Acute Care CPS Flashcards
3 ways to diagnose anaphylaxis
- 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+ of involvement of skin/mucosa, resp compromise, reduced BP/end organ dysfunction, persistent GI symptoms that occurs after exposure to LIKELY allergen
- Reduced BP after exposure to known allergen
What weights should use
1. EpiPen Jr
2. EpiPen
- 10 to 25 kg
- > 25 kg
How does epi work in anaphylaxis
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
What epi formulation is used in anaphylaxis? And what is the dose?
1:1000
Dose is 0.01 mg/kg with max of 0.5 mg
Why are H1 and H2 antagonists used in anaphylaxis?
H1 can releive the cutaneous symptoms of anaphylaxis
H2 helps with cutaneous in combination with H1
Meds that can be used in anaphylaxis
Epi (first line)
H1 and H2 antihistamines
Corticosteroids
Inhaled medications (salbutamol, inhaled epi)
When do we use
1. IV epi
2. Glucagon
in anaphylaxis?
- Persistent hypotension
- For patients who regularly take beta blockers
When do biphasic reactions occur in anaphylaxis?
1 to 72 hours
Which patients are more likely to have biphasic anaphylactic reactions?
Delayed administration of epi
More than one dose of epi required
More severe symptoms on presentation
How long do you need to observe someone post anaphylaxis
4 to 6 hours (most biphasic reactions occur in this time)
Who should be admitted to hospital for observation post anaphylaxis?
Repeated doses of epi
More severe symptoms
Biphasic reaction
Consider high risk features too: peanut allergy, asthma, beta blocker use
Shock dosing for VF
Initial dose is 2-4 J/kg
Post ROSC care goals for
1. Oxygenation
2. BP
3. Temp
4. Seizures
- Oxygen therapy 94-99% (avoid hyperoxemia)
- Fluids/inotropes to keep SBP > 5th % for age
- 5 days of normothermia OR 32-34 for 2 days, then 3 days of 36 to 37.5 deg
- Prophylactic meds not needed routinely, but treat clinical seizures. EEG in the first 7 days
Why can you use adenosine in a wide complex tachycarida?
Can distinguish between ventricular or supraventricular rhythms
BUT, avoid in WPW
Sizing ETTs for children
1. < 1 year old
2. 1-2 years old
3. > 2 years old
- 3 mm cuffed
- 3.5 mm cuffed
- 3.5+ age/4
Add 0.5 for uncuffed tubes
When/how does CCHD screening occur?
Between 24 and 36 hours after birth
Using right hand and either foot
Cardiac lesions that are USUALLY CYANOTIC and are detectable using pulse ox screening (7)
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
Cardiac lesions that MAY BE CYANOTIC and are detectable using pulse ox screening (5)
Coarctation of the aorta
Double outlet right ventricle
Ebstein’s anomaly
Interrupted aortic arch
Defects with single ventricle physiology
What is a
1. Abnormal
2. Borderline
result when using pulse ox screening for CCHD
- < 90% in right hand or foot
- 90-94% in right hand and foot OR > 3% difference
3 borderline readings 1 hour apart = fail
Triad of lab findings in DKA
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
Risk factors for DKA (13)
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
DKA severity definitions
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
Risk factors for cerebral edema in DKA (10)
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
Goal rate to decrease glucose in DKA
No more than 5 an hour to 15-17
When do you start insulin for DKA patients?
After the first hour of fluid therapy AND when K is > 3.3
When (and how much) K should be added to IV fluids in DKA?
K of 40
When measured K is <5.5 and after recent urine output
When do we replace phosphate in DKA
Measured levels < 0.5 OR concerns of cardiac dysfunction, resp failure, GI dysmotility, or metabolic encephalopathy
Treatment of cerebral edema from DKA
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
What age range is most common in ITP? And how long does it usually take to resolve?
2-5 years
Resolution within 6 months
Recommended treatment options for ITP with
1. No active bleeding
2. Moderate bleeding
3. Severe bleeding
- Observation first line, oral steroids or IVIG second line
- Active therapy with single dose IVIG or short course corticosteroids
- IV steroids and IVIG, may need TXA but discuss with hematology, PLT transfusion only if acute life threatening bleeds or needing immediate surgery
When do children with ITP typically relapse?
One third of children will relapse within 2 to 6 weeks
Definition of
1. No/mild
2. Moderae
3. Severe
bleeding in ITP
- None or at most bruising, petechiae, or mild epistaxis, no interference with daily living, may have some mild oozing of petechiae
- More severe skin manifestations, some mucosal lesions, more troublesome epistaxis or menorrhagia
- Bleeding episodes (epistaxis, melena, menorrhagia, or ICH) needing hospitalization
2 options for length of treatment of steroids in ITP
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
Which treatment for ITP should be used if rapid increase is required?
IVIG
Increase in platelets within 24 hours, peak response at 2 to 7 days
Steroids have increase within 48 hours
2 definitions of convulsive status epilepticus
Continuous GTC activity with loss of consciousness for longer than 30 mins
2 or more discrete seizures without return to baseline mental status
Definition of early/impeding status epilepticus
Continuous or intermittent seizures lasting longer than 5 mins without full recovery of consciousness between seizures
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?
NOT phenytoin or fosphenytoin
Phenobarbital is better choice
Best seizure med to treat status in children <6 mo, prolonged febrile seizures, and seizures caused by toxic ingestions/drug withdrawals?
Phenobarbital
When should you avoid giving valproate?
In children with known or suspected mitochondrial disease
Including children <2 years with unexplained dev delay
When is pyridoxine (B6) helpful in status?
