Don’t Forget The Brain Busters – the live final

Cite this article as:
Team DFTB. Don’t Forget The Brain Busters – the live final, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.25641

With 130 teams entering Don’t Forget The Brain Busters, and 50 teams making it through the kids’ round, the toughest round with the toughest critics, we have been bowled over by the incredible answers sent through. We’re delighted to announce the final leader board.

 

 

 

 

The top four teams have made it through to the live final: The Salisbury Paediatric Warriors, Cardiff PPE, Universally Challenged and The Leftovers. The competition was fierce.

 

The live final

The DFTB Brain Busters live final will be on Friday 15th May at 11am – 12pm UK time, 8pm – 9pm Sydney/Melbourne time, 10-11pm NZ time.

The four teams will be fighting for the title of DFTB 2020 Brain Busters champion and a special, limited edition DFTB Brain Busters t-shirt.

Tune in to cheer the teams on – you will need to register in advance. You can do that by filling out the form at the bottom of this page, or here.

 

The Qualifying Rounds

In case you missed them, here are our five qualifying rounds again, this time with answers.

Round 1: The neonatal crossword. Answers here

Round 2: The Bubble wrap treasure hunt. Answers here

Round 3: The minor injuries picture round. Answers here

Round 4: The emoji round. Those long awaited answers here

Round 5: The kids’ round.

 

The kids’ round answers

Our mini quiz masters are allowing us to share their marking criteria along with some of their favourite answers.

 

If you were a Pokemon, which would you be and why? (Kai, age 11)

Kai set a pretty stringent scoring system.

5 points: fire, grass, water (they are the starter pokemon)

4 points: normal (few weaknesses, has the most pokemon), fighting (most damage but can ricochet), steel (one of the strongest), poison (double the damage)

3 points: dragon (not that much damage but good attacks), ice (can freeze but no damage), psychic (make you confused), rock (some throw rocks)

2 points: electric (paralysis and damage but not that strong), ground (can only attack on the ground), dark (can only attack at night), flying (weak, only when flying)

1 point: bug, ghost, and fairy (these are all weak pokemon)

 

The kids loved the rationale behind some of your answers.

“I would be Luxray. The coolest looking of pokemon and has the medical superpower of X-Ray vision. This means children in A and E would have to wait much less time as I could just quickly cast my eyes on them, see what the problem is and make a plan for it to be fixed much sooner.” Universally Challenged (University Hospital North Madlands)

“I’d be a Chansey so I can continue working at the hospital and caring for sick children. Chanseys know a lot about medicine because they are used to work with nurse Joy. Plus they know the power “sleep” to help sedate the patient. Plus they are super cute.” Fri-Burgers

“Dr Anderson says: I would like to be Nurse Joy (because nurses are awesome and she heals other characters) but my children say that I am SNORLAX (because he likes sleeping and he is fat… apparently)” Salisbury Paediatric Warriors

 

If you were a teacher in Hogwarts, what subject would you teach and why? (Jude, age 8)

Like Kai, Jude was pretty specific about the points allocation for this question.

5 points: defence against the dark arts (you only last a year as a teacher but it can save your life), care of magical creatures (scary and fun), Quidditch (world class level)

4 points: potions, transfiguration and flying (super useful and cool)

3 points: charms and astronomy (useful but not fun)

1 point: herbology and arithmancy (just a bit dull)

1 point: muggle studies, history of magic and divination (just too boring)

 

“We would start a new subject called Pomfrey’s Emergency Wiziatrics. This is because young wizards and witches should learn essential first aid skills to deal with their…magical accidents! We would teach them to never forget to use distraction methods for little wizards, such as Pygmy Puffs (or other age-appropriate Weasly Wizard Wheezes products). We would also start an owl-line resource with information on how to provide muggle first aid, in case they need to do so, which of course would be called Don’t Forget The Muggles.” by Haris, age 36 on her approaching birthday, on behalf of Containment Entertainment

“We would be Defence Against the Dark Arts teacher because working in a hospital can be super scary, but we can defend against it really well (plus it’s cool so meet all the crazy monsters and cast spells!)” Myoclonic Jerks, Ireland

“I would be a potions professor, working alongside Madam Pomfrey on the Hospital Wing. I’d be famous from the numerous books I authored such as ” Otitis Media and the philosopher’s itch” “Erythema Neonaturum and other potions to combat spots” and my best work ” Levateracetam and other twitch stopping tinctures.” Universally Challenged (University Hospital North Madlands)

If you could choose a superpower, what would it be and why? (Katie, age 12)

The kids tell us that this was a tough one to score. They were looking for originality, adventure and something that would do good in the world, and of course, something that made them laugh. Here are some of their favourites.

