EMER 115 Obs, Peds, Gyne, GI/GU Flashcards
Peristalsis
propel food bolus toward the stomach without involvement of brain stem
Portal vein
transports venous blood from the GI tract directly to the liver for processing of nutrients that have been absorbed
The cardiac sphincter
controls the amount of food that moves back up the esophagus
Chyme
the materials that exit through the pyloric sphincter
Duodenum
the portion of the small intestine that begins the absorption of nutrients and where the pancreas, liver and gallbladder connect to digestive system
Stomach absorbs
water, fat soluble substances
Alcohol is absorbed
rapidly in small intestine
primary role of the large intestine
is to complete the reabsorption of water
Abdominal disorders can result from
inflammation, infection, and obstruction
Gastroesophageal reflux
occurs when acid, normally localized to the stomach, enters the esophagus
Other causes of gastroesophageal reflux are:
•Nicotine •Fried or fatty foods •Chocolate •Coffee •Citrus fruits and juices •Peppermints •Pregnancy
Esophagitis
Esophagitis is the irritation and inflammation of the esophagus caused by stomach acids and digestive enzymes repeatedly refluxing up from the stomach
Esophagitis Signs and Symptoms
•Burning sensation in chest •Pain when swallowing •Dysphagia (caused by the narrowing of lower esophagus due to scarring resulting in food sticking in the area) •Bleeding if ulcers develop (noted by black stools, anemia and vomiting blood)
Gastritis
Gastritis is an acute or chronic inflammation of the gastric mucosa caused by an increase gastric acid secretion. Gastritis is often associated with alcohol ingestion, drugs, and stress.
Esophageal Varices what is itsigns and symptomstreatment
Condition: hemorrhagic Pain, bright red blood, Melena, shock Common with hepatic disease and often result from portal hypertension caused by cirrhosis of the liver Tachy, hypotension, pale cool clammy skin Give fluid to map of 65 Check peripheral pulses Airway issues
Bowel Obstruction what is itsigns and symptomstreatment
Signs include -abdominal pain and fullness. -Rigidity usually all over -Look pregnant -Diarrhea initially -Constipation may eventually result. -Nausea and vomiting are common in later stages -Extreme cases have feculent breath Management -watch for sepsis -Fluid resuscitation can be useful -Needs fluid even if map is good
Peptic Ulcer Disease
Protective layer of the stomach and small intestine erode allowing the acid to eat into the lining of the stomach Condition: Acute inflammation Pain, often relieved by food intake, bleeding
Upper GI bleed
Mouth, stomach, esophagus Condition: hemorrhagic Pain, hemorrhage Upper GI bleeding: The upper GI tract is located between the mouth and the upper part of the small intestine.
Mallory-Weis Syndrome
the oesophageal lining tears during severe vomiting and may lead to severe haemorrhage and sepsis
Perforated ulcer
when it eats all the way through the stomach
Cholecystitis what is itsigns and symptomstreatment
-Gall stones, gall bladder attack Obstruction of the cystic duct leading from the gallbladder to the duodenum, Inflammation of the gallbladder; usually by gallstones Fever, jaundice, tachycardia Gallbladder is in right upper under liver Pain radiates to right shoulder ALS for pain med Give Zofran Give IV for n/v meds
cholecystjts Risk factors
Risk factors Females Pregnant Older people Caucasians Overweight or recent extreme weight loss
Cirrhosis what is itsigns and symptoms
-Cirrhosis is the final phase of chronic liver disease. -irreversible scarring of the liver resulting in poor liver function. Signs and symptoms -Edema and ascites (fluid from the peritoneal cavity) -Jaundice -Itching -Gallstones -Medication sensitivity -Toxicity
Hepatitiswhat is itsigns and symptoms
- Infectious - Inflammation and damage of the liver - Associated with the sudden onset of malaise, weakness, anorexia, intermittent nausea and vomiting, and dull RUQ pain
hepatitis causetreatment
- Causes o Viral(Hep A,B,C-in Canada D,E,F,G) A and E: transmitted through fecal matter B,C and D transmitted through contact typically sexual o Epstein Barr virus o Bacterial Infections o Liver Cancer - Pain meds from ALS- IV yes- O2 based on signs and symptoms of shock o Nasal cannula for n/v pts
Pancreatitis what is itsigns and symptoms
- Pancreas creates enzymes that we use to digest our foodo Creates insulin- In the area of the epigastric - Some common contributing factors to pancreatitis are an increase in alcohol consumption and Gallstones - More prevalent in the male population - Can also be caused by certain medications, trauma, cancerSigns and Symptoms - Nausea and Vomiting - Sharp, Epigastric or RUQ pain that can radiate to back - Possible fever, tachycardia, hypotension, possible muscle spasms in extremities - Grey turner sign: bruising to flanks- Cullen sing: bruising around umbilical region
Appendicitiswhat is itsigns and symptoms
- Caused by an accumulation of material, usually feces.- Lower right- Obstruction of normal flushing- Ripe condition for bacterial reproduction- Can result in ultimate rupture, peritonitis ( generalized abdominal pain), sepsis, and death Signs and Symptoms - Periumbilical pain that migrates to RLQ - Duration is usually less than 48 hours - As the condition progresses the pain will change characteristics and locations - Guarding - Rebound tenderness (parietal pain): doesn’t hurt when you push but when you let go it hurts
Diverticulitiswhat is itsigns and symptoms
- Is caused typically by a decrease in fiber intake- Consistency of stool become more solid- Hard stools take more contractions- Small defects in colonic wall fail- Diverticula: Feces become trapped in these pouches - Fistula: abnormal connection between two cavities and are typically found between colon and bladder- Can occur anywhere in the colon but most common in LLQSigns and Symptoms- Abdominal pain- Tends to be localized to the left side of the lower abdomen- Classic signs of infection - Fever, malaise, body aches, chills, nausea, and vomiting
