Pediatric Diseases

Name the four ways drowning is classified.

1. Witnessed vs. Unwitnessed 2. Immersion vs. Submersion 3. Cold water vs. Warm water 4. Freshwater vs. Salt water

BP in NICU

60/40 increases as we age

It is considered a cold water drowning if the water is _______ degrees celcius. Which is what degree Fahrenheit?

<20 C 68 F

A sweat chloride that is considered of clinical significance is:

>60 mEq/l

The risk of developing Reye's syndrome increases with the use of _____ for the treatment of a ________. a. aspirin, viral infection b. aspirin, bacterial infection c. antibiotics, viral infection d. phenobarbitol, seizures e. tylenol, viral infection

A

You are working in the emergency room when a 23 year old African American male comes in c/o CP et SOB. The patient's SpO2 on RA is 86%. How do you treat this patient? What is your dx?

Antibiotics RBC transfusion pain control nitric oxide sickle cell anemia

asthma treatment

Beta 2 (subcutaneous or aerosolized) corticosteroids hydration solumedrol decadron

A child with moderate to severe bronchiolitis with deteriorating arterial blood gas values has a positive RSV culture. How should this child be treated? (NBRC land + real world)

Both Isolation NBRC: Begin ribavirin via SPAG Real world: suction, oxygenate, ventilate if necessary

What population does RSV affect?

Children less than 2 years immunocompromised children children with chronic lung disease preemies elderly

Name the symptoms of RSV:

Coryza and nasal congestion cough fever malaise retractions nasal flaring tachypnea wheezes dehydration from decreased feedings

Treatment of ARDS

Early intervention Ventilatory/Oxygenation support steroids albumin HFOV ECMO

Define Submersion

Entire body covered in water

Supraglottic swelling

Epiglottitis

T/F It is always a good idea to treat a drowning victim with antibiotics prophylactically.

False

T/F RSV is a bacterial infection.

False

T/F When a patient is hypothermic, it is best to warm them up quickly.

False

What NM disease is not usually seen in pediatrics?

Guilliane barre

A near drowning (submersion) victim is brought into the E.R. How would you expect this patient to appear? (Name the signs and symptoms you would expect.)

Hypoxic Hypercarbic Hypothermic Pulmonary edema Surfactant washout Larygospasm

Reye's syndrome includes: I. Encephalopathy II. Liver dysfunction III. Bronchospasm IV. Cerebral edema V. V/Q mismatch

I, II, and IV I. Encephalopathy II. Liver dysfunction IV. Cerebral edema

Which of the following medications would be appropriate for treatment of an acute asthmatic attack requiring hospitalization? I. Intal II. IV Steroids III. B2 sympathomimetics IV. B1 sympathomimetics V. Subcutaneous terbutaline VI. IV aminophylline

II, III, V and VI only II. IV Steroids III. B2 sympathomimetics V. Subcutaneous terbutaline VI. IV aminophylline

Common triggering factors for ARDS in the pediatric patient include: I. Status asthmaticus II. Near-drowning III. Hydrocarbon aspiration IV. Head injury V. Smoke inhalation

II, III, and V

From the following, identify characteristics of Tetralogy of Fallot. I. PDA II. Atrial Septal Defect III. Ventricular septal defect IV. Aorta overrides both ventricles V. Obstruction to blood flow to pulmonary artery

III, IV and V only III. Ventricular septal defect IV. Aorta overrides both ventricles V. Obstruction to blood flow to pulmonary artery

In which of the following circumstances is hyperventilation appropriate treatment? I. ARDS II. Aspiration pneumonia III. Bacterial pneumonia IV. Head injury V.Hypoxic or anoxic brain injury

IV and V only IV. Head injury V.Hypoxic or anoxic brain injury

How do you treat a patient with ARDS?

Low Vt High PEEP Low PIP P/F 300 APRV HFOV Prone

When is RSV season?

October to March (sometimes may)

You are working in a 25 bed hospital where a six month old child has been admitted for probable RSV. You are awaiting results from the nasal washing. The doctor asks you if you can administer "that drug that is used for RSV that has to have a special machine". What drug does the doctor want you to give? You tell the physician you are unable to give that drug because your hospital has not has a SPAG since Reagan was in office. The doctor then asks your suggestions on how to proceed with this patient, assuming he is positive for RSV. How do you respond?