“I can influence the weather by singing. In Belgium, it rains a lot and it can make people grumpy. But not anymore! Now there are only sunny days and happy people due to my cheerful songs.” The Quizmaskers

“Invisibility PPE so that we don’t scare all the children while we look after them in hospital.” Stay Another Day, East End Crew

“I would go back to the day the DFTB team made up the emoji round and tell them not to make it so hard!” Nerd Immunity

“To make people laugh when no one else can – because if you can make people see the funny side of things, you’re most of the way to making everything all right.” Laura, age 27, on behalf of The Tele(health)Tubbies

“I would like to be able to control the weather (Atmokinesis- a bit like Elsa from Frozen) although I would definitely choose sunshine for when I’m off work or on holidays to play outdoors and maybe snow at Christmas as you can’t beat a White Christmas 🙂 or if I choose to befriend a snowman hehe.” Mental Arrythmias

“If I could choose a Superpower I would like to have the superpower of Elsa from Frozen so that I can freeze naughty bugs that make children ill so that they can get better quickly. I could also create magical worlds out of snow and ice. Imagine a giant slippy “Ice slide” going from your house to your best friend’s house? Most importantly, I can fly!” Curosurfing School of Babies

“I’m a doctor, so I think the superpower I would choose would be one I get to use every day… I would love to have a superpower to fix broken bones. Then the children I see who’ve hurt themselves wouldn’t be in pain any more, and they’d be able to run, and jump on trampolines, and play on monkey bars again straight away!” The Smooth Obturators

 

If you had a time machine for a day, what would you do? (Finlay, age 9, and Rhys, age 7)

Another question with some impressive answers and, so we’re told, a tough one to score. These are their top picks.

“We would use the time machine to travel forwards to the day of the DFTB Quiz Final. We would take part in an outwardly light-hearted and whimsical manner, and appear relaxed about our mediocre performance. In reality, however, we would be writing down everyone else’s answers with unwavering focus and a grim determination to win at all costs. We would then return in our time machine to the present day, emotionally numb but looking forward to certain victory and our share of the multimillion DFTB prize fund. Given more time, we would also try to do something about COVID and the JFK assassination, but we only have this time machine for one day, and presumably would need to work in comfort breaks.” Rob, age 36 and ½, on behalf of Containment Entertainment

“I would use the time machine to travel the past to find a couple of Unicorns and bring them back. I’m convinced that Unicorns really did exist in the past because if you look closely at the British Passport, it has a Unicorn on the front of it!” Curosurfing School of Babies

“The ability to teleport. It would mean I could go anywhere, whenever I wanted, even make Brisbane for DFTB20 ;-D” Clinicians Of Varying Intellectual Dispositions

“I would go back in time and show people what is going to happen to the earth we live on if they don’t look after the environment, and ask them to please please take care of the world, so that it can be here for my children and my children’s children to enjoy too.” The Smooth Obturators

“We’d go back in time to just before the chicken stepped out into the road and ask them, “why are you crossing the road?” and then we’d know the answer to the oldest question in the world.” Don’t Forget The Chloral

“Go forward to the day when Tottenham Hotspur win the premier league in 2090.” Tallafornia

 

What’s you best joke? (Will, age 9)

Where do triceratops sit?

On their tricerabottoms

Eliza, 6, on behalf of Universally Challenged (University Hospital North Madlands)

 

What did the finger say to the thumb?

I’m in glove with you.

Mental Arrhythmias

 

Why didn’t Elsa see a doctor for her sore throat and cough?

Because the cold never bothered her anyway.

Curosurfing School of Babies

 

If you’re English in the lounge, German in the hallway, and Italian in the bedroom, what are you in the bathroom?

European

Clinicians Of Varying Intellectual Dispositions

 

What did the magic tractor do?

It drove down the road and turned into a field!

The Smooth Obturators

 

Well, I’ve got this racing snail. It’s not been doing very well for the last couple of weeks. So I took its shell off to see if it would make it go faster.
If anything…….

It’s made it more sluggish!

The LeftOvers

 

Why don’t you give Elsa a balloon?
Because she would just let it go

PJ Masks N95

 

What do you call a sleeping bull?
A Bulldozer

Team Cork’s Crew

 

What do you call two octopuses that look the same?

Itenticle

Nerd Immunity, UK

 

What do you call a sick crocodile?

We were looking for an illigator, crock (or similar) or crocod-ill but we had to laugh when we saw these answers:

A handbag. Baby Sharks

An ambulance (otherwise it would be a very illigator). The Salisbury Paediatric Warriors

 

Why did the chimney call for a doctor?

Common answers were the flue, she wanted to stop smoking and he was burning up. But these were our favourites:

Because it had a foreign body (Santa) stuck inside of it. Broken Pencils

He had a bad cough/has the flue from all his smoking (but also considered differential diagnosis of small brick carcinoma). Herd Immunity

 

The best-paired joke was from the Brancatisano Beasties

What do you call a sick crocodile? A corona-dile?

Why did the chimney call for a doctor? Because the corona-dile was in it?

 

And our favourite team name?

Baby It’s COVID Outside

 

Don’t forget to join us for the live final on Friday 15th May at 11am – 12pm UK time, 8pm – 9pm Sydney / Melbourne time, 10-11pm NZ time. Register by completing this form.

Don’t Forget The Brain Busters – Round 5

Cite this article as:
Team DFTB. Don’t Forget The Brain Busters – Round 5, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.24803

The Kids’ Round

Do you think you have what it takes to talk to kids? These questions have been set by kids and will be marked by kids. So pull out all the stops to impress this panel of mini quiz masters.

If you were a Pokemon, which would you be and why? (Kai, age 11)

If you were a teacher in Hogwarts, what subject would you teach and why? (Jude, age 8)

If you could choose a superpower, what would it be and why? (Katie, age 12)

If you had a time machine for a day, what would you do? (Finlay, age 9, and Rhys, age 7)

What’s your best joke? (Will, age 9)

What do you call a sick crocodile?