Crohn’s Disease:
- May affect the entire GI tract - Immune system attacks the GI tract. - Most likely site of inflammation is the ileum. - Scarred, narrow, stiff, and weakened portion of the small intestine
Ulcerative Colitiswhat is itsigns and symptoms
Caused by o Generalized inflammation of the colon o Chronic inflammation o Thinning of the wall of the intestine o Weakened, dilated colon prone to infections by bacteria and bleeding o Most common second decade of life - Signs and Symptoms o Bloody diarrheao Abd pain (mild to severe)
Lower GI bleeding
- The lower GI tract is located between the upper part of the small intestine and the anus. The lower GI tract includes the small and large bowels. - Intestinal Bleeding Causes – Polyps, ulcers, diverticulitis, tumors, radiation therapy - Rectroanal Area bleeding – Hemorrhoids resulting from straining
Hemorrhoids
- Swelling and inflammation of blood vessels surrounding the rectum - Common problem- Increased pressure on the rectum- Irritation of the rectum
Bowel Obstruction
- Presentation Varies according to the underlying cause - Signs include abdominal pain and fullness. o Rigidity usually all overo Look pregnant- Diarrhea initially - Constipation may eventually result. - Nausea and vomiting are common in later stages - Extreme cases have feculent breath
- Hematochezia
bright red bleeding
- Hyperperistalsis- Hypoperistalsis
- Hyperperistalsis: Increased activity in the bowel- Hypoperistalsis: decreased bowel sounds
- Absent bowel sounds
mean no sounds for 2 mins
- Biliary pain
commonly radiates around the right side of the back and angle of the scapula
- Pancreatic pain
goes straight through the epigastrium to the back in the midline
- Blood/puss under the diaphragm
may present as pain in the top of the shoulder
- A leaking or ruptured aneurism
causing abdominal pain and back pain which may radiate to upper thighs
- Uterine and rectal pain
will present in suprapubic area, lower back or both
Visceral pain
- Hollow organs- Difficult to localize: described as burning, cramping, gnawing or aching usually felt superficially - Cause: organ contracts too forcefully or is distended (stretched)
Parietal pain/ rebound pain
- Peritoneum- Steady, achy pain, more easy to localize than visceral, pain increases with movement- Causes: inflammation of the peritoneum
Somatic pain
- Peripheral nerve tracts - Well localized pain usually felt deeply - inflammation or injury to tissue, causing activation of peripheral nerve tracts
Referred pain
- peripheral nerve tracts - pain originating in the abdomen and causes pain in distant locations; similar paths for the peripheral nerves of the abdomen and the distant location - causes: usually occurs after an initial visceral, parietal or somatic pain
- Fertilization
: Occurs in distal third of fallopian tube
- Implantation
Occurs in the uterus
- Placenta
begins to develop after 4th week
- Umbilical cord
o Has 2 arteries 1 vein
Fetal circulation
- Arteries carries the deoxygenated blood back to the placenta- The veins carry oxygenated blood back to baby
- Ductus venosus
duct that opens when blood comes in- Blood will leave from left atrium to lungs and return back through ductus arteriosus
- Gestation usually averages
40 weeks from time of fertilization to delivery
24 Weeks
- Sex organs visible- Covered with lanugo and vernix- Breathing by inhaling amniotic fluid into lungs
40 Weeks
- Surfactant present - Baby now about 7.5 lbs - Week 35-36 baby gain .5lb per week- Placenta detaches & umbilical cord ceases functioning as child takes first breath of air - Child’s breathing triggers changes in the structure of the heart and bypass arteries which will force all blood to travel through the lungs
maternal cardiac output increases to approximately
40% reaching its maximum capacity approximately 22 weeks and then declines approximately 20%
- A pregnant woman’s heart
increases slightly due to increased cardiac workload is displaced upward, forward and to the left with a slight rotation in its long access which causes the apex of the heart to shift laterally
- Enlarged uterus contributes
to slowed venous return, pooling, dependent edema, haemorrhoids and varicose veins
- Lying supine position maternal cardiac output can increase as much is- Maternal oxygen consumption increases by
25%20% of 40% above nonpregnant levels entitle volume increases gradually to approximately 40%
- Primigravida
: A woman who is pregnant for the first time
- Multigravida
: A woman who has had two or more pregnancies
- Nullipara- Primipara- Multipara- Grand multipara
- Nullipara: A woman who has never delivered - Primipara: A woman who has given birth only once - Multipara: A woman who has had two or more deliveries - Grand multipara: A woman who has had seven deliveries or more
- EDC
estimated date of confinement (40wks/280 days from last menstrual period)
Indications that birth is imminent
- Active labor 5mins apart- Contractions 1-2mins apart get ready to deliver- Mom feels like she needs to poop- Get her top pant so she wont bare down
Prepare for an imminent delivery
- Regular contractionso 45 to 60 seconds at 1-2 minute intervals - The mother has urge to bear down/sensation of a bowel movement - There is a large amount of bloody show - Crowning occurs(!) - Mother believes delivery is imminent
Dilation – Stage 1
- Start of contractions to full 10cm dilation & thinning of cervix.- Bloody show - mucus plug- Rupture of amniotic sac “…water breaks…”- Cramp-like pains - 10 - 20 min apart - 30-60seclong- Last days.
