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Peds Rotation > 2 Peds Emergencies > Flashcards

2 Peds Emergencies Flashcards

1
Q

_________ are the leading cause of childhood death in the U.S.

A

Injuries

Every well-child visit should include age-appropriate injury prevention counseling

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2
Q

Why are infants and toddlers more susceptible to head injuries?

A

Large heads in comparison to body size

Weak neck muscles —> prone to acceleration-deceleration injuries (shearing forces)

Thin skulls —> poor brain protection

Physically uncoordinated

Lack cognitive ability to predict/understand danger

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3
Q

Head injuries in kids have a _______ distribution

A

Bimodal

> 8: due to sports, MVA, ATVs, bikes, scooters etc

<1: falls from walking and furniture, abuse

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4
Q

Concerning signs after a head injury

A

Excessively sleepy or hard to arouse, vomiting, irritability

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5
Q

What are the first things you do when examining a peds head injury?

A

ABC’s

Neuro status (use the Glasgow Coma Scale, pupils, sucking reflex for an infant, muscle tone)

Vital signs

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6
Q

What is Cushing’s Triad

A

Vital signs findings in head injuries

WIDE pulse pressure
Bradycardia
Abnormal respirations

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7
Q

What are the three components of the Glasgow Coma Scale and what are the points?

A 
Eye Opening:
Spontaneous = 4
To speech = 3
To pain = 2
No response = 1

Best Verbal Response:
Oriented (coos or babbles in infant) = 5
Confused (irritable cries in infant) = 4
Inappropriate words (cries in pain in infant) = 3
Incomprehensible sounds (infant moans) = 2
No response = 1

Best Motor Response:
Obeys (infant moves spontaneous/purposefully) = 6
Localizes (infant withdraws to touch) = 5
Withdraws to pain = 4
Abnormal flexion = 3
Abnormal extension = 2
No response = 1

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8
Q

What is the highest score for the Glasgow Coma Scale?

A

15

≤8 needs immediate action

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9
Q

Battle’s sign, periorbital ecchymosis (raccoon eyes), hemotympanum, otorrhea/rhinorrhea (CSF)

A

Basilar skull fracture

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10
Q

Other things to look for in head/neck exam after head injury

A

C-spine alignment

Funduscopic exam

Hematomas (size and location), step-offs, crepitus, lacerations, fontanelles

Signs of basilar skull fracture

Don’t forget the rest of the body and TAKE PICTURES

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11
Q

What is the tool we use to determine whether or not to do a CT on a kid with a head injury?

A

PECARN

100% accurate in kids <2 (like 97% in kids >2)

CATCH and CHALICE are alternative

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12
Q

Concerning signs after head injury

A 
GCS < 15 or acute mental status change
Signs of skull fracture
Vomiting > 3 times
Seizure
Less than 2 years
Non frontal scalp hematoma
LOC > 5 seconds
Severe mechanism
“Not acting right” or lethargic
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13
Q

Brain bleed with a poor prognosis

A

Subdural hematoma

Occurs between the dura and arachnoid membrane and is associated with diffuse brain injury

Low pressure bleed, dissects arachnoid away from dura

Associated with LOC, lingering symptoms (irritability, lethargy, bulging fontanelle, vomiting)

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14
Q

CT findings for subdural hematomas

A

Crescent-shaped, usually in parietal area, crosses suture lines

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15
Q

Brain bleed with a better prognosis

A

Epidural Hematoma

Rupture of the arteries, esp the middle meaning earl artery, +/- underlying fracture

Brief LOC, lucid period, followed by deterioration

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16
Q

CT findings for epidural hematoma

A

Elliptical shape, that does NOT cross suture lines

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17
Q

Most common brain bleed

A

Subarachnoid Hemorrhage

Injury to the parenchymal and subarachnoid vessels

Symptoms range from normal to LOC

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18
Q

CT findings for Subarachnoid Hemorrhage

A

Small, dense “slivers” on CT

Blood in cisterns, sulci, and fissures

Blood in CSF

May take time to evolve and be visible on CT

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19
Q

How to manage a head injury if no intracranial hemorrhage, no skull fracture

A

Head injury precautions

Responsible caregiver, monitor for behavior change, vomiting, decreased arousability, seizure activity, irritability

