Pediatrics Flashcards Preview

EMERGENCY MED > Pediatrics > Flashcards

Flashcards in Pediatrics Deck (110)
Loading flashcards...
1

Initial approach to ped patient who "appears well"

(Alert, engaged, calm)

1. 5 Vital signs
2. (S) Focused history
3. (O) Focused physical
4. (A) Assessment and differential
5. (P) Order appropriate labs and radio graphics as needed

2

Initial approach to ped patient who "appears sick"

5 Key Interventions

Act first, talk later

1. O2 and ventilation if needed
2. Pulse Ox
3. Cardiorespiratory monitor
4. IV access
5. CXR / EKG

3

Primary Survey, ABCDE

Airway
Breathing and ventilation
Circulation
Disability
Exposure / Environmental control

4

Easiest way to assess patent airway

Ask patient to talk: "What's your name?"

- able to answer?
- sound of voice? (gargle, muffle, wheezing, stridor)

5

Conditions that put patients at risk of developing airway compromise

Angioedema / allergy

Inhalation injury / burn

Facial trauma

Neck trauma

GSW or stab to neck

6

Unique features of pediatric airway

Smaller (more prone to obstruction)

More anterior and cephalad in location

Shorter (right main stem intubation)

Funnel shaped in < 8yrs old (most narrow at sub glottis, just below vocal cords)

7

Simple trick to help upen airway (esp considering large heads of toddlers)

Rolled towel under shoulders

plus "jaw thrust" to line up airways

8

Maneuver to ensure sufficient seal in bag mask ventilation

"C" and "E"

9

Ensure you see this during bag mask ventilation (so yo know it's working)

Chest rise

10

Excessive ventilation in bag mask may result in

Excessive ventilation increases risk of gastric air, regurgitation, and aspiration

May result in barotrauma (pneumothorax)

May increase intrathoracic pressure and impair venous return.

This in turn decreases cardiac output, cerebral blood flow, and coronary perfusion.

11

Three signs to note while assessing work of breathing

Retractions

Nasal flaring

Grunting (ominous - resp failure)

12

Two common pathways leading to pediatric cardiac arrest

Respiratory failure

Shock

(rarely cardiac origin / sudden)

13

Three potential causes of respiratory failure, pediatrics

Intrinsic lung disease

Airway obstructions

Inadequate effort

**Distress precedes failure**

14

Where do you assess central pulse in infants?

Brachial artery

15

Where do you assess central pulse in older children?

Femoral artery

16

Signs of poor perfusion

Mottled, cool skin

Delayed capillary refill

Tachycardia

17

Pediatric blood pressure and shock: what to be careful of

Normal BP is maintained until over 30% of child's circulating volume is lost

**Hypotension is LATE finding in kids!!**

18

Formula for pediatric BP normal range

Mean systolic BP: 90 mmHg + (2 x age in yrs)
Lower limit: 70 mmHg + (2 x age in yrs)

19

What is BP like in shock?

Can be normal, low, or high

20

Fluid resuscitation in pediatrics

Isotonic fluids

20 ml/kg boluses until signs of improved perfusion, resolution of tachycardia

If shock due to hemorrhage, after 2 boluses give PRBC 10 ml/kg

21

How to assess disability? (in ABCDE)

Quick neuro exam

Engaged?
Pupils?
Moving all 4 extremities?
Symmetric strength and sensation?

22

AMPLE history

Allergies

Medications

PMH

Last meal

Events surrounding visit

23

Review: overall assessment in ED

How does the patient look?
If sick → oxygen, pulse ox, monitor, IV access, CXR & EKG
ABCDs intact?
If not, address airway, breathing, circulation, and disability in that order
5 vital signs
AMPLE history
Secondary survey

24

Review: overall assessment in ED

How does the patient look?
If sick → oxygen, pulse ox, monitor, IV access, CXR & EKG
ABCDs intact?
If not, address airway, breathing, circulation, and disability in that order
5 vital signs
AMPLE history
Secondary survey

25

Most common cause of death and disability in children

Injury

>10 million children require care in ED for injuries each year
>10,000 children die from serious injuries each year in the US
Injury mortality surpasses deaths from all other childhood illnesses combined


**MVC most common cause of death in children**

26

Multisystem injury in pediatric trauma

Rule, rather than exception

Smaller body mass
Less fat and connective tissue
Closer proximity of internal organs

27

Head injuries in peds: anatomical differences

**Leading cause of death in pediatric trauma**

Large head relative to body > more torque

Less myelin > more shearing forces, greater neuronal injury

Soft cranium > may have intracranial injury without skull fracture

28

Types of head injuries in children

Contusions

Diffuse axonal injury

Subdural hemorrhage
Epidural hemorrhage
Subarachnoid hemorrhage
Intraparenchymal hemorrhage

29

Management of head injuries in children

Maximize Oxygen

Maintain BP

30

Signs of increased ICP, and what to do

(Pupillary / macular signs)

Elevate head of bed 30 degrees
Hypertonic saline (3%) 5ml/kg
Mannitol 0.5-1 mg/kg

31

Special considerations about chest injuries in children

Chest injuries serve as marker for other injuries

2/3 of children with chest injury will have other injuries as well

Significant thoracic trauma possible without rib fractures (ribs are very pliable in kids)

Mediastinum very mobile

Increased risk of pneumothorax

32

Two most vulnerable organs in abdominal injuries

Liver, spleen - lower, below rib cage, in children

33

If you see a "seatbelt sign" on a child from a MVC, what next step is warranted?

