Acute Care Flashcards
What is the definition of status epilepticus?
-continuous generalized tonic-clonic seizure activity with loss of consciousness for longer than 30 minutes or 2 or more discrete seizures without a return to baseline mental status
What is the mortality associated with status epilepticus?
2.7-8%
What are common aetiologies of status epilepticus?
- CNS infection (meningitis, encephalitis)
- metabolic derangement (hypoglycemia, hyperglycemia, hypoNa, anoxic injury)
- antiepileptic durg noncompliance or withdrawal
- antiepileptic drug overdose
- non AED drug overdose
- prolonged febrile seizure
- cerebral migrational disorders (eg schizencephaly)
- perinatal HIE
- progressive neurodegenerative d/o
- idiopathic
What are the objectives of acute management of status epilepticus?
- maintain ABCs
- terminate sz and prevent recurrence
- identify and treat any life threatening causes
- appropirate referral for ongoing care
- management of refractory status
What are factors about status epilepticus that may make maintaining ABCs difficult? How can you overcome these?
- clenched jaw
- poorly coordinated respirations
- lots of secretions
- vomiting
- hypoxia
- suction
- jaw thrust
- 100% O2 by facemark
What are the common vital sign derrangements in a seizing patient?
hypoxia
high BP
high HR
Why do we want to treat seizures early?
Because seizures longer than 5-10 minutes are at high risk for continuing for at least 30 minutes
What are your prehospital options for managing status epilepticus in terms of meds?
Lorazepam buccal/PR 0.1mg/kg (max 4 mg)
Midaz buccal 0.5 mg/kg (max 10 mg)
Midaz intranasal 0.2 mg/kg (max 5 mg/nostril)
Diazepam PR 0.5 mg/kg (max 20 mg/dose)
CHECK GLUCOSE
Once you have an IV, what are your options for IV meds for a seizing patient?
- Lorazepam IV 0.1 mg/kg (max 4 mg) give over 30-60 sec
- Midaz IV 0.1 mg/kg (max 10 mg)
- Diazepam IV 0.3 mg/kg (max 5mg if 5 yrs), give over 2 mins
If still seizing after 2-3 doses of benzo what is your next line?
Fosphenytoin IV 20mg PE/kg over 5-10 mins (max 1000mg)
Phenytoin IV 20 mg/kg over 20 mins
Phenobarb 20 mg/kg IV over 20 mins
*all of the above have a max of 1000mg
If still refractory seizures despite benzos and being loaded what is your next step?
- if loaded with Phenytoin then give phenobarb and vice versa
- next step RSI
- midazolam continuous infusion (0.15mg/kg bolus then 2 microgram/kg/min) increase as needed q5mins (max is 24 microgram/kg/min)
If are on a midaz infusion and still seizing at max doses what is your next step?
Thiopental or pentobarbital bolus and infusion
What critical labs should draw in a patient with status epilepticus?
- electrolytes
- glucose
- gas
- calcium
- consider CBC, AED levels, LFTs, tox screen, metabolic screen (lactate, ammonia) and BCx
What should you choose preferentially as your loading anti epileptic and why?
Forphenytoin is preferred, otherwise phenytoin unless the pt is already on phenytoin maintenance or is a neonatal patient in which case consider phenobarb to load first
-Fosphenytoin has decreased side effects compared to phenytoin, less resp depression
In kids
Intravenous pyridoxine (Vitamin B6) 100mg initially then 50 mg IV/PO bid
b/c pyridoxine-dependent epilepsy can be an undiagnosed metabolic condition
What are are the side effects of benzos?
- hypotension
- resp depression
- sedation
What are the side effects of phenytoin?
- hypotension
- bradycardia
- arrythmia
If a patient is already on phenytoin or phenobarb maintenance but you want to load them how should you proceed?
Give 5 mg/kg and then subsequent doses based on anticonvulsant levels
What other medication that we almost never use is also on the status epilepticus algorithm and what are the side effects?
