ED Flashcards
Management of foreign body aspiration
Patient alert and able to maintain airway: supplemental O2 and leave patient in position of comfort
Patient with complete airway obstruction:
Infant ( < 1 year old) - perform five back blows followed by 5 chest thrusts
Child (>=1 yo)- perform abdominal thursts
If BLS manuevers fail, begin bag mask ventilation
If no chest rise with bag mask ventilation perform laryngoscopy and remove FB with pediatric Magill forceps
If foreign body aspiration what is the next step?
complete obstruction: back blows (infants), Heimlich maneuver (children); CPR for any age if the child becomes unresponsive
§ manual extraction of object if able to visualize it; do not attempt blind finger sweep
partial obstruction: anteroposterior-view x-ray of chest, neck, and/or abdomen
bronchoscopy, depending on type and location of object
What does radiodense mean?
radiodense=radiopaque
inhibits passage of electromagnetic radiation
WHITE
EJ.BONE
What does radiolucent mean?
radiolucent
passage of electromagnetic radiation
black or gray - skin and muscles
How are coins seen in Rx
Radiopaque- white
Coin in trachea: visualized in sagital plane on AP Rx
Coin in esophagus: coronal on frontal chest Rx
Chest Xray sensitivity and specificity in FB aspiration
sensitivity and specificity of 67% to detect abnormalities consistent with a FB aspiration
For pathophysiological variables that help determine nature of any lesion affecting the brain, functional level involvement and rate of progression
Pattern of respiration
Size and reactivity of pupils
Spontaneous and induced eye movements
Motor response
Location of respiratory centers
medulla oblongata and pons- two in the medulla and one in the pons.
medulla : dorsal and ventral respiratory groups.
In the pons, the pontine respiratory group two areas: pneumotaxic centre and the apneustic centre.
Types of respiratory patterns to consider in brain lesions
Postventilation apnea ( forebrain injury) Cheyne Stokes (Metabolic encephalopathy) Central neurogenic hyperventilation (Midbrain dysfunction ) Apneustic breathing(Pontine infarction, anoxic encephalopathy, severe meningitis)
Characteristics of post ventilation apnea and where is the lesion?
brief periods of apnea lasting 10-30 seconds, followed by voluntary deep breathing.
Forebrain injury
Cheyne stokes respirations characteristics and what does it indicate
Hyperpnea episodes alternating with apnea. depth of breathing waves.
lesion affecting deep brain structures or diencephalon
Central neurogenic hyperventilation characteristics and what does it indicate
sustained regular and rapid respirations despite normal PaO2 and low PaCO2.
Midbrain dysfunction
Apneustic breathing characteristics and what does it indicate
brief inspiratory pauses that last 2-3 seconds, often alternating with end expiratory pauses.
Pontine infarction, anoxic encephalopathy, severe meningitis
Pupils in transtentorial herniation
initially small–> but as herniation occurs asymetric pupils and then fixed and dilated.
Two specific eye manuevers to assess comatose child
Oculocephalic or doll’s reflex
Oculovestibular reflex evaluated with caloric testing.
Normal or positive Oculocephalic or doll’s reflex
conjugate deviation of the eyes opposite of the direction in which the head is turned.
Normal Oculovestibular reflex
Normal - COWS-Cold opposite Warm
With cerebral lesions, the eyes look to __ the lesion
towards the lesion
With brainstem lesions, the eyes look to __ the lesion
away of the lesion
What is setting sun sign and it is associated with
downward deviation of the eyes
upper midline lesions and hydrocephalus
Decerebrate posturing- where is the lesion
brainstem, pons.
Labs for ALOC with undetermined cause
CBC Electrolytes BUN Creatinine Bedside and serum glucose
Labs for ALOC suspecting metabolic
liver function testing, ammonia, tox screen
in additiion to: CBC Electrolytes BUN Creatinine Bedside and serum glucose
Differential dx of ALOC
AEIOU TIPS
Abuse/Alcohol Electrolytes/Endocrine ( SIADH, adrenal insuff) /Encephalopathy(Reye syndrome, lead Infection ( meningitis, encephalitis) Overdose ingestion Uremia ( HUS)
Trauma
Inborn errors of metabolism/Insulin and Hypoglycemia( consumption of family oral hypoglycemia agent, ketotic hypoglycemia)/Intussusseption
Psychogenic
Seizure, Shock, AVMs, Shunt
Reye syndrome
rapidly progressive encephalopathy. .
cause of Reye syndrome is unknown.
It usually begins shortly after recovery from a viral infection, such as influenza or chickenpox. About 90% of cases in children are associated with aspirin (salicylate) use. Inborn errors of metabolism are also a risk factor.
Hemolytic Uremic Syndrome
prodromal phase of GI or URI dollowed by acute onset of renal failure, microangiopathic hemolytic anemia and thrombocytopenia.
CUSHING TRIAD
Bradycardia, hypertension, irregular respirations
Etiology of bacterial meningitis in neonates
GBS strep
E.coli
Listeria
Etiology of bacterial meningitis in infants
S.pneumoniae
N.meningitidis
GBS
Gram negative bacilli
aseptic meningitis
viral meningitis and they look less ill
When does neck stiffness is reliable for nuchal rigidity
18 months- previous to this age the neck musculature might not be adequately developed
presentation of bacterial meningitis in neonates vs infants
neonates: irritability , temperature instability, lethargy , poor feeding, apnea, tremor.
children older than 18 months: nuchal rigidity, anorexia, headache, vomiting, focal neuro signs, seizures
Brudzinski sign and Kernig sign
flexion of neck causes flexion at the hip, knee or ankle
Kernig: inability to extend the legs when hips flexed
If petequiae is present in a meningitis, what is the cause?
N. meningitidis
S. pneumoniae
H. influenza
CSF Labs viral vs. bacterial meningitis
Bacterial: appearance clear WBC :10-500 (PMN 0-30) Glucose 50-90 protein 50-150 Gram stain negative
Viral appearance clear or cloudy WBC :100-20,000 (PMN >90) Glucose < 40 protein >250-500 Gram stain positive
Labs when suspecting bacterial meningitis
CSF culture and PCR
Blood culture
Serum glucose measurement
Electrlytes
Should we still order CSF in a pretreated with abcs bacterial meningitis?`
multicenter retrospective study showed WBCs count or absolute neutrophil count was not affected if antibiotics were given 24 hours before lumbar puncture.
But the flucose was higher and protein lower with pretreatment specially after 12 hours later.
Differential dx of meningitis
Cervical or retropharyngeal adenitis Retropharyngeal abscess Sinusitis, mastoiditis, CNS tumor , abscess, encephalitis pharyngitis Torticollis Cervical spine trauma
