Acute Care Flashcards
Best way to assess ventilation in an intubated pt:
- chest motion + capnography + SaO2
- chest motion + aus + SaO2
- chest motion + aus + capo
- aus + capnography + SaO2
- aus + venous gas + capnograph
Chest motion (symmetric or not)
+ Auscultation
+ Capnography (exhaled CO2 within tubing near ETT measure CO elimination via capnograph)
Initial vent settings for child:
- FiO2 100% or less for sat
- RR 20 (20-30 infant and 12-20 for child)
- PIP 20
- PEEP 5
Plan: ABG in 10-15 minute and adjust accordingly
What is the ETT tube size formula?
Uncured ETT (mm)
= Age (years)/4
+ 4
i.e. 2 year old
= 2/4 = 0.5 + 4= 4.5
When should a child be intubated:
- A: can’t maintain patent airway or protect against aspiration
- B: can’t maintain adequate oxygenation
- B: can’t control blood CO2
- C/D: need sedation or paralysis for procedure
- Expecting deterioration that would lead to one of situation above.
What is an absolute contraindication for intubation
Complete airway obstruction
= Do ER cricothyroidotomy instead
Pyloric stenosis. Severe metabolic alkalosis. Give:
- HCL
- (lg) amt of IV Cl-
- KCL Bolus
- OR immediately
Large amt of chloride IV
Pyloric Stenosis: thickening of muscle from 2 wk-2 mon.
List 3 RF for pyloric stenosis
- 1st born male
- bottle feeding
- erythro or azithro given in < 2 wk old
- (+) FHX
What is icteropyloric syndrome?
Pyloric stenosis
+ Hyperbilirubin
Resolve w/ Sx
When do you provide IVF for pre-Sx Fluids?
- Infants dehydrated so IV fluid within 8h of last feed
- Teen= NPO overnight
What is the ED treatment for severe malnutrition who is in shock?
SHOCK
= lethargic, unconscious & cold hands
+ slow CRT or weak fast pulse
= ABC = O2 = **D10 5cc/kg IV bolus = **15cc/kg over 1 hr (0.45NS + D5W) = monitor HR or RR
If not improvement assume septic shock
Do you give IVF to pt with severe malnutrition w/ severe dehydration but NO SHOCK? Why or why not?
NO
Refeeding Syn RISK
If Hgb <40 + resp distress= lasix + blood
Ensure BG > 3
Ensure T > 35 (Ax)
Slow feed 100 kca/kg/day goal
Goal: 0.5-1 pound/wk till ~90% avg BW for sex, ht, age
What is refeeding syndrome?
Acute tachy HR + HF w/ neuro symp
assoc with acute decline in serum phosphate + Mg.
- excess carb= insulin spike= hypo K, hypo-Phos, hypo-Mag
Hallmark = severe low phosphate during 1st week of refeeding
Serum phosphate < 0.5= wk, rhabdo, neutrophil dysfunction, cardioresp failure, arrhythmia, sz, LOC
When do you expect refeeding syndrome?
Wt fall 80% below expected wt for height.
List indications for hospitalization of anorexia nervosa.
Psych
> SI intent + plan
> poor family + pt motivation to recover
Physical <80% of healthy BW > Temp 36 or less > HR < 50 > cardiac rhythm disturbances > BP < 80/50 > postural low BP with > 10 mmHg drop or > 25 HR increase
Lab > low K > low phos > low BG > dehydrated > hepatic, cardiac, renal compromise
Other
> require supervision after meals and using restroom
> failed day tx
How do you define severe wasting and/or b/l edema
Severe acute malnutrition
= severe wasting +/- b/l edema on feet
- Wasting= wt for length or ht < 3rd SD
- Marasmus= severe wasting
- Kwashiorkor= edema (protein loss)
- Maramic-Kwashiorkor= severe wasting + edema
Most damaging component on air transport for closed head injury
LOW BP
- brain ischemia occur as cerebral perfusion pressure fall
Which of following LEAST associated with increased ICP?
- meningitis
- encephalitis
- TCA overdose
- intracranial bleed
- tumour
TCA overdose
10% pneumo about to be air transported. Best treatment?
- chest tube
- needle in 2nd intercostal space midclavicular line
- leave pneumo
- only tube if tension
Chest tube
Defined HTN emergency. List two meds that can lower BP acutely. List one AE of each (not including low BP).
= Severe HTN with life threatening symptom or end organ injury
- less vision
- papilledema
- encephalopathy (h/a, sz, LOC)
- HF
- renal f’n deteriorate
Goal: reduce BP 10% in 1st hr and 15% in next 3-12h
IV meds:
- labetolol = low HR, bronchospasm
- nicardipine= sustained tachy HR, CP, flushing
- Na nitroprusside
= severe low BP, dizzy, hypo-thyroid, muscle twitch, cyanide poisoning
What are the 3 components of brain death?
“ABC”
- Apnea
- Brainstem reflex Absent
- Cause known and Irreversible
+ 2 exams show same finding between observation period (24h BB and 12h everyone else)
List some reversible causes of coma that must be R/O before brain death?
Coma: unresponsive to noxious stimuli
Aetiologies:
- **toxins
- **metabolic dx
- **hypothermia
- hypoxia
- hypotension/ shock
- **low BG, Na
- non convulsive sz
- hypothyroid
- hypocortisol
- **liver failure
- **renal failure
- **sepsis
- **meningitis
- encephalitis
What are the brainstem reflexes in brain death?
EXTRA INFO
- Pupillary light
- Corneal reflex
- Doll’s eye
- Oculovestibular reflex (irrigate TM and look for eye mvmt)
- Gag or cough reflex
What is apnea test?
Normal ABC, No apnea drugs.
- FiO2 100%
- Adjust vent to get CO2 of 40
- get base line gas
- Repeat blood gas every 5-10 min.
Until pCO2 > 60 or > 20 above baseline.
T or F: ancillary studies (EEG, radio nucleotide cerebral blood flow) required for brain death dx?