CT of abdomen

seatbelt sign = linear bruising in distribution of seatbelt)

34

Normal pediatric blood volume

70 ml/kg

Tremendous ability to compensate for blood loss by vasoconstriction
HYPOTENSION IS A LATE FINDING
Treat shock early to avoid sudden deterioration

35

Due to children having less fat and connective tissue, they are at higher risk of

Hypothermia

36

Hypothermia puts children at higher risk of

Coagulopathy and Acidosis

37

Reassuring signs and symptoms in children presenting with abdominal pain

Frequent watery diarrhea

Normal appetite (eating in the exam room)

Fever onset before pain
(*fever is late finding in appendicitis, once it's ruptured*)

The “JUMP TEST”

38

What area should always be checked for male ped presenting w abdominal pain

Groin area - testicles, hernia

39

What should always be tested in adolescent females w abdominal pain

Urine HCG and pelvic exam (**12 yrs old and up)

40

Beware of vomiting without diarrhea

May not be stomach virus - could be bowel obstruction, pregnancy, head injury

41

Two common conditions with referred abdominal pain in pediatrics

Lower lobe pneumonia

Strep pharyngitis (GAS)

42

Warning signs of abdominal emergencies in pediatrics

Bilious vomiting - obstruction

Vomiting WITH abdominal distention - bowel twist / obstruction

Pain BEFORE vomiting - appendicitis

Blood in stool of ill appearing infant - intussusception

Focal abdominal pain (esp + guarding) - appendicitis

Involuntary guarding

43

Blood in stool of ill appearing infant

Intussusception

44

Pain BEFORE vomitting might indicate ___ as opposed to ___

Appendicitis, viral

45

Neonates abdominal emergency DDX

Slide 6, peds abominal

Malrotation w/ volvulus
NEC
Intestinal atresias/stenosis
Hirschsprung disease

46

1-2 month abdominal emergency DDX

Pyloric Stenosis

47

6-10 month abdominal emergency DDX

Intussusception

48

Pre school / school age abdominal emergency DDX

Appendicitis
Intussusception
Testicular/ovarian torsion
Incarcerated hernia*
NAT with blunt abdominal trauma*

49

Adolescent female abdominal emergency DDX

Ectopic pregnancy
Ovarian cyst/torsion
Appendicitis
STD/PID
Tuboovarian abscess

50

Bilious emesis in a neonate is what kind of surgical emergency until proven otherwise

Intestinal malrotation with midgut volvulus

51

Risk of midgut volvulus is highest at what age

First month - 50-70%

90% in first year

52

Why is midgut volvulus a surgical emergency

Bowel necrosis can occur within hours

53

Study of choice for midgut volvulus

Upper GI series with contrast (CT?)

Findings:

Trace contrast passes in corkscrew configuration
Abnormal position of duodenum

54

Malrotation / midgut volvulus management review

IV fluid resuscitation
NG tube to intermittent suction
Call your surgeon
Upper GI series
Laparotomy

55

Ultrasund / CT findings for intussusception

"Target sign" or "Crescent sign" of bowel within bowel

Bull's eye" or "Coiled spring" on ultrasound

56

Most common abdominal emergency in early childhood

Intussusception

57

Why is it common for children to have a viral infection before intussusception?

Virus causes inflamed lymphatic tissue in gut - Hypertrophy of Peyer patches in terminal ileum can serve as lead point

58

Most common area of intestine for intussusception

Ileo-colic

59

"Classic" presentation of intussusception

sudden onset of intermittent, severe, crampy abdominal pain
Toddlers and infants may “draw up legs” toward abdomen
Episodes occur ~20 min intervals

Classic triad of pain, palpable sausage shaped mass, currant jelly stools occurs < 15% of the time

60

Management of Intussusception

ABCs

Resuscitate with IVF

If frequent vomiting, decompress stomach with NGT

Consider IV antibiotics if concern for perforation

Notify surgery early

Abdominal xrays (including left lateral decub) to exclude perforation w/ free air prior to air enema reduction (and exclude constipation)

