Acute Care Flashcards
What is pulmonary re-expansion edema?
• Rapid removal of ≥1L of pleural fluid may be associated with the development of systemic hypovolemia and shock
- Large volumes of fluid move from the vascular space to airspaces of the rapidly reinflated lung
- Caused by sudden marked lowering of the intersitital fluid pressure
○ Increased vascular permeability to protein
○ Increased and excessive stretch or tension of the alveolar septal walls during reexpansion of lungs that have been collapsed for several days
What is the clinical course of action in a child who has just swallowed a button battery?
- If in the esophagus, must be removed urgently
- If the child is <5 and the battery is 20 mm in diameter, must be admitted and plan for removal in next 48 hours; if symptomatic, must remove urgently
- If the child is 5 or older, and the button battery is <20 mm in diameter, may monitor as outpatient over the next 48 hours
What are the 3 clinical indications for emergent endoscopy?
- Suspected esophageal obstruction (unable to handle secretions)
- Swallowing large, elongated and sharp object (>6 cm)
- Button battery that has remained in the esophagus
What is the criteria for intubation of the head injury child?
- GCS score ≤10
- Decrease in GCS of >3 independent of the initial GCS score
- Aniscoria >1 mm
- Cervical spine injury compromising ventilation
- Apnea
- Hypercarbia (PCO2 >45)
- Loss of pharyngeal reflex
- Spontaneous hyperventilation causing PCO2 <25
What are the features of Cushing’s Triad?
- Elevated BP
- Hypoventilation
- Decreased HR (Bradycardia)
What interventions should be done to immediately manage a child with a blown pupil after a traumatic head injury?
- Hyperventilation
- Mannitol/hypertonic saline
- Elevate the head of the bed (30 degrees)
- Loosen collar if present
- Sedate +/- paralyze
- Keep head in midline
- Call neurosurgery for ICP probe +/- CSF drainage
Glasgow Coma Scale: Eyes
4- Spontaneous eye opening
3- To voice
2- To pain
1- No eye opening
Glasgow Coma Scale: Verbal response
5- Appropriate 4- Confusion 3- Unintelligible 2- Moaning to pain 1- None
Glasgow Coma Scale: Motor response
6- Spontaneous movement 5-Withdraws to touch 4- Withdraws to pain 3- Decerebrate 2- Decorticate 1- No movement
What ECG changes are to be expected in the case of an amitriptyline overdose (anticholinergic overdose)?
slow intervals, fast HR
• QRS prolongation ○ QRS > 100ms is predictive of seizures, QRS > 160ms is predictive of ventricular tachycardia • PR interval prolongation • dominant R wave in aVR • QT interval prolongation
What clinical signs are seen in anticholinergic overdose?
- Hyperthermia (“Hot as a hare”)
- Tachycardia (“Heart runs alone”) – EARLIEST & MOST RELIABLE finding of anticholinergic toxidrome
- Mydriasis (dilated pupils)
- Absent bowel sounds (“Bowel and bladder lose their tone”)
- (Flushed skin – “red as a beet”)
- (Dry mouth & urinary retention – “Dry as a bone”)
- (Confusion – “Mad as a hatter”)
- (Decreased visual acuity – “Blind as a bat”)
- Delirium/confusion/agitation, sedation, seizures, coma
What are the mainstays of treatment in cases of amitriptyline overdose?
1) Intubation and hyperventilation (aim for pH 7.50-7.55)
2) Sodium bicarbonate (100 mmol or 2mmol/kg) IV every 1-2 minutes until rhythm and perfusion are restored
Second line treatment is lidocaine (1.5mg/kg) IV once pH is greater than 7.5
What are the 3 classifications of burns?
- Superficial
- Partial thickness
- Full thickness
What are the criteria for considering hospitalization in the case of burns?
- > 15% total BSA (10% if <10 yoa, >20% if >10 yoa)
- Significant burns to hands/feet, major joints, face or genitals
- Pregnancy
- The burn is concerning for non-accidental injury or abuse
- Presence of 3rd degree burns
- High tension or lightning burns
- Chemical burns
- Concerns for inhalation injury (regardless of BSA)
- Inadequate home or social environment
- Burns in those with preexisting medical conditions that may complicate acute recovery phase
- Presence of associated injuries (i.e. fractures)
What are the 4 signs of possible inhalation injury?
