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2011-07-12 13:09:09

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  1. what are the 2 main causes of cardiac arrest?
    • respiratory failure
    • circulatory failure
  2. what are the 2 main categories of respiratory failure with 3 eg of each?
    • respiratory obstruction: foreign body, asthma, croup/acute epiglottitis
    • respiratory depression: convulsions, poisoning/drugs, raised ICP
  3. what are the 2 main categories of circulatory failure with 3 eg of each?
    • fluid LOSS: blood loss, burns, D&V
    • fluid SHIFTS/MALDISTRIBUTION: sepsis, anaphylaxis, cardiac failure (peripheral/pulm oedema)
  4. what is the main difference in cardio-resp arrest between children and adults
    • children: it is usually at the end of physiological deterioration. they arrest because they are already so ill.
    • so even if defib - very high death rate
  5. how can you tell if A&B are at a cricital state?
    • increased work of breathing - ie respiratory distress
    • absent or decreased respiratory effort - due to exhaustion or respiratory depression
  6. what are the 3 main key signs to look for in A&B
    • effort
    • efficacy
    • effect ie adequacy of oxygenation
  7. what 5 things do you look for - effort of breathing?
    • respiratory rate
    • inspiratory or expiratory noises (stridor or wheeze)
    • grunting
    • nasal flaring
    • use of accessory muscles/paradoxical breathing
  8. how do you assess the efficacy of air entry?
    • breath sounds
    • pulse oximetry
  9. how do you assess the adequacy of oxygenation?
    • heart rate
    • skin colour
    • mental status
  10. what are the 4 signs of potential circulatory failure (shock)?
    • tachycardia
    • pulse volume reduction - weak peripheral, if weak central then
    • increased cap refill time >2s
    • BP low - preterminal sign
  11. what are the effects of circulatory failure on the body?
    • metabolic acidosis with increased respiratory rate (to compensate)
    • skin: pale, mottled, cold
    • mental state: agitation then drowsy as reduced cerebral perfusion
    • urine output: oliguria as reduced renal perfusion
  12. what are the 3 signs of potential CNS failure?
    • level of consciousness
    • posture: hypotonic
    • pupils: dilatation, unreactivity, inequality
  13. what are the effects of CNS failure?
    • respiratory depression
    • abnormal respiratory patterns
    • systemic hypertension with sinus bradycardia - Cushing's response (indicates herniation of cerebellar tonsils through foramen magnum)
  14. what is the most common cardiac arrest rhythm in children?
  15. what is the treatment for cardiorespiratory arrest?
    • BLS
    • SAFE
    • shout for help
    • approach with care
    • free from danger
    • evaluate ABCs
    • check responsiveness: ask loudly as you all right? do not shake in case c-spine injury
    • shout for help if unresponsive (if responsive then leave child in same position and reassess regularly, get help if needed)
    • turn child to his back
    • open airway using head tilt chin lift
    • look listen feel for breathing only for 10s
    • if breathing normally - then recovery position - get help
    • if breathing is NOT normal then
    • - remove obvious airway obstruction
    • - 5 initial rescue breaths
    • - note any gag or cough response to your action.
    • assess circulation: signs of life, carotid pulse in neck if >1yo or brachial pulse if <1yo
    • if detect signs of circulation then continue rescue breaths
    • if no signs of life start chest compression rate of 100-120/min
    • 15 compression then 2 effective breaths
    • due for 1 minute then call for help
  16. after BLS, what 3 things may you need to do for the child in cardioresp arrest?
    • A: intubate
    • B: ventialte
    • C: circulatory access - venous or intraosseous, ECG monitor
  17. what are the 2 ways of giving chest compressions to an infant?
    • 2 finger technique if ALONE
    • hand encircling and using thumbs on lower half of sternum
  18. what is method of chest compression for a small child?
    • one handed - heel of the hand over lower half of sternum
    • lift fingers so pressure not applied to ribs
  19. once you have a heart rhythm, which are the shockable and which are non shockable?
    • shockable: VF, pulseless VT - then give 1 shock 4J/kg then immediately CPR 2 minutes
    • non shockable: PEA, systole - immediately resume CPR 2 minutes
  20. what are the reversible causes of cardioresp arrest?
    • HHHH: hypoxia, hypovolaemia, hypothermia, hyper/hypoK+
    • TTTT: thrombosis, tension PT, toxins, tamponade
  21. what are the 4 main causes of upper airway obstruction?
    • foreign body inhalation
    • acute croup
    • epiglottitis/tracheitis
    • anaphylaxis
  22. what is the cardinal sign of upper airway obstruction?
    • stridor: noise associated with breathing due to obstruction of extrathroracic airway
    • worse on inspiration
  23. what are features of severe upper airways obstruction?
    • severe DIB: exhaustion
    • poor air entry
    • chest wall recession
    • cyanosis
    • tachycardia
    • decreased conscious level
  24. what are 3 main features of acute croup?
    • stridor
    • dry, barking cough
    • hoarse voice
    • low grade fever <38.5
  25. what age does croup usually affect?
    3month - 5yr
  26. which croup differential is difficult to distinguish from croup?
