PICU Interview - Please Help!

Pediatric Critical Care Columnist · Mar 16, 2014

Way to go!! Don't overthink this whole "clinically-focused" thing. You know a lot. There are some differences with peds in terms of which catastrophe precedes which (almost always respiratory then cardiac), abnormal rhythms (kids rarely have v-fib, but a lot of bradycardia and SVT), the way they respond to drugs (some they only need a whiff and others they need a bucketful), weight-based dosing for everything, and the structure of their airways (more like a funnel than a cylinder, with the narrowest part at the cricoid level). Oh, and they're much more prone to hypoglycemia than hyper... and seize at a much higher glucose level than big people. Hypothermia in neonates and young infants can point to an infection just as easily as fever does.

The types of questions you'll be asked will be assessing your critical thinking and you've already got that. An example: You're getting an admission from the ED. The patient is 8 years old and was in a car-vs-bike collision. There's a closed head injury that neurosurgery is going to monitor. What do you need at your bedside? Here's another: Your patient is a 15 month old who has been admitted following a limp, blue spell at home. While you're doing your morning assessment her heart rate suddenly jumps from 124 to 200; she's sound asleep and her blood pressure is okay. What's going on and what's your first response? And one more: Your patient is 5 months old, an ex-prem and has been admitted with bronchiolitis. He's well-sedated and calm. Gradually over the last half hour his sats have started to drop, not alarmingly so, but noticeably, and his ETCO2 has started to slowly rise as well. You look at the ventilator and notice that his peak inspiratory pressure, which had been 14 cm H2O is now 18. What is happening and what do you do? Same patient, later in the day. Now the sedation isn't adequate any more and the baby has been quite agitated. Suddenly his sats start to fall fast from 96 to 82 to 65 and his heart rate from 170 to 30 to 90. What do you think is going on and what do you do? (Clue: Any time there's a sudden change the very first thing you do is call for help! Even if it turns out to be a false alarm, you're better to be thanking people for doing nothing than trying to explain why your patient is dead.)

When you're reviewing, get a good grip on normal vital signs across the age span. Know that hypotension is a VERY late sign and often is the point of no return. Young, healthy hearts can handle a huge amount of fluid given over a really short time. Don't be surprised if you have to give 100 mL/kg to a septic baby. And never trust a sick child!

dupuisea · Mar 16, 2014

Wow! Thank you for putting so much time into this post!

meanmaryjean, DNP, RN · Mar 16, 2014

I think one thing you can emphasize is that, as an ED nurse, you have a healthy 'sense of danger'. You don't EVER trust your patients- nor should you! :) This is CRITICAL for PICU.

Pediatric Critical Care Columnist · Mar 16, 2014

You're welcome! I want you to succeed. Now, how would you answer those questions? :whistling:

dupuisea · Mar 16, 2014

Thanks Jan! Alright, here we go...

- Patient #1, the 8yo with closed head injury. We are worried about the possibility of increasing ICP. To monitor that we'll want equipment for an EVD at the bedside. I have never assisted in this procedure so I honestly couldn't tell you what exactly you would need, but I DO know the warning signs of increasing ICP, which include: lethargy/irritability/change in level of consciousness, decreased response to painful stimuli, increased systolic blood pressure, tachycardia or bradycardia, dilated pupils, and changes in breathing pattern. Keeping regular neuro checks on this patient would be important as well as keeping an eye on the EVD since bleeding and infection are two main concerns.

- Patient #2: the 15 mo with HR jumping to 200 is probably experiencing supraventricular tachycardia. If she's not on a heart monitor let's get her on one to confirm the heart rhythm. Additionally, let's do some perfusion checks. How are her O2 sats? Her BP? How is her color, breathing pattern, peripheral pulses? Once you can confirm the patient is stable, notify the physician.

- Patient #3: 5yo on ventilation for bronchiolitis. In the first situation I would assume he needs to be suctioned. If the PIP is increasing then there is something "in the way." Another problem could be atelectasis. Second situation, yes, call for help! Possibly since the child was agitated the breathing tube was displaced. Start manually bagging the child.

