Pediatrics (neonates to school age; adolescence is another topic) is probably my least favorite specialty to deal with and they are one of the hardest to help at times with all the elements that go with the patient. Whether it is dealing with the sick child or the distraught parents, we must sift through the physical findings and the information from the parents to understand what is going on. This gets especially sticky when it comes to some upper airway complications in the younger group.
Two very common upper airway problems in the younger populations include Croup and Epiglottitis. Both can be dangerous, but require different management when treatment is concerned. This article will give you a brief overview of the pathophysiology, signs and symptoms, treatments, and key points to remember.
Croup
Pathophysiology: Commonly a viral infection (RSV, adenovirus, influenza A and B, etc.) of the upper respiratory system for ages 6 to 36 months. Major inflammation has occurred in the larynx, trachea, bronchi, bronchioles, and lung parenchyma; causing obstruction of the airway. As the swelling progresses supraglottic the patients with begin show signs of respiratory distress. Further along, the patient’s lower airway may begin to begin having atelectasis, due to the lack of air keeping the alveoli open.
Croup is a slow progression of inflammation. Noticing early that the patient has upper respiratory issue is key in the management. Due to the smaller airway of children, we must not hesitate to seat
Signs and Symptoms: The most common sign of croup will be the seal like bark with inspiratory stridor. With this means that the patient is in respiratory distress and quickly heading to failure. If you hear the seal like bark, check the lower lung fields for crackles, because possible atelectasis may have begun.
Commonly more serious during night, awakening them from sleep. Other signs to know include:
Tachypnea
Retractions
Cyanosis
Shallow respirations
Fever
Treatment: Emergency treatment for croup is a humidified air and a dose of corticosteroids. If in further destress, racemic epinephrine will assist with edema. ETCO2 and O2 readings will help determine if there is retention of gasses, which may lead to acidosis. ABGs will be needed to confirm this as well.
Usually, patients will be able to return home to be monitored. Family should watch for difficulty breath and be using humified air. Antipyretics will assist in keeping fevers down as well.
Epiglottitis
Pathophysiology: Influenza type B, streptococcus pneumoniae or aureus may cause epiglottitis. The epiglottis is a small flap above the glottic opening, which is used to prevent foreign objects entering the trachea. When the epiglottis is infected, with will swell, narrowing the airway for the patient. Increased work of breathing may occur and soon my might have a patient in respiratory failure.
Epiglottitis is a more acute problem, with sudden onset and quick changes to mentation form the restriction of airflow.
Signs and symptoms: As the epiglottis swells, the child may begin to develop stridor. When stridor occurs, we must ask the question is this an object or is this medical. Other signs that might point you towards epiglottitis will be:
Sore throat
fever
Odynophagia
Drooling
Irritability
Cyanosis
Tripoding or nasal flaring
Treatment: The most important thing with these patients is to ensure they have an airway. Do not try and examine the patient, especially if you are a paramedic on scene (Load and go). When gathering a medical history, it is especially important to ask for vaccination in the pediatric population. Today, Influenza vaccinations are given to children, but we do have a set population now that do not vaccinate their children. X-rays of neck will be done and a visual examination may be performed. Keep the patient calm at this time, further agitation may cause the airway to swell more.
Patient will commonly receive an antibiotic, such as ceftriaxone, to help with the bacteria. ET tubes may be places in severe cases and usually remain for 24 to 48 hours. Trachostomes may be required, if a ET tube cannot pass the glottic opening.
Key Points
Both Croup and Epiglottitis can be dangerous to pediatric patients. If you have a child that has stridor and any signs of distress, they will need immediate attention.
Out of hospital, assume epiglottitis and rule it out when you can. This load and go for you
Croup X rays may show steeple sign, but epiglottitis won’t
I’ve been unfortunate to have lost a few good stethoscopes the past year and each time I replaced them, I continued to buy cheaper ones. Sadly, I did notice a drop in quality with the products when I did this. Each time I went to a different brand and try to reason that it really didn’t matter what I got so long as it was useful to me.