Ribavirin given via SPAG Suction Fluids Supplemental O2 Contact isolation Monitor SpO2

Signs/Symptoms of ARDS

SOB, refractory hypoxemia, increased WOB, hypercapnia cytokines are released which cause inflammation, travel throughout body and can cause multi system organ failure

There is no true vaccine for RSV; however, we can administer antibodies to those who are at most risk of becoming ill with RSV. Name the two drugs we use to deliver antibodies:

Synagis Respigam

Instances when intervention is indicated based on a patient's cardiopulmonary status

Systolic BP is observed to drop 10 mmHg RR greater than 60 Tachycardia/bradycardia increased WOB (retractions, nasal flaring, grunting) Cyanosis or decreased Saturation Altered LOC Seizures fever with petechiae trauma burns>10% of body surface area

When taking care of drowning victims, or anybody who is suffering from hypothermia, the saying to remember is:

They aren't dead until they are warm and dead

T/F The amount of time a patient is hypoxic is related to the outcome of the patient.

True

T/F You should always be prepared for ARDS when taking care of a near drowning (submersion) victim.

True

T/F You should assume all drowning (submersion) victims are asphyxiated.

True

most common pediatric neuromuscular disorder

Werdnig-Hoffman (defect of muscles - limited movement)

An 18 month old child arrives in ER with parents. Complaints are of an upper airway infection with runny nose, cloudy secretions, barky cough, low grade fever and stridor. Breath sounds are clear bilaterally. A lateral neck xray shows subglottic swelling. Treatment for the child at this point is: (consider each answer separately) a. Admit if signs of respiratory distress are present b. Intubate in controlled situation c. Begin IV ribavirin d. Keep hydrated e. Place in cool, humidified oxygen environment and deliver aerosolized racemic epinephrine to relieve symptoms

a. Admit if signs of respiratory distress are present d. Keep hydrated e. Place in cool, humidified oxygen environment and deliver aerosolized racemic epinephrine to relieve symptoms

You are assigned to deliver a treatment to a 8 year-old Cystic Fibrosis patient. When you enter the room you would expect to note which of the following signs? (more than one) a. Clubbing b. Stridor c. Peripheral cyanosis d. Periorbital cyanosis e. Small for age f. Barrel chest g. frequent loose cough h. bilateral wheezing i. very thin j. barking cough

a. Clubbing c. Peripheral cyanosis d. Periorbital cyanosis e. Small for age f. Barrel chest i. very thin

From the following, identify characteristics of epiglottitis. (choose all that are correct) a. Supraglottic swelling b. Subglottic swelling c. Bacterial infection d. Drooling e. Muffled voice or cry f. Viral infection

a. Supraglottic swelling c. Bacterial infection d. Drooling e. Muffled voice or cry

A neonate with a known patent ductus arteriosus has a PaO2 from the right arm of 66 mmHg and PaO2 from the umbilicus of 66 mmHg. This indicates: a. a lab error b. a right to left shunt c. a left to right shunt

a. a lab error

Which of the following is not appropriate for treatment of an acute asthma attack? a. aerosolized mucomyst b. subcutaneous epinephrine c. steroids d. B2 agonists e. theophylline

a. aerosolized mucomyst

Glasgow coma scale is used to: a. assess level of coma b. assess level of spinal cord injury c. assess developmental milestones d. assess the presence of Reye's syndrome

a. assess level of coma

A 4 year old child sustains an accidental blow to the head from a baseball bat and suffers a closed head injury. The initial injury caused some subdural bleeding and a skull fracture. Which of the following would cause secondary brain injury? Select more than one. a. cerebral swelling b. hypotension c. abrasions d. cerebral hypoxia e. hyperglycemia f. compression from the bleed

a. cerebral swelling b. hypotension d. cerebral hypoxia f. compression from the bleed

