Acute Care Flashcards
What is the most common cause of paediatric deaths in children aged 1- 4 years?
trauma
What is the most effective strategy to prevent submersion injuries in children? how high? how many adults per baby? per child?
4 sided fence with self-locking, self-closing gates
must be at least 4 feet high
Toddlers should always be within arm’s length of an
adult, even in a bathtub
1 adult per baby and 1 adult per 2 young children
what is the most common preventable cause of death? who is at greatest risk?
submersion injury
children <5
typically during summer months
M>F
Do swimming programs for children < 4 years decrease rates of drowning?
NO! Swimming programs for children < 4 years do not
decrease rates of drowning
who is too young to wear PFD?
Babies who cannot sit unsupported are too young to wear PFDs
Should be worn by all infants at least 9 kg
what medical conditions are risk factors for submersion injuries? (4)
Seizure disorder
toxin (primarily ethanol)
prolonged QT
syncope
what are risk factors for submersion injury? (4)
leaving children unattended
alcohol or drug abuse (50% of adult drownings)
limited swimming ability
underlying medical condition (Seizure disorder, toxin, prolonged QT, syncope)
when is cervical spine immobilization recommended for submersion injuries?
diving
alcohol or other substances
trauma (boat, water skis)
* should not delay removal from water, can delay rescue breaths, hypoxia is the most common reason people don’t make it
After a submersion injury what type of ventilation if they are breathing? if they are not breathing?
spontaneously breathing- high flow oxygen
if they fail high flow oxygen- non invasive ventilation (CPAP)
non breathing- endotracheal intubation
decompress stomach after airway secured
avoid routine use of abdominal thrusts
What investigations would you order for submersion injury
early arterial blood gas to assess degree of hypoxemia electrolytes BUN, CRE CXR- to look for signs of ARDs EKG Ethanol level Core temperature
what must the temperature be before you can stop resuscitation?
discontinue resuscitation efforts only after temp 35C
A 14 y.o. M is pulled from an icy lake
after being found face down. What is
the most important strategy
influencing survival
Immediate CPR by rescuers
what are good prognostic indicators after submersion injury? (4)
- Return of spontaneous circulation in < 10 min
- Submersion < 5 min
- Pupils equal and reactive at scene
- Normal sinus rhythm at scene
what are poor prognostic indicators after submersion injury? (3)
- Delayed CPR
- Return of spontaneous circulation > 25 min
- Submersion > 10 min
what are some complications of submersion injury? (6)
ARDS Pulmonary edema Pneumonia Cerebral edema leading to increased ICP Trauma Hypothermia
what is hypothermia?
core temp <35C
can occur in water as warm as 21C
At what temperature does shivering stop?
core temp <32C
what are the 3 major metabolic disturbances associated with hypothermia?
hypoglycemia hypokalemia hypocalcemia metabolic acidosis * also associated with pancreatits* coagulopathy
what findings are associated with core temp:
31-32C
28-31C
<28C
31-32 C
- Normal ECG, ↑ HR, ↑ BP, loss of shivering
28-31 C
- ↓ HR, ↓ BP, flipped T, atrial fibrillation, sluggish,
dilated pupils, pathognomonic J wave
< 28 C
- absent pulse and BP, VF, coma, fixed dilated pupils
A 12 year girl was pulled from a lake and presents to the ED with a core temp of 28 C. What is the name given to the upward deflections on her ECG?
Osborn waves/ J wave
what EKG findings are associated with a T <32
Marked sinus bradycardia
First degree AV block
Osborn or J waves
Associated with prolonged QT and bradycardia
If a patient has a pulse and a core temp of 34-36 how do you rewarm them?
passive rewarming
remove wet clothes
dry
If a patient has a pulse and a core temp of 30-34 how do you rewarm them?
Passive AND active external warming of truncal areas only • electric blanket • overhead warmer • hot water bottles • heating pads Minimizes “after-drop” or shock associated with peripheral vasodilation
If a patient has a pulse and a core temp <30 how do you rewarm them?