Expulsion – Stage 2
- Pass through cervix into vagina- Contractions - 2‐3minsapart- lasting 45 ‐ 90 secs- Pressure on rectum- Feeling like pushing- Bulging of perineum - Crowning- Cephalic normal- Head turn to side- Can last up to 50 min - Ends with delivery of the baby
Placenta Delivery - Stage 3
- From delivery of the baby to delivery of the placenta - Up to 30 min - Know time
Assisting with Delivery
- Control deliver2. Start to turn baby3. Slip finger along head to check for cord4. Clear airway IF NEEDED5. Gently guide head downward to deliver upper shoulder6. Gently guide head up to deliver lower shoulder7. Maintain newborn at level of vagina to prevent blood drainage from umboilical cord8. Dry warm stimulate baby9. Give baby to mom10. Record time11. Fundus massage
Para
how many live deliveries
Gravida
how many times shes been pregnant
Ectopic pregnancy
- Egg fertilized in distal 3rd of fallopian tube - Happens usually 8-9 weeks- Unilateral pain- Bleeding- Pain
Pre-eclampsia/eclampsia
- 3rd trimester complication- Women younger than 18 who are experiencing their first pregnancy and women with advanced maternal age 35 years or older and women with risk of chronic hypertension or all at increased risk- Something happens to the placenta- 3 main signso extreme edema to face o Any blood pressure over 140/90 is flagged pre-eclampsia o Proteins in urine- Eclampsia vs pre-eclampsia= seizures o Only thing that can help is delivering the baby- Airway management - Load and go
Abruptio placenta
- 3rd trimester condition- Placenta separates from uterine wall baby is no longer supplied- Excruciating tearing pain - Partial separation: concealed bleeding or apparent bleeding- Rapid transport
Placenta previa
- Low placenta- Placenta comes out first - Painless bleeding
Uterine rupture
- 3rd trimester complications- Usually a result of multiple c-sections- Compromise in the wall of uterus or is weak and it ruptures- Excruciating pain - Tons of blood- Weakness, dizziness, thirst- Strong painful contractions that weaken
Spontaneous Abortion (Miscarriage)
- 1st trimester before 20th week- Most of the time happens because of a x-some defect
Fetal membrane disorder PROM and Amniotic Fluid Embolism
- 3rd trimester - Water breaks but shes not in labouro Clearo Smello Color
Management of Third Trimester Bleeding
- Initial assessment (LOC, ABC’s, Skin, etc.)- Obtain V/S- Nature of the bleeding? OPQRST?- Quantity of blood loss? - Orthostatic changes?- Oxygen- ECG and V/S- Establish 1x (consider 2x) IV lines to maintain appropriate BP 18 GAUGE- 250ml blous and continue up to 20ml/kg- Left lateral recumbent- Loose trauma pads (no packing) to vaginal area.- Transport to appropriate facility- CONSTANTRE‐EVALUATION
Breech Presentation
- Elevate the hips - Spread legs very far apart- Push knees back- May have to put hand in to secure airway
Limb Presentation
- Limbs come out first- Position on all fours - Not common- Don’t push
Prolapsed Cord
- Position hips up on pillows and knees back2. Oxygen3. Instruct pt to pant with each contraction to prevent bearing down4. With 2 gloved fingers push presenting part back into vagina until its no longer pressing on the cord5. While u maintain pressure get partner to put moist dressing on umbiloical cord6. Hold until hospital
Cephalopelvic Disproportion
- Head and pelvis disproportioned - Head is too big for pelvis
Uterine Inversion
- Placenta fails to detach properly and stays attached to uterine wall - You have 1 attempt to push it back in
Maternal Hemorrhage
- Blood loss exceeds 500ml in 24hrs- Uterine massage and encourage woman to breast feed
- Diabetes
o Increased chance of miscarriage, pregnancy‐ induced hypertension, and birth defecto Gestational diabetes: inability to process carbohydrates during pregnancyo Oral hypoglycaemic agents can cross the placenta barrier in affect the fetuso Prehospital management includes high flow oxygen, intravenous, fluids and DW
General Management
- In absence of distress / injury, transport patient in position of comfort (usually left lateral recumbent) - ECG monitoring, high-flow O2 and IV fluid therapy may be indicated
- Embryo:
the egg third week after conception
Hyperemesis gravidum
- Continuous morning sickness- Prehospital treatment:o NRB oxygeno BGLo IV 250ml boluseso Gravolo Vital signso Transport
- Rh factor
: is a protein found on the red blood cells of most people when this factors absent the person is said to be Rh negative
Rh Sensitization
- When a woman who is Rh negative becomes pregnant by a man who is Rh positive the fetus inherits this factor in the fetal blood can pass through the mothers circulation and produce maternal antibodies to the factoro This can result in death for the fetus or cause haemolytic disease in a newborn
Molar pregnancy
- Malfunction of the egg or sperm resulting in an abnormal placenta- Normal progression of pregnancy but there is no fetus
Kidney Stones (Renal Calculi or Renal Colic)
- Originate in the renal pelvis o Result when an excess of insoluble salts or uric acid crystallizes in the urine o Insufficient water intake
kidney stones Patient presentation
- Some will be agitated and restless (walk and move to relieve pain). - Others will attempt to remain motionless and guard the abdomen. - Palpation of the abdomen difficult
kidney stones Prehospital management
- Centers on pain relief- Consider Intercept- Breathing techniques - Establish an IV line and administer fluids- Transport
Acute Renal Failure
- Sudden decrease in filtration through the glomeruli o Accompanied by an increase of toxins in the blood o Accounts for 30% of all ICU patients (5% of all hospitalizations) o Overall mortality rate of 50% o Reversible if diagnosed and treated early oliguria: urine output less than 500ml per day o Anuria: urine production stops
o Prerenal
anything that will cause decreased kidney disfunction but is not directly related to kidney ex: drug OD, trauma,
o Intrarenal
ex: kidney stone, infection, scarring from diabetes
Signs and symptoms - Prerenal acute renal failure:
o Caused by hypo perfusion of the kidneyso Hypotensiono Tachycardiao Dizzinesso Thirst
Signs and symptoms - Intrarenal acute renal failure
o Damage to one of the areas in the kidney which hinders blood flowo Flank paino Joint paino Oliguria- thirsto Hypertensiono Headacheo Confusiono Seizure
Signs and symptoms - Postrenal acute renal failure
o Caused by obstruction of urine flow from the kidneys blocked by an enlarged prostate, kidney stone, blood clots or structureso Pain in lower flank abdomen, groin and genitailia o Oliguriao Distended bladdero Hematuriao Peripheral edema
Chronic Kidney Disease
- Progressive and irreversible inadequate kidney function due to permanent loss of nephrons o Develops over months or yearso More than half caused by systemic diseases Can also be caused by congenital disorders or prolonged pyelonephritis
- Nephrons
o Damaged and cease to function o Scarring in the kidneys, tissue begins to shrink and waste away. o Kidney function diminishes, fluid builds up in the blood. o Uremia, Azotemia
Chronic Renal Failure Signs and symptoms
- Altered level of consciousness - Late stages: seizures and coma are possible. - Lethargy, nausea, headaches, cramps, and signs of anemia - Skin: pale, cool, and moist - Jaundice - Uremic frost - Edema - Hypotensive and tachycardia
Urinary Tract Infection
- Usually develop in the lower urinary tract (urethra and bladder) - Normal flora bacteria enter the urethra and grow- More common in women - In the upper urinary tracts (ureters and kidneys) occur most often when lower UTIs go untreated- May present with vague symptoms often including confusion
- Pyelonephritis
inflammation of the kidney linings
- Abscesses
reduce kidney function
Urinary Tract Infection Symptoms
- Painful urination- Frequent urges to urinate- Difficulty urinating- Bladder pain in women- Prostate pain in men- Urine may have a foul odor or appear cloudy
Proliferative Phase
- Increased endometrium thickness. - Initiates ovarian cycle. - Stimulates cells producing estrogen.
Secretory Phase
- Follows ovulation. - Estrogen & progesterone influence this phase. - Prepares the endometrium for gestation.
Menstrual Phase
- Absent during pregnancy. - Last for approx. 4 – 6 days. - Occurs when the ovum is not fertilized.
