BRS Emergency Medicine Flashcards
2 ways to open up the airway
head tilt method
jaw thrust method if suspect cspine injury
MCC of cardiac arrest in a child is _______
lack of oxygen supply to the heart
heart disease is an uncommon cause in children
assess breathing with this method
look listen feel
where to assess pulse in infants vs. children
infants- brachial
children- carotid
compensated
decompensated
irreversible
*describe these forms of shock
compensated- normal BP and CO with adequate tissue perfusion, maldistributed blood flow to essential organs
decompensated- hypotension, low CO, inadequate tissue perfusion
irreversible- cell death, refractory to medical treatment
_____ is the MCC of shock in kids
it is commonly due to _____ or _____
hypovolemic
hemorrhage, dehydration
in hypovolemic shock, volume losses > _____ lead to decompensated shock
25%
2 phases of septic shock
- hyperdynamic stage- bounding pulses, high CO, warm extremities, wide pulse pressure
- decompensated stage- impaired mental status, cool extremities, diminished pulses
2 types of distributive shock
anaphylactic- acute angioedema of upper airway, bronchospasm, pulmonary edema, urticaria, hypotension
neurogenic- total loss of distal sympathetic cardiovascular tone with hypotension 2/2pooling of blood within the vascular bed
changes in ____ often occur before changes in BP in shock
HR- tachycardia occurs before hypotension
initial fluid management in shock
20 mL/kg bolus of NS or LR
give ______ for DIC
FFP
_____ are the leading cause of trauma in kids
MVA
special considerations in trauma in kids
- they have larger heads so head injuries are more common
- rib cage is more pliable so more energy is transmitted to lungs, liver, spleen
- growth plates are weak and are at the highest risk of injury (ligaments are stronger than the growth plate)
causes of PEA
cardiac tamponade
tension ptx
profound hypovolemia
in addition to primary and secondary survey, do these tests
EKG
urinary cathether
NG tube
CXR
seizures are common after head trauma… what do you do?
nothing… they are self limited
infants are at risk for bleeding in the ______ and ______ because of open fontanelles and cranial sutures
subgaleal and epidural
epidural hematoma is tearing of the ______
on CT, you see _______
tx by _______
middle meningeal artery
lenticular density
surgical drainage
subdural hematoma is due to tearing of ______
on CT, you see _______
how to tx
bridging veins
crescentic density
neurosurg consult and usually surgical drainage
intracerebral hematoma usually occurs on _____ (side/opposite side) of trauma
opposite side
contrecoup injury
______ is an early sign of herniation in children < 4 years of age
bradycardia
cushing’s triad (late sign of herniation)
bradycardia
HTN
irregular breathing
how to manage increased ICP
mild hyperventilation
elevation of head
diuretics like mannitol
neurosurg consult
kids are prone to spinal cord injuries w/o radiographic abnormality
yep
SCIWORA
distended neck veins, decreased breath sounds, hyperresonance to percussion, displaced trachea, PEA, shock
tension pneumothorax
tx with needle decompression
occurs after injury to RUQ (esp bicycle handle bar)
- abdominal pain and vomiting
- bowel obstruction is found on radiographic evaluation
duodenal hematoma
lap belt injuries
chance fracture- flexion disruption of the lumbar spine
liver and spleen lacs
bowel perfs
_____ are the second MCC of accidental death in children
esp due to _____
burns
scalding injuries from hot liquids
classifying degree of burn
first degree- only the epidermis
-red, blanching, painful skin (ex. sunburn)
second degree (partial thickness)- epidermis and part of the dermis
- superficial partial thickness- entire epidermis and outer portion of dermis; moist, painful, red; blister but no scar
- deep partial thickness- entire epidermis and lower portion of the dermis; pale white; may blister and heal with scarring
third degree (full thickness)- epidermis, dermis, part of subcu tissue
- dry, white, leathery
- insensitive to pain b/c nerve endings are destroyed
- skin grafts are needed
if you suspect someone inhaled hot gases, do this
intubate!!
for burns, fluid resuscitation is critical
yep
skin care for burns
1st degree
-moisturizers, analgesics
2nd degree
-opiates, debridement of dead skin to prevent infection
3rd degree
-skin grafting, hydrotherapy, escharotomy
abx in the form of topical 1% silver sulfadiazine for 2nd and 3rd degree
victims of near drowning may suffer from aspirating liquid (_____) or from laryngospasm (______)
wet drowner
dry drowner
near drowners might cough up ______
in the next few days, monitor for these things
pink frothy material
aspiration pneumonia
deterioration of pulmonary function
bruises on fleshy or protected areas (face, cheek, back, chest, abdomen, buttocks, genitalia) suggest______
child abuse
what do nonaccidental burns look like
clear line of demarcation
aging of bruises by color
red blue: 0-3 days
blue purple: 3-5 days
green: 5-8 days
yellow brown: 8-14 days
top 2 causes of death in child abuse cases
head injuries
visceral injuries
fxs of first or posterior rib, sternum, scapula, vertebral spinous processes
bucket handle or corner fxs
child abuse!
