Acute Care Flashcards

Question

Antidote for Nifedipine?

Answer 1

Sodium Bicarb...for QRS >100

Answer 2

Fomepizole

Answer 3

Gasoline, nail polish remover, lighter fluid common

Answer 4

Aspiration is common and pulmonary toxicity accounts for most fatalities Changes seen 2-8 hours post Deterioration in 24-48 hours Perihilar infiltrates Pneumatoceles

Answer 5

Stat CXR and repeat in 4-6 hours post-ingestion... If both look good you can send them home Oxygen +/- bronchodilators Can d/c at 4-6 hours if asymptomatic and normal CXR Supportive Care

Answer 6

Lactic Acidosis | Usually normal Glucose

Answer 7

Glyburide Beta blockers Ethanol Salicylates

Answer 8

Toxic metabolite is NAPQI Toxic dose is 150 mg/kg (7.5 grams in adult) Hepatoxicity reported in children given > 90 mg/ kg/day for more than 1 day

Answer 9

Anion gap metabolic acidosis Acute tubular necrosis Fulminant liver failure

Answer 10

``` Stage I (0-24 hrs): Asymptomatic or nausea/ vomiting Stage II (24-72 hrs): Right upper quadrant pain and onset of hepatocellular injury Stage III (72-96 hrs): Maximal hepatoxicity; Most deaths occur during this phase Stage IV (> 4 days): Recovery ```

Answer 11

Activated charcoal within 1 hour NAC dosing based on Rumack-Matthew nomogram (nomogram only works for up to 8h) Best outcomes if NAC started within 8 hours Follow transaminases, INR/PTT, RFTs, lipase

Answer 12

``` ASA Bismuth salicylate (antidiarrhoeal agent) Methyl salicylate (Rub A535TM) Salicylic acid (wart removal) ```

Answer 13

Hyperpnea / tachypnea....respiratory alkalosis AG metabolic acidosis...pulmonary/cerebral edema Nausea, vomiting, gastrointestinal bleed Tinnitus (early) or hearing loss Hyperglycemia...hypoglycemia Diaphoresis

Answer 14

Charcoal up to 6 hours (bezoar formation) Glucose to all patients with altered mental status regardless of peripheral glucose Treat hypokalemia: because it can impair alkalinization Alkalinize serum to urine pH between 7.5 - 7.6 to “trap” salicylate anions in blood and renal tubule Hemodialysis - indicated for CNS symptoms

Answer 15

Toxic quantity calculated as elemental iron Ferinsol bottle and “gummy bears” not toxic Serum iron within 4-6 hours of ingestion Abdominal x-ray suggestive If no opacities are seen, patient is unlikely to benefit from gastric decontamination

Answer 16

``` Chloral hydrate Opioid packets (latex) Iron and other heavy metals Neuroleptics (early) Sustained-release tablets / Salicylates (early) ```

Answer 17

``` Stage I (30 min-6 hrs): Nausea, vomiting, diarrhea Stage II (6-12 hrs):“Quiescent” phase Stage III (12-24 hrs): Metabolic acidosis: Shock, GI haemorrhage, coagulopathy, respiratory failure Stage IV (2-3 days): ARDS, liver failure Stage V (3-4 wks): GI strictures at gastric outlet ```

Answer 18

GI symptoms Acidosis Multiorgan failure

Answer 19

No role for either charcoal or gastric lavage Fluid resuscitation essential WBI if tablets seen on AXR or if < 6 hours from ingestion (textbook answer only!) ``` IV deferoxamine (DFO) is the antidote of choice and must be given early ``` Dose is 15 mg/kg/hr until urine color clears

Answer 20

The most common toxic alcohol ingested Hallmark is ketosis without acidosis As little as 2 cc can lead to symptoms Mainly causes inebriation that peaks in 1-2 hours

Answer 21

Rule out co-ingestion with ethanol, methanol or ethylene glycol ingestion No role for activated charcoal No role for ADH inhibition with fomepizole or ethanol Discharge after 2 hours if asymptomatic