False.
UNLESS:
- Cspine injury (b/c can’t do doll’s eye)
- Sedation med
- Too unstable for apnea test.
Benefit: shorten observation time
Con: must wait 24h to repeat test if shows activity
What is criteria for neurologic determination of death?
- absent hyperthermia
- apnea despite hypercapnia
- spinal reflexes absent
- characteristic EEG
Apnea despite hypercapnea
List 4 medical reason why brain dead pt may not be organ donor:
Infection
- *- active CMV
- *- active Hep B
- *- active Hep C
- *- viral encephalitis
- active West Nile virus
- active disseminated TB
- severe untreated sepsis
- AIDS
Malignancy
**- active extra cranial malignancy
determination of death using neurological criteria is also known as
Brain death
T or F: spinal reflexes may occur in brain death
True.
i.e. subtle semi-rhythmic mvmt of facial nerve, finger flexor or tonic neck reflexes etc.
Boy struck by lightning. Most likely consequence:
- liver failure
- renal failure
- cardiovascular collapse
Cardiovascular collapse
R/O delayed cerebral edema, intracranial bleed, sz, systole, trauma from thrown body
What is the classic pattern of burn that suggest lightning?
Tree like or feathering
Describe cardiac arrest pathway.
Cardiac Arrest:
> CPR + give O2 and attach monitors
> Rhythm shockable
- VF or pulses VT
SHOCK 2J/kg
> CPR x 2 min + IV access
SHOCK 4J/kg
> CPR
EPI- 0.1mL/kg of 1:10K Repeat q3-5 min. (or ETT 1 in 1K)
> CPR
Check rhythm + pulse q 2 minutes
Shock
> Amoidarone or Lidocaine
NOTE: if not shockable then CPR + Epi.
NOTE: treat reversible causes
Describe appropriate CPR:
- Push hard >1/3 of AP diameter chest
- Push fast (min. 100 /min)
- Allow chest recoil
- Minimize interruption in compression
- Rotate compressors every 2 minutes
- No leaning (stool if need to)
- Avoid excessive ventilation
What are reversible causes in cardiac arrest to R/O?
5 H + 5 T’s
> Hypovolemia > Hypoxia > Hydrogen (Acidosis) > Hypoglycemia > Hypo/hyperkalemia > Hypothermia
> Tension pneumo > Tamponade, cardiac > Toxin > Thrombosis, pul > Thrombosis, Coronary
Child with pulseless wide-complex tachy. Got defibrillated x 1. Getting CPR. IV in. What to do next?
- shock 2 J/kg
- shock 4J/kg
- epi 1: 10 K 0.1cc/kg
- lidocaine
Epi 1:10K 0.1cc/kg
What is pulseless electrical activity?
Normal appearing cardiac monitor and non responsive + no pulses.
- Give EPI
What med do you give for asystole?
Epinephrine
What med do you give for bradycardia arrest?
Epinephrine
OR atropine if increased vagal tone or primary AV block
What med do you give for SVT?
Adenosine
0.1 mg/kg (max 6mg)
2nd dose= 0.2 mg/kg
What med do you give for V tach w/ pulse? Without a pulse?
w/ Pulse: Amiodarone, Lidocaine
*if no hemodynamic instability and regular monomorphic QRS can give adenosine first
w/out Pulse= Defibrillate then Epi > Last choice amiodarone
What med do you give for pulseless electrical activity?
Epinephrine
Blood loss after MVA. 15%. VS that most represent pt?
- HR 120, RR 30, BP 90/60
- HR 130, RR irregular, BP 100/70
- HR 220, RR 36, BP 100/70
- HR thready, RR 36, BP not obtainable
15-29%= MILD
- HR up (120) **>100
- ** Normal BP
- U/O low
- RR normal to mild up (20-30)
If RR > 30= 30-40% blood loss.
Best early sign of shock:
- high HR
- low BP
- low Temp
Tachycardia
List 5 signs of shock:
Low mentation high HR low BP CRT restricted or flush Low U/O peripheral and core temp difference
Sick in ICU w/ strep pneumoniae sepsis. Hypotension. HR 220. Low LOC. This is:
- uncompensated hypovolemic shock
- compensated cariogenic shock
- uncompensated distributed shock
- uncompensated obstructive shock
Uncompensated
+
Sepsis = distributive shock.
Example:
- hypovolemic= hemorrhage, dehydration
- cardiogenic= cardiomyopathy, metabolic dx, duchenne
- distributive= anaphylaxis, sepsis, neurogenic
- obstructive= tension pneumo, PE, tamponade
Newborn. Resp distress. RR 80. HR high. CRT poor. BP poor. hyper inflated chest with little undraping. No sounds on left. Turning cyanotic. Likely dx? Test? Tx?
Tension pneumo.
Transillumination
Tx: needle decompression
Describe your steps for needle decompression.
Butterfly needle (23 gauge if > 32 wk) \+ 3 way stop cock and syringe
Insert into 2nd ICS mid-clavicular (above 3rd rib)
List 2 dx criteria for ARDS
“One Bilateral Failure”
within 1 wk of insult
+ b/l opacities not fully explained
+ resp failure (not explained by HF or fluid)
List two life threatening ppt for anterior mediastinal mass.
- Airway compromise -> lose airway, resp failure
- Cardiac tamponade -> cause obstructive stroke
- Vascular obstruction (SVC syndrome) -> cause obstructive shock
List status asthmatics meds in order of progression.
- Oxygen
- Beta agonist (Ventolin)
- Ipratropium (Atrovent)
- Systemic steroids (Pred, Prednisolone, Methylpred)
- **IV salbutamol
- ** IV magnesium sulfate
- ** IV theophylline
- ** Ketamine
- ** +/- Epinephrine (if anaphylaxis)
- ** Heliox
- ** Non invasive resp support
- AVOID intubate
Fever, WOB. White out on 1 lung CXR. Next step:
- decubitus XR
- Chest US
- consult Sx
- Bronch
Chest US
DDX: pleural effusion, empyema, hemothorax, complete lung collapse, CAP, mass
US to see drainage + Sx consult
Teen with tension pneumo. Where do you put the needle?
