11) Paediatrics

Question 1

How is sepsis defined in the paediatric population?

Answer 1

Life threatening organ dysfunction caused by a dysregulated host response to infection

Severe Paediatric sepsis - 2 or more SIRS criteria, Confirmed or suspected invasive infection, CVS dysfunction/ ARDS/ 2 or more other organ system dysfunctions

Paediatric Septic Shock - Severe infection leading to cardiovascular dysfunction (Hypotension, need for vasoactive medication or impaired perfusion)

Question 2

When may invasive ventilation be required? (Bronchiolitis)

Answer 2

Severe disease not responding to therapy/ deteriorating

May be required in presence of life-threatening features, significant respiratory acidosis or hypoxia despite NIV

3-5% of bronchiolitis will required PICU admission

Question 3

How might TSS present?

Answer 3

Fever
Flu-like symptoms
Tissue swelling/ erythema/ rash
Circulatory compromise and multi-organ dysfunction
Myocarditis
Severe pain in extermities
Abdominal pain and tenderness
Endophthalmitis
Hypothermia

Question 4

What are the starting/ go to Paediatric sedation agents/ starting doses?

Answer 4

Morphine - 10 - 40 mcg/kg/hr (start at 20)
Midazolam - 50 - 250 mcg/kg/hr (start at 120)
Rocuronium - 500 - 1000 mcg/kg/hr

Alternatively

Ketamine - 600 - 2700 mcg/kg/hr
Fentanyl - 1 - 5 mcg/kg/hr

Question 5

What is the formula for maintenance fluids in a paediatric patient?

Answer 5

24 hour fluid requirement is the sum of:

100 ml/kg/day for first 10kg of body weight
50 ml/kg/day for second 10kg
20 ml/kg/day for each additional kg

Question 6

Are there any special considerations to injury patterns in children?

Answer 6

Chest:
Relatively elastic tissue so rib fractures sign of high energy transfer, serious injury may occur without fracture
High incidence of pulmonary contusion

Abdomen:
Blunt injury, commonly due to road traffic collisions
Thin wall, less protection to injury
Liver and spleen low and more anterior, more exposed
Bladder intra-abdominal so more exposed

Head:
Most commonly due to RTCs
Most common single cause of trauma death
Fontanelle/ sutures may allow for more sig. bleeding before signs of raised ICP
Prone to cerebral oedema

Spine/ Limbs:
Extremity injury is common but unlikely to be life threatening
Pelvic fractures relatively uncommon
Closed femoral fractures may cause 20% circulating volume loss
Significant spinal cord damage can occur without fracture
If GCS <13 whole spine and CT head indicated

Question 7

Outline the initial therapeutic principles in severe bronchiolitis?

Answer 7

Supportive

Airway - Ensure not blocked by superficial secretions
Respiratory - HFNO, Nasal CPAP/ BIPAP, Gastric decompression
Hydration
Treat secondary bacterial infections

Question 8

Can you describe the epidemiology of paediatric trauma?

Answer 8

Incidence higher in males than females
Type of injury related to stage of development
2-6x mortality from injury in lower socio-economic groups
More common in families with mental illness, substance abuse, marital discord, when moving home

Question 9

Which presentations might alert you to physical non-accidental injury (paediatrics)?

Answer 9

Head - Fractures, SDH, signs of raised ICP
Fractures - Long bones (multiple, different stages of healing), Spine, Ribs
Ruptured abdominal viscus
Burns/ Scalds - Glove and stocking, imprints
Cold injury
Poisoning
Suffocation
Bruising - non-mobile infant, non-exposed areas, imprints

Also consider signs of neglect, emotional and sexual abuse

Question 10

Why might there be a poor response to neonatal resuscitation?

Answer 10

Oesophageal intubation
Intubation of right main bronchus
Pneumothorax
Hypovolaemia
Equipment failure
Congenital heart disease

Question 11

How are chest compressions performed in the neonate?

Answer 11

Increase FiO2 to 1.0
3:1 compression to breaths
Recheck every 30s
Hand encircling technique, lower half of sternum

Question 12

How is oxygen therapy managed in neonatal life support?

Answer 12

Term/ >32/40 - Air
28-31/40 - 0.21-0.3
<28/40 - 0.3

Initially targeting sats above 25th centile of term baby:
2 min - 65%
5 min - 85%
10 min - 90%

Try to avoid sats >95%

Question 13

What factors are associated with worse outcomes in bronchiolitis?

