Case 25: 2mo - child abuse Flashcards
describe what is involved in cardiopulmonary resuscitation
C == chest compressions
A
B
Assess = RR, WOB, pulse Ox, HR, perfusion, strength of pulses
Causes of apnea in infants (based on system)
CNS
- Seizures ==> hemorrhage, meningitis/encephalitis, structural abn, metabolic or electrolyte d/o, genetic d/o, epilepsy
- Breath-holding spells == in kids 6mo-6yo; halting breath during expiration (reflexive d/t injury or anger) - pallid / cyanotic –> LOC +/- seizure, asystole
- Increased ICP ==> bleed, trauma, tumor, infection
- non-accidnetal closed head injury
CARDIAC
- congenital heart block; long-QT syndrome, arrythmia==> bradycardia + apnea
- congenital heart disease (esp. ductal-dependent lesions - Tetralogy of Fallot) –> acute decompensation in first few weeks of life assoc. with decreased pulmonary BF
PULMONARY
- RSV infection == esp. premature infants and kids <2yo
- pertussis
- other lower respiratory infections = viral/bacterial pneumonias
GI
- swallowing abnormalities
- transesophageal fistula = chronic
+/- reflux ==> choking, gagging, color changes, laryngospasm
SYSTEMIC
- systemic sepsis (in infants <1mo) == apnea, pallor, tachycardia, tachypnea, fever/hypothermia, decreased feeding, change in tone (==> Group B Strep,E. coli, Listeria(–>meningitis), HSV (–>encephalitis))
- botulinum toxin (soil, raw honey) (in infants <1yo) == hypotonia, constipation, paralysis, resrpiatory failure
- metabolic disorders == esp. apnea and AMS
- meds/toxins == respiratory depression, cardiac arrhythmias, seizures
- environmental exposures (carbon monoxide) == AMS, hypoxia, respiratory distress
common cause of arrhythmia in infants
- which cause apnea?
- SVT
- congenital heart block; long-QT syndrome ==> APNEA
most common cause of apnea in infant?
who is at greatest risk for this?
RSV
–> premature infants and kids <2yo
does GERD cause apnea in infants?
NO
APNEA –> hypoxia == relaxation of the LES –> reflux
Brief Resolved Unexplained Event (BRUE)
- define:
- sxs
DIAGNOSIS OF EXCLUSION
- define: event occuring in infant <1yo when observer reports a sudden, brief, now resolved (back to baseline) including >/= 1:
1) cyanosis, pallor
2) absent/ decreased/ irregular breathing
3) marked change in tone (hyper/hypo)
4) altered level of responsiveness
== no underlying etiology
emergency measures in infant with head trauma and deteriorating neurologically. multiple correct answers
Which of the following would be the next best steps?
Multiple Choice Answer:
A Notify your attending and call for a rapid response team
B Get prepared for CPR
C Obtain IV access
D Do a head CT
E Call the critical care unit to admit the baby
F Consult neurology
A, B, C
calling critical care to admit, consulting neurology, and head CT are needed, but LATER
CALL RAPID RESPONSE –> b/c can stop breathing / seize
1) CPR ready
2) IV access (2 large bore IVs)
normal neurological findings in 2mo
NEURO
- fix and follow easily with eyes
- exhibit meaningful smile in response to voices
- strong suck reflex
- beginning to coo
GROSS MOTOR
- lie flexed at hips with good tone; move all 4 extremities well
- can raise heads from side to side (180deg)
- CANNOT hold head up well, roll over
abusive head trauma
- mortality rate:
- mechanism:
- sxs:
- mortality rate: 25%
- mechanism: violent shaking and throwing (==> hemorrhage, diffuse axonal injury)
- sxs (morbidity 20-40%): neurological sequelae, no other signs of physical abuse
causes of subdural hematoma
==> head trauma
1) intentional trauma = violent shaking ==> retinal hemorrhages
2) accidental trauma (MVA)
3) delivery - esp. with vacuum / foreceps == resolve within 4-6w
4)
shaken baby syndrome
- sxs:
- mechanism
- CT findings
- prognosis:
- sxs: lethargy, retinal hemorrhage (found in 65-95%), subdural hematoma, full fontanelle, tachypnea
+/- seizure
+/- old healing fractures (rib fractures, spiral tibial fractures in non-walking infants, Metaphyseal fractures in nonactive kids d/t torsional force on joint) - mechanism: shaking/throwing ==> extreme rotational cranial acceleration force to brain + diffuse axonal injury to neurons ==> tearing of bridging vessels
- CT: Acute subdural hematoma [acute bleeding is white in color] in the right frontal area with prominent extra-axial cerebral spinal fluid [darker color] in the bifrontal subarachnoid spaces and the left Sylvian fissure.
- prognosis: long-term developmental delays, seizures, and/or difficulty with vision
can subdural hematomas result from CPR/seizures/short falls
how about retinal hemorrhages?
NO
NO
== these are very indicative of child abuse (esp if the story doesn’t make sense)
in cases of suspected child abuse, who are the medical professionals
neurologist == assess extent of injury, recommend tx, f/up monitoring
child advocacy doctor (pediatrician) == for specific skeletal studies, coag studies (r/out bleeding diathesis for continued bleeding) additional consulations
ophthalmology == eye exam for retinal hemorrhage
social worker
skeletal survey findings that raise suspicion for abuse
- fractures / injuries that are inconsistent with reported mechanism of injury and/or developmental abilities of child
- multiple fractures or injuries at different stages of healing
- fracture of femur or tibia in non-walking child
- posterior rib fractures ==> d/t squeezing of thorax perpetrator’s hands during shaking
- skull fracture in infant (if the story doesn’t fit)
define toddler’s fracture
- is this a sign of abuse?
- define: common injury to the tibia in young, walking children
NOT a sign of abuse
interpret these abnormalities of vital signs in a 2mo infant
- rectal temp <96.5 or >100.4F
- tachycardia
- decreased respiratory rate
- increased respiratory rate
- elevated BP
- rectal temp <96.5 or >100.4F == hypo/hyperthermia
- tachycardia ==> deteriorated CV status d/t sepsis, shock
- bradycardia==> increased ICP
- decreased respiratory rate==> CNS depression
- increased respiratory rate ==> sepsis, respiratory infection
- elevated BP==> compensatory response to CV system == pain, compensated shock, increased ICP
define: cushing’s triad
==> increased ICP
- Hypertension (progressively increasing systolic blood pressure)
- Bradycardia
- Widening pulse pressure (
infant colic
- define:
- etiology
- progression
- sxs
==> syndrome of crying several hours a day (usually PM) >5 nights/week; where baby is inconsolable
- etiology: unknown
- progression: starts after 2wo –> peak @ 6w –> resolves after 3-4mo
- sxs: otherwise normal; just causing a lot of anxiety and frustration with caregivers