Air enema reduction

61

Preferred treatment for intussusception

Nonoperative reduction

Air enema or water-soluble contrast enema
Study of choice in typical presentation
Diagnostic and therapeutic
Success rate 75-90% in ileo-colic intussusception
Perforation risk is small, less than 1%

62

Contraindicatons for nonoperative reduction for intussusception

Prolonged symptoms (> 3 days)
Signs of peritonitis
Evidence of free air on plain x-ray

63

Indications for surgical treatment of intussusception

when nonoperative reduction fails or is incomplete

64

Ovarian torsion

Presentation is non-specific
Difficult to differentiate from other causes of abdominal pain in children

Classic presentation in children:
Sudden onset of unilateral lower abdominal pain
Right side > left side (3:2)
Nausea and vomiting (70-80%)

65

Management of ovarian torsion

Pain control
IVF
US with doppler - STAT!

Emergent operative intervention

Prolonged symptoms does not preclude possible ovarian salvage

May have intermittent torsion

66

Managing pediatric seizure

Assess ABCs
Place patient on his/her side

O2, O2 sat, monitor, IV access, bedside glucose

Intervene medically if needed for seizure > 3 min

67

Best medications for seizures

Intervene medically if needed for seizure > 3 min

Lorazepam (0.05-0.1 mg/kg) IV or IM
Diazepam (0.3-0.5 mg/kg) IV or PR
Midazolam (0.2 mg/kg) IV/IM or intranasal

68

Pre-seizure history questions

Well prior to event
History of prior seizures
History of fever, recent infections
Recent antibiotics
Recent trauma
Adult Rx medications, toxic ingestions

69

Seizure history questions

Eye deviation, blank stare, drooling, cyanosis, incontinence
Generalized vs focal
Duration
Responsive or unresponsive

70

Post Seizure history questions

Single or multiple
Mental status after event
EMS observations at time of arrival

71

Physical Exam for seizure

Vital signs (rectal temp)

General appearance and mental status

Focused exam:
- Focal neurologic deficits
- Signs of increased ICP (bulging fontanelle, papilledema)
- Skin lesions (Ashleaf spots, shagreen patch, café au lait)
- Nuchal rigidity
- Poor perfusion
- Altered motor tone
- Prolonged post-ictal lethargy
- Generalized petechiae

72

Categories of febrile seizures

Simple and complex

73

Qualifications for a Simple Febrile Seizure

Last less than 15 minutes
Generalized
No focal features
Does not recur within 24 hrs

74

Qualifications for a Complex Febrile Seizure

Last more than 15 minutes
Focal features or postical paresis (Todd’s paralysis)
Recurrence within 24 hrs

75

Evaluation and Management of Febrile Seizure, Peds

Stabilize the patient
Focused history & physical
Categorize the seizure (simple vs complex)
Determine probability of intracranial infection and acute bacterial meningitis
Determine need for diagnostic studies
Establish disposition

76

First time simple febrile seizure - labs / imagining?

Not needed - no benefit

Only workup should be for underlying cause of fever (UA, chest X-ray, etc)

77

Questions to ask in assessing risk of CNS infection

Vaccination status?

Antibiotics taken recently?
- can mask signs of meningitis

78

Concerning exam findings in pediatric (febrile) seizures

Focal neurological deficits
Altered motor tone
Nuchal rigidity
Poor perfusion
Generalized petechiae

79

Status epilepticus + fever indicates >>

Bacterial meningitis

**LP indicated**

80

Clear discharge instructions for parents (peds w seizures)


Safe place
Place child on his/her side
Nothing in mouth
Chin lift/jaw thrust
When to call EMS

81

Indications for admission in febrile seizures

Prolonged postictal phase
Complex febrile seizure
Age < 6 months
Social concerns
Inability of caretakers to provide appropriate observation
Prolonged distance to medical care

82

Absent staring with/without eyelid flutter

Absence Epilepsy

ethosuximide, valproic acid, lamotrigine, levetiracetam

83

Myoclonic Jerks (> in AM)
Onset adolescence
Precipitated by stressors
May have tonic-clonic and absence seizures as well

Juvenile Myoclonic Epilepsy

valproic acid, topiramate, levetiracetam

84

Somatosensory changes (numbness/tingling), speech arrest, facial twitching, drooling, may have tonic clonic seizures at night, often during sleep

Benign Epilepsy of Childhood with Centrotemporal Spikes (BECTS/Rolandic)

**may not need treatment - may outgrow**

85

Sudden flexion, extension or mixed movements of trunk and proximal muscles
Treated differently and with more urgency

Infantile Spasms **

ACTH, steroids, zonisamide, topiramate, vitamin B-6

86

Onset at 3-5 years
Mixed seizure types
Most children have severe developmental delay

