2 Peds Emergencies Flashcards
_________ are the leading cause of childhood death in the U.S.
Injuries
Every well-child visit should include age-appropriate injury prevention counseling
Why are infants and toddlers more susceptible to head injuries?
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
Head injuries in kids have a _______ distribution
Bimodal
> 8: due to sports, MVA, ATVs, bikes, scooters etc
<1: falls from walking and furniture, abuse
Concerning signs after a head injury
Excessively sleepy or hard to arouse, vomiting, irritability
What are the first things you do when examining a peds head injury?
ABC’s
Neuro status (use the Glasgow Coma Scale, pupils, sucking reflex for an infant, muscle tone)
Vital signs
What is Cushing’s Triad
Vital signs findings in head injuries
WIDE pulse pressure
Bradycardia
Abnormal respirations
What are the three components of the Glasgow Coma Scale and what are the points?
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
What is the highest score for the Glasgow Coma Scale?
15
≤8 needs immediate action
Battle’s sign, periorbital ecchymosis (raccoon eyes), hemotympanum, otorrhea/rhinorrhea (CSF)
Basilar skull fracture
Other things to look for in head/neck exam after head injury
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
What is the tool we use to determine whether or not to do a CT on a kid with a head injury?
PECARN
100% accurate in kids <2 (like 97% in kids >2)
CATCH and CHALICE are alternative
Concerning signs after head injury
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
Brain bleed with a poor prognosis
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)
CT findings for subdural hematomas
Crescent-shaped, usually in parietal area, crosses suture lines
Brain bleed with a better prognosis
Epidural Hematoma
Rupture of the arteries, esp the middle meaning earl artery, +/- underlying fracture
Brief LOC, lucid period, followed by deterioration
CT findings for epidural hematoma
Elliptical shape, that does NOT cross suture lines
Most common brain bleed
Subarachnoid Hemorrhage
Injury to the parenchymal and subarachnoid vessels
Symptoms range from normal to LOC
CT findings for Subarachnoid Hemorrhage
Small, dense “slivers” on CT
Blood in cisterns, sulci, and fissures
Blood in CSF
May take time to evolve and be visible on CT
How to manage a head injury if no intracranial hemorrhage, no skull fracture
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
How to manage a head injury if positive intracranial hemorrhage, +/- skull fracture
Neuro consult
Admit to PICU
Evacuation of ICH/surgery to repair fracture vs observation w/ repeat imaging
Mild traumatic brain injury is another name for…
Concussion
Definition of a concussion
Traumatically induced alteration in mental status, w/ or w/o an associated LOC
Direct blunt force —> stretching/shearing of axons
Symptoms of a concussion
Amnesia (either retrograde or antegrade) Confusion and/or blunted affect, distractibility Delayed response Emotional lability Visual changes Repetitive speech pattern
Important history considerations in concussion cases
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)
Headache, mental fogginess and other mild concussion symptoms typically resolve within…
7-10 days (90% within 30 days)
Severe, prolonged or worsening H/A, vomiting, deterioration in mental status are emergent
Concussion symptoms lasting 3 months or longer is called…
Post-concussive syndrome
What is second-impact syndrome?
2nd concussion within weeks of a 1st —> brain swelling, herniation, death
Children are at an increased risk
Multiple concussions —> permanent changes in mood, behavior, pain
Chronic Traumatic Encephalopathy
Treatment protocols for concussions
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
Cervical spine injuries are rare in peds, but when they do occur they are most often from …
MVA’s
<8 years old - usually C2-4, usually from falls
> 8 years old - usually C5-7, usually from sports
Adolescents with cervical spine injuries more commonly have…
SCIWORA - injury that doesn’t show up on MRI right away
Test of choice for cervical spine injuries
MRI
Concerning findings in possible cervical spine injuries
Bilateral pain
Neuro deficits
Torticollis
Bony abnormalities
What should you always do before and after splinting/reduction/any fracture intervention?
