Acute Care Flashcards
(76 cards)
1
Q
What is pulmonary re-expansion edema?
A
• Rapid removal of ≥1L of pleural fluid may be associated with the development of systemic hypovolemia and shock
- Large volumes of fluid move from the vascular space to airspaces of the rapidly reinflated lung
- Caused by sudden marked lowering of the intersitital fluid pressure
○ Increased vascular permeability to protein
○ Increased and excessive stretch or tension of the alveolar septal walls during reexpansion of lungs that have been collapsed for several days
2
Q
What is the clinical course of action in a child who has just swallowed a button battery?
A
- If in the esophagus, must be removed urgently
- If the child is <5 and the battery is 20 mm in diameter, must be admitted and plan for removal in next 48 hours; if symptomatic, must remove urgently
- If the child is 5 or older, and the button battery is <20 mm in diameter, may monitor as outpatient over the next 48 hours
3
Q
What are the 3 clinical indications for emergent endoscopy?
A
- Suspected esophageal obstruction (unable to handle secretions)
- Swallowing large, elongated and sharp object (>6 cm)
- Button battery that has remained in the esophagus
4
Q
What is the criteria for intubation of the head injury child?
A
- GCS score ≤10
- Decrease in GCS of >3 independent of the initial GCS score
- Aniscoria >1 mm
- Cervical spine injury compromising ventilation
- Apnea
- Hypercarbia (PCO2 >45)
- Loss of pharyngeal reflex
- Spontaneous hyperventilation causing PCO2 <25
5
Q
What are the features of Cushing’s Triad?
A
- Elevated BP
- Hypoventilation
- Decreased HR (Bradycardia)
6
Q
What interventions should be done to immediately manage a child with a blown pupil after a traumatic head injury?
A
- Hyperventilation
- Mannitol/hypertonic saline
- Elevate the head of the bed (30 degrees)
- Loosen collar if present
- Sedate +/- paralyze
- Keep head in midline
- Call neurosurgery for ICP probe +/- CSF drainage
7
Q
Glasgow Coma Scale: Eyes
A
4- Spontaneous eye opening
3- To voice
2- To pain
1- No eye opening
8
Q
Glasgow Coma Scale: Verbal response
A
5- Appropriate 4- Confusion 3- Unintelligible 2- Moaning to pain 1- None
9
Q
Glasgow Coma Scale: Motor response
A
6- Spontaneous movement 5-Withdraws to touch 4- Withdraws to pain 3- Decerebrate 2- Decorticate 1- No movement
10
Q
What ECG changes are to be expected in the case of an amitriptyline overdose (anticholinergic overdose)?
A
slow intervals, fast HR
• QRS prolongation ○ QRS > 100ms is predictive of seizures, QRS > 160ms is predictive of ventricular tachycardia • PR interval prolongation • dominant R wave in aVR • QT interval prolongation
11
Q
What clinical signs are seen in anticholinergic overdose?
A
- Hyperthermia (“Hot as a hare”)
- Tachycardia (“Heart runs alone”) – EARLIEST & MOST RELIABLE finding of anticholinergic toxidrome
- Mydriasis (dilated pupils)
- Absent bowel sounds (“Bowel and bladder lose their tone”)
- (Flushed skin – “red as a beet”)
- (Dry mouth & urinary retention – “Dry as a bone”)
- (Confusion – “Mad as a hatter”)
- (Decreased visual acuity – “Blind as a bat”)
- Delirium/confusion/agitation, sedation, seizures, coma
12
Q
What are the mainstays of treatment in cases of amitriptyline overdose?
A
1) Intubation and hyperventilation (aim for pH 7.50-7.55)
2) Sodium bicarbonate (100 mmol or 2mmol/kg) IV every 1-2 minutes until rhythm and perfusion are restored
Second line treatment is lidocaine (1.5mg/kg) IV once pH is greater than 7.5
13
Q
What are the 3 classifications of burns?
A
- Superficial
- Partial thickness
- Full thickness
14
Q
What are the criteria for considering hospitalization in the case of burns?
