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2 Peds Emergencies Flashcards

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1
Q

_________ are the leading cause of childhood death in the U.S.

A

Injuries

Every well-child visit should include age-appropriate injury prevention counseling

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2
Q

Why are infants and toddlers more susceptible to head injuries?

A

Large heads in comparison to body size

Weak neck muscles —> prone to acceleration-deceleration injuries (shearing forces)

Thin skulls —> poor brain protection

Physically uncoordinated

Lack cognitive ability to predict/understand danger

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3
Q

Head injuries in kids have a _______ distribution

A

Bimodal

> 8: due to sports, MVA, ATVs, bikes, scooters etc

<1: falls from walking and furniture, abuse

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4
Q

Concerning signs after a head injury

A

Excessively sleepy or hard to arouse, vomiting, irritability

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5
Q

What are the first things you do when examining a peds head injury?

A

ABC’s

Neuro status (use the Glasgow Coma Scale, pupils, sucking reflex for an infant, muscle tone)

Vital signs

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6
Q

What is Cushing’s Triad

A

Vital signs findings in head injuries

WIDE pulse pressure
Bradycardia
Abnormal respirations

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7
Q

What are the three components of the Glasgow Coma Scale and what are the points?

A 
Eye Opening:
Spontaneous = 4
To speech = 3
To pain = 2
No response = 1

Best Verbal Response:
Oriented (coos or babbles in infant) = 5
Confused (irritable cries in infant) = 4
Inappropriate words (cries in pain in infant) = 3
Incomprehensible sounds (infant moans) = 2
No response = 1

Best Motor Response:
Obeys (infant moves spontaneous/purposefully) = 6
Localizes (infant withdraws to touch) = 5
Withdraws to pain = 4
Abnormal flexion = 3
Abnormal extension = 2
No response = 1

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8
Q

What is the highest score for the Glasgow Coma Scale?

A

15

≤8 needs immediate action

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9
Q

Battle’s sign, periorbital ecchymosis (raccoon eyes), hemotympanum, otorrhea/rhinorrhea (CSF)

A

Basilar skull fracture

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10
Q

Other things to look for in head/neck exam after head injury

A

C-spine alignment

Funduscopic exam

Hematomas (size and location), step-offs, crepitus, lacerations, fontanelles

Signs of basilar skull fracture

Don’t forget the rest of the body and TAKE PICTURES

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11
Q

What is the tool we use to determine whether or not to do a CT on a kid with a head injury?

A

PECARN

100% accurate in kids <2 (like 97% in kids >2)

CATCH and CHALICE are alternative

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12
Q

Concerning signs after head injury

A 
GCS < 15 or acute mental status change
Signs of skull fracture
Vomiting > 3 times
Seizure
Less than 2 years
Non frontal scalp hematoma
LOC > 5 seconds
Severe mechanism
“Not acting right” or lethargic
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13
Q

Brain bleed with a poor prognosis

A

Subdural hematoma

Occurs between the dura and arachnoid membrane and is associated with diffuse brain injury

Low pressure bleed, dissects arachnoid away from dura

Associated with LOC, lingering symptoms (irritability, lethargy, bulging fontanelle, vomiting)

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14
Q

CT findings for subdural hematomas

A

Crescent-shaped, usually in parietal area, crosses suture lines

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15
Q

Brain bleed with a better prognosis

A

Epidural Hematoma

Rupture of the arteries, esp the middle meaning earl artery, +/- underlying fracture

Brief LOC, lucid period, followed by deterioration

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16
Q

CT findings for epidural hematoma

A

Elliptical shape, that does NOT cross suture lines

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17
Q

Most common brain bleed

A

Subarachnoid Hemorrhage

Injury to the parenchymal and subarachnoid vessels

Symptoms range from normal to LOC

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18
Q

CT findings for Subarachnoid Hemorrhage

A

Small, dense “slivers” on CT

Blood in cisterns, sulci, and fissures

Blood in CSF

May take time to evolve and be visible on CT

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19
Q

How to manage a head injury if no intracranial hemorrhage, no skull fracture

A

Head injury precautions

Responsible caregiver, monitor for behavior change, vomiting, decreased arousability, seizure activity, irritability

Sleeping is ok, wake up every 2-3 hours and watch for signs of worsening condition

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20
Q

How to manage a head injury if positive intracranial hemorrhage, +/- skull fracture

A

Neuro consult

Admit to PICU

Evacuation of ICH/surgery to repair fracture vs observation w/ repeat imaging

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21
Q

Mild traumatic brain injury is another name for…

A

Concussion

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22
Q

Definition of a concussion

A

Traumatically induced alteration in mental status, w/ or w/o an associated LOC

Direct blunt force —> stretching/shearing of axons

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23
Q

Symptoms of a concussion

A 
Amnesia (either retrograde or antegrade)
Confusion and/or blunted affect, distractibility 
Delayed response
Emotional lability
Visual changes
Repetitive speech pattern
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24
Q