Document neurovascular status
Management of an open compound fracture
Splint/dress, start IV abx, ortho consult
Management of a non-displaced open fracture (overlying laceration)
Start PO abx, repair laceration, splint, outpatient ortho f/u
How to manage grossly deformed/displaced fractures
May compromise NV structures
Will require closed/open reduction, possible fixation (ortho consult)
Skin infections from bacterial entry via breaches in the skin —> erythema, warmth, tenderness, induration +/- fever, n/v/d
Cellulitis and Erysipelas
Cellulitis involves the deeper dermis and subcutaneous fat
Erysipelas involves the upper dermis and superficial lymphatic
Treatment of cellulitis or erysipelas
Warm wet compresses
Topical abx (Bactroban)
Oral abx (Keflex, Bactria)
If failed outpatient treatment —> admit, labs, IV abx
Most common hematogenous spread of an infection to bone
Osteomyelitis (bone destruction)
Most common in kids under 5, M>F
Can affect long bones, including femur, tibia, humerus
Common pathogens for Osteomyelitis
Staph aureus (most common, MRSA)
Strep pneumoniae
Strep pyogenes
How does Osteomyelitis present?
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
Best study for evaluation of osteomyelitis
MRI - can show marrow edema and abscesses
Also do lab studies (CBC, CRP, ESR, Lactic Acid, Wound and Blood cultures)
Treatment for osteomyelitis
Supportive care
IV Abx (empiric, then directed) - usually start with vancomycin, clindamycin, rocephin
Surgical drainage or debridement
Hyperbaric oxygen therapy (for chronic osteomyelitis)
What is the nationwide poison control number?
1-800-222-1222
Plants that can be toxic if ingested
Dieffenbachia
Philodendron
Poinsettia
Things that can be deadly in a single dose (sorry, it’s a long fucking list…)
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)**
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
Toxidromes
Typically helpful in establishing a diagnosis when the exposure is not well defined
Name the toxidrome: Delirium, flushed skin, dilated pupils, urinary retention, decreased bowel sounds, memory loss, seizures
Anti cholinergic
“Hot as a hare, dry as a bone, red as a beet, blind as a bat”
Name the toxidrome: Confusion, weakness, salivation, lacrimation, defecation, emesis, diaphoresis, muscle fasciculations, miosis, seizures
Cholinergic
Name the toxidrome: Disorientation, HALLUCINATIONS, visual illusions, panic reaction, moist skin, hyperactive bowel sounds, seizures
Hallucinogenic
Name the toxidrome: Altered mental status, unresponsiveness, miosis, shock
Opiate/narcotic
Name the toxidrome: Coma, stupor, confusion, sedation, progressive deterioration of CNS function
Sedative/hypnotic
Name the toxidrome: Delusions, paranoia, diaphoresis, piloerection, mydriasis, hyperreflexia, seizures, anxiety
Sympathomimetic
Name the toxidrome:
Tachycardia
Hyperthermia
Hypertension
Anticholinergic
Name the toxidrome:
Bradycardia
Hypothermia
Tachypnea
Cholinergic
Name the toxidrome:
Tachycardia
Tachypnea
HTN
Hallucinogenic
Name the toxidrome:
Shallow Resps Slow RR Bradycardia Hypothermia Hypotension
Opiate/narcotic
Name the toxidrome:
Apnea
Sedative/hypnotic
Name the toxidrome:
Tachycardia
Bradycardia (if pure alpha agonist)
HTN
Sympathomimetic
Name the toxidrome:
Scopolamine Jimson Weed Angel Trumpet Benztropine Tricyclic antidepressants Atropine
Anticholinergic
Name the toxidrome:
Organophosphates
Carbamates
Mushrooms
Cholinergic
Name the toxidrome:
Amphetamines
Cannabinoids
Cocaine
Phencyclidine (PCP)
Hallucinogenic
Name the toxidrome:
Opiates
Propoxyphene
Dextromethorphan
Opiate/Narcotic
Name the toxidrome:
Barbiturates
Benzos
Ethanol
Anticonvulsants
Sedative/hypnotic
Name the toxidrome:
Cocaine Amphetamines Meth Phenylpropanolamine Ephedrine Pseudoephedrine Albuterol Ma huang
Sympathomimetic
How to decontaminate a patient with toxic ocular exposure
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
How to decontaminate a patient with toxic skin exposure
Copious NS and water if exposed
Follow with soap to concentrated lipid-soluble toxins
How to decontaminate a patient with toxic GI ingestion
Activated charcoal, cathartic, whole bowel irrigation
Enhance elimination
How to decontaminate a patient with toxic blood stream
Antidote
Why isn’t Ipecac recommended anymore?