A
- > 15% total BSA (10% if <10 yoa, >20% if >10 yoa)
- Significant burns to hands/feet, major joints, face or genitals
- Pregnancy
- The burn is concerning for non-accidental injury or abuse
- Presence of 3rd degree burns
- High tension or lightning burns
- Chemical burns
- Concerns for inhalation injury (regardless of BSA)
- Inadequate home or social environment
- Burns in those with preexisting medical conditions that may complicate acute recovery phase
- Presence of associated injuries (i.e. fractures)
15
Q
What are the 4 signs of possible inhalation injury?
A
- carbonaceous sputum
- facial burns
- wheeze, hoarse voice or stridor
- singed nasal hairs
16
Q
What are 4 mechanisms by which you can receive an inhalation injury?
A
- Inhalation of toxic vapours
- Direct heat injury
- Asphyxia
- Carbon monoxide poisoning
17
Q
What additional injuries must you assess for in a burn victim?
A
- Carbon monoxide poisoning - 100% O2
* Cyanide poisoning - hydroxocobalamin
18
Q
In what circumstance do you apply the “Rule of 9s” in estimating BSA involvement?
A
If the child is 14 years and older
Otherwise, must use modified chart
19
Q
What is the Parkland Formula?
A
• 4 mL/kg/hr x %BSA
- 1/2 to be replaced in the first 8 hours with remaining 1/2 to be replaced in the following 16 hours
20
Q
When to consider watchful waiting approach in cases of spontaneous pneumothoraces?
A
• If “small” - no explicit percentage, based on clinical appearance of patient as stable with appropriate vital signs
21
Q
Treatment options for spontaneous pneumothorax?
A
- watchful waiting over 7 days +/- 100% oxygenation
- needle decompression in 2nd intercostal space
- chest tube placement if pt has large pneumothorax, is unstable, or if pneumothorax is associated with underlying disease such as cystic fibrosis or malignancy
- recurrent pneumothoraces can be treated definitively using sclerosing agents such as medical grade talc
22
Q
What is the lowest possible acceptable systolic blood pressure?
A
70+ 2(age of patient)
PALS: hypotension 0-28d: < 60 1-12 months: <70 1-10 years: 70 x (2+age) >10 years: <90
23
Q
What are the risk factors for predicting cerebral edema in cases of DKA?
A
- Age <5
- New diagnosis of diabetes
- Use of sodium bicarbonate
- Insulin bolus
- Early IV insulin infusion (within the first hour)
- Overhydration with hypotonic fluids
24
Q
Why is potassium low in DKA?
A
Excess blood glucose results in osmotic diruesis and activation of renin-angiotensin-aldosterone system that leads to K+ loss
25
What is the biochemical criteria for establishing a diagnosis of DKA?
* BG >11 mmol/L
* pH <7.3 (Mild = 7.2-7.3 Mod = 7.1-7.2 Severe <7.1
* Bicarbonate <15
* presence of Ketones
26
Why might urine strip testing for ketones underestimate the severity of DKA?
Majority of ketones produced in DKA is betahydroxybutyrate which is not picked up by urine strip testing
27
What are the Ottawa Ankle Rules?
Guidelines for determining whether a child should have an x-ray of their ankle
- pain or tenderness in the posterior edge of either the medial or lateral malleolus
- pain or tenderness of either the medial or lateral malleolus
- painful or tender navicular or base of the 5th metatarsal
- failure to bear weight post accident and in ER
28
What are the steps re: resuscitation in the case of a patient who is unconscious and found without a pulse?
• Call for help, call for AED
• Start CPR x 2 mins
• Assess for shockable rhythm
- if VT/Vfib 2 J/kg and continue CPR x 2 mins; establish IV access if possible, reassess for shockable rhythm; give Epi if 2nd shock unsuccessful or PEA (1:10 000 Epi 0.01 mg/kg IV)
- if PEA, give first dose of Epi before resuming CPR, may give Epi every 3-5 mins; reassess for shockable rhythm
• Treat for reversible causes
29
What are the Hs and Ts?