A patient born with meconium ileus should be suspect for: a. cystic fibrosis b. meconium aspiration c. necrotizing enterocolitis d. asthma

a. cystic fibrosis

In patients with Transposition of the great vessels, the aorta arises from the _____ and the pulmonary artery arises from the _____. a. right ventricle/left ventricle b. left ventricle/right ventricle c. right ventricle/right atrium d. left ventricle/left atrium e. pulmonary veins/right ventricle

a. right ventricle/left ventricle

Signs of cerebral edema include: I. Nausea and vomiting II. Apnea and Bradycardia III. Head ache IV. Disorientation V.Uneven or decreased pupilary reaction to light

all

Which of the following pathophysiological changes would you expect to find in a 10 year old with severe pulmonary cystic fibrosis? I. Nasal polyps II. Thickened mucus of TB tree III. Bronchiectasis IV. Emphysematous changes V.Right ventricular hypertrophy

all

A sweat chloride that is considered of clinical significance is: a. >40 mEq/l b. >60 mEq/l c. 28-32 mEq/l d. <50 mEq/l

b. >60 mEq/l

Which of the following neuromuscular disorders is least common in pediatric patients? a. Duchenne's muscular dystrophy b. Guillaine Barre' c. Werdnig-Hoffman syndrome d. Spinal cord injury

b. Guillaine Barre'

Which of the following infectious agents is most often associated with bronchiolitis (choose all that are correct)? a. Hemophillus influenza b. Parainfluenza c. Respiratory syncytial virus d. Virazole e. Varicella

b. Parainfluenza c. Respiratory syncytial virus

A 5 year-old patient with cystic fibrosis has a sputum culture done. The most likely infectious agent to appear is: (select more than one) a. RSV b. Pseudomonas c. E coli d. Streptococcus e. Viral f. Staphylococcus g. Seratia h. H influenza

b. Pseudomonas f. Staphylococcus g. Seratia h. H influenza

Sudden onset of symptoms with a temperature of above 38.4° C is indicative of: a. viral infection b. bacterial infection c.parasitic invasion

b. bacterial infection

Haziness seen on a lateral neck xray located subglottically and in the trachea, produced by mucosal edema is indicative of: a. epiglottitis b. croup c. foreign body aspiration d. meconium aspiration

b. croup

The patient that has suffered a near drowning episode in a salt-water environment will have all of the following except: a. hypovolemia b. hypervolemia c. possible caustic burn of the airway and gas exchange units d. surfactant washout e.pulmonary edema

b. hypervolemia

Upon diagnosing epiglottitis, which of the following is most appropriate? a. STAT aerosolized racemic epinephrine b. intubation by skilled clinician in a controlled environment (as much as possible) c. emergency tracheotomy d. place patient in cool mist tent until surgery is scheduled e. leave patient alone if possible until she can be intubated by a skilled clinician in a controlled environment

b. intubation by skilled clinician in a controlled environment (as much as possible)

The drug of choice for a patient with croup is: a. terbutaline b. racemic epinephrine c. subcutaneous epinephrine d. atropine e. theophylline

b. racemic epinephrine

The most common infectious agent for croup is: a. bacterial b. viral c. staphylococcus d. streptococcus

b. viral

RSV is a common cause of viral pneumonia and _________________.

bronchiolitis

A 3 year old child enters the ER in mother's arms with the following: Temp 102.5, RR 45 and labored, HR 144, Patient is ill-looking. Has an audible, high-pitched inspiratory phase. Cheeks are flushed and red. You should first: a. take the child away from mom b. look at the child's epiglottis c. assess for presence of hypoxemia d. do 3 blood cultures 30 minutes apart e. immediately intubate with a 6.0 uncuffed ET tube Next you should: a. call for a lateral neck xray STAT b. administer 0.25ml racemic epinephrine/3ml NS c. immediately intubate with a 4.5 uncuffed ET tube d. do a cutdown for central venous access

c. assess for presence of hypoxemia a. call for a lateral neck xray STAT

Which leukocyte is increased in patient's having an allergic asthmatic attack? a. neutrophils b. basophils c. eosinophils d. monocyte e. lyphocyte

c. eosinophils

The patient that has suffered a near drowning episode in a fresh-water environment is at risk for all of the following except: a. ARDS b. hypervolemia c. hypovolemia d. surfactant washout e.pulmonary edema

c. hypovolemia

A patient arrives in ER with a severe, closed head injury. The ER physician intubates and the child is taken to pediatric intensive care and placed on a mechanical ventilator. The physician asks you for advise in the oxygenation/ventilation status of this child. Your advise: a. keep pH on acidotic side b. monitor CO2 and keep in the 80-100 mmHg range c. monitor CO2 and keep in the 25-30 mmHg range d. monitor PaO2 and keep at less than 60 mmHg to prevent suppression of the hypoxic drive e. keep pH low to alleviate swelling of the brain

