EMERGENCIES Flashcards
(150 cards)
1
Q
D/d for Stridor
A
Foreign Body Aspiration
Infections
2
Q
Presence of Stridor Indicates?
A
An upper airway obstruction
3
Q
Stridor + Fever. Dx?
A
Likely an Infective upper airway obstruction.
Likely Infections: Epiglottitis, Laryngotracheobronchitis
4
Q
What causes Epiglotitis?
A
A bacterial infection.
Most Commonly: Haemophilus influenza
5
Q
Presentation of an Epiglotitis Patient
A
Stridor, very high fever
Patient will be in Tripod Position
More serious than Croup
Causes complete obstruction of upper airway within a few hours.
6
Q
What is Tripod Position? In what instance can we see this?
A
Patients with Epiglotitis use this position.
Seated leaning forward, neck extended, mouth open.
7
Q
Initial Management of an epiglotitis patient.
A
Do not disturb the child
Ask mother to keep oxygen mask on child’s face.
Do not examine throat, do not cannulate
Call anaesthetist and ENT Surgeon
Send the child to theatre or ICU
Intubation in Theatre
If it fails, a tracheostomy should be done by the ENT Surgeon.
Put a canula and start IV antibiotics (Cefotaxime, ceftriaxone)
When child gets better, Take tube out and send to ward.
8
Q
What antibiotics are used for the Mx of Epiglotitis?
A
Ceftriaxone
Cefotaxime
9
Q
What causes Croup?
A
Acute larygnotracheobronchitis is caused by a viral infection,
Parainfluenza virus.
10
Q
Presentation of Croup
A
Stridor, Low grade fever, Barking Cough
11
Q
Presentation of Mild Croup and Severe Croup
A
Mild Croup - Stridor, Barking Cough, No respiratory difficulty
Severe Croup - Barking Cough, Stridor, Cyanosis, Breathing difficulty
12
Q
Mx of croup
A
- Steroids
a. Inhaled/ Nebulized: Budesonide (Pulmicort)
b. Oral: Dexamethasone (Commonly given), Prednisone
c. IV: Hydrocortisone - Adrenaline Nebulization (Used as a vasoconstrictor)
13
Q
What’s the difference in Mx of mild and severe croup?
A
In Mild croup Mx - Steroids first, then Adrenaline nebulization if no response to steroids.
In Severe croup - Mx begins with Adrenaline Nebulization
14
Q
A child presents with barking cough, fever and stridor. Initial Mx of Steroids followed by adrenaline nebulization yielded no response. What’s the likely diagnosis?
A
Psuedocroup: Bacterial tracheitis.
15
Q
What causes Pseudocroup?
A
Staphylococcus aureus
16
Q
Mx of pseudocroup
A
Cloxacillin
Flucloxacillin
Vancomycin
17
Q
Reduced breath sounds in one side until proven otherwise is?
A
Foreign body aspiration
18
Q
Child presenting with sudden onset stridor while eating peanuts. What’s the most likely diagnosis?
A
Foreign body aspiration
19
Q
Mx of a child presenting with FB Aspiration
A
If FB clearly visible in mouth, take it out in direct vision (Blind finger sweeping is not advised).
If FB not visible but child can cough, encourage coughing.
If coughing does not bring FB out or child does not cough - Back blows, chest thrusts, abdominal thrusts.
If that does not work, cricothyroid puncture.
If that does not work, Tracheostomy
If that does not work, Bronchoscopy
20
Q
Child comes in unconscious, Diagnosed as FB aspiration. What’s the Mx?
A
CPR
21
Q
What are the X-Ray changes in a FB aspiration causing Complete obstruction?
A
Affected lung will collapse due to no air and the trachea will deviate to the side of obstruction.
22
Q
What are the X-Ray changes in a FB aspiration causing incomplete obstruction?
A
Affected lung will be hyperextended. Trachea deviates to the opposite side.
Hyperexpansion - Since inspiration is an active process and expiration is passive, while air comes in not all air comes out collecting air leading to hyperexpansion.
23
Q
Is it a good practice to always do a X-Ray for FB aspiration? Why?
A
No.
Most of the FB’s are not visualized in X-Rays.
24
Q
Dx of patients with unilateral rhonchi and B/L Rhonchi.