Paraldehyde 400mg/kg PR (max 10g); dilute 1:1 in oil
s/e: mucosal irritation
If you measure a glucose in a seizing kid at what level should you bolus and how much?
bolus with glucose below 2.6
Give 2-4ml/kg of D25 or 5ml/kg of D10
Recheck in 3-5 minutes
What is the fastest and most effective way to deliver anti epileptics in a seizing kid?
IV but if not available intranasal is th next best choice
Which benzo is our first line in hospital and why?
Lorazepam b/c longer lasting and less resp depression than diazepam
After how many doses of benzos do you start to see resp depression?
more than 2
When do we consider status epilepticus to be refractory?
-when it is unresponsive to 2 different anti epileptic medications (e.g. bento + phenytoin)
In refractory status epilepticus if you start a barbiturate (thiopental or pentobarbital) what do you need to do with the other anti seizure drugs?
- stop midazolam and phenobarbital
- maintain phenytoin at therapeutic serum levels
What is bronchiolitis?
-viral LRTI characterized by obstruction of small airways due to acute inflammation, deem and necrosis of the epithelial cells and increased mucus production
What is your risk of getting bronchiolitis if you’ve had it already?
- primary infection does not give protective immunity
- can continue to get reinfected although these are usually milder
How do you diagnose bronchiolitis?
clinically
How does bronchiolitis typically present and progress?
first episode wheeze before 12 months
- 2-3 days of viral prodrome, fever, cough, rhinorrhea
- progresses to tachypnea, wheeze, crackles and varying degrees of resp distress
- risk of dehydration
What is the Ddx for bronchiolitis?
- asthma
- other pulmonary infections (e.g. pneumonia)
- laryngotracheomalacia
- FB aspiration
- GER
- CHF
- vascular ring
- allergic rxn
- CF
- mediastinal mass
- TEF
What diagnostic studies need to be done for bronchiolitis and why or why not?
- usually don’t need any
- CXR nonspecific, patchy hyperinflation with atelectasis (can be misinterpreted as consolidation)
- Nasal aspirates not helpful for dx but can be useful for infection control and cohering
- CBC not useful in predicting serious bacterial infections
- BCx not routinely recommended
What are some key things that might help you decide whether to admit?
- severe resp distress (indrawing, grunting, RR>70)
- supplemental O2 needed to keep sats >90%
- dehydration or hx of poor fluid intake
- cyanosis or hx of apnea
- at risk for severe disease
- family unable to cope
Which groups are at highest risk for severe disease from bronchiolitis?
-prems
What are the treatments in bronchiolitis that are supported by evidence?
- oxygen (to keep sats > 90%)
- hydration (support frequent feeds and breastfeeding; NG and IV are equally effective)
What conditions suggest that a baby with bronchiolitis may not be safe to feed orally?
-RR>60 +/- nasal congestion
b/c increased risk of aspiration
For which treatments in bronchiolitis is the evidence equivocal?
- epi nebs (only use if clear evidence it causes improvement)
- nasal suctioning
- 3% hypertonic saline neb (theory is that it increases mucociliary clearance and rehydrates airway surface liquid; Cochrane review showed it may reduce LOS by 1 day for admissions >3days)
- epi and dex combined
For which interventions is there no evidence in bronchiolitis?
- ventolin
- corticosteroids
- antivirals
- chest physio
- cool mist therapies or NS neb
What are the recommendations around continuous monitoring and bronchiolitis?
- continuous monitoring may prolong LOS
- ECG monitoring is to detect episodes of apnea
- ECG monitoring useful for high risk patients in acute phase of illness but not for majority of patients
- continuous versus intermittent O2 sat monitoring is controversial
What discharge criteria should be used in patients with bronchiolitis?
- tachypnea and WOB improved
- maintain sats >90% without supplemental O2 or if on home O2 are back to baseline
- adequate PO feeding
- education provided and follow up is arranged
What is a traumatic brain injury?