Answer 22

windshield wash, bingo dabbers

Answer 23

Less inebriating than ethanol Toxicity associated with as little as one teaspoon! Formate causes retinal injury (blurring, central scotoma, blindness) Normal methanol level doesn’t rule out ingestion Profound AG acidosis presents late (> 24 hrs)

Answer 24

antifreeze, paints, brake fluid

Answer 25

``` Colorless, odorless, sweet taste Inebriation with no odor of ethanol Metabolic acidosis:cardiac decompensation Hypocalcemia: prolonged QTc Oxalate crystals appear late ```

Answer 26

Inebriation Odor Osmolal gap or Acidosis

Answer 27

Wash skin if exposed Fomepizole or ethanol based on ingestion history, OG, serum level Hemodialysis if high AG acidosis or end-organ damage Cofactor therapy with folic acid or leucovorin Thiamine 100 mg and pyridoxine 50 mg

Answer 28

Inhibit norepinephrine and serotonin reuptake Block cardiac fast Na channels- wide QRS Block muscarinic receptors- weakly anticholinergic Block histamine receptors- sedation Block alpha receptors- hypotension Block GABA receptors- seizure

Answer 29

Activated charcoal Frequently require intubation because obtunded NaHCO3 for QRS > 100 because of significant morbidity and mortality Norepinephrine infusion if hypotensive Physostigmine contraindicated

Answer 30

Initially headache, dizziness, nausea, confusion, seizure, syncope, coma but don’t correlate with COHb level Dysrhythmia and cardiac arrest in < 30%

Answer 31

Standard pulse oximetry and arterial pO2 normal COHb < 5% (non-smokers) and < 10% (smokers) Carboxyhemoglobin (COHb) level > 3% consistent with toxic inhalation Check cyanide level Follow ECG and cardiac enzymes

Answer 32

Remove from source and rule out smoke inhalation Treat if COHb > 10% if 100% FiO2 Hyperbaric oxygen (best if < 6 hrs of exposure) if: - COHb > 25% (> 15% in pregnant female or child) - Neurologic Symptoms (loss of consciousness, seizure, cardiac ischemia, cerebellar deficits)

Answer 33

House fire CO poisoning Persistent lactic acidosis with CO poisoning ``` Cerebral edema, seizures, coma House fire (wool, plastics), stone fruit pits, cassava root, nitroprusside infusion ```

Answer 34

Antidote is hydroxycobalamin kit Indicated if increased lactate or decreased BP Transiently reddening of skin and urine (chromaturia) Adequate oxygenation necessary often with mechanical ventilation

Answer 35

Dihydropyridines: amlodipine, nifedipine | Non-dihydropyridines: verapamil, diltiazem (high glucose)

Answer 36

Ingestion of at least 5x normal dose can develop severe intoxication Hypotension and bradycardia can be profound and refractory May maintain pristine mental status despite hypotension Precipitous deterioration is common so early aggressive therapy is needed

Answer 37

Atropine (0.02 mg/kg) 0.5-1.0 mg IV Q2-3 minutes Calcium gluconate bolus or infusion Glucagon 5 mg IV but causes severe N/V Norepinephrine is initial vasopressor of choice High dose insulin euglycemic therapy (has positive inotropic effects) Insulin 1 unit/kg bolus —> 1-10 units/kg/hr + K Must add 2.5 mL/kg of IV D10W

Answer 38

Vomiting, drooling, respiratory distress Airway compromise and esophageal perforation Skin burns

Answer 39

supportive | ave them drink a glass of water

Answer 40

Onset of vomiting, diaphoresis, confusion within 2 hrs Seizures, initial ↑BP, ↑RR, ↑HR ⇒ ↓BP, ↓RR, ↓HR

Answer 41

Males > Females Children < 5 years at greatest risk Usually during the summer months Associated with hypothermia and trauma

Answer 42

Most effective prevention strategy is a four-sided self-closing fence with a self-locking gate 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 Swimming programs for children < 4 years do not decrease rates of drowning

Answer 43

Should be worn by all infants at least 9 kg Babies who cannot sit unsupported are too young to wear PFDs Water wings, inflatable undies, pool noodles are not safety devices

Answer 44

Leaving children unattended Alcohol or drug abuse (50% of adult drownings) Limited swimming ability Underlying medical conditions(?): - Seizure disorder, toxin, prolonged QT, syncope

Answer 45

Immediate bystander CPR is most important factor influencing survival What are other good prognostic indicators? - Return of spontaneous circulation in < 10 min - Submersion < 5 min - Pupils equal and reactive at scene - Normal sinus rhythm at scene

Answer 46

What are poor prognostic indicators? - Delayed CPR - Return of spontaneous circulation > 25 min - Submersion > 10 min

Answer 47