Needle over 3rd rib in 2nd ICS in midclavicular line.
23 gauge BB
20 gauge teen
Name four signs of tension pneumo:
**resp distress
**trach deviation toward contralateral side
hyper resonance on affected side
hyper expansion of affected side
**low breath sides on affected side
**pulsus paradoxus
What is purpose of the flutter valve in chest tubes?
One way valve within tube that allow air/fluid to exit but prfevent air or fluid from entering.
Post-Sx. Sudden CP, cough, O2 drop. 3 Likely causes of sudden dx. 3 investigation to confirm.
- Pulmonary venous thromboembolism
- Pulmonary fat embolism
- Pneumothorax
3 tests: - D dimer - Spiral CT with contrast - CXR or U/S with doppler (DVT) or ECG
Seizing child. Failed IV. HR 180 for 3 y.o. RR 60. BP stable. Next?
- intubate
- intranasal midaz
- IV valproic
- IV phenytoin
Intranasal Midaz
Other CPS option:
- ativan buccal/ PR
- midaz buccal/ IM/ intranasal
- diazepam PR
What are second line status epilepticus meds:
No IV:
- fosphenytoin IM
IV:
- fosphenytoin IV in D5W or NS over 5-10 min.
5 minute later= Still seizing: use phenobarb
10 min later= Still seizing= midaz infusion
Still persist= Thiopental
Define GCS:
Four Eyes
- 4= spontaneous
- 3= speech
- 2= pain
- 1= no response
Jackson Five
- 5= oriented
- 4= confused
- 3= inappropriate words
- 2= incomprehensible
- 1= no response
V6 (Motor Strength)
- 6= obey
- 5= move to local pain
- 4= flex to withdraw from pain
- 3= abN flexion
- 2= abN extension
- 1= no response
Child w/ flexion to pain, incomprehensible moan. Eyes don’t open. GCS?
GCS= 7
4 eyes= get 1
Jackson 5= get 2
V6 Motor= 4
Severe h/a and progressive LOC. GCS 6. ABC stable. Tumour on CT. which is LEAST imp in management
- control fever
- analgesia, sedation
- hyperventilation
- hyperosmolar fluid
Hyperventilation
B/C= ONLY if brain herniation (irregular resp, HTN, brady HR, blown pupil, decerebrate or decorticate posturing)
AVOID otherwise.
Neuro PALS Tx:
- maintain BP
- maintain BG
- control temp
- tx ICP
- tx sz
T or F: posterior rib fractures are specific to abuse.
True
Dog bite on hand. Both child + dog vac UTD. Full ROM with mild edema. Tx?
- irrigate w/ antibx sol’n
- irrigate w/ saline
- irrigate w/ saline + cover topical Abx
- irrigate w/ saline + Tx with clavulin prophylaxis
- swab for Cx and tx IV clinda
Irrigate w/ Saline
+ Prophylactic Clav
** DO NOT irrigate puncture wound
** NO swab for fresh wound unless look infected
XR if penetrating injury
If MCP joint, cranial bite or extensive wound then OR debridement.
Assess tetanus immunization, risk of rabies from animal, risk of Hep B from human bite.
F/U in 48 hr
Tooth knocked out in play. Two things in tx?
- *- find tooth = rinse
- insert into socket or cold cow’s milk solution
- go directly to dentist
- R/O other head/facial trauma
Nail puncture through sole of shoe + foot. Organism?
Pseudomonas (aeruginosa)
T or F: low risk of HIV infection in daycare bite.
True
Blunt abdo trauma. List one reason to go to OR for laparotomy:
** free intraperitoneal air
- peritonitis
- evidence of ruptured diaphragm, GI tract etc.
- *- blunt trauma w/ hypotension suspected to be intraperitoneal
What are most common abdominal trauma seen in ED?
Spleen
Liver
Retroperitoneal spared (kidney, pancreas etc.)
Left shoulder pain. Where is the abdo trauma?
Spleen
Lap belt mark. What type of abdo trauma/ injury?
Bowel or mesenteric injury.
T or F: Most kid with stable splenic, hepatic, renal injury from blunt trauma go to OR.
False.
T or F: in GU trauma bladder should ALWAYS be cath.
False.
Usually but DON’T if blood dropping from urethral meatus as indication for potential injury.
Blunt abdo trauma. Gross hematuria. (+) Peritoneal Lavage. Next?
- CT
- XR
- AUS
- Transfuse blood
- Foley
Most correct: Abdo CT
pRBC depend on ABC
NO foley if bleeding from urethral meatus.
What is the most likely long-term sequelae from severe head injury: Sz or LD?
Specific LD.
Severe head trauma if GCS < 9.
Head injury after MVA. No CT or neuro Sx. Intubated w/ IV. 3 Tx?
- continuous monitor VS (esp EtCO2)
- ventilate to maintain normal O2 and Co2
- normal T
- sedation, analgesia
- fluid to maintain normal BP and avoid low BP
- refer
List 4 factors that can cause secondary brain injury after initial traumatic brain injury.
- *1. Hypotension
- Hypoxia
- Hypo /hypercarbia
- Hyperthermia
- Hypo glycaemia
Which palsy do you see with ICP?
6th nerve= can’t move lateral
3rd nerve= dilated pupil, ptosis, down and out protruding eye
What are signs of impending brain herniation
Cushing Triad
- HTN
- brady HR
- irregular resp
Dilated pupil
Extensor posturing
List three steps to manage Raised ICP:
HOB 30 degree midline posturing 3% NS Mannitol Maintain normal BP, BG, T, O2, Co2
What do you do if the brain is herniating?
Hyperventilate until pupil not blown.
100% FiO2
Mannitol or Hypertonic NS
Infant with skull # and suspected abuse. Likely what type of intracranial bleed?
Subdural
Why should ketamine NOT be used in head injury?