Lennox Gastaut

87

Evaluation of Infantile Spasms

Need urgent EEG, MRI, and metabolic evaluation with neurology consultation

Mortality as high as 15-20%

Only 5-10% or children with infantile spasms have normal intelligence

88

Treatment for Infantile Spasms

ACTH, steroids, zonisamide, topiramate, vitamin B-6

89

Lab Evaluation of Seizures Without Epilepsy

Electrolytes, glucose, Ca, Mg, Phos
Ammonia, Lactic Acid
Metabolic syndrome suspected
Drug Screen
Possible toxin exposure

LP plus Antibiotics
Only if meningeal signs or sustained AMS

90

Preferred neuroimaging study for seizure

MRI (usually)

EEG

91

Indication for EEG

All first time, non febrile seizures

92

When to admit for non febrile seizures

Age (< 6 months)
Etiology of seizure
Seizure control
Social concerns
Inability of caretakers to provide appropriate observation
Prolonged distance to medical care

93

Categories of DKA

Mild pH < 7.30, bicarbonate < 15 mmol/L

Mod pH < 7.20, bicarbonate < 10 mmol/L

Severe pH < 7.10, bicarbonate < 5 mmol/L

94

Symptoms of Hyperglycemia

Polyuria: increased volume and freq of urination
Polydipsia: increased thirst
New urinary incontinence
Weight loss
Muscle cramps

95

Symptoms of Acidosis

Abdominal pain
Vomiting
Shortness of breath
Headache
Confusion
Altered mental status

96

PE findings in DKA

Kussmaul respirations
Dehydration (sunken eyes, dry mucous membranes)
Tachycardia
Delayed capillary refill
Abdominal tenderness (nonfocal or epigastric)

97

Why do kids with DKA have electrolyte imbalances?

Ketoacids bind Na+ and K+ and they are excreted in the urine

Hyponatremia and hypokalemia result

98

DKA Precipitants (I's)

Remember the “I”s

Insulin lack
Indiscretion (dietary)
Infection
Impregnation or other stressors

99

Treatment of DKA

Correct dehydration - IV Fluids

Correct acidosis and reverse ketosis - Insulin, DRIP! not bolus
Restore normoglycemia

Correct electrolyte imbalances - Na, K

Avoid complications of treatment -
*Cerebral Edema from rapid fluid resuscitation*

Identify and treat precipitating event - infection, etc

100

ED Management of DKA

ABCs, cardiac monitor, vital signs, accucheck
IV access (2 is best, one for fluids, one for insulin drip)

BMP, VBG, UA, +/- CBC
Consider EKG

Accucheck every 1 hr
VBG every 1-2 hr
BMP every 4 hr
Neurologic checks every hr

Consultation with endocrinology & critical care

101

Step 1 DKA treatment

IV hydration
Initial bolus: NS bolus or LR (Lactate Ringer) bolus 20 ml/kg over 1 hour

Next: LR at 2x MIVF rate

102

Step 2 DKA treatment

(After initial IVF bolus)

Insulin infusion 0.05-0.1 U/kg/hr regular insulin
**No insulin bolus in children!!! (may increase risk of cerebral edema)**

Ideally don’t want glucose to fall more than 100 mg/dl per hour

Switch to D5NS when glucose is < 300 mg/dL

103

Step 3 DKA treatment

Next 4-6 hours
NS with 40 mEq/L K+ (20mEq/L KCl and 20 mEq/L KPhos)
Rate is 2x maintenance rate

After 4-6 hrs: Switch to 0.45% saline with electrolytes

104

K+ and DKA

Total body K+ is depleted in DKA

It is excreted in the urine when it binds to the ketoacids

Also once you start giving insulin and correct the
acidosis, this drives the K+ into the cells lowering your K+ levels further

105

Bicarb and DKA?

Multiple downsides
- Paradoxical CNS acidosis
- Rapid correction can worsen hypokalemia
- May increase hepatic ketone production

Selected benefit: Only if arterial pH < 6.9 or if there is hypotension, shock, arrythmia, severe hyperkalemia
**Must give cautiously NaHCO3 at 1-2 mEq/kg over 60 minutes**

106

Most serious complication / cause of mortality in children w DKA

Cerebral Edema - 60-90% of all DKA deaths

107

Signs/Symptoms of cerebral edema

Headache
Gradual decrease in LOC
Slowing of HR inappropriately with increase in BP
Change in pupils

*Onset 4-12 hours after treatment initiated, but may be present before tx begins*

108

Cerebral Edema treatment

Reduce rate of IVF infusion
Mannitol 0.5-1 g/kg over 20 min
3% saline 5-10 ml/kg over 30 min
Consider intubation if cannot protect airway

109

Other complications of DKA

Hyponatremia
Hypokalemia
Acute renal failure (pre-renal, low perfusion)
Rhabdomyolysis
Rarely ARDS and pulmonary edema

110

Cushing's triad

irregular respirations, decreased heart rate with increased BP