A
Unilateral - FB unitl proven otherwise
B/L - Asthma until proven otherwise
25
Initial assessment of a 6 year old asthmatic presenting with difficulty in breathing.
A brief history - From the mother
Examine child - Auscultate for rhonchi, Check respiratory rate and HR.
26
What's the purpose of checking RR and HR in the initial assessment of a known asthmatic with difficulty in breathing?
To differentiate between simple asthma and severe asthma.
27
What are the Cut-offs of RR and HR for Severe asthma?
<5yrs: HR > 130bpm RR > 50/min
>5yrs: HR > 120bpm RR > 30/min
28
6 year old. Known Asthmatic. B/L Rhonchi. HR - 140bpm. RR - 55/min. What's the most likely Dx?
Acute severe asthma.
29
How are the lung sounds "Rhonchi" formed?
Due to the bronchoconstriction of the airways which causes a turbulent flow.
30
Differentiate between acute severe asthma and life threatening asthma.
Acute severe asthma
HR and RR above cut-off, No cyanosis, Low CO2 levels, Patient active, pH increased (Alkalosis)
Life threatening Asthma
HR and RR reduced, cyanosed, High CO2 levels, patient is drowsy, pH decreased (acidosis, SILENT CHEST (No Rhonchi)
31
Why are there no Rhonchi in Life threatening Asthma?
Due to complete obstruction of airway.
32
What happens when Acute severe asthma is not managed properly or at all?
Due to broncho-constriction,
Low Oxygen and High CO2 - Affects brain, casues drowsiness.
High CO2 - Acidosis - Supresses heart and lungs.
Low O2 - Cyanosis, Bluish Fingers
33
What are the 2 methods of asthma Mx?
Reducing inflammation
Broncho-dilation
34
Types of Bronchodilators used in Asthma MX
Nebulized - Salbutamol, Ipratropium Bromide
Injections - Salbutamol, Aminophyllin, MgSO4
35
Types of Steroids used in Asthma Mx
Oral - Prednisone, Dexamethasone
IV - Hydrocortisone
36
Mx of Acute Severe Asthma
1. Nebulize with salbutamol + O2 - 3 times back to back nebulization. Time interval is time taken to refill liquid.
If child gets better (No rhonchi on auscultation) with 1st & 2nd doses, 3rd is not required.
If no Response
2. Nebulize with Salbutamol + Ipratropium Bromide.
Give a steroid as well - IV Hydrocortisone, Oral prednisone.
If no Response
3. IV MgSO4
4. Salbutamol/Aminophyllin IV
5. Chest X-Ray and Blood gas
If normal but child is not getting better - 6. Send to ICU for mechanical ventilation.
37
Is the efficacy of IV hydrocortisone and Oral Prednisone same/different?
The efficacy is the same.
38
Mx of Life threatening asthma
Same as mx of acute severe asthma, but begins with step 2.
1. Nebulize with Salbutamol + Ipratropium Bromide.
Give a steroid as well - IV Hydrocortisone, Oral prednisone.
If no Response
2. IV MgSO4
3. Salbutamol/Aminophyllin IV
4. Chest X-Ray and Blood gas
If normal but child is not getting better - 5. Send to ICU for mechanical ventilation.
39
Adverse effects of drugs used in the Mx of Asthma
Salbutamol and Aminophylline casues increased Beta 2 Receptor activation leading to SNS over activity.
Salbutamol - Tremors, Tachycardia, Hypokalemia (Results in increased K+ intake by cells)
Aminophyllin - Arrythmia, seizures
MgSO4 - Hypotension, Respiratory arrest due to neurodepression.
40
(T/F)
1. Most seizures will settle within 7 minutes.
2. IV diazepam is the best benzodiazepine for generalized tonic clonic seizures
3. CBS and an ABG should be done during a seizure.
4. Most common cause of seizures in children is fever
5. Patients with snake bites can become unconscious
6.Phenobarbitone can cause arrhythmias.
7.Time duration between 2 PR diazepam doses is 10 minutes.