Why did the chimney call for a doctor?

Don’t Forget The Brain Busters – Round 4

Cite this article as:
Team DFTB. Don’t Forget The Brain Busters – Round 4, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.24908

The DFTB team have been having great fun deciphering the Emoji quizzes doing the rounds on social media. But, despite digging deep, we couldn’t find a paediatric one… so we’ve made our own. Can you crack the code? Once you think you’ve sussed it, fill in the form below and press ‘Submit’ to see the answers.

See the answers here: Round 4 answers

Don’t Forget the Brain Busters – Round 2

Cite this article as:
Team DFTB. Don’t Forget the Brain Busters – Round 2, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.24719

The Bubble Wrap Treasure Hunt Round

This round is an excellent excuse to go on a hunt through some studies we think are pretty important.

 

Q1: Freedman et al conducted a study of the management of gastroenteritis – apple juice was found to have fewer treatment failures than electrolyte maintenance solution. But how many of the recruited 647 children actually had evidence of dehydration?

A: 85 (13.1%)
B: 206 (31.8%)
C: 324 (50.0%)
D: 400 (61.8%)
E: 512 (79.1%0

 

Q2: Maitland et al conducted the groundbreaking FEAST study examining different fluid regimes for the management of sepsis. How many children in TOTAL (of 3141 randomized) had severe hypotension (a systolic less than 50mmHg in <12 months old, <60mmHg in 1-5 year olds, <70mmHg in older than 5-year-olds plus one or more feature of impaired perfusion)?

A: 6
B: 58
C: 234
D: 789
E: 1899

 

Q3: Cunningham et al conducted the influential BIDS study which assessed whether the 90% or higher target for management of oxygen supplementation was equivalent to a normoxic 94% or higher target for infants admitted to hospital with viral bronchiolitis. What was the primary outcome measure?

A: Length of stay on a paediatric ward
B: Length of stay in intensive care
C: Number of days on oxygen
D: Time to resolution of cough
E: Escalation to high flow or CPAP therapy

 

Q4: Winter et al conducted a 4 year retrospective review of 33185 children. How many adverse events were there in children discharged with at least one abnormal vital sign?

A: None
B: 24
C: 314
D: 1024
E: 3987

 

Q5. Bexkens et al conducted a meta-analysis of pulled elbows. How many patients do you have to treat with hyper-pronation for a benefit over supination-flexion to be demonstrated?

A: 1
B: 4
C: 11
D: 300
E: 1000

See the answers here: Round 2 answers

Don’t Forget The Brain Busters – Round 1

Cite this article as:
Team DFTB. Don’t Forget The Brain Busters – Round 1, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.24692

The Neonatal Crossword Round

This round, created by @PaedsMichka, tests your neonatal knowledge and calls upon your crossword cracking prowess. Once you’ve busted this one, you will find a word hidden in the yellow boxes. Unscramble the letters and type it in the answer box below. Then press ‘Submit’ to see the answers.

Download a printable copy of the crossword here.

Clues

Down

  1. A congenital infection presenting with a maculopapular rash that can desquamate and have characteristic x-ray long bone changes.
  2. Prolonged and can be split.
  3. 13, 18, 21
  4. A 20-day old baby presents with worsening respiratory distress since birth. Which investigation will differentiate between a diaphragmatic hernia and phrenic nerve palsy.
  5. This test is positive when a posterior dislocation of the hip is reducible with this manoeuvre.

 

Across

  1. An acronym used to explain an event in an infant which could be due to a totally benign or alternatively very serious condition.
  2. Babies become alkalotic when this becomes obstructed.
  3. Monitored for in high -risk babies but no one can agree on a universal definition.
  4. Can be in or out. Has 3 vessels.
  5. A congenital cause of short gut.
  6. “Sophie is ………… and her murmur has disappeared. I think she’s having a hypercyanotic spell.”
  7. Passage of this is delayed in Hirschprung’s.
  8. A blood test that should always be sent when a baby is lethargic (and in fact when any child has a decreased conscious level of unknown cause but is often forgotten).
  9. Get this out of the cupboard when a baby comes in blue or shocked.

 

See the answers here: Round 1 answers

Don’t Forget The Brain Busters

Cite this article as:
Team DFTB. Don’t Forget The Brain Busters, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.24841

In what is proving to be a tough time for many of us, we thought we’d inject some fun. After all, nothing beats having a laugh with your friends and if there’s a bit of bonus learning at the same time, even better. With this in mind, Don’t Forget The Bubbles are excited to be launching Don’t Forget The Brain Busters, a quiz with a difference. Now we say with a difference because we’re encouraging some healthy inter-department rivalry. Intrigued? Read on…

Much like the FIFA World Cup*, the Don’t Forget The Brain Busters is made up of qualifying rounds followed by a live final.

 

When will the quiz start?

Starting Monday 20th April, we’ll publish a Brain Buster every other day for 10 days, that’s five Brain Busters, each with a different theme. Each Brain Buster will stay open until Sunday 3rd May so don’t worry if you can’t get to it that day, there’ll be time to get your answers in.

 

How do we enter?

Pub quiz rules are out the window – teams are allowed to consult, google, ask a friend or do anything (within reason) to solve the clues. Simply fill in your answers at the bottom of each post and press Submit. This will take you to the correct answers and, as long as you’ve registered, will put your team forward to be considered for the live final.

