Paediatric 00 / 22 , all cards and bookmarks
The infant's small reserve 01 / 22 Infants have little oxygen reserve and high ventilation for their functional residual capacity (FRC): they desaturate and induce fast.
Resuscitation at birth: the ladder 02 / 22 Dry and stimulate; heart rate below 100: ventilate, correct, intubate; below 60: compress, then adrenaline.
Newborn at birth Next step Apnoeic, cyanosed newborn at delivery → , open its explanation Warm, dry and stimulate first Still apnoeic or gasping after a minute → , open its explanation Start positive‑pressure ventilation Heart rate below 100 after drying, stimulation → , open its explanation Bag‑mask positive‑pressure ventilation; compressions only below 60 Heart rate below 100 despite mask ventilation → , open its explanation Correct ventilation; intubate if chest still not rising Vigorous baby after meconium‑stained fluid → , open its explanation Keep with mother, routine care; never intubate Vigorous meconium baby with secretions → , open its explanation Gently clear mouth and nose if needed Preterm under 32 weeks at birth → , open its explanation Blended oxygen at 30% or more Saturation target, preterm under 32 weeks → , open its explanation 85–95% by 10 minutes; never above 95% Heart rate below 60 despite effective ventilation → , open its explanation 3:1: 90 compressions, 30 breaths per minute Heart rate below 60 despite compressions and ventilation → , open its explanation Adrenaline 0.01–0.03 mg/kg IV/IO; tracheal 0.05–0.1 until access
Report a problem with card 2: Resuscitation at birth: the ladder
Fluids by weight 03 / 22 Give isotonic fluid by weight: 20 mL/kg for hypovolaemia; never hypotonic dextrose for losses.
Proceed or postpone 04 / 22 Active airway disease postpones what can wait; for what cannot, plan around the risk.
Pyloric stenosis: the plan 05 / 22 Pyloric stenosis is medical first: correct, empty the stomach, operate, then watch for apnoea.
Which test 06 / 22 Before surgery, look for the heart: echocardiogram in Down syndrome, fistula and omphalocele.
Preparation, premedication and pain assessment 07 / 22 Match the approach to the child's age: honest words, premedication, a calm parent, the pain scale.
Preparing the anxious or young child Child before induction Preparation Anxious, high risk of emergence delirium → , open its explanation Premedicate with dexmedetomidine Anxious, unpremedicated, separation fear, or developmental problems → , open its explanation Parental presence, used selectively Routine case or young infant → , open its explanation No parental presence Calm young child asking what will happen → , open its explanation Tell the child yourself in simple, age‑appropriate words
Oral sedatives Choosing a pain scale Report a problem with card 7: Preparation, premedication and pain assessment
Choosing the anaesthetic 08 / 22 Choose the technique by the main risk: lost access, apnoea, the airway or vomiting.
Child and procedure Technique Shunt revision, IV lost, not stuporous → , open its explanation Sevoflurane, early mask ventilation, then cannulate, relaxant, intubate Hernia repair, former preterm, apnoea‑risk age → , open its explanation Caudal 0.25% bupivacaine 1 mL/kg, no opioids; admit overnight MRI, CPAP‑dependent neonate needing intubation → , open its explanation Prefer intubation in intensive care before transfer Strabismus surgery induction → , open its explanation Sevoflurane, spontaneous breathing; no nitrous oxide
Report a problem with card 8: Choosing the anaesthetic
Tracheal tube size 09 / 22 Size tubes by age in children, by weight in preterm babies; cuffed tubes run smaller.
The neonatal surgical lesion: induction and ventilation 10 / 22 Protect lung and gut: gentle ventilation, no gas into gut or fistula, full relaxation for closure.