Active external and internal rewarming • Warmed IV or intraosseous (IO) fluid (without K+) at 43 C • Warm humidified oxygen at 42-46 C • Peritoneal lavage, ECMO, esophageal warming tubes Do not delay advanced airway placement
If a patient has NO pulse with temp >30 what should you do? <30?
> 30: CPR, IV meds as needed, defibrillation as needed
<30: CPR, NO IV meds, limit defibrillation to 3 shocks!
warm with cardiopulmonary bypass
nelsons says give one shock at max power and then warm 1-2 degrees or until >30 for additional shocks
Be-Low 3-0?
Just Push
No Do (pamine or Epi)
NO VASOACTIVE DRUGS UNTIL TEMPERATURE >30
Defibrillate all cases of pulseless VT or VF to max of
______ shocks if temperature < 30 C
3!!
How should you treat frostbite in ER
In ER, 42 C water bath, do not rub,
keep rewarmed areas open, dry, and
sterile
What is the metabolic disturbance associated with hyperthermia
loss of NaCl
acute tubular necrosis seen in 30% of cases of heat stroke
what are heat cramps? tx?
exercise-associated muscle cramps
intense painful muscle contractions
due to excess water (hypotonic fluids) resulting in salt depletion
tx: oral electrolyte solution or IV fluids, salt replacement
what happens with heat exhaustion? what are the two types of heat exhaustion
Temp >39C but neurologic status intact
excessive peripheral vasodilation
inability to deliver sufficient blood volume
muscle fatigue
profuse sweating
excessive water and/or sodium losses
TYPE 1: water depletion type- temp >39, water depletion= hypernatremia
TYPE 2: salt depletion type- hyponatremia (CF patients at risk)
what is heat stroke?
core body temp >40 with CNS dysfunction
- headache
- DISORIENTATION
- dizziness
- weakness
- GAIT DISTURBANCE
what is the management of heat stroke?
Remove clothing
Active cooling: ice packs in groin, axillae, neck, cooling
fans over body sprayed with tap water at 15 C
Stop cooling when T < 38.5
Coma may persist for > 24 hours after normothermia
Fluid AND salt replacement orally
diuresis for rhabdomyolysis
what are the complications of heat stroke? (5)
Hyponatremia Seizure Rhabdomyolysis DIC Multi-system organ failure
what are the 4 types of burns?
superficial
superficial partial thickness
deep partial thickness
full thickness
what is a superficial burn?
epidermis only
reddness, pain, no blisters
heals in 3-5 days
what is a superficial partial thickness burn?
epidermis + 1/2 dermis red/pink pain moist BLISTERS heals in 2 weeks
what is deep partial thickness burn?
epidermis + >1/2 dermis pale dry less tender speckled appearance GRAFTING OFTEN NEEDED
what is full thickness burn?
subcutaneous tissue pale charred leathery appearance non-tender most require grafting
What is the initial management for burns?
Cover with sterile bandages Early cooling ( < 30 min) prevents further injury TETANUS (DIRTY WOUND) analgesia remove smoldering clothes
what are some indications for early intubation for burn patients? (4)
- Carbonaceous sputum
- Singed nasal hairs
- Soot in airway
- Hoarseness
what is the Parkland formula? what type of fluid do you use?
Age > 5: Parkland formula = 4 cc/kg/BSA over 24
hours (1st half in 8 hours, 2nd half in 16 hours)
add maintenance to Parkland
Use Normal Saline or Ringer’s Lactate (no albumin)
what is the admission criteria for burns?
Suspected non-accidental injury > 10% BSA partial thickness > 2 % BSA full thickness > 1% BSA of hands/feet/face/perineum Circumferential burn Enclosed space fire or evidence of inhalation injury Electrical injury with high tension wire (rhabdomyolysis) Associated trauma
what complications are associated with burns
Children < 20 kg at risk of hypoglycemia
No role for prophylactic broad spectrum antibiotics
Early infection: Staph aureus, GAS
Late infection: Pseudomonas, Bacteroides
Daily dressing change with topical antibiotic BID until
re-epithelialization
what type of current is seem with lightening? what type of pattern do we see? what is the main thing we watch for?
direct current
feathering or arborescent pattern common
monitor for delayed cerebral edema, ICH, seizure, arrhythmia, rhabdomyolysis, asystole and respiratory failure
What is the most common cause of morbidity and
mortality in burn patients?
