PAEDIATRIC EMERGENCIES Flashcards by Iseoluwa Ojo

Paediatric emergencies

List 4

• Acutely Raised Intracranial Pressure
• Shock
• Respiratory failure
• Status Epilepticus

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Raised intracranial pressure
Definitions:
• Intracranial pressure (ICP) is the __________ exerted by ________________________ (blood, brain and CSF) within the intracranial cavity
• Usually less than ____mmHg
• Raised ICP: A clinical condition in which this pressure is raised.

pressure ; intracranial contents

10mmHg

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Pathophysiology of raised ICP
• Intracranial contents are in a state of delicate equilibrium
• Intracranial contents: _______,_______,_________
• The brain is ____________________ so any increase in ICP will __________ and/or ________________________

blood, CSF, brain

non compressible

reduce CSF

cerebral blood flow

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Pathophysiology of raised ICP
• Pressure increases __________ with increases in volume up to a point; thereafter pressure increases __________

slightly ; steeply

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Cerebral perfusion pressure (CPP) is the effective pressure that results in
___________ in the brain

• CPP = ______ – _______

blood flow

MAP – ICP

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Cerebral autoregulation: _______ changes in BP produce ___________ changes in cerebral blood flow

Large

Only Small

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Predisposing factors to raised ICP
• _____________
• _____________
• _____________
• Brain oedema
• _____________ to CSF flow
• _____________
• _____________

Infections
Space occupying lesions
Trauma
Obstructions to CSF flow
Cerebrovascular accidents
Seizures

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Predisposing factors to raised ICP
• Infections: __________ , __________, cerebral __________
• Space occupying lesions: __________, __________
• Trauma: intracranial ________ and __________
• Brain oedema: toxins, cerebral hypoxia, encephalopathies (hepatic, hypoxic ischaemic, _______ syndrome)
• Obstructions to CSF flow: ____________

meningitis, encephalitis, cerebral
abscess

tumors, cysts

intracranial bleeds and hematomas

Reye’s ; hydrocephalus

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Clinical features of raised ICP
• ___________
• Early ________ ________
• ________ vision
• Seizures
• Cranial nerve palsy : CN _____
• ________ consciousness
• ________ consciousness
• Localizing signs: hemiparesis, hypertonia
• Cerebellar signs: ________, ________

Headaches ; morning vomiting

Blurred vision ; CN VI

Altered consciousness

Loss of consciousness

ataxia ; nystagmus

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Clinical features of raised ICP
• Sluggish or absent ____________
• ____________: late sign
• Increase in ____________
• ____________ and tense ____________

pupillary light reflex

Papilledema ; head size

Bulging ; fontanels

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• Cushing triad of ICO

???

– Hypertension
– Bradycardia
– Waxing and waning respiration with apnoea

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Complications of raised ICP
• Brain ____________
• ________________
• Global cerebral ____________
• ____________
• ____________
• Death

• Brain herniation
• Status epilepticus
• Global cerebral ischaemia
• Coma
• Stroke
• Death

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Management of raised ICP
• Emergency management
– Optimizing ________ , ________, ________ and ________ level
• Positioning: ________ the head to about _____ degrees
• Respiratory care: ________ +/- ________
• ________ control
• ________ control
• Treatment of ________
• ________ control
• Sedation and analgesia
• Prophylactic hypothermia

airway ; breathing ; circulation

sugar level ; Elevate

30 degrees ; suctioning

intubation ; Fever ; Blood pressure

anaemia ; Seizure

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Management of raised ICP
• Investigations:
– _______ count
– Electrolytes urea and creatinine
– Blood _______
– Cranial imaging: _______, _______
– _______ studies
– _______
– Lumbar puncture for CSF analysis

Full blood count

Blood sugar

CT scan, MRI

Toxicology studies

– Blood culture

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Management of raised ICP
• Ventilatory support: heavy __________ and paralysis
• __________
• Hyperosmolar therapy: __________, hypertonic saline
• Steroids: __________
• __________ coma
• Surgical management: __________ of tumors, __________ of abscesses, __________, ______________________

heavy sedation and paralysis

Hyperventilation

mannitol ; dexamethasone

Barbiturate coma

resection; drainage

ventriculostomy ; ventriculo-peritoneal shunt

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Shock is an __________ syndrome, characterized by inadequate _________________________ , so that the ___________________ of vital organs and
tissues are not met.

