final - emergency Flashcards
(30 cards)
head injuries
-Range in severity from minor asymptomatic trauma without sequelae to fatal injuries
-Nonspecific symptoms: Headache, dizziness, N/V, disorientation, amnesia, slowed thinking, and perseveration
-Worsening symptoms in first 24 hours may indicate more severe TBI
-Obtain vital signs and assess child’s LOC by AVPU system or GCS
-PE:
-Detailed neurologic examination
-CSF or blood from ears or nose, hemotympanum, or later appearance of periorbital hematomas (“racoon eyes”) or bruising over mastoid process (“battle sign”) imply a basilar skull fracture
-Eval for associated injuries/C-spine
-Consider child abuse if injury is not consistent with history, developmental stage, and the injury mechanism
head injuries: imaging
-Close observation versus CT scan (PECARN score)
-In infants, normal neurologic exam does not exclude significant intracranial hemorrhage
-Consider imaging if large scalp hematoma or concerns of nonaccidental trauma in younger children
head injuries: complications
-CNS infection: Open head injuries, basilar skull fractures (allow direct entry of organisms)
-Acute intracranial HTN
-AMS, headache, vision changes, vomiting, gait difficulties, pupillary abnormalities
-Signs: Papilledema is cardinal sign
-> Others include stiff neck, cranial nerve palsies, and hemiparesis
-Cushing triad (bradycardia, HTN, and irregular respirations) is a late/common finding
-CT scan prior to LP to avoid herniation
-Tx: ABCs, supportive care (intubation), mannitol/hypertonic saline, neurosurgical consult
head injuries: prognosis and prevention
-Prognosis:
-Depends on severity of initial injury, presence of hypoxia or ischemia, development and subsequent management of intracranial HTN, and associated injuries
-Prevention:
-Helmets
-Over 50% of children fail to wear helmets when riding bicycles
-More stringent helmet use while playing contact sports now in place in child and high school sports programs
-Toppled TVs, dressers, and other unsecured furniture can also result in mild to severe head injuries in young children (anticipatory guidance should be provided)
thermal burns
-Common cause of accidental death and disfigurement in children
-Common causes include hot water/food, appliances, flames, grills, vehicle-related burns, and curling irons
-Associated with child abuse and preventable nature of burns constitute an area of major concern in pediatrics
thermal burns: clinical manifestations
-Superficial-thickness burns: Painful, dry, red, and hypersensitive (sunburn)
-Partial-thickness burns: Superficial or deep
-Superficial partial-thickness: Red, BLISTER
-Deep partial-thickness: Pale, edematous, blanch with pressure, decreased sensitivity to pain!
-Full-thickness burns: Extend through all layers of skin, as well as into the underlying fascia, muscle, and possible bone
-Singeing of nasal or facial hair, carbonaceous material in the nose and mouth, and stridor indicate inhalational burns -> critical airway obstruction
burns: physical abuse
-25% of burns in children may be due to physical abuse
-Symmetric immersion burns with glove and stocking distributions with sharp margins
-Buttock burns that spare center and result in a “doughnut appearance”
-Simultaneous deep burns of buttock, perineum, and both feet
-Burns with clear pattern of hot object (iron, cigarette lighter)
-Lower extremity burns that spare flexor surfaces
-Delay in seeking care, unknown or unwitnessed cause of burn, or burn pattern not consistent with mechanism
thermal burns dx and tx
-Labs
-Extensive partial-thickness and full-thickness burns: CBC, BMP, and CK (tracking infections, renal function)
-Inhalational injuries: ABG, carboxyhemoglobin levels
-Evaluation
-Burn extent classified as major or minor based on calculating total percent of body surface area (BSA) affected by partial-thickness or full-thickness burns
-Minor: < 10% BSA for partial-thickness; < 2% for full-thickness