Infection!!
what complications are seen with high tension wires? what must you do for monitoring?
Muscle damage → Compartment syndrome, rhabdomyolysis → ARF CNS injury common VF/arrest common Must monitor with urinalysis and ongoing ECG
After bitting electrical injury what should you warn the parents about
eschar can detach and cause significant bleeding from labial artery 1-3 weks later
what should you do for a patient with a low voltage electrical injury?
EKG and look for an exit wound
can still cause arrhythmia and seizure if contact is near chest or head
if exit wound or tender compartment, rule out rhabdomyolysis
what are 3 cholinergic drugs
organophosphates (sarin “nerve” gas
carbamates (neostigmine, pyridostigmine, aldicarb)
Alzheimer’s drugs (donepezil)
what is the main difference between organophosphates and carbamantes
organophosphates bind IRREVERSIBLY to inhibit acetylcholinesterase at 24-48h
carbamates transiently inhibit acetylcholinesterase so symptoms are REVERSIBLE within 48 hours
Cholinergic toxidrome
DUMBELLS
D- diaphoresis U- urination M- miosis B- bronchorrhea/bradycardia E- emesis L- lacrimation L- lethargy S- salivation
- organophosphates and carbamates
what is the treatment for cholinergic toxidrome
atropine (q5min)
pralidoxime (2-PAM) with atropine
100% oxygen
early intubation
PPE, remove clothing and vigorously irrigate the skin
what type of toxidrome is seen with Jimsonweed
ANTICHOLINERGIC
what are the features of anticholinergic toxidrome
mad as a hater red as a beet dry as a bone blind as a bat hot as a desert
*dry skin, agitation, flushing
dilated pupils confused dry mouth flushed skin tachycardia shaking
what is the treatment for TCA with prolonged QT
sodium bicarbonate
if QRS >100msec administer sodium bicarb
what is the treatment for agitation seen with anticholinergic toxidrome?
lorazepam
when should you consider physostigmine for anticholinergic toxidrome?
consider if both peripheral and central toxicity (Delirium) is present
what are examples of sympathomimetic drugs? (4)
cocaine
amphetamine/methamphetamine
ETDA
ephedrine
what is the main difference between anticholinergic and sympathomimetic toxidrome?
sympathomimetic- diaphoresis
antiperspirants keep you dry and so do anticholinergics!!
what are 2 clues to amphetamine (sympathomimetic) exposure
diaphoresis
agitation
How do you diagnoses MDMA overdose?
diagnose with MDMA screen in urine
what symptoms do you see with MDMA (6)
HTN Hyperthemia Hyponatremia Serotonin syndrome cardiac ischemia hepatotoxicity
what is the management for MDMA HTN Hyponatremia agitation hyperthermia
HTN- lorazepam 1mg IV Hyponatremia- fluid restrict or 3% NS if seizing Activated charcoal within 1 hour agitation- lorazepam 1mg IV hyperthermia- cool water mist and fans
how low does sodium have to be before there is a risk of seizures
typically <120
what is the key presentation associated with LSD or “Acid”
HALLUCINATIONS
one of the most potent hallucinogens putting patient as risk of severe injury
common to have co-injestion with MDMA at raves
what is the key presentation associated with PCP or “angel dust”
nystagmus while awake*
structurally similar to ketamine
dystonic posturing, muscle rigidity, myoclonus, hyperreflexia fluctuating behavior with delirium, paranoia and agitation
what is the difference between serotonin syndrome and neuroleptic malignant syndrome
Serotonin syndrome: <12h increase bp, RR, HR, T pupils: ENLARGED mucosa: sialorrhea skin: diaphoresis neurologic: INCREASED REFLEXES (LE) AND TONE mental status: agitation
Neuroleptic Malignant syndrome: 3-4d increase bp, RR, HR, T pupils: NORMAL mucosa: sialorrhea skin: diaphoresis neurologic: RIGID mental status: STUPOR
What SSRI should you worry about most in overdose?
citalopram- risk of seizures and qt prolongation
what is the most popular opioid with teens?
fentanyl
what is the most popular opioid overdose in toddlers?
methadone (prolongs QT interval)
What synthetic opioid is 100 times more potent then fentanyl
W-18 is 100 times more potent than fentanyl
What are the features of opioid toxidrome? (5)
bradycardia hypotension respiratory depression miosis coma
what is the treatment for opioid overdose?