Honestly, though, I found that Littman produces some of the best stethoscopes with a wide pricing range based on what you want to spend.
3M Littmann Lightweight II
If you’re looking for something on the cheaper end, but still solid quality, I would always go with the 3M Littmann Lightweight II. It’s lightweight with a flexible hose. It’s fantastic when you’re trying to listen to lung sounds and you can get decent heart tones when necessary. The price is reasonable at less than $40.
You get what you pay for and this is no different with stethoscopes. While I love the 3M Littmann Classic II, I found it lacked a few qualities I needed when working in the emergency rooms or with a variety of patients. It only had the one large bell, which could get me generally sounds quickly, but the sound details weren’t of the highest quality.
3M Littmann Classic III
The 3M Littmann Classic III has a higher quality sound though and has the class two bell system with it. I found it much more efficient when it came to listening to the ranges of high and low pitch sounds that couldn’t be heard in the 3M Littmann Classic II. Also, the clarity of the sound made easier for me to hear those heart tones that may or may not be an S3 or S4.
Another added benefit is with pediatric patients. The smaller bell always helps me gather clearer heart tones and lung sounds, without picking up the tiny adorable stethoscope they hide at the nursing stations in a draw so physicians don’t steal the only one they have. Ultimately the 3M Littmann Classic III is my #1 for affordable and highest quality.
3M Littmann 6163
This last Littman is by the best one I’ve probably every used in my career. The 3M Littmann 6163 Cardiology IV is $170, but it is worth every penny. Higher frequency sounds can be heard with as little as pushing a little hard against the patient’s chest. It had a Dual-lumen tubing, which assisted in the rubbing noises we would hear in another stethoscope. It is made of lightweight material, but extremely durable to wear.
If you’re the type of person that won’t let a single soul touch your stethoscope, or you feel like it won’t go missing, then I would invest the extra money on the 3M Littmann 6163 Cardiology IV.
For those of you that lose your stethoscope like me:
I was in the ER working when I noticed an RN had something attached to his stethoscope. It was a Tile Mate. One of those wifi assisted devices that help you find your car keys were attached to it with a simple zip tie. While it wouldn't entirely prevent theft, it does eliminate the guessing where you left it last.
I got a message to do some toxicology pieces and that kind of reminded me of something I saw over the weekend that I just HAD to research. It is a series of drugs that the news was calling 100 times more potent than heroin or fentanyl, but in reality, it just wasn’t a narcotic.
Warning, due to the limited information out on the drug and its actual effects on a human, I am going to have to go over the pharmacological results for the most part and what I’ve pondered about this drug. I also had to do a Wikipedia search, so not going to say it’s 100% accurate, but not terrible either.
W-18 and -15
The history
First off, these two drugs are being used as a heroin substitute by many addicts. The news has gotten ahead of itself and calling it a narcotic because it originally came from the 1980’s research for analgesic drugs at the University of Alberta. It was actually apart of a series of 32 drugs. The series would later become Schedule 1 narcotics, making them illegal to use in any situation.
Pharmacology
At UNC School of Medicine, a comprehensive pharmacological profile was made of the two major players for this heroine replacement. The major goal of this study was to determine, which receptors the chemicals would bind to, how it was metabolized in the body, and how long would they take to break down.
The most important discovery of this reacher determined that they have no opioid activity. The abstract alone stated:
“Although W-18 and W-15 have been described as having potent antinociceptive activity and are presumed to interact with opioid receptors, we found them to be without detectible opioid activity at µ, δ, κ and nociception opioid receptors in a variety of assays.” (source 2)
Later in the paper, it does state that can bind with weakly binding sigma receptors and some benzodiazepine receptors.
Finally, they found a weak adherence to the H3-histamine receptor, which can play a big role in cardiac function.