Answer 13

Chronic lung disease
Congenital cardiac disease
Prematurity
Immunodeficiency
Adenovirus
<6 weeks of age

Question 14

What are the main causes of mortality in paediatric DKA?

Answer 14

Cerebral oedema - Most cases

Hypokalemia
Aspiration Pneumonia
Inadequate resuscitation

Question 15

What is Toxic Shock Syndrome (TSS)?

Answer 15

TSS is an acute inflammatory multisystem disorder mediated by exotoxin release from severe gram-positive infections. It is characterised by early shock, rash, desquamation and fever

Question 16

How does the presentation and management of DKA differ in children?

Answer 16

First presentation of diabetes more likely
More susceptible to cerebral oedema hence difficulty in adequate fluid resuscitation
Blood glucose will fall faster with rehydration, avoid insulin until 1-2 hrs of initial therapy trialed (Insulin is 0.05-1 unit/kg/hr)
VTE risk in >16 years
Abdominal pain common

Question 17

Can you describe the main steps in the newborn life support algorithm?

Answer 17

First 60s:
Delay cord clamping if possible
If >32 weeks dry, if <32 place into bag. Warm and aim for normothermia
Assess colour, tone, breathing and HR
Open airway, consider CPAP if preterm
5 Inflation breaths (PEEP 5-6 cmH2O if able)

Ongoing:
Reassess - If no HR improvement, look for chest wall movement
If no Chest wall movement, optimise airway opening/ BVM technique
Repeat 5 inflation breaths
Reassess
If chest wall moving, HR not improved, Ventilate for 30s
If after 30s ventilation HR <60 - CPR 3:1

Reassess every 30s, consider tubing, IV access, drugs

Oxygen titrated to sats targets of neonate, make sure to keep neonate warm

Question 18

What is meant by ‘duct-dependent’ congenital heart disease?

Answer 18

‘Duct dependant’ disease refers to pathological configurations that are reliant on a patent ductus arteriosus in order to maintain end-organ perfusion. Most congenital heart disease may have significant duct dependancy.

Typical presentation is with cyanosis unresponsive to increases in FiO2. Femoral pulses may be absent/ poor and saturations will differ between pre/post ductal sites.

Question 19

When might extracorporeal support be indicated? (Paediatric Sepsis)

Answer 19

RRT - Fluid overload unresponsive to diuresis

VV-ECMO - Sepsis-induced paediatric ARDS with refractory hypoxaemia

VA-ECMO - Refractory septic shock

Question 20

How are paediatric organ dysfunctions defined?

Answer 20

Respiratory - P/f <300 (excluding CHF/ Lung disease chronically), PCO2 >20 mmHg above baseline, need for mechanical ventilation

CVS, following 40ml/kg fluids in 1 hour - Hypotensive, Need for Vasoactive drugs, 2 or more of: Unexplained metabolic acidosis/ High lactate/ UO <0.5 ml/kg/hr / CRT >5s

Neuro - GCS <11/ acute change in mental status

Renal - Cr >2 x upper limit of normal for age or 2 x baseline

Hepatic - Bilirubin >4 mg/dl, ALT 2 x upper limit of normal

Haematological - Plts <80, 50% drop from highest platelet count, INR >2

Question 21

Which therapies should not be used in paediatric sepsis?

Answer 21

Colloids
Routine use of levothyroxine
Prokinetics for feed intolerance
Vitamins/ trace elements
IVIg
Prophylactic platelets/ plasma

Question 22

Which important differential diagnosis should be considered in bronchiolitis?

Answer 22

Pneumonia - Particularly if febrile or persistently focal crackles
Early-onset asthma: Absence of crackles, episodic wheeze, atopy
Viral-Induced Wheeze

Question 23

When would an emergency CT head scan be indicated in a child with a head injury?

Answer 23

One of:
Suspected NAI
Seizure without history of epilepsy
GCS <14 or <15 if under 1 on initial presentation
GCS <15 at 2 hrs post injury
Suspected open/ depressed skull fracture/ tense fontanelle
Suspected basal skull fracture
Focal neurology
<1 yr with bruise/ swelling/ laceration >5cm on head

Two of:
LOC >5 min
Abnormal Drowsiness
3 Discreet vomits
Dangerous Mechanism
Amnesia > 5min

Question 24

How might a child present with congenital heart disease to the intensivist?

