Pediatric Emergencies Flashcards
(155 cards)
1
Q
Leading cause of childhood deaths
A
Injuries (counsel on safety at every well-child visit)
2
Q
Head injuries in infants/toddlers because
A
large heads
weak neck muscles (acceleration-deceleration injuries –> shearing forces –> injury to neurons and vascular structure)
thin skulls
physically uncoordinated
lack cognitive ability to predict/understand danger
3
Q
Causes of head injuries
A
MVA, falls, abuse, recreational activities
Bimodal dist:
>8: sports, MVA, ATV’s bikes, scooters
<1 Yo: walking, furniture, abuse
4
Q
Diffuse axonal injury
A
smash one side of head and the other gets injured
5
Q
Bones of the skull
A
frontal, parietal, occipital, temporal, sphenoid, ethmoid
6
Q
Hx questions
A
witnessed? heigh immediate cry consolable vomiting (more than 3x) time since injury arousable (is it nap-time) size of mass other injuries
7
Q
parents worried about “drowsiness”
A
ask if “normal” nap or bed time
concerning signs: excessive sleepy or hard to arouse, vomiting, irritability
8
Q
Exam for head injury 1st survey
A
ABC’s (airway, breathing, circulation)
Neuro status: Glasgow coma scale (GSC), pupils, sucking reflex, muscle tone
Vitals: Cushings triad
9
Q
Glasgow coma scale (GSC)
A
checks for coma
15 - highest
<8 needs immediate resussitation
Evaluates:
- eye opening
- best verbal response
- best motor response
10
Q
Cushings triad
A
wide PP
bradycardia
abnormal respiration
(body’s response to increased ICP – typically showing hemorrhage or bleed, etc.)
11
Q
Eval for head injury 2nd survey
A
Head/neck:
- C-sline alignment, funduscopic exam, hematomas, step-offs, crepitus, lacerations, fontanels
- basilar skull fracture: battle sign, periorbital ecchymosis (racoon eyes), hemotypanum, otorhea/rhinorrhea (CSF)
- REST OF BODY
12
Q
Basilar skull fracture
A
battle’s sign (behind ear)
periorbital ecchymosis (racoon eyes)
hemotympanum
otorrhea/rhinorrhea (CSF)
13
Q
Dx of head injuries
A
X-ray (minimal value, body injury, air-fluid levels, no soft tissue (brain) visualization)
CT - high radiation, only for HIGH-RISK
- based on PECARN, CATCH, CHALICE tests
14
Q
PECARN
A
most important/accurate
15
Q
CATCH
A
CT based on irritability on exam
16
Q
CHALICE
A
CT based on high-speed MVA (>40 mh)
17
Q
Who gets CT?
A
GCS <15 or acute mental status change Fx signs vomiting >3x seizure <2 YO Hematoma- non-frontal scalp LOC > 5 seconds MOA - severe "weird acting" or lethargic
“Guy with friendly voices start 2 make Lauren horny.”
18
Q
How many who get scanned have TBI?
A
0.9%
19
Q
Subdural hematoma prognosis
A
poor
20
Q
What is a subdural hematoma
A
b/w the dura and arachnoid membrane– associated w/ diffuse brain injury
tearing of bridging veins – LOW PRESSURE BLEED, dissects arachnoid away from dura
21
Q
Sx of subdural hematoma
A
LOC
Lingering sx – irritability, lethargy, BULGING FONTANELLE, vomiting
22
Q
Dx of subdural hematoma
A
CT - crescent-shaped, usually parietal area
- CROSSES SUTURE LINES (KEY)
23
Q
Epidural hematoma prognosis
A
better than subdural
24
Q
What is epidural hematoma
A
rupture of the arteries +/- underlying fracture
25
Hx of Epidural hematoma
brief LOC
| lucid period followed by deterioration!