-Major: Burns to hands, feet, face, eyes, ears, and perineum
-Tx:
-Superficial-Thickness and Partial-Thickness Burns
-Initial analgesia
-Saline irrigation followed by application of clear antibiotic ointment and nonadherent dressing -> Small blisters may be left intact under dressing; larger left intact versus drainage
-Protect wound with bulky dressing, re-examine in 48 hours and serially thereafter
-Cool compresses/pain control continued at home
-Full-Thickness, Deep or Extensive Partial-Thickness, and Subdermal Burns
-ABCS, artificial airway (oral/nasal burns), intubation (singeing of oro- or nasopharynx), NGT, bladder catheterization
-Primary/secondary surveys
-Fluid resuscitation: Based on weight and percentage of BSA with partial- and full-thickness burns
-Parkland formula
-4 mL/kg/% BSA burned for first 24 hours
-½ administered in first 8 hours, ½ in second 16 hours
-Maintenance fluids in addition
-Goal urine output is 1-2 mL/kg/hour
thermal burns disposition and complications
-Disposition:
-Burns > 10% in circumferential pattern, suspicious for abuse, associated with inhalational injury/explosions/fractures > admitted
-Admission for those requiring parenteral analgesia as well
-Burns > 20% > admission versus burn center
-Subdermal burns > burn center
-Complications:
-Deep partial-thickness and full-thickness burns are at risk for scarring
-Loss of barrier function predisposes to infection
-Damage to deeper structures may result in loss of function, contractures, and compartment syndrome (circumferential burns)
-Renal failure secondary to myoglobinuria from rhabdomyolysis
-Prognosis: Greater the BSA and depth of burn, the greater the risk of long-term morbidity and mortality
thermal burns: prevention
-Place hot liquids as far as possible from counter edges
-Panhandles turned away from stove edge
-Water heater thermostats turned to less than 120F
-Irons/electrical cords out of reach
-Barriers around fireplaces
-Protective clothing/hats outdoors
-Infant approved sunscreen for 6 months and older
electrical injuries
-Vary from exposure to low-voltage, high-voltage, or lightning strikes
-Children electrocuted with household current (low-voltage) who are awake and alert at time of evaluation are unlikely to have significant injury
-ECG unnecessary in these cases
-Brief contact with high-voltage source results in contact burn (treat accordingly)
-Infants and toddlers that bite cords may result in burns to the commissure of the lips > labial artery hemorrhage
-If current passes through the body, pattern of injury depends on path of current
-“Locking-on” effect: Alternating current causes tetany
-Extensive nerve and muscle injury, fractures, and cardiac arrhythmias, in addition to dermal burns are possible
-Lab evaluation (UA for rhabdomyolysis) as well as cardiac monitoring should be performed
-Lightning strikes may induce asystole and blast trauma: May not have physical injuries, but can present in cardiopulmonary arrest
heat related injuries: heat cramps
-Brief, severe cramps of skeletal or abdominal muscles following exertion
-Core body temperature normal/slightly elevated
-Electrolyte disturbance is rare and mild (lab evaluation is not indicated)
heat-related injuries: heat exhaustion
-Multiple, vague constitutional symptoms following heat exposure
-Continue to sweat with varying degrees of sodium and water depletion
-Core temperature normal/slightly elevated
-Signs/Symptoms: Weakness, fatigue, headache, disorientation, pallor, thirst, nausea with or without vomiting, muscle cramps without CNS dysfunction; shock may be present
heat related injuries: heat stroke
-Life-threatening failure of thermoregulation
-Dx based on a rectal temperature above 40.6C with associated neurologic dysfunction (severe CNS dysfunction is a hallmark – incoherent/combative) in a patient with an exposure history
-Severe cases: Vomiting, shivering, coma, seizures, nuchal rigidity, and posturing
-Cellular hypoxia, enzyme dysfunction, and disrupted cell membranes lead to global end-organ derangements:
