Emergency Flashcards by Bridie Peters

What is the AVPU score?

A - alert

V - voice

P - pain

U - unresponsive

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What is warm shock?

Hyperdynamic shock

High cardiac output, low peripheral resistance

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What is cold shock?

Hypodynamic shock

High systemic vascular resistance and low cardiac output

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Why do patients have a narrow pulse pressure in cold shock?

Systolic: low due to low CO

Diastolic: high due to catecholamines that increase systemic vascular resistance to increase venous return

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Why do patients with warm shock have a wide pulse pressure?

Lowered diastolic BP

Cytokines increase vascular permeability and cause systemic vasodilation, lowering the systemic vascular resistance

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Which vasopressor is used for cold shock?

Adrenaline

Strong B1 activity - increases CO

Given if fluid resuscitation is inadequate

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Which vasopressor is used for warm shock?

Noradrenaline

Acts on alpha 1 and beta 1 receptors, producing potent vasoconstriction and a modest increase in cardiac output

Given if fluid resuscitation is inadequate

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Is cold or warm shock more common in infants/neonates?

Cold shock

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What is the difference between SJS and TEN?

Extent of spread

<10% SJS

>30% TEN

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What is the most common cause of SJS?

Drugs (80%)

Antibiotics (sulfonamides), corticosteroids, antiepileptics, alllopurinol, antiretrovirals

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What is the pathophysiology of SJS?

Delayed type IV hypersensitivity

Cytotoxic t cells → keratinocyte damage

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How does mucous membrane involvement differentiated SJS from staphylococcal scalded skin syndrome?

Involved in SJS

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How is SJS treated?

Cease offending drug

Supportive

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How is Kawasaki disease diagnosed?

Fever + 4 of

Fever lasting > 4 days
Bilateral conjunctival injection (non-exudative)
Erythematous rash
Dry/red fissured lips or strawberry tongue
Oedema of hands/feet
At least once cervical lymph node > 1.5cm

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How are the points in the GCS distributed?

Eye - 4

Verbal - 5

Motor - 6

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How are eye responses scored for the GCS?

4 - spontaneous

3 - verbal command

2 - pain

1 - no eye opening

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How are verbal responses scored for the GCS?

5 - orientated

4 - confused

3 - inappropriate words

2- incomprehesible sounds

1 - no verbal response

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How is motor response scored for the GCS?

6 - obeys commands

5 - localises pain

4 - withdraws from pain

3 - flexion to pain

2 - extension to pain

1 - no motor response

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How is DIC from meningococcal treated?

Antithrombin

(thrombotic/organ failure type)

Antithrombin inhibits thrombin and other coagulation factors

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What is the empirical treatment for suspected meningococcal sepsis?

Benzylpenicillin IV or IM

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How is adrenaline dosed in childhood?

10 micrograms/kg

0.01mL/kg of 1:1000

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What doses are children defibrillated with?

4 J/kg

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What is the definition of hypoglycaemia in a child?

BGL < 2.6 mmol/L

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What fluid type is given for resuscitation/bolus?

0.9% NaCl

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How is a child's fluid bolus calculated?

20mL/kg 0.9% NaCl

How are a child's replacement fluids calculated?

Weight x % deficit x 10mL (only replace to 5% in the first 24 hours)

How do you calculate a child's daily fluid requirements for maintenance?

What % body weight loss corresponds with mild, moderate and severe dehydration?

3% mild 5% moderate 10% severe

When is supplemental oxygen used in an asthma attack?

SaO2 \< 94% Maintain \> 94%

When is Ipratropium used for acute asthma? Include timing and dose

Severe +/- moderate asthma Every 20 minutes x 3 with salbutamol \< 6 years: 4 puffs 6+ years: 8 puffs

What is third space loss?

Too much fluid moves from the intravascular space into the interstitial space ## Footnote * Three spaces:* * 1. intracellular* * 2. intravascular* * 3. interstitial*

What BSL should be maintained in DKA treatment before insulin is infused?

10-15 So insulin can be administered and resolve ketoacidosis

What serum potassium level is a contraindication to insulin in DKA?