    • bacterial tracheitis
    • it will become apparent when there is deteriorating course without antibiotics
  27. what is the management of croup?
    • gentle confident handling - avoid unnecessary upset for child
    • monitor O2 sats and heart rate
    • give O2 - wafting
    • seek help if intubation and ventilation required
    • nebulised budesonide (steroid) or oral dexamethasone
    • nebulised adrenaline (5ml of 1:1000): transient relief to buy time for steroids to work or intubation
  28. why is epiglottitis becoming uncommon?
    Hib vaccine
  29. what is management of acute epiglottitis?
    • call for help - senior pads, anaesthetist, ENT surgeon
    • KEEP CALM, DO NOT LIE DOWN, DO NOT EXAMINE THROAT - any distress can further compromise airway so defer until full support available
    • give oxygen
    • expert will intubate and ventilate
    • then swab epiglottis and take blood cultures
    • iv antibiotics - iv ceftriaxone 80mg/kg/day
  30. what are the causes of lower airways obstruction?
    • asthma
    • bronchiolitis
  31. what are the RF for acute asthma attack?
    • poor control: long duration of symptoms, night wakening
    • previous attack needing IV therapy or PIC
    • poor response to Rx in current episode
  32. what are the features of acute SEVERE asthma?
    • too breathless to talk or feed
    • O2 sats < 92%
    • tachycardia
    • tachypnoea
    • recession and accessory muscle use
  33. what is the management of acute SEVERE asthma?
    • high flow oxygen
    • inhaled SABA: via large volume spacer 10 puffs of salbutamol 100mcg each.
    • or nebulised SABA 2.5 (up to 12yo) -5mg (12-18yo).
    • repeat SABA 10-20mins
    • predisolone 1-2mg/kg, max 40mg. or iv hydrocortisone 4mg/kg
    • if poor response give inhaled ipratropium bromide
  34. what are features of life threatening asthma?
    • silent chest
    • poor respiratory effort, exhaustion
    • cyanosis
    • O2 sats < 92%
    • reduced level consciousness
    • peak flow <33%
  35. what is Rx of life threatening asthma?
    • high flow O2
    • nebulised salbutamol
    • prednisolone/hydrocortisone
    • ipratropium bromide
    • (iv salbutamol, Mg, aminophylline)
    • burst therapy - back to back bronchodilators. 3 in an hour. reassess after each burst
  36. what is the commonest serious respiratory infection in infancy?
  37. what is bronchiolitis characterised by?
    • tachypnoea >60
    • irregular breathing
    • recurrent apnoea
    • hypoxia
  38. what causes bronchiolitis?
    • direct inflammation of bronchiole walls and mucus plugging
    • virus: RSV, metapneumovirus, influenza, parainfluenza
  39. how does bronchiolitis present?
    • age <1yo
    • acute DIB - SOB, inc effort
    • cough
    • wheeze
    • poor feeding
    • cyanosis
    • recurrent apnoea in neonates
    • signs of dehydration
  40. what Qs need to ask mother in bronchiolitis?
    • age
    • ability to feed
    • preterm birth
    • underlying cardio/resp disease
    • preceding coryza
    • fever
    • vomit?
  41. what is the management of bronchiolitis?
    • help
    • monitor O2 sats, RR, HR
    • airway/nasal passage clearance: may reduce respiratory distress (Yankauer suction catheter at nares)
    • give humidified O2 by headbox or nasal cannulae to maintain O2 sats >94%
    • HYDRATION: oral feed (mild), NG feed (mod), iv fluids (severe)
    • can give nebulised hypertonic saline (3%) to draw water into lungs away from airways
    • adrenaline can reduce the oedema and buy time
    • CPAP can keep airways open and make easier to breathe
  42. which 3 drugs have no role in bronchiolitis?
    NO role for bronchodilators, steroids or antibiotics!
  43. what is Rx when there is exhaustion or apnoea?
    • ventilation!
    • as will become hypoxic and hypercapnic
  44. what is the definition of shock?
    • acute failure of circulatory function
    • leading to poor TISSUE PERFUSION
  45. what are the 2 common causes of shock in chidlren?
    • hypovolaemic
    • distributive - sepsis/anaphylaxis
  46. what are the early physical signs of shock?
    • pallor: due to vasoconstriction
    • tachycardia with reduced pulse volume
    • poor skin perfusion: cold, long cap refill
    • hypotension
    • signs of bleeding
  47. what are the late signs of shock? think of END ORGAN FAILURES!
    • rapid deep breathing: response to metabolic acidosis
    • agitation, confusion due to brain hypoperfusion
    • oliguria: <2ml/kg/h in infants and <1ml/kg/h in children
  48. if there is warm shock what does that indicate?
    toxin mediated - gut organisms
  49. what is the Rx of circulatory shock?
    • help
    • ABC
    • 100% O2
    • iv access x2
    • fluids: 20ml/kg
    • reassess
    • if no improvement repeat 20ml/kg normal saline
    • reassess if still no improvement
    • intubate, ventilate
    • inotropes
    • ICU
  50. how do you manage anaphylactic shock?