-symptoms and signs that result from trauma to the brain itself which may or may not be associated with findings of injury on imaging
Why are kids more likely to develop an intracranial lesion due to head trauma?
- larger head to body size ratio
- thinner cranial bone
- less myelinated neural tissue
*also more commonly develop diffuse axonal injury and secondary cerebral edema compared to adults
Which types of injuries are more frequently associated with intracranial injury?
- falls from height above 3 feet (91 cm) or twice the length of the person
- involvement in a MVC
- impact from a high-velocity projectile
What are some signs and symptoms of head trauma?
- headache
- amnesia
- impaired or loss of LOC
- confusion
- vomiting
- blurred vision
- seizures
- lethargy
- irritability
- *higher chance of intracranial injury with:
- prolonged LOC or impaired LOC
- disorientation or confusion
- worsening h/a
- repeated or persistent vomiting
What is a mild, moderate or severe head trauma?
mild: GCS 14-15
moderate: GCS 9-13
severe: GCS
What are all the components of the GCS for verbal kids?
Eye:
4 spontaneous, 3 to verbal stimuli, 2 to pain, 1 nothing
Verbal:
5 oriented, 4 confused, 3 inappropriate words, 2 incomprehensible sounds, 1 none
Motor:
6 follows commands, 5 localizes to pain, 4 withdraws to pain, 3 flexion to pain, 2 extension to pain, 1 nothing
What are all the components of the GCS for preverbal kids?
Eye:
4 spontaneous, 3 to verbal stimuli, 2 to pain, 1 nothing
Verbal:
5 coos/babbles, 4 irritable/cries, 3 cries to pain, 2 moans to pain, 1 none
Motor:
6 normal spontaneous movement, 5 withdraws to touch, 4 withdraws to pain, 3 abnormal flexion, 2 abnormal extension, 1 nothing
What secondary injury to the traumatized brain do you want to prevent?
- hypoxia
- hypotension
- hyperthermia
- raised ICP
In your ABCD management for head trauma what things in particular do you need to do or consider?
A: -consider cspine injury, maintain head and neck in neutral position -immobilization -cervical collar B -intubation with c-spine precautions C -HD instability unlikely from head injury alone but consider 2 large bore IVs -bolus D -do GCS -pupil size and reactivity to light -tone, reflex, movement of limbs -fontanelle -signs of basal skull fracture
What are signs of a basal skull fracture?
- periorbital ecchymosis
- battle’s sign (bruising over mastoid)
- obvious leakage of CSF from nose or ears
- hemotympanum
- if these are present do not put any tubes in the nose
Who should get a skull X-ray in head trauma?
-kids
Who should get a CT scan for head trauma?
- all pts with moderate or severe trauma
- patients who fit the CATCH rule
- focal neuro deficit
- clinically suspected open or depressed skull #
- there are a list of relative indications as well
What is the CATCH rule?
CT head for all kids with minor head injury (injury in the past 24 hrs with witnessed LOC, definite amnesia, persistent vomiting or irritability) plus any ONE of the following:
HIGH RISK
-GCS 3ft or down 5 stairs, falling from bicycle without a helmet)
When can patients with a minor head trauma (GCS 14 or 15) go home?
- if asymptomatic and reliable family
- need to observe for a period if there is headache or repeated vomiting, hx of LOC at time of trauma
- if no improvement pt needs to be admitted
- if persistent symptoms after 18-24 hrs then may need CT if haven’t already had one
Which skull fractures need follow up and why?
-widened or diastatic skull fracture (>4mm) increases risk of developing a leptomeningeal cyst
What measures should be put in place to maintain a normal ICP and cerebral perfusion pressure?
- continous end tidal monitoring if possible
- normal oxygenation and ventilation
- normal core temp
- giving sedation and analgeseia esp with procedures and transport
When do post-traumatic seizures usually occur?
most within first 24 hrs but can be up to 7 days
What risk factors increase risk for post-traumatic seizures?
- younger age
- severe head trauma (GCS
How do you manage post-traumatic seizures?