Naloxone
what is promoted online as a treatment for opioid withdrawal?
Imodium (loperamide)
NOT detected in urine drug screen
what are the signs of loperamide overdose?
euphoria prolonged QT, QRS respiratory depression highly toxic to young children in overdose *not detected in urine drug screen
what is the usual time frame for activated charcoal?
typically within 1 hour of ingestion
1g/kg (max 50g)
when does activated charcoal FAIL?
P- potassium H- hydrocarbons A- alcohols I- iron L- lithium S- solvents if it is used to make something shiny it doesn't work! avoid if compromised airway/caustic ingestion/patient non compliant
when do we consider intralipids?
for life-threatening overdoses of local anesthetics, bupropion, amitriptyline
what is the antidote for: iron carbon monoxide pesticide nifedipine amitriptyline methanol glyburide
iron- desferoxamine carbon monoxide- oxygen pesticide- atropine nifedipine- glucagon amitriptyline- sodium bicarbonate methanol- fomepizole glyburide- glucose
what do we worry about for hydrocarbons? what is the initial investigation?
we worry about pulmonary aspiration
aspiration is common and pulmonary toxicity account for most fatalities
CXR on arrival and repeat 4-6h post ingestion (can see perihilar infiltrates and pneumatoceles)
Can d/c after 4-6 h if asymptomatic and normal CXR
what are common hydrocarbons
gasoline, nail polish remover, lighter fluid
what can be seen on bloodwork with metformin ingestion?(2)
normal glucose
lactic acidosis
what would be seen with glyburide ingestion?
hypoglycaemia that is difficult to control
Glieburide….lies are bad…. hypoglycemia that is difficult to control
List 4 drugs that cause hypoglycemia
salycilates
ethanol
glyburide
beta blockers
what is the toxic metabolite of acetaminophen
NAPQI
what is the toxic dose of acetaminophen?
150mg/kg
7.5g in adults
what are 3 complications of acetaminophen overdose
anion gap metabolic acidosis
acute tubular necrosis
fulminant liver failure
what are the 4 stages for acetaminophen overdose
stage 1: 0-24h, asymptomatic or nausea/vomiting
stage 2: 24-72h, right upper quadrant pain and onset of hepatocellulr injury
stage 3: 72-96h, maximal hepatotoxicity; most deaths occur during this phase
stage 4: >4d, recovery
** peak hepatic injury 3 days post ingestion **
what is the treatment for acetaminophen overdose?
activated charcoal within 1 hour (Avoid if sedated or suspected GI obstruction)
NAC (N-acetylcysteine) dosing based on Rumack- Matthew nomogram
what time frame is associated with the best outcome for NAC
best outcomes if NAC started within 8 hours
when do you start NAC if a patient has ingested a toxic dose of acetaminophen
start IV NAC protocol immediately
what is the minimum level above which toxic effects are seen on Rumack- Matthew nomogram
1000umol/L is the minimum level above which toxic effects are seen
nomogram applies to acute ingestions only
nomogram begins at 4 hours
List 3 examples of salycilates
ASA
bismuth salicylate (antidiarrheal agent)
methyl salicylate “Rub A535”
what is the treatment of salicylate overdose? 4
charcoal up to 6 hours (risk of bezoar formation)
***glucose to all patients with altered mental status REGARDLESS of peripheral glucose
treat hypokalemia
alkalinize serum to urine pH between 7.5-7.6 to “trap salicylate anions in blood and renal tubule
how is the toxic quantity of iron calculated? can iron be seen on xray
toxic quantity calculated as elemental iron
measure a serum iron within 4-6 hours of ingestion
iron can appear on xray
what are the radio-opaque drugs
C- chloral hydrate O- opioid packets (latex) I- iron and other heavy metals N- neuroleptics (early) S- sustained- release tablets/ salicylates (Early)
what is the treatment for iron overdose?