``` ARDS Pulmonary edema Pneumonia Cerebral edema leading to increased ICP Trauma Hypothermia ```

Answer 48

Defined as core temp < 35 C

Answer 49

Shivering stops at core temp < 32 C Accompanied by hypoglycemia, hypocalcemia, hypokalemia, metabolic acidosis Associated with pancreatitis

Answer 50

- Normal ECG, ↑ HR, ↑ BP, loss of shivering

Answer 51

- ↓ HR, ↓ BP, flipped T, atrial fibrillation, sluggish, dilated pupils

Answer 52

- absent pulse and BP, VF, coma, fixed dilated pupils

Answer 53

Marked sinus bradycardia First degree AV block Osborn or J waves Associated with prolonged QT and bradycardia Seen in core T < 32 C

Answer 54

Avoid CPR in T < 28 and good pulse If pulseless → CPR If VF → defibrillation x 3 but no more until T > 30 Drugs rarely effective until T > 30 Can trigger dysrhythmia if T < 30 just by bumping bed!

Answer 55

Passive rewarming: Remove wet clothes Dry

Answer 56

Passive AND active external warming of truncal areas only electric blanket use Bair Hugger overhead warmer hot water bottles heating pads

Answer 57

Active external and internal rewarming Warm humidified oxygen at 42-46 C warming tubes Warmed IV or intraosseous (IO) fluid (without K+) at 43 C Peritoneal lavage, ECMO, esophageal

Answer 58

T > 30 Continue CPR IV meds as needed Defibrillation as needed

Answer 59

T < 30 Continue CPR but no IV meds Limit defibrillation to 3 shocks

Answer 60

En route avoid warming if significant time to ER In ER, 42 C water bath, do not rub, keep rewarmed areas open, dry, and sterile

Answer 61

Excessive peripheral vasodilation then Inability to deliver sufficient blood volume then Muscle fatigue Profuse sweating Excessive water and/or sodium losses

Answer 62

Exercise-associated muscle cramps Intense painful muscle contractions Due to excess water and electrolyte losses Highly conditioned athlete post-exercise Painful muscles Labs ↓ Na,↓ Cl people who don’t hydrate properly with water and salt

Answer 63

``` Core T > 40 with CNS symptoms Headache Disorientation Dizziness Weakness Gait disturbance ``` **think tourists at a resort who don't drink enough water Heat Wave Infants left in vehicles T > 40 Hot skin, CV collapse, rhabdo, ARF, severe CNS dysfunction Normal/↑ NaCl ↑ CK ↓ Ca

Answer 64

Unacclimatized in hot climate with inadequate water intake (tourists) T < 40 Lethargy, N/V, headache, ↓ BP, ↑ HR ↑ Na,↑ Cl

Answer 65

Unacclimatized in hot climate with inadequate salt intake (CF) T > 38 Above with severe muscle cramps ↓ Na

Answer 66

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

Answer 67

``` Hyponatremia Seizure Rhabdomyolysis DIC Multi-system organ failure ```

Answer 68

Superficial Epidermis only Redness, pain, no blisters Heals in 3-5 days

Answer 69

Epidermis + 1/2 Dermis Red/pink, pain, moist, blisters Heals in 2 weeks

Answer 70

Epidermis + > 1/2 Dermis Pale, dry, less tender, speckled appearance Grafting often needed

Answer 71

Subcutaneous tissue Pale, charred, leathery appearance, non-tender Most require grafting