Metabolism is done majorly in the liver and there was no change in how where or how the drug affected the receptors after broken down by the liver enzymes.
Excretion is believed to follow common routes of urination at this time.
Personal thoughts
While there isn’t a lot of information, I can honestly say that this fake opioid will NOT work with a standard convention of Narcan, but with the weak affinity for peripheral benzo receptors, maybe a flumazenil may do the trick.
The H3-histamine receptor is another concern. If you find a patient taking this drug, you may find them going into some kind of dysrhythmia. The patient that I dealt with states to have had an allergic reaction, causing his lower extremities to swell up, but had a heart rate of 130 bpm and in a normal sinus rhythm at the time. The patient was hyperthermic and BP was holding up well. Pt was honestly stable, but his last usage was greater than 24 hours and he still had some symptoms. Pt was later admitted to observation to ensure the swelling returned to normal to watch for lab and cardiac changes.
There is quite a lot to be said about the medications we use for patients with arrhythmias. It’s easy to get lost as to what drugs do what and how, but thankfully there was a kind enough person by the name of Vaughan Williams, who actually broke them down into separate classes. Each class effects separate parts of the cardiac cycle, ultimately changing the electrical current of the heart.
Cardiac Action Potential
Before looking at the medications, we have to understand the cardiac cycle and how it actually works.
The above chart presents the four phases of an action potential in a ventricular myocardial cell and how the electrolytes are used to cause the depolarization and repolarization of myocardial cells.
Phase 0 begins with a slight influx of sodium until it passes the potential threshold. Once past the threshold, more sodium channels will open and flood the cell, causing it the depolarize.
Phase 1 is an efflux of potassium from the cell, causing the cell to reach 0mV.
Phase 2 happens at this point. This is when calcium influx happens, prolonging the repolarization period. This period also goes by the name of an absolute refractory period for the cell, since it cannot depolarize during this time.
Phase 3 Calcium channels close again and potassium continues to efflux from the myocardial cell until the internal cell voltage returns to -90mV. Majority of potassium channels then close and the heart enters phase 4, which potassium is allowed to continue to leak into from the cell.
This process happens anywhere from 60 to 100 times per MINUTE!
Vaughan Williams Classifications
The major purpose of the medications in this class effect they way the cardiac action potential works in the cells of the heart. The drugs usually help to slow down specific phase to the heart and allow the heart to fix itself a bit.
Class I - Sodium Channel Blockers
These medications are designed to disrupt phase 0, causing a prolongation of it. There are 3 subcategories (a,b,c) that are broken down into moderate, weak, and strong.
This article won’t go into great depths, but the major goal of the class is to prolong the QRS complex and prolong or shorten QTi.
Medications include:
Lidocaine
Verapamil
Procainamide
Propafenone
Class II - Beta Blockers (-olol or -alol)
Quite commonly used out of hospital for patients with hypertension, beta blockers are actually a common antidysrhythmic. The basic pharmacology is: by blocking the beta-1 receptor sites, it prevents stimulation of the cardiac muscle to beat faster. The increase of sympathetic tone will decrease the rate the heart will beat.
Medications include:
Propranolol
Metoprolol
Carvedilol
Class III - Potassium Channel Blockers
Similar to the Class Ia medications, potassium channel blockers are used to prolong APD, which can cause a prolongation of ERP. This class of medication is commonly known to treat different ventricular dysrhythmias (Vtach or Vfib). The most common medication for this class is Amiodarone and deserves a post of its own.
It’s most common use is during CPR, when the patient is in pulses Vtach or Vfib rhythm and is then followed by a drip with ROSC is achieved. An important note to make about Amiodarone is it can take 16 weeks to leave the system.
Medications include:
Amiodarone
Sotalol
Ibutilide
Class IV - Calcium Channel Blockers
Commonly uses for Afib with RVR and PSVT, a calcium channel blocker will prolong phase 2 of the action potion in the cell. The goal is to slow the conduction through the atrioventricular (AV) node, slowing the ventricular tachycardia that is occurring. By prolonging the ERP in the AV node, the heart is able to regulate the rate better.