what to do if you suspect child abuse
call CPS
skeletal survey
dilated ophtho exam to look for retinal hemorrhages
what postmortem finding is common in SIDS pts
intrathoracic petechiae
most cases of poisoning in children are 2/2 child abuse
F
90% are accidental
poisoning: bitter almond odor
cyanide
poisoning: garlic odor
arsenic
organophosphates
poisoning: acetone odor
salicylates
isopropyl alcohol
poisoning: wintergreen odor
methylsalicylate
poisoning: moth ball odor
camphor
poisoning skin finding: cherry red color
carbon monoxide
cyanide
poisoning skin finding: sweaty
organophosphates
sympathomimetics
poisoning skin finding: dry skin
anticholinergics
poisoning skin finding: urticaria
allergic reaction
poisoning skin finding: gray cyanosis
methemoglobinemia
poisoning miosis
opiates
phencyclidine
organophosphates
phenothiazines
poisoning mydriasis
amphetamines
cocaine
TCAs
atropine
poisoning nystagmus
dilantin
phencyclidine
poisoning retinal hemorrhages
CO
methanol
in a poisoning situation, radio-opaque stuff in the stomach on imaging may indicate:
CHIPE chloral hydrate and calcium heavy metals iodine and iron phenothiazines enteric-coated tablets
in AMS, always give these
dextrose and naloxone
ipecac
- what does it do
- is it effective
rapidly induces emesis
does not really improve clinical outcome
gastric lavage can be performed if it’s within _____ of ingestion of a toxin
1 hour
activated charcoal improves clinical outcome but is ineffective for the following:
iron lithium alcohols ethylene glycol iodine K arsenic
whole bowel irrigation is a rapid and complete emptying of the intestinal tract with ______ and ______
polyethylene glycol and an electrolyte solution
pathophys of acetaminophen poisoning
depletion of glutathione (a cofactor used during metabolism of acetamionphen by the cytochrome P-450 system) –> accumulation of toxic intermediates –> hepatocellular necrosis
4 phases of acetaminophen poisoning
stage 1 -30 min-24 hours -asymptomatic, or N/V/D stage 2 -24-72 hours -GI sxs resolve; hepatic transaminases begin to increase stage 3 -72-96 hours -hepatic necrosis, jaundice, hypoglycemia, hepatic encephalopathy, renal failure, etc stage 4 -4 days-2 weeks -resolution of sxs, progressive liver damage, or death
how to tx acetaminophen poisoning
- gastric lavage
- activated charcoal
- get serum acetaminophen levels 2-4 hours after ingestion –> Matthew-Rumack nomogram –> if hepatitis, give NAC (give it within 8 hours of ingestion)
respiratory alkalosis with anion gap metabolic acidosis indicates ______ poisoning
salicylate (aspirin)
pathophys of salicylate poisoning
- directly stimulates respiratory center –> respiratory alkalosis
- uncouples ox phos –> lactic acidosis
fever, diaphoresis, flushed appearnace, tinnitus, etc
poisoning by _____
salicyclate
how to tx salicylate poisoning
gastric lavage
activated charcoal
get serum salicylate level 6 hours after ingestion –> Done nomogram
alkalinize the urine with sodium bicarb, IV fluids
antidote for acetaminophen
NAC
antidote for anticholinergic agents
physostigmine
antidote for benzos
flumazenil
antidote for black widow spinder
antivenin lactrodectus mactans
antidote for CO
oxygen
antidote for coral snake
antivenin micrurus fulvius
antidote for cyanide
CN antidote kit
hydroxocobalamin (vitamin B12)
antidote for digitalis
digoxin specific Fab antibodies
antidote for heavy metals
D-penicillamine
dimercaprol
DMSA
EDTA, Ca
antidote for inducers of dystonia
diphenhydramine
benztropine
antidote for inducers of mehemoglobinemia
methylene blue
antidote for iron
deferoxamine
antidote for isoniazid
pyridoxine (vitamin B6)
antidote for methanol and ethylene glycol
ethanol
fomepizole
antidote for narcotics
naloxone
antidote for organophosphates; carbamate pesticides
atropine
pralidoxime
antidote for beta blockers; CCBs
glucagon
antidote for sulfonylurea oral hypoglycemic agents
octreotide
glucagon
pathophys of iron poisoning in children
direct damage to GI tract –> hemorrhage
hepatic injury and necrosis
third spacing and pooling of blood in the vasculature
interference with ox phos
stages of iron toxicity
stage 1: 1-6 hours
-abd pain, N/V/D, GI bleeding, shock, fever, leukocytosis
stage 2: 6-12 hours
-resolution of stage 1 sxs
stage 3: 12-36 hours
-metabolic acidosis, circulatory collapse, hepatic and renal failure, DIC, neuro deterioration
stage 4: 2-6 weeks