Answer 72

``` Cover with sterile bandages Early cooling ( < 30 min) prevents further injury Tetanus (dirty wound) Analgesia Remove smoldering clothing Measure carboxy-hemoglobin ```

Answer 73

Need to know this! - Carbonaceous sputum - Singed nasal hairs - Soot in airway - Hoarseness

Answer 74

Age > 5: Parkland formula = 4 cc/kg/BSA over 24 | hours (1st half in 8 hours, 2nd half in 16 hours)

Answer 75

Age > 9: Rule of 9’s | Age < 9: Child’s palm = 1% BSA (not superficial)

Answer 76

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

Answer 77

``` 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 ``` * Admission criteria (Per Nelson’s) * > 15% BSA * Full thickness (“3rd degree”) * Electrical burns caused by high-tension wires/lightening * Chemical burns * Inhalation injury * Social concerns * Suspected abuse * Burns to hands/feet/face/perineum/genitals/major joints • Complex underlying medical conditions * Underlying fractures * Pregnancy

Answer 78

Muscle damage → Compartment syndrome, rhabdomyolysis → ARF CNS injury common VF/arrest common Must monitor with urinalysis and ongoing ECG CLUES: Entrance/exit wounds Rhabdomyolysis VF/arrest

Answer 79

``` Cerebral edema (delayed), ICH, seizure Rhabdomyolysis Asystole and respiratory failure Monitor for delayed cerebral edema and arrhythmia ```

Answer 80

respiratory failure

Answer 81

Asynchronous 100:10 | Breaths and compressions happening independently of each other

Answer 82

Compressions: Lower sternum at nipple line On a firm surface 1/3 anterior diameter of the chest (4cm infant; 5cm child) 100-120 times per minute, allowing for full chest recoil

Answer 83

(must have hypotension, altered mental status, signs of shock) Epinepherine 0.01mg/kg of the 0.1mg/mL solution Repeat every 3-5 minutes Pacing if needed

Answer 84

NO SHOCKING CPR Epinephrine 0.01mg/kg of the 0.1mg/mL solution Give every 3-5 minutes

Answer 85

Vagal maneuvers Adenosine 0.1mg/kg (max 6mg) Second dose 0.2mg/kg (max 12mg) Need expert consultation for amiodarone and procainamide

Answer 86

Synchronized cardio version 0.5-1 J/kg If ineffective then do 2J/kg Can used adenosine 0.1mg/kg (max 6mg) Second dose 0.2mg/kg (max 12mg) ADENOSINE SHOULD NOT DELAY CARDIOVERSION

Answer 87

Adenosine 0.1mg/kg (max 6mg) Second dose 0.2mg/kg (max 12mg) Need expert consultation for amiodarone and procainamide Synchronized cardio version 0.5-1 J/kg If ineffective then do 2J/kg

Answer 88

``` shock shock epi (0.01 mg/kg of the 0.1mg/mL solution shock Amiodarone/lidocaine repeat ``` Shock 2, 4, 6, 8, 10J/kg

Answer 89

``` Hypovolemia Hypoxia Hydrogen Ions Hypoglycemia Hypothermia Hypo/Hyperkalemia ``` ``` Tension Pneumo Tamponade (cardiac) Toxins Thrombosis, pulmonary Thrombosis, coronary ```

Answer 90

noooooo compression only CPR isn’t appropriate for children etiology in kids is mostly resp failure! so doesn’t make sense to just do compressions

Answer 91

Use pediatric dose attenuator up to 25 kg or eight years of age

Answer 92

Avoid adenosine in patients with known WPW

Answer 93

Infants <30 days | If >30 days shouldn't use it automatically

Answer 94

If comatose after out of hospital cardiac arrest, its reasonable to maintain 5d of normothermia (36.5-37.5C)

Answer 95

With ROSC target O2 sat >94 and <100%, maintain normotension

Answer 96

Reduction of LV afterload Need to decrease demand or regular physiology Patient can't ventilate or oxygenate Impending resp failure Impending failure of: lungs, airway, MSK, CNS, PNS

Answer 97