Sleeping is ok, wake up every 2-3 hours and watch for signs of worsening condition

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20
Q

How to manage a head injury if positive intracranial hemorrhage, +/- skull fracture

A

Neuro consult

Admit to PICU

Evacuation of ICH/surgery to repair fracture vs observation w/ repeat imaging

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21
Q

Mild traumatic brain injury is another name for…

A

Concussion

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22
Q

Definition of a concussion

A

Traumatically induced alteration in mental status, w/ or w/o an associated LOC

Direct blunt force —> stretching/shearing of axons

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23
Q

Symptoms of a concussion

A 
Amnesia (either retrograde or antegrade)
Confusion and/or blunted affect, distractibility 
Delayed response
Emotional lability
Visual changes
Repetitive speech pattern
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24
Q

Important history considerations in concussion cases

A

Witness accounts are important

MOI

Length of LOC and length of confusion/mental status changes

Seizure activity, movement of extremities at scene

Hx of previous concussions or more significant brain injury

Substance use (EtOH or others - must CT, regardless of PE findings)

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25
Q

Headache, mental fogginess and other mild concussion symptoms typically resolve within…

A

7-10 days (90% within 30 days)

Severe, prolonged or worsening H/A, vomiting, deterioration in mental status are emergent

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26
Q

Concussion symptoms lasting 3 months or longer is called…

A

Post-concussive syndrome

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27
Q

What is second-impact syndrome?

A

2nd concussion within weeks of a 1st —> brain swelling, herniation, death

Children are at an increased risk

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28
Q

Multiple concussions —> permanent changes in mood, behavior, pain

A

Chronic Traumatic Encephalopathy

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29
Q

Treatment protocols for concussions

A

NO SAME-DAY RETURN TO PLAY regardless of symptom resolution - consider absolutely no sports for 1-2 weeks, depending on severity

Physical and cognitive rest - no cell phones, video games, adequate sleep, noise reduction for first 48 hours

Structured return-to-play protocols

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30
Q

Cervical spine injuries are rare in peds, but when they do occur they are most often from …

A

MVA’s

<8 years old - usually C2-4, usually from falls

> 8 years old - usually C5-7, usually from sports

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31
Q

Adolescents with cervical spine injuries more commonly have…

A

SCIWORA - injury that doesn’t show up on MRI right away

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32
Q

Test of choice for cervical spine injuries

A

MRI

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33
Q

Concerning findings in possible cervical spine injuries

A

Bilateral pain

Neuro deficits

Torticollis

Bony abnormalities

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34
Q

What should you always do before and after splinting/reduction/any fracture intervention?

A

Document neurovascular status

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35
Q

Management of an open compound fracture

A

Splint/dress, start IV abx, ortho consult

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36
Q

Management of a non-displaced open fracture (overlying laceration)

A

Start PO abx, repair laceration, splint, outpatient ortho f/u

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37
Q

How to manage grossly deformed/displaced fractures

A

May compromise NV structures

Will require closed/open reduction, possible fixation (ortho consult)

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38
Q

Skin infections from bacterial entry via breaches in the skin —> erythema, warmth, tenderness, induration +/- fever, n/v/d

A

Cellulitis and Erysipelas

Cellulitis involves the deeper dermis and subcutaneous fat

Erysipelas involves the upper dermis and superficial lymphatic

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39
Q

Treatment of cellulitis or erysipelas

A

Warm wet compresses

Topical abx (Bactroban)

Oral abx (Keflex, Bactria)

If failed outpatient treatment —> admit, labs, IV abx

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40
Q

Most common hematogenous spread of an infection to bone

A

Osteomyelitis (bone destruction)

Most common in kids under 5, M>F

Can affect long bones, including femur, tibia, humerus

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41
Q

Common pathogens for Osteomyelitis

A

Staph aureus (most common, MRSA)
Strep pneumoniae
Strep pyogenes

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42
Q

How does Osteomyelitis present?

