Acute care/NICU Flashcards

Question

Concussion investigations? When to order head imaging? Management? Concussion definition

Answer 1

Investigations Assessment tool: The Sport Concussion Assessment Tool 3 (SCAT3) is recommended for use in patients ≥13 years of age. The Child-SCAT3 has been developed for use in children five to 12 years of age and includes a parent symptom report as well as more age-appropriate cognitive tests Simple: none (unless red flags – see below) Complex: neuroimaging, neuropsychiatric testing, referral to neurologist **Neuroimaging indications: continued emesis, prolonged headache, persistent antegrade amnesia (poor short-term memory), seizures, Glasgow Coma Scale score

Answer 2

DDx of shock: Cardiogenic: arrhythmia, myocarditis, post-op cardiac tamponade, cor pulmonale: increased PVR, PPHN secondary to pulmonary vascular reactivity exacerbated by hypoxia from URTI? Septic: c a little late post-op, but could be late wound infection gone septic (Unlikely hypovolemia, neurogenic or anaphylactic, given clinical scenario) • Call for appropriate help (MD, RT, nurses) and delegate roles for team members • Ensure proper equipment present • Oxygen mask, laryngoscope with proper size blade and various size tubes (age/4 + 4), oral airway, nasal airway, CO2 detector, suction tubes (5F-14F), Yankauer suction, bag-valve mask • Large bore IV, Normal saline, intraosseus needle o Medications • Broselow tape • Ask for vitals including temperature, apply monitor and O2 § Airway o Listen for stridor, talking o Head-tilt chin lift o Consider intubation if obstruction, or signs of impending obstruction § Breathing o Look for chest rise, listen for bilateral air entry, look at colour o Assess respirations, O2 sat, work of breathing o Apply O2 if needed o Consider intubation if irregular respirations § Circulation o o o Assess HR, BP, look at colour, cap refill, mucous membranes, skin turgor, cyanosis/pallor Start IV, bolus 20cc/kg (even if cardiac – better to treat shock and worry about lungs later) Consider CPR, epinephrine, cardioversion, adenosine depending on scenario § Disability o AVPU (alert, verbal, pain, unresponsive) o Pupils, motor activity bilaterally, lateralizing signs, seizures, posturing o Assess for increased ICP (pupils if not given atropine, heart rate, BP, LOC, resp, posturing) o if increased consider mannitol 1g/kg over 15 minutes, 3cc/kg of 3% NS, slight hyperventilation, raise HOB up Exposure/Secondary survey □ AMPLE history – allergy, meds, PMH, last meal, events associated □ Insert NG □ Insert foley unless signs of urethral injury (blood at meatus) □ Initial blood work: CBC, cross and match, gas, lactate, lytes, liver enzymes, BUN, creat, INR/PTT, blood culture □ CXR, ECG, ECHO □ Tx: volume, inotropes, anti-arrhythmics, antibiotics Speak to family about patient’s condition

Answer 3

MEDICATIONS Intubation: Atropine 0.02 mg/kg Personal protective equipment (wash hands, mask, gown, glove) Ensure proper resuscitation equipment present S uction → flexible 5F-14F (2 x ETT size); Yankauer O 2 mask → simple mask, bag-valve mask A irway → oral airway, nasal airway (nasal trumpet) → laryngoscope (3-5 kg infant = 0-1 straight blade) → ETT (age/4 + 4) → term infant = 3.0-3.5 uncuffed → ETT stylet → End-tidal CO2 detector → tape P harmacology (including reversal agents) M onitoring E quipment IV, IO needles Normal saline o Broselow tape Weight (estimate ~4 kg) Term or preterm baby? General appearance (well, unwell, toxic) Vital signs (HR, BP, RR, O2 sat, Temp) Cardiorespiratory monitors Airway o Assess for sounds, stridor, secretions o Head tilt, chin lift (or jaw-thrust if C-spine precautions) o Suction o Oral airway (if obtunded) or nasal airway (if stridorous) o Intubation if obstruction or signs of impending obstruction (e.g., burns) Breathing o Look for chest rise, listen for bilateral air entry, look at colour o Assess respirations, work of breathing o O2 sats and apply O2 if needed → Bag-mask ventilation (may need to show nurse how to use) o Intubation if irregular respirations o Call for CXR o Consider Ventolin NEB (0.5 mL if

