Acute Care CPS Flashcards Preview

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Flashcards in Acute Care CPS Deck (119):
1

In the statement "Minimum equipment guidelines for pediatric prehospital care", what is the most notable new recommendation made for a piece of equipment that should be available for paramedic use?

AED

2

What percentage of anaphylactic reactions end up having an identifiable trigger?-top 3 most common trigger?

30%-Most common triggers: food, insect bites, medications

3

What is the clinical criteria for diagnosis of anaphylaxis?

Any 1 of the 3 criteria:1. Acute onset of skin or mucosal tissue changes (minutes to hours) with one of the following:-respiratory compromise (dyspnea, wheeze, stridor, hypoxemia)-reduced BP or associated symptoms of end organ dysfunction (incontinence, syncope, hypotonia)2. For patient exposed to a LIKELY allergen for that patient, need two of the following:-involvement of skin-mucosal tissue-respiratory compromise-reduced BP or associated symptoms of end organ dysfunction-persistent GI symptoms (crampy abdo pain or vomiting)3. For patient exposed to a KNOWN allergen:-reduced BP (in minutes to hours)

4

What are the available doses of self-injectable epinephrine?

10-25 kg: 0.15 mg EpiPen Jr>25 kg: 0.30 mg EpiPen(<10 kg: consider EpiPen Jr or syringe-drawn epi)

5

What are the medications used in the management of anaphylaxis: name, dose, max dose

Epinephrine (1:1000)-dose: 0.01 mg/kg (0.01 ml/kg) q5-15mins as required-max: 0.5 mgCetirizine (H1 antagonist, non-sedating)-dose: 6 mo - < 2 yrs: 2.5 mg PO OD 2-5 yrs: 2.5 - 5 mg PO OD >5 yrs: 5-10 mg PO ODDiphenhydramine (Benadryl, H1 antagonist, sedating)-dose: 1 mg/kg PO/IV q4-6h for cutaneous symptoms-max: 50 mgRanitidine (H2 antagonist)-dose: 1 mg/kg q8h for cutaneous symptoms-max: 50 mgCorticosteroids (prednisone PO or methylpred IV)-dose: 1 mg/kg-max: 75 mg prednisone, 125 methylpredSalbutamol:-dose: 5-10 puffs via MDI or 2.5-5 mg nebs q20 minutes for respiratory symptoms (wheezing/SOB)Nebulized epi (1:1000):-dose: 2.5-5 ml neb q20minutes for stridorEpinephrine IV infusion-dose: 0.1-1 mcg/kg/min for hypotension -max: 10 mcg/kg/min

6

What is the vascular access recommended in all patients experiencing anaphylaxis and why?

2 large bore IVs should be inserted since anaphylaxis causes distributive shock and patients can lose up to 35% of their circulating blood volume in the first 10 minutes.

7

What position should patients in anaphylaxis be placed in and why?

Supine or trendelenburg position to optimize venous return to the heart and prevent pooling of blood in lower extremities due to systemic vasodilation

8

For patients with anaphylaxis and cardiovascular signs (hypotension, tachycardia, delayed capillary refill), what should management be?

Aggressive fluid resuscitation with boluses!If persistently poor perfusion and hypotension despite fluid boluses, will need epinephrine infusion and ICU admission

9

What is the minimum amount of time patients with anaphylaxis should be observed in hospital prior to discharge home and why?

Increased risk for biphasic response in first 4-6 hours but can occur in up to 72 hours-should observe for minimum of 4-6 hours

10

What are the effects of epinephrine in the pathophysiology of anaphylaxis?

Alpha-adrenergic properties: increases peripheral vascular resistance and reverses peripheral vasodilationBeta-1 adrenergic effects: inotropic and chronotropic effects on the heartBeta-2 adrenergic effects: bronchodilation and reduction of inflammatory mediator release from mast cells and basophils

11

What form of epinephrine is proven to be most effective in treatment of anaphylaxis?-Why IM over IV?