A

Fever, bone pain, swelling, redness, and guarding

Focal tenderness during exam

X-ray will show soft tissue swelling early, 10-14d later—> bone destruction with LYTIC LESIONS

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43
Q

Best study for evaluation of osteomyelitis

A

MRI - can show marrow edema and abscesses

Also do lab studies (CBC, CRP, ESR, Lactic Acid, Wound and Blood cultures)

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44
Q

Treatment for osteomyelitis

A

Supportive care

IV Abx (empiric, then directed) - usually start with vancomycin, clindamycin, rocephin

Surgical drainage or debridement

Hyperbaric oxygen therapy (for chronic osteomyelitis)

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45
Q

What is the nationwide poison control number?

A

1-800-222-1222

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46
Q

Plants that can be toxic if ingested

A

Dieffenbachia
Philodendron
Poinsettia

47
Q

Things that can be deadly in a single dose (sorry, it’s a long fucking list…)

A 
Aspirin**
Beta Blockers
CCBs
Camphor
Chloroquine
Clonidine
Iron**
Lindane
Methyl Salicylate
Methadone**
Nicotine**
Oils (hydrocarbons)
Theophylline
Tricyclics Antidepressants**
Codeine (breaks down to morphine —> resp suppression)**
48
Q

Grouped, physiologically-based abnormalities of vital signs, general appearance, skin, pupils, mucus membranes, lungs, heart, abdomen and neurologic examination that are known to occur with specific classes of substances

A

Toxidromes

Typically helpful in establishing a diagnosis when the exposure is not well defined

49
Q

Name the toxidrome: Delirium, flushed skin, dilated pupils, urinary retention, decreased bowel sounds, memory loss, seizures

A

Anti cholinergic

“Hot as a hare, dry as a bone, red as a beet, blind as a bat”

50
Q

Name the toxidrome: Confusion, weakness, salivation, lacrimation, defecation, emesis, diaphoresis, muscle fasciculations, miosis, seizures

A

Cholinergic

51
Q

Name the toxidrome: Disorientation, HALLUCINATIONS, visual illusions, panic reaction, moist skin, hyperactive bowel sounds, seizures

A

Hallucinogenic

52
Q

Name the toxidrome: Altered mental status, unresponsiveness, miosis, shock

A

Opiate/narcotic

53
Q

Name the toxidrome: Coma, stupor, confusion, sedation, progressive deterioration of CNS function

A

Sedative/hypnotic

54
Q

Name the toxidrome: Delusions, paranoia, diaphoresis, piloerection, mydriasis, hyperreflexia, seizures, anxiety

A

Sympathomimetic

55
Q

Name the toxidrome:

Tachycardia
Hyperthermia
Hypertension

A

Anticholinergic

56
Q

Name the toxidrome:

Bradycardia
Hypothermia
Tachypnea

A

Cholinergic

57
Q

Name the toxidrome:

Tachycardia
Tachypnea
HTN

A

Hallucinogenic

58
Q

Name the toxidrome:

Shallow Resps
Slow RR
Bradycardia
Hypothermia
Hypotension
A

Opiate/narcotic

59
Q

Name the toxidrome:

Apnea

A

Sedative/hypnotic

60
Q

Name the toxidrome:

Tachycardia
Bradycardia (if pure alpha agonist)
HTN

A

Sympathomimetic

61
Q

Name the toxidrome:

Scopolamine
Jimson Weed
Angel Trumpet
Benztropine
Tricyclic antidepressants
Atropine
A

Anticholinergic

62
Q

Name the toxidrome:

Organophosphates
Carbamates
Mushrooms

A

Cholinergic

63
Q

Name the toxidrome:

Amphetamines
Cannabinoids
Cocaine
Phencyclidine (PCP)

A

Hallucinogenic

64
Q

Name the toxidrome:

Opiates
Propoxyphene
Dextromethorphan

A

Opiate/Narcotic

65
Q

Name the toxidrome:

Barbiturates
Benzos
Ethanol
Anticonvulsants

A

Sedative/hypnotic

66
Q

Name the toxidrome:

Cocaine
Amphetamines
Meth
Phenylpropanolamine
Ephedrine
Pseudoephedrine
Albuterol
Ma huang
A

Sympathomimetic

67
Q

How to decontaminate a patient with toxic ocular exposure

A

Test pH
Copious normal saline lavage until pH is normal
Flush at least 15 min before re-evaluation
Make sure contacts removed
Acidic v alkali
Consult ophthalmology STAT

68
Q

How to decontaminate a patient with toxic skin exposure

A

Copious NS and water if exposed

Follow with soap to concentrated lipid-soluble toxins

69
Q

How to decontaminate a patient with toxic GI ingestion

A

Activated charcoal, cathartic, whole bowel irrigation

Enhance elimination

70
Q

How to decontaminate a patient with toxic blood stream

A

Antidote

71
Q

Why isn’t Ipecac recommended anymore?