Calcium channel blockers are commonly prescribed by physicians to assist in the care of such arrhythmias. One side effect of these drugs is it may drop the patient’s BP, so ensure you have an SBP >100 or a MAP >65, prior to administering the medication
Class V - Others
This is the mix bag class. These drugs do not truly fit in any category but are still highly important to mention anyways. Two of these medications are Adenosine and Digoxin.
Adenosineprevents the re-entry of a signal in a sinus rhythm, preventing SVT. A warning though is for patients that have WPW syndrome may cause an increase in heart rate instead, so make sure you’re reading the rhythm correctly.
Digoxineffects vagal tone and is seen less as an emergency drug and more as a maintenance drug for chronic heart issues. A major issue with this drug is it holds a very narrow therapeutic index. Toxicity is quite possible if given too much.
Summary
Each class works in its own way on the action potential in the cardiac conduction system. How they affect the heart greatly determines when and how the medication should be used in different medical scenarios. The point of this article is to help a bit with the pharmacodynamics involved with the medications and to hint at the situations a person in the medical field would use them?
Remember to check out my facebook page. Feel free to send suggestions for possible article ideas, it might pop up some time. Always remember that medicine is an art, just as much as a science.
I have been working on this concept for a while now. I want to create not one application but a series of them. Each would be for the specific specialty of medicine and then another for community health.
The Problem
I currently don’t have the time or training to create applications to their fullest potential.
The Opportunity
I am looking for people looking to create apps with some experience and want to take part this venture with me. The gig will be perfect for college students or people currently finishing up in a course on app development.
The End Goal
This is not an upfront paying job. This is an opportunity to test your skills as an app developer and after completion receives a portion of the profits that are made if any are to be made.
Contact me if you are interested with your name, experience, and a little about yourself. I’m hoping to have at least 2-3 developers collaborating and at least 1 UX designer.
We all know this age group when our young ones begin to learn to talk and feed themselves. They learn to use the potty and start making new friends. This is when they love the word, “No!”
A lot of development occurs during this period of time and the growth in children, both mentally and physically are key. Here are some brief notes for you to look at for reference to what is to come with this age group:
Increase in illness, due to being around new children and playing with them.
Immune system will begin to grow in new environments
Neuromuscular growth occurs as they begin to develop finer motor skills
Brain will weigh 90% of an adult’s
Renal development is important as they begin to learn toilet training.
12 to 15 months feeling of fullness is known
18 months ability to control bladder muscles for excretions
Separation anxiety peeks 10 – 18 months
Basic language is mastered at 36 months
Age 3 – 4 most can understand full sentences.
Children begin learning sexual differences by observing their role models and siblings
Tip: do no try reason with children this age as to why a procedure needs to be done.
From time of conception through the first year of life, infants change a lot. There are a few key psychological and physiologic changes to the human during this time.
In the first month, the newborn cannot rollover
Fontanels are present and can be a good sign dehydration or inflammation of the brain
Large head and short neck
Notable reflexes a newborn will have are:
Rooting reflex – The Baby’s cheek is stroked. Ensures the infant’s feeding will be a reflexive habit
Grasp reflex – An object is pressed into the palm of the baby. Helps in exploratory learning
Moro reflex – Loud noises or a sudden drop in height while holding the baby. Protects from falling; could have assisted infants in holding onto their mothers during rough traveling.
Piaget’s Stages of Cognitive Development first state is Sensorimotor
Birth to ~2 years – primary senses seeing, hearing, touching, and tasting. How children learn about the world
I recently passed the NCLEX in 75 Q and created this list of tips I would’ve loved to have before I wrote!
- Essentials: Saunders & UWorld
- Nonessential but nice add on: @yournursingeducators ‘s (on Instagram) NCLEX high yield notes.