 

What about the live final?

Our panel of quiz masters (aged 7 and up) will score each entry. The highest four scoring teams will be invited to a live virtual final, with some fancy tech (think University Challenge via Webinar).

With entries anticipated from Australasia, Europe and Africa, we’re keeping the date and time of the live final fluid, but are aiming to schedule it for the beginning of May. Watch this space for more information.

 

Some q-tips

Choose your team wisely. The questions will range from neonatal to trauma so have a think about who would complement your knowledge-base. Humour is a bonus. A team of 6 is ideal.

Multiple teams from a department are welcome.

Think up a good name – there may be some bonus points for originality.

Let us know where your team is based, either geographically or virtually.

If you’d like your answers to be marked for the live final, register your team below.

 

*The Fédération Internationale de Football Association (FIFA for short) was established in 1905 in Paris. As well as winning the 1966 World Cup final, England, as one of only 6 countries to ever win the tournament while hosting, is famous for managing to lose the trophy 3 months before winning it, when it was stolen from Westminster. The trophy was eventually found by a dog called Pickles whilst out for a walk. “Brazil said it was a sacrilege that would never have been committed in Brazil where even its thieves loved football too much.” (source: BBC News on this day)

We having a minor technical glitch so if you are having trouble submitting the form then just email the info to hello@dontforgetthebubbles.com instead

The curious incident of the wheeze in the night time

Cite this article as:
Costas Kanaris. The curious incident of the wheeze in the night time, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.22330

The first rule of the DFTBquiz is that the approach to each particular case and patient is not dogma, nor is it the only way in which the case can be safely managed in our virtual ED. There are numerous ways to approach critical illness. As long as the applied clinical treatment passes both the evidenced based medicine and family litmus then we have nothing to fear apart from the disease process itself.

So how would the DFTB team at Bubbles Central Hospital approach the child with life threatening bronchospasm, altered sensorium that has a pneumothorax and an SVT?

If you missed the original question – check it out here

This has been the second most successful #pedsicu f#ridayquiz to date with >30k impressions and answers from 29 different countries! It was a complex case of common pathologies amalgamated in one patient – status asthmaticus with a pneumothorax and SVT.

We outline the DFTB team’s take on the case and how we would approach it if we had this patient in our own resus bay. Please note this is not the only way to approach the patient but rather what our consensus is as to how to prioritize clinical issues and minimize risk in this patient by using a rational, evidence-based and pharmacologically prudent approach.  There were numerous excellent answers from across the globe. Here are a few highlights…

Things to consider are:

  • What is immediately the most life-threatening pathology? The pneumothorax? The SVT? The severe bronchospasm?
  • Why does the child have lactic acidosis?
  • Is it really an SVT or is it a tachycardia, exacerbated by nebulized beta-agonists? What risks are posed by any intervention we undertake?
  • How do we minimize the risks identified above?
  • What drugs should we use for intubation and what how do we maintain anaesthesia thereafter?

1. What is immediately the most life-threatening pathology? 

It is clear that this child is at high risk of cardiorespiratory arrest if we do nothing.

Clues to that are hypoxia, hypercarbia (especially in the context of altered sensorium)[1]; air trapping to the extent where a pneumothorax has developed (a known complication of asthma)[2] and the lactic acidosis, which in this case is likely to be secondary to a combination SVT leading to myocardial hypoperfusion and the respiratory muscles tiring (more on that later).

On the ABCDEFG approach (Airway, Breathing, Circulation, Disability, Exposure, Fluids, Glucose) we are taught to approach airway first. This failsafe approach may work well in most clinical emergencies but in this case, intubating before achieving cardiorespiratory stability is likely to put the patient in an even stickier situation.  Breathing (i.e. adequate oxygenation) is likely to be the first pathology to lead to cardiorespiratory arrest. That needs to be addressed first. The SVT is likely to cause considerable instability during intubation; this is superimposed to the pre-existing high risk of adverse events that accompany life-threatening asthma[3]. So the SVT needs to be cardioverted prior to intubation if possible.

Furthermore, the risk of converting a pneumothorax to a full-blown tension pneumothorax by attempting to intubate first is significant. Most modified RSI methods include a bag and mask ventilation technique. The application of positive pressure ventilation either before or after the ETT is in place –once the patient is established on a ventilator- risks changing the nature of the pneumothorax from a simple one to a life-threatening tension-type one[4].

In this case, therefore, airway stabilization – although high on the list of priorities – should come after we have optimized breathing and circulation (unless the patient arrests beforehand).


2. Why does the child have lactic acidosis?

The latter is important to understand and differentiate in someone who has been receiving a beta-agonist.

In the context of asthma lactic acidosis may be due to overproduction and/or inadequate clearance of lactic acid. Therefore, lactic acidosis in a child with severe bronchospasm could result:-

      • if patients were in occult shock
      • if produced by tiring respiratory muscles (i.e., respiratory muscle oxygen demand outstripping oxygen supply)
      • if produced by the lung parenchyma
      • if changes in glycolysis were caused by beta-agonist administration.
      • lactic acid could also be under metabolized by the liver

In our case the patient did not receive any IV salbutamol and only a couple of nebulizers; pharmacogenic lactic acidosis is therefore unlikely.