- sympathomimetic
- (-) isotropy
- resp suppression
low dose ketamine= catecholamine (sympathomimetic)
= can increase ICP
What do you tell kids about sports after they had acute concussion:
Return to Play
- start at no activity and work way up ladder with 24hr duration
- Progress only if symptom free and if symptom recur then try last step when asymptomatic
- once no symptom x 7-10d then can return to play
Sports game with concussion. How long will he sit out minimum?
1 week
3 step in management epidural hematoma w/ posturing and biown pupil.
HOB 30 degree
hyperventilation with FiO2 100%
Hypertonic saline or mannitol.
Call Neuro Sx
What is the leading cause of death in children?
Injuries
** Specifically leading cause of death from unintentional injury in < 4 y.o. (drowning, suffocation, MVA)
MVA day before. Now orange urine and Cr tripled. Likely dx?
Rhabdomyolysis
- Muscle Pain
- Weakness
- Hematuria
- CK ++
- Myoglobinuria
- Risk:
Lytes imbalance + acute kidney injury
How do you manage nose bleed?
- compress with child upright and titled fwd
Still bleeding= ozymetazoline topical vasoconstriction
Still bleeding
= anterior nasal pack
Once controlled= obliteration via cautery
When do you call ENT for nosebleed?
B/L bleeding or hemorrhage that is NOT from Kiesselbach Plexus.
e.g. tumour, polyp, telangiectasia
Teen sexual assault that night. In ED. 5 things on management:
Hx P/E R/O physical injury Consider forensic evaluation Psych support Preg emergency contraception Serum HIV, Hep B, syphilis and repeat Empiric tx STI (Ceftiraxone, Azithro) \+/- Hep B vac if not previous vaccine \+/- discuss HIV ART although low risk
What are two findings on XR compatible with retropharyngeal abscess?
Increased retropharyngeal space
Air fluid level in retropharyngeal space
What makes a good XR for looking for retropharyngeal abscess?
** Neck extended
**Inspiration film
Good penetration
No rotation
Bat in room with 2 y.o. screaming. No marks. P/E normal. Any tx?
No prophylaxis UNLESS direct contact known or evidence of contact.
If prophylaxis: Rabies
Central sleep apnea:
- MRI
- ENT
- CPAP overnight
MRI
List acute bacterial sinusitis clinical dx?
nasal dx or daytime cough with no change x 10d min.
OR
fever and nasal d/c and facial pain x 3d
OR worsening cough, d/c, cough or fever after initial improvement
Tx: amox, keflex
2 y.o. Bright red blood. Mixed withs tool. Pale. Hob 94. Likely Dx?
Meckel’s diverticulum
Day 10 of Abx for URTI. Rash, joint pain, anemia, hematuria. Likely dx? Tx?
Serum Sickness
Tx if severe= steroids
Supportive otherwise
Child brought in without pulse. Ratio of compression to breath via provider?
15:2
10kg Child. Rhythm but no pulse. Med to give:
- Atropine 1mg
- Atropine 0.1mg
- Epi 1/1000 1mL
- Epi 1/10 K 1mL
Epi 1 in 10K
1ML
Known peanut allergy. Hives all over body. Which is correct:
- Give IV epi
- Benadryl PO, IM, IV
- Hydrocort does not prevent late effect
- desensitization undertaken
Hydrocortisone does not prevent late onset effects.
- IM epi
- Benadryl can be all three but in anaphylaxis give IM or IV
- Ventolin only if wheezing
- immunotherapy only good for seasonal or insect
Severe abdo pain + bilious vomiting. Previous 3 episodes. Like most likely dx and test when feeling well?
Malrotation w/ intermittent volvulus
Test: Upper GI Series
What is serum sickness and serum sickness-like dx etiology? Other differences?
Serum sickness
> type 3 hypersensitivity rxn w/ immune complex
> infliximab (and other monoclonal and chimeric antibody)
> snake bite venom
> classic + rare complication of carditis, renal, neuro (GBS)
> low complement, U/A (+) blood
SS-like > cofaclor, beta lactam abx, antisz > direct toxic effect of drug > classic only (fever, rash, joints) > no immune complex, low complement, vessel or renal dx
List three things in teen boy with intermittent testicular pain?
Testicular Torsion Torsion of appendix Testis Epididymitis Trauma (hematocele) Incarcerated inguinal hernia
Most common cause of perineal warts in kids < 2 y.o.?
Vertical
perinatal acquisition even if mother without lesions
List signs of gravol (Dimenhydrinate) overdose:
= Anticholinergic
Red… flushed dry skin
Hot… hyper-temp, Tachy
Can’t see= mydriasis
Can’t pee= urine retained
Can’t spit= dry mouth, MM, dry skin
Can’t Shit= low BS
What is the anticholinergic toxidrome saying?
Red Hot Can't see Can't pee Can't spit Can't shit
List anticholinergic that you could see in toxidrome questions:
- Atropine, Benzotropine
- Scopolamine
- Jimson weed
- Diphenhydramine
- Gravol (dimenhydrainate)
- TCA, clozapine
What four signs on P/E if ingested Jimson Weed. Tx?
Anticholinergic!
Red (flushed dry) Hot (high T, HR) Can't see= dilated pupils Can't pee= urinary retention Can't spit= dry MM, dry mouth Can't shit= low BS
Other: disoriented, delirium, visual hallucination
Tx: supportive (ABC)
- activated charcoal if intact LOC and airway
- benzo if sz
- physostigmine if threat to other or self (only do if CNS= delirium present!)
How can you tell the difference between anticholinergic and sympathomimetic (epinephrine, cocaine, amphetamine)
Bowel sounds:
- BS up in Symph.
- BS down in Anticholinergic.
Skin
- Sweat in symp
- dry skin in anticholinergic
When do you use physostigmine?
Anticholinergic toxicity
And harm to self or others. (need CNS dysfunction)
Ensure no conduction delay on ECG.
Describe the opioid versus sympathomimetic toxidrome?