Important history considerations in concussion cases

A

Witness accounts are important

MOI

Length of LOC and length of confusion/mental status changes

Seizure activity, movement of extremities at scene

Hx of previous concussions or more significant brain injury

Substance use (EtOH or others - must CT, regardless of PE findings)

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25
Headache, mental fogginess and other mild concussion symptoms typically resolve within...
7-10 days (90% within 30 days) Severe, prolonged or worsening H/A, vomiting, deterioration in mental status are emergent
26
Concussion symptoms lasting 3 months or longer is called...
Post-concussive syndrome
27
What is second-impact syndrome?
2nd concussion within weeks of a 1st —> brain swelling, herniation, death Children are at an increased risk
28
Multiple concussions —> permanent changes in mood, behavior, pain
Chronic Traumatic Encephalopathy
29
Treatment protocols for concussions
NO SAME-DAY RETURN TO PLAY regardless of symptom resolution - consider absolutely no sports for 1-2 weeks, depending on severity Physical and cognitive rest - no cell phones, video games, adequate sleep, noise reduction for first 48 hours Structured return-to-play protocols
30
Cervical spine injuries are rare in peds, but when they do occur they are most often from ...
MVA’s <8 years old - usually C2-4, usually from falls >8 years old - usually C5-7, usually from sports
31
Adolescents with cervical spine injuries more commonly have...
SCIWORA - injury that doesn’t show up on MRI right away
32
Test of choice for cervical spine injuries
MRI
33
Concerning findings in possible cervical spine injuries
Bilateral pain Neuro deficits Torticollis Bony abnormalities
34
What should you always do before and after splinting/reduction/any fracture intervention?
Document neurovascular status
35
Management of an open compound fracture
Splint/dress, start IV abx, ortho consult
36
Management of a non-displaced open fracture (overlying laceration)
Start PO abx, repair laceration, splint, outpatient ortho f/u
37
How to manage grossly deformed/displaced fractures
May compromise NV structures Will require closed/open reduction, possible fixation (ortho consult)
38
Skin infections from bacterial entry via breaches in the skin —> erythema, warmth, tenderness, induration +/- fever, n/v/d
Cellulitis and Erysipelas Cellulitis involves the deeper dermis and subcutaneous fat Erysipelas involves the upper dermis and superficial lymphatic
39
Treatment of cellulitis or erysipelas
Warm wet compresses Topical abx (Bactroban) Oral abx (Keflex, Bactria) If failed outpatient treatment —> admit, labs, IV abx
40
Most common hematogenous spread of an infection to bone
Osteomyelitis (bone destruction) Most common in kids under 5, M>F Can affect long bones, including femur, tibia, humerus
41
Common pathogens for Osteomyelitis
Staph aureus (most common, MRSA) Strep pneumoniae Strep pyogenes
42
How does Osteomyelitis present?
Fever, bone pain, swelling, redness, and guarding Focal tenderness during exam X-ray will show soft tissue swelling early, 10-14d later—> bone destruction with LYTIC LESIONS
43
Best study for evaluation of osteomyelitis
MRI - can show marrow edema and abscesses Also do lab studies (CBC, CRP, ESR, Lactic Acid, Wound and Blood cultures)
44
Treatment for osteomyelitis
Supportive care IV Abx (empiric, then directed) - usually start with vancomycin, clindamycin, rocephin Surgical drainage or debridement Hyperbaric oxygen therapy (for chronic osteomyelitis)
45
What is the nationwide poison control number?
1-800-222-1222
46
Plants that can be toxic if ingested
Dieffenbachia Philodendron Poinsettia
47
Things that can be deadly in a single dose (sorry, it’s a long fucking list...)
``` Aspirin** Beta Blockers CCBs Camphor Chloroquine Clonidine Iron** Lindane Methyl Salicylate Methadone** Nicotine** Oils (hydrocarbons) Theophylline Tricyclics Antidepressants** Codeine (breaks down to morphine —> resp suppression)** ```
48
Grouped, physiologically-based abnormalities of vital signs, general appearance, skin, pupils, mucus membranes, lungs, heart, abdomen and neurologic examination that are known to occur with specific classes of substances
Toxidromes Typically helpful in establishing a diagnosis when the exposure is not well defined
49
Name the toxidrome: Delirium, flushed skin, dilated pupils, urinary retention, decreased bowel sounds, memory loss, seizures
Anti cholinergic “Hot as a hare, dry as a bone, red as a beet, blind as a bat”
50
Name the toxidrome: Confusion, weakness, salivation, lacrimation, defecation, emesis, diaphoresis, muscle fasciculations, miosis, seizures