IM injection of 1:1000 epinephrine 0.01 ml/kg (max 0.5 mg) into the anterolateral thigh and repeat q5-15 mins depending on patient's response to previous doses.-IM administration results in faster and higher peak plasma concentrations compared with IM or subcutaneous injection into the upper arm-IV administration of epinephrine boluses is NOT ideal because immediate effects are short-lived and can induce cardiac arrhythmias when administered too quickly

12

What are examples of H1 antagonists and H2 antagonists used in anaphylaxis?-why should you use both?

H1 antagonists: diphenhydramine and cetirizine (can use either)-cetirizine in a patient who is not vomiting is best since it is faster in onset and less sedatingH2 antagonists: ranitidine or famotidineGive both H1 and H2 antagonists because combined effect is superior in treating cutaneous manifestations compared with use of H1 antagonists alone

13

What is the evidence for steroid use in anaphylaxis?

No evidence for use!-No randomized controlled trials have demonstrated a proven benefit of steroids in the treatment of anaphylaxis-most experts would still recommend treatment with steroids with the knowledge that onset is slow and there will likely be little beneft in the acute phase of management

14

What is the evidence for use of epi nebs for treatment of upper airway obstruction in anaphylaxis?

No studies have documented the clinical efficacy of epi nebs for treatment of upper airway obstruction induced by anaphylaxis-the first line treatment for symptoms of upper or lower airway obstruction due to anaphylaxis is IM epi!!!!

15

What is the first line mainstay of treatment of upper and lower airway obstruction symptoms due to anaphylaxis?

IM EPINEPHRINE!-salbutamol and epinephrine nebs are only supportive! (Not great evidence supporting their use)

16

In a patient with anaphylaxis and persistent hypotension despite fluid boluses, what is the management?

No evidence for repeated doses of IM epinephrine in improving hypotension-need epinephrine infusion at dose of 0.1 mcg/kg/min and gradual titration to produce a normal blood pressure (max 10 mcg/kg/min)

17

What is the management for a patient in anaphylaxis who is on regular beta blockers with persistent hypotension despite epinephrine administration?

Due to beta blockers, the IM epinephrine may not be able to produce effects on beta receptors-need to give reversal agent = glucagon-glucagon activates adenylate cyclase independent of the beta receptor to reverse cardiovascular effects of anaphylaxis-20 mcg/kg to 30 mcg/kg IV over 5 minutes (max 1 mg) followed by glucagon infusion at rate of 5 mcg/min to 15 mcg/min

18

Biphasic anaphylactic reactions are more likely to occur in which 3 clinical scenarios?-what is the management of a biphasic anaphylaxis reaction?

1. Delayed administration of epinephrine2. Presentation with severe symptoms (resp distress or hypotension)3. Multiple doses of epinephrine requiredBiphasic anaphylaxis reaction: repeat IM epi and other supportive therapies and admit into hospital for monitoring

19

Which patients with anaphylaxis should strongly be considered for overnight observation or admission (aka more than 4-6 hrs in ED)? (3)

1. Patients with peanut allergy2. Patients with asthma3. Use of beta blockers

20

What is the discharge management of patients from the ED with anaphylaxis?

1. Rx for self-injectable epinephrine2. Leave the ED with an epinephrine autoinjector in case a biphasic reaction occurs on the way home3. Counsel parents how and when to give the self-injectable epinephrine and that two doses should be available for administration with the child at all times (at school and with the parent or child)4. Recommend MedicAlert bracelet5. Refer to allergist or immunologist

21

When a patient with known asthma presents with sats < 92% before oxygen or bronchodilator treatment, what is this a predictor of?

Higher morbidity and greater risk for hospitalization

22

What is the most common cause of emergency room visits?-2 most common causes of acute gastroenteritis?

Acute gastroenteritis-2 most common causes: rotavirus and norovirus

23

What is the mechanism of action of ondansetron?-onset of action?

selective serotonin 5-HT3 receptor antagonist-if taken orally, quickly absorbed into GI tract and onset 1-2 hrs

24

What is the most common side effect of ondansetron use in gastroenteritis?