26
Dx of epidural hematoma
eliptical shape -- DOES NOT CROSS SUTURES
27
Subarachnoid Hemorrhage (SAH)
injury to the parenchymal and subarachnoid vessels
28
Sx of SAH
normal to LOC
29
CT findings for SAH
small, dense "slivers" on CT -- blood in cisterns, sulci and fissures, blood in CSF, may take time to evolve and be visible on CT
30
Most common bleed
SAH
31
Management of head trauma- No ICH, no skull fracture
head injury precautions
Monitor for: behavior change, vomiting, decreased arousability, seizure activity, irritability
SLEEPING IS OKAY -- if concerned, wake up every 2-3 hours
32
Management of head trauma w/ positive ICH +/- skull fracture
Neuro consult
Admit (PICU?)
Evacuation of ICH/surgery to repair fracture vs observation w/ repeat imaging
33
Concussion aka
mild traumatic brain injury
34
What is a concussion
traumatically induced alteration in mental status, with or without LOC
35
Phys behind concussion
direct blunt force --> stretching/shearing of axons
36
Sx of concussion
amnesia
Confusion and/or blunted affect, distractibility
delayed response
emotional lability
visual changes
repetitive speech pattern (repeating questions)
37
Types of amnesai
antigrade -- new memories
| retrograde -- pulling up old memories
38
Hx for concussion
MOI
length of LOC
length of confusion/mental status changes
seizure?
movement of extremities at scene
hx of previous concussions or brain injury
Substance use - -ETOH or other
39
When to CT
ALWAYS IF THERE WAS SUBSTANCE USE INVOLVED (regardless of PE findings)
40
PE for concussion
Complete neuro exam: GCS rating, CN II-XII balance, gait, cogn/memory testing
Head: hematoma, deformiting, step off, crepitus, mastoid
Eyes: pupils, acuity, racoon eyes
Ears: earing, hemotypanum
Nose: CSF rhinorrhea? fx?
Neck/throat: cervical spinous process tenderness, neck ROM
Chest: trauma
Extremities: ROM, strength , reflexes
41
Concussion prognosis
h/a, mental fogginess, mild sx - resolve 7-10 days (90% w/i 30)
worsening h/a, vomit, deterioration in mental status = emergent
post concussive syndrome: sx lasting 3 months or longer
Second impact syndrome: 2nd concussion w/i weeks --> brain swelling, herniation, death
Chronic traumatic encephalopathy - multiple concussion, permanent change in mood, behavior, pain
42
Post concussive syndrome
sx last 3 months or longer
43
Second impact syndrome
2nd concussion w/i weeks --> brain swell, herniation and death
children at increased risk
44
What can multiple concussions lead to
chronic traumatic encephalopathy
45
Tx for concussion
NO SAME DAY RETURN TO PLAY
- must be COMPLETELY sx free to return
- consider NO SPORTS 1-2 weeks, depending on severity
- slow advancement of activity after complete sx resolution
Physical and cognitive rest: no cell phone, video games, adequate sleep, NOISE REDUCTION for first 48 hours
46
return to play protocol stages
1-6
47
Stage 1 return to play
sx limited activity (aim)
daily activities that don't provoke sx (activity)
Goal: gradual reintroduction to work/school
48
stage 2 return to play
light aerobic
walking/stationary cycle; no resistance training
goal: increase HR
49
stage 3
sport specific exercise
running or skating drills; no head impact activities
Goal: add movement
50
Stage 4
non-contact training drills
harder training (passing drills); start progressive resistance training
goal: exercise, coordination and increased thinking
51
Stage 5
full contact practicce
follow med clearance, participate in normal training activities
goal: restore confience and assess skills
52
Stage 6
return to sport
normal game play
53
Cervical spine injuries
VERY RARE IN PEDS
Causes: MVA
< 8 yo: falls (C2-4)
> 8 YO: sports (C5-C7)
adolescent typically have SCIWORA
54
SCIWORA
spinal cord injury w/o radiographic abnormality
55
test of choice for cervical spine injuries
MRI
56
Concerning sx for cervical spine injury
bilateral pain
neuro deficit
torticollis
bony abnormalities
57
Open fracture management
compound - splint/dress, start IV abx, ortho consult
non-displace (overlying laceration) -- start PO abx, repair laceration, splint, outpatient ortho f/u