``` S = suction O = oxygen A = airway equipment • Laryngoscopeandblade • ETT above and below • Stylette • BVM–well fitting mask • Back-up option ``` P = Pharmaceuticals • Atropine +/- • Ketamine/fentanyl/midazolam/propofol • Rocuronium/succinylcholine ME = monitoring equipment

Answer 98

• <1 y: 3.0, 1-2: 3.5 ETT • 2 years and older 4 + (age/4) uncuffed 3.5 (age/4) microcuffed

Answer 99

Look for bilateral chest movement and listen for equal breath sounds • Listen for gastric inflation over stomach • Check exhaled carbon dioxide with CO2 detector or capnography • check oxygen saturation with a pulse oximeter • In hospital: perform a chest x-ray to verify that the tube is in the mid trachea

Answer 100

Healthy lung: age appropriate respiratory rate, tidal volumes (VT) of 7- 10 ml/kg healthy lung

Answer 101

PIP 20 cmH2O, PEEP 5 cmH2O, VR 25 FiO2 0.5

Answer 102

Patient’s respiratory pattern does not match what is set on the ventilator • Affects VT delivery • Excessive intrathoracic pressures can lead to barotrauma, discomfort and affect cardiac output

Answer 103

increase patient sedation

Answer 104

Increase PIP and ventilator rates if you want to increase CO 2 clearance

Answer 105

Increase PEEP and FiO2 if you need to improve oxygenation

Answer 106

Hypovolemic shock is characterized primarily by fluid loss and decreased preload. Tachycardia and an increase in systemic vascular resistance are the initial compensatory responses to maintain cardiac output and systemic blood pressure.”

Answer 107

Blood pressure! Compensated: normal NP Uncompensated: Hypotension

Answer 108

``` Diarrheal illness Hemorrhage Burns Vomiting Volume depletion ``` Decreased PRELOAD!

Answer 109

``` Tachycardia Orthostatic hypotension dry mucous membranes decreased urine output, perfusion normal-> impaired ```

Answer 110

CHD Myocarditis Arrhythmia Left ventricular failure, impaired myocardial function Decreased contractility

Answer 111

Tachycardia, cool extremities, delayed capillary refill time, poor perfusion, decreased urine output

Answer 112

Pericardial Tamponade Tension pneumothorax Pulmonary embolism Congenital heart disease lesions that are dependent on PDA for systemic blood flow and duct closes Reduced SV due to pathology that prevents adequate LV preload “mechanical barrier”

Answer 113

``` Tachycardia cool extremities delayed capillary refill time poor perfusion decreased urine output ``` SIGNS OF THE UNDERLYING ETIOLOGY

Answer 114

Anaphylaxis Neurogenic shock Pharmacologic Inadequate vasomotor tone, capillary leak, reduced intravascular volume

Answer 115

``` Tachycardia or bradycardia peripheral vasodilation flash capillary refill bounding pulses poor urine output ```

Answer 116

``` <30% blood loss Increased HR thready peripheral pulse normal SBP normal Pulse pressure Anxiety, irritability, confusion Cool, mottled, prolongs cap refill low to very low U/O ```

Answer 117

``` 30-45% blood loss Increased HR thready central pulse Peripheral pulses absent normal SBP lethargic, poor response to pain cyanotic, markedly prolongs cap refill very low U/O ```