Increased diarrhea up to 48 hrs after administration - mild and self-limiting-no other adverse events seen

25

In published studies, what does the use of a single dose of oral ondansetron for pediatric gastroenteritis do? (3)

1. Decreases frequency of vomiting in ED2. Decreases need of IV fluid administration 3. MAY be effective in reducing hospital admissions

26

What is the age group of which oral ondansetron therapy is suggested for management of acute gastroenteritis in PED?-which group is ondansetron NOT recommended?

6 mo - 12 yo who present with vomiting due to acute gastroenteritis with mild-moderate dehydration OR who have failed oral rehydration therapy-should start ORT 15-30 mins after administration of oral ondansetron-not recommended for children whose predominant symptom is moderate to severe diarrhea

27

How does ORT work at the cellular level?

Glucose and sodium in the oral rehydration solution is cotransported by the sodium-potassium ATP pump on the enterocyte which then causes subsequent water absorption across the intestinal membrane

28

When would you consider using a rice-based oral rehydration solution?

Rice based ORS = gives favourable ratio of glucose to sodium and adds additional calories without increasing osmotic loadFor children with cholera = found in meta-analysis to reduce stool output(not in children with noncholera diarrhea though)

29

What is the management of acute gastroenteritis?-mild dehydration (5%)-moderate dehydration (5-10%)-severe dehydration (>10%)

1. Mild dehydration-rehydration with ORT 50 ml/kg over 4 hrs-Replace ongoing losses with ORT-Age-appropriate diet after rehydration2. Moderate dehydration-rehydration with ORT 100 ml/kg over 4 hrs-replace ongoing losses with ORT-age appropriate diet after rehydration3. Severe dehydration-IV bolus 20 ml/kg over 1 hr (repeat prn)-began ORT when pt stable-replace ongoing losses-age appropriate diet

30

What are the components of the PRAM score? (5)

1. Suprasternal indrawing: -present: 2 points-absent: 0 points2. Scalene retractions:-present: 2 points-absent: 0 points3. Wheezing:-0: absent-1: exp only-2: insp & exp-3: audible without stethoscope or silent chest with minimal air entry4. Air entry:-0: normal-1: decreased at bases-2: widespread decrease-3: absent/minimal5. O2 sat on RA:-0: >93%-1: 90-93%-2: <90%Max pram score: 12PRAM Score: -mild: 0-4-moderate: 5-8-severe: 9-12

31

What O2 sat on presentation of acute asthma exacerbation is associated with higher morbidity and greater risk for hospitalization?

O2 sat < 92%

32

What are 4 risk factors for ICU admission and death in children presenting with acute asthma exacerbation?

1. Previous intubation2. Previous ICU admission3. Previous life-threatening events4. Deterioration while already on systemic steroids

33

When is a blood gas indicated in acute asthma exacerbation?

1. When the patient has no clinical improvement with maximal aggressive therapy2. In severe to impending respiratory failure-remember that a normal cap carbon dioxide level despite persistent resp distress is a sign of impending resp failure

34

What is the evidence for a specific goal of SpO2 in acute asthma exacerbations?

No strong evidence for a specific goal but CPS statement suggests keeping sats >94% in context of acute resp distress

35

According to the CPS statement, what is preferred in acute asthma exacerbation: MDI vs. neb?

MDI with a spacer is the preferred device for ventolin since it is more efficient than a nebulizer-less likely to provoke hypoxemia and tachycardia than a neb-if patient needs O2, can use nasal prongs at same time as giving MDI

36

What are the 3 main side effects of salbutamol?-when should patients be monitored for cardiac arrhythmias while on salbutamol?

1. Tachycardia2. Hypokalemia3. Hyperglycemia-monitor for cardiac arrhythmias if on continuous nebulized salbutamol

37

In which group of children should atrovent (ipratropium bromide) be used cautiously?

In children with soy allergy

38

What is the evidence for use of atrovent nebs in acute asthma exacerbations?-what are side effects of magnesium sulfate in acute asthma exacerbations (2)?

Randomized control trials found reduced hospital admission rates and better lung function with atrovent was added with ventolin DURING THE FIRST HOUR OF PRESENTATION for moderate-severe asthma exacerbations-no evidence for use beyond the first hour-side effects: hypotension & bradycardia

39

When do you consider use of magnesium sulphate in acute asthma exacerbations?