Children <18 mo with seizures that may be caused by an undiagnosed metabolic disorder
Most common cause of convulsive status epilepticus
Prolonged febrile seizure
When should you consider non-convulsive status?
LOC not improving as expected after the convulsions have stopped
Neuromuscular paralysis being used
Symptoms of hyponatremia
headache, nausea and vomiting, irritability, decreased LOC, seizures, apnea
Initial IV fluid to use if Na is 145-154
Use D5 0.45% and monitor lytes frequently
Common causes of febrile neutropenia in immunocompetent children
Viral or bacterial infections
Recent antibiotics
Anticonvulsant therapy
Autoimmune neutropenia
B12/folate deficiency
Neutropenia
1. definition
2. mild
3. moderate
4. severe
5. very severe
- ANC < 1.5
- 1-1.5
- 0.5-1
- < 0.5
- < 0.2
Management plan for children NOT at risk for invasive bacterial infection, with ANC of
1. > 1
2. 0.5 -1
3. < 0.5
- Manage as if normal ANC
- No abx, repeat CBC in 1-3 months
- Blood cultures, consider UA, UCx, RPCR. If well appearing, abx only if < 0.2, close follow up
Risk factors for invasive bacterial infections
Immunocompromised (malignancy, post transplant, primary immunodef, immunsuppressants, BM failure or aplastic anemia)
Hx of neutropenia
Severe or recurrent infections (meningitis, sepsis, abscesses, OM, cellulitis, severe PNA)
Fam hx (immunodef, neutropenia, BM failure, leukemia)
Intravascular device
Unimmunized
Co-morbidities
Exam/Investigations (unwell, HSM, LNs, high MCV, other cell lines suppressed)
Low risk for IBIs in infants < 90 days using PECARN criteria
All of:
UA negative for leuks, nitrits, and pyuria
ANC < 4.09
PCT < 1.71
Cell counts suggestive of meningitis in infants
1. < 28 days
2. > 28 days
- > 15 cells
- > 9 cells
Correction factor for traumatic LPs
Subtract 1 WBC for every 1000 RBCs
Do not use if the sample contains > 100 000 RBCs
Which viral infection is associated with higher risk of serious bacterial infections in infants
Rhinovirus
If a fever persists for longer than ___ hours post immunization, the infant is no longer considered low risk
24 hours
If longer, they need a UA performed
Managment for infants 0-28 days who are
1. Low risk
2. High risk
CBC, CRP, PCT, cultures, UA.
1. Option to hospitalize and observe without abx, or perform LP and hospitalize +/- abx. Observe for 36 hours or 24 if virus that is not rhino
2. LP, start abx. Observe until cultures negative at 36 hours
Management for infants who are 29-60 days old and
1. Low risk
2. High risk
CBC, CRP, PCT, BCx, UA, UCx
1. LP not required. Normal inflam markers are at low risk even with positive UA. Can discharge and FU in 24-48 hours or hospitalize and observe x 24 h.
2. Abnormal inflam markers are high risk. LP, start abx, observe until negative at 36 h
Infants 61-90 days can be managed the same
What is sickle cell trait?
One sickle beta-globin gene with one normal beta-globin gene
Usually do not exhibit clinical manifestations or require disease specific care
What extra vaccines do children with sickle cell disease require?
Pneumococcal (13-valent conjugate and polysaccharide)
Meningococcal
Booster for Hib
Hepatitis A and B
Seasonal influenza
Travel: Salmonella typhi and malaria prophylaxis
Which children with SCD require antibiotic prophylaxis? How long? Which abx?
Daily amoxicillin for children 2 months to 5 years (erythromycin or cotrimoxazole if penicillin allergy)
Extended treatment for those who have had a splenectomy, hx of invasive bacterial infections, or immunizations are not up to date
Which children with SCD need hydroxyurea? Why?
All children > 9 months
Held when patient is cytopenic
Reduces the risk of acute chest syndrome, vaso-occlusive episodes, transfusions, hospitalizations, and mortality
Acute chest syndrome definition
New pulmonary infiltrate in the presence of fever and respiratory signs/symptoms
Can be caused by infection, pulmonary infarction, or fat embolism
Antibiotics used in acute chest syndrome
CTX and azithromycin
Why is fever in a patient with SCD an emergency? How do you treat?
Functional asplenia puts patients at increased risk for invasive bacterial infections
Treat with CTX or cefotaxime, vanco if unstable
If low risk criteria can discharge home and return to ED for CTX until cultures are negative
Aplastic crisis in children with SCD
What is it, signs, treatment
Aplastic crisis secondary to parvovirus B19
Severe anemia, low retic count, mild thrombocytopenia, leukopenia
Indication for RBC transfusion
How and who to screen for stroke in SCD?
Children 2-9 years old should be screened for vasculopathies annually using TCD
When to transfuse children with SCD
When hemoglobin is
1. > 20 below their baseline
2. < 60
3. Baseline is unknown
Low risk for criteria with SCD to be discharged home with fever (still return to ED pending cultures)
Well appearing, hemodynamically stable
Fever < 40
Age > 6 months
WBCs 5-30, platelets > 100 and not significantly lower than baseline
No resp distress or CXR abnormalities
No clinical findings suggestive of meningitis, osteomyelitis, septic arthritis, or splenic sequestration
No hx of pneumococcal sepsis or meningitis
No sig pain or dehydration
Initial visit
Safe with follow up ability
Criteria for children with croup to be admitted to hospital
Child received steroid 4+ hours ago and has:
Moderate resp distress without agitation or lethargy
Stridor at rest
Chest wall indrawing