Answer 24

Malformations requiring intensive care management are often those resulting in severe cyanosis or HF. Some less severe defects may become apparent later in life during other intensive care procedures (failure to wean from vent etc.). Many affected children are now surviving to adulthood and could present to the adult intensive care unit. Presentation while pregnant may pose very high-risk pregnancies.

Severe cyanosis:
Usually respiratory, congenital heart disease is an important differential however
Mumur may not be present
Differentials: Transposition of the great vessels, pulmonary atresia/ stenosis, Ebstein’s anomaly, obstructed TAPVD, persistent pulmonary hypertension of the newborn

Cardiac Failure:
Obstruction of the left heart (AS, coarctation, hypoplastic left heart)
May present as the ductus arteriosus closes and collateral flow is lost
Cold, pale, weak peripheral pulses, deteriorating rapidly
Progressive hepatomegaly, pulmonary oedema, cardiomegaly, severe metabolic acidosis
Differentials: Sustained SVT, myocarditis, sepsis, metabolic disorders

Question 25

What are the causes of bronchiolitis?

Answer 25

RSV - 80% Metapneumovirus Influenza Parainfluenza Adenovirus Rhinovirus Boca Virus Mycoplasma

Question 26

How should fluid therapy be managed in paediatric DKA?

Answer 26

Shock: 10 ml/kg 0.9% NaCl over 15min Further 10 ml/kg boluses to restore circulation up to a total of 40 ml/kg After 40 ml/kg, inotropes or vasopressors may be needed Stable: 10 ml/kg over 60 min Replacement of deficit over 48 hours Maintenance fluids as per formula Potassium 20 mmol per 500 ml of fluid until glucose <14 Monitor sodium levels Avoid IV sodium bicarb unless life threatening hyperkalaemia or impaired myocardial contractility due to acidosis

Question 27

What are the main management principles in patients with congential heart disease?

Answer 27

Reduce oxygen demand - May need intubation Treat respiratory disease Correct acidosis Avoid high PVR (e.g. high ventilatory pressures, hypercarbia, hypoxaemia, certain drugs) Consider iNO in pulmonary hypertension Consider keeping ductus arteriosus open with prostaglandins Inotropes for cardiac dysfunction Discussion with specialist paediatric cardiac centre - ?ECMO/ Surgery

Question 28

What is the prognosis of PIMS-TS?

Answer 28

Most patients survive. Average LOS in PICU is 3-4 days.

Question 29

Which therapies are recommended against routinely in bronchiolitis?

Answer 29

Antibiotics Hypertonic saline Nebulised adrenaline Salbutamol Montelukast Ipratropium bromide Corticosteroids Caffeine and aminophylline have been trialed to prevent apnoeas

Question 30

How is bronchiolitis diagnosed?

Answer 30

Clinical Typical features are coryza, cough, wheeze, crepitations with varying degrees of respiratory distress. Fever and poor feeding are common. Symptoms can last several weeks. Diagnostic criteria: Coryzal prodrome 1-3 days Persistent cough Either of: Tachypnoea and/or chest recession or Wheeze and/or crackles on chest auscultation

Question 31

What clinical features may you see in PIMS-TS?

Answer 31

All will have: Persistent fever >38.5, Oxygen requirement, Hypotension Other features: A/B - Mucus membrane changes, neck swelling, respiratory symptoms, cough, sore throat, lymphadenopathy C - Syncope D - Confusion, headache, conjunctivitis E - Abdominal pain, diarrhoea, vomiting, rash, swollen hands & feet

Question 32

When is ECLS indicated in paediatrics?

Answer 32

In-hospital cardiac arrest - Presumed reversible cause, conventional resuscitation not leading to ROSC, able to rapidly initiate ECLS Out-of-hospital - Hypothermic cardiac arrest if cannulation possible pre-hospitally

Question 33

Name some types of injury prevention (paediatrics)?

Answer 33

Primary - Speed limits, cycles lanes, fireguards, child-resistant medication closures Secondary - Fitted seat belts, bicycle helmets Tertiary - Application of cold water to burns, pressure to laceration, CPR training

Question 34

When might you diagnose PIMS-TS?