acute ; circulatory supply of oxygen

metabolic demands

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Morbidity and mortality of shock
• Leading cause of morbidity and mortality in children
• Can be a progressive process due to the continued presence of the initiating factor with exaggerated and potentially harmful neurohomural, inflammatory and intracellular responses.
• Mortality is increased significantly by the presence of _________________
(____% if only 1 organ system involved, _______% in 2 organ systems, >_____% if 3 or more organ systems)

multiple organ dysfunction

25%; 60%

> 85%

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Aetiology of shock
• Reduced blood in the circuit
– ______________
– Dehydration from ___________, ___________
– ______________
– Maldistribution due to ‘______________’ – many causes including anaphylaxis)

• Pump failure
– Sepsis
– ______________/ ______________
– ______________

• Inadequate oxygen carrying capacity
– ______________
– __________ poisoning

Haemorrhage ; diarrhoea

vomiting; Sepsis

‘third spacing ; Cardiomyopathy/ myocarditis

Arrhythmias

– Anaemia
– CO poisoning

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Classification of shock

List all

• Hypovolaemic
• Distributive
• Cardiogenic: Obstructive
• Dissociative
• Septic

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Hypovolemic shock

• Pathophysiology:
– Loss of ____________________ leading to reduced ________with resultant reduced ______________

intravascular volume ; Preload

cardiac output

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Most common type of shock in children is??

Hypovolemia shock

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Hypovolemic shock

• Aetiology
– Hemorrhagic: _________ bleed, _______ with concealed blood loss (liver/spleen injuries, long bone fractures),
____________ hemorrhage
– Non-hemorrhagic: __________ /__________, heat stroke, __________, __________________

GI ; trauma

vomiting/diarrhea ; burns

diabetic ketoacidosis

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Hypovolemia shock

• Classically, ___________ and ___________ without signs of ____________________ are seen in the patient.

hypotension ; tachycardia

congestive heart failure

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Distributive shock, Pathophysiology:
– Loss of _______________________ (________) results in abnormal distribution of blood flow
– Loss of _________ due to release of endotoxin, vasoactive substances, complement cascade activation, and microcirculation thrombosis leads to loss of preload with blood volume _________ in the periphery.

Systemic Vascular Resistance

afterload; vascular tone

pooling i

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Distributive Shock Aetiology: Sepsis, anaphylaxis, envenomation, spinal cord injury and drug reaction (barbiturates, antihypertensives, phenothiazines)

Distributive shock • Aetiology: _________ , ___________ , envenomation, __________ injury and drug reaction (barbiturates, antihypertensives, phenothiazines)

Sepsis ; anaphylaxis spinal cord injury

Cardiogenic shock Pathophysiology: – The underlying process here is _________________ (______ failure) i.e. Low ______________ in the presence of high systemic vascular resistance – Subsequent increase in LV ______, LV _________, and cardiac _______________ – Cardiac output decreases and ultimately results in volume retention, ____________ , and ______________________ failure

impaired contractility ; pump failure Cardiac output ; afterload work ; oxygen consumption pulmonary edema ; Right ventricular

Cardiogenic Shock Aetiology: ____________ , ___________ lesions, __________, myocarditis, cardiac ____________

Cardiomyopathy obstructive arrhythmias tamponade

Septic shock • SEPTIC SHOCK is not an entirely different entity, but is a clinical syndrome that can include features of both ___________ and ___________ shock.

cardiogenic distributive

Septic Shock • _______% presentation – classic “_______ shock” with _______ extremities, _______ pulses _______cardia, _______pnoea, _______ urine output and mild metabolic _______ – This is characterized by _______ CO, _______ SVR.

• 20% warm ; warm bounding ; tachycardia!; tachypnoea, adequate ; acidosis High; low

Septic shock • ____% presentation – “_____ shock” with _______ extremities, _________ pulses, _________ capillary refill, _________ respiration and _________ urine output – This is characterized by ______ CO, ________ SVR • A small percentage present with mixed pictures.

60% ; cold ; cold thready ; prolonged ; shallow inadequate ; Low; high

Clinical features of shock • Early signs – Fussy, _________ – Reduced _________ – Sinus _________cardia, small volume /_________ pulse – _________ capillary refill age in years)

irritable; urinary output tachycardia ; thready Delayed

Clinical features of shock • Late signs – ______cardia – _________ _________ status (lethargy, coma) – _______tonia, ______eased deep tendon reflexes – _________ breathing – ______________ is a very late sign Lower limit of SBP = _______ + (_____ x _____________)

Bradycardia ; Altered mental status Hypotonia ; decreased Cheyne-Stokes ; Hypotension 70 + (2 x age in years)

Management of shock • Immediate identification of life - threatening conditions (primary survey) – GET ____________ IN EARLY • Rapid Correction of _________ compromise • Maintain adequate _________________ • Eliminate underlying cause

