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EMERGENCY MED > Pediatrics > Flashcards

Pediatrics Flashcards

1
Q

Initial approach to ped patient who “appears well”

Alert, engaged, calm

A
  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
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2
Q

Initial approach to ped patient who “appears sick”

5 Key Interventions

A

Act first, talk later

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

Primary Survey, ABCDE

A 
Airway
Breathing and ventilation
Circulation
Disability
Exposure / Environmental control
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4
Q

Easiest way to assess patent airway

A

Ask patient to talk: “What’s your name?”

  • able to answer?
  • sound of voice? (gargle, muffle, wheezing, stridor)
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5
Q

Conditions that put patients at risk of developing airway compromise

A

Angioedema / allergy

Inhalation injury / burn

Facial trauma

Neck trauma

GSW or stab to neck

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6
Q

Unique features of pediatric airway

A

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)

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7
Q

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

A

Rolled towel under shoulders

plus “jaw thrust” to line up airways

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8
Q

Maneuver to ensure sufficient seal in bag mask ventilation

A

“C” and “E”

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9
Q

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

A

Chest rise

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10
Q

Excessive ventilation in bag mask may result in

A

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.

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11
Q

Three signs to note while assessing work of breathing

A

Retractions

Nasal flaring

Grunting (ominous - resp failure)

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12
Q

Two common pathways leading to pediatric cardiac arrest

A

Respiratory failure

Shock

(rarely cardiac origin / sudden)

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13
Q

Three potential causes of respiratory failure, pediatrics

A

Intrinsic lung disease

Airway obstructions

Inadequate effort

Distress precedes failure

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14
Q

Where do you assess central pulse in infants?

A

Brachial artery

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15
Q

Where do you assess central pulse in older children?

A

Femoral artery

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16
Q

Signs of poor perfusion

A

Mottled, cool skin

Delayed capillary refill

Tachycardia

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17
Q

Pediatric blood pressure and shock: what to be careful of

A

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

Hypotension is LATE finding in kids!!

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18
Q

Formula for pediatric BP normal range

A

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

Lower limit: 70 mmHg + (2 x age in yrs)

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19
Q

What is BP like in shock?

A

Can be normal, low, or high

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20
Q

Fluid resuscitation in pediatrics

A

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

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21
Q

How to assess disability? (in ABCDE)

A

Quick neuro exam

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

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22
Q

AMPLE history

A

Allergies

Medications

PMH

Last meal

Events surrounding visit

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23
Q

Review: overall assessment in ED

A

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

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24
Q

Review: overall assessment in ED

A

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

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25
Q

Most common cause of death and disability in children

A

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

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26
Q

Multisystem injury in pediatric trauma

A

Rule, rather than exception

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

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27
Q

Head injuries in peds: anatomical differences

A

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

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28
Q

Types of head injuries in children

A

Contusions

Diffuse axonal injury

Subdural hemorrhage
Epidural hemorrhage
Subarachnoid hemorrhage
Intraparenchymal hemorrhage

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29
Q

Management of head injuries in children

A

Maximize Oxygen

Maintain BP

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30
Q

Signs of increased ICP, and what to do

A

(Pupillary / macular signs)

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

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31
Q

Special considerations about chest injuries in children

A

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

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32
Q

Two most vulnerable organs in abdominal injuries

A

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

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33
Q

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

A

CT of abdomen

seatbelt sign = linear bruising in distribution of seatbelt)

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34
Q

Normal pediatric blood volume

A

70 ml/kg

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

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35
Q

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

A

Hypothermia

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36
Q

Hypothermia puts children at higher risk of

A

Coagulopathy and Acidosis

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37
Q

Reassuring signs and symptoms in children presenting with abdominal pain

A

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”

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38
Q

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

A

Groin area - testicles, hernia

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39
Q

What should always be tested in adolescent females w abdominal pain

A

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

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40
Q

Beware of vomiting without diarrhea

A

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

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41
Q

Two common conditions with referred abdominal pain in pediatrics

A

Lower lobe pneumonia

Strep pharyngitis (GAS)

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42
Q

Warning signs of abdominal emergencies in pediatrics

A

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

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43
Q

Blood in stool of ill appearing infant

A

Intussusception

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44
Q

Pain BEFORE vomitting might indicate ___ as opposed to ___

A

Appendicitis, viral

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45
Q

Neonates abdominal emergency DDX

Slide 6, peds abominal

A

Malrotation w/ volvulus
NEC
Intestinal atresias/stenosis
Hirschsprung disease

46
Q

1-2 month abdominal emergency DDX

A

Pyloric Stenosis

47
Q

6-10 month abdominal emergency DDX

A

Intussusception

48
Q

Pre school / school age abdominal emergency DDX

A 
Appendicitis
Intussusception
Testicular/ovarian torsion
Incarcerated hernia*
NAT with blunt abdominal trauma*
49
Q

Adolescent female abdominal emergency DDX

A 
Ectopic pregnancy
Ovarian cyst/torsion
Appendicitis
STD/PID
Tuboovarian abscess
50
Q

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

A

Intestinal malrotation with midgut volvulus

51
Q

Risk of midgut volvulus is highest at what age

A

First month - 50-70%

90% in first year

52
Q

Why is midgut volvulus a surgical emergency

A

Bowel necrosis can occur within hours

53
Q

Study of choice for midgut volvulus

A

Upper GI series with contrast (CT?)