\< 3.3 mmol/L

How fast should BSL fall in DKA management?

4 mmol/L to prevent cerebral oedema

What is the proposed pathophysiology of cerebral oedema with DKA?

Hyperglycaemia → hyperosmolality Insulin → reversal of osmolality → fluid moves intracellularly → cerebral oedema

What are the clinical features of cerebral oedema in the management of DKA?

Headache, vomiting, irritability, lethargy, elevated BP, altered mental status, incontinence, focal neurological deficits

During basic life support, for how long do you attempt to feel a pulse before commencing chest compressions?

10 seconds

Which pulses are most reliable for palpation in children?

Carotid, femoral, brachial

What is the COACHED approach to defibrillation?

C - compressions continue O - oxygen away A - all else clear C - charging H - hands off/I'm safe E - evaluate rhythm D - defibrillation or disarm and dump

How much energy should be given in a shock from a defibrillator?

4J/kg

What is unstable bradycardia?

HR \< normal PLUS signs of shock HR \< 60 bpm in infants

How should unstable bradycardia be managed in a responsive patient?

1. Bag and mask ventilation with high flow oxygen 2. Volume expansion 20ml/kg 0.9% NaCl 3. Consider atropine 20mcg/kg IV or IO if vagal cause

What gas flow rate should be set for neonates on the neopuff?

10L/min

What maximal pressure should be set for neonates on the neopuff?

50cm H2O

What PEEP should be set for neonates on the neopuff?

5-8 cm H2O

What PIP should be set for neonates on the neopuff?

30cm H2O (term) 20-25 cm H2O (preterm)

What does a small amount of PEEP do?

Prevent end-expiratory alveolar collapse

What are 3 paediatric insertion sites for an IO access?

1. Distal femur 2. Proximal tibia 3. Distal tibia 4. Proximal humerus

Where is the IO insertion site on the proximal tibia?

2cm below the tibial tuberosity 1cm medially

Where is the IO insertion site on the distal femur?

1-2cm above the superior border of the patella with the leg in extension

Where is the IO insertion site on the distal tibia or fibula?

1-2cm superior to the melleoli in the bone's axis

Where is the IO insertion site on the proximal humerus?

Greater tubercle

What are the clinical features of an effective cough?

Crying or talking Loud cough Able to take a breath before coughing Fully responsive *Mild airway obstruction*

What are the clinical features of an ineffective cough?

Unable to cry to talk Quiet or silent coug Unable to breathe Cyanosis Decreased level of consciousness

How is an ineffective cough managed in a conscious patient?

Call for help 5 back blows, 5 chest thrusts Assess and repeat

What is the effect of adenosine on the heart?

Slows heart rate Suppresses SA node activivation and slows conduction through the AV node

How is stable SVT managed?

1. Vagal manoeuvre - ice pack to the face 2. IV adenosine 0.1mg/kg

How is the shocked patient with SVT managed?

Synchronised DC cardioversion 1 joule/kg

What do the 4 H's and 4 T's describe?

Reversible causes of cardiac arrest

What is involved in a septic workup?

1. Blood cultures 2. CXR 3. Lumbar puncture 4. Urine culture

Over what period of time is the fluid deficit in DKA corrected?

48 hours The aim is the achieve sufficient perfusion to avoid acute tubular necrosis but keep the patient relatively hydrated while the metabolic defect is corrected

What is the ABCDE approach to a sick child?

A - airway B - breathing C - circulating D - disability E - exposure (F - fluids) (G - glucose)

What dose of salbutamol is given via a nebuliser in severe asthma? (nebulised not given in mild/moderate)

1-5 years: 2.5 mg 6+ years: 5 mg

What dose of nebulised ipratropium is given to children with a severe asthma exacerbation? (Ipratropium + nebulised bronchodilators are not used in mild/moderate asthma)

1-5 years: 250 mcg 6+ years: 500 mcg

What are the features of a severe asthma exacerbation?

Intercostal/subcostal recession or tracheal tug Unable to complete sentences in one breath Obvious respiratory distress Oxygen saturation 90–94%