Answer 118

``` >45% blood loss Increased HR followed by decreased HR weak or absent central pulse Peripheral pulses absent Hypotension, DBP may be undetectable Coma pale and cold no U/O ```

Answer 119

bolus NS 20ml/kg, correct hypoglycemia/hypocalcemia start antibiotics

Answer 120

Eye Opening Response • Spontaneous--open with blinking at baseline 4 points • To verbal stimuli, command, speech 3 points • To pain only (not applied to face) 2 points • No response 1 point ``` Verbal Response • Oriented 5 points • Confused conversation, but able to answer questions 4 points • Inappropriate words 3 points • Incomprehensible speech 2 points • No response 1 point ``` Motor Response • Obeys commands for movement 6 points • Purposeful movement to painful stimulus 5 points • Withdraws in response to pain 4 points • Flexion in response to pain (decorticate posturing) 3 points • Extension response in response to pain (decerebrate posturing) 2 points • No response 1 point

Answer 121

Severity: Mild GCS 14-15 Moderate GCS 9-13 Severe GCS <9

Answer 122

- Increased CSF pH/decreased CO2: vasoconstriction cerebral arterioles and can lead to inadequate perfusion and ischemia o Hyponatremia: worsen cerebral edema o Hypotension and hypertension: affect cerebral blood flow is cerebral autoregulation impaired by the injury o Hyperthermia increases cerebral metabolic demand o Hypoglycemia leads to neuronal apoptosis, seizures increase cerebral metabolic demand and can result in loss of airway control and hypoxemia

Answer 123

CT of the head is required for children with a minor head injury* plus any one of the following findings: High risk (need for neurological intervention) - Glasgow Coma Scale score <15 at 2 h after injury - Suspected open or depressed skull fracture - History of worsening headache - Irritability on examination Medium risk (brain injury on CT scan) - Any sign of basal skull fracture (eg, hemotympanum, ‘raccoon’ eyes, otorrhea or rhinorrhea of cerebrospinal fluid, Battle’s sign) - Large, boggy hematoma of the scalp - Dangerous mechanism of injury (eg, motor vehicle collision, fall from a height ≥3 feet (≥91 cm) or down five stairs, falling from a bicycle without a helmet) *Minor head injury is defined as an injury sustained within the past 24 h associated with witnessed loss of consciousness, definite amnesia, witnessed disorientation, persistent vomiting (more than one episode) or persistent irritability (in a child younger than two years of age) in a patient with a Glasgow Coma Scale score of 13 to 15.

Answer 124

• Mild: discharge with WRITTEN anticipatory guidance, | Observe in hospital if: headache, repeated vomiting or GCS <15 after period of observation

Answer 125

•Moderate: CT head, consult neurosurgery, supportive care and likely admission to ICU

Answer 126

• Severe: intubation and ventilation, supportive care (prevent secondary injury): normothermia, normal blood pressure, normal sodium, normal CO2, normal glucose, head of bed 30 degrees, head midline, ensure c-spine collar not obstructive cerebral venous drainage, adequate analgesia/sedation, consider seizure prophylaxis (efficacy unproven)

Answer 127

•Suspected conning (dilated pupils, hypertension, bradycardia, extensor posturing, abnormal respirations: hyperventilate (CO2 25-35), FiO2 1, hyperosmolar therapy

Answer 128

• Conning: hypertension, bradycardia, irregular respirations, signs of 6th or 3rd CN palsy

Answer 129

- Established etiology capable of causing neurologic death - Absence of reversible conditions that can mimic brain death AND absent confounders: unresuscitated shock, hypothermia (<34 °C), severe metabolic disorders that can cause reversible coma: glucose, electrolytes, IEM, liver and renal dysfunction, peripheral nerve or neuromuscular dysfunction, drug intoxications - Deep, unresponsive coma ABSENCE of motor responses EXCLUDING spinal reflexes and ABSENT brain stem reflexes: cough, gag, corneal, pupils, vestibulo-occular - (Apnea Test) Patient does not breathe, PaCO2 at least 60mmHg and at least 20 mmHg above pre apnea test level and pH 7.28 following apnea test

Answer 130

After first determination of brain death

Answer 131

Two fully licensed physicians with skills in the management of severe brain injury and neurologic determination of death

Answer 132

24h after a hypoxic ischemic brain injury, term neonates >48h old, cerebral perfusion study

Answer 133

Impossible to complete brain death testing OR unresolved confounding factors in a patient with etiology capable of causing brain death in a deep, unresponsive coma Eg cerebral radiocontrast angiography, radionuclide angiography

Answer 134

- must be> 36 weeks GA, - assessment must also include occulocephalic and suck reflexes - must be at least 36 °C - must be at least 48h old - assessed by 2 physicians at least 24h apart

Answer 135

- Assess the occulocephalic reflex instead of vestibulo- occular reflex - two full separate exams by different physicians

Answer 136

MVA then submersion injury

Answer 137

Observe in hospital minimum 6-8h for signs of pulmonary edema, many with mild respiratory symptoms at first return to normal by 4-6h

Answer 138

No indication for prophylactic antibiotics

Answer 139

Warm by 1-2°C per hour

Answer 140

Neurologic examination during the first 24-72h is the best prognostication of long term outcome

Answer 141

• Swimming programs <4 years of age isn’t an effective prevention strategy

Answer 142

* Residential pools fenced on all 4 sides with self closing, self latching gate * Constant arms-length adult supervision * Government approved personal flotation devices should be used for children who cannot swim+ constant supervision * Parents and pool owners need to know CPR and have an emergency action plan

Answer 143

CHEST TUBE Physiologic considerations: gasses expand 10-15%, sounds of the transport may make physical exam more challenging by obscuring assessment, motion and vibration can lead to increased metabolic rate, fatigue, shortness of breath

Answer 144

Ground/ambulance: more spacious, can handle more weight than a helicopter, able to make stops if patient deteriorates and procedures are needed, slowest

Answer 145

• Airplane gas expansion > 30%, decrease in arterial oxygen saturation (93% vs 100% at sea level) So what?: blood loss or shock should receive supplementary oxygen, NG for ileus and chest tube for pneumothorax MUST be inserted first, Change ETT cuff from air to saline because of changes on the plane!

Answer 146

• Helicopter: LOUD, faster than ground, lower altitude than airplane and only works in certain weather conditions

Answer 147