1. F ( 5 minutes)
2. F (IV Lorazepam > Midazolam
> Diazepam)
3. F (Only CBS)
4. T ( Febrile convulsions)
5. T
6. F ( Respi arrest)
7. T
41
Ideal position to keep an epileptic patient mid seizure
Left lateral position
42
Initial Mx of generalized tonic clonic seizure
Left lateral position
Suck out secretions
Give Oxygen
Check CBS
43
Anti- epileptic routes
1.iv ( BEST)- Lorazepam, Midazolam, Diazepam
2.PR (USUALLY USED)- Diazepam
3. Buccal mucosa
4. Intranasal
5.IM
44
PR diazepam dose
0.5mL/kg
45
PR diazepam can be repeated .... times
two
46
PR Diazepam cannot be repeated more than twice because
can cause respiratory arrest
47
Diazepam, Midazolam, lorazepam belongs to ( drug class)
Benzodiazepines
48
Final step in status epilepticus Mx if drugs fail
Send to ICU for paralysis and ventilation
49
During the seizure which drug route should be secured
iv - best route to deliver anti- epileptics fast
50
Anal atresia patient presents with status epilepticus and iv access cannot be secured, best drug route
buccal - midazolam
51
Benzodiazepine preference order if iv access is gained
Lorazepam > Midazolam > Diazepam
52
Status epilepticus Mx of a patient
1.Keep the patient in the left lateral position
2.Clear secretions from the mouth with a suction machine
3.Give Oxygen
4.Check CBS
5.Wait for five minutes to see if the episode settles. Meanwhile try and get the iv access.
6.If the episode doesn't settle, and iv access wasn't obtained, give anti- epileptics through another route ( PR diazepam , IM, buccal, intranasal midazolam)
7.Wait for 10 minutes and if there's no improvement repeat.
8. No improvement- give PR Paraldehyde
9.Send the child to ICU for paralysis and ventilation
53
Status epilepticus Mx if IV access is gained
1.Keep the patient in the left lateral position
2.Clear secretions from the mouth with a suction machine
3.Give Oxygen
4.Check CBS
5.Wait for five minutes to see if the episode settles. Meanwhile try and get iv access.
6. Give a BZ
7. Wait five minutes
8. Repeat if no improvement
9.Give iv Phenobarbital/ Phenytoin Na
10. Send to ICU for Paralysis and ventilation
54
ADRS of Midazolam (BZs)
Respiratory arrest
55
ADRS of Phenobarbital
Respiratory arrest
56
ADRS of Phenytoin Na
Arrhythmia
57
What needs to be done before giving Phenobarbitone
Call the ICU and make sure a bed is available
58
What needs to be done before giving Phenytoin Na
Connect the child to a cardiac monitor
59
How to choose between Phenytoin and Phenobarbital if iv access is gained
depends on the child's drug Hx.
Give the drug, the child wasn't prescribed
60
Causes of seizures in children
Fever
Hypoglycemia
Reduced Na+, Mg2+, Ca2+
Meningitis
61
A child admitted to the ICU for treatment for meningitis develops seizures, best drug to give
iv Lorazepam
62
Ideal Systolic BP for a 9 year old
80 + (9x2) = 98mmHg
63
An unconscious 9 year old, BP 100/75mmHg, PR 88/min, Breathing normal. Immediate Mx?
Check if the airway is patent
Start Oxygen
Check CBS
Rest depends on the possible cause
64
Possible causes of unconsciousness
Hypoglycemia
Head trauma
Snake bites
Cerebral Edema
65
An unconscious 9 year old, BP 100/75mmHg, PR 88/min, Breathing normal. CT shows cerebral edema. Mx?
Check if the airway is patent
Start Oxygen
Check CBS
Prop the head- end of the bed by 20 degrees
Keep the neck straight
Start diuretics ( Mannitol)
66
What is the initial assessment of a child presenting with sudden onset unconsciousness?
A - Airway patent: Talk to child, see for response
B - Feel warmth of breath, look for chest movements
C - Check central pulses: Carotid, Brachial, Femoral
67
An unconscious child with no palpable central pulses and no breathing movements, what's the most likely Dx?
Cardiopulmonary arrest
68
Initial management of a Child that is cardiopulmonary arrested
Keep airway patent: Triple manoeuvre - Head tilt, chin lift, jaw thrust
Mouth-to-mouth breathing
Start chest massage
69
After the initial Mx of the cardiopulmonary arrested child, what follows in the ETU?