Opioid= all down
- low HR, BP, RR, T
- dry skin
- mitosis (small pupil)
- low BS
Symph= all up
- HR, BP, RR, Tmp
- Diaphoresis
- Pupil big
- BS up
How do you manage C2 poisoning?
100% oxygen
at normal atmospheric pressure
via non rebreather face mask
Severe= hyperbaric O2
What are the symptoms of carbon monoxide poisoning?
Non specific
- h/a
- N/V
- LOC, syncope
- Coma, MI, acidosis
P/E: cherry red skin
Sequelae: delayed cognitive + cerebellar effects.
T or F: carbon monoxide come from carbon combustion (wood burning stove, heater, car, closed fired).
True
What does ibuprofen toxicity look like?
N/V, abdo pain
GI bleed
Altered LOC/CNS depression
List three BW tests and results to order w/ ibuprofen toxicity?
1. venous or arterial gas = high AG met acid 2. BUN + Cr + Lytes = renal insuff 3. Acetaminophen level, salicylate level (co-ingestant)
Is there a tx for ibuprofen toxicity?
Supportive
- activated charcoal within 1-2h
- anti-emetic and acid-blockade
T or F: There is NO specific antidote for ibuprofen toxicity
True
Which is treated in methanol overdose?
- fomepizole
- physostigmine
- flumazenil
- naloxone
- pralidoxime
Fomepiazole= Methanol
Other:
Physostigmine= Anticholinergic
Pralidoxime= cholinergic (specifically orgagnophosph esp insecticide)
Flumazenil= benzo Naloxone= Opioids
What is usually in windshield and washing fluid? What’s the antidote?
Methanol
if OD= Fomepizole
Toxicity- blurred vision, “feeling like in snowstorm”, optic disc edema. Severe high AG met acidosis. What is this? What is antidote?
Methanol
“Feeling of being in snowstorm”
High AG Met acid
High serum Methanol
Antidote: Fomepizole
How do you treat methanol and ethylene glycol toxicity?
- ABC
- Fomepizole (inhibit alcohol dehydrogenase to make less formic acid/ toxins)
- If N/A or allergy= GIVE ethanol as block metabolism of methanol!
- Na bicarb (for AG met acid)
- IV folate
- Hemodialysis
Child ingest paint thinner (hydrocarbon). What to do:
- gastric lavage
- activated charcoal
- observe and tx symptom
- D/c home
Observe and treat symptomatically
Paraffin oil ingestion in toddler.
Paraffin = hydrocarbon
- poorly absorbed by GI but often aspirated if vomit
- Concern: resp distress if aspirate
- Most= no or minor clinical effect
- ABC
- Observe only
- No W/U
- AVOID gastric lavage b/c risk pneumonitis
T or F: you should gastric lavage a pain thinner or paraffin oil?
FALSE
hydrocarbon
Don’t want to risk aspiration; low risk systemic toxicity otherwise.
Just observe.
List 3 side effects of SSRI overdose. What is tx?
- sedation
- tachy HR
- QT prolongation
Serotonin Syn= HARMED
- *- Hyperthermia
- *- Autonomic
- Rigid + Reflex UP
- Myoclonus
- *- Encephalopathy
- Diaphoresis
Tx:
- Signs + Symp
- ECG
- Supportive Care
- Benzo if mild symp
Overdose imipramine. Low LOC. Next?
- phenytoin
- Na bicarb
- activated charcoal
Activated Charcoal
TCA=
- charcoal (secure airway first)
- serial ECG (wide QRS; high very high can give Na bicarb)
- altered LOC
If asymptomatic:
= gastric decontaminate via charcoal
- monitor 6h via serial ECG
- if all normal= home
What are the stages of acetaminophen toxicity
Stage 1-= 24 up
- N/V, lab normal except tylenol
Stage 2= 24-48h
- RUQ abdo pain, elevated LFT, INR
Stage 3-5d= peak LFT, liver failure, multi-organ failure or death
Stage 4= 4d- 2wk
- resolution
How can you tell a coma with PCP instead of opiates:
- no resp depression
- muscle rigid
+ ++ DTR
- muscle rigid
- nystagmus
- no response to naloxone
Teen agitated + aggressive. Brought in unconscious. Rigid and ++ DTR. What is the ingested?
- cocaine
- PCP
- heroine
PCP
in OD of TCA all possible EXCEPT:
- high HR
- urinary retention
- bowel sound increase
- mydriasis
- seizure
Increased bowel sounds
TCA= anticholinergic
Red (skin red) Hot (temp high) Can't see (mydriasis) Can't pee (retain pee) Can't spit (dry MM) Can't shit (low BS)
Name one example of an organophosphate. What is the organophosphate mnemonic?
“Smells like garlic”
Insecticide, nerve gas, neostigmine, Alzheimer drug
DUMBBELS
- diarrhea
- urination
- miosis
- bronchospasm, bronchorrhea
- bradycardia
- emesis
- lacrimation
- sweat
- salivation
Combative. Irritable. HR up. Flushed. Pupil dilated. How do you manage?
- supportive
- naloxone
- flumazenil
- atropine
Supportive
Sounds AntiCholin.
- intact charcoal if normal LOC and ABC
- benzo if agitated
- consider physostigmine if threat to self or other
Other Answers:
Flumazenil= Benzo
Naloxone= Opioid
Atropine= Organo
List 3 serotonin symptom/AE:
Common AE:
- insomnia
- appetite changes
- GI symptom
- h/a, restless
- sexual dysfunction
Serotonin Syndrome HARMED **- Hyperthermia **- Autonomic - Reflexes ++ and Rigid - Myoclonus **- Encephalopathy - Diaphoresis
Teen HTN, high HR, agitated. Tx:
- physical restraints
- activated charcoal
- chlorpromazine
- diazepam
Amphetamine: everything up including HTN
Supportive +
Tx: diazepam
Took pills w/ white powder. Coma with HTN, muscle rigid, myoclonus jerk, nystagmus.