* Hypothermia
* Hypovolemia
* Hypo-/Hyperkalemia
* Hypoglycemia
* Hypoxia
* H+ (acidosis)
* Toxins
* Tamponade
* Tension pneumothorax
* Thrombosis (coronary/pulmonary)
30
What are the doses of resuscitation medications?
* Epinephrine (1:10 000) 0.01 mg/kg Iv
* Epinephrine (1:1000) 0.01 mg/kg by ETT
* Amiodarone 5 mg/kg IV
* Lidocaine 1 mg/kg IV followed by 50 mcg/kg/min infusion
31
What is the threshold for SVT in pediatrics?
* Infants: HR >220 with absent P-waves
| * Children: HR >180 with absent P-waves
32
What are the treatment options for cardioversion in SVT?
* Synchronized cardioversion 0.5-1 J/kg followed by 2 J/kg if needed
* Adenosine 0.1 mg/kg to max of 6 mg pushed in a large, proximal IV, followed by 0.2 mg/kg to a max of 12 mg
* Procainamide 15 mg/kg IV given over 30-60 mins
* Amiodarone 5 mg/kg IV given over 30-60 mins
33
What is a toxic dose of iron?
>40 mg/kg
34
How many stages are involved in Iron toxicity? What are the cardinal features of each?
Four.
1) Initial stage
- Profuse vomiting and bloody diarrhea
- Volume losses +++
2) Second stage (6-24 hours post ingestion)
- Quiescent phase
- GI symptoms resolve
3) Third stage (12-24 hours post ingestion)
- Multisystem organ failure, shock, hepatic and cardiac dysfunction
- ARDS
- Metabolic acidosis
4) Fourth stage
- 4-6 weeks post ingestion
- GI strictures and obstruction
35
What toxins are poorly absorbed by activated charcoal?
"PHAILS"
```
Pesticides
Hydrocarbons and heavy metals (Lead)
Alcohols, Alkalis and Acids
Iron
Lithium
Solvents
```
36
What are the contraindications to Whole Bowel Irrigation?
Bowel obstruction or airway compromise
37
What is the formula for determining the size of an ET tube?
- Uncuffed: 4+ (Age/4)
| - Cuffed: 4 + (Age/4) - 0.5
38
How does the CPS suggest children with moderate asthma exacerbations should be treated?
* Ventolin x 3
* Keep O2 sats >94%
* Oral steroids
* Consider Ipratropium bromide
* If still not stable after 2 hours of treatment, consider admission
39
How does the CPS suggest children with the most severe asthma exacerbations should be treated?
* Continuous O2 sat and vital sign monitoring
* O2 by non-rebreather
* Ventolin and Ipratropium bromide neb x 3 in 1 hour
* IV methylprednisone
* Consideration of IV MgSO4, aminophylline, ventolin
* Consideration of ICU admission
40
What is the Systemic Inflammatory Response Syndrome (SIRS) criteria?
```
2/4 of the following:
• *fever of at least 38.5C or low temp <36C
• *elevated WBC
• elevated heart rate
• tachypnea
```
41
What is the criteria for Sepsis?
Must meet criteria for SIRS but with proven infection
42
What is the diagnostic criteria for Severe Sepsis?
Must meet criteria for sepsis plus one of the following:
• ARDS
• cardiovascular collapse i.e. even post 40 mL/kg fluid resuscitation
• two systems affected and approaching end organ dysfunction
43
During fluid resuscitation, what clinical features should alert the physician to change their method of resuscitation?
* Hepatosplenomegaly
* Presence of crackles or rales on auscultation
* Should prompt transition to ionotropes as these signs are suggestive of cardiogenic shock
44
What antibiotics are suggested in children with suspected sepsis/meningitis?
* 0-28 days - ampicillin/gentamicin (M: amp/cefotaxime)
* 29-90 days - ampicillin/cefotaxime (M: ampicillin/cefotaxime/vancomycin)
* 3-36 months - cetriaxone/vancomycin
45
Why is propofol not an acceptable option for long-term sedation?