Thank you for checking these! I answered them like I would in an interview (just based off what I know already), so I am more than open to your feedback in how I can improve.

Pediatric Critical Care Columnist · Mar 17, 2014

- Patient #1, the 8yo with closed head injury. We are worried about the possibility of increasing ICP. To monitor that we'll want equipment for an EVD at the bedside. I have never assisted in this procedure so I honestly couldn't tell you what exactly you would need, but I DO know the warning signs of increasing ICP, which include: lethargy/irritability/change in level of consciousness, decreased response to painful stimuli, increased systolic blood pressure, tachycardia or bradycardia, dilated pupils, and changes in breathing pattern. Keeping regular neuro checks on this patient would be important as well as keeping an eye on the EVD since bleeding and infection are two main concerns.

Good start! Most units will have a bin with all the necessary bits and pieces to set up an EVD. The neurosurgeon may or may not bring a ventriculotomy tray to the unit - it contains the sterile drill and bit, the scalpel and blade, a razor, sometimes sutures but usually not and a few other instruments. The surgeon will ask for xylocaine and a fine needle, some sedation (not ketamine - it raises ICP) and a paralytic. You'll need a separate pole to secure the EVD to and a level. A flashlight with new batteries is essential. You might want to have a litre bag of saline hanging, some mannitol, some 3% saline, maybe a cooling blanket, temperature probe, monitor modules, suction for the ETT the kid will almost certainly have, suction for oral secretions and one for gastric secretions. And the usual admission stuff.

- Patient #2: the 15 mo with HR jumping to 200 is probably experiencing supraventricular tachycardia. If she's not on a heart monitor let's get her on one to confirm the heart rhythm. Additionally, let's do some perfusion checks. How are her O2 sats? Her BP? How is her color, breathing pattern, peripheral pulses? Once you can confirm the patient is stable, notify the physician.

Very few PICU patients are NOT on a cardiorespiratory monitor. So let's assume you see a rate of 200 that doesn't vary, with a sudden onset. SVT, right? What's a quick vagal maneuvre you can try to see if the kid will convert? There are a couple... remember the child's age.

- Patient #3: 5 month-old on ventilation for bronchiolitis. In the first situation I would assume he needs to be suctioned. If the PIP is increasing then there is something "in the way." Another problem could be atelectasis. Second situation, yes, call for help! Possibly since the child was agitated the breathing tube was displaced. Start manually bagging the child.

Think of the external diameter of the ETT. It's going to be roughly the same size as the baby's little finger. Bronchiolitis produces GOBS of thick bubbly secretions. The ETT will be at risk of obstruction all the time. So you caught that part. Part two: if the ETT is displaced, will your bagging do much to bring the sats or the HR up? (This one just happened a few days ago on my unit.) how comfortable are you with pulling the tube and BMV ventilating?

Good job!! You answered pretty much as I would expect someone with only a passing familiarity with peds, but with a decent critical care background. I think you're good to go! I'll be waiting to hear...

Pediatric Critical Care Columnist · Mar 19, 2014

Well??? How did it go?? When do you start??

dupuisea · Mar 20, 2014

Hi Jan! That was really sweet of you to check in on me. Unfortunately, the phone interview did not go as well as I had hoped. It was VERY technical and I got nervous and stumbled over my answers. You live and learn, right? Perhaps it did not go as bad as I am thinking, but I did not hang up the phone feeling very confident. Anyways, we will see what happens. Regardless, thank you for helping me prepare! You are the best!

Pediatric Critical Care Columnist · Mar 20, 2014

That wasn't what I was expecting to hear. I'd wager though that you did better than you think. They're not going to compare your responses to someone with 20 years of PICU experience. After all, why do they have PICU education and orientation? You obviously impressed the PCM enough for her to set up a second interview. I'll be thinking about you while you wait... :nailbiting:

dupuisea · Mar 23, 2014

Didn't get it

At least I have a lot of interviewing practice under my belt now!

Pediatric Critical Care Columnist · Mar 23, 2014

I'm sorry to hear that. But keep trying. Now that you've had one of their interviews you'll know how to prepare for the next one.