- Cocaine
- Psilocybin (shroom)
- PCP
- LSD
- Amphetamine
PCP
Fluctuating behav. Delirium Muscle rigid. Myoclonus. ** nystagmus awake!
List three things activated charcoal are ineffective with?
Hydrocarbon Organophosphate Electrolytes Alcohol Lithium
T or F: TCA overdose has increased ICP?
False
T or F: Reye Syn can have increased ICP
True
Mitochondrial hepatopathy in susceptible person interacted of viral infection (esp flu, varicella) AND salicylate use.
What is organophosphate treatment?
Insecticide
Has cholinergic symptoms.
100% oxygen
early ETT (know will get worse)
Decontaminate clothing + skin
Tx: Atropine until wheezing stops + Pralidoxime
List 3 treatments for hyperuricemia?
- Hydration
- Allopurinol
- Alkalinize Urine
- Rasburicase
Initial fluids in DKA?
0.9% NaCl
Rate of initial fluids for DKA?
If hypotensive: Bolus 10cc/kg
Otherwise:
3-9 kg= 6 cc/kg/hr
10-19 kg= 5cc/kg/hour
>20 kg= 4 cc/k/g hour (max 250cc/hour)
- this is equivalent to maintenance + 10% deficit give over 48h*
Add KCL when void and K < 5.
Add dextrose when BG < 15
Insulin 0.1U/kg/hour 1-2h after fluids start.
Unwell child. Na 132 and K 6.2. Likely dx?
Adrenal insufficiency
(Or Congenital Adrenal Hyperplasia)
Tx: Fluid bolus, Glucose if low, HydrocortisoneIV
Then physiologic hydrocortisone and florin + medic alert braclet
Hyperammonia. 3 steps in management:
“Hydrate+ Substrate- Med- Dialysis”
- Rehydrate
= stop protein catabolism in tissue - Give Substrate=
Fluid, Fat, Lytes
= D10W, NaCL, lipids
w/ min. amt of essential a.a. - Priming doses then infusion of: “ABP”
* > Arginine HCL
* > Na benzoate
* > Na phenyl acetate - dialysis if tx above fails
6 mon. Hx of developmental delay. Need Resus. Next step in dx:
- Ct scan
- lactate, carnitine, ammonia
- serum organic acid
- urine a.a.
Lactate
Carnitine
Ammonia
Patient w/ septo optic dysplasia. Low BP. WBC normal. Na 138, K 6.1. After fluid resus:
- IV hydrocortisone
- Abx
- Hyotonic Na
- Kayexalate
IV hydrocortisone
Septo-optic dysplasia= hypo pit and adrenal insuff
In pyloric stenosis. Bircarb 34. What solution to rehydrate and why?
D5NS + 20 KCL
- goal to correct fluid base, lytes, alkalosis
- lots of Cl- help correct alkalosis
- alkalosis is risk of post-op apnea
Ortho Sx. Bedrest x 11 day. Anorexia, polydipsia, polyuria. Glucose normal. BMI 29. What is dx? One test?
Immobilization hypercalcemia.
= Excess Ca2+ due to immobilization
= GI= N/V, anorexia, constipation, pancreatitis
= GU= renal concentration altered= polyuria, polydipsia
= Cardiac= low QT, arrhythmia
= CNS= low tone, confused
One test= Ionized Ca
Tx: Hyperhydrate + Lassie (clear renal Ca2+)
Describe mild versus moderate versus severe hydration?
Mild =<5%
- slight decreased U/O, slightly dry MM, slightly HR high
Moderate= 5-10% - low U/O moderate thirst **- dry MM **- elevated HR **- sunken eyes - less skin turgor
Severe= > 10% - U/O DOWN - VERy dry MM - HR very high - less skin turgor lethargic - cold limbs
How do you rehydrate kids with gastro based on mild, mod, severe
Severe= IV NS, R/A and ORT when stable
Mild-Mod= ORT
%= 10 = cc/kg over4h
- Mild= 5%= 10= 50 cc/kg over 4 hour
- Mod= 10%= 100 cc/kg over 4 hour
+ replace ongoing losses and then age-appropriate diet after
List 6 clinical signs of early hypovolemic shock:
- Tachycardia
- orthostatic hypotension
- mild tachypnea
- absent tears
- dry MM or depressed fontanel
- sunken eyes
- abnormal skin turgor
- dry axillae
- cold limbs
- delayed CRT
- low U/O
What are the most reliable signs of dehydration?
- CRT
- skin turgor (most severe)
- absent tears
- abnormal resp
- U/O
3 clinical signs of ICP in 8 mo. BABY
- low LOC
- HTN, brady, irregular resp
- bulging fontanelle
- irritable
- 6th nerve palsy (eye look inward)
- 3rd nerve palsy (eye dilated and down)
10 y.o. Febrile. Resp fine. HR 140. BP 60/–. Diffuse red rash that look like impetigo. Given bolus. No change. Next?
- Bolus - intubate- pen
- Bouls - inotrope- Clox
- Bolus- Ceftriax- Intubate
- Inotrope- Intubate- Clox
- Intubate-Bolus-Pen
Bolus
+ Inotrope
+ Cloxacillin
B/C Toxin Mediated Septic Shock -> fever, generalized red macular rash, low BP and organ failure - Fluid ++ - Abx: antistaph + anti-toxin = Clox + Clinda
2 wk sepsis. Low bP. RR 70. 50% Oxygen with sat 95%. Next step:
- IV Abx
- Bag Mask
- Intuabte
IV Abx
** ABX key in septic shock
Three things to do in refractory hypotensive septic shock (After boluses):
- *1. ongoing boluses 20cc/kg (until perfusion better or rales or hepatomegaly)
- *2. vasopressor
- epi if cold hypotensive shock
- norepi if warm
- normotensive= dopa
3. 1st dose ABX if not given - *4. Consider steroids if fluid refectory
5. Correct any low BG, low Ca
6. Early intubation
7. ICU consult
List 3 symptoms of high Na
Dehydration or polyuria
Irritable
Cognitive dysfunction
Sz, Coma
Kid V/D. Glucose water only fed. Na 108. Not sz. Tx?