• Risk of propofol infusion syndrome (propofol induced metabolic acidosis, bradycardia, cardiac failure, rhabdomyolysis, hyperlipidemia, profound shock, and death)
46
How quickly should hyponatremia be corrected?
No more than 10 mEq/L in a 24 hour period
47
Why is it important to have a shoulder belt rather than just a lap belt when it comes to seat belts in cars?
Distributing the weight with a shoulder belt prevents a flexion fulcrum being applied anterior to the abdomen at the time of impact, thus protecting the child from getting a Chance Fracture
48
What are the 3 most common causes of PE in children?
* Indwelling catheters/lines
* OCP
* Hypercoagulable states i.e. SLE, cancer
49
What are the symptoms seen in drug-induced dystonia?
○ Sustained muscle contractions, repetitive/twisting, abnormal postures i.e. trismus, mouth opening, grimacing, pleharospasm, glossopharyngeal contraction, stridor, oculogyric crisis, opisthotonus, torticollis
50
What drugs, if given in large doses, can lead to dystonia?
○ Antipsychotics (haloperidol, chlorpromazine)
○ Atypical antipsychotics (quetiapine, olanzapine, risperidone – less than typicals)
○ Anti-emetics (prochlorperazine, promethazine, droperidol)
○ Carbamazepine
○ Antimalarials
○ Antihistamines
○ TCA
○ Lithium
51
What medication is given to treat children with drug-induced dystonia?
Diphenhydramine (1-2 mg/kg/dose given IV, max 50 mg/dose)
52
What is the pathophysiologic mechanism for Tylenol toxicity and liver damage?
Tylenol is metabolized by cytochrome P450 enzyme CYP2E1, which is then rapidly conjugated with glutathione; in overdoses, the body runs out of glutathione, resulting in build up of toxic metabolites which induce hepatocellular necrosis
53
What is a toxic dose of acetaminophen in children?
200 mg/kg or repeated daily maximums of 90 mg/kg
54
What are the 4 stages of acetaminophen toxicity?
Stage 1 (First 24 hours)
- Normal labs, high acetaminophen level
- Anorexia, vomiting
Stage 2 (24-48 hours)
- Resolution of stage 1 symptoms
- Elevated liver enzymes and INR
- RUQ pain and tenderness
Stage 3 (3-5 days)
- Signs of liver and/or multisystem dysfunction
- Peak transaminase elvations
```
Stage 4 (5-14 days)
- Complete resolution or death
```
55
What is the antidote for acetaminophen toxicity?
N-acetylcysteine (NAC)
56
What is the name of the nomogram used to track blood acetaminophen levels?
Matthew-Rumack Nomogram
57
What are indications for liver transplant?
□ Acidemia (pH <7.3) post fluid resuscitation
□ Coagulopathy (INR >6)
□ Renal dysfunction (creatinine >3.4 mg/dL)
□ Grade III or IV hepatic encephalopathy
58
What are the indications for inducing Whole Bowel Irrigation in cases of iron ingestion?
Serum iron concentration >500 µg/dL OR
| Moderate to severe symptoms of toxicity (e.g., acidosis), regardless of serum iron concentration
59
What changes occur to the resuscitative algorithm in cases of hypothermia?
* Body must be warmed to at least 35 C before death can be declared
* Until rewarmed to >30 C, max 3 attempts at shock
* No medications to be given IV until rewarmed to >30 C
* Active rewarming must be done as soon as possible
60
Why are children at greater risk of hypothermia than adults?
○ High body volume to surface area ratio
○ Decreased subcutaneous fat
○ Limited thermogenic capacity
61
What ECG finding is common in cases of hypothermia?
○ Osborne waves (dome or hump noted at the J point - where the QRS complex meets the ST segment)
62
What is the best indicator for prognosis in a child who has just been rescued from drowning?
• Duration of submersion
Submersion duration <5 min → Intact survival or mild neurologic impairment (91%)
63
How do you treat children who have ingested hydrocarbons?