Cholinergic
51
Name the toxidrome: Disorientation, HALLUCINATIONS, visual illusions, panic reaction, moist skin, hyperactive bowel sounds, seizures
Hallucinogenic
52
Name the toxidrome: Altered mental status, unresponsiveness, miosis, shock
Opiate/narcotic
53
Name the toxidrome: Coma, stupor, confusion, sedation, progressive deterioration of CNS function
Sedative/hypnotic
54
Name the toxidrome: Delusions, paranoia, diaphoresis, piloerection, mydriasis, hyperreflexia, seizures, anxiety
Sympathomimetic
55
Name the toxidrome: Tachycardia Hyperthermia Hypertension
Anticholinergic
56
Name the toxidrome: Bradycardia Hypothermia Tachypnea
Cholinergic
57
Name the toxidrome: Tachycardia Tachypnea HTN
Hallucinogenic
58
Name the toxidrome: ``` Shallow Resps Slow RR Bradycardia Hypothermia Hypotension ```
Opiate/narcotic
59
Name the toxidrome: Apnea
Sedative/hypnotic
60
Name the toxidrome: Tachycardia Bradycardia (if pure alpha agonist) HTN
Sympathomimetic
61
Name the toxidrome: ``` Scopolamine Jimson Weed Angel Trumpet Benztropine Tricyclic antidepressants Atropine ```
Anticholinergic
62
Name the toxidrome: Organophosphates Carbamates Mushrooms
Cholinergic
63
Name the toxidrome: Amphetamines Cannabinoids Cocaine Phencyclidine (PCP)
Hallucinogenic
64
Name the toxidrome: Opiates Propoxyphene Dextromethorphan
Opiate/Narcotic
65
Name the toxidrome: Barbiturates Benzos Ethanol Anticonvulsants
Sedative/hypnotic
66
Name the toxidrome: ``` Cocaine Amphetamines Meth Phenylpropanolamine Ephedrine Pseudoephedrine Albuterol Ma huang ```
Sympathomimetic
67
How to decontaminate a patient with toxic ocular exposure
Test pH Copious normal saline lavage until pH is normal Flush at least 15 min before re-evaluation Make sure contacts removed Acidic v alkali Consult ophthalmology STAT
68
How to decontaminate a patient with toxic skin exposure
Copious NS and water if exposed | Follow with soap to concentrated lipid-soluble toxins
69
How to decontaminate a patient with toxic GI ingestion
Activated charcoal, cathartic, whole bowel irrigation | Enhance elimination
70
How to decontaminate a patient with toxic blood stream
Antidote
71
Why isn’t Ipecac recommended anymore?
Only helps if given within 30 min of exposure
72
What is activated charcoal used for?
May help in select poisoning: carbamazepine, barbiturates, Dawson, quinine, theophylline Some evidence for use with digoxin and phenytoin Little evidence for use with salicylates NOT indicated with hydrocarbons, lithium, strong acid/base, metals, EtOH
73
What are the enhanced elimination modalities?
Activated charcoal Urine alkalization Diuresis Dialysis/Hemoperfusion
74
Antidote for acetaminophen
Acetylcysteine***
75
Antidote for Anticholinergics
Physostigmine
76
Antidote for Benzodiazepines
Flumazenil***
77
Antidote for Beta Blockers
Glucagon
78
Antidote for Calcium Channel Blockers
Calcium
79
Antidote for Digoxin
Digibind
80
Antidote for Heavy Metals
Chelating agents
81
Antidote for Narcotics
Naloxone***
82
What labs to do in cases of toxic ingestion (even if you know what it is...)
``` Salicylate level ACETAMINOPHEN level*** Urine drug screen Digitalis, theophylline, methemoglobin levels Lithium level PT/INR (warfarin) CO level CMP, coags, ABGs standard*** ``` Also, put them on cardiac monitoring
83
Once an ingested object passes the pyloric, it usually...
continues to the rectum and is passed in the stool w/o complications
84
When to be concerned about foreign body ingestion
Sharp or irregular edges —> can penetrate/perforate GI tract If lodged in esophagus —> may obstruct airway Perforation may result from direct mechanical or chemical erosion Aspirated vegetable matter —> intense pneumonitis, difficult to remove
85
How does an esophageal foreign body present?
Refusal to eat Vomiting Choking, coughing, stridor Neck/throat pain, inability to swallow Increased salivation FB sensation in chest
86
Exam findings in esophageal foreign body situations
Red throat Palatial abrasions Anxiety/distress Wheezing Decreased BS Fever Peritoneal signs OR NONE OF THE ABOVE
87
How to work up a foreign body ingestion
Patency of airway Radiography of neck, chest, abdomen (Neg XR doesn’t r/o) Procedure of choice for removal: • Esophagus —> ENDOSCOPY • Trachea —> BRONCHOSCOPY Progress of FB can be tracked
88
Indications for consult following FB ingestion
Sharp/elongated objects Multiple FB, ESP. MAGNETS*** Button batteries Evidence of perforation Presence of FB for >24 hrs Airway compromise Coin at the level of the cricopharyngeus muscle
89
Why are button batteries such a big fucking deal?