Connect to cardiac monitor
Start bag and mask ventilation
Continue cardiac massaging - 15 massages : 2 breaths
After 2mins of massaging adrenaline can be administered,
Dose - 1 : 10,000 0.1ml/kg IV/IO
Every 3mins of massaging, adrenaline can be given
General cardiac massaging is continued for 20mins
70
What are the types of shocks?
Cardiogenic shock - Due to cardiac arrest, Cardiac arrythmias
Hypovolemic shock
Maldistributive shock - Anaphylactic shock, septic shock
71
What is the other name for Irregular broad complex bizzare tachycardia?
V. Fib
72
How do you manage V. Fib?
De-fibrillating Shock
soon after the shock, CPR must be commenced.
After 2mins of CPR, if rhythm is not back to normal, shock can be repeated.
There is also a place for other drugs - Adrenaline, Amiodarone
73
How are the pedals of the defibrillator placed on a child and a neonate?
Child - One pedal under the R/Clavicle, Other on top of heart
Neonate - One pedal on heart, the other on the back.
74
Can a patient be left connected to a cardiac monitor while being shocked?
If the cardiac monitor is DC-shock compatible, Yes.
If not, Must be disconnected.
75
What is known as SVT?
Supraventricular tachycardia.
Narrow complex tachycardia & tachycardia with no P waves.
76
How do you calculate the HR from a ECG?
300/R-R intervals
77
How do you differentiate SVT from Sinus Tachycardia?
SVT - If <2yrs HR > 220
If >2yrs HR >170
P waves absent
Sinus Tachy - If <2yrs HR < 220
If >2yrs HR < 170
P waves present
78
SVT Mx
1. Vagal Manoeuvres - Immersion of face in Ice (More suitable for infants)
Unilateral Carotid massage
Val Salva Manoeuvre - Forced expiration against closed glottis. (Best method for small children)
2. If that doesn't work, see if child is in shock,
If Yes - DC Shock
If No - Adenosine, Amiodarone
78
How is Adenosine administered?
It has a very short life. It should be administered as a rapid injection from a vein near to the heart followed by a normal saline flush.
79
How do you calculate the normal Systolic BP?
80 + (Age * 2)
79
13yrs old 40Kg child with severe diarrhea and vomiting for 5 days presented with drowsiness. PR - 160/min. BP - 70/40mmHg. CRT - 5s. What is the most likely Dx?
Hypovolemic Shock.
79
How do you initially approach Hypovolemic shock?
1. Put 2 cannulae and then give a crystalloid - Normal saline 20ml/kg RAPID BOLUS (Squeeze bottle)
2. If no impovement - repeat Normal saline 20ml/kg rapid bolus.
3. If no impovement - Give a colloid.
4. If no impovement, Give a vasoconstrictor - Adrenaline
80
What are the types of Colloids?
Dextran, Hetastarch, Blood
81
In general practice, why isn't a colloid given as the first step of Mx of Hypovolemic Shock?
Expensive
Remains in circulation for a long time
Can cause anaphylaxis by reacting
82
A child developed difficulty in breathing and faintishness while on a blood transfusion. What's the most likely Dx?
Anaphylaxis/ Anaphylactic shock
83
What are the features of anaphylaxis?
Rhonchi on auscultation
Vasodilatation leading to reduced blood supply to brain causing faintishness
Swelling
Itching
Stridor- laryngeal edema
84
Mx of anaphylaxis due to a blood transfusion
Stop blood transfusion immediately
IM adrenaline 0.01ml/kg 1 : 1000
If child is having rhonchi, nebulize with salbutamol
Fluid boluses can be given
To prevent the recurrence, steroids like hydrocortisone can be given
Chlorpheniramine can be given.
85
How can anaphylaxis be managed at home
If patient has an adrenaline pen, give dose as an injection
Adrenaline can be given through clothes
86
Difference in adrenaline doses during cardiac arrest and anaphylaxis
Cardiac arrest - IV/IO 1 : 10,000 0.1ml/kg
Anaphylaxis - IM. 1 : 1000 0.01ml/kg
87
A 3yr old presenting with a wide spread rash and very high fever. BP 65/30mmHg. PR 160/min. CRP 70 (Normal upto 6). What's the most likely Dx?
Septic Shock.
