EM critical and emergency Flashcards
The symptoms and the fixed, dilated pupil strongly suggest _____ herniation. The third nerve is compressed against the edge of the tentorium and causes third nerve palsy. The unequal pupil is on the same side as the herniation.
transtentorial
Air trappings, which can occur in patients with lower airway diseases such as BPD, may result in
tension pneumothorax.
______ though a common occurrence, would most commonly cause decreased breath sounds on the left because tracheal tube tends to enter the straighter right main bronchus.
Displacement of the tracheal tube,
Insertion of an intraosseous needle directly into the _____ is relatively easy and will assure rapid vascular access. This infant’s clinical presentation of decreased activity, mottled, dusky skin, and weak pulses suggests severe volume depletion.
anterior tibia. Whatever the cause, and in this emergent situation that can be assessed later, rapid fluid resuscitation and possibly pressors are indicated.
A ___ would be very difficult to cannulate in this volume-depleted infant. Blood would be shunted away from the periphery to more vital organs.
peripheral scalp vein. Also, these small caliber veins would not allow a large bore needle for rapid fluid resuscitation.
Injuries penetrating into or beyond the dermis with moderate or high tension of apposing edges, such as lacerations, require medical intervention to provide an epithelial covering by _______ after thorough cleaning and debridement.
primary intention with sutures or adhesives.
Clean wounds can be closed easily within 8 hours of injury or longer for face and scalp wounds. Contaminated wounds should be left open if more than 6-8 hours old, due to high risk of infection.
Replacement of ______ should be initiated first if bleeding continues after receiving several packed RBC transfusions. The platelet count should increase by 10^5 when given 1U/10kg of body weight. Blood product replacement should ideally be guided by laboratory values and a specific component provided.
platelets and clotting factors.
However, in cases of acute volume loss, lab values may not accurately reflect equilibration, and transfusions should then be based on hemodynamic status and response to initial fluid resuscitation.
CT is the diagnostic procedure of choice for assessing acute brain injury in children. It is usually readily available, study time is short, and it is more sensitive (sensitivity varies from 60-100%) than MRI for detecting _______
acute subarachnoid hemorrhage, which will appear as a hyper dense clot located in the cisterns and sulci at the base of the brain. It allows rapid definition of any surgical lesions, permitting neurosurgical intervention.
CT scan is also sensitive to
bony abnormalities within the cranium and vertebra and diagnosing fractures.
MRI is better at detecting abnormalities within the cerebellum and brain stem because
CT scans are more likely to pickup artifact signals from surrounding bony structures.
MRI scan is highly sensitive to
cerebral edema and demyelinating disorders
Spinal cord injury without radiographic abnormality (SCIWORA) occurs almost exclusively among children younger than 8 years of age. Increased elasticity of the pediatric spine allows injury to the cord without obvious bony disruption. Up to 27% of these children may experience delayed onset of neurological signs. This delayed period may range from 30 minutes to 4 days, with a mean of 1.4 days. Clues to this condition may be the presence of certain transient symptoms immediately after the injury.
These include, in addition to a lightning sensation down the spine associated with neck movement, paresthesia in the hands and legs or a subjective feeling of generalized weakness. The chief measures to improve outcome include injury prevention, prompt recognition through examination, search for such transient symptoms, use of MRI with electrophysiological verification, and timely bracing of SCIWORA patients.
Subdural hemorrhage (SDH) in children under 2 years of age is a relatively common occurrence that is usually the result of child abuse with a high morbidity and mortality due to brain edema and diffuse axonal injury. Unlike epidural hemorrhage, SDH are caused by global high-energy rotational acceleration/deceleration forces that are commonly generated during episodes of abuse, particularly during violent shaking of the infant back and forth in shaken baby syndrome.
These hematomas most often conform to the shape of the brain, exhibit concave inner margins, and do not cross the midline insertion of the falx or the tentorial attachment, as noted on head CT and MRI. The ruptured blood vessel is often a bridging vein connecting the cortical surface to the dural sinuses.
The pupils get parasympathetic innervation from the mesencephalic Edinger-Westphal nucleus. This nerve controls the constrictor pupillae and ciliary muscles.
Large, non-reactive pupils indicate damage to this nerve. In this case, the most likely diagnosis is expanding intracranial hematoma, which represents an immediate threat to life.
scalp hematoma over the right temporal bone and a fixed dilated pupil on the same side. What is the most likely cause of the dilated pupil?
compression of the third nerve by a supratentorial lesion.