- correct ovr 4-6 hr via 3% NS
- correct to 135-140 in 24 hr
- correct to 118-120 in 24 hour
Correct to 118-120 in 24 h
No faster than 0.5 meq/hour (or max 10 per day)
Why do you remove esophageal foreign bodies that are sitting for > 24 hour?
- esophagitis
- aspiration
- risk of esophageal perf
Risk of esophageal perforation
4 clinical signs suggestive of inhalation injury in acute burn?
- Facial burns
- Soot in mouth, nares
- Singed Facial Hair
- Edema or blister of oropharynx
- Stridor or WOB, Drooling, Crackle, Wheeze
- Carbonaceous sputum
What are complication of inhalation injury in burn?
Early: CO poisoning, airway obstruction, pulmonary edema
Acute: ARDS
Late: pneumonia or PE
Child in house fire. Soot by nostrils. Stridor. Tx?
- observe as will likely improve
- arrange urgent intubation
- racemic epi
- IV steroids
- IV Abx
Arrange urgent intubation
Describe what these burns look like:
- superficial (1st)
- partial thick (2nd)
- deep partial thick (3rd)
- full thickness (4th degree)
1st degree= Superficial: red sunburn; peel and heal w/in 4-5d; doesn’t count in BSA %
2nd degree=
>Partial Thickness: red, wear, BLISTER, MOIST underneath, heal 1-2d of wound care
3rd degree=
> Deep Partial Thickness= white, WAXY, SPECKLED, wks to heal, may need skin graft
4th degree= extend to muscle + bone
Full Thickness: Leathery, dry, no pain, Need Sx (excision + graft)
How do you estimate BSA in burns?
Rule of 9 until < 9.
Rule of 9 (each arm, head= 9%, torso each side or each leg= 18%)
< 8= Cild’s Palm= 1% BSA
T or F: you should give prophylactic Abx for kids with mod-severe burn.
False.
Breed resistance
When do you refer to a burn centre?
- *- Burn > 10% TBSA
- *- 3rd degree burn (deep partial)
- *- inhalation injury
- *- burn to face, hands, feet, perineum, genital, major joints
- high electrical voltage burn or lighting (risk rhabdo)
- chemical burn
- major trauma associated
- ** child abuse or neglect suspected
- pregnancy
- inadequate home or social environment
What type of burn injury should you suspect if pt burnt in closed space?
Inhalation injury
What is the most important management in inhalational burns?
Intubate early
+/- beta agonist for wheeze
+/- chest PT if prolonged intubation
BB. Burn on both hands + scald on chest. Told pulled coffee pot on self. What do you do? List three reasons to admit.
- Call child protective services.
3 reasons to admit:
- Suspected abuse or neglect
- Burn to face, hands, perineum, genital, or major joints.
- Burns affecting > 10% TBSA
What prognostic feature associated w/ worst neuro outcome in drowning:
- increased submersion time
- GCS < 7
- poor quality CPR at scene
- cardioresp arrest at scene
Increased length of submersion
*>5 min. most critical
Other:
- resus time > 1/2 hr
- GCS < 5
- CPR need in ED
- art blood pH < 7.1
How do you tx drowning?
- Immediate CPR at scene
- C-spine precaution if worry of injury based on mech
- no Pulse= CPR + warm w/ ECMO
- defibrillate pulseless VT or VF max 3 X
- Intubate
- Warm, Humidified air + IVF
- NO epi if < 30C
- Warm to 34 C
- If no effective rhythm to CPR AFTER body temp warm 32-34 then d/c resus
- if non-icy water can stop resus after 30 min.
Icy submersion. T28C. VS absent. CPR started. Can you stop resus after 30 min? Why or why not?
No.
Continue until pt warm to min. 32-34C
Even if normal temp resus till 30 min.
What should you do with submersion pt who is asymptomatic by the time they get to ED?
Observe min. 6-8 hour
as 1/2 will get WOB or hypoxemia progressing to pulmonary edema in first 4-8 h usually
T or F: it is mandatory to do CXR in all asymptomatic submersion pt in ED prior to d/c
Controversial
- PIR: not necessary as not reliable predictor of clinical course
Intubation Mnemonic
7P’s:
- prepare (pt, MD, pharm, equipment)
- pre oxygenate
- premedicate
- paralysis
- placement of ETT
- post intubation care
How do you confirm the ETT placement
5C’s
- clinical (AE)
- clinical by direct laryngoscopy
- Co2
- condensation in ETT
- CXR
Four causes of hypoxemia:
- Hypoventilation
- V/Q mismatch (ventilation/perfusion ratio)
- R-L shunt
> areas of no ventilation
> no change with ++ FiO2 - Diffusion impairment
> impaired barrier to gas exchange
i.e. pul fibrosis, edema
Sudden deoxygenation while ETT. Mnemonic
DOPE
- Displaced ETT
- Obstruction
- Pneumo
- Equipment Failure
Define shock
Inadequate oxygen delivery to meet metabolic demands.
When do you use atropine in intubation?
< 6 y.o.
Risk of bradycardia
SVT. When to shock and when med
Cardio resp compromise (low BP, LOC, signs of shock)
OR IO/IV unavailable
= 0.5-1J/kg
If ineffective= 2J/kg
If stable + IV/IO= Adenosine 0.1 mg/kg bolus
What is the bradycardia w/ poor perfusion algorithm?
ABC
ID and tx underlying cause
> Cardioresp compromise > CRP if HR < 60 WITH POOR perfusion despite good vent > Persist= Epi 0.1 mL/kg 1:19K > Atropine for increased vagal tone
Definition of anaphylaxis
Low BP after KNOWN allergen
2+ after LIKELY allergen (skin/MM, GI, resp, BP)
Acute + Skin/MM + AND either resp or BP down.
PGE dosing
0.1 mcg/kg/min
AE: apnea, fever, flushing, tachy or bradycardia, low BP.