Low BP + Fever
88
Septic Shock Mx
Same as Hypovolemic Shock + Antibiotic
1. Normal Saline 20ml/kg as a rapid bolus
2. Repeat if no response.
3. Use a colloid if no response.
4. Use vasoconstrictors if no response.
89
What are the types of antibiotics used in the Mx of Septic shock?
Cefotaxime
Ceftriaxone
90
Which organism can cause a wide spread purple rash?
Neisseria meningitides
91
most venomous snakes
Cobra - Naya
Common krait
Sri Lankan krait - karawala
Russel's viper - polanga
Saw- scaled viper
92
Kraits Sx
Bites at night
Targeted When the person lies on the floor
Only Neuro Sx
93
Cobra Sx
Neuro Sx
Local Sx
94
Viper Sx
Blood, neuro, Kidney, local bite site Sx
95
Anti venom comes in what form
white coloured powder form
96
Immediate step in snake bite
Reassure and calm the child. ( To prevent accelerated systemic spread of the venom)
97
Early signs of systemic envenomation
Nausea
Vomiting
Abd Pain
98
Test done in snake bites
WBCT - put 2 mL of blood to a tube and keep for 20 minutes and see if blood has undergone coagulation
99
Steps in a snake bite Mx on- site
Calm the child
Wash the bite site with soap
Immobilize the bite site
Send to the hospital
100
Is splinting or tying a tourniquet recommended in snake bite Mx
Nopesy. Restricting the blood flow to the bite region which already has undergone necrosis will further accelerate the necrosis.
101
Anti- venom works on...
Viper
Kraits
Cobra
102
Anti- venom dose
dissolve the powder in 10 mL of water or NS. Give 10 vials (100mL) over one hour
103
Why should the child be closely monitored during anti venom administration
High risk of getting anaphylaxis
104
Steps followed if the child goes into anaphylaxis during the third anti- venom vial
Stop the transfusion
Manage the anaphylaxis - IM adrenaline (1:1000) 0.01mL/kg
If rhonchi + - salbutamol
Continue the anti venom once stable
105
On what situations of snake bites are anti- venom given
If there are signs of systemic envenomation
106
Will all snakes prolong WBCT
Nopesy. Krait won't
107
Steps of snake Mx once in the ETU
WBCT
Check for signs of systemic envenomation
Start anti- venom
108
Initial Mx of a dog bite on-site
Wash the bite with soap
Take to the hospital
109
Mx of a major dog bite
Rabies Ig + Vaccine
110
Mx of a minor bite
only the vaccine
111
Rabies vaccine doses given days
Given on D0
D3
D7
D14
D28
112
Besides the rabies vaccine what other vaccine is given
Tetanus toxoid if the child hasn't gotten it during the last five years
113
Major exposures of a dog bite
1. Single or multiple bites with bleeding on head, neck, face, chest, upper arms, palms, tips of fingers & toes, genitalia
2.Multiple deep scratches with bleeding on the head, neck, face
3..Single or multiple deep bites on any body part
4.. contamination of mucous membranes with saliva.
5. Bites of wild animals with bleeding
114
Minor exposures of a dog bite
1.Single, superficial bite or scratch with bleeding on the lower limbs, upper limbs, abdomen, neck
2.Nibbling of uncovered skin
3.Contamination of open wounds with saliva.
4. Single or multiple bites or scratches without bleeding on any body part.
5.Drinking raw milk of rabit cow or goat
115
Usual PCM dose
15mg/kg
116
Toxic and lethal PCM doses
Toxic >100mg/kg
Lethal >200mg/kg
117
How much PCM is there in a PCM syrup bottle
120mg PCM in 5mL of the syrup
118
PCM dose per kg for a 30kg child who has ingested 25 tablets of PCM
Total PCM dose = 25x500= 12500mg
PCM dose per kg= 12500/30= 416.66mg
Exceeded the lethal dose
119
Mx of PCM OD'd child who came to the ETU in under 1 hour
Gastric lavage
Activated charcoal
Check the Blood PCM levels ~4h after ingestion
Start NAC/ Methionine
Test AST/ALT, PT/INR, Blood sugar
Refer the child to a psychiatrist and inform the JMO
120
Gastric lavage in PCM poisoning
Take a 100mL syringe and an NG tube
Push water in and aspirate it out
keep repeating until the aspirated fluid appears like only water
121
Activated charcoal process
Dissolve in water and send through an NG tube
122
Is the test to check for the PCM doses in blood always done
no. not readily available
123
Mx of PCM OD'd child who came to the ETU in 5 hours
Take a history from the mothet
Start NAC/ Methionine
Refer to psychiatry and inform the JMO
124
Mx of a child who ingested kerosene oil
Careful monitoring of the respiration
Give O2
Do a CXR
Give steroids + ABx w senior opinion
Counsel parents on safe location and inform if this will be repeated that they will be alerted to the police.