Use in children with moderate-severe presentations with incomplete response to conventional therapy during the first 1-2 hrs-so do what you would do first (V&A back to back, dose of steroid), THEN reassess and if not better, start MgSO4-if you use it, consider consulting PICU or respirology

40

What are 3 treatments for acute asthma exacerbations if patient fails conventional therapy (including MgSO4 and IV steroids) and is going to PICU?

1. Continuous nebulized ventolin2. IV ventolin (especially in resp failure patients since ventolin nebs will no longer reach the bronchioles given the severe level of bronchospasm)3. IV aminophylline4. Heliox

41

What are the potential complications of intubation in a patient with severe acute asthma exacerbation?

Up to 26% of children intubated due to asthma will have complications:-pneumothorax-impaired venous return due to air trapping-cardiovascular collapse**Overall, associated with increased risk of death

42

When should admission to hospital be considered for a patient with acute asthma exacerbation? (4)

1. Ongoing O2 need2. Beta agonists needed more often than q4-8h after 4-8 hr of conventional treatment3. Persistent increased work of breathing4. Patient deteriorates while on systemic steroids

43

What are discharge criteria from the ED for patient with acute asthma exacerbation?

1. B2 agonist less often than q4h after conventional treatment2. O2 sat > 94% on RA3. Minimal or no signs of resp distress4. Improved air entry

44

Which patients presenting with acute asthma exacerbation should be prescribed inhaled corticosteroid upon discharge home? (2)

1. Children with persistent asthma presentations2. Those presenting with moderate or severe episode

45

What advice should be given to a parent on discharge whose child came in with an acute asthma exacerbation?

1. Asthma action plan2. Inhaled corticosteroid daily x 1 month3. PO steroids x 3-5 d4. Continue ventolin MDI puffer at home at 0.3 puffs/kg to a max of 10 puffs q4h until exacerbation resolves and then prn5. F/U with family doctor within 2-4 weeks

46

What are the usual doses of Alvesco (ciclesonide)?

100-200 mcg as starting dose ONCE DAILY and can be increased up to 400 mcg BID for severe cases -main benefit of alvesco over over inhaled corticosteroids is that it is once daily

47

What are the indications for a CXR in acute asthma exacerbations?

1. If concerned for pneumothorax2. If concerned for foreign body aspiration3. To rule out pneumonia4. Focal findings on exam

48

What are the steps to treating an acute asthma exacerbation for a child with respiratory failure?

1. Vent & atrovent back to back x 32. O2 with non rebreather to keep sats >94%3. IV methylpred4. Keep NPO5. Keep on monitors6. MgSO47. Continuous Neb --> IV ventolin8. Aminophylline9. Order lytes/gas****Epineprhine IM MAY be an option since anaphylaxis can sometimes mimic acute asthma exacerbation

49

What are the benefits of steroids in acute asthma exacerbation?

1. Decreased risk of relapse after initial treatment2. Facilitates earlier discharge3. Decreases hospitalization

50

What are the generic steroid names for the following:-QVAR-pulmicort-flovent-alvesco-what is the minimum age that each are licensed for use?

QVAR: bechlomethasone->5 yoPulmicort: budesonide->6 yo for dry powder->3 mo for nebFlovent: fluticasone->1 yoAlvesco: ciclesonide-> 6 yo

51

Why are hospitalized children at increased risk of hyponatremia with the use of hypotonic maintenance IV fluids?

Because you're giving electrolyte free water to children who are at increased risk of SIADH due to acute illness/stress, etc.

52

What are clinical features of acute hyponatremia (ie. decrease in Na in less than 48 hrs)?

Results from acute cerebral edema1. Headache2. Lethargy3. Seizures4. Cardiac/respiratory arrest secondary to brain stem herniation

53

What conditions have increased risk of SIADH (3)?

1. Post-op2. Acute neurological infection (meningitis, encephalitis, etc.)3. Acute respiratory infection (pneumonia, bronchiolitis)

54

What investigation should be ordered before starting IV fluids in children?

Baseline serum electrolytes

55

How frequently should you monitor serum electrolytes in children receiving maintenance IV fluids?