Much more likely is a lactic acidosis as a result of tiring respiratory and cardiac muscles. The latter is especially important to recognize in the context of an SVT. The myocardium perfuses during diastole[6]. If the HR is 300, the diastolic time is minimal, so there isn’t much time for the myocardium to be adequately perfused.

Tired respiratory and cardiac muscles make for a very high-risk intubation process.


3. Is it really an SVT or is it a tachycardia, exacerbated by nebulized beta-agonists?

It is tempting to think that such a significant tachycardia has been caused by a combination of factors: the patient is hypovolaemic, the patient is stressed, we gave him a couple of salbutamol nebs – and so on.

How can we differentiate a sinus tachycardia from an SVT?

Most textbooks will empirically state if the HR is >210-220 then the rhythm’s is more likely to be SVT, if it is <200-210 then it is likely to be sinus tachycardia.

This is loosely true but not always, especially in the context of paediatrics where we have different HR norms for each age.

Beat-to-beat variability is important in differentiating SVT from sinus tachycardia. Whilst in SVT each (P) QRST complex looks the same as the one after it, in sinus tachycardia each PQRST complex is different. A 12 lead ECG will help you ascertain this more accurately.

The presence of P waves is another determining factor.  A true SVT oughtn’t to have P waves preceding the QRS complex, whereas in a sinus tachycardia a P wave is usually present.  This is often tricky to differentiate in practice, especially if the ECG or cardiac monitors are tuned onto real-time speed. The best trick to apply is to slow the monitors down enough. This will slow down the speed of the PQRST complexes, allowing us to better visualize the P wave.

Vagal manoeuvers and pharmacological therapy if there is uncertainty about the cardiac rhythm is poor practice and should be avoided.  Cardiac output equals stroke volume times heart rate (CO= SVxHR). If we try to slow down the heart in the context of very fast sinus tachycardia with drugs or by stimulating the vagus nerve we will drop the cardiac output and put the patient at risk of a cardiac arrest.  We always need to be sure of the rhythm before any intervention.

If you are still uncertain, a reasonably safe bedside test would be to give 10ml/kg fluid bolus (ideally balanced solution) and keep an eye on the monitor whilst it’s infusing. If it is an SVT the HR will not budge. If it is sinus tachycardia, you are much more likely to see some slowing down of the rate.


4. What risks are posed by any intervention we undertake?

The risks of intubating someone with pneumothorax have been outlined above.

PPV can change a stable, small pneumothorax into a life-threatening tension pneumothorax. This dictates that we should ideally put a temporary chest drain in to decompress the thorax prior to intubation.

The other risk in optimizing breathing in this scenario is an exacerbation of the SVT by giving IV bronchodilating agents that are known to have a potent chronotropic effect. Both aminophylline [7] and salbutamol [8] are known to be chronotropic, but evidence would suggest that aminophylline causes less of a chronotropic effect than salbutamol[9]. With that in mind, loading with IV aminophylline in order to break the bronchospasm spiral would be the best (or least bad) option.

Also worth noting that MgSO4 is a potent vasodilator, so if we intend to use it in this setting to optimize bronchodilation it needs to be done as a low infusion (over 25-30 minutes)

The risks we may encounter whilst in improving circulation prior to intubation are twofold.

Firstly, in addressing cardioversion, adenosine is the most commonly used agent in treating SVT pharmacologically. A known side effect of adenosine, however, is bronchospasm[10].  There is little high-quality evidence to assess the effects of adenosine on asthmatic airways. What little evidence there is (and the evidence is nearly all from adult subjects) would suggest that adenosine is safe to use in patients with reactive airways[11],[12].

Secondly, this patient is likely to have a degree of dehydration. This degree of tachypnoea and work of breathing increases fluid loss through the respiratory tract. The degree of tachycardia also suggests a hyper-metabolic demand, again suggesting increased fluid consumption. It would, therefore, be prudent to give this patient some volume prior to intubation.  As the patient already has metabolic acidosis,  (ab)normal saline would be a poor choice. The chloride content is likely to increase chloride levels leading to a worsening metabolic acidosis [13], which in turn would worsen myocardial contractility [14],[15]. Balanced solutions (Plasmalyte 148 or Hartmann’s) are by far more physiologically appropriate and unlikely to exacerbate the metabolic acidosis [16],[17] and therefore preferred in this instance.


5. How do we minimize the risks identified above?

We have alluded to a lot of the steps in the analysis above. The main objective is to optimize oxygenation and primum non-nocere.

Bronchodilation prior to intubation is key. In this case, it is reasonable to go “all-out” and load with IV aminophylline, IV Hydrocortisone, IV Magnesium and a triple agent nebulizer (repeat if needed) consisting of salbutamol, ipratropium, and adrenaline (croup dose) to try and minimize air trapping by opening up the airways.

A temporary chest drain is important. This will help with pre-intubation oxygenation and reduce the risk of a peri-intubation tension pneumothorax from developing.

Cardiovascular stabilization is also important prior to intubation. Volume resuscitation prior to intubation is best done with a balanced solution (as outlined above) and –if anaemic- possibly blood as that would help with the overall oxygen-carrying capacity and give the patient more reserve. It is important to remember that this should be done in 10ml/kg aliquots because a high proportion of children with SVT will have concomitant congenital anatomical abnormalities. Give the fluid, assess response, check for rhonchi and hepatomegaly, and repeat as necessary. It is possible that the patient may still need cardiovascular support after intubation.