- as you would any other seizures
- patients with a seizure at the time of the event or shortly after but who are otherwise normal with normal CT are at low risk of further complications
Should you prophylax against post-traumatic seizures?
-not proven effective but is still used prequently
What are indicators of poor prognosis in patients with documented intracranial head injury?
-severity at initial presentation (esp GCS
What are the management objectives in the emergency department for acute asthma exacerbations?
- immediate and objective assessment of severity
- prompt and effective Rx to decrease resp distress and improve O2
- appropriate disposition after ED Rx
- Arrange f/u
What objective measures can you use to assess asthma in the ED? What are the difficulties with this?
- spirometry is objective measure of airway obstruction
- difficult to perform in kids
What tests should you do for kids with asthma exacerbation?
- none routinely
- CXR if suspect pneuma, pneumonia, FB or not improving
- gas only if not improving (normal CO2 with resp distress suggests IMPENDING RESP FAILURE)
What are the treatment steps and recommendations for regular asthma exacerbation?
- oxygen to keep sats greater than or equal to 94%
- Ventolin (better as MDI than neb b/c less likely to provoke hypoemia and tachycardia); give NP o2 while using MDI
- if super severe give continuous neb
- Atrovent only evidence for this if used in the first hour
- steroids give ASAP for moderate or severe
- consider MgSO4
What are the side effects of ventolin?
- tachycardia
- hypokalemia
- hyperglycemia
When do you consider MgSO4 in a patient with an asthma exacerbation?
-in the first 1-2 hours if incomplete response to other treatments
What options are there if have failed management on the ward/ED?
aminophylline-bronchodilator -used in ICU if failed max Rx (cautions inhaled B2 agonist, IV steroids)
heliox - in PICU
-intubation - last resort b/c +++adverse effect
What are the complications relating to intubating an asthmatic?
- pneumo
- impaired venous return
- CV collapse due to increased intrathoracic pressure
- risk of death
How do you treat a mild asthma exacerbation?
- Ventolin B2B x3, consider inhaled steroids
- if stay mild observe in ED for 2 hrs if no further tx needed then send home on ICS and f/u with MD
How do you treat moderate asthma exacerbation?
- Ventolin B2B
- PO steroids
- consider Atrovent B2B
- reassess after 1 hour if still moderate continue with Ventolin q1h
- if after 2 hours of treatment patient needs Ventolin more often than every 4 hrs then admit to hospital
How do you treat severe asthma exacerbation?
- consider O2 100%
- Ventolin and Atrovent B2B
- PO steroids, consider IV
- consider continuous ventolin
- Consider IV MgSO4
- keep NPO
- reassess
- give ventolin q20mins until able to tolerate q1hr
- admit
How do you treat severe to impending resp failure in an asthma exacerbation?
- nonrebreather with oxygen 100%
- continuous ventolin and Atrovent B2B
- NPO
- IV access
- continuous monitor
- IV steroids
- consider IV MgSO4, aminophylline or IV ventolin
- draw gas and lights
- consider submit epic
- consider intubation if none of above are working
What would a kid with a mild asthma attack look like?
normal speech and activity min retractions moderate wheeze minimal dyspena sats >94% on RA peak flow >80% of personal best
What would a kid with a moderate asthma attack look like?
agitate decreased activity or feeding speaks in sentences retractions loud exsp and inspiratory wheeze sats 91-94% on RA peak flow 60-80% of personal best
What would a kid with a severe asthma attack look like?
agitated infant stops feeding speaks in words signficant resp distress hunched forward paradoxical muscle use wheezes might be audible without stethoscope sats
What would a kid with impending resp failure look like?
- drowsy or confused
- marked resp distress
- absence of wheeze
- bradycardia
What are discharge criteria from the ED?
- needs ventolin 94% on RA
- minimal or no resp distress
Do ICS impair final adult height?
no
Who should get ICS for asthma?