125
What steps are not done in kerosene poisoning. Why
Gastric lavage and activated charcoal method
Can cause aspiration leading to chemical pneumonitis
126
A 12 year old child presented following an accidental ingestion of a liquid 30 minutes before. He is having diarrhea. Examination revealed B/L pupillary constriction. Most likey Dx
Organophosphate poisoning
127
Sx of Organophosphate poisoning
DUMBBELSS
Diarrhea
Urination
Miosis
Bradycardia
Bronchoconstriction
Emesis
Lacrimation
Secretions
Salivation
128
Mx of Organophosphate poisoning
Remove contaminated clothes
Suck out secretions
If the patient came <1h do a lavage or use the activated charcoal with senior opinion
Give atropine
Give pralidoxime if atropine doesn't work
129
Mechanism of Organophosphate poisoning
Organophosphate blocks the activity of Acetylcholine esterase causing accumulation of Ach.
Accumulated Ach causes hyperstimulation of Muscarinic and nicotinic receptors. leading to a cholineregic crisis
130
Features of atropinization after Mx of Organophosphate poisoning
Reduced muscarinic effects-
No diarrhea, vomiting
Urinary retention
Mydriasis
Tachycardia/clear lungs
No tears
Dry mouth/ Dry armpits
131
7/12 baby presents w cough, cold and mild fever for 4/30. He has a runny nose. **Today mother has noticed the baby is struggling to breathe.** Dx?
Bronchiolitis
132
# Bronchiolitis
Common age group of presentation
< 2 years
133
# Bronchiolitis
causative MO
RSV
134
# Bronchiolitis
Sx
* Mild fever
* cough
* cold
* dyspnea from 4th-5th day
135
# Bronchiolitis
How long does mild fever, cough, cold last
usually a week
136
# Bronchiolitis
When does dyspnea develop
first 1-3 days will be fine. During the 4-5th days they will come to a peak in difficulty in breathing and usually they will get better.
137
# Bronchiolitis
How do they present
Presents w
* mild fever
* cough
* cold
* nasal blockage and discharge
* dyspnea
* small children can have a small period of apnea
138
# Bronchiolitis
DDs
* Pneumonia
* if the child >2 years- asthma
* URTI
139
# Bronchiolitis
Why is asthma not usually considered to be a DD for Bronchiolitis
* if the child is <2 years highly unlikely
* usually asthma does not present w fever
140
# Bronchiolitis
What are the likely examination findings
* fever
* runny nose
* blocked nose
* features of dyspnea- tachypnea, intercostal recessions, dehydrated
* Rhonchi, crepitations on auscultation
141
# Bronchiolitis
Ix
* CXR
* Naso- pharyngeal aspirate
* FBC
* ABG
142
# Bronchiolitis
CXR findings
* horizontal ribs ( due to air trapping, chest hyper inflates)
* Hyperinflated lung ( flat diaphragm)
* Inflammatory shadows
* Hyperlucent chest- dark lung fields
143
# Bronchiolitis
why is naso- pharyngeal aspirate done
to look for RSV
144
# Bronchiolitis
FBC findings
increased WBC w predominant lymphocytes
145
# Bronchiolitis
Mx
* Suck out secretions
* normal saline nasal drops for nasal blockage
* NG feeding, iv fluids if not feeding properly
* O2 via face mask if hypoxic
* Some may need breathing support- high flow O2
146
# Bronchiolitis
Prevention is done by
RSV vaccine
147
# Bronchiolitis
If the child is going into respi failure. Mx
* will need intubation and mechanical ventilation.
* If child is not very ill- can nebulize w normal saline
* salbutamol nebulization is not proven to be effective. You can give- some may improve, others might not
* Streoids, ABx not given