Endometriosis
- Endometrial tissue grows outside the uterus generally on the surface of abdominal and pelvic organs - Can be sometimes sometimes not- Localized lower back pain, pelvic and abdominal regions
Endometritis
- Inflammation and infection of the endometrium (lining of the uterus)- Usually caused by std- Fever- Pain- Constipation- Abdominal distention- Vaginal bleeding- Can lead to septic shock- Treat with Tylenol- Transport
Painful bladder system
- Chronic bladder condition with an unknown cause it results in an inflamed or irritated bladder wall- Symptoms vary but may mimic the symptoms associated with a UTI and STDs
- Dysmenorrhea
painful menses classified into categories primary and secondary
- Primary dysmenorrhea
: occurs with the advent of the menstrual flow and normally lasts for the first 1 to 2 days with gradual relief
- Secondary dysmenorrhea
pain that is present before during or after menstrual flow
- Amenorrhea
absence of menses
- Menorrhagia
if the flow of blood last several days longer than normal or is excessive
- Polymenorrhea
: if the blood flow occurs more often then a 21 day interval
o 4 causes for menorrhagia and polymenorrhea
Organic causes such as infection bleeding disorders endocrine disorders anatomic causes iatrogenic causes
- metrohagia
blood flow occurring irregularly but frequentlyo Treatment for stable non-pregnant patient is TXA & NSAIDs
Pre-termtermpostterm
- Pre-term: An infant delivered at less than 37 completed weeks of gestation- Term: an infant born at 37 to 42 weeks of gestation- Postterm: an infant born at more than 42 weeks of gestation
Transition from fetus to newborn
- As newborns begin to breed the lungs expand with air and pulmonary vascular resistance drops- blood flows to the lungs for gas exchange- Fetal circulation switches to a functional adult circulation by the closure of the ductus venosus, the ductus arteriosus and the foreman ovale
- Polycythemia
: an abnormally high red blood cell count caused by a delay in clamping the umbilical cord and keeping the infant below the level of the placenta
when to bag baby
- For very preterm infants younger than 32 weeks plastic wrap maybe used to wrap the newborns body prior to drying
where do you assessrespiratory rate, respire Tori effort, pulse rate and pulse ox measures on a newborn
right arm
- Oxygen saturations greater than 90% are typically not reached until
6 to 7 minutes after birth- room air or 30% oxygen should be used to resuscitate newborn if required
Need for Resuscitation
- if the baby has a normal breathing pattern, and a pulse greater than 100 but maintains central cyanosis provide free flow supplemental oxygen
- if the newborn is apneic or has a pulse less than 100 after 30 secs of drying and stimulating begin bag valve mask
- after 30 secs of adequate ventilation with bvm with 100% oxygen if the infants heart rate is less than 60 begin compressions
- Set flow rate of oxygen at
5lpm
- Choanal atresia
: boney or membrane is obstruction of the back of the nose preventing airflow can be rapidly fatal but usually responds to a placement of an oral airway or a gloved finger
- Pierre robin sequence
: series of developmental anomalies including a small chin, cleft palate and posteriorly position tongue that frequently leads to airway obstructions o positioning the patient prone may relieve obstruction if not insert OPA
bag valve mask- Indicated when a newborn is
o Apneao Pulse less than 100o Peristant central cyanosis despite breathing 100% oxygen
- Signs of respiratory distress that suggest a need for ventilation include
include periodic breathing, intercostal retractions, nasal flaring and grunting on expiration
- Tidal volume of a neonate is
5 to 8 ml/kg
ventilating
- Ventilate 40-60/min- Count breath-two-three, breath-two-three- Continue as long as pulse is under 100 or resp rate is ineffective
Intubabtion- Indicated when:
o Meconium stained amniotic fluid is present and newborn is not vigourous o Congential diaphragmatic hernia: abdominal organs herniate to chest cavityo No response to BVM and chest compressionso Prolonged ppv and hospital is more than 30mins away
Chest compressions
- Indicated if pulse rate remains less than 60 bpm despite positioning, clearing the airway, dragon stimulation and 30 seconds of effective PPV- To rescue her technique with the thumbs is the preferred and recommended technique when possible- Depth is 1/3 of the chest- No interruption in chest compressions at any time- The person ventilating delivers of breath during the sequence breed and- Compression to ventilation ratio of 30 to 2 for single rescuer and 15 to 2 for multiple rescuers- Pulse rate is assessed at 62nd intervals and once the pulse is above 100 bpm gradually slow the rate and decrease the pressure of the positive pressure ventilation
Epinephrine- Indicated
- Indicated with the infant has a pulse rate less than 60 after 30 seconds of effective ventilation and 30 seconds of chest compressions
- Hypoxic newborn that is severely anaemic will look
pale not cyanotic
Diaphragmatic hernia
- Abnormal opening in the diaphragm most commonly on the left side- Heart sound shifted to the right, decreased breath sounds on the left, bowel sounds heard in the chest and scaphoid abdomen - Mortality may be as high as 50%
Apnea
- Respiratory pause greater than or equal to 20 seconds common in infants delivered before 32 weeks but rarely seen in the first 24 hours after delivery- Risk factors include prematurity, infection, prolonged or difficult labor, drug exposure, hypoglycemia, hypothermia, seizures and metabolic disorders