58
Managment of grossly deformed/displace fracture
may compromise neurovascular structures
| will require closed/open reduction, possible fixation (ortho consult in ED)
59
Other fx management
splint, pain control, ortho f/u
60
Always do this w/ fractures
document neurovascular status BEFORE and AFTER splinting/reduction/any other intervention
61
Skin infections
cellulitis
| erysipelas
62
Sx of skin infection
```
erythema
warmth
tenderness
induration
+/- fever, n/v/d
```
63
Cellulitis
involves deeper dermis and subcutaneous fat
64
erysipelas
involves upper dermis and superficial lymphatics
65
Tx of skin infection
warm wet compress
Bactroban- topical
Keflex/Bactrim- oral
66
Skin infection that fails outpatient tx
admit
labs
IV abx
67
Osteomyelitis cause
hematogenous spread of infection to bone --> bone destruction
68
Epidemiology of osteomyelitis
under age 5
M>F
long bones, including femur, tibia, humerus
69
Pathogens of osteomyelitis
Staph aureus (most common, poss MRSA)
S. pneumo
S. pyogenes
70
Presentation of osteomyelitis
```
fever
bone pain
swelling
redness
guarding
focal tenderness during exam
```
71
Dx of osteomyelitis
x-ray: early: soft tissue swelling, 10-14 days later: bone destruction w/ lytic lesions
MRI: BEST STUDY FOR EVAL: marrow edema, abscesses
labs: CBC, CRP, ESR, lactic acid, wound culture, blood culture (before abx)
72
Best study for osteomyelitis
MRI
73
Tx for osteomyelitis
supportive
IV Abx (empiric, then directed)-- vanco, clinda, rocephin
Surgical drainage if needed
debridgement
hyperbaric oxygen therapy: change w/ 100% oxygen
74
Deadly in a dose
```
ASA
BB
CCB
Codeine
Camphor
Chloroquine
Clonidine
Iron
Lindane
Methyl Salicylate
Methadone
Nicotine
Oils (hydrocarbons)
theophylline
Tricyclic antidepressants
```
75
Hx for toxic ingestion
substance (ingredient, concentration/strength)
route
quantity (count pills left in bottle)
long b/w exposure and eval
progression of sx since exposure
home tx administer (induced vomiting meds)
underlying med conditions
76
Toxidromes
sx that occur w/ specific substances: helpful in establishing dx when exposure not well defined
77
Anticholinergic presentation
delirium, flushed skin, dilated pupils, urinary retention, decreased BS, memory loss, seizures (hot as a har, dry as a bone, red as a beet, blind as a bat, mad as a hatter)
Tachycardic, hyperthermia, hypertension
78
Anticholiergic agents
```
antihistamines
scopolamine
jimson weed
angel trumpet
benztropine
TCA's
atropine
```
79
Cholinergic presentation
confusion, weakness, salivation, lacrimation, defecation, emesis, diaphoresis, muscle fasciculations, miosis, seizures
bradycardic, hypothermic, tachypnea
80
Cholinergic agents
organophosphates
carbamates
muschrooms
81
Hallucinogenic presentation
```
disoriented
hallucination
visual illusions
panic reaction
moist skin
hyperactive BS
seizures
```
tachycardic, tachypnea, hypertension
82
Hallucinogenic agents
amphetamines
cannabinoids
cocaine
phencyclidine (PCP)
83
Opiate/narcotic presentation
altered mental status
unresponsive
miosis, shock
shallow resp
slow RR
bradycardia, hypothermia, hypotension
84
Opiate agents
opiates
propoxyphene
dextromethorphan
85
Sedative/hypnotic presentation
coma, stupor, confusion, sedation
progressive deterioration of CNS function
apnea
86
Sedative agents
barbiturates
benzos
ehtanol
anticonvulsants
87
Sympathomimetic
delusion, paranoia, diaphoresis, piloerection, mydriasis, hyperreflexia, seizures, anxiety
tachycardic, bradycardia (if pure alpha agonist)
hypertension
88
Sympathomimetic
```
cocaine
amphetamines
meth
phenylpropanolamine
ephedrine
pseudoephedrine
albuterol
ma Huang
```
89
Tachycardic
anticholinergic
hallucinogen
sympathomimetic
90
bradycardia
cholinergic
| opiate
91
apnea
sedative/hypnotic
92
Tx for toxin ingestion
(ABC-DDD)
1. Stabilize pt (ABC)
2. Contact poison center
3. DDD (disability, drugs, decontamination)
93
ABC
airway
breathing
circulation
94
Ocular decontamination
test pH
copious normal saline lavage until pH normal: flush at least 15 min before re-eval