NO role for either charcoal or gastric lavage
fluid resuscitation is essential
whole bowle irrigation if tablets seen on AXR or if <6h from ingestion
IV deferoxamine (DFO) is the antidote of choice and MUST be given early
continue deferoxamine until urine color clears
what are 3 clues to iron exposure
gi symptoms
acidosis
multiorgan failure
cardiovascular collapse happens at 12 hour mark
what is the only toxic alcohol that will result in an increase in serum ketones
isopropyl alcohol
what is the most common toxic alcohol ingested?
isopropyl alcohol
the hallmark is KETOSIS without acidosis
mainly causes inebriation that peaks in 1-2 hours
what should you do if patient presents with isopropranol ingestion
rule out co-ingestion with ethanol, methanol or ethylene glycol
no role for activated charcoal
discharge after 2 h if asymptomatic
Methanol
highly toxic- toxicity associated with as little as one teaspoon
less inebriating then ethanol
formate causes retinal injury (blurring, central scotoma, blindness) (formic acid= metabolic acidosis= retinal injury)
profound AG acidosis presents late (>24h)
what are the 2 drugs you give for methanol ingestion
fomepizole or ethanol
folic acid or leucovorin
can you rule out an ingestion based on a normal osmolar gap?
No!
increases only in the presence of the parent alcohol so insensitive in late presentations
not sufficiently sensitive to exclude small ingestion
what is the treatment for TCA overdose?
activated charcoal
NaHCO3 for QRS >100 because of significant morbidity and mortality
NOREPINEPHRINE if hypotensive
physostigmine is CONTRAINDICATED
what is the treatment for canabinoid hyperemesis
standard antiemetics INEFFECTIVE
TOPICAL CAPSAICIN has shown consistent benefit
haloperidol has also shown promise
volume assessment and rehydration necessary
CEASE USE
what is seen with synthetic cannabinoid use in children <12
acute psychosis in children <12
more potent then THC but less pleasurable and more toxic
supportive therapy and benzodiazepines if agitated
why do we worry about carbon monoxide
240x higher infitinity to Hb than O2- hypoxemia
initially HEADACHE, dizziness, nausea, confusion, seizure, syncope, coma but don’t correlate with COHb level
worry about DSYARRHYTHMIA AND CARDIAC ARREST (<30%)
what is the treatment for carbon monoxide
treat if COHb level >10% with 100% FiO2
what carboxyhemoglobin level is consistent with toxic inhalation
> 3%
when is hyperbaric oxygen recommended for carbon monoxide poisoning
COHb >25% (>15% in pregnant female or child)
ANY neurologic symptom! (loss of consciousness, seizure, cardiac ischemia, cerebellar deficits)
what is the management of cyanide exposure
antidote is HYDROXYCOBALAMIN KIT
indicated if increased lactate or decreased blood pressure
transiently see reddening of skin and urine (chromaturia)
what lab finding is suggestive of cyanide exposure
LACTIC ACIDOSIS- prevents aerobic metabolism
primarily seen with house fires!
what is seen with calcium channel blocker ingestion?
hypotension and bradycardia- can be profound and refractory!
ex of calcium channel blockers- verapamil, diltiazem, amlodipine, nifedipine
what is the treatment for calcium channel blocker ingestion?
atropine 0.5-1mg IV q2-3minutes
calcium glucagon bolus or infusion
glucagon 5mg IV
norepinephrine is the vasopressor of choice
HIGH DOSE INSULIN EUGLYCEMIC THERAPY HAS POSITIVE INOTROPIC EFFECTS
in children what type of trauma predominates?