Premature low birth weight
- Weighing less than 2500 g is considered low birth weight- If a newborn is delivered prior to 24 weeks of gestation or weighs less than 500 g and he’s born outside of center equipped to manage such deliveries the newborn is unlikely to survive- Premature newborns are at higher risk for respiratory distress due to surfactant deficiency
- Subtle seizure
is characterized by high deviation, blinking, sucking and peddling movements of legs and apnoea
- Tonic seizure
may be classified as focal or generalized
o Focal tonic seizure
the persistent posturing of one limb, the neck, or the trunk with horizontal I deviation is characteristic of a focal tonic seizure
o Generalized tonic seizure
more common and typically involve atomic flexion of arms with tonic extension of legs
- Clonic seizures
: maybe classified as either a focal seizure if one body part is involved or a multi focal seizure if multiple body parts are involved
- Myoclonic seizure
: categorized as focal, multifocal and generalizedo The jerks in myoclonic seizures are much more rapid and do not have rhythm
o Focal myoclonic
: activity often involves flexion of arms
o Multifocal myoclonic
activity involves twitching of multiple body parts
o Generalized myoclonic
: bilateral jerking with flexion of the arms, and occasionally flexion of the legs
- Hypoxic ischaemic encephalopathy
usually secondary to prenatal asphyxia is the single most common cause of seizures in both term and preterm infantso Characteristically occur in the first 24 hours over 2 to 3 days
- Hypoglycemia
most frequently sent an infants who are small for the gestational age, those who are large for gestational age and those whose mothers were diabetic during pregnancy neurological symptoms consist of jitteriness, hypoTonia, apnea, poor feeding and seizures’
Assessment and management of seizures
- Obtain vital signs and oxygen saturations- provide additional oxygen- assisted ventilation- blood pressure evaluation- IV access- D 10 W solution may be given as an IV bolus to millilitres per kilogram if the newborns blood glucose level is less than 2.6 mmol/l
- Average normal temperature of a newborn is
37.5 the range is 36.6 to 37.2
o Evaporation heat loss occurs
when water evaporates from the skin and respiratory tract
convection heat loss occurs
to cooler surrounding air the extent of heat loss depends on the air temperature and air movement
o In conduction heat loss occurs
occurs to cooler solid objects in direct contact with the body
radiation heat loss occurs
to cooler surrounding objects not in direct contact with the body
Hypothermia
- Drop in body temperature to less than 36- May have pale skin and acrocyanosis- May present with apnea, bradycardia, sinuses, irritability and a weak cry- Extremely hypothermic babies the face and extremities may appear bright red
Hypoglycemia
- Blood glucose level less than 2.6 mmol per litre- Most infants remain asymptomatic until glucose falls below 2.2 mmol per litre for significant time- Symptoms of hypoglycaemia include cyanosis, apnea, irritability, poor sucking or feeding and hypothermia- Also associated with lethargy, tremors, twitching or seizures, coma, tachycardia, tachypnoea or vomiting
- Meconium plug syndrome
the passage of meconium is delayed in the first 24 hours of life
- Caput succedaneum
swelling of the soft tissue of the infant scalp as it presses against the dilating cervix o very common
- cephalohematoma
Area of bleeding between the parietal bone and it’s covering periosteum
- linear skull fractures
skull fractures are occasionally seen in difficult births
Neonate and infant
- First month of life is neonatal. I- infancy refers to the first 12 months of life - infants between two and six months of age begin to hold their heads up - 6 to 12 months infants begin to crawl in Babble
ToddlerPreschool aged
Toddler- The toddler. Extends from ages 1 to 2 yearsPreschool aged- 3 to 5- They will be able to tell you what hurts
School aged childAdolescent
School aged child- 6 to 12 years- By eight years the child anatomy and physiology are similar to those of an adult- Ask the child questions rather than the caregiverAdolescent- 13 to 18 years
Neck and airway
- The airway of a young child is also smaller than an adult airway making it more prone to obstruction- During the first 4 to 6 months of life infants are obligate nose breathers and nasal obstruction with mucus can result in significant respiratory distress- The narrowest part of a young child airway occurs at the level of the cricoid cartilage rather than at the vocal cords as an adult
Chest and lungs
- A child’s chest wall is quite then making it easy to hear heart and lung sounds but also means that sounds are transmitted throughout the chest- Children have fewer rib fractures and flail chest events however thoracic organs may be more severe- Children are more vulnerable than adults the pulmonary contusions, cardiac Tampa nod and diaphragmatic rupture- Signs of a pneumothorax or haemothorax and children are often subtle
Heart
- During the first year of life ECG axis and voltage of shift to reflect left ventricular dominance
Abdomen and pelvis
- abdominal distension in a healthy infant is due to two factors the weakness of the abdominal wall muscles and the size of the solid organs- liver extends below the rib cage in infants- Abdominal injuries are the second leading cause of serious trauma in children- The liver and spleen extend below the rib cage and do not have much boney protection as they do in an adult the kidneys as well