Answer 34

PIMS-TS emerged during Covid-19 pandemic Case definition as per RCPCH = Child presenting with persistent fever, inflammation, evidence of organ dysfunction with additional features, other microbial causes/ TSS/ Myocarditis excluded. Inflammation is indicated by neutrophilia, elevated crp and lymphopaenia. The main differential is Kawasaki disease.

Question 35

What might the initial therapy for paediatric DKA associated cerebral oedema include?

Answer 35

Hypertonic Saline (2.5-5 ml/kg of 3%) or Mannitol 0.5-1 g/kg) over 15 min Repeat after 30 min if no improvement Consider intubation and ventilation CT head to exclude other causes

Question 36

How would you determine a child's consciousness level?

Answer 36

Children aged <4 need modified Children's GCS: E & M are the same V - 5 = Alert/ babbles/ words as normal for child, 4 = Less than usual words/ irritable cry, 3 = Cries only to pain, 2 = Moans to pain, 1 = no response In pre-verbal patients, V uses 'Grimace response' 5 = Spontaneous/ normal facial/ oromotor activity, 4 = less than usual spontaneously, only response to touch stimuli, 3 = Vigorous grimace to pain, 2 = Mild grimace to pain, 1 = no response

Question 37

What drugs are used in neonatal life support?

Answer 37

Can consider (if all other measures haven't worked): Adrenaline IV/IO - 20 mcg/kg - Repeat every 3-5 min Glucose 250mg/kg Crystalloid 10ml/kg

Question 38

What vascular access may be used? (Neonatal Life Support)

Answer 38

Umbilical venous access first line IO access

Question 39

How is Non-streptococcal TSS diagnosed?

Answer 39

Laboratory criteria: Negative blood/ CSF cultures (except blood culture for staph aureus) Negative serology for Rocky Mountain spotted fever, leptospirosis, measles Clinical criteria: Temperature 38.9 and above Diffuse macular erythroderma Desquamation 1-2 weeks after onset of rash Hypotension (SBP <90 or <5th centile for age) Multisystem involvement (3 or more organ systems: GI - Vomiting/ Diarrhoea Muscular - Severe myalgia or CK 2x upper limit Mucus membrane - Oropharyngeal/ Conjunctival/ Vaginal hyperaemia Renal - Urea/ Cr 2x upper limit or urinary sediment with pyuria without UTI Liver - AST, ALT or Bili 2x upper limit/ baseline Haematologic - Platelets <100 CNS - Altered level of consciousness without focal signs (when no fever/ hypotension) Probable = Laboratory criteria + 4 or more clinical criteria Confirmed = Laboratory criteria + 5 clinical criteria including desquamation

Question 40

What causes TSS?

Answer 40

Strep. Pyogenes (Group A) - Burns, Nec. Fasc. Staph Aureus - Menstrual products, nasal packing, intrauterine devices, soft tissue infections (burns, surgical wounds, post-partum), pneumonia

Question 41

What constitutes severe disease in bronchiolitis?

Answer 41

Severe: FiO2 >0.5 to maintain sats >95% Severe intercostal recession Tachypnoea Tachycardia Frequent apnoeas (>2/hr) Life-threatening: Sats <88% despite HFNO or CPAP Respiratory acidosis Episodes of desaturation Apnoeas needing BVM ventilation or causing desaturations Exhaustion, grunting

Question 42

What transfusion targets will you aim for? (Paeds Trauma)

Answer 42

Platelets > 50 Fibrinogen > 1 Ionised calcium > 1 mmol/L Hb - 80-120

Question 43

What are the paediatric SIRS criteria?

Answer 43

Paediatric SIRS = 2 or more of the 4 criteria (one must be an abnormal temperature or raised WCC) Temperature - >38.5 or <36 WCC - Elevated above set values per age/ >10% immature neutrophils HR (In absence of confounder i.e. pain) - Elevated above set values for age persistently for 0.5-4 hrs or Bradycardic persistently for 0.5 hrs RR - Elevated above set values/ mechanically ventilated (and this isn't related to underlying chronic issue)

Question 44

Which investigations may aid diagnosis and management in TSS?