Answer 4

o IV, IO needles o Normal saline o Broselow tape Weight (estimate ~10 kg for 3 year old child) q General appearance (well, unwell, toxic) q Vital signs (HR, BP, RR, O2 sat, Temp) q Cardiorespiratory monitors q Call for Epinephrine at first suspicion of anaphylaxis Airway o Assess for sounds, stridor, secretions o Head tilt, chin lift (or jaw-thrust if C-spine precautions) o Suction o Intubation if obstruction or signs of impending obstruction (e.g., burns) Breathing o Look for chest rise, listen for bilateral air entry, look at colour o Assess respirations, work of breathing Ventolin NEB

Answer 5

History Present episode (recent foods, quantity of food, onset of symptoms, type of symptoms (rash, respiratory distress, GI symptoms such as nausea and vomiting, swelling of face, etc), duration of symptoms) Previous reactions? When? Other foods and symptoms of concern in the past? Management to date (skin testing, RAST, elimination diet, MedicAlert, Epi-Pen) PMHx (eczema, asthma, rhinitis) Medications Allergies Immunizations FMHx (atopy, anaphylaxis, hereditary angioedema) Social Hx (who lives at home, supervision of child, insurance to cover cost of Epi-Pen and MedicAlert bracelet, school environment, etc) How does this illness/diagnosis impact the child and family Explore DDx (infectious, reflux, lactose intolerance, celiac, etc) Counsel Educate regarding anaphylaxis (e.g., life-threatening reaction...) Educate all potential caregivers, day care, school, etc Discuss symptoms (e.g., urticarial rash, difficulty breathing, wheezing, hoarseness, chest pain, tachycardia, nausea, vomiting, difficulty swallowing, dizziness, etc) Do NOT give Benadryl at home (this may mask a reaction and lead to a more fatal reaction) Strict avoidance of the specific food(s) → Provide a list of foods to avoid (e.g., egg may be listed as ‘albumin’ or ‘lecithin’) → Be aware of potentially lethal substitutions (e.g., cheap peanuts for almonds) → Be aware that any bulk foods can be cross-contaminated → Children should not eat food from other children/adults other than their own caregivers → Life long allergy, so do not re-challenge o MedicAlert bracelet o Have injectable epinephrine available at all times (Ana-Kit or EpiPen) → day care, school, etc → watch for expiry date → ensure prescription with refills o All children should have an Anaphylaxis Emergency Plan o Consider referral to an Allergist o Follow-up with primary care physician qReview Epi-pen use o Form a fist around the auto-injector with the black tip facing down o Pull off the grey safety cap o Place the black tip against the outside of the upper thigh; be sure the black tip is perpendicular ot the thigh (this can be done through clothing, even jeans) o Push the pen firmly against the thigh → this will trigger the injection o Hold the pen firmly in place and count to 10 o Call 911

