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)
-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
⚡️ Electrical Injuries: Quick Overview
🚸 Types of Exposure
Type Key Features
Low-voltage (<1000 V) Household current, usually less severe
High-voltage (>1000 V) Power lines, industrial → deep tissue damage
Lightning strike Massive energy, blast trauma, cardiac arrest, may lack visible burns
🔍 Clinical Patterns by Exposure
🧒 Low-voltage (e.g., household outlets)
Most children are fine if awake and alert
No ECG needed if asymptomatic, normal exam
👶 Cord-biting toddlers
Burns at lip commissure
Risk of labial artery hemorrhage as eschar sloughs off
⚠️ High-voltage or current through body
Path of current determines injury (e.g., hand-to-foot = through heart)
Can cause:
Cardiac arrhythmias
Rhabdomyolysis → myoglobinuria
Compartment syndrome
Deep muscle and nerve injury (worse than skin suggests)
“Locking-on” tetany with AC current
🧪 Labs: Check urinalysis for myoglobin (rhabdo), CK, electrolytes
📟 Monitor: Continuous cardiac monitoring if LOC, high voltage, abnormal ECG, or suspected arrhythmia
⚡️ Lightning Strike
May cause:
Asystole, V-fib
Blast injuries
Tympanic membrane rupture
Victim may be pulseless but revivable
Resuscitate aggressively even if no external burns
🛠️ Management Summary
Step Do This
ABCs first CPR if needed (especially in lightning injury)
Burn care As per thermal injury guidelines
ECG + cardiac monitoring If high voltage, LOC, or symptoms
Urinalysis for myoglobin Rhabdomyolysis screen
IV fluids Prevent AKI if rhabdo present
Watch for compartment syndrome Especially with deep burns or tense limbs
🔑 TL;DR
Awake, alert kid with household shock → no ECG needed
Lip burns from cords → risk of delayed labial artery bleed
High-voltage or current through body → ECG + UA for rhabdo
Lightning strike → treat aggressively even if unresponsive — asystole is common but reversible
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
🌊 Submersion Injuries (Drowning)
Definition: Respiratory impairment from immersion/submersion in liquid
Pathophysiology involves hypoxia, acidosis, and pulmonary injury
🧠 Symptoms: Vary by Duration and Severity
System Findings
Respiratory Cough, retractions, wheezing, nasal flaring, grunting, cyanosis
Neuro Lethargy, altered LOC, coma, seizures if prolonged hypoxia
Cardiac Bradycardia, arrhythmias, myocardial depression
Hypothermia May protect brain, but delays recovery
🧠 Apneic + pulseless at <33°C = poor prognosis
🧪 Diagnosis: What to Look For
Test Purpose
ABG Hypoxemia, acidosis
CXR May be normal early or show pulmonary edema / ARDS
CT brain If comatose, prolonged downtime, or head trauma suspected
C-spine imaging Consider if diving, trauma, or teen intoxication
💊 Treatment: Supportive + Prevent Complications
🛟 Initial Management
ABCs first (Airway, Breathing, Circulation)
High-flow O₂
Rewarming (especially if <33°C)
Monitor for pulmonary edema even if patient looks okay
📍 Disposition Based on Presentation
If… Then…
Asymptomatic at arrival Observe 12–24 hrs for late deterioration
Respiratory symptoms, abnormal ABG/CXR Admit for O₂, monitoring, frequent reassessment
Apnea + asystole after warming Poor prognosis, likely severe neurologic outcome
⚠️ Prognosis
Factor Prognosis
Anoxia > 4–6 minutes Irreversible brain injury likely
Rapid rescue + good resuscitation Often full recovery (esp. children)
Persistent asystole post-rescue Very poor outcome
🧠 TL;DR
Submersion → hypoxia + ARDS
Symptoms may be delayed → observe even if well-appearing
Labs: ABG (hypoxemia, acidosis)
Imaging: CXR, CT brain if altered, consider C-spine if trauma
Tx = supportive + rewarming + oxygen
Prognosis hinges on duration of hypoxia
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