Which inotrope is best will be dictated by whether or not we have managed to successfully cardiovert (by vagal maneuvers first, by incremental doses of adenosine second and by DC cardioversion third). The inotropes need to be pre-drawn, prior to intubation so that we can start them quickly. This is not a scenario where we should be playing catch-up and preparation is key.

IV adrenaline would be a strong favorite in the usual asthmatic, not least because it has potent bronchodilatory effects and is reasonably safe to use in asthmatics[18]. If we have managed to stop the SVT then there would be a strong argument to favour this.  Adrenaline, of course, is also a potent chronotrope, so we should; on balance avoid it in someone with SVT. Noradrenaline is the least chronotropic out of our inotrope choices, so if we are still in SVT or we think that the patient is at high risk of reverting back into SVT then it would, on balance, be our best choice. Have a low threshold for inserting an IO if you don’t have enough large-bore access.


6. What drugs should we use for intubation and what how do we maintain anaesthesia thereafter?

 There is a long-standing truism in the art of rapid sequence intubation that says, “there is no such thing as a cardiostable induction”. This is especially true in the intubation process of critically ill children. All induction agents tend to vasodilate and cause a blood pressure drop. Couple that with the vagal stimulation caused by the laryngoscope and you can see why RSI is tricky business.

Arguably the least cardio-unstable combination of drugs in this setting would be ketamine  (1-2mg/kg),fentanyl (1mcg/kg), and rocuronium (1-2mg/kg). Ketamine has the added benefit of being a bronchodilator so it would definitely help in reducing the bronchospasm[19].

Intubating using sevoflurane may also be attractive for experienced anesthetists, not least because of the potent bronchodilatory effect that it can offer us[20]. This would still be my second choice however, because of how much vasodilation and blood pressure drop it may cause.

Always be prepared for adverse events during intubation. In this case, our chest drain needs to be in first, we need some inotropes pre-drawn as well as some volume in case the BP drops. A favorite trick of mine is using dilute adrenaline as a bolus to improve BP or HR or both should they drop during intubation.

The dilution is essentially tenfold of the resuscitation dose. Take the resus dose, dilute it with 10 ml of saline and you can bolus the eventual solution in 1ml aliquots. This is a superior drug when compared to commonly used atropine as it addresses also the BP drop and not just the HR drop.

Maintenance of anaesthesia is often with continuous infusion of morphine and midazolam. In this case, those agents would not be the best choice. Morphine is known to increase histamine release and is therefore likely to exacerbate bronchospasm and peripheral vasodilatation.  Fentanyl, as a continuous infusion, is proven to cause less histamine release and is, therefore, a superior choice in this case[21].

Coupling the fentanyl with a ketamine infusion (instead of midazolam) would also be preferable, mainly because of ketamine’s bronchodilatory effects. For doses /rates and dilutions of these pharmacological agents fill in and print the drug chart on crashcall.net or the one provided by your regional paediatric critical care transport team.

 

So what plan would go up on the PED resus board?

  1. Optimize B and C first. Prepare Airway trolley  (including 4, 4.5 and 5 cuffed ETT) and draw up 10ml aliquots of Plasmalyte dilute adrenaline. Draw up noradrenaline and adrenaline for infusions if needed.
  2. Break the bronchospasm cycle. IV aminophylline, slow IV MgSO4, triple neb (adrenaline, salbutamol, ipratropium). Temporary chest drain –and prepare for a more robust one after intubation.
  3. Confirm rhythm. 10ml/kg fluid volume, vagal maneuvers, incrementally increasing doses of adenosine until Cardioversion 100mcg/kgè200mcg/kgè 300mcg/kgè500mcg/kg. If adenosine fails for DC Cardioversion. Ideally prior to intubation.
  4. 1-2mg/kg ketamine, 1mcg/kg fentanyl, 1-2mg/kg Rocuronium; maintain anaesthesia with ketamine and fentanyl infusions (crashcall.net doses/rates)
  5. Empirical cover, include cover for atypical infections: Ceftriaxone + Clarithromycin. If flu possible consider Oseltamivir.
  6. Avoid 0.9%Saline, 10ml/kg aliquot of Plasmalyte or Hartman’s, if anaemic consider blood. Reassess after every bolus (liver size and rales).
  7. Keep an eye, likely to rise (stress response, steroids, salbutamol) unlikely to need treatment even if high.

Remember, this is just the DFTB team’s approach. There are numerous ways to skin a cat; if you have an alternative way we are keen to hear it!

References

[1] Holley, Anthony D., and Robert J. Boots. “management of acute severe and near‐fatal asthma.” Emergency Medicine Australasia 21.4 (2009): 259-268.

[2] Porpodis, Konstantinos, et al. “Pneumothorax and asthma.” Journal of thoracic disease 6.Suppl 1 (2014): S152.

[3] Zimmerman, JANICE L., et al. “Endotracheal intubation and mechanical ventilation in severe asthma.” Critical care medicine 21.11 (1993): 1727-1730.

[4] Bacon, A. K., et al. “Crisis management during anaesthesia: pneumothorax.” BMJ Quality & Safety 14.3 (2005): e18-e18.