"Regularly"-in patienst with impaired renal water excretion, need to check at least daily

56

In hospitalized children 1 mo - 18 yo with normal serum sodium at baseline, what fluids should be used for IV maintenance?

D5W.0.9%NaCl (preferred) or D5W.0.45%NaCal-when serum electrolytes are not available, start D5W0.9NaCl!

57

In hospitalized children 1 mo - 18 yo with serum sodium 145-154, what IV maintenance fluid should be used?

D5W.0.45%NaCl and need frequent monitoring

58

Why is Ringer's Lactate not used for maintenance IV therapy in children (2)?

1. Absence of dextrose which kids need (due to low glycogen stores)2. Presence of lactate is inappropriate for young children

59

What is the most important immediate risk to the patient with status epilepticus?-causes? (3)

Inability to maintain the airway1. Clenched jaw2. Poorly coordinated respirations3. Production of secretions and vomitus

60

What is the dose for midazolam buccal vs. intranasal vs IV for seizure management? Max dose?-diazepam route and dose?

Midazolam buccal/PR: 0.5 mg/kg (max 10 mg)-intranasal: 0.2 mg/kg (max 5 mg/nostril)-IV 0.1 mg/kg (max 10 mg)-diazepam PR 0.5 mg/kg (max 20 mg/kg) OR IV 0.3 mg/kg (max 5 mg for < 5 yo, 10 mg > 5 yo) given over 2 minutes

61

What is the dose of lorazepam for seizure management? Max dose?

Lorazepam 0.1 mg/kg IV/SL/PR-max dose = 4 mg

62

What is the advantage of fosphenytoin over phenytoin IV in seizure management? (3)-max dose for both?

1. Fosphenytoin can be given over 5-10 minutes whereas phenytoin has to be given over 20 minutes2. Fosphenytoin can be run in with dextrose containing solution whereas phenytoin cannot3. Phenytoin can cause purple glove syndrome if extravasation occurs because of its high pH. this does not occur with fosphenytoin which is a water soluble prodrug of phenytoin-max dose for both: 1000 mg

63

When can you use paraldehyde in management of status epilepticus?

Can use paraldehyde PR 400 mg/kg (0.4 ml/kg/dose) to a max of 10 g diluted 1:1 in oil IF you cannot establish IV/IO access and you've tried benzo x 2 and fosphenytoin or phenobarb with no effect

64

What is the dose for midazolam continuous infusion?-max infusion rate?

IV 0.15 mg/kg bolus then 2 mcg/kg/min infusion-increase as needed by 2 mcg/kg/min q5mins with a bolus prior to each increase-max infusion rate: 24 mcg/kg/min

65

What are 3 side effects seen with benzos in management of seizures?

1. Hypotension2. Resp depression3. Sedation

66

What are 3 side effects seen with phenytoin in management of seizures?-limitations in terms of administration? (2)/

1. Hypotension2. Bradycardia3. ArrhythmiaLimitations in administration:1. Needs to be given in NONglucose-containing solution so either need to stop dextrose infusion or get 2nd IV line2. Has to be given over 20 minutes in NS

67

What are 3 side effects of phenobarbital?

1. Respiratory depression, especially if benzo has been used2. Hypotension3. sedation

68

What are frequently encountered mistakes in management of status epilepticus? (3)

1. Inadequate dosing of benzos2. Treating with more than 2 doses of benzos and a delay in initiating second-line treatment-ideally, YOU SHOULD ASK for phenobarb or phenytoin at the same time you are giving your first dose of benzo3. Delay in initiating refractory status epilepticus treatment: RSI and intiation of midazolam infusion

69

What is the treatment for refractory status epilepticus?

1. Rapid sequence induction/intubation2. Initiation of midazolam infusion with 0.15 mg/kg IV bolus, followed by 2 mcg/kg/min infusion

70

What is the management of hypoglycemia in status epilepticus?-what blood glucose level should prompt treatment?

BG 2.6 or less = treat-2-4 ml/kg D25W or 5 ml/kg D10W (0.5 g/kg) IV-recheck BG 3-5 mins post bolus

71

What is more effective for treating seizures: buccal midazolam vs. rectal diazepam?-what is the advance of IV lorazepam over IV diazepam?