c. monitor CO2 and keep in the 25-30 mmHg range

Which of the following arterial blood gases represents expected results from an asthmatic patient in the early stages? a. pH 7.23, PaCO2 32, PaO2 64 mmHg b. pH 7.44, PaCO2 48, PaO2 56 mmHg c. pH 7.44, PaCO2 35, PaO2 78 mmHg d.pH 7.33, PaCO2 52, PaO2 56 mmHg

c. pH 7.44, PaCO2 35, PaO2 78 mmHg

A 8 year-old patient admitted for status asthmaticus has shown a change in his status. Previously his respiratory rate was 40-50, he now is breathing 20-25 bpm. Also, his high pitched wheezes have quieted and very few wheezes are heard with limited air movement. The patient had been very anxious and now appears much calmer even sedated. Based on this information, which of the following statements are most true. a. this patient is greatly improved b. this patient is showing signs of hypoxic drive suppression c. this patient may be deteriorating, further evaluation is necessary. d. this patient's IV medications have started acting and he is resting e.this patient's B2 sympathomimetic therapy can be decreased.

c. this patient may be deteriorating, further evaluation is necessary.

Foreign body aspiration of organic material __________ on xray. a. will appear as an area of translucency b. will show no visible signs c. will appear as an infiltrate d. will appear as a clear outline

c. will appear as an infiltrate

Subglottic swelling

croup

In epiglottitis the pathological agent most frequently the cause is: a. parinfluenzae b. Influenza A c. Adenoviruses d. Bacterial e. RSV

d. Bacterial

Which of the following statements is not true of childhood asthma? a. strong familial history of asthma and/or allergies b. increased IgE levels c. patient often has eczema, urticaria, an allergic rhinitis d.asthma is due to overactive parasympathetic nervous system

d.asthma is due to overactive parasympathetic nervous system

Treatment of CF

dietary supplements antibiotics vest therapy CPT mucolytics humidification bronchodilators oxygen when needed heart lung transplant

According to the World Congress on Drowning, what is the definition of drowning?

drowning refers to all forms of submersion injury leading to respiratory impairment, including nonfatal events that previously have been described as near-drowning

A patent ductus arteriosus that is shunting from left to right will result in: a. right sided heart failure b. pulmonary congestion c. decreased cardiac output d. venous admixture e. all but d

e. all but d

The infectious disorder found most frequently in babies and toddlers that results in swelling of the supraglottic structures is known as: a. chlorine inhalation b. pneumonia c. bronchiolitis d. bronchitis e. epiglottitis

e. epiglottitis

A patient arrives in ER with a severe, closed head injury. The ER physician intubates the child and she is taken to pediatric intensive care and placed on a mechanical ventilator. The following arterial blood gas is obtained: pH 7.52, PaCO2 29 mmHg, PaO2 105 mmHg. Which of the following would be most appropriate. a. decrease ventilation to keep pH acidotic and alleviate swelling of the brain b. make no changes. The above arterial blood gases are appropriate c. increase FIO2 d. monitor PaO2 and keep at less than 60 mmHg to prevent suppression of the hypoxic drive e.increase ventilation. PaCO2 should be in the 20-25 mmHg range

e.increase ventilation. PaCO2 should be in the 20-25 mmHg range

Define Immersion

face and airway are immersed in water

High grade fever

greater than 38.4 C, bacterial, epiglottitis

What is cystic fibrosis

hereditary disorder, sodium chloride in wrong place so it doesn't bind where it should. affects entire body

in fresh water near drowning patient will have

hypervolemia

In salt water near drowning pt will have

hypovolemia because water will go where the salt is

Laboratory studies for asthma

increased eosoniphils

How does extrinsic differ from intrinsic

may not have eosinophils intrinsic = internal extrinsic = external

Signs/symptoms of cystic fibrosis

meconium ileus recurrent pneumonas nasal polyps, sinusitis large appetite- fx to thrive thick bulky stools barrel chest cyanosis clubbing small for age right heart failure/cor pulmonale

Laboratory studies for CF

sweat test >60 mEq/l obstructive w/restrictive PFT

Causes of ARDS

trauma aspiration near-drowning smoke inhalation sepsis

How are neuromuscular disorders treated in the pediatric population

treat the symptoms

Low grade fever

usually viral - croup

When to ventilate an asthmatic patient

when the pt is in stage 3 or 4