[5] Forsythe, Sean M., and Gregory A. Schmidt. “Sodium bicarbonate for the treatment of lactic acidosis.” Chest 117.1 (2000): 260-267.

[6] Heusch, G. “Heart rate in the pathophysiology of coronary blood flow and myocardial ischaemia: benefit from selective bradycardic agents.” British journal of pharmacology 153.8 (2008): 1589-1601.

[7] Urthaler, Ferdinand, and Thomas N. James. “Both direct and neurally mediated components of the chronotropic actions of aminophylline.” Chest 70.1 (1976): 24-32.

[8] Crane, J. et al “Cardiovascular and hypokalaemic effects of inhaled salbutamol, fenoterol, and isoprenaline.” Thorax 44.2 (1989): 136-140.

[9] Morice, A. H., et al. “A comparison of the ventilatory, cardiovascular and metabolic effects of salbutamol, aminophylline and vasoactive intestinal peptide in normal subjects.” British journal of clinical pharmacology 22.2 (1986): 149-153.

[10] Bennett-Guerrero, Elliott, and Christopher C. Young. “Bronchospasm after intravenous adenosine administration.” Anesthesia & Analgesia 79.2 (1994): 386-388.

[11] Burki, Nausherwan K., Mahmud Alam, and Lu-Yuan Lee. “The pulmonary effects of intravenous adenosine in asthmatic subjects.” Respiratory research 7.1 (2006): 139.

[12] Terry, Polly, and Gail Lumsden. “Using intravenous adenosine in asthmatics.” Emergency Medicine Journal 18.1 (2001): 61-61.

[13] Kellum, John A. “Saline-induced hyperchloremic metabolic acidosis.” Critical care medicine 30.1 (2002): 259-261.

[14] Cingolani, Horacio E., et al. “Depression of human myocardial contractility with “respiratory” and “metabolic” acidosis.” Surgery 77.3 (1975): 427-432.

[15] Williamson, John R., et al. “Effects of acidosis on myocardial contractility and metabolism.” Acta medica scandinavica199.S587 (1976): 95-112.

[16] Bellomo, Rinaldo, et al. “Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults.” Jama 308.15 (2012): 1566-1572.

[17] Chowdhury, Abeed H., et al. “A randomized, controlled, double-blind crossover study on the effects of 2-L infusions of 0.9% saline and plasma-lyte® 148 on renal blood flow velocity and renal cortical tissue perfusion in healthy volunteers.” Annals of surgery 256.1 (2012): 18-24.

[18] Putland, Mark, Debra Kerr, and Anne-Maree Kelly. “Adverse events associated with the use of intravenous epinephrine in emergency department patients presenting with severe asthma.” Annals of emergency medicine 47.6 (2006): 559-563.

[19] Allen, Joseph Y., and Charles G. Macias. “The efficacy of ketamine in pediatric emergency department patients who present with acute severe asthma.” Annals of emergency medicine 46.1 (2005): 43-50.

[20] Schutte, D., et al. “Sevoflurane therapy for life-threatening asthma in children.” British journal of anaesthesia 111.6 (2013): 967-970.

[21] Rosow, Carl E., et al. “Histamine release during morphine and fentanyl anesthesia.” Anesthesiology 56.2 (1982): 93-96.

 

Don’t Forget The Brain Busters rego

Cite this article as:
Team DFTB. Don’t Forget The Brain Busters rego, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.25076

If you haven’t yet registered for the Don’t Forget The Brain Busters don’t worry, it’s not too late to enter.

 

When will the qualifying rounds close?

A Brain Buster will be published every other day for 10 days, that’s five Brain Busters, each with a different theme. Each Brain Buster will stay open until Sunday 3rd May so don’t worry if you can’t get get to it that day, there’ll be time to get your answers in.

 

How do we enter?

Pub quiz rules are out the window – teams are allowed to consult, google, ask a friend or do anything (within reason) to solve the clues. Simply fill in your answers at the bottom of each post and press Submit. This will take you to the correct answers and, as long as you’ve registered, will put your team forward to be considered for the live final.

 

What about the live final?

Our panel of quiz masters (aged 7 and up) will score each entry. The highest four scoring teams will be invited to a live virtual final, with some fancy tech (think University Challenge via Webinar).

With entries anticipated from Australasia, Europe and Africa, we’re keeping the date and time of the live final fluid, but are will schedule it for the beginning of May. Watch this space for more information.

 

Some q-tips

Choose your team wisely. The questions will range from neonatal to trauma so have a think about who would complement your knowledge-base. Humour is a bonus. A team of 6 is ideal.

Multiple teams from a department are welcome.

Think up a good name – there may be some bonus points for originality.

Let us know where your team is based, either geographically or virtually.

If you’d like your answers to be marked for the live final, register your team below.

 

Don’t Forget The Brain Busters – Round 1 answers

Cite this article as:
Team DFTB. Don’t Forget The Brain Busters – Round 1 answers, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.24705

And here are the answers to the Neonatal Crossword Round

 

 

1. Syphilis

A congenital infection presenting with a maculopapular rash that can desquamate and have characteristic x-ray long bone changes.

Congenital syphilis is not uncommon in developing countries. Pathognomic signs for congenital syphilis include a generalised maculopapular rash that can desquamate, rhinorrhoea and involvement of the long bones. Long bone x-rays will show translucent metaphyseal bands, osteochondritis, osteitis and metaphysitis and periostitis. Have a look at Trisha’s post on neonatal rashes you shouldn’t ignore for some more serious neonatal rashes.