- persistent asthma and/or who have a moderate or severe episode
- if already taking then they should have the dose adjusted
What are discharge medications and instructions for pts with asthma exacerbation?
- PO steroids for 3-5 days
- Ventolin q4h (0.3 puffs/kg) until exacerbation resolve and then prn
- AAP
- review puffer techniques
- ensure f/u
What is low/medium/high dosing for the various ICS?
Beclamethasone dipropionate (QVAR), ciclesonide (AlvescO), Fluticasone (Flovent) for kids 6-11 yrs low is 400-500 For budesonide (pulmicort) low is 800
FOR KIDS 12 and UP
-it is similar except low doses for QVAR, alvesco and flovent is 250 (alvesco is 200) and pulmicoty is 400; high dose is >400-500 for the first 3 and >800 for pulmicort
What is the alternate name for each of these and for what ages are they approved? Beclomethasone dipropionate HFA Budesonide Ciclesonide Fluticasone
Beclomethasone dipropionate HFA = QVAR = 5 yrs and up
Budesonide = Pulmicort = 3 months and up
Ciclesonide = Alvesco = 6 yrs and up
Fluticasone = Flovent = 12 months and up
What are the recommendations for AEDs and paramedics?
- should have AED suitable for paediatric use if do not have a defibrillator
- AEDs can be safely used in kids
Can all paramedics do the same things?
no some are advanced care and some are BLS
What is anaphylaxis?
-severe, acute, life-threatening condition due to systemic release of mediators from mast cells and basophils in response to an allergen
What are the most common triggers of anaphylaxis?
1) food (peanuts, tree nuts, fish, milk)
2) hyemoptera venom (bee, wasp)
3) medications
What systems can be affected by anaphylaxis and how does it manifest?
skin: urticaria, pruritis, angioedema, flushing
Resp: wheeze, cough, dyspnea, hoarseness, stridor, edema, rhinorrhea, sneezing
CVS: tachycardia, dizziness, hypotension, syncope
GI: nausea, vomiting, diarrhea, abdo pain
CNS: irritability, drowsiness, lethargy, sonmolence
What is the criteria for anaphylaxis?
at least one of:
1) acute onset of illness (mins to hours) with involvement of skin and/or mucosal tissue (e.g.. hives, pruritus, angioedema) and at least one of: RESP or hypotension or end organ dysfunction (syncope, incontience)
2) after possible allergen exposure, 2 or more of occurring within mins to hours:
skin-mucosal; resp; CVS or GI sx
3) after a known allergen hypotension within mins to hours (low BP for age or >30% drop in sBP)
What is the treatment for anaphylaxis?
0.01 mg/kg of IM epinephrine (1:1000) (max 0.5 mg) q 5-15 mins
supplemental O2
2 large bore IV
if hypotensive give NS boluses
How does epinephrine act in anaphylaxis?
alpha adrenergic - increases SVR
beta1 adrenergic - positive chronotropic (HR) and inotropic (contractility) effects on heart
beta 2- bronchodilation
What are some adjunct medications that can be used as adjuncts in anaphylaxis? What is their effect?
- H1/H2 blockers: relieve cutaneous symtpoms
- steroids: no benefit in acute, slow onset (4-6 h)
- inhaled ventolin: give if wheezing; epi for stridor (no evidence)
How do you treat anaphylaxis with refractory hypotension?
-if still hypotensive despite boluses start epic infusion 0.1 mcg/kg/min and titrate up
if pt taking beta blockers give gulag to reverse the effect of the beta blockers (bolus) then put on epi infusion
When do biphasic reactions occur?
within 1-72 hours but most within 4-6 hours
How long should you observe a pt in the ED after an anaphylactic reaction?
4-6 hours
What do you need to do on discharge after an anaphylactic reaction?
- prescribe epicene and tell them to fill script asap
- educate about administration of epicene
- 2 doses of epi available at all times, must be available at school
- avoid trigger
- medic alert bracelet
- referral to allergist
- can consider 3 day course of PO cetirizine and ranitidine and PO steroids (limited evidence)
What is the definition of hyponatremia? severe hyponatremia?
hyponatremia = Na
What contributes to hyponatremia in hospitalized kids?