Buccal midazolam is more effective (75%) compared to rectal diazepam (60%)-lorazepam is longer lasting and causes less respiratory depression than diazepam

72

What is the success rate of first dose benzo in status epilepticus?-2nd dose benzo?

1st dose = 80% success rate-2nd dose = 17%

73

If a child has received a benzo in the prehospital setting, how many doses of benzo should you give them in hospital if they are still seizing on arrival?-what are the risks of treating with more than 2 doses of benzos? (2)

One repeat IV dose may be adequateb efore moving onto second-line treatments-if no IV access is available, a second dose of benzo should be given through buccal, intranasal, rectal or IM route while IV access is being obtained. -timing is critically important!!! No delays if possible!-More than 2 doses of benzos:1. Not likely to be effective2. Respiratory depression

74

Why is fosphenytoin/phenytoin preferred over phenobarbital in children > 1 yo?

Less likely to cause resp depression and decreased LOC

75

What is "purple glove syndrome"?

Edema, discoloration and pain distal to the site of phenytoin extravasation into the tissues = severe subcutaneous irritation-this is because phenytoin has high pH

76

Why can paraldehyde only be given rectally?

IV and IM use results in serious side effects = cyanosis, cough, hypotension and pulmonary edema

77

What medication can be considered for a child younger than 18 months of age in whom seizures may be caused by an undiagnosed metabolic disorder?

Pyridoxine (vitamin B6) 100 mg IV initially, then 50 mg IV or PO BID

78

What is the most common cause of status epilepticus?

Prolonged febrile seizure

79

What is the definition of refractory status epilepticus?-treatment agents? (5)

Status epilepticus that continues DESPITE two different antiepileptic medications (ie. benzo and phenytoin)Treatment agents:1. Midazolam infusion2. Barbiturates (thiopental and pentobarbital)-thiopental 2-4 mg/kg followed by 2-4 mg/kg/hr3. Propofol4. Topiramate5. Keppra

80

What is the recommended compression to ventilation ratio for single-rescuer CPR vs. two-rescuer CPR in pediatric patients?-when an advanced airway is in place, what is the rate of compressions and ventilations?

Single-rescuer: 30:2Two-rescuer: 15:2-advanced airway in place: continuous compressions (at least 100/min) and 8-10 breaths/min

81

What instructions will you give to providers of chest compressions to ensure they are effective?

1. Compress at least 1/3 of the AP diameter of the chest2. Allow for full recoil3. Minimize interruptions4. Avoid excessive ventilation5. Rotate compressors every 2 minutes6. Limit pulse checks to max of 10 seconds

82

How should a rescuer decide whether CPR is necessary in an emergency situation? -lay person vs. HCP?

-layperson: 1. assess the victim for responsiveness2. determine whether the patient is breathing normally. If they are not, then start CPR immediately! (ie. don't feel for a pulse)-HCP: do the same and can check for a pulse but limit that to 10 secs and start CPR if no pulse is palpated or if unsure

83

Up to what weight or age is a pediatric dose attenuator for AED recommended?

1. Up to 25 kgOR2. Up to 8 yo

84

What is the definition of wide-complex tachycardia?

QRS interval > 0.09

85

What is the correct size of ETT for:-infant < 1 yo-child 1-2 yo-child > 2 yo

-infant < 1 yo: 3 mm cuffed-child 1-2 yo: 3.5 mm cuffed-child > 2 yo: (age/4) + 4 uncuffed (for cuffed, decrease by 0.5)

86

What is the evidence for using cricoid pressure during intubation?

Insufficient evidence to recommend routine use to prevent aspiration during intubation-may make intubation more difficult

87

What is the survival rate of in-hospital cardiac arrest?

25%

88

What is the most common reason for admission to hospital in the first year of life?

Bronchiolitis

89

What anatomical differences in children put them at increased risk of developing an intracranial lesion due to head trauma (3)?

1. Larger head to body ratio2. Thinner cranial bone3. Less myelinated neural tissue**more commonly develop diffuse axonal injury and secondary cerebral edema compared with adults

90

Intracranial injury is more frequent following what mechanisms of injury (3)?