    • ABC, remove allergen
    • lie flat, raise legs
    • im adrenaline 1:1000 10ug/kg
    • 20ml/kg fluid if shocked
    • repeat
    • repeat adrenaline, fluids every 5 mins if no improvement
    • once stable: iv hydrocortisone
    • iv chlorpheniramine
    • monitor: pulse, ECG, BP
  51. what are the main causes of septic shock? organisms
    • neisseria meningitides
    • Hib
    • G+ve: staph, strep
    • G-ve bacteria
  52. what shape and gram is n.meningitides?
    • G-ve
    • diplococci
  53. what are features of early septic shock (ie compensated)
    • increased cardiac output
    • decreased systemic resistance
    • warm extremities
    • high fever
    • mental confusion
  54. what are features of late ie decompensated septic shock?
    • reduced CO
    • hypotension
    • cool peripheries
    • metabolic acidosis
  55. what is the cardinal sign of meningococcal septicaemia?
    • petechial or purpuric rash
    • in early stage may be blanching
  56. if meningococcal sepsis is suspected what must be done asap?
    im benzylpenicillin
  57. how do you manage septic shock?
    • A&B: give oxygen
    • C: HR, BP, cap refuel - iv access, blood tests, fluids 20ml/kg
    • antibiotics: iv ceftriaxone
    • metabolic: blood glucose, blood gas - acidosis, DIC
    • level of consciousness assess
    • meningitis: check fontanelles, LP
    • may need ITU - continuous monitoring - central venous pressure, UO, pulse O2
  58. in DKA, why do you get production of ketones?
    • without insulin, G cant be taken into cells and used
    • so fat is used as energy source - leading to ketone production and metabolic acidosis
  59. what are symptoms of DKA in a new diabetic?
    • polyuria due to osmotic diuresis
    • polydipsia to compensate
    • weight loss
    • vomiting
    • lethargy
    • abdominal pain
  60. what is trigger for known diabetic in DKA and symptoms
    • intercurrent illness eg infection
    • vomiting
    • poor control of glucose levels
    • ketonuria
    • may have poor compliance with insulin
  61. what are the 4 essential Ix in DKA?
    • blood glucose
    • U&E
    • blood gas
    • urine: glucose, ketones
  62. what are the typical abnormalities in DKA
    • blood glucose > 15mmol/l
    • U&E: increased urea, Na low, K can be low/normal/high depends on renal function and degree of acidosis
    • ABG: metabolic acidosis low pH, HCO3 low, PaCO2 low as respiratory compensation
  63. what are the 3 main categories of signs in DKA?
    • dehydration: dry MM, reduced skin turgor, tachycardia, hypotension
    • acidosis: ketones breath, kussmaul
    • cerebral oedema: headache, decreased conscious, seizure, high ICP signs
  64. in DKA what is total body K+ like?
  65. how do you prevent cerebral oedema?
    slow metabolic correction and rehydration
  66. how do you treat DKA?
    • fluids: treat shock, maintenance fluids rehydrate over 48hours (in case cerebral oedema)
    • 0.9% saline initially
    • insulin: iv 0.1U/kg/h
    • avoid drops of G >5mmol/l/h
    • when glucose < 14 add dextrose
    • add K+ after giving insulin - need ECG monitor
    • treat cause - infection
  67. what things need to be monitored in DKA?
    • blood glucse
    • ABG
    • U&E
    • fluid balance - input, output, weight
    • ECG
    • vital signs, near - ceberal oedema
  68. what are the 2 main complications of DKA?
    • cerebral oedema: prevent by avoiding rapid falls in glucose or Na
    • cardiac dysrhythmias: K+ levels
  69. what is status epilepticus?
    • continuous/recurrent seizures >30mints
    • where pt doesn't regain normal baseline mental state
  70. what are causes of status epileptics?
    • febrile convulsions
    • epilspy
    • head injury
    • meningitis, encephalitis
    • metabolic: hypoglycaemia, poison
  71. what is Rx of status epilepticus?
    • help
    • ABC - may need nasopharyngeal airway
    • oxygen
    • check BM
    • iv access - check glucose, calcium, Mg
    • iv lorazepam --> still after 10 mins then more lorazepam
    • if no iv access then PR diazepam or buccal midazolam --> still seizing then iv lorazepam or if no iv access then PR paraldehyde mixed with olive oil
    • still seizing then iv phenytoin (infusion under ECG and BP monitoring) or phenobarbitone if already on phenytoin
    • intraosseous if no iv
    • then paralyse and intubate and ventilate
    • treat on ICU - thiopentone or BZD infusion
  72. what are causes of high ICP?
    • bleeding
    • oedema
    • hydrocephalus
    • BIH
  73. what are symptoms of high ICP?
    • headache
    • vision
    • altered consciousness
    • seizure
    • cushig's sign: bradycardia and hypertension
    • asympmetrial pupils
  74. what is Rx of ICP?
    • help
    • O2
    • 30 degrees head up
    • aim is to reduce activity of brain to reduce blood supply and reduce oedema
    • intubate, sedate, paralyse
    • need to maintain normoCO2
    • iv mannitol or 3% saline to reduce oedema