ACUTE CARE 2019 Flashcards
CSE If after intial Rx in hospital in Px with no iv access is still seizing and NO iv access - what to do?
Consider IO insertion
N.B. Benzos can be given at least 3 times before having to give AED through IO if PIV cannot be obtained
CSE What tests and steps should you do when child comes into hospital?
-
Blood:
a. blood for electrolytes, glucose, CBG/ABG, CBC, cultures
b. Serum calcium, blood urea nitrogen, magnesium, liver enzymes, lactate and ammonia may be required in selected cases.
c. Anticonvulsant levels should be measured for patients on long-term anticonvulsant therapy. - Urine and blood can be sent for toxicology screening.
- A decision - (LP) should be deferred until the patient’s vital signs are stable, there is no suspicion of increased ICP and the convulsion has stopped.
- If sepsis is believed to be likely, IV antibiotics may be given immediately after blood cultures without waiting to perform the LP.
FB How should you manage the following tyoes of FB’s in GIT?
Sharp objects:
Oval
Thin long objects
Open safety pin
Multiple magnets:
Lead-containing objects
Sharp objects:If sharp objects are not able to be removed but no progress is observed in location during 3 days, surgical removal is indicated
Oval objects larger than 5 cm in diameter or 2 cm in thickness tend to lodge in the stomach - endoscopic retrieval
Thin long objects > 6 cm in length fail to negotiate the pylorus or duodenal sweep and should also be removed
Open safety pin requires urgent endoscopic removal if within reach
Multiple magnets: risk of obstruction, fistula development, and perforation across intestines - should be retrieving endoscopically if within the stomach
Lead-containing objects can cause lead poisoning
CSE What steps should you take when child comes into hospital?
CSE What do you do in hospital if still seizing and THERE IS iv access?
IF STILL SEIZING AFTER THIS RX?
Repeat this Rx once within 5 minutes
CSE Convulsive Status epilepticus What can you do if no iv or pre hospital?
CSE What do you do in hospital if still seizing and NO iv access?
IF STILL SEIZING AFTER THIS RX?
Repeat this Rx once within 5 minutes
OR
If iv access obtained - swithc to iv route
Capacity How do you define capacity for decisions in adoloescents?
- Appropriate information: disease course, tx options, benefits, risks
2. Voluntariness: not made under coercion, can change mind at any point
3. Decision making capacity: can receive, understand and communication information greater the risk of harm assoc with intervention, the greater demand for full capacity
Police What is required for a Dr to share info with police?
- patient consent or
- the disclosure is required by law.
Dehydration What is the Rx with moderate dehydration 5-10%?
1) Rehydrate with ORS (100 mL/kg) over 4 hours.
2) Replace ongoing losses with ORS.
3) Age-appropriate diet after rehydration.
Na low What may happen if Na is corrected to quickly in chronic low Na?
irreversible osmotic demyelination syndrome resulting in diffuse demyelination in the brain and the development of profound irreversible neurologic symptoms (dysarthria, confusion, obtundation, and coma
Dehydration What are the signs of severe dehydration? > 10%
Markedly decreased or absent urine output
Greatly increased thirst
Very dry mucous membrane
Greatly elevated heart rate
Decreased skin turgor
Very sunken eyes
Very sunken anterior fontanelle
Lethargy/Coma
Cold extremities/Hypotension
Dehydration What is the Rx with no dehydration?
1) Age-appropriate diet.
2) Replace ongoing losses with ORS.
Dehydration What is the Rx with severe dehydration > 10%?
1) Intravenous resuscitation with normal saline or Ringer’s lactate (20-40 mL/kg) for one hour.
2) Reassess and repeat if necessary.
3) Begin ORT when patient is stable.
4) Replace ongoing losses with ORS.
5) Age-appropriate diet after rehydration.
Dehydration What is the Rx with mild dehydration < 5%?
1) Rehydrate with ORS (50 mL/kg) over 4 hours.
2) Replace ongoing losses with ORS.
3) Age-appropriate diet after rehydration
Na Low How do you treat Symptomatic hyponatremia?
seizures or altered mental status
- hypertonic (3 %) saline with - 3 to 5 mL/kg of
N.B. Na+ should be raised only high enough to cause an improvement in mental status, and in no case faster than 0.5 mEq/L/hr or 12 mEq/L/24 hr.
- Consider cause and ? water restriction
- Measure Na+ after bolus
- if seizures are ongoing, the infusion should be repeated.
- Once the acute CNS Sx have abated, ensure total daily correction, including the 3% saline bolus, is less than 12 mEq/L.
Dehydration What are the signs of moderate dehydration? 5-10%
Decreased urine output
Moderately increased thirst
Dry mucous membrane
Elevated heart rate
Decreased skin turgor
Sunken eyes
Sunken anterior fontanelle
FB What problems can batteries cause?
Can leak mercury or alkali or
cause low-voltage intestinal burns.
FB What are the complications of battery ingestions?
- Esophageal: tracheoesophageal fistula, esophageal perforation, esophageal stenosis,
- Mediastinal: vocal cord paralysis, mediastinitis, spondylodiscitis, aspiration pneumonia, perforation of the aortic arch,
- Intestional: gastric hemorrhage, gastric perforation, and intestinal perforation.
Na low What is the definition of Severe acute hyponatremia:
Na <130 within 48 hours in child with normal baseline Na
CSE what if seizures persist
Dx is Refractory CSE
- RSI
- Midazolam infusion, maintain phenobarbitol and phenytoin levels
- Persist: Consider Thiopental/phenobarbitol
https: //www.cps.ca/en/documents/position/convulsive-status-epilepticus
Police When can a Dr to share info with police without consent?
1. the physician receives from police a subpoena, court order, or search warrant.
- Risk to patient - abuse, death
- Risk to other person, eg gunshot
CSE What is still seizing after 5 minutes aafter above Rx?
CSE What is still seizing and IV access present?
Dehydration What are the signs of mild dehydration? < 5%
Slightly
decreased urine output
increased thirst
dry mucous membrane
elevated heart rate
CSE What is still seizing after 5 minutes after above Rx with NO iv access?
FB What types of betteries should be removed?
Lithium batteries
batteries larger than 15 mmthat do not pass the pylorus within 48 hr are less likely to pass spontaneously and generally require removal
Na low What are the Sx of low Na?
Na < 125
Na < 120
Na < 125: nausea and malaise
Na < 120: Headache, lethargy, obtundation, and seizures
Na low How do you treta Low Na chronic?
Targeted corrected rate of 6 to 8 mEq/Lincrease in plasma sodium for each 24-hour period
Na low What is the commonest cause of fluid loss associated with hyponatremia
Gastroenteritis.