- High risk of pneumonitis, support airway (cuffed tube)
- No gastric lavage, induction of vomiting, activated charcoal or whole bowel irrigation
- If CHAMP, consider gastric emptying
- Camphor, halogenated hyydrocarbons, aromatics those associated with heavy Metals or Pesticides
64
What complication is of greatest concern in children with camphor ingestions?
The hydrocarbons greatly reduce surface tension in the lungs, leaving to risk of pneumonitis and pneumatocele formation
65
What is the physiologic effect of salicylates on the body?
* Stimulation of respiratory centre - respiratory alkalosis
* Uncoupling of oxidative phosphorylation - metabolic acidosis
* Stimulation of glycolysis and gluconeogenesis
* Tachycardia and significant insensible losses
* Tinnitus
* Fever
66
How do you treat ASA overdose?
1) Aggressive fluid resuscitation
2) Prompt sodium bicarbonate therapy
- Target pH of 7.45-7.55
3) Urinary alkalinization
- Target pH 7.5-8
- Converts salicylates to the ionized form, trapping it in the renal tubules and enhancing elimination
4) Watch potassium as hypokalemia impairs alkalinization of urine
5) Monitor levels every 2-3 hours
6) Consider dialysis in cases of severe disease
67
What does the CMPA advise in the case of interactions with the police?
"Physicians are bound by a duty of confidentiality to their patients. As such, physicians should not provide any patient information to the police unless the patient has consented to this disclosure or where it is required by law"
68
What criteria needs to be fulfilled in order to declare brain death (5)?
• Established etiology capable of causing neurological death in the absence of reversible conditions capable of mimicking neurological death
• Deep unresponsive coma with bilateral absence of motor responses (excluding spinal reflexes)
• Absent brainstem reflexes as defined by:
○ absent gag and cough
○ bilateral absence of corneal responses
○ bilateral absence of pupillary responses to light with pupils at mid-size or greater
○ vestibulo-ocular responses
• Absent respiratory effort based on the apnea test
• Absent confounding factors
69
What are the conditions of the apnea test?
○ Pre-oxygenation on 100% oxygen for a defined period prior to the test and the administration of 100% oxygen delivered into the trachea during the test
○ Arterial blood gas measurements are taken at the beginning of the test and at defined intervals throughout the test
○ The patient is observed closely throughout the test for any signs of respiratory effort
The test is considered confirmatory if:
○ There is no respiratory effort
○ The PaCO2 is greater than 60 mm Hg (AND >20 mm Hg above the pre-apnea test level)
○ The pH is less than 7.28 as confirmed by arterial blood gas measurement
70
Are there any variations re: brain death depending on the child's age?
Yes.
In children >1 year of age, 2 people may examine the patient at the same time.
If between 30 days and 1 year, two exams must be done at separate time intervals (interval not specified)
If <30 days of age, the minimum time from birth is 48 hours and the 2 exams must be separated by at least 24 hours
71
What are the 4 guiding principals in managing patients who are agitated or violent?
1. Prioritizing the safety of the patient and the treating staff;
2. Assisting the patient in managing his or her emotions and regaining control of his or her behavior;
3. Utilizing age-appropriate and the least-restrictive methods possible; and
4. Recognizing that coercive interventions may exacerbate the agitation.
72
What is the first line medication used in cases of medical agitation? Psychiatric?
Benzodiazepines
Benzos +/- Antipsychotics
73
What basic principals must be remembered when applying physical restraints?
* Apply with 5 or more providers if possible
* Use only if other measures have failed previously
* Protect the airway by keeping the patient supine, and their airway clear
74
What is the order of medications to be given in the case of status epilepticus?
Benzos x 3 (IV preferable, but IN, buccal or rectal acceptable)
Phenobarbital or Phenytoin (20 mg/kg)
Paraldehyde (400 mg/kg)
Midazolam infusion
Pentobarbital bolus and continuous infusion
75
What is the classic toxidrome for PCP?
```
ANGEL
• Agitated/aggressive
• NYSTAGMUS
• riGid
• Elevated temperatures and BP
• Lethal
```
76
What is the classic toxidromee for LSD?
LSD
• haLLucination
• Sweating
• Dilated pupil
