Acute Care CPS

Question 1

3 ways to diagnose anaphylaxis

Answer 1

1. Acute illness with involvement of skin and/or mucosal tissue (hives, pruitis, flushing, swollen tongue/uvula) and ONE OF resp compromise or reduced BP/end organ dysfunction (hypotonia, syncope, incontinence)
2. 2+ of involvement of skin/mucosa, resp compromise, reduced BP/end organ dysfunction, persistent GI symptoms that occurs after exposure to LIKELY allergen
3. Reduced BP after exposure to known allergen

Question 2

What weights should use
1. EpiPen Jr
2. EpiPen

Answer 2

1. 10 to 25 kg
2. > 25 kg

Question 3

How does epi work in anaphylaxis

Answer 3

Alpha effects: increase PVR, reverses vasodilation, decreases angioedema and urticaria
Beta effects: B1 chronotropy and ionotropy on the heart, B2 bronchodilation and reduction of inflammatory mediators

Question 4

What epi formulation is used in anaphylaxis? And what is the dose?

Answer 4

1:1000
Dose is 0.01 mg/kg with max of 0.5 mg

Question 5

Why are H1 and H2 antagonists used in anaphylaxis?

Answer 5

H1 can releive the cutaneous symptoms of anaphylaxis
H2 helps with cutaneous in combination with H1

Question 6

Meds that can be used in anaphylaxis

Answer 6

Epi (first line)
H1 and H2 antihistamines
Corticosteroids
Inhaled medications (salbutamol, inhaled epi)

Question 7

When do we use
1. IV epi
2. Glucagon
in anaphylaxis?

Answer 7

1. Persistent hypotension
2. For patients who regularly take beta blockers

Question 8

When do biphasic reactions occur in anaphylaxis?

Answer 8

1 to 72 hours

Question 9

Which patients are more likely to have biphasic anaphylactic reactions?

Answer 9

Delayed administration of epi
More than one dose of epi required
More severe symptoms on presentation

Question 10

How long do you need to observe someone post anaphylaxis

Answer 10

4 to 6 hours (most biphasic reactions occur in this time)

Question 11

Who should be admitted to hospital for observation post anaphylaxis?

Answer 11

Repeated doses of epi
More severe symptoms
Biphasic reaction
Consider high risk features too: peanut allergy, asthma, beta blocker use

Question 12

Shock dosing for VF

Answer 12

Initial dose is 2-4 J/kg

Question 13

Post ROSC care goals for
1. Oxygenation
2. BP
3. Temp
4. Seizures

Answer 13

1. Oxygen therapy 94-99% (avoid hyperoxemia)
2. Fluids/inotropes to keep SBP > 5th % for age
3. 5 days of normothermia OR 32-34 for 2 days, then 3 days of 36 to 37.5 deg
4. Prophylactic meds not needed routinely, but treat clinical seizures. EEG in the first 7 days

Question 14

Why can you use adenosine in a wide complex tachycarida?

Answer 14

Can distinguish between ventricular or supraventricular rhythms
BUT, avoid in WPW

Question 15

Sizing ETTs for children
1. < 1 year old
2. 1-2 years old
3. > 2 years old

Answer 15

1. 3 mm cuffed
2. 3.5 mm cuffed
3. 3.5+ age/4

Add 0.5 for uncuffed tubes

Question 16

When/how does CCHD screening occur?

Answer 16

Between 24 and 36 hours after birth
Using right hand and either foot

Question 17

Cardiac lesions that are USUALLY CYANOTIC and are detectable using pulse ox screening (7)

Answer 17

Hypoplastic left heart syndrome
Pulmonary atresia with intact ventricular septum
Total anomalous pulmonary venous return
Tetralogy of Fallot
Transposition of the great arteries
Tricuspid atresia
Truncus arteriosus

Question 18

Cardiac lesions that MAY BE CYANOTIC and are detectable using pulse ox screening (5)

Answer 18

Coarctation of the aorta
Double outlet right ventricle
Ebstein’s anomaly
Interrupted aortic arch
Defects with single ventricle physiology

Question 19

What is a
1. Abnormal
2. Borderline
result when using pulse ox screening for CCHD

Answer 19

1. < 90% in right hand or foot
2. 90-94% in right hand and foot OR > 3% difference

3 borderline readings 1 hour apart = fail

Question 20

Triad of lab findings in DKA

Answer 20

Hyperglycemia (> 11)
Serum ketosis (beta-hydroxybutyrate 3 or more) and/or ketonuria (moderate or large)
Acidosis (pH <7.3 or bicarb < 18) with AG > 12

Question 21

Risk factors for DKA (13)

