambulate w/ minimal assistance
4) Talk
5) Sit up unaided
6) Cardiovascular function satisfactory + stable
7) Airway patency uncompromised + stable
8) Pt easily arousable + protective reflexes intact
9) State of hydration adequate
Discharge instructions should include?
1) Diet (administer gatordate w/ large diameter straw to overcome dehydration from NPO, irritability from hypoglycemia
2) Activity
3) Pain control
4) Expected side effects (can have paradoxical)
5) When to call a doctor (vomit 3+ times, continuous, fever, bleeding)
6) Contact phone number
1) Special post-op instructions to protect airway?
1) Carry child with child's shoulders/neck resting in parent's elbow area,
2) Put in car seat and adult besides driver keeps chin elevated
3) If child wants to sleep or lay down, place with pillows in back and front of child so they stay on their side.
4) Check every 5 minutes for breathing
1) Can you charge Behavior Management fee in addition to non-IV sedation and Nitrous oxide?
2) Things to do to stay out of trouble?
1) NO!
2) Use therapeutic doses of sedative + LA, shoudler roll/rubber dam/chin-up at all tiems, cognizance of tonsile size + airway patency, non-dominant hand supporting mandible during mandibular procedures, monitor appropriately