Answer 6

``` O2: 100% non-rebreather Monitors IV: 2 large bore, send trauma labs Weight Talking to you=ABCs OK Airway: q C-spine collar, spine board q look/listen/feel q jaw thrust q RSI (oral/nasal airways risk aspiration) q inline stabilization q attn local trauma Breathing: qO2 q WOB, AE, sounds, sats, RR, trachea, chest markings q needle thoracostomy, chest tube(s) q open PTX dressing q RSI: open PTX, massive flail chest Circulation: q colour, cap refill, pulse(x4) q abdo soft? q pelvis stable? q limbs deformed? q control bleeding q boluses(warmed) & prep blood(give after 60ml/kg NS) q rapid infuser q if unstable despite ++fluid consider: Disability: q AVPU, GCS q Pupils ``` Exposure q core temp q warm blankets q Adjuncts AMPLE hx: include age or weight NG/OG, Foley XRs: C-spine, CXR, pelvic Transport

Answer 7

PEP: What size ETT would you need? 7-8 What induction drugs would you use for his RSI if: -hypotensive: ketamine -HI: etomidate or low-dose thiopental; consider lidocaine pre-med What would be contraindications to succ in his case? -inc ICP, penetrating globe injury, late presentation(risk hyperK) What are life-threatening chest injuries he may have? Tension PTX, open PTX, flail chest, hemothorax, airway disruption, tamponade, pulmonary contusion, commotio cordis, aortic disruption

Answer 8

Brief Hx of issues for baby: ‐GA ‐BW and Discharge weight ‐Specific issues that the baby had been dealing with in NICU: ROP, IVH, Ventilated, GI Mother’s info: ‐First baby? Mother’s age? ‐Social situation: who lives at home? Supports? Caregivers? ‐ smoking in the home? other children at home? ‐any concern at home with alcohol or drug use, violence or conflict? BASIC CARE: ‐mother needs diapers, wipes, Vaseline, sleepers, basin for bathing, bottles, crib ‐does she know how to bathe the baby? Dress the baby? FEEDS: breast feeding or bottle? EBM or formula? ‐amount baby is taking over how long, concerns ‐ Vit D and Fe if BF ``` SLEEP: ‐needs to be place on back in a standard crib with crib mattress ‐no quilts, bumper pads, pillows ‐ONLY a thin blanket allowed ‐may place crib in parent’s room ‐never sleep on sofa or soft surface ``` ``` BREATHING: cannot have apneas x 1 wk before DC ‐should be off caffeine ‐should be off O2 CNS: ‐results of previous HUS ‐grades I and II‐ no f/u ‐grade III or more: weekly HC HEARING SCREEN: ‐was it done? any concerns VISION ROP ``` IUTD: RSV: ‐prophylaxis started? ‐will they require it? ‐explain about handwashing especially if other children at home ‐no contact with sick people because prone to infections CAR SEAT: ‐90 minute test with O2 sat monitor IMMEDIATE PLAN: Care by parent room for at least one night to work on BF and feel comfortable with baby not in a monitored environment

Answer 9

History  History of Presenting Illness o Circumstances of injury (who, what, where, when, how) o Information about animal (domesticated vs wild, shots received) o T etanus status  Past Medical History  Medications, Allergies, Immunizations Physical Examination  General appearance  Growth parameters (height, weight, HC)  Vital signs (HR, BP, RR, O2 sats, temp)  Airway, breathing, and circulation  Wound o Bite > 3 cm → suspect child abuse o Swelling, tenderness, redness, purulent drainage o Lymphadenitis  Neurovascular assessment Investigations  Bloodwork o CBC and diff o +/- ESR, CRP (if signs of cellulitis, joint infection, osteomyelitis) o +/- aerobic and anaerobic blood cultures (if signs of systemic infection)  Wound culture (if bite is infected; wound culture is useless in clinically uninfected bites)  Imaging o AP and lateral radiographs (disruption of bone / joint; evidence of foreign body; sc gas) o Ultrasound (abscess formation) ``` Management  Stabilization (direct pressure)  Wound preparation o Local anesthesia o Iodine o Irrigation with copious amounts of saline → pressure irrigation (20 cc syringe; 18-20 gauge needle)  Closure o Dog bites → primary closure if ```

Answer 10

General 1) Introduce yourself as the pediatrician on call 2) Confirm the name of the patient 3) State the purpose of the meeting is to discuss whether or not the baby should be delivered at this time 4) Inquire / offer to contact partner and other supports 5) Medical History a. Mother’s age b. Confirm gestational age / EDC c. GTPAL d. Confirm singleton pregnancy e. Prenatal care (e.g., dating U/S, integrated prenatal screening) f. Congenital anomalies g. Blood type h. Antenatal steroids (can be given up to 34 weeks) 6) Past medical history 7) Education level 8) Inquire about religious affiliations 9) Ask about the family’s social situation Counsel 10) (Re)state that the purpose of the meeting was to discuss whether or not the baby should be delivered at this time 11) Ask about understanding of the current situation and plan a. Is she in active labour? Is birth imminent? b. Has she been given steroids (in anticipation of a preterm delivery) 12) Ask the mother whether she had any understanding of the prognosis for the baby 13) Discuss the options: a. 1) Deliver the baby, resuscitate and provide intensive care, and then re-evaluate the situation b. 2) Deliver the baby and provide comfort care only c. 3) If C-section required, this will pose risks to mother as well d. 4) Another option would be that of non-intervention; expectation that the baby may die in utero 14) Use terms which are easily understood by a non-medical person 15) Explain the risk of mortality and disability if delivered a.