remove contacts
optho consult STAT
95
Skin decontamination
copious NS and water
| follow w/ soap to concentrated lipid-soluble toxins
96
GI decontamination
activated charcoal, cathartics, whole bowel irrigation
97
Blood stream decontamination
antidote
98
GI decontaminates
1. Ipecac- helpful w/i 30 minutes, not recommended
2. Gastric lavage- no longer used
3. Cathartics - not helpful
4. Whole bowel irrigation - sustained release med (poop alot)
5. Activated charcoal -- GO TO!
6. simple dilution- mild toxins
99
Activated charcoal not used with
```
salicylates
hydrocarbons
lithium
strong acids/base
metals
EtOH
```
100
Charcoal used wi
```
carbamazepine
barbiturates
dapsone
quinine
theophylline
digoxin?
phenytoin?
```
101
Enhancing elimination
activated charcoal (bind toxins)
urine alkalization (inc. urination)
diuresis
dialysis/hemoperfusion
102
Antidote for acetaminophen
acetylcysteine
103
antidote for anticholinergics
physostigmine
104
*benzodiazepine antidote
Flumazenil
105
Beta blocker antidote
glucagon
106
CCB antidote
Calcium
107
Digoxin antidote
Digibind
108
heavy metal antidte
chelating agents
109
narcotics antidote ***
Naloxone
110
Labs for toxin ingestion
```
salicylate level
acetaminophen level*
UDS (urine drug screen)
digitalis, theophylline, methemoglobin levels
lithium level
PT/INR (warfarin)
CO level
CMP, coags, ABGs - standard
```
cardiac monitor
administer antidotes
111
FB lodges in what narrow spaces
cricopharyngeal narrowing-upper esophageal sphincter
tracheal bifurcation
aortic notch
lower esophageal sphincter (LES)
112
FB concerns
sharp/irregular edges
if lodged in esophagus: airway obstruction, stricture, perforation
perforation: result of direct mechanical or chemical erosion
aspirated vegetable matter can cause intense pneumonitis, often difficult to remove
113
Aspirated vegetables cause
intense pneumonitis
114
Esophageal FB presentation
```
refuse to eat
vomiting
choking, cough, stridor
neck/throat pain, inability to swallow
increased salivation
FB sensation in chest
```
115
PE for esophageal FB
```
red throat
palatal abrasions
anxiety/distress
wheezing
decreased BS
fever
peritoneal signs
.... OR NONE
```
116
FB work up
patency of airway
| radiograph of neck, chest, abdomen ( - XR does not mean - ingestion)
117
Tx for FB
esophagus - endoscopy
| trachea - bronchoscopy
118
When to consult for FB
```
sharp/elongated objected
multiple (magnets)
button batteries
perforation evidence
FB > 24 hrs
airway compromise
coin at cricopharyngeus
above cricopharyngeus - ENT
below cricopharyngeus - GI
below esophageal sphincter - leave it
```
119
Esophageal button battery
MEDICAL EMERGENCY
120
Problem w/ esophageal BB
extremely rapid action of the alkaline substance on the mucosa, pressure necrosis, residual charge
burns to esophagous in as few as 4 hours, perforation at 6 hrs
121
How soon til BB burns esophages
4 hours
122
perforation timing of esophagus from BB
6 hours
123
Worse outcome of BB
lithium battery
124
Mercuric oxide batteries
heavy metal poisonin gb/c they fragment
125
When to obtain blood and urine mercury levels
if cell is observed to split in GI tract
126
Tx for BB ingestions
emergent removal if lodged in esophagus
if passed esophagus: no need to remove if asymptomatic UNLESS not passed through pylorus after 24-48 hours
GI s/sx = immediate surgical consult
127
BB usually excreted w/i
48-72 hours
128
mechanism of drowing
respiratory impairment from submersion in liquid-- liquid prevents indiv from breathing oxygen
129
Drowning ages
Children <4 YO
| Young adults 15-24 YO
130
Secondary drowning classifications
wet drowning
dry drowning
near-drowning
secondary drowning
131