A

Only helps if given within 30 min of exposure

72
Q

What is activated charcoal used for?

A

May help in select poisoning: carbamazepine, barbiturates, Dawson, quinine, theophylline

Some evidence for use with digoxin and phenytoin

Little evidence for use with salicylates

NOT indicated with hydrocarbons, lithium, strong acid/base, metals, EtOH

73
Q

What are the enhanced elimination modalities?

A

Activated charcoal

Urine alkalization

Diuresis

Dialysis/Hemoperfusion

74
Q

Antidote for acetaminophen

A

Acetylcysteine***

75
Q

Antidote for Anticholinergics

A

Physostigmine

76
Q

Antidote for Benzodiazepines

A

Flumazenil***

77
Q

Antidote for Beta Blockers

A

Glucagon

78
Q

Antidote for Calcium Channel Blockers

A

Calcium

79
Q

Antidote for Digoxin

A

Digibind

80
Q

Antidote for Heavy Metals

A

Chelating agents

81
Q

Antidote for Narcotics

A

Naloxone***

82
Q

What labs to do in cases of toxic ingestion (even if you know what it is…)

A 
Salicylate level
ACETAMINOPHEN level***
Urine drug screen
Digitalis, theophylline, methemoglobin levels
Lithium level
PT/INR (warfarin)
CO level
CMP, coags, ABGs standard***

Also, put them on cardiac monitoring

83
Q

Once an ingested object passes the pyloric, it usually…

A

continues to the rectum and is passed in the stool w/o complications

84
Q

When to be concerned about foreign body ingestion

A

Sharp or irregular edges —> can penetrate/perforate GI tract

If lodged in esophagus —> may obstruct airway

Perforation may result from direct mechanical or chemical erosion

Aspirated vegetable matter —> intense pneumonitis, difficult to remove

85
Q

How does an esophageal foreign body present?

A

Refusal to eat

Vomiting

Choking, coughing, stridor

Neck/throat pain, inability to swallow

Increased salivation

FB sensation in chest

86
Q

Exam findings in esophageal foreign body situations

A

Red throat

Palatial abrasions

Anxiety/distress

Wheezing

Decreased BS

Fever

Peritoneal signs

OR NONE OF THE ABOVE

87
Q

How to work up a foreign body ingestion

A

Patency of airway

Radiography of neck, chest, abdomen (Neg XR doesn’t r/o)

Procedure of choice for removal:
• Esophagus —> ENDOSCOPY
• Trachea —> BRONCHOSCOPY

Progress of FB can be tracked

88
Q

Indications for consult following FB ingestion

A

Sharp/elongated objects

Multiple FB, ESP. MAGNETS***

Button batteries

Evidence of perforation

Presence of FB for >24 hrs

Airway compromise

Coin at the level of the cricopharyngeus muscle

89
Q

Why are button batteries such a big fucking deal?

A

Extremely rapid action of the alkaline substance on the mucosa, pressure necrosis, residual charge

Burns to the esophagus have been reported to occur in as few as 4 hours, perforation as soon as 6 hours

90
Q

Which type of button battery is associated with the most adverse outcome?

A

Lithium

91
Q

With ________ batteries, concern with heavy metal poisoning because they can fragment

A

Mercuric Oxide batteries

Blood and urine mercury levels should be measured if cell is observed to split in the GI tract

92
Q

When should a button battery be removed emergently?

A

If lodged in the esophagus

If it has not passed through the pylorus after 24-48 hours of observation (usually excreted within 48-72 hours)

If any GI signs of symptoms, immediate surgical consult

93
Q

What is the definition of drowning?