- Start early and start slow. Consider your preceptorship/final semester your opportunity to start studying for the NCLEX. Depending on your unit there will likely be downtime, bring a review book and do practice questions.
- Do 30-50 practice questions a day during preceptorship on the days your not working. It’s not much and it’s a good way to ease yourself into it.
- Make Flashcards with key concepts that are straight “memorizables”: lab values, antidotes (especially warfarin -> vit K, heparin -> protamine, digoxin -> digibind, Ca -> Mg), rules and formulas (like parkland formula, MAP formula), and mnemonics (like NSAID for cervical collar or “we better think high glucose” for metabolic syndrome)
- Book your exam and don’t look back. Trust that you’ll be ready when the time comes.
- Two-Three weeks before your exam is crunch time. 225-300 UWorld questions a day (3-4 75 question exams).
- Review the rationales how ever works best for you, but actually review and understand them! For me, I wrote them down in a word document separated into sections, putting drugs & diagnoses in bold.
- Before every study session in the crunch time, review your Flashcards and your rationales document.
- Treat each 75 question test like the actual NCLEX - no food or drinks, no pee breaks, no music. If you plan to use ear plugs, practice with ear plugs. I also found it helps to have a specific scent your relate to NCLEX study time. I got a new hand lotion that I used before every session and in the morning before my NCLEX.
- During crunch week set a time or # of questions to do each day and then be DONE. I would go for a walk afterwards to reset my brain. Over studying can happen and you don’t want to burn out.
- Mistakes are how you learn. Don’t be upset when you get questions wrong - be excited that you got it wrong when it didn’t matter and gave you the opportunity to learn something new.
- You will never been 100% ready, but if you’re consistently scoring above average on the Uworld questions, you’re probably good to go. Trust your gut.
- Treat your anxiety symptoms consistently and treat them the same way on the day of the NCLEX even if you think you’re all good. It’s probably partly related to adrenaline but when you get in there you might start feeling anxious - it’s all good. For me, I took the ginger gravol (not the dimenhydrinate) pretty much every night the last two weeks and on the morning of the exam.
- Don’t look up “Uworld % to pass NCLEX” or anything like that. Don’t compare your understanding to anyone else. Uworld’s site says “Test takers with a test bank score of 56% pass at a rate of 92%” - that’s the only number you should maybe think about, but don’t look up what other people had before the test because it doesn’t always correlate.
- Try not to think of it as a 75 question exam that gets longer if you’re doing worse, really try to think of it as a 145 question exam (at present, due to Covid) that gets shortened when you prove you’re doing well. It’s not essential to get 100% on 75 to be done in 75, the computer adapts quicker than that.
- I seriously recommend doing every single Uworld question. Ultimately the best practice for the exam isn’t Flashcards or memorizing concepts, it’s learning how to maneuver the NCLEX style questions.
Conspiracy theory: the test is way over hyped so all these companies can continue to profit off of your self doubt. Your education prepared you for this. Visualize your success. Visualize how cool your name, BN RN is gonna look. Your BN was WAY harder then the NCLEX. You’ve got this.
@crystalcanyon you asked for any advice and it reminded me to post this, so thank you ☺️
I honestly can’t believe we’re at this point but: I’m done my nursing degree! It’s been an absolutely incredible ride and I love that the studyblr community was such an influential part of that experience for me. Thank you all for your support and kind words for the past 4+ years.
At this point, I’m not sure what that means for this account, but if you have any ideas feel free to shoot me a message ❤️
hey everyone! i’m a peer tutor at my university and i wanted to share some study strategies that i’ve found really helpful in my stem/content-heavy courses. please feel free to share yours with me as well!
25 August - I got a desk today!! With New Zealand in Level 3 at the moment, I have to work and stay at home and I was finding uni so hard without having a proper work station, not anymore! so exciting!