OXYGEN ; circulatory perfusion pressure

Management of shock Airway • The ability to speak or cry without stridor generally indicates a __________ airway. – __________ airway – +/- mechanical ventilation – Assess mental state using __________ criteria (__________, response to __________, response to __________, __________) during the initial survey of the patient. Breathing – __________ of breathing – Check ______________ with pulse oximeter.

patent ; oropharyngeal AVPU ;Alert, response to Verbal command response to Painful stimulus Unresponsive work ; oxygen saturation

Management of shock • Circulation – Heart rate, pulses, blood pressure. Remember ____________ (relative to age norm) is key sign of shock even before blood pressure is reduced. ___________ is a late sign. – Capillary refill– to assess perfusion to organ systems – Vascular assess should be obtained early either through a _______________ or _______________ route can be used after _____ failed attempts at venous cannulation. There is no place for the lengthy nature of the procedure.

TACHYCARDIA BRADYCARDIA large bore vein ; intra-osseous 2

Management of shock • Dextrose/Drugs? - Do ____________ level and if necessary correct using 2-4ml/kg of ____% __________.

Random blood sugar level 10% Dextrose.

History/ examination and investigations in shock • Brief medical history should be obtained while resuscitation is on-going focusing on – __________ events, recent __________ or __________ – __________ History • Allergies & exposure to ________ – Focused physical examination • __________ System: _______ status using __________ • Cardiovascular System: HR, perfusion, ? __________ ? __________ • Respiratory system: __________, __________ • Investigations: ______,_______,_________ and __________

Preceding events ; illness ; trauma Past Medical History ; toxins Central Nervous System ; mental status Glasgow Coma Scale ?gallop; ?murmur crackles ; wheezing CBC, EUCr, Group and crossmatching

Management of shock • Fluid resuscitation: – Fluids: __________ , ____________ – Volume: _____mls/kg – Duration: as quickly as possible – Repeat if required • Inotropes: • Usually used early in septic shock • Used after failure to respond to ____ml/kg fluid in first hour • Include: _________ , _________, _________, noradrenaline, milrinone, vasopressin

Normal saline ; Ringer’s lactate 20mls/kg ; 40ml/kg fluid dobutamine, dopamine, adrenaline,

Summary: Shock • Recognize shock quickly - ____________ IS THE FIRST SIGN, __________ IS LATE. • _________ remains your first step in initial care • Gain access quickly - if needed use IO. • If patient is not responding the as quickly you expect, broaden your differential; think about other types of shock. • The on-going management of the shocked child will depend on the specific cause and may include interventions such as _________ , _________ antibiotics, _________ support and _________ intervention.

TACHYCARDIA ; HYPOTENSION ABCD ventilation ; broad spectrum antibiotics ; inotropic surgical

Respiratory Failure Definition • A clinical condition which occurs when the ___________________________________________________ is unable to match the body's metabolic demands • An important cause of morbidity and mortality in children

rate of gas exchange (oxygen delivery and carbon dioxide removal) between the atmosphere and the blood

Respiratory failure • PaO2 <_____mmHg and PaCO2> ____mmHg on room air

60 50

Respiratory failure • Respiratory distress (can or cannot?) occur without respiratory disease • Respiratory failure (can or cannot?) occur without respiratory distress

can can

• Respiratory failure can be acute or chronic Chronic causes include: bronchopulmonary dysplasia, ___________ , ___________

cystic fibrosis obstructive sleep apnoea

Aetiology of respiratory failure Lower airway obstruction List 4

• Bronchial asthma • Bronchiolitis • Aspiration pneumonia • Meconium aspiration

Aetiology of respiratory failure Lung/interstitium List 3

• Pneumonia • ARDS/ RDS • Pulmonary oedema

Aetiology of respiratory failure Thoracic cage • Chest wall deformities: _________ • Diaphragmatic _____________ •_______ chest • Abdominal distension

kyphoscoliosis, pectus herniation/eventration Flail

Management of respiratory failure • Emergency care: ________ • Investigations: – _______ , ________ , ________, – Imaging: CXR, neck /post nasal space xray, brain imaging • Treat underlying cause • Adequate __________ – Bag and mask ventilation – Supplemental oxygen: face mask, nasal prongs, – ________________________ • Adequate ventilation – __________ with mechanical ventilation

ABCD CBC, EUCr, ABG, oxygenation Continuous Positive Airway Pressure Intubation

Aetiology of respiratory failure Upper Airway obstruction: List 5 • Adenoidal hypertrophy