A

Primary respiratory impairment from submersion in a liquid

94
Q

What does the age distribution of drowning cases look like?

A

Bimodal

Peak incidences in children < 4 and young adults 15-24

95
Q

What are the two primary problems related to impaired ventilation?

A

Hypoxemia

Acidosis

96
Q

Most drowning victims aspirate ______ of liquid

A

< 4 mL

97
Q

This occurs when laryngospasm —> hypoxia —> LOC but there is no fluid in lungs

A

Dry drowning

98
Q

Aspiration of water into the lungs —> dilution and washout of surfactant —> dismissed gas transfer —> atelectasis —> V/Q mismatch

A

Wet drowning

Can occur in fresh or salt water

99
Q

A drowning event is considered to be a ___________ when survival is > 24 hr

A

Near-drowning

Severe brain damage occurs in 10-30% of Peds non fatal drowning victims

100
Q

Patients most likely to recover from a drowning

A

Those who are alert or mildly obtunded at ED presentation, especially if <14 years

101
Q

Drowning patients with very poor prognosis

A

Comatose, receiving CPR en route to the ED, or have fixed and dilated pupils and no spontaneous respiration’s

35-60% die

60-100% of survivors experience long-term neurologic damage

102
Q

Most critical factor associated with a poor prognosis in drowning

A

Duration of submersion >5 min**

Also consider:
Time to effective BLS >10 min
Resuscitation duration >25 min
Age >14 years
Glasgow coma scale <5
Persistent apnea and requirement of CPR in the ED
Arterial blood pH <7.1 upon presentation
103
Q

Child abuse should be considered in these near drowning cases

A

Children < 6 months

Toddlers with atypical presentation

Adult supervision in conjunction with properly installed and maintained fences could prevent 50-90% of preschool aged drowning events

104
Q

__________ drowning may cause death up to 72 hours after near drowning incident

A

Secondary drowning

Fresh water drowning results in hemodilution, primarily from INGESTED water

If large enough volume of water aspirated —> significant hemolysis or cardiac arrhythmias (due to electrolyte disturbance)

105
Q

What should the ED treatment focus be in the case of drowning?

A

Assist ventilation as needed (keep PO2 >95%)

Warmed isotonic IV fluids and warming blankets

Address any assoc injuries, treat electrolyte abnormalities, monitor cardiac rhythm

Get initial CXR, repeat at 6 hours

Admit for observation

106
Q

What is the goal when encountering a fever without a source?

A

Identify occult systemic bacterial infections (ie - PNA, UTI, bacteremia, HHV-6, infections, meningitis)

107
Q

What is considered a fever?

A

Rectal temp > 38˚C (100.4˚F)

108
Q

Workup for Fever w/o a source is based on…

A

Age (Neonates vs Children 3 months-3 years)

Appearance (toxic?)

Risk factors (birth Hx, travel, exposures, vaccination status, immune deficiencies)

109
Q

Other symptoms of infection in neonates with fevers

A 
Irritability
Decreased activity
Poor feeding/lack of weight gain
Lethargy
Change in sleep patterns 
Vomiting/diarrhea
Hypothermia
110
Q

How to work up a neonate with a fever

A

Full septic workup - CBC w diff, UA, CXR, LP, blood cultures)

Early admission of empiric abx

Admission pending culture results

111
Q

Management of ill appearing 3-36 months olds with fevers

A 
Labs 
UA
Cultures (blood, urine, CSF, stool)
CXR - if tachypnea or leukocytosis (≥20,000) is present
Parenteral abx
Admit
112
Q

Management of well appearing but not completely immunized kids with fever

A

CBC w diff
Blood cultures if WBC ≥15,000
UA (girls <24 months, uncircumcised boys <12 months, and circumcised boys <6 months)
CXR if leukocytosis >20,000

113
Q

Management of well appearing, completely immunized kids with fever

A

UA (Cath) and culture (girls <24 months, uncircumcised boys <12 months, and circumcised boys <6 months)

Girls >24 months, uncircumcised boys >12 months and circumcised boys >6 months —> no routine labs, no presumptive abx therapy but do need UA C&S

IF fever ≥39C and abnormal US should treat for UTI

Peds Rotation (13 decks)

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