ACUTE CARE 2019

Question 1

CSE If after intial Rx in hospital in Px with no iv access is still seizing and NO iv access - what to do?

Answer 1

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

Question 2

CSE What tests and steps should you do when child comes into hospital?

Answer 2

1. 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.
2. Urine and blood can be sent for toxicology screening.
3. 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.
4. If sepsis is believed to be likely, IV antibiotics may be given immediately after blood cultures without waiting to perform the LP.

Question 3

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

Answer 3

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

Question 4

CSE What steps should you take when child comes into hospital?

Answer 4

Question 5

CSE What do you do in hospital if still seizing and THERE IS iv access?

Answer 5

IF STILL SEIZING AFTER THIS RX?

Repeat this Rx once within 5 minutes

Question 6

CSE Convulsive Status epilepticus What can you do if no iv or pre hospital?

Answer 6

Question 7

CSE What do you do in hospital if still seizing and NO iv access?

Answer 7

IF STILL SEIZING AFTER THIS RX?

Repeat this Rx once within 5 minutes

OR

If iv access obtained - swithc to iv route

Question 8

Capacity How do you define capacity for decisions in adoloescents?

Answer 8

1. 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

Question 9

Police What is required for a Dr to share info with police?

Answer 9

1. patient consent or
2. the disclosure is required by law.

Question 10

Dehydration What is the Rx with moderate dehydration 5-10%?

Answer 10

1) Rehydrate with ORS (100 mL/kg) over 4 hours.

2) Replace ongoing losses with ORS.
3) Age-appropriate diet after rehydration.

Question 11

Na low What may happen if Na is corrected to quickly in chronic low Na?

Answer 11

irreversible osmotic demyelination syndrome resulting in diffuse demyelination in the brain and the development of profound irreversible neurologic symptoms (dysarthria, confusion, obtundation, and coma

Question 12

Dehydration What are the signs of severe dehydration? > 10%

Answer 12

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

Question 13

Dehydration What is the Rx with no dehydration?

Answer 13

1) Age-appropriate diet.
2) Replace ongoing losses with ORS.

Question 14

Dehydration What is the Rx with severe dehydration > 10%?

Answer 14

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.

Question 15

Dehydration What is the Rx with mild dehydration < 5%?

Answer 15

1) Rehydrate with ORS (50 mL/kg) over 4 hours.

2) Replace ongoing losses with ORS.
3) Age-appropriate diet after rehydration

Question 16

Na Low How do you treat Symptomatic hyponatremia?

seizures or altered mental status

Answer 16

1. 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.

2. Consider cause and ? water restriction
3. Measure Na+ after bolus
4. if seizures are ongoing, the infusion should be repeated.
5. Once the acute CNS Sx have abated, ensure total daily correction, including the 3% saline bolus, is less than 12 mEq/L.

Question 17

Dehydration What are the signs of moderate dehydration? 5-10%

Answer 17

Decreased urine output

Moderately increased thirst

Dry mucous membrane

Elevated heart rate

Decreased skin turgor

Sunken eyes

Sunken anterior fontanelle

Question 18

FB What problems can batteries cause?

Answer 18

Can leak mercury or alkali or

cause low-voltage intestinal burns.

Question 19

FB What are the complications of battery ingestions?

Answer 19

1. Esophageal: tracheoesophageal fistula, esophageal perforation, esophageal stenosis,
2. Mediastinal: vocal cord paralysis, mediastinitis, spondylodiscitis, aspiration pneumonia, perforation of the aortic arch,
3. Intestional: gastric hemorrhage, gastric perforation, and intestinal perforation.

Question 20

Na low What is the definition of Severe acute hyponatremia:

Answer 20

Na <130 within 48 hours in child with normal baseline Na

Question 21

CSE what if seizures persist

Answer 21

Dx is Refractory CSE

1. RSI
2. Midazolam infusion, maintain phenobarbitol and phenytoin levels
3. Persist: Consider Thiopental/phenobarbitol
   https: //www.cps.ca/en/documents/position/convulsive-status-epilepticus

Question 22

Police When can a Dr to share info with police without consent?

Answer 22

1. the physician receives from police a subpoena, court order, or search warrant.

2. Risk to patient - abuse, death
3. Risk to other person, eg gunshot

Question 23

CSE What is still seizing after 5 minutes aafter above Rx?

Answer 23

Question 24

CSE What is still seizing and IV access present?

Answer 24

Question 25

Dehydration What are the signs of mild dehydration? < 5%

Answer 25

Slightly

decreased urine output

increased thirst

dry mucous membrane

elevated heart rate

Question 26

CSE What is still seizing after 5 minutes after above Rx with NO iv access?

Answer 26

Question 27

FB What types of betteries should be removed?

Answer 27

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

Question 28

Na low What are the Sx of low Na?

Na < 125

Na < 120

Answer 28

Na < 125: nausea and malaise

Na < 120: Headache, lethargy, obtundation, and seizures

Question 29

Na low How do you treta Low Na chronic?

Answer 29

Targeted corrected rate of 6 to 8 mEq/Lincrease in plasma sodium for each 24-hour period

Question 30

Na low What is the commonest cause of fluid loss associated with hyponatremia

Answer 30

Gastroenteritis.