Answer 44

General: Blood cultures (positive in 60% of strep but <5% Staph) MC&S of pleural fluid, peritoneal fluid, tissue, throat swab, CSF FBC/ U&E/ LFT/ Albumin/ Calcium/ Lactate/ CK/ Coag Urinalysis for haemoglobinuria CXR - ARDS Specific: Serology - Rocky Mountain spotted fever (a rickettsia), leptospirosis, measles Acute and convalescent staphylococcal antibody Streptococcal exotoxin subtypes

Question 45

What are the other important differentials of neonatal collapse?

Answer 45

Other than sepsis: Cardiac - second most common Trauma including NAI Metabolic Surgical

Question 46

What are the challenges of Paediatric Resuscitation?

Answer 46

Anatomical and physiological differences Equipment and dosing variations by size/ age May not have presented yet with conditions (i.e. Diabetes) Conditions relatively unique to paediatrics (cardiac malformations/ metabolic etc) Variable autonomy and capacity Potential for longer-term implications of therapies/ complications (Radiation) Emotive for healthcare providers

Question 47

What microbiological tests should you request in PIMS-TS?

Answer 47

Urine, blood, stool, throat swab MC&S Nasopharyngeal aspirate/ throat swab PCR - Respiratory panel/ Covid Blood PCR - Pneumococcal, meningococcal, group A strep, Staph Aureus, EBV, CMV, adenovirus, enterovirus, Covid Stool PCR - Covid, viral screen Covid serology Anti-streptolysin titre Enterotoxin, staph toxins

Question 48

What are the doses of resuscitative agents in paediatric haemorrhage?

Answer 48

TXA - 15mg/kg Packed red cells/ FFP - 5ml/kg Crystalloid - 10mg/kg After 20ml/kg blood products - 10-15 ml/kg platelets + 0.1 ml/kg 10% Calcium Chloride Cryoprecipitate - 10ml/kg Activated Factor VII after 2 cycles

Question 49

What investigation findings might you expect in PIMS-TS?

Answer 49

All: High fibrinogen, CRP, D-dimer, ferritin and neutrophils Low albumin, lymphocytes Absence of other causative organisms on cultures/ PCR Sometimes: High IL-10, IL-6, CK, LDH, Triglycerides, ALT, Troponin Thrombocytopaenia Proteinuria AKI Anaemia Coagulopathy Imaging: CXR - Patchy inflitrates, effusions Echo - Myocarditis, Valvulitis, Effusion, Coronary artery dilatation Abdominal US - Colitis, Ileitis, Lymphadenopathy, ascities, hepatosplenomegaly

Question 50

What other resuscitative measures are suggested in paediatric sepsis?

Answer 50

Source control Fluids - 40-60 ml/kg in 10 ml/kg challenges during the first hour if shocked Adrenaline/ Noradrenaline - 0.05 - 0.2 mcg/kg/ min (Peripheral Adrenaline), 0.05 - 1 mcg/kg/min (Central). - 0.02 - 0.1 mcg/kg/min Norad Add Vasopressin if high doses of above - 0.03 - 0.09 units/kg/hr IV hydrocortisone if refractory haemodynamic instability High PEEP in septic ARDS iNO as a rescue therapy in refractory hypoxia Transfusion threshold of 70 for Hb

Question 51

What are the commonest injuries causing death in paediatrics?

Answer 51

Motor vehicle collisions Drownings Burns Falls from height Poisoning

Question 52

How is Streptococcal Toxic Shock diagnosed?

Answer 52

Clinical case definition: Hypotension (SBP <90 or <5th centile for age) Multi-organ involvement (2 or more systems): Renal (Cr >177 or 2x Upper limit/ baseline) Haematologic (Platelets <100) Liver (ALT, AST or Bili 2x upper limit/ baseline) ARDS Generalised erythematous macular rash that may desquamate Soft tissue necrosis Probable = Clinical case definition in absence of another identified aetiology + isolation of group A strep. from non-sterile site Confirmed = as above but from normally sterile site (blood, CSF, joint, pleural, pericardial)

Question 53

What signs might indicate that cerebral oedema is developing? (DKA)

Answer 53

Early: Headache Agitation Bradycardia Hypertension Late: Decreased GCS Abnormal breathing pattern Oculomotor palsies Abnormal posturing Pupillary abnormalities

Question 54

When should neonatal resuscitation be withheld or discontinued?