-pyloric or intestinal scarring with stenosis
how to tx iron poisoning
- gastric lavage **note: activated charcoal doesn’t work
- obtain serum iron level 2-6 hours after ingestion
- give IV deferoxamine if serum iron levels > 500, severe GI sxs, more than 100 mg/kg of iron was ingested
- can also do deferoxamine test dose… if urine turns pink/red, give it
lead poisoning is typically _____ in timeline
chronic
sxs of lead poisoning
abdominal- colicky pain, constipation, anorexia, vomiting
neuro- irritabliilty, seizures, listlessness
peripheral blood smear- microcytic anemia with basophilic stippling
dense metaphyseal bands on xrays of the knees and wrists (lead lines)
how to dx and tx lead poisoning
dx with elevated lead level or elevated erythrocyte protoporphyrin
tx for significant toxicity with dimercaprol, BAL, EDTA
____ cause coagulation necrosis that produces superficial damage to the mouth, esophagus, and stomach
acids (toilet bowl cleaner)
_______ cause liquefaction necrosis that produces deep and penetrating damage
alkalis (oven and drain cleaners, bleach, laundry detergent)
gastric perforation and peritonitis may follow ______ ingestion
acid
esophageal perforation with mediastinitis may follow _____ ingestion
alkali
how to manage caustic ingestions
no ipecac, gastric lavage, or activated charcoal
do an endoscopy
pathophys of CO poisoning
- CO displaces oxygen from hemoglobin, creating carboxyhemoglobin (CO-Hb)
- oxygen hemoglobin dissociation curve is shifted to the left (they are bound tighter… impaired release of oxygen to tissues)
- CO interferes with cellular oxidative metabolism
low levels: HA, flulike illness, dizziness
high levels: visual and auditory changes, vomiting, confusion, slurred speech, cyanosis, MI, coma, death
CO poisoning
cherry red skin and retinal hemorrhages suggest ______
CO poisoning
CO poisoning can cause delayed permanent neuropsych syndrome (memory loss, personality change, deafness, seizures, etc)
yep
how to dx CO poisoning
dx CO poisoning by measuring CO-Hb levels
how to tx CO poisoning
100% oxygen
hyperbaric oxygen if available
hospitalization for CO-Hb > 25% or > 10% if there are other problems
management of bite wounds
copious irrigation
wounds on face, large wounds, wounds < 12 hours old- suture it!
abx like augmentin
tetanus ppx if needed
cat bites are at high risk of infection with ____
P multocida
you might also get cat scratch disease
human bites are especially serious if at the MCP joint
likelihood and organisms of infection
high risk of infection
strep viridans, staph aureus, bacteroides, peptostreptococcus, eikenella corrodens
spider with red or orange hour glass marking on the ventral surface
what kind of toxin is the venom
black widow spider
neurotoxin
black widow spider bite sxs
few local sxs
severe HTN and muscle cramps
nonspecific sxs
how to tx black widow bite
local wound care
benzos for muscle camps
latrodectus antivenin
spider with a brown violin-shaped marking on the dorsum of the thorax
brown recluse/fiddleback spider
brown recluse spider bite clinical features
- initial bite not bad… after 1-8 hours, painful itchy papules that increases in size and discolors
- some pts develop necrotic and ulcerated deep lesion
- systemic rxns within 24-48 hours: fever, chills, weakness, vomiting, joint pain, DIC, renal failure
how to tx brown recluse spider bite
local wound care, tetanus ppx
steroids, skin grafting, dpasone, hyperbaric oxygen
no antivenin available
most snake bites are via the _____
pit viper snakes (rattlesnake, cottonmouth, copperhead)
venom of the pit viper snakes
clinical features
proteolytic enzymes
- paresthesias of the scalp, periorbital fasciculations, weakness, metallic taste in mouth
- coagulopathy, thrombocytopenia, hypotension, shock
how to tx pit viper snake bite
crotalidae polyvalent antivenin within 4-6 hours
children require more of the antivenin
can also give crotalidae polyvalent immune Fab
coral snakes- how to know if they’re dangerous
tx for their bites
red next to yellow, kill a fellow
red next to black, venom lack
neurotoxic venom causes severe systemic sxs… there is antivenin for the Eastern US and Texas coral snakes
GCS < ____ signifies severe head injury
8
infection with pasteurella is more common in cat/dog bites than human bites (T/F)
T
ingestion of prenatal vitamins puts kids at risk for ____ poisoning
iron