1. Fall from height above 3 feet or twice the length/height of the individual2. MVA3. Impact from high-velocity projectile

91

Classify head trauma according to GCS:-minor-moderate-severe

Minor: GCS 14-15Moderate: GCS 9-13Severe: GCS < 8

92

What is the first priority in managing head injury?

Stablize vital signs to avoid secondary injury to the traumatized brain from hypoxia, hypotension, hyperthermia or raised ICP

93

What are 4 signs of basal skull fracture?

1. Hemotympanum2. Battle's sign (ecchymosis over mastoid bone)3. Periorbital ecchymosis ("racoon eyes")4. Leakage of CSF from nose or ears**If one or more of these signs are present, do NOT place any tubes via nasal route

94

For children younger than 2 yo, what is an indication for skull xrays in a child with minor head trauma?-What imaging should be ordered in a patient with obvious penetrating lesion or suspected depressed skull fracture in an older patient?

Large, boggy hematoma-in older patient, can order skull xray but CT head is more commonly performed

95

Which patients presenting with acute head trauma should receive CT head (ie. absolute indications) (3)?-relative indications (2)

1. All patients presenting with moderate (GCS 9-13) or severe (GCS < 8) head trauma2. Patients with minor head trauma (GCS 14-15) who meet CATCH criteria3. Patients with focal neurological deficits4. Clinically suspected open or depressed skull fracture or a skull fracture on skull xrayRelative indications:*in addition to CATCH rule*-seizures at time of event or later-known coagulation disorder

96

What does CATCH stand for?-describe the study

Canadian Assessment of Tomography for Childhood Head Injury-prospective cohort study involving 3886 children presenting with symptomatic minor head trauma to 10 Canadian pediatric teaching institutions-prospective calidation study found CATCH rule to be 98% sensitive for predicting acute brain injury

97

What is the CATCH rule?-define minor head injury (5)-define high risk and medium risk

**Minor head injury: injury in a patient with current GCS 13-15 sustained within the past 24 hrs associated with1. witnessed LOC2. definite amnesia3. witnessed disorientation4. persistent vomiting (>1 episode)5. persistent irritability (in child < 2 yo)CT head is required for children with a minor head injury PLUS any one of the following findings:A) High risk - need for neurological intervention1. GCS < 15 at 2 h after injury2. Suspected open or depressed skull fracture3. History of worsening headache4. Irritability on examB) Medium risk - brain injury on CT scan1. Any sign of basal skull fracture2. Large boggy hematoma of the scalp3. Dangerous mechanism of injury (MVC, fall from height > 3 feet or down five stairs, falling from bike without helmet)

98

What is the management of patients with minor head trauma who are asymptomatic?

Discharge home to care of reliable parents with written instructions for signs to watch for (worsening headache, persistent vomiting, difficulty in awakening)

99

What is the management of patients with minor head trauma who have headache, repeated vomiting, or LOC at time of trauma?

Period of clinical observation in ED x 4-6 hrs. -If symptoms improve and GCS is 15, patient may be discharged home with written instructions-If no improvement, admit to hospital with neurovitals q2-4h. May need IV rehydration-If symptoms persist > 18-24 hrs, may need CT scan if not already performed, neurosx consult

100

What is the management of minor head trauma in a child < 2 yo?

Based on careful clinical assessment, may need longer observation period. Discharge may be appropriate if toddler is asymptomatic and ambulatory. If infant or baby, may need to admit to observe

101

What is the potential complication of a widened skull fracture?

Leptomeningeal cyst

102

What is the management of moderate head trauma?

1. CT head +/- skull xrays2. Admission 3. Neurosx consult

103

What is the management of severe head trauma?

1. Intubation2. CT head +/- skull xray3. Admission to ICU for monitoring of increased ICP-continuous vitals monitoring with end tidal CO2-mechanical ventilation to maintain normal oxygenation and ventilation-maintenance of normal core temperature (avoid hyperthermia)-sedation and analgesia to prevent increased ICP-fluid administration to maintain normovolemia and avoid hypotension4. Emergent neurosx consult

104

When do post-traumatic seizures typically occur?-What are factors that increase risk of developing post-traumatic seizures (5)?

