Acute Care Flashcards
Status epilepticus
- definition
> 30 min of sz or w/o return to b/l btwn
Length of seizure to cause brain cell loss?
> 30 min
Status epilepticus tx
1st line - Benzo (2 doses)
Pre hospital: buccal or IN midaz
Hospital: IV lorazepam
Get Pheno/Pheny ready while giving Benzo because takes time
2nd line: Pheny/fosphenytoin 20mg/kg
(less likely than phenobarb to cause resp depression and alter LOC)
Then phenobarbital 20mg/kg loading
Side effects
Phenytoin
Phenobarbital
Phenytoin S/E - purple glove syndrome (extravasion - severe subcut irritation), cardiac arrhythmias, bradycardia, hypotension
Fosphenytoin - S/e: cardiac arrhythmias, bradycardia, hypotension
Phenobarbitals - S/E - sedation, resp depression, hypotension
Most common cause of status epileptics
Febrile sz
Investigations for status epilepticus
B/W - lytes, gluc, CBC + diff, Cx, gas
Anticonvulsant levels if on therapy
Serum Ca, BUN, Mg, LFTs, lactate, ammonia
Consider LP (defer until stable, no signs incr ICP)
BCx then Abx if suspicious for sepsis
CT head if hx trauma, evidence increased ICP, focal neuro signs, unexplained LOC, suspicion of cerebral herniation
**Normal CT does not exclude significantly increased ICP
Consider activated charcoal if intoxication
EEG
Admission criteria for Asthma exacerbation
- An ongoing need for supplemental oxygen
- Persistently increased work of breathing
- ß2-agonists are needed more often than q4 h after 4 to 8 h of conventional treatment
- The patient deteriorates while on systemic steroids
Asthma exacerbation - discharge from ER plan
3-5 day course of oral steroids
Continue short-acting ß2-agonists until exacerbations resolve and then PRN
Written asthma action plan
Review techniques for MDI
Appropriate F/U (primary care physician or a local asthma clinic)
What are the 4 components of a rapid response system
Four main components: an event detection and response-triggering arm a planned response arm a quality monitoring arm an administrative support arm
CPR - if advanced airway what compression rate and breathing rate
continuous compressions >/=100-120 comp/min w/o pause for rescue breaths
breaths (8-10 vent/min)
Key aspects of compressions
>/= ⅓ AP diameter of chest (4cm infants, 5cm children) Allow for full recoil Minimize interruptions Avoiding excessive ventilation Rotate compressor q2min
How long can a pulse check be
max 10 sec
Meds for shock refractory vent fib or pulseless vent tachycardia
Amiodarone or lidocaine
What is considered Wide Complex?
> 0.09s
Doses of epi pen
EpiPen Jr 0.15mg - 15-25kg; EpiPen 0.3mg - >25kg
Dx of anaphylaxis
Skin findings + (Resp OR Cardiac)
Likely allergen + 2 of (Skin/Resp/Cardiac/GI)
Known allergen + low BP
Biphasic reaction
- timing
- RF
most likely 4-6 hours
within 72 hours
delayed administration of epinephrine
more than one dose of epinephrine
initially presented with more severe symptoms
anaphylaxis when to observe overnight
Biphasic reaction
Use of Bblockers
Repeated Epi
More severe presenting sx (hypotension, severe resp distress)
higher risk of severe brochiolitis
prematurity < 35wga
<3mo at presentation
hemodynamically significant cardiopulmonary dz
immunodeficiency
Proven tx of bronchiolitis
O2 to keep sats > 90%
hydration
Mgmt of croup
Mild: dex
Mod-Sev: dex + epi neb
how does high flow work
- Delivers high oxygen concentration (not diluted by r/a)
- Provides some degree of positive intrathoracic pressure
- Washes out anatomic dead space
- Humidity/heating allows higher flow rates to be tolerated
- Both upper and lower airway resistance are reduced significantly
What clinical conditions can respond to HHHFNC therapy
OSA Bronchiolitis Asthma Pneumonia Heart failure
Why are Children are more likely to develop intracranial lesion due to head trauma
Larger head to body size ratio
Thinner cranial bone and less myelinated neural tissue
What are most frequent causes of Intracranial injury
- falls from a height above 3 feet (91 cm or twice the length/height of the individual),
- involvement in an MVA or
- impact from a high velocity projectile
When to do a skull xray in head trauma
Large boggy hematoma
Suspicious for child abuse
When to do CT for head trauma
Any moderate or severe head trauma
Absolute indications
- Focal neuro deficit on exam
- Clinically suspected open or depressed skull # or a widened or diastatic skull # observed on xray
Increased risk of seizure post head trauma
Younger age Severe head trauma Cerebral edema Subdural hematoma Open/depressed skull #
Poor prognostic indicators for head trauma
Poor prognosis indicators: Severity at initial presentation Presence of raised ICP Other body site injury/severeity Pre injury ADHD SES
What is the concentration of Na in NS?
154 mmol/L
Treatment for ITP
No active bleeding: observation. Second line = oral corticosteroids or IVIG
Moderate bleeding: IVIG or corticosteroids. Second line = IV anti-D immune globulin
Severe bleeding: in hospital with IV steroids and IVIG. Adjunct = Tranexamic acid
Bugs in gastroenteritis
Rotavirus & Norovirus
Gastroenteritis - kids are at risk for
Dehydration, Electrolyte abnormalities, Need for NG/IV rehydration + admission
dose ondansetron
0.15mg/kg
8-15kg: 2mg
15-30kg: 4mg
>30kg: 6-8mg
Rapid response system:
- Goal?
- Issues leading to adverse events?
- 4 main components?
- Key factors for effective team?
Goal: ID critically ill pts and mobilize a clinical response to prevent or reverse pt deterioration
Issues leading to AE:
- Failure to plan
- Failure to communicate
- Failure to recognize a deteriorating patient
4 components:
- Event detection and response trigger
- Planned response
- Quality monitoring
- Administrative support
Key factors for team:
- Leadership/Team leader
- Situational awareness (prevents fixation errors)
- Resource allocation – assigning tasks
- Communication – “closed loop”
Mechanism of Heated Humidified High Flow NC?
- Delivers high oxygen concentration (not diluted by r/a)
- Provides some degree of positive intrathoracic pressure
- Washes out anatomic dead space
- Humidity/heating allows higher flow rates to be tolerated
- Both upper and lower airway resistance are reduced significantly
What settings to start Heated Humidified High Flow NC?
1-2 L/Kg/min at FiO2 50%
Conditions potentially responsive to Heated Humidified High Flow NC?
- OSA
- Bronchiolitis
- Asthma
- Pneumonia
- Heart failure
3 modes of intervention for mgmt of pain/distress for procedure
- physical
- psychological
- pharmacotherapy