The musculskeletal system
- The growth plates of a child’s bones are made of cartilage, or relatively weak and are easily fractured- Fractures are more common than sprains
PAT to form a general impression
- Begins with your general assessment of how the patient looks sick or not sick- Including three elements the child’s parents work of breathing and circulation
Appearance
- Appearance reflects the adequacy of ventilation, oxygenation, brain perfusion, body homeostasis and central nervous system function
- TICLS pneumonic
highlights the most important features of a child’s appearance tone, interactiveness, consolability, look or gaze and speech or cry
Work of breathing
- Listening for abnormal airway sounds and looking for signs of increased breathing effort- Abnormal positioning and retractions are physical signs of increased work of breathing that can easily be assessed without touching the patient- Combined the characteristics of work of breathing abnormal airway sound, abnormal positioning, retraction, and nasal flaring to make your general assessment
- Grunting
involves exhaling against a partially closed glottis o the short low pitch sound is best heard at the end of exhalation and is often mistaken for whimperingo Grunting suggest moderate to severe hypoxia lower airway condition such as pneumonia, bronchitis and pulmonary oedema
sniffing position - Tripod position
trying to align the axis of airways to improve patency and increase airflowis creating the optimal mechanical advantage to use accessory muscles of respiration
- Retractions
represent the recruitment of accessory muscles of respiration to provide more muscle power to move air into and out of the lungs in the face of airway or lung disease or injuryo May be evident in the Super clavicular area above the clavicle, the intercostal area between the ribs, or the sub sternal area under the sternumo Head bobbing is another form of retractions
- Nasal flaring
exaggerated opening of the nostrils during labour inspiration and indicates moderate to severe hypoxia
- The three Characteristics considered when assessing the circulation
pallor, modelling and cyanosis
- Pallor
may be the initial sign of poor circulation or even the only visual sign in a child with compensated shocko May indicate anaemia or hypoxia
- Modelling
reflects vasomotor instability in the capillary beds as demonstrated by Alicia pattern in areas of vasoconstriction and vasodilation
Breathing assessment
- Calculating the respiratory rate, auscultating breath sounds, and checking pulse ox for oxygen saturation
assessment of circulation
pulse rate and quality, skin colour temperature in condition plus capillary refill time, and blood pressure
- Tachycardia may indicate
early hypoxia or shock or less serious condition such as fever, anxiety, pain or excitement
- Acceptable blood pressure in children 1 to 10 years is determined by
70 + (2 x age)
- Immediate transport
for trauma and the child has a serious mechanism of injury, physiological abnormality, potentially significant anatomic abnormality, or if the scene is unsafe- In these cases stabilize the spine, manage the airway and breathing, stop external bleeding and begin transport attempt vascular access on the way
Focused history and physical exam- Four objectives:
o Obtain complete description of the chief complaint using sample and OPQRSTo Determine the MOI or nature of illnesso Perform rapid trauma or medical assessmento Obtain baseline and subsequent vital signs
Ongoing assessment
- Include the PAT, reassessment of patient priority, vital signs every five minutes for unstable every 15 minutes for stable, assessment of effectiveness of interventions, and reassessment of focussed examination areas
- Respiratory distress
increased work of breathing to maintain oxygenation or ventilation it is a compensated o State in which increased work of breathing resulting in adequate pulmonary gas exchange o Hallmarks of respiratory distress are classified as mild, moderate or severe these include retractions, abdominal breathing, nasal flaring and grunting
- Respiratory failure
Can no longer compensate for underlying pathologic or anatomic problem by increased work of breathing so hypoxia and carbon dioxide retention occurso Signs include decreased or absent retractions going to fatigue, altered mental status owing to inadequate oxygenation and an abnormally low respiratory rateo Decompensated state
- Respiratory arrest
implies that patient is not breathing spontaneously o administer immediate bag mask ventilation with supplemental oxygen to prevent progression to cardio pulmonary arrest
Foreign body aspiration or obstruction
- In the absence of fever, cough or respiratory congestion suspect foreign body aspiration when a child has a sudden onset of respiratory distress accompanied by coughing, gagging, strider or wheezing
Epiglottitis
- The severe inflammation of supraglottic structures usually due to bacterial infection- Classic presentation is easily distinguished using the PAT and initial assessment the child will look sick and anxious, will sit up right in the sniffing position and maybe drooling because of an inability to swallow secretions- The work of breathing is increased, and pallor or cyanosis may be evident there may be strider, muffled voice, decreased or absent breath sounds and hypoxia
Bronchiolitis
- Is an inflammation of small airways in the lower respiratory tract due to viral infection- An infant with a first time wheezing episode occurring in the late fall or winter likely has bronchiolitis- Mild to moderate retractions, tachypnea, diffuse wheezing and diffuse crackles and mild hypoxia characteristics