• Choanal atresia • Foreign body aspiration • Epiglottitis • Laryngotracheobronchitis • Anaphylaxis

Aetiology of respiratory failure Brain and spinal cord • ___________ injury • CNS ___________/___________ • CNS ___________ • Intracranial ___________ • ______________ • Transverse myelitis • ___________ • ___________ of ___________

Trauma/head injury depressants/sedatives infections Intracranial bleed Raised ICP Poliomyelitis Apnoea of prematurity

Aetiology of respiratory failure Neuromuscular •________ nerve palsy • Infant __________ •_____________ syndrome • Myaesthenia gravis •___________________ poisoning

Phrenic botulism Gullain Barre Organophosphate

Clinical features of respiratory failure • Increased _______________ • Tachypnoea • Dyspnoea • _____________ (_______________, _______________, _______________) • _______________ • _______________ • Irregular respiration • _______________ • Altered mental status

work of breathing Retractions (intercostal, subcostal, suprasternal) Grunting; Nasal flaring Apnoea

Status epilepticus • Definition – ________ seizure lasting more than ______________ – __________ seizure occurring without ____________ May be __________ or ___________

Single ; five minutes Multiple ; full recovery convulsive ; non convulsive

Identifying a child with respiratory failure Key signs: 2R,2C,1A ???

Increased Respiratory rate Increased Work of breathing • Colour change (cyanosis) Decreased Consciousness change Decreased Air entry

Status Epilepticus Risk of complications increases with ____________ Mortality rate up to ____%

duration 10%

Status epilepticus may be the first presentation of a seizure T/F

Pathophysiology of status epilepticus • ___________ and persistent __________________ • Ineffective recruitment of ___________ neurons • Excitatory neurotransmitters: ___________, ___________, ___________ • Inhibitory neurotransmitter: ___________ • Associated ___________, ___________, ___________ and ___________ exacerbate neuronal damage

Excessive ; excitation of neurons inhibitory neurons; glutamate, aspartate ; acetyicholine ; GABA hypoxia ; hypotension acidosis ; hyperpyrexia

Investigation of status epilepticus • Labs – EUCr: Na, Ca, Mg, PO4 , glucose – CBC, blood cultures, urinalysis, MP – Arterial blood gases – Liver function tests, ammonia – Serum anticonvulsant level – Toxicology

Tired

Morbidity and mortality of shock Morbidity may be wide spread and involve multiple organs with effects such as  ________ failure,  ________ damage,  ________ ischemia,  ________ failure,  ________ ________,  ________ (DIC),  ________(ARDS),  ________ failure, and  death.

renal failure,  brain damage,  gut ischemia,  hepatic failure,  metabolic derangements,  Disseminated Intravascular Coagulation (DIC),  acute respiratory distress syndrome (ARDS),  cardiac failure, and  death.

Management of status epilepticus Principles • Ensure adequate vitals, systemic and cerebral __________ • _________ seizure activity • Prevent seizure __________ • Establish the diagnosis and treat the underlying disorder

oxygenation seizure activity recurrence

Investigation of status epilepticus • Lumbar puncture – Always defer LP in ________ patient, but never ____________________ if indicated • CT scan Indicated for _______ seizures or deficit, history of ________ or __________ disorder • EEG: especially in _______________ SE

unstable delay antibiotic/antiviral medication focal ; trauma ; bleeding non convulsive

Management of status epilepticus • Abort seizures: – 1st line: ______ acting ___________ (_________ , ___________), repeat if seizure continues – 2nd line: ______ acting ___________: ___________, ___________ – 3rd line: IV ________________, levetiracetam – ICU care with elective ___________ and ___________ if airway compromised or no response to 3rd line agents – Midazolam infusion – ________________ : ___________ or ___________ on _____ monitoring

Short ; benzodiazepine Diazepam ; Lorazepam Long ; anticonvulsants Phenytoin ; Phenobarbitone sodium valproate ; intubation mechanical ventilation Barbiturate coma ; pentobarbital thiopental ; EEG

Management of status epilepticus • Relevant history (after _________) – Description of the event – ________ or ________ seizure – Associated symptoms – Anticonvulsant medications (previous use/ type/change/adherence) – Trauma – Fever – Ingestions • CNS examination: Coma scale, Pupillary light reflex, CNS examination

stabilization Previous ; first time seizure

Complications of status epilepticus • _________ __________ • Focal neurological deficits • _________ disorders • Chronic _________

Mental retardation Focal neurological deficits Chronic epilepsy

PAEDIATRIC EMERGENCIES Flashcards

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