``` 3 x salbutamol with ipratropium bromide • Steroids (Dex/Methylpred/hydrocortisone) • Magnesium sulfate • IV salbutamol • Don’t forget to phone a friend... ``` ``` WITH PICU: • Aminophylline • Heliox • Mechanical support • Ketamine • Epinephrine • Above should only be done with ICU support!!!! ```

Answer 148

Ideally NEVER Only two indications • Decreased LOC not maintaining ventilation drive • Refractory, severe hypoxemia • Never based on a gas!!!!!!

Answer 149

RSV is the major culprit * RSV season usually 4-5 months long, starts Nov-Jan * 10-30% have multiple viruses

Answer 150

- Infants born prematurely (<35 weeks’ gestation) - <3 months of age at presentation - Hemodynamically significant cardiopulmonary disease - - Immunodeficiency

Answer 151

- Signs of severe respiratory distress (eg, indrawing, grunting, RR >70/min) - Supplemental O2 required to keep saturations >90% - Dehydration or history of poor fluid intake - Cyanosis or history of apnea - Infant at high risk for severe disease (Table 4) - Family unable to cope

Answer 152

Recommended: - Oxygen Hydration - Epinephrine nebulization Evidence Equivocal: - Epinephrine nebulization - Nasal suctioning - 3% hypertonic saline nebulization - Combined epinephrine and dexamethasone

Answer 153

Recommended for: • Hemodynamically significant CHD or CLD <12m at start of season • Preterm before GA30 at start of season • GA <36 now <6months in remote communities • Immunodeficiencies, T21, C.F., upper airway concerns, chronic pulm disease other than CLD should not be routinely offered • Considerforseveredisease/homeO2 • Not recommended to continue it break through disease

Answer 154

- Obstructive sleep apnea - Bronchiolitis - Asthma - Pneumonia/Pneumonitis - Heart failure

Answer 155

parainfluenza

Answer 156

* Mild croup: consider dexamethasone * Mod-severe: humidified O2, NPO, neb epi, observe for at least 2 hrs after neb epi to ensure continued improvement, administer dex, consider use of heliox for severe * Impending failure: high conc O2 (NRB mask), assist ventilation, administer IV/IM dex, ETT (smaller tube – half size smaller than predicted for age), prepare for surgical airway if needed

Answer 157

* Refractory volume overload * Persistent hyperkalemia * Severe, refractory metabolic acidosis * Uremia * Calcium/phosphorus imbalance * Neurologic symptoms * Certain toxins

Answer 158

Management • Remove iatrogenic causes Stabilize • Calcium Shift • Sugar/insulin • Bicarb • Ventolin Remove • Furosemide • Dialysis Confirm • Repeat tests • ECG