- carbonaceous sputum
- facial burns
- wheeze, hoarse voice or stridor
- singed nasal hairs
What are 4 mechanisms by which you can receive an inhalation injury?
- Inhalation of toxic vapours
- Direct heat injury
- Asphyxia
- Carbon monoxide poisoning
What additional injuries must you assess for in a burn victim?
- Carbon monoxide poisoning - 100% O2
* Cyanide poisoning - hydroxocobalamin
In what circumstance do you apply the “Rule of 9s” in estimating BSA involvement?
If the child is 14 years and older
Otherwise, must use modified chart
What is the Parkland Formula?
• 4 mL/kg/hr x %BSA
- 1/2 to be replaced in the first 8 hours with remaining 1/2 to be replaced in the following 16 hours
When to consider watchful waiting approach in cases of spontaneous pneumothoraces?
• If “small” - no explicit percentage, based on clinical appearance of patient as stable with appropriate vital signs
Treatment options for spontaneous pneumothorax?
- watchful waiting over 7 days +/- 100% oxygenation
- needle decompression in 2nd intercostal space
- chest tube placement if pt has large pneumothorax, is unstable, or if pneumothorax is associated with underlying disease such as cystic fibrosis or malignancy
- recurrent pneumothoraces can be treated definitively using sclerosing agents such as medical grade talc
What is the lowest possible acceptable systolic blood pressure?
70+ 2(age of patient)
PALS: hypotension 0-28d: < 60 1-12 months: <70 1-10 years: 70 x (2+age) >10 years: <90
What are the risk factors for predicting cerebral edema in cases of DKA?
- Age <5
- New diagnosis of diabetes
- Use of sodium bicarbonate
- Insulin bolus
- Early IV insulin infusion (within the first hour)
- Overhydration with hypotonic fluids
Why is potassium low in DKA?
Excess blood glucose results in osmotic diruesis and activation of renin-angiotensin-aldosterone system that leads to K+ loss
What is the biochemical criteria for establishing a diagnosis of DKA?
- BG >11 mmol/L
- pH <7.3 (Mild = 7.2-7.3 Mod = 7.1-7.2 Severe <7.1
- Bicarbonate <15
- presence of Ketones
Why might urine strip testing for ketones underestimate the severity of DKA?
Majority of ketones produced in DKA is betahydroxybutyrate which is not picked up by urine strip testing
What are the Ottawa Ankle Rules?
Guidelines for determining whether a child should have an x-ray of their ankle
- pain or tenderness in the posterior edge of either the medial or lateral malleolus
- pain or tenderness of either the medial or lateral malleolus
- painful or tender navicular or base of the 5th metatarsal
- failure to bear weight post accident and in ER
What are the steps re: resuscitation in the case of a patient who is unconscious and found without a pulse?
• Call for help, call for AED
• Start CPR x 2 mins
• Assess for shockable rhythm
- if VT/Vfib 2 J/kg and continue CPR x 2 mins; establish IV access if possible, reassess for shockable rhythm; give Epi if 2nd shock unsuccessful or PEA (1:10 000 Epi 0.01 mg/kg IV)
- if PEA, give first dose of Epi before resuming CPR, may give Epi every 3-5 mins; reassess for shockable rhythm
• Treat for reversible causes
What are the Hs and Ts?
- Hypothermia
- Hypovolemia
- Hypo-/Hyperkalemia
- Hypoglycemia
- Hypoxia
- H+ (acidosis)
- Toxins
- Tamponade
- Tension pneumothorax
- Thrombosis (coronary/pulmonary)
What are the doses of resuscitation medications?
- Epinephrine (1:10 000) 0.01 mg/kg Iv
- Epinephrine (1:1000) 0.01 mg/kg by ETT
- Amiodarone 5 mg/kg IV
- Lidocaine 1 mg/kg IV followed by 50 mcg/kg/min infusion