-Rhabdomyolysis, myocardial necrosis, electrolyte abnormalities, ATN/renal failure, hepatic degeneration, ARDS, and DIC
heat-related injuries: tx
-Removal from offending environment, removal of clothing
-Heat cramps: Rest and rehydration with electrolyte solutions
-Heat exhaustion: Evaluation of electrolytes to guide fluid rehydration
-Heat stroke:
-ABCs with oxygen
-Monitoring, rectal temperature probe, Foley catheter, NG tube
-IV fluids (isotonic crystalloid; possibly cooled) with possible CVP monitoring
-Possible diazepam for comfort
-Active cooling: Fanning/misting with cool water, ice application to neck/groin/axillae (discontinue once core temperature reaches 38C to prevent shivering)
-Labs: CBC, electrolytes, glucose, creatinine, PT/PTT, CK, LFTs, ABGs, UA, serum Ca/Mg/phosphate
-PICU admission
heat-related injuries: prognosis and prevention
-Prognosis
-Full recovery for heat cramps/exhaustion
-Heat stroke: Most recover fully with intensive management
-Prognostic indicators: Initial temperature, duration of elevated temperature, and number of systems involved
-Prevention
-Avoid exposure to extremes of temperature for extended periods
-Plan athletic activities for early morning or late afternoon/evening
-Acclimatization, adequate water, shade, and rest period
hypothermia
-Core body temperature < 35C
-Peripheral vasoconstriction: Cool, mottled skin
-Shivering increases heat production to 2-4x basal levels
-Decreased HR and mental status
-HR as low as 4-6 bpm may provide adequate perfusion due to lowered metabolic needs
-Severe cases (< 28C) mimic death: Pale/cyanotic, pupils fixed/dilated, muscles rigid, and there may be no palpable pulses
-Death not pronounced until patient has been rewarmed and remains unresponsive to resuscitative efforts
-Dx:
-Standard evaluation: CBC, electrolytes, creatinine, coagulation studies, glucose, ABGs; consider toxicology screen
-Coagulopathy, hypoglycemia, and acidosis are common
-Correction of derangement via rewarming/resuscitation
-Imaging: Submersion is MCC of hypothermia > CXR
hypothermia tx
-General supportive measures
-Warmed, humified oxygen
-Continual monitoring of body temperature via indwelling rectal thermometer (low-reading)
-Correct hypoglycemia
-Gentle handling > prone to arrythmias (VF)
-Rewarming: Passive external, active external, or active core rewarming
-Passive external for mild cases (33-35C): Removing wet clothing, covering with blankets
-Active external: Warming lights, thermal mattresses or electric warming blanket, and warm bath immersion
-Active core rewarming: Warm/humidified oxygen, crystalloid IV fluids, warm peritoneal and pleural lavage
-ECMO preferred
-Prognosis:
-High mortality rates, related to presence of underlying disorders and injuries
-Children with core temp as low as 19C have survived w/o neurologic compromise
submersion injuries
-drowning - respiratory impairment from submersion/immersion in liquid
-morbidity from CNS and pulmonary insult
-nonfatal drowning describes survivors
-Water hazards are everywhere (even toilets, buckets, washing machines pose a threat)
-RF: Epilepsy, alcohol, lack of supervision
-!!!!Prevention: Protective fencing around public/private pools, use of life vests, avoiding swimming alone, adequate supervision
-Swimming lessons, even for those 1-4yo
submersion injuries sx, dx, tx
-Depends on duration of submersion and any protective hypothermia effects
-Cough, nasal flaring, grunting, retractions, wheezes, cyanosis common
-Cardiovascular changes include myocardial depression/arrhythmias
-ARDS may develop
-Child rewarmed to 33C, but who remains apneic and pulseless is unlikely to survive to discharge or will have severe neurologic deficits
-Aggressive resuscitation should continue in a patient with return of circulation
-Lab findings: ABG with hypoxemia and acidosis
-Imaging:
-CXR: May be normal or with pulmonary edema
-CT brain: For comatose patients or those believed to have suffered prolonged asphyxia or blunt head trauma