Answer 159

Peaked T waves long QRS Long PR then becomes a sinusoidal wave

Answer 160

* Diagnosis * Euveolmic/hypervolemic * Hyponatremia, low serum osmoles * High urine osmoles * High urine sodium

Answer 161

• Total body water x (Serum sodium – desired sodium)/desired sodium • = (0.6L/kg x Wt(kg)) x (Serum Sodium – desired sodium)/desired sodium • Ex = (0.6 x 20) (160-140)/140) • = 1.7 L

Answer 162

Defined as: INR>1.5, uncorrectable by Vit K, with encephalopathy or INR > 2 uncorrectable by Vit K * Evidence of acute liver injury * No evidence of chronic liver disease

Answer 163

* Upper airway obstruction * Mediastinal mass * Known difficult airway

Answer 164

patients with PHTN need alkalosis for pulmonary vasodilatation

Answer 165

``` Causes of Hypoxemia: 1. Low FIO2 2. Hypoventilation 3. V/Q mismatch 4. Shunt (intracardiac or intrapulmonary) = most common...good blood flow, but alveoli obstructed, etc. 5. Impaired alveolar-capillary diffusion emphysema, asthma, etc. ```

Answer 166

Medical - Previous attack with rapid/severe deterioration - Previous PICU admission - Previous mechanical ventilation - Syncope/seizure during attack Psychosocial - Denial, non-compliance - Depression or other psychiatric disorder - Dysfunctional family - Inner city resident

Answer 167

``` SEVERE ASTHMA WARNING SIGNS: • Cyanosis, PaO2 <70 in 40% oxygen • Absent breath sounds • Marked expiratory wheeze • Maximal accessory muscle use • Altered level of consciousness • Inability to speak • Marked pulsus paradoxus ```

Answer 168

AIRWAY AND BREATHING: – POSITION patient on side +/- chin lift/jaw thrust – PATENCY: Suction secretions – APPLY 100% OXYGEN – Assist ventilation if signs of respiratory depression or if saturations low despite 100% oxygen by face mask CIRCULATION: – Cardiorespiratory monitor – IV access CHECK Bedside blood glucose level – Give IV dextrose 10% 5ml/kg if <2.6mmol/L - CHECK sodium, calcium GIVE ANTICONVULSANTS (ALL MUST BE IN WITHIN 45 min) – IV Lorazepam 0.1mg/kg (max4mg) OR IV Midazolam 0.1mg/kg – Give benzodiazepines within the first 5 minutes – IV fosphenytoin 20mg/kg over 20 minutes – IV phenobarbital 20mg/kg over 20minutes – If no resolution, IV midazalom infusion – Consult neuro

Answer 169

Reducing the space occupied by any of the four components: - Reduce brain size (hyperosmolar therapy) - Reduce CSF by drainage - Reduce blood by vasoconstriction *only when showing signs of brainstem compression - Surgical removal of hematoma - Open the skull to allow expansion of the structures (?)

Answer 170

Increased BP, Decreased HR, Abnormal RR Altered LOC Pupillary changes

Answer 171

Clinical • New onset • Age <5 Lab • Initial pH < 7.1 • High Urea • Initial corrected Na > 145 Treatment • Failure of Na to rise as glucose decreases • Bicarbonate use

Answer 172

Newborns: < 30 days and ≥ 36 wks gestation – 2 full exams with apnea tests with ≥ 24h interval between exam – Must be ≥ 48h after birth

Answer 173

Infants: 30 days ≥ and ≤ 1 year | – Full, separate exams must be performed, but no fixed interval

Answer 174

Children ≥ 1 year old to adults – Still need two physicians, but can perform exam, including apnea testing concurrently – In the setting of hypoxic-encholapathic injury, exam must be delayed ≥ 24h post injury. - If examined separately, apnea test must be repeated

Answer 175

A POSITIVE Apnea Test is present when: PaCO2 ≥ 60mmHg AND is 20mmHg greater than pre-apnea value AND pH ≤ 7.28 AND Patient remained apneic (respiratory reflex is absent.)