Problems from impaired ventilation:
hypoxemia
acidosis - metabolic and/or respiratory
most drowning victims aspirate <4 mL of liquid
132
CNS impairment
from hypoxemia during drowning and subsequent:
- arrhythmia
- ongoing pulmonary injury
- reperfusion injury
- multi-organ dysfunction (secondary injury)
133
Dry drowning
laryngospasm --> hypoxia -- LOC
NO FLUID IN LUNGS
134
Wet drowning
more common
aspiration of water into lungs
dilution and washout of surfactant --> diminished gas transfer across alveoli --> atelectasis --> ventilation-perfusion mismatch
135
near-drowning
survival >24 h post-event (severe brain damage 10-30% of peds nonfatal drowning victims)
136
Sx of near-drowning
alert or mildly obtunded at ED presentation (may experience full recovery)
comatose, receiving CPR en route to ED, fixed and dilated pupils and no spontaneous respiration (poor prognosis): 35-60% die, 60-100% survivers have long-term neuro damage
137
Poor prognosis associated with:
```
subermesion > 5 min
time to effective BLS >10 in
resuscitation duration >25 min
age >14 YO
GCS <5 (comatose)
persistent apnea and requirement of cardiopulmonary resuscitation in the ED
Arterial blood pH < 7.1 on presentation
```
138
When to consider child abuse in near-drowning
less than 6 mo
| toddlers w/ atypical presentation
139
Secondary drowning
may cause death up to 72 hours after near drowning incident
140
Mechanism of secondary drowning
fresh water drowning results in hemodilution from ingested water --> if large enough volume aspirated --> significant hemolysis and cardiac arrhythmias (electrolyte disturbance)
141
Tx of secondary drowning
pre-hsopital care is CRITICAL
ED focus:
- assist ventilation
- warmed isotonic VI fluids and warming blankets
- address any associated injuries; treat electrolyte abnormalities; monitor cardiac rhythm
- get initial CXR, repeat in 6 hrs
- admit for observation (maintain ventilation and prevent neuro injury)
142
Fever w/o source is considered
rectal temp >38 C (100.4)
143
Goal of fever w/o source
identify OCCULT SYSTEMIC BACTERIAL INFECTION: pnemonia, UTI, bacteremia, Herpes virus 6, meningitis
144
Workup for unknown fever
"septic workup"
145
septic work up based on
age: <3 mo (neonates), 3 mo-3yr: infants and young children
Appearance
Risk factors: birth hx, exposures, vaccination status, immune deficiencies
146
Infants <3 mo w/ fever w/o source
DO WORKOUT REGARDLESS OF APPEARANCE
incidence of serious bacterial infection (SBI)
147
Birth hx for fever
```
premature
STD exposure
PROM
fetal hypoxia
maternal peripartum infections
other fetal loss
```
(5-10% w/ GBS sepsis also have meningitis)
148
Sx of infection w/ neonatal fever
```
irritability
decreased activity
poor feeding/lack of weight gain
lethargy
change in sleep patterns
v/d
hypothermia
```
149
Management of neonatal fever
```
septic workup:
CBC w diff
UA (cath)
CXR
LP
Blood cultures
```
early administration of empiric abx
admission pending culture results
150
Management of 3mo-36 mo fever ill-appearing
```
labs
UA
Cultures: blood, urine, CSF, stool
CXR: if tachypnea or leukocytosis (>20,000)
parenteral abx
admit
```
151
well appearing, not completely immunized fever
CBC w diff
blood culture if WBC >15,000
UA (girls <24 mo, uncircumcised boys <12 mo, circumcised boys <6 mo)
CXR - leukocytosis >20,000
152
who gets UA if well appearing and not immunized
girls <24 mo
uncircumcised <12 mo
circumcised <6 mo
153
when to give CXR in well appearing, not immunized
leukocytosis >20,000
154
Well appearing, immunized management
UA and C&S
Girls >24 mo, uncircum >12, circum >6 = no routine labs, no abx, just UA and CS
155
Fever >39 + abnormal UA
treat for UTI