Only helps if given within 30 min of exposure
What is activated charcoal used for?
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
What are the enhanced elimination modalities?
Activated charcoal
Urine alkalization
Diuresis
Dialysis/Hemoperfusion
Antidote for acetaminophen
Acetylcysteine***
Antidote for Anticholinergics
Physostigmine
Antidote for Benzodiazepines
Flumazenil***
Antidote for Beta Blockers
Glucagon
Antidote for Calcium Channel Blockers
Calcium
Antidote for Digoxin
Digibind
Antidote for Heavy Metals
Chelating agents
Antidote for Narcotics
Naloxone***
What labs to do in cases of toxic ingestion (even if you know what it is…)
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
Once an ingested object passes the pyloric, it usually…
continues to the rectum and is passed in the stool w/o complications
When to be concerned about foreign body ingestion
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
How does an esophageal foreign body present?
Refusal to eat
Vomiting
Choking, coughing, stridor
Neck/throat pain, inability to swallow
Increased salivation
FB sensation in chest
Exam findings in esophageal foreign body situations
Red throat
Palatial abrasions
Anxiety/distress
Wheezing
Decreased BS
Fever
Peritoneal signs
OR NONE OF THE ABOVE
How to work up a foreign body ingestion
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
Indications for consult following FB ingestion
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
Why are button batteries such a big fucking deal?
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
Which type of button battery is associated with the most adverse outcome?
Lithium
With ________ batteries, concern with heavy metal poisoning because they can fragment
Mercuric Oxide batteries
Blood and urine mercury levels should be measured if cell is observed to split in the GI tract
When should a button battery be removed emergently?
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
What is the definition of drowning?
Primary respiratory impairment from submersion in a liquid
What does the age distribution of drowning cases look like?
Bimodal
Peak incidences in children < 4 and young adults 15-24
What are the two primary problems related to impaired ventilation?
Hypoxemia
Acidosis
Most drowning victims aspirate ______ of liquid
< 4 mL
This occurs when laryngospasm —> hypoxia —> LOC but there is no fluid in lungs
Dry drowning
Aspiration of water into the lungs —> dilution and washout of surfactant —> dismissed gas transfer —> atelectasis —> V/Q mismatch
Wet drowning
Can occur in fresh or salt water
A drowning event is considered to be a ___________ when survival is > 24 hr
Near-drowning
Severe brain damage occurs in 10-30% of Peds non fatal drowning victims
Patients most likely to recover from a drowning
Those who are alert or mildly obtunded at ED presentation, especially if <14 years
Drowning patients with very poor prognosis
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
Most critical factor associated with a poor prognosis in drowning
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
Child abuse should be considered in these near drowning cases
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
__________ drowning may cause death up to 72 hours after near drowning incident
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)
What should the ED treatment focus be in the case of drowning?
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
What is the goal when encountering a fever without a source?
Identify occult systemic bacterial infections (ie - PNA, UTI, bacteremia, HHV-6, infections, meningitis)
What is considered a fever?
Rectal temp > 38˚C (100.4˚F)
Workup for Fever w/o a source is based on…
Age (Neonates vs Children 3 months-3 years)
Appearance (toxic?)
Risk factors (birth Hx, travel, exposures, vaccination status, immune deficiencies)
Other symptoms of infection in neonates with fevers
Irritability Decreased activity Poor feeding/lack of weight gain Lethargy Change in sleep patterns Vomiting/diarrhea Hypothermia
How to work up a neonate with a fever
Full septic workup - CBC w diff, UA, CXR, LP, blood cultures)
Early admission of empiric abx
Admission pending culture results
Management of ill appearing 3-36 months olds with fevers
Labs UA Cultures (blood, urine, CSF, stool) CXR - if tachypnea or leukocytosis (≥20,000) is present Parenteral abx Admit
Management of well appearing but not completely immunized kids with fever
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
Management of well appearing, completely immunized kids with fever
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