-Consider cervical spine injury in teens where diving or intoxication may be involved
-TX:
-Supportive care, correcting hypothermia, treating symptomatically
-Those who appear well initially: Observe for 12-24 hours for late pulmonary or neurologic compromise
-Respiratory distress, abnormal CXR, abnormal ABGs, or hypoxemia > Maximal supplemental oxygen, cardiopulmonary monitoring, and frequent reassessment
-Prognosis:
-Anoxia from laryngospasm or aspiration leads to irreversible CNS damage after only 4-6 minutes
-Survival depends on duration of anoxia and degree of lung injury
-Children with brief submersion with effective, high-quality resuscitation are likely to recover without sequelae
-Children presenting with asystole are unlikely to survive
bite injuries: dogs
-Boys bitten > girls
-dog known by victim usually
-Younger kids have a higher incidence of head and neck wounds
-school-age are bitten on upper extremities MC
-abrasions, lacerations, and puncture wounds
-Larger dogs may tear skin, subcutaneous tissue, and muscle; even cause fracture
-S&S related to involved structures
-Imaging: For fractures, dislodged teeth
-TX:
-Analgesia/anesthesia prior to wound care
-Debridement of any devitalized tissue with removal of foreign material
-Irrigation with normal saline under high pressure and volume (> 1 L)
-Tetanus prophylaxis based on immunization status
-Rabies prophylaxis in developed countries rarely indicated
-Never use tissue adhesive! -> Infection
-Pasteurella canis and Pasteurella multocida, streptococci, staphylococci, and anaerobes may infect dog bites -> Amoxicillin-clavulanic acid (Augmentin) is 1st-line
-Bites involving tendon, joint, periosteum, or assoc with fx -> prompt orthopedic surgery consult
-Complications: Scarring, skin infections, CNS infections, septic arthritis, osteomyelitis, endocarditis, sepsis, and posttraumatic stress
bite injuries: cats
-Girls > boys
-main complication is infection (more puncture wounds versus dog bites)
-Abrasions and puncture wounds
-Within 12hrs -> bite may result in cellulitis or tenosynovitis/septic arthritis
-S&S related to involved structures
-Cat scratch ds:
-Occurs after bites/scratches, especially from kittens
-Local papule, vesicle, or pustule at site of inoculation with regional lymphadenitis (hallmark)
-Labs:
-Serologic tests for Bartonella henselae available
-CRP/ESR may be useful to monitor tx response
-Complications: Cellulitis, tenosynovitis, septic arthritis
-Tx:
-Management similar to dog bites
-High pressure irrigation should be avoided with isolated puncture wounds
-May force bacteria deeper into the tissue
-Should not be closed except when necessary for cosmesis
-P. multocida is MC pathogen
-1st-line: Amoxicillin-clavulanic acid (Augmentin)
-Surgical consult and/or admission and parenteral antibiotics for infected wounds on hand and feet due to higher risk of infection and worsened clinical outcomes
bite injuries: humans
-Most infected during fights with clenched fist and bared teeth
-MC pathogens: Streptococci, staphylococci, anaerobes, and Eikenella corrodens
-Hand wounds and deep wounds should be treated with antibiotic prophylaxis: Amoxicillin-clavulanic acid (Augmentin)
-Wound care:
-Only severe lacerations to face should be sutured
-Other wounds managed by delayed primary closure or healing by secondary intention
-Major complication is infection of the metacarpophalangeal joints
-Hand surgeon should evaluate clenched fist injuries from human bites if extensor tendon injury is identified or joint involvement suspected
poisoning: cosmetic and related products
-MC involved substance in pediatric patients < 5 years of age and second MC in all age groups -Most do not cause significant toxicity -High toxicity: Hydrogen peroxide -Moderate toxicity: Fingernail polish, fingernail polish remover, hair tonic -Low/minimal toxicity: Perfume, deodorants, bath salts, liquid makeup, cleansing creams/lotions