Answer 54

An undetectable HR for >10 min should prompt review of clinical factors (e.g. dysmorphism, effectiveness, view on continuing) Discontinuation should be discussed if there has been no response after 20 min, and reversible causes have been excluded. Partial response may need NICU/ PICU to navigate further. Withholding needs discussion with parents about evidence of outcomes: Inappropriate if >90% predicted neonatal mortality and unacceptably high morbidity in survivors Usually indicated if >50% predicted survival rate and acceptable morbidity If survival <50% predicted and anticipated burden for child is high, ask the parents If no discussion do it

Question 55

What is the significance of congenital heart disease to adult critical care?

Answer 55

Survival of patients with congenital heart disease has increased significantly. Around 85% survive to adult life with 'adult congenital heart disease (ACHD). These patients may present acutely unwell/ peri-operatively. Management considerations: ACHD passport carried by patient Specialist input from ACHD centre Cardiac catheterisation may be helpful Transfer if appropriate/ able

Question 56

What critical care involvement may be required in PIMS-TS?

Answer 56

Commonest presentation to critical care in these patients is with shock, 60% of patients require mechanical ventilation, often for cardiovascular indications. Respiratory failure is uncommon. Critical care often involves vasopressors, CVC, inotropes for cardiac dysfunction. ECLS is rarely needed. RRT is uncommon.

Question 57

What would ongoing management in the PICU involve? (Bronchiolitis)

Answer 57

Lung protective ventilation Appropriate tube positioning as directed by CXR Secretion management Change to nasal tube if prolonged intubation anticipated Appropriate feeding regime Supporting parents/ carers

Question 58

How is DKA diagnosed in children?

Answer 58

Paediatric DKA: Bicarb <15 or pH <7.3 and Ketones >3 Mild - pH 7.2-7.29 or Bicarb 10-15 Moderate - pH 7.10-7.19 or Bicarb 5-10 Severe - pH <7.10 or Bicarb <5

Question 59

What is your management of bradycardia in children?

Answer 59

Treat hypoxia and shock If signs of vagal overactivity give 20mcg/kg of Atropine Otherwise give adrenaline 10mcg/kg followed by adrenaline infusion/ pacing if needed

Question 60

What is the Fontan circulation?

Answer 60

It is the circuit formed during repair of certain cardiac malformations with a single functional ventricle. Multi-stage process: 4-12 months old - Cavopulmonary connection or bidirectional shunt created permitting increased blood flow to the lungs. 1-5 years - Completion of Fontan circuit - This involves the connection of the IVC to the pulmonary arteries, both SVC and IVC drain into pulmonary arteries which go into lungs.

Question 61

Can you name some inflammatory syndromes that present in children?

Answer 61

Kawasaki disease Toxic Shock Syndrome Sepsis Macrophage activation syndrome Haemophagocytic Lymphohistiocytosis Paediatric multisystem inflammatory syndrome temporally associated with SARS-CoV-2 (PIMS-TS)

Question 62

How is TSS managed?

Answer 62

Specific: Source control - Broad spectrum abx plus antitoxin (i.e. clindamycin/ linezolid), may need debridement IVIg in streptococcal TSS Possibly in the future - Hyperbaric O2, Anti-TNF, Pentoxifylline Supportive: Supportive therapy + High fluid requirement Corticosteroids Wound care Notification of public health services Primary prevention: Handwashing and hygiene measures Avoidance of extended tampon use Isolation until 24 hours post start of abx course in Strep. Throat

Question 63

What approach would you take to managing the seriously injured child?

Answer 63

Similar principles to the management of an adult trauma patient Primary survey - AcBCDE - Catastrophic haemorrhage control with direct pressure, haemostatic dressings or tourniquet, give TXA as early as possible. Secondary survey Continuing stabilisation - Respiration, Circulation, Nervous system, Metabolism, Host Defence Consideration of non-accidental injury and safeguarding issues

Question 64

What is your approach to management of tachycardia with circulatory compromise in children?

Answer 64

Narrow Complex: Sinus tachy - (infant <220, child <180, gradual onset) - Treat cause SVT - (infant >200, child >180, abrupt onset) - Syncronised DCCV 1J/kg, 2-4 J/kg subsequently - Adenosine (<1 yr = 150mcg/kg max 2 doses, neonate 500mcg/kg, infant 1-11yrs 100mcg/kg max 12mg, 12-17 yrs 3, 6 & 12mg) Broad complex: VT - Synchronised DCCV 2 J/kg then 4 J/kg - Amiodarone 5mg/kg before 3rd shock

Question 65

How would you approach a paediatric cardiac arrest?