Bag mask ventilations
- Deliver breath at a rate of 12 to 20 breaths per minute for infants and children squeeze in the bag only until you see chest rise- Ventilate at the appropriate rate and volume over approximately one second until the chest visibly rises do not hyperventilate
- Tachypnoea without retractions or abnormal airway sounds
is common in an infant or child with primary cardiac problems it is a mechanism for blowing off carbon dioxide to compensate for metabolic acidosis related to poor perfusion
- For suspected cardiovascular compromise
start with airway and breathing and provide support care as needed- Ensure adequate oxygenation and ventilation and then assess the circulation by checking heart rate, pulse quality, skin CTC, and blood pressure
o A child and compensated shock
tachycardia and signs of decreased peripheral perfusion such as cool extremities with prolonged Capillary refill
- Decompensated shock
shock is a state of inadequate perfusion in which the bodies on mechanisms to improve perfusion are no longer sufficient to maintain a normal blood pressure by definition a child a decompensated shock will be hypotensive for his or her age
o A child in decompensated shock may have
an altered appearance, reflecting inadequate perfusion of the braino Hypertension is it late and I’m gonna sign in an infant or younger child an urgent intervention is needed to prevent cardiac arrest
Hypovolemic shock
- Most common cause of shock in infants and young children with lots of volume occurring due to illness or trauma- The child may appear pale, modelled or cyanotic- Signs of dehydration such as sunken eyes, dry mucous membranes, poor skin turgor or delayed calf refill with cool extremities
Distributive shock
- Decreased vascular tone develops, resulting in vasodilation and third spacing of fluids due to increased vascular permeability - May be due to sepsis, anaphylaxis and spinal cord injury- Early in distributive shock the child may have warm flushed skin and bounding pulses as a result of peripheral vasodilation- The symptoms and signs of late distributive shock will look much like hypovolaemic shock on initial assessment fever is a key finding in septic shock
Obstructive shock
- There is impaired filling of the heart thus reduce cardiac output- A child with obstructive shock usually has a history of abrupt onset symptoms of shock and or a history of trauma to the chest- Sign specific to the underlying cause such as asymmetric chest rise an absent breath sounds on the side of a tension pneumothorax, or muffled heart sounds and an elevated jugular venous pressure in cardiac tamponade
Cardiogenic shock
- Is the result of a pump failure- Myocardial function is poor- Uncommon in paediatric and less they have an underlying congenital heart disease
Bradydysrythmias
- Most often occur secondary to hypoxia rather than as a result of primary cardiac problem- Initiate electronic cardiac monitoring as part of your initial assessment- If the child’s pulse rate is lower than normal for age but perfusion is poor despite providing adequate oxygenation and ventilation begin chest compressions and ventilations
Menegitis
- Entails inflammation or infection of the meninges the covering of the brain and spinal cord - most often caused by a viral or bacterial infection- Viral meningitis is rarely a life-threatening infection bacterial meningitis is potentially fatal- Young infants will have to have a fever, lethargic, irritability, poor feeding at a bulging fontanel along with neck stiffness
- Meningococcal meningitis with sepsi
is typically characterized bypetechial (small purple nonblaching spots on the skin or purpuric (larger purple or black spots) rash in addition to other menegitis symptoms
Febrile seizures
- Child must be between three months and six years old have a fever and no identifiable precipitating cause
- Simple febrile seizure
brief generalized tonic clonic seizures lasting less than 15 minutes that occur in a child without underlying neurologic abnormalities
- Aytipical febrile seizure
: longer than 15 minutes, or focal or occur in a child with baseline developmental or neurologic abnormalities
- Status epilepticus
: is defined as a condition in which seizures recur every few minutes or last more than 20-30mins
Sudden Unexpected Infant Death 3 causes
- Sudden infant death syndrome2. Unkown cause3. Adccidental suffocation and strangulation in bed
Brief resolved unexplained event (BRUE)
- A brief resolved unexplained event formally known as an apparent life-threatening event is an episode during an infant becomes pale or cyanotic chokes gags or has an acne expel or loses muscle tone
BurnsAssessment
- For infants to head and trunk each account for 18% of body surface area, the arms each count as 9% and the legs each count as 13.5%
CSF- Hydrocephalus
is a condition resulting from impaired circulation in absorption of CSF leading to the increase size of the ventricles and increased ICP
- CSF shunts
: inserted to drain excessive fluid from brain normalizing ICPo When pressure buildup in ventricle the one-way valve opens and CSF drains into the peritoneum word is reabsorbed
- A CSF shunt obstruction
occurs when the drainage of fluid from the brain through the shunt becomes blocked without adequate fluid drainage the CSF fluid continues to accumulate resulting in increased ICP- Typical symptoms include headache, fatigue, vomiting