-hypotonic maintenance IVF and ADH secretion
What are signs of hyponatremia?
- h/a, lethargy, seizures
- if severe risk of rap, cardiac arrest from herniation
Why are kids at increased risk for complications from hyponatremia?
-increased brain/intracranial volume ratio
Why is ADH secreted in hospitalized kids?
-due to nausea, stress, pain, pulmonary and CNS disordesr, surgical interventions, medications (morphine)
What is are preferred maintenance fluid and how much Na is in it?
D5NS = 154 mmol/L of Na
- esp in kids for surgery, CNS or resp infections
*unless pt has impaired Na excretion, renal concentrating defect, significant water loss or prolonged fluid restriction
What monitoring should be done for patients on IVF?
daily lytes if high risk (euro or resp infections) monitor ins and outs daily weights watch for signs of hypoNa remember PO fluids are hypotonic
Which kids are at particularly high risk for ADH secretion?
- kids undergoing surgery
- kids with acute near or resp infections
If a kid has a normal Na, and is not high risk for ADH secretion what fluids should you run?
D5NS preferred but D5 0.45NaCl is ok too
If the Na is 145-154 what fluids should you run?
D5 0.45 NaCl and monitor sodium frequently
Why don’t we usually use ringers as maintenance?
-no glucose and it contains lactate
Na content is 130
For an asystolic cardiac arrest what is the order you do things?
CAB for both IN and OUT of hospital arrests
- start CPR ASAP
- avoids delays
What are the recommended compression to ventilation ratios?
30:2 for single rescuer
15:2 for 2 rescuer
if have an advanced airway, do contiuous CPR with breaths throughout at rate of 8-10 per min do not stop CPR to bag
What makes CPR high quality?
- 1/3 AP diameter
- rate of 100 per min
- allow full recoil
- minimize interruptions
- avoid excessive ventilation
- rotate compressors every 2 mins
- limit pulse check to 10 seconds
What is the recommendation if you com upon someone lying on the ground?
- NO MORE look, listen, feel
- if unresponsive and append or gasping start CPR right away
- health professionals can check for a pulse for max 10 s
What is the recommended method of defibrillating infants?
manually (2 J/kg to 4 J/kg), max is 10 J/kg
-if not available, use AED with peds dose attenuator, if not use adult
What are the principles of post-arrest care?
- hyperoxemia can be harmful
- O2 to keep sats 94-99%
- therapeutic hypothermia to temp 32-34 degrees may be considered for kids who remain comatose after rests in consultation with expert
What is the definition of a wide complex tachycardia?
> 0.09s for QRS
Which patients should not get adenosine?
those with known WPW if have a wide complex tachycardia
What intubation/sedation medication should be avoided in paediatric septic shock and why?
Etomidate b/c adrenal suppression and associated with increased mortality
Should you use cuffed or uncuffed ETT in septic shock?
either but cuffed might help decrease risk for aspiration
What is the formula for uncuffed ETT?
2 yrs = 3.5 + (age/4)
for cuffed tubes go 0.5 mm higher
What % of inhospital cardiac arrest patients die?
75%
What is ondansetron and how quickly does it work?
-selective serotonin 5-HT3 receptor antagonist that is rapidly absorbed and reaches peak plasma concentrations in 1-2 hrs
What are the main side effects of Ondansetron?
-mild diarrhea, does NOT cause drowsiness
What is the evidence for ondansetron use in the ED?
-single dose is effective in reducing vomiting and IV fluid administration in kids 6-12 months with gastro and MAAY be effective in reducing hospitalization
Who should get ondansetron in the ED?
-kids 6 mo to 12 years with acute gastro with mild to moderate dehydration OR who have failed ORT
How soon after giving ondansetron should ORT resume?
15-30 mins after