Neonatal lesion Anaesthetic plan Congenital diaphragmatic hernia: induction → , open its explanation Intubate without mask inflation; never nitrous oxide Congenital diaphragmatic hernia: ventilation → , open its explanation Gentle controlled ventilation, accept hypercapnia Congenital diaphragmatic hernia: oxygen target → , open its explanation Preductal saturation above 85% (Barash); 90–95%, no hyperoxia (Faust) Tracheo‑oesophageal fistula repair: induction → , open its explanation Inhalational induction, keep spontaneous breathing Tracheo‑oesophageal fistula before ligation → , open its explanation No relaxant, no mask positive pressure Omphalocele repair: intraoperative plan → , open its explanation Arterial line, full relaxation, generous balanced salt replacement Omphalocele repair: after surgery → , open its explanation Ventilate 24–48 hours unless defect very small
Report a problem with card 10: The neonatal surgical lesion: induction and ventilation
Results and normal values by age 11 / 22 Predict the result from the illness; judge each value against the norm for age.
Neonatal surgical lesions by presentation 12 / 22 Name the lesion by where and when: cord sac, bare bowel, first-feed choking, vomiting weeks later.
Presentation Lesion and associations Defect within umbilical cord, covered by sac → , open its explanation Omphalocele; other anomalies common, especially cardiac Periumbilical defect, no sac, inflamed bowel → , open its explanation Gastroschisis; associated anomalies rare Drooling, choking, cyanosis at first feed → , open its explanation Oesophageal atresia with distal fistula (type C, 85–90%) Vomiting starting weeks after birth → , open its explanation Pyloric stenosis: first‑born males, 3–5 weeks; confirm by ultrasound Heart defect, macroglossia or bladder exstrophy → , open its explanation Omphalocele, not gastroschisis
Report a problem with card 12: Neonatal surgical lesions by presentation
The blue, breathless or noisy infant 13 / 22 Name the cause from the sign: a saturation gap across the duct, sweating at feeds, stridor.
Bradycardia in theatre 14 / 22 Name the trigger and remove it: traction, the volatile, repeated succinylcholine; atropine if it persists.
Arrhythmia and arrest 15 / 22 Shock by weight: pulseless unsynchronised, unstable with a pulse synchronised; feel brachial in infants.
Sudden deterioration in the neonate and infant 16 / 22 Name the cause from what changed, then reverse it: decompress, dilate lung vessels, relax infundibular spasm.
Sudden event Cause and action Tetralogy of Fallot: acute cyanotic spell → , open its explanation Abort with morphine or short‑acting beta‑blocker Tetralogy of Fallot, between spells → , open its explanation Maintenance propranolol to prevent recurrence Sudden bradycardia, hypotension, desaturation: diaphragmatic hernia repair → , open its explanation Contralateral pneumothorax: chest drain on that side Pulmonary hypertensive crisis, including after diaphragmatic hernia → , open its explanation Inhaled nitric oxide first; extracorporeal membrane oxygenation if failing Abdominal closure: rising airway pressure, falling venous return → , open its explanation Excessive abdominal pressure: release fascia, stage with silo Tracheo‑oesophageal fistula, cannot mask‑ventilate → , open its explanation Gastric filling: vent stomach surgically, urgently
Report a problem with card 16: Sudden deterioration in the neonate and infant
New signs after a procedure 17 / 22 Trace a new sign back to what was just done before treating it.
How the newborn differs 18 / 22 Newborns differ: a reopenable duct, immature kidney and heat control, age-dependent volatile dose, a lower cord.
In the newborn Feature Newborn kidney sodium handling → , open its explanation Increased sodium loss, decreased sodium reabsorption Newborn glomerular filtration and renal vascular resistance → , open its explanation Filtration low; vascular resistance high before birth, falling from birth Ductus versus foramen ovale at one year → , open its explanation Ductus sealed by 4–6 weeks; foramen may stay patent Ductus kept open or reopened after asphyxia → , open its explanation Low oxygen, high carbon dioxide, acidosis; correct them Brown fat heat production → , open its explanation Non‑shivering thermogenesis driven by sympathetic noradrenaline Minimum alveolar concentration (MAC) by infant age → , open its explanation Peaks early infancy, lowest preterm; sevoflurane may peak term Spinal cord and dural sac until one year → , open its explanation Cord L3 (or L4), sac S3–S4; puncture L4–L5 or L5–S1
Report a problem with card 18: How the newborn differs
Preterm, post-term and ex-premature babies 19 / 22 Gestation sets the risks: preterm and growth-restricted babies differ, and ex-premature infants risk apnoea after surgery.