Answer 11

History Explain your role as pediatrician, need to obtain medical history Do not accuse or discuss what you’ve been told by others (often unfounded, biased!) Pregnancy Maternal age, preg history (incl spont abortions), health, blood group, serologies (Syphilis, HBV, HIV, Rubella) Smoking, Etoh, meds, OTC, herbal and recreational substances − Timing of exposure (start, frequency, when most recent)  Organogenesis affected most during 1st trimester, later = physiologic effects − Dose − Route (if IV, where needles from) − Any toxicity/overdose to mother during pregnancy (require hospitalization, treatment) − Screen for other risky behaviours and stressors during pregnancy (use HEADS as template)  Home (where, with whom)  Education/work (level of education, employment)  Eating (nutrition during pregnancy, folic acid)  Activities, Abuse during pregnancy  Drugs  Sex  Safety, trauma  Suicide, depression Genetic screening, ultrasounds Complications during pregnancy − Eg: Infection, DM, PIH, placental abruption L&D Mode of delivery, ROM GA, BW APGAR, resuscitation Dysmorphism, birth length and HC if known Neonate Breathing (tube, CPAP, O2) Jaundice, feeding (breast vs formula) Seizures, tremor, startle reflex, sleep Fever, sweating, sneezing Vomiting, diarrhea Medications Requirement of morphine, phenobarbital, benzodiazepine Extended family history Parental age, ethnicity, health, occupation Consanguinity Sibling age, health Psychiatric illness (schizophrenia, anxiety, depression) Social History Who will be living at home, where will be living Supports – reliable family/friends involved Plans for substance use, quitting o Alcohol in the home, access to cocaine and other drugs o Financial situation, other stressors o Second hand smoking o Plans for breastfeeding o Previous CAS involvement, previous abuse o Previous criminal/legal involvement Physical Examination Full exam Specific features of neonatal abstinence: Vitals: Fever, tachypnea, tachycardia, hypertension Growth parameters: LBW, decreased length, microcephaly General − Dysmorphic features [FAS = short palpebral fissures, thin upper lip, smooth philtrum, maxillary hypoplasia] − Irritability, hyperactivity − Sweating − Yawning HEENT − Nasal congestion, sneezing (heroin, other opioid) − Excessive sucking CVS − Septal defects associated with FAS MSK − Subtle joint and limb defects Neurological exam − High-pitched cry − Hyper-alert, startles easily, jittery − Hyperactive Moro − Tremor − Hypertonia − Myoclonal jerks or generalized seizures Derm − Mottling ``` Differential Diagnosis T eratogens o Fetal Alcohol syndrome o Fetal cocaine exposure o Exposure of fetus to other substances o Teratogenic drugs Other o Birth asphyxia: HIE o Neurologic: hemorrhage, malformation o Sepsis ```

Answer 12

Investigations o Regular glucometer checks o Blood gas o CBC, extended electrolytes, glucose, urea, Cr o Maternal STI testing o ECHO if concerned o Blood culture (if concerned about sepsis) o EEG and head imaging if seizures o Drug testing − Maternal if possible − Newborn: urine has low sensitivity (requires recent exposure) -Meconium and hair samples are more sensitive for in-utero exposure -Results take time, not useful for immediate management Counseling and Management Counselling What is mother’s understanding of risk of alcohol and cocaine exposure to fetus Explain current findings (dysmorphic features, neurological findings, growth) Explain what is associated with alcohol and cocaine exposure (see chart below) and it is difficult to tell right now if baby will develop these manifestations If safe to do so, infants should remain with birth families Referrals below Management Environment: quiet, reduce external stimuli (lights, interruptions), swaddling Rx: seizures, diarrhea, or hyperirritability affecting sleep, feeding patterns, weight gain − Opioid withdrawal: Opioid + Phenobarbital, ± further sedation − IV fluids − NPO if risk of aspiration Use Neonatal Abstinence Score to monitor signs/symptoms Call: − MotherRisk for advice regarding breastfeeding  If substance abuse to continue, advise not to breastfeed − CAS always: to determine well-being of child − Social Work to see mother Referrals: − MotherRisk for follow-up and further counseling − Psychiatry for any psychiatric issues − FAS multidisciplinary team − Parenting courses Keep in hospital until discharge can be done safely