Answer 21

Younger age
Lower SES
Delayed diagnosis in new patients
Previous DKA
Poor glycemic control
Unrecognized insulin pump malfunction
Infection
Certain meds (atypical antipsychotics, steroids, etc)
Ethnicity
Limited access to care
Co-existing mental health or social and family issues
Peripubertal stage
Adolescence

Question 22

DKA severity definitions

Answer 22

Mild: pH 7.2-7.29, bicarb 10- <18
Moderate: 7.1 to 7.19, bicarb 5 to 9
Severe: pH < 7.1, bicarb < 5

Question 23

Risk factors for cerebral edema in DKA (10)

Answer 23

New onset diabetes
Longer duration of symptoms
Age < 5
Severe acidosis
Lab evidence of severe dehydration (elevated urea, hematocrit)
Hypocapnia (CO2 < 21)
Insulin therapy in first hour and/or insulin bolus
Rapid administration of hypotonic fluids
Use of sodium bicarb
Failure of sodium to rise

Question 24

Goal rate to decrease glucose in DKA

Answer 24

No more than 5 an hour to 15-17

Question 25

When do you start insulin for DKA patients?

Answer 25

After the first hour of fluid therapy AND when K is > 3.3

Question 26

When (and how much) K should be added to IV fluids in DKA?

Answer 26

K of 40
When measured K is <5.5 and after recent urine output

Question 27

When do we replace phosphate in DKA

Answer 27

Measured levels < 0.5 OR concerns of cardiac dysfunction, resp failure, GI dysmotility, or metabolic encephalopathy

Question 28

Treatment of cerebral edema from DKA

Answer 28

Minimize patient movement and agitation
HOB to 30 deg
Head in midline position
Isotonic fluids (change if using 0.45%)
Reduce rate of IV to 75% of calculated hourly rate
3% saline or mannitol
PCCU consultation

Question 29

What age range is most common in ITP? And how long does it usually take to resolve?

Answer 29

2-5 years
Resolution within 6 months

Question 30

Recommended treatment options for ITP with
1. No active bleeding
2. Moderate bleeding
3. Severe bleeding

Answer 30

1. Observation first line, oral steroids or IVIG second line
2. Active therapy with single dose IVIG or short course corticosteroids
3. IV steroids and IVIG, may need TXA but discuss with hematology, PLT transfusion only if acute life threatening bleeds or needing immediate surgery

Question 31

When do children with ITP typically relapse?

Answer 31

One third of children will relapse within 2 to 6 weeks

Question 32

Definition of
1. No/mild
2. Moderae
3. Severe
bleeding in ITP

Answer 32

1. None or at most bruising, petechiae, or mild epistaxis, no interference with daily living, may have some mild oozing of petechiae
2. More severe skin manifestations, some mucosal lesions, more troublesome epistaxis or menorrhagia
3. Bleeding episodes (epistaxis, melena, menorrhagia, or ICH) needing hospitalization

Question 33

2 options for length of treatment of steroids in ITP

Answer 33

4 mg/kg/day (BID to QID) for 4 days with no taper
2 mg/kg/day orally for 1-2 weeks, with taper
No evidence to support one over other

Question 34

Which treatment for ITP should be used if rapid increase is required?

Answer 34

IVIG
Increase in platelets within 24 hours, peak response at 2 to 7 days
Steroids have increase within 48 hours

Question 35

2 definitions of convulsive status epilepticus

Answer 35

Continuous GTC activity with loss of consciousness for longer than 30 mins
2 or more discrete seizures without return to baseline mental status

Question 36

Definition of early/impeding status epilepticus

Answer 36

Continuous or intermittent seizures lasting longer than 5 mins without full recovery of consciousness between seizures

Question 37

For children seizing because of toxic ingestions or drug withdrawals (specifically theophylline and TCA ingestions) which second line med should you NOT give? What should you give instead?

Answer 37

NOT phenytoin or fosphenytoin
Phenobarbital is better choice

Question 38

Best seizure med to treat status in children <6 mo, prolonged febrile seizures, and seizures caused by toxic ingestions/drug withdrawals?

Answer 38

Phenobarbital

Question 39

When should you avoid giving valproate?

Answer 39

In children with known or suspected mitochondrial disease
Including children <2 years with unexplained dev delay

Question 40

When is pyridoxine (B6) helpful in status?

Answer 40

Children <18 mo with seizures that may be caused by an undiagnosed metabolic disorder

Question 41

Most common cause of convulsive status epilepticus

Answer 41

Prolonged febrile seizure

Question 42

When should you consider non-convulsive status?

Answer 42

LOC not improving as expected after the convulsions have stopped
Neuromuscular paralysis being used