BLUNT trauma
in adolescents penetrating trauma increases accounting for 15% of trauma and higher mortality
what does SOAPME stand for
S- suction
O- oxygen
A- airway equipment
- laryngoscope and blade
- ETT above and below
- stylette
- BVM- well fitting mask
- Back up such as LMA, video laryngoscopy
P- pharmaceuticals (ex: ketamine and rocuronium/succinylcholine)
ME- monitoring equipementwhat are the absolute contraindications to succinylcholine (3)
DO NOT give in any circumstance where you may have elevated CK or potassium or risk of malignant hyperthermia
- muscular dystrophies and myopathies
- burns, crush, trauma (48-72h later)
what are the relative contraindications to succinylcholine (3)
- increased ICP
- increased intraocular pressure
- known pseudocholinesterase deficiency (risk for prolonged duration of action)
what are signs of tension pneumothorax and what are the treatment options?
absent breath sounds on one side
tracheal deviation AWAY from affected side
hypotension
TREAT WITH NEEDLE DECOMPRESSION FIRST AND THEN CHEST TUBE
need chest tube prior to transport
What are the landmarks for needle decompression
2nd intercostal space mid clavicular line
ABOVE THE 3RD RIB- neurovascular bundle is below
What is the treatment for massive hemothorax
large bore chest tube (4x ETT)
what is Beck’s triad for cardiac tamponade
muffled heart sounds
distended neck veins
hypotension
what is the treatment of cardiac tamponade
fluid resuscitation
pericardiocentesis
thoracotomy
what are the sights of major hemorrhage
floor and 4 more!
- chest
- pelvis
- abdomen
- long bones (teens)
what are the signs with class 1, 2, 3 and 4 hemorrhage
class 1: <15%, normal vitals apart from tachypnea class 2: 15-30%, tachypnea, tachycardia, BP NORMAL (see narrowing of pulse pressure) class 3: 30-40%, see signs of hypotension * consider fluid replacement with crystalloid and blood class 4:>40%, very comatose
what is massive hemorrhagic protocol (3)
start with o negative blood 15ml/kg
tranexamic acid (TXA) if within 3 hours of traumatic injury
then activate MTP if need more blood
2:1:1 (pRBC’s: FFP: platelets)
what is the key complication associated with massive hemorrhage protocol
hyperkalemia- peaked t waves on EKG
what is AVPU
A- awake/alert
V- responds to verbal stimulation
P- responds to painful stimulation
U- the patient is unresponsive
PU= equivalent to GCS <8
What is GCS eyes
4- spontaneously
3- to voice
2- to pain
1- no eye opening
what is GCS verbal
5- oritented 4- confused 3- inappropriate words 2- incomprehensible sounds 1- none
what is GCS motor
6- obeys commands 5- localizes to pain 4- withdrawal to pain 3- flexion to pain 2- extension to pain 1- none
what is lab belt complex
hyperflexion leads to CHANCE FRACTURE (fracture L1-L2) (compression fracture of lumbar spine)
compression of intra-abdominal organs (duodenal perforation messenteric disruption, pancreatic, bladder injuries)
what are the indications for CT for abdominal trauma
low BP abdominal tenderness femur fracture elevated liver enzymes microscopic hematuria initial hematocrit <30%
what does the cps recommend for trampoline use in homes and playgrounds
CPS recommends AGAINST ALL at home/playground
fractures most common in the upper limb
most occur on mat, some by falling off
most occur when >1 person on trampoline
what does cps recommend for ATV
<16yo should NOT operate any ATV including youth model
>16yo should have license/training course, helmet, eye protection, boots, gloves, long pants; restrict passengers to number ATV designed for
what does cps say about bicycle helmet use in canada
helmets reduce risk of head injury by 70%
legislation increases rate of helmet use
car seats: rear facing? front facing? booster seat? seat belt?
rear facing: <1<10kg
front facing: >1, >10 kg
booster (typically 5-9): at least 18kg (40lb)
seat belt: at least 36kg (80lb) and 145cm tall
what GCS is associated with mild, moderate and severe head injury
mild: GCS 14-15
moderate: 9-13
severe: GCS <8
what are the high risk criteria for CATCH
W- worsening headache
I- irritability on exam
G- GCS <15 at 2h after injury
S- suspected open or depressed skull fracture
what are the medium risk criteria for CATCH
S-sign of basal skull fracture
D- dangerous mechanism of action (MVA, fall >3 feet or 5 stairs, fall off bike with no helmet)
H- hematoma (large boggy hematoma of the scalp)
what are the signs of basal skull fracture (4)
raccoon eyes otorrhea or rhinorrhea of CSF battle sign hemotypmpanum if there are signs of basal skull fracture then no tube by nasal route!!