Baby by gestation Typical problems Preterm, born before 37 weeks → , open its explanation Respiratory distress, intracranial bleed, hypoglycaemia, hypocalcaemia, hyperbilirubinaemia Post‑term or growth‑restricted neonate → , open its explanation Polycythaemia (not anaemia), hypoglycaemia, meconium aspiration, asphyxia, hypothermia, later sepsis Ex‑premature, under 60 weeks postconceptual age → , open its explanation Postoperative apnoea risk; do not offer day surgery
Report a problem with card 19: Preterm, post-term and ex-premature babies
The child with obstructive sleep apnoea 20 / 22 Sleep apnoea: admit under 3, index ≥10 or nadir below 80%; cut opioids up to half.
Traps Check these before you finish 1 card · about 2 min 22 Traps
Traps 22 / 22 The tempting choice is the adult reflex or the louder sign; the books name another.
Tempting Right call Half‑normal saline to rehydrate pyloric stenosis → , open its explanation Resuscitate with balanced salt first; potassium once urine flows Hyperventilation expected after pyloric stenosis surgery → , open its explanation Postoperative hypoventilation; alkalosis, not acidosis Oxygen alone for congenital diaphragmatic hernia → , open its explanation Intubate, no mask inflation; gentle ventilation; oxygen to target Hypotonic dextrose–saline for surgical blood loss → , open its explanation Isotonic crystalloid, normal saline or lactated Ringer, at 3:1 Intubation for vigorous baby after meconium → , open its explanation Routine care with mother; clear mouth and nose if needed Intubating a preterm to push saturation above 95% → , open its explanation Blended oxygen from 30%; titrate to 85–95% at 10 minutes Atropine first for oculocardiac bradycardia → , open its explanation Ask the surgeon to stop pulling on the eye Oculocardiac reflex as the deadly squint association → , open its explanation Malignant hyperthermia: rare, deadly; watch throughout Parent in theatre for a young infant → , open its explanation Selective: separation‑anxious unpremedicated child, or developmental/behavioural problems Delayed induction with left‑to‑right shunt → , open its explanation Normal‑speed inhalational and intravenous induction Projectile vomiting as the oesophageal atresia sign → , open its explanation Drooling, choking and cyanosis at the first feed Hyperglycaemia as the typical preterm problem → , open its explanation Hyperbilirubinaemia; hypoglycaemia, hypocalcaemia, respiratory distress, intracranial bleed Cervical spine films in Down syndrome under 3 → , open its explanation Echocardiogram for every child with Down syndrome Same‑day discharge after tonsillectomy for obstructive sleep apnoea (OSA) → , open its explanation Admit if under 3, index ≥10 or nadir below 80% Propofol blamed for neonatal bradycardia → , open its explanation Repeat succinylcholine; give anticholinergic before redosing
Report a problem with card 22: Traps
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Sheet 09 · Paediatric 22 / 22
That is Paediatric, all 22 cards.
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Part 1 · Decisions What to do
04 · Proceed or postpone Active airway disease postpones what can wait; for what cannot, plan around the risk. 05 · Pyloric stenosis: the plan Pyloric stenosis is medical first: correct, empty the stomach, operate, then watch for apnoea. 06 · Which test Before surgery, look for the heart: echocardiogram in Down syndrome, fistula and omphalocele. 07 · Preparation, premedication and pain assessment Match the approach to the child's age: honest words, premedication, a calm parent, the pain scale. 08 · Choosing the anaesthetic Choose the technique by the main risk: lost access, apnoea, the airway or vomiting. 09 · Tracheal tube size Size tubes by age in children, by weight in preterm babies; cuffed tubes run smaller. 10 · The neonatal surgical lesion: induction and ventilation Protect lung and gut: gentle ventilation, no gas into gut or fistula, full relaxation for closure.