Within 24 hrs of head injury-Risk factors for developing post-traumatic seizures1. Younger age2. Severe head trauma (GCS < 8)3. Cerebral edema4. Subdural hematoma5. Open or depressed skull fracture

105

What is the disposition management of patients with post-traumatic seizures from head injury?

Depends: if the seizure occurred immediately after the head trauma (impact seizures) or had one isolated seizure shortly after the event but have a normal neuro exam and head imaging, can be safely discharged home (low risk of further complications)

106

In a patient with severe head injury, why is it important to treat post-traumatic seizures?

If left untreated, post traumatic seizures may contribute to secondary brain injury-impact seizures or isolated seizure shortly after the event do not cause secondary brain injury

107

What 4 factors help determine whether an infant with bronchiolitis should be admitted?

1. Respiratory status2. Ability to maintain adequate hydration3. Risk for progression to severe disease4. Family's ability to cope

108

Should we use a bronchiolitis scoring system to determine whether an infant with bronchilolitis should be admitted?-what 3 parameters have been found to be most helpful in all the severity scores out there?

No. No scoring system has been shown to have predictive validity-parameters:1. O2 saturation 2. Subcostal retractions3. Respiratory rate

109

What are 2 consistent predictors of hospitalization in bronchiolitis seen in outpatient populations?

1. Age < 3 mo2. History of prematurity (<35 weeks)

110

What 4 groups are at higher risk for severe bronchiolitis?

1. Premature (< 3 mo at presentation3. Hemodynamically significant cardiopulmonary disease4. Immunodeficiency

111

What are the only 2 interventions shown to have benefit in treatment of bronchiolitis?-what 4 interventions have equivocal evidence supporting them?-what 5 interventions are not recommended?

Benefit for sure:1. Oxygen for sats

112

What is the evidence for NG vs. IV for rehydration in bronchiolitis?

Recent randomized control trial found NG and IV to be equally effective with no difference in length of hospital stay.-NG insertion may require fewer attempts with higher success rate than IV placement

113

What is the evidence for use of epi nebs in bronchiolitis?

Overall: equivocal evidence-1 study found it may be effective for reducing hospital admissions, 1 study showed combined treatment with epi and steroids reduced admissions-BUT evidence is insufficient to support routine use in the ED.-try administering one dose and see if there's response. If there is, continue. If not, discontinue.-systematic review of 19 studies shows NO effect on length of hospital stay and there is insufficient evidence to support routine use in admitted patients.

114

What is the evidence for use of 3% hypertonic saline in bronchiolitis?

Overall: evidence is equivocal and it MAY be helpful in the inpatient setting only-Cochrane review of 11 trials found that nebulized hypertonic saline was associated with a reduced length of stay by 1 day in settings where the admission was longer than 3 days-further studies showed mixed results-no evidence for use in the outpatient/ED setting

115

What is the evidence of combined epi and dex in bronchiolitis?

Amy Plint's study showed possible reduced hospitalization rate-but these results were rendered nonsignificant when adjusted for multiple comparisons-currently, this combo is not recommended for the therapy of otherwise healthy children with bronchiolitis

116

What is the evidence of ventolin in bronchiolitis?

NOT recommended! (not even a trial is recommended) 1. Bronchiolitis is due to obstructed airways, not constricted airways2. Infants have inadequate beta agonist lung receptor sites and immature bronchiolar smooth muscles so ventolin is not effective***overall: shown to have NO effect on O2 saturation, admission rate or length of stay in hospital

117

What is the evidence on chest physiotherapy in bronchiolitis?

9 clinical trials have compared physio to no treatment.-NO PT techniques were shown to improve clinical scores or reduce hospital stay or duration of symptoms-thus, NOT recommended!

118

What is the evidence for nasal suctioning in bronchiolitis?

Equivocal evidence: one study did show that if it is to be done, should be superficial only and should be frequent

119

What kind of babies are more likely to experience apnea with bronchiolitis?

1. Young age < 1 mo2. Previous apneic episode