Findings:

Trace contrast passes in corkscrew configuration
Abnormal position of duodenum

54
Q

Malrotation / midgut volvulus management review

A 
IV fluid resuscitation
NG tube to intermittent suction
Call your surgeon
Upper GI series
Laparotomy
55
Q

Ultrasund / CT findings for intussusception

A

“Target sign” or “Crescent sign” of bowel within bowel

Bull’s eye” or “Coiled spring” on ultrasound

56
Q

Most common abdominal emergency in early childhood

A

Intussusception

57
Q

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

A

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

58
Q

Most common area of intestine for intussusception

A

Ileo-colic

59
Q

“Classic” presentation of intussusception

A

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
Q

Management of Intussusception

A

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
Q

Preferred treatment for intussusception

A

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
Q

Contraindicatons for nonoperative reduction for intussusception

A

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

63
Q

Indications for surgical treatment of intussusception

A

when nonoperative reduction fails or is incomplete

64
Q

Ovarian torsion

A

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
Q

Management of ovarian torsion

A

Pain control
IVF
US with doppler - STAT!

Emergent operative intervention

Prolonged symptoms does not preclude possible ovarian salvage

May have intermittent torsion

66
Q

Managing pediatric seizure

A

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
Q

Best medications for seizures

A

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
Q

Pre-seizure history questions

A 
Well prior to event
History of prior seizures
History of fever, recent infections
Recent antibiotics
Recent trauma
Adult Rx medications, toxic ingestions
69
Q

Seizure history questions

A

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

70
Q

Post Seizure history questions

A

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

71
Q

Physical Exam for seizure

A

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
Q

Categories of febrile seizures

A

Simple and complex

73
Q

Qualifications for a Simple Febrile Seizure

A

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

74
Q

Qualifications for a Complex Febrile Seizure

A

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

75
Q

Evaluation and Management of Febrile Seizure, Peds

A

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
Q

First time simple febrile seizure - labs / imagining?

A

Not needed - no benefit

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

77
Q

Questions to ask in assessing risk of CNS infection

A

Vaccination status?

Antibiotics taken recently?
- can mask signs of meningitis

78
Q

Concerning exam findings in pediatric (febrile) seizures

A 
Focal neurological deficits
Altered motor tone
Nuchal rigidity
Poor perfusion
Generalized petechiae
79
Q

Status epilepticus + fever indicates&raquo_space;

A

Bacterial meningitis

LP indicated

80
Q

Clear discharge instructions for parents (peds w seizures)

A 
Safe place
Place child on his/her side
Nothing in mouth
Chin lift/jaw thrust
When to call EMS
81
Q

Indications for admission in febrile seizures

A 
Prolonged postictal phase
Complex febrile seizure
Age < 6 months
Social concerns
Inability of caretakers to provide appropriate observation
Prolonged distance to medical care
82
Q

Absent staring with/without eyelid flutter

A

Absence Epilepsy

ethosuximide, valproic acid, lamotrigine, levetiracetam

83
Q

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

A

Juvenile Myoclonic Epilepsy

valproic acid, topiramate, levetiracetam

84
Q

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

A

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

may not need treatment - may outgrow

85
Q

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

A

Infantile Spasms **

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

86
Q

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

A

Lennox Gastaut

87
Q

Evaluation of Infantile Spasms

A

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
Q

Treatment for Infantile Spasms

A

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

89
Q

Lab Evaluation of Seizures Without Epilepsy

A 
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
Q

Preferred neuroimaging study for seizure

A

MRI (usually)

EEG

91
Q

Indication for EEG

A

All first time, non febrile seizures

92
Q

When to admit for non febrile seizures

A 
Age (< 6 months)
Etiology of seizure
Seizure control
Social concerns
Inability of caretakers to provide appropriate observation
Prolonged distance to medical care
93
Q

Categories of DKA

A

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
Q

Symptoms of Hyperglycemia

A 
Polyuria: increased volume and freq of urination
Polydipsia: increased thirst
New urinary incontinence
Weight loss
Muscle cramps
95
Q

Symptoms of Acidosis

A 
Abdominal pain
Vomiting
Shortness of breath
Headache
Confusion
Altered mental status
96
Q

PE findings in DKA

A

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

97
Q

Why do kids with DKA have electrolyte imbalances?

A

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

Hyponatremia and hypokalemia result

98
Q

DKA Precipitants (I’s)

A

Remember the “I”s

Insulin lack
Indiscretion (dietary)
Infection
Impregnation or other stressors

99
Q

Treatment of DKA

A

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
Q

ED Management of DKA

A 
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
Q

Step 1 DKA treatment

A

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

Next: LR at 2x MIVF rate

102
Q

Step 2 DKA treatment

A

(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
Q

Step 3 DKA treatment

A

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
Q

K+ and DKA

A

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
Q

Bicarb and DKA?

A

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
Q

Most serious complication / cause of mortality in children w DKA

A

Cerebral Edema - 60-90% of all DKA deaths

107
Q

Signs/Symptoms of cerebral edema

A

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
Q

Cerebral Edema treatment

A

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
Q

Other complications of DKA

A 
Hyponatremia
Hypokalemia
Acute renal failure (pre-renal, low perfusion)
Rhabdomyolysis
Rarely ARDS and pulmonary edema
110
Q

Cushing’s triad

A

irregular respirations, decreased heart rate with increased BP

EMERGENCY MED (10 decks)

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