why are children more prone to intracranial injury
large head: body ratio
thinner cranial bones
less myelinated neural tissue
more likely: diffuse axonal injury with cerebral swelling or subdural in infants
less likely: epidural, parenchymal intracranial hemorrhages
what is primary injury with head trauma? seocndary injury?
primary injury- occurs at the time of injury
we cannot do anything about this
secondary injury- occurs later (hours-days)
process of cerebral edema developing and affecting autoregulation
what is the formula for CPP
CPP- MAP-ICP
target 50-70
if you have increased ICP then need higher MAP to maintain CPP
What is the management of secondary injury for head trauma (7)
ICP peaks 2-3 days later (48-72h) Normal MAPs Normal CO2 Normal temperature Normal glucose Normal saturation no seizures no infections
what are the signs of herniation
hypertension bradycardia irregular respiration 3rd or 6th nerve palsy 3rd- eyes down and out, dilated pupil, ptosis (seen with uncal herniation) 6- lateral rectus palsy
what is the management for herniation?
intubate and hyperventilate (CO2 30-35 with FiO2 100%)
head of bed to 30 degrees
head midline
mannitol (1g/kg) or 3% hypertonic slaine (3-5mL/kg) or both
sedation
if seizing- loading dose of phenytoin or phenobarb
what are the most common c spine injuries in kids
upper c spine injuries C1-C3
c spine injuries are rare in kids (<3% of blunt trauma)
what x rays do you order for cpsine
ap
lateral
odontoid
CT of c-spine NOT routine
what is SCIWORA
spinal cord injury without radiologic abnormality
related to ligamentous injury
need MRI
have an abnormal MRI
what are the 6 steps for return to play concussion guidelines
- No activity * children should remain at this step until symptom-free for several days (optimally 7-10 days) must be fully back to school before return to play
- Light aerobic exercise
- sport specific exercise
- non-contact training drills
- full-contact practice
- return to play
what are common etiologies of convulsive status epilepticus in children (10)
Acute CNS infection (bacterial meningitis, viral meningitis, encephalitis) metabolic derangement antiepileptic drug non compliance antiepileptic drug overdose non-antiepileptic drug overdose prolonged febrile seizure
remote: cerebral dysgenesis perinatal HIE progressive neurodegenerative disorders cerebral migrational disorders
what are the treatment options for status epilepticus
benzos x 2 then phenytoin/fosphenytoin then phenobarb, then midazolam
what is the dose for lorazepam for status epilepticus
0.1 mg/kg IV/IO/buccal/PR max 4 mg
what is the dose for midazolam for status epilepticus
- 5mg/kg buccal (max 10mg)
0. 2mg/kg IN/IM max 10mg (5mg/nostril)
what is the dose for diazepam for status epilepticus
0.5mg/kg PR (max 20mg/dose)
what loading doses/medications can you give for status epilepticus if you cannot get IV access
fosphenytoin IM- 20mg/kg
paraldehyde PR- 400mg/kg
phenytoin IO- scant evidence- 20mg/kg (max 1000mg)
what is the definition of a BRUE
child <1 year old with >1 of the following: cyanosis or pallor absent, decreased or irregular breathing marked change in tone altered level of responsiveness NO other explanation
what is low risk criteria for BRUE
age <60 days
gestational age >32 weeks and postconceptual age >45 weeks
occurrence of only 1 BRUE (no prior BRUE ever and not occurring in clusters)
duration of BRUE <1 minute
no CPR required
no concerning historical features/physical examination findings (ie cardiac, seizures)
what should you do with a low risk patient with a BRUE prior to sending them home? what MAY you consider
educate the caregivers about BRUEs offer resources for CPR training to caregiver
May consider:
EKG
pertussis test
observe in ER
what should you NOT do for BRUE
should NOT
- obtain WBC count, blood culture, CSF, serum sodium, potassium, chloride, BUN, creatinine, calcium, ammonia, blood gases, urine organic acids, plamsa amino acids, chest radiograph, echo, EEG, studies for GER
- initiate home cardio-respiratory monitoring
- prescribe acid suppression therapy for anti-epileptic medications
Need NOT
- obtain viral respiratory test, urinalysis, blood glucose, serum bicarbonate, serum lactic acid, neuroimaging, eval for anemia
- admit to hospital solely for cardiorespiratory monitoring
what is the definition of DKA
blood glucose >11
pH< 7.3 or bicarb <15
ketonemia or ketonuria
what are some clinical manifestations of DKA
tachypnea, deep sighing Kussmaul respiration dehydration nausea vomiting abdominal pain confusion drowsiness progressive obtundation loss of consciousness fuity breath odour polyuria polydipsia weight loss
what is mild hypothermia? moderate? severe?
