Emergencies Flashcards
What about infant anatomy makes them more prone to head injuries?
Large heads in comparison to body size, weak neck muscles, thin skulls, open sutures
What bones comprise the base of the skull?
sphenoid, temporal, occipital, ethmoid
What information is good to gt on a fall history?
Witnessed? Height? Immediate cry? Inconsolable? Vomiting? Time since injury? arousability? Size of hematoma? Other injuries?
Why might it not be concerning if a child is “drowsy?” What is a concerning sign as far as sleep after trauma is concerned?
Normal nap time; Excessively sleepy or hard to arouse with vomiting and irritability
What does primary survey consist of (time sensitive)?
ABC’s, Neuro status, Vital signs
What components are in the neuro status exam?
Glasgow Coma Scale, pupillary responses, sucking reflex absent, muscle tone (floppy baby is an axial injury)
What are the scores of the GCS for Eye Opening?
No response: 1
To pain: 2
To speech: 3
Spontaneous: 4
What are the scores of the GCS for Best Verbal Response?
No response: 1 Incomprehensible sound: 2 Inappropriate words: 3 Confused (irritable infant): 4 Oriented (infant coos): 5
What are the scores of the GCS for Best Motor Response?
No Response: 1
Abnormal extension (decerebrate posturing): 2
Abnormal flexion (decoricate posturing): 3
Withdraws to pain: 4
Localizes (infant withdraws to touch): 5
Obeys (infant moves spontaneously/purposefully): 6
What are the components of the secondary survey?
Head/neck and the rest of the body
What are the components of the head/neck survey?
C-spine alignment (x-ray through collar), fundoscopic exam, hematomas (size and location), step-offs, crepitus, lacerations, fontanels, basilar skull fx
What are signs of a basilar skull fx?
Battle’s sign, periorbital ecchymosis, hemotympanum, otorrhea/rhinorrhea (CSF)
DOCUMENT NEGATIVE EXAM FINDINGS
What is the prognosis for a subdural (dural border) hematoma? Where does it occur? What is pathognomonic for this injury?
Poor; between the dura and the arachnoid membrane, there is a tearing of bridging veins and low pressure bleeds, dissects arachnoid away from dura; diffuse brain injury is a/w it (pathognomonic)
What symptoms is a subdural hematoma usually a/w? What does a CT reveal? What is special in this lesion?
LOC (lingering), irritability, lethargy, bulging fontanelle, vomiting. CT reveals crescent-shaped lesion, usually in the parietal area. It usually crosses suture lines
What is the prognosis for an epidural hematoma?
Better than subdural (it takes more force to get blood into the subdural space, not as much a/w this injury)
What is the mechanism of injury for epidural hematoma?
Rupture of arteries +/- underlying fx (usually +). Typical hx: brief LOC, lucid period followed by deterioration
What is unique about an epidural hematoma?
It is eliptically shaped, doesn’t cross sutures (confined by suture lines so it bulges into the brain instead of spreading around.
What is the prognosis of a subarachnoid hemorrhage (SAH)?
Better than epidural, most blood comes from arteriole venous malformation.
What are CT findings of SAH?
Small dense “slivers,” blood in cisterns,, sulci, and fissures. Blood also in CSF.
What are sx of SAH?
from normal to LOC, may be visible on CT
How do you treat SAH?
Serial CTs, WARN PARENTS OF THINGS TO LOOK OUT FOR!
How do you manage an SAH with no ICH and no skull fx after CT?
Take head injury precausions, PALPATE INTO LACERATION, monitor for behavior change, vomiting, decreased arousability, seizure activity, and irritability. Wake up every 2-3 hours if you are concerned about sleep.
How do you manage an SAH with ICH +/- skull fx?
neuro consult, admit (PICU?) where they will do an evacuation of ICH with surgery to repair fx OR observation with repeat imaging
How do you define a concussion? How is it usually caused?
Traumatically induced alteration in mental status with or without an associated loss of consciousness; direct blunt force leads to stretching and shearing of axons (they can snap)
Symptoms of concussion
Amnesia, confusion or blunted affect, distractability, delayed response, emotional lability, visual changes, repetitive speech pattern
When MUST you get a CT?
With EtOH or other substance use; with vomiting following head trauma
Prognosis of a concussion
HA, mental fogginess, etc resolves within 7-10 days. Severe, prolonged or worsening HA, vomiting, deterioration in mental status are emergent. Post concussive syndrome can last for 3 months or longer.
Second impact syndrome
2nd concussion within weeks results in brain swelling, herniation and death. Children are at increased risk. May need cleared by neuro.
What are important components of a post-concussive exam?
GCS rating, CN II-XII test, balance, gait, cognitive/memory testing, head, eyes, ears, nose, neck/throat, chest, and extremity exam
What is the classification used for epiphyseal fractures called?
Salter-Harris
What is a toddler’s fracture?
Usually occurs around the time children begin to walk, non-displaced spiral fx of the tibia, sx are irritability, refusal to walk
What one thing should you ALWAYS do before and after splinting/reducing/ or any other intervention?
DOCUMENT NV STATUS
What bones should you should you suspect child abuse if they are broken?