Extremely rapid action of the alkaline substance on the mucosa, pressure necrosis, residual charge Burns to the esophagus have been reported to occur in as few as 4 hours, perforation as soon as 6 hours
90
Which type of button battery is associated with the most adverse outcome?
Lithium
91
With ________ batteries, concern with heavy metal poisoning because they can fragment
Mercuric Oxide batteries Blood and urine mercury levels should be measured if cell is observed to split in the GI tract
92
When should a button battery be removed emergently?
If lodged in the esophagus If it has not passed through the pylorus after 24-48 hours of observation (usually excreted within 48-72 hours) If any GI signs of symptoms, immediate surgical consult
93
What is the definition of drowning?
Primary respiratory impairment from submersion in a liquid
94
What does the age distribution of drowning cases look like?
Bimodal Peak incidences in children < 4 and young adults 15-24
95
What are the two primary problems related to impaired ventilation?
Hypoxemia Acidosis
96
Most drowning victims aspirate ______ of liquid
< 4 mL
97
This occurs when laryngospasm —> hypoxia —> LOC but there is no fluid in lungs
Dry drowning
98
Aspiration of water into the lungs —> dilution and washout of surfactant —> dismissed gas transfer —> atelectasis —> V/Q mismatch
Wet drowning Can occur in fresh or salt water
99
A drowning event is considered to be a ___________ when survival is > 24 hr
Near-drowning Severe brain damage occurs in 10-30% of Peds non fatal drowning victims
100
Patients most likely to recover from a drowning
Those who are alert or mildly obtunded at ED presentation, especially if <14 years
101
Drowning patients with very poor prognosis
Comatose, receiving CPR en route to the ED, or have fixed and dilated pupils and no spontaneous respiration’s 35-60% die 60-100% of survivors experience long-term neurologic damage
102
Most critical factor associated with a poor prognosis in drowning
Duration of submersion >5 min**** ``` Also consider: Time to effective BLS >10 min Resuscitation duration >25 min Age >14 years Glasgow coma scale <5 Persistent apnea and requirement of CPR in the ED Arterial blood pH <7.1 upon presentation ```
103
Child abuse should be considered in these near drowning cases
Children < 6 months Toddlers with atypical presentation Adult supervision in conjunction with properly installed and maintained fences could prevent 50-90% of preschool aged drowning events
104
__________ drowning may cause death up to 72 hours after near drowning incident
Secondary drowning Fresh water drowning results in hemodilution, primarily from INGESTED water If large enough volume of water aspirated —> significant hemolysis or cardiac arrhythmias (due to electrolyte disturbance)
105
What should the ED treatment focus be in the case of drowning?
Assist ventilation as needed (keep PO2 >95%) Warmed isotonic IV fluids and warming blankets Address any assoc injuries, treat electrolyte abnormalities, monitor cardiac rhythm Get initial CXR, repeat at 6 hours Admit for observation
106
What is the goal when encountering a fever without a source?
Identify occult systemic bacterial infections (ie - PNA, UTI, bacteremia, HHV-6, infections, meningitis)
107
What is considered a fever?
Rectal temp > 38˚C (100.4˚F)
108
Workup for Fever w/o a source is based on...
Age (Neonates vs Children 3 months-3 years) Appearance (toxic?) Risk factors (birth Hx, travel, exposures, vaccination status, immune deficiencies)
109
Other symptoms of infection in neonates with fevers
``` Irritability Decreased activity Poor feeding/lack of weight gain Lethargy Change in sleep patterns Vomiting/diarrhea Hypothermia ```
110
How to work up a neonate with a fever
Full septic workup - CBC w diff, UA, CXR, LP, blood cultures) Early admission of empiric abx Admission pending culture results
111
Management of ill appearing 3-36 months olds with fevers
``` Labs UA Cultures (blood, urine, CSF, stool) CXR - if tachypnea or leukocytosis (≥20,000) is present Parenteral abx Admit ```
112
Management of well appearing but not completely immunized kids with fever
CBC w diff Blood cultures if WBC ≥15,000 UA (girls <24 months, uncircumcised boys <12 months, and circumcised boys <6 months) CXR if leukocytosis >20,000
113
Management of well appearing, completely immunized kids with fever
UA (Cath) and culture (girls <24 months, uncircumcised boys <12 months, and circumcised boys <6 months) Girls >24 months, uncircumcised boys >12 months and circumcised boys >6 months —> no routine labs, no presumptive abx therapy but do need UA C&S IF fever ≥39C and abnormal US should treat for UTI

Peds Rotation (13 decks)

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