List some TBI EBM guidelines:
ICP probe if GCS min. 8 if ICP > 20 x 5 min = sedation = muscle relax = hyperosmolar therapy = drain EVD if present
** only hyperventilate (pCO2 25-30) if impending herniation (Cushing’s triad, blown pupil)
How do you manage cerebral herniation?
Dx= blown pupil, Cushing’s triad
HOB 30
Hyperventilate
Mannitol or hypertonic NS (5 cc/kg IV push)
Consult NeuroSx
Basic approach to burn?
- remove clothes + other exposure
- ABCDE + 100% FiO2 + trauma assessment
- wash w/ tepid water, flush chem burns, cool minor burns
- estimate % BSA w/ partial or full thickness
If > 10%= Parkland formula
4 cc/kg x %TBSA + Normal 24 maintenance
- 1/2 volume in first 8hr and other half over 16 hour
- + IVF dextrose in addition to burn
- control pain
- no prophylactic Abx
- tetanus booster if deeper than superficial
How can we re-warm patients?
Remove wet clothing
Rewarming
> Passive (blanket cover body)
Active
> External: hair huggers, heating blankets
> Internal: heated 42 C, humidified air via ETT, heated IV fluid, gastric, blades, colon, peritoneal lavage w/ warm saline
Continue until min. 34 C
Hypothermic w/ no rhythm. What do you do?
- Airway
- CPR
- shock if V fib
- Rewarm min. 32-34C
** Not responsive to cardiac med so don’t give Epi until > 30 C!
Chocolate blood associated w/ which abnormal hemoglobin-O2 thing?
Methemoglobinemia
Hob iron put into oxidized state -> can’t bind O2.
Tx: methylene blue
Cherry red skin . Linked with which abN Hgb-O2 thing?
Carbon monoxide
Co2 bind Hgb w/ more affinity so O2 not binding
Tx: 100% O2 or hyperbaric
Flushed. lactic acidosis. High venous saturation. “Functional hypoxia”. Linked to which Hgb-O2 relationship?
Cyanide
Suspect if house fire recovery.
Tx: inhaled amyl nitrate, Iv Na nitrate to induced methemglobinemia.
Who needs dialysis?
AEIOU
- Acid-base
- Electrolyte
- Intoxication
- Overload
- Uremic
Most effective strategy to prevent submersion injuries:
- personal floatation if > 12 mo
- 4 sided fence w/ self -lock and self-closing gate
- swimming till bronze level
- parent CPR training
4 sided fence w/ self-closing and self-locking ability
Min. 4 feet high.
** swimming program for < 4 y.o. do NOT decrease rate of drowning
T or F: personal flotation device should be worn by all min. 9 kg.
True.
If can’t sit= can’t wear it!
RF for submersion?
- Male
- child unattended; no supervision
- Exposure to water
- limited swimming ability
- med dx (Sz, long Qt etc.)
- alcohol + drug
T or F: you should delay removal from submersion victim for cervical spine immobilization.
False.
Do not delay removal from water.
Only immobilize if suspect:
- diving
- alcohol or other
- trauma
T or F: you should do abdo thrust for submersion victims.
False. Avoid.
Can decompress stomach once airway secured.
Most important strategy influencing survival in submersion victims?
- immediate C-spine immobilization
- immediate CPR
- passive external rewarming, EMS activation for core rewarming
- early airway
Immediate CPR by rescuers
Good prognostic factors in victims of submersion injuries:
- Immediate bystander CPR (most imp)
- Return to spontaneous circulation < 10 min
- submersion < 5 min
- PERLA at scene
- normal sinus at scene
Complications of submersion victims:
- ARDS
- pul edema
- pneumonia
- cerebral edema -> ICP
- Trauma
- Hypothermia
What is the definition of hypothermia?
< 35 Core Temp
Be-Low 3-0
Just push
No Do
<30 C pt
Just CPR
No dopa or epinephrine
What is heat stroke?
Core T > 40
CNS dysf’n (disoriented, gait disturbance)
Tx: remove clothing Active cooling (ice packs)
Stop once < 38.5
Replace fluid + slat orally
Leading cause of morbidity and mortality in burns?
Infection
T or F: household circuit rarely harmful and only cause local injury.
True.
IF SEE entry+ exit then know went through heart and do ECG
Smells like garlic. What time of toxidrome?
Cholinergic.
DUMBBELLS
Cocaine
Amphetamine
MDMA (ecstasy)
All examples of what toxidrome?
Sympathomimetics
All = UP
List complications of ecstasy?
HTN
Hyperthermia
Hyponatremia (drinking too much water b/c hot)
Serotonin Syn= HARMED (high temp, autonomic, rigid, DTR ++ , myoclonus, encephalopathy, diaphoresis)
Cardiac ischemia
Match the antidote:
- Iron
- Carbon monoxide
- Pesticide
- Nifedipine
- Methanol
- Glyburide
Iron= Deferoxamine
CO= O2
Pesticide= Atropine
Nifedipine= Glucagon
Methanol= Fomepizole
Glyburide= BG
Glyburide or Metformin cause hypoglycaemia? The other causes?
Glyburide= low BG
Metformin= fine BG but lactic acidosis!!
Toxic dose of acetaminophen?
150 mg/kg
How do you treat acetaminophen toxicity?
- Activated charcoal if within 1 hour (avoid if sedated)
- NAC (based on nomogram)
- Nomogram start at 4h
- NAC best if given within first 8h
- F/U BW (INR, LFT, lipase)
What are salicylate take home?
AG Met Acid
+ Resp alkalosis (high RR)
Hearing loss
Low BG
Tx: Glucose, alkalinize serum
If CNS symp= Hemodialysis
F with stupor after house fire. Metabolic acidosis. Lactate 23. Likely cause:
- Carbon monoxide
- metformin OD
- hydrocarbon
- cyanide exposuer
Cyanide exposure
Post house fire= cyanide!
Lactic acidosis!