mild 32-35
moderate 28-32
severe <28
At what potassium level would you terminate CPR
terminate CPR if potassium >12
what is the equation for osmolarity
2 x Na + glucose + urea
2 salts and a sticky bun
what is osmolar gap? what is normal
measured osmolarity- calculated osmolarity
normal: 0-5
what is anion gap?
Na - Cl- HCO3
Normal 8-12
what are some things that cause an anticholinergic toxidrome? (7)
jimsonweed scopolamine atropine glycopyrrolate diphenhydramine dimenhydrinate olanzapine
what drug should be avoided with anticholinergic toxidrome?
phenytoin!!
can cause FATAL ARRHYTHMIAS!
what drugs should you NOT give with TCA
physostigmine- leads to complete heart block
phenytoin- fatal arrhythmia
flumazenil- worsens seizures
hemodialysis is not useful because the drug is highly protein bound with a large Vd
what is the antidote for benzodiazepine?
flumazenil
what are the signs and symptoms of salicylates? what is the one key feature?
nausea/vomiting fever TINNITUS ** diaphoresis tachypnea seizures
what is the key bloodwork feature for ASA overdose
respiratory alkalosis and metabolic acidosis
dehydration
intracellular hypoglycemia
what is Reye syndrome? what do we see on bloodwork?
rapidly progressive encephalopathy, associated with liver toxicity. It usually begins shortly after recovery from a viral infection. About 90% of cases in children are associated with aspirin (salicylate) use
On bloodwork: elevated AST/ALT low glucose elevated ammonia fatty acid infiltration of liver increased ICP
what is a common co-ingestant with ASA
acetaminophen
don’t forget to order an acetaminophen level!
what is the main side effect seen with NAC
anaphylactoid type reaction
stop infusion
treat with benedryl/epi/ventolin as needed
which of the following is NOT expected with an iron overdose ileum hypovolemia an asymptomatic period metabolic acidosis
ILEUS!
List 4 signs of recent marijuana use
Conjunctival injection Dry mouth Increased appetite Euphoric mood Paranoia Perceptual changes Depersonalization Agitation Impaired reaction time Impaired concentration Tachycardia Hypertension Ataxia
Left shoulder pain
small splenic capsular tears may cause abdominal or referred left shoulder pain
Give the 4 fracture findings that are specific in non-accidental trauma:
Posterior rib fracture Femoral metaphyseal corner fractures Scapula spinous process fracture Femur fractures in non-ambulatory children Proximal humeral fractures
corner fractures in the metaphysis are the most classic.
Transverse fractures in long bones are the most prevalent
lap belt fracture
chance fracture
What 3 things would you go Red Man Syndrome
stop infusion
It can be prevented by slowing the vancomycin infusion (1/2 the original rate) rate or by pre-administration of H1-receptor blockers
Treatment for Acute Dystonic Reactions
Benadryl
Iatrogenic cause of methemoglobinemia
Inhaled Nitric Oxide
what are two treatment options for hypertensive emergency?
nicardipine
labetalol
esmolol
sodium nitroprusside
What is the long term complication of methanol toxicity
blindness
what are two treatments that you should start for Kawasaki disease
ASA 3-5mg/kg PO daily
IVIG 2g/kg IV now