 

2. Hyperbilirubinaemia

Prolonged and can be split.

Prolonged hyperbilirubinaemia (>14 days in term and >21 days in prems) needs further investigation. Look for clinical clues like hepatomegaly and encephalopathy. For a brilliant acronym on clinical signs, causes and investigations for pathological jaundice read Shalome’s neonatal jaundice post.

 

3. Trisomy

13, 18, 21

Trisomy 13, 18 and 21 are examples of chromosomal structural abnormalities and these children present with syndromes of recognisable patterns of morphological abnormality. Genetic testing benefits include confirmation and implications for treatment, prognosis and recurrence. Have a look at this post for a few more examples of genetic syndromes.

 

4. Ultrasound

A 20 day old baby presents with worsening respiratory distress since birth. Which investigation will differentiate between a diaphragmatic hernia and phrenic nerve palsy?

Phrenic nerve palsies can occur after birth trauma and commonly after thoracic surgery causing hemi-diaphragmatic paralysis. Both phrenic nerve palsies and congenital diaphragmatic herniae can look similar on chest x-ray so ultrasound can be really useful to differentiate between them. Plication is the most common surgical treatment. Read more on whether there is a connection between phrenic nerve and Erb’s palsies on Abbey’s a pair of palsies post. 

 

5. Ortolani

This test is positive when a posterior dislocation of the hip is reducible with this manoeuvre.

Infants can have asymmetric skin creases but not all have asymmetric skin creases with risk factors for Developmental Dysplasia of the Hip (DDH). Read more on the clinical exam and use of imaging for diagnosing in Andy’s post on diagnosing DDH.

 

6. BRUE

An acronym used to explain an event in an infant which could be due to a totally benign or alternatively very serious condition.

This new definition: a Brief, and now Resolved, Unexplained Event stratifies patients. Low-risk BRUE’s do not need admission but do require certain investigations. Read more on who fulfils criteria as a low-risk BRUE and what to do for them in Tessa and Damian’s Fancy a BRUE and Tessa’s BRUE is the new black posts.

 

7. Pylorus

Babies become alkalotic when this becomes obstructed.

Only 1 in 7 cases of pyloric stenosis will have the classic triad of forceful and projectile vomiting, visible peristalsis and the palpable ‘olive’. Babies usually present at around 6 weeks of age and are usually hungry and dehydrated. Read more on typical gas findings and management in Erin’s pyloric stenosis post.

 

8. Hypoglycaemia

Monitored for in high-risk babies but no one can agree on a universal definition.

Some risk factors for hypoglycaemia include prematurity, small for gestational age babies, infants of diabetic mothers and even hereditary defects in carbohydrate or amino acid metabolism. It is always best to screen those at risk, avoid hypoglycaemia in hospital and check your hospital protocol for the correct threshold for intervention in hypoglycaemia. Want to read more about low sugar level thresholds? Read How low can you go? by Becky, Jasmine and Alasdair.

 

9. Umbilicus

Can be in or out. Has 3 vessels.

2 Arteries. 1 Vein. Did you know the umbilical vessels can be catheterised up to 7-10 days after delivery? If the cord is dry, apply saline-soaked gauze around the cord for at least one hour prior to the procedure. Read more on topics involving the umbilicus in Andy’s navel gazing post.

 

10. Gastroschisis

A congenital cause of short gut.

Other common causes of short bowel syndrome or short gut include those children who have undergone procedures for necrotising enterocolitis and volvulus. The amount and anatomy of the remaining gut determines the outcome of enteral and parenteral nutrition. Read more on the complications and management of short bowel syndrome in this post by Li-Zsa.

 

11. Desaturating

“Sophie is ………… and her murmur has disappeared. I think she’s having a hypercyanotic spell.”

Cyanotic heart conditions generally have some derangement with either their pulmonary or systemic blood flow. Baseline saturations or status of Tetralogy of Fallot depends primarily on the degree of pulmonary stenosis (or pulmonary outflow obstruction). Read further on how to manage a tet spell in Tessa’s congenital heart disease in PEM post.

 

12. Meconium

Passage of this is delayed in Hirschprung’s.

When faced with a delayed  passage of meconium also think about cystic fibrosis, meconium plug syndrome and make sure there are no anorectal malformations. Want to know about infant stools? Read Andy’s poop patrol post.

 

13. Ammonia

A blood test that should always be sent when a baby is lethargic (and in fact when any child has a decreased conscious level of unknown cause but is often forgotten).

Always suspect metabolic disease when things don’t quite fit together. History is key, together with signs and start with tests including glucose, ammonia, lactate, gas, LFT’s, FBC, plasma amino acids and acylcarnitine’s and urine organic acids. Read more on inherited metabolic disorders in Katie’s spotting the zebras post.

 

14. Prostin

Get this out the cupboard when a baby comes in blue or shocked.

Congenital cyanotic right heart obstructions such as TOF’s, transposition of the great arteries with ventricular septal defect and pulmonary stenosis generally present after the resuscitaire. Listen to this great DFTB podcast to learn more about congenital heart disease.

 

 

And the hidden word?

BUBBLES (of course)

 

Take a look at our next Brain Buster round – the Bubble Wrap Treasure Hunt.