Answer 65

5 rescue breaths CPR 15:2 in 2 min cycles Non-shockable - Adrenaline 10mcg/kg Shockable - 4 J/kg, Adrenaline after 3rd shock, Amiodarone after 3rd and 5th shock (5 mg/kg) Ventilate at following rates: Infant - RR 25, 1-8 yrs RR 20, 8-12 RR 15

Question 66

What are the risk factors for requiring stabilisation or resuscitation at birth?

Answer 66

Antepartum: Fetal: Intrauterine growth restriction <37/40 gestation Multiple pregnancy Congenital abnormality Oligo/polyhydramnios Maternal: Infection Gestational diabetes Pregnancy induced HTN Pre-Eclampsia High BMI Short stature Preterm lack of antenatal steroids Intrapartum: Evidence of fetal compromise Meconium Breech vaginal delivery Forceps/ Vacuum delivery Bleeding C-section before 39/40 Emergency C-section General anaesthesia

Question 67

What management principles apply to children with PIMS-TS?

Answer 67

Treat as suspected Covid (appropriate PPE) Evaluate degree of cardiac dysfunction Suspect multisystem involvement Empirical antibiotics on presentation Early involvement of critical care, infectious disease, immunology, rheumatology Anticoagulation may be needed Immunomodulation may be needed Consider IVIg if Kawasaki/ TSS criteria fulfilled Research studies

Question 68

What common problems are encountered with bronchiolitis patients on PICU?

Answer 68

Secondary bacterial infection Mucous plugging Bronchospasm and gas trapping Bradycardic episodes Hyponatraemia

Question 69

What types of congenital heart disease do you know of?

Answer 69

CHD is one of the commonest birth defects. Risk factors include chromosomal conditions and maternal: Infection, medications, smoking, alcohol use and diabetes Examples: Septal defects - Atrial, ventricle Patent ductus arteriosus Coarctation of the aorta Pulmonary stenosis Transposition of the great arteries Tetralogy of Fallot - VSD, Pul. Stenosis, Overriding Aorta & RV hypertrophy Aortic stenosis Ebstein's anomaly Hypoplastic left heart syndrome Tricuspid atresia Total/ partial anomalous pulmonary venous drainage (TAPVD) Truncus arteriosus

Question 70

What is the mortality in TSS?

Answer 70

Streptococcal - 30-85% Staphylococcal - 5% non-menstrual, 1.8% menstrual

Question 71

How are antimicrobials managed in paediatric sepsis?

Answer 71

Septic shock - Within 1 hour of recognition Organ dysfunction - Within 3 hours Empiric broad spectrum therapy to cover all likely pathogens Narrow cover once culture result is known Daily assessments to de-escalate

Question 72

What is the role of therapeutic hypothermia in neonatal life support?

Answer 72

If there is evidence of significant risk of moderate - severe hypoxic ischaemic enecphalopathy consider inducing hypothermia. Target is a temp of 33-34 degrees.

Question 73

What is bronchiolitis?

Answer 73

An infection of the respiratory tract, characterised by high secretion load, typically in children under 2 years old. Most common in winter months in infants (particularly aged 3 - 6 months).

Question 74

How to make a non-cardiac arrest adrenaline push dose for kids?

Answer 74

1:10,000 Adrenaline = 1mg in 10ml Therefore: 100 mcg/ml 1 ml of 1:10,000, diluted to 10ml with saline This make 10 mcg/ml Dose is 1mcg/ kg

Question 75

Pending completion: How do you size a paediatric ETT, what blades should you use and when?

Answer 75

Neonate - 3.0mm 0-6 months - 3.5mm 6-12 months - 4.0mm Cuffed ETT: (Age/4) + 3.5 Uncuffed ETT: (Age/4) + 4 Length at incisor: (Age/2) + 12 Miller/ Straight blade - Under 1 year old/ infant Mac blade - Over 1

Question 76

Pending completion: What are your go to RSI drugs for paediatrics?

Answer 76

1 : 1 : +/- 1 Ketamine - 1-2 mg/kg Rocuronium - 1 mg/kg +/- Fentanyl - 1mg/kg