Femur, acromion, spinous process, skull, posterior rib (pathognomonic), any spiral fx with a story that doesn’t line up
What is the CP of a child with a nursemaid’s elbow dislocation?
arm is slightly flexed and prone, refusal to use arm
How do you dx and tx a nursemaid’s elbow?
normal radiographs (r/o fx), history; reduction (give them a lollipop after), educate adults
What are the most common causitive organisms for acute septic arthritis?
s. aureus or strep pneumo (also MRSA). In adolescents: N. gonorrhea
What are the symptoms of acute septic arthritis?
Fever, worsening joint pain, warm, swollen joint and pain with ROM, hip typically held in flexion/external rotation
How do you diagnose acute septic arthritis?
CBC, CRP, ESR, Blood culture, Joint Aspiration (c&s)
How do you manage acute septic arthritis?
Antibiotics PLUS repeated aspiration (smaller joints) OR surgical drainage (hips and shoulders)
When and where is osteomyelitis most common? What are the responsible pathogens (triple S)?
In boys younger than five and in the long bones; s. aureus, s. pneumoniae, s. pyogenes
What is the best study to order if you suspect osteomyelitis?
MRI to show bone marrow edema or abscesses
What lab studies should you order if you suspect osteomyelitis?
CBC, CRP, ESR
What is the CP of osteomyelitis?
fever, bone pain, swelling, redness, guarding of the affected limb, focal tenderness during the exam
How to you treat osteomyelitis?
IV Abx, surgical drainage, debridement, and hyperbaric oxygen therapy
What ages is transient synovitis the most common in?
18 months to 12 years
What is the etiology and symptoms of transient synovitis?
Etiology unknown, often follows a URI, streptococcal infection, or mild trauma; symptoms include ABRUPT ONSET OF PAIN TO HIP, THIGH, OR KNEE, normal or slightly elevated temperature, usually FROM
How do you diagnose transient synovitis?
WBC and ESR (normal or slightly elevated), x rays, ultrasound (may show effusion). Just make sure it’s not septic arthritis (diagnosis of exclusion)
What is the treatment for transient synovitis?
Pain relief, observation, close follow up
What is Legg-Calve-Perthes dz and what does it look like? What population is it most common in?
idiopathic avascular necrosis of the femoral head; looks like SCFE; Boys ages 4-9
What is the main symptom of LCPerthes dz?
limp, little or no pain, nontoxic, insidious onset, hip is held internally rotated and shows limited abduction
How do you diagnose and treat Legg-Calve-Perthes?
x-ray (AP and frog-leg lateral hip), bone scan, and urgent ortho referral
What is slipped capital femoral epiphysis (SCFE) and what population is it seen the most in? What is it associated with?
When the femoral head slips and exposes the anterior/superior aspects of the femoral neck; seen in teenage males, a/w obesity, increased height, genital underdevelopment, and pituitary tumors
What are the symptoms of SCFE? How do you diagnose?
Acute or chronic hip or knee pain; x ray shows “ice cream falling off the cone”
What is the treatment for SCFE?
conservatively with bed rest and traction (PT). Most require some measure of surgery.
What is your ddx for hip/joint pain in a pediatric patient?
fracture (unlikely), acute septic arthritis, osteomyelitis, transient synovitis, Legg-Calve-Perthes dz, SCFE
When is gastric lavage generally indicated?
rarely for TCAs, CCBs, iron, lithium, and EtOH
When is charcoal indicated?
carbamazepine, barbs, dapsone, quinine, and theophylline injestions, some with digoxin and phenytoin
Is charcoal helpful for use with salicylates?
Little evidence is given for it
What is charcoal NOT indicated for?
hydrocarbons, lithium, strong acid/base, metals, EtOH
What methods are considered to be “enhanced elimination”?
Charcoal, Urine Alkalization, Diuresis, Dialysis, Hemoperfusion
What is the antidote for acetaminophen?
Acetylcysteine
What is the antidote for anticholinergics?
Physostigmine
What is the antidote for benzos?
Flumazenil
What is the antidote for beta blockers?
Glucagon
What is the antidote for calcium channel blockers?
Calcium
What is the antidote for digoxin?
Digibind
What is the antidote for heavy metals?
Chelating agents
What is the antidote for narcotics?
Naloxone
What is the most important lab to get drawn if you suspect toxicity?
acteaminophen
What are some exam findings that are positive for esophageal FB?
Red throat, palatal abrasions, wheezing, decreased BS, fever, peritoneal signs
What is the procedure for removing FB in the trachea?
Bronchoscopy
What is the procedure of choice for removing FB in the esophagus?
Endoscopy
What are some indications for consultation after FB ingestion?
Sharp or elongated objects above the level of cric, button batteries, multiple FB, or evidence of perforation, coin at the level of cricopharyngeus muscle, or presence of FB more than 24 hours
How do you differentiate between a button battery or a coin?
BB has a rim, coin does not, BB appears to be raised, coin does not
What are two primary problems related to impaired ventilation?
Hypoxemia and acidosis (most drowning victims aspirate less than 4 mL of liquid)
CNS damage may occur due to hypoxemia sustained during the drowning episode (primary injury) and subsequent:
arrhythmias, ongoing pulmonary injury, reperfusion injury, multi-organ dysfunction
What is considered “dry drowning” (no fluid in lungs)?
Laryngospasm leads to hypoxia and then LOC
What is considered “wet drowning”?
More common, aspiration of water into the lungs, dilution and washout of surfactant leads to fiminished gas transfer across alveoli leads to atelectasis leads to ventilation perfusion mismatch.
It is important to know fresh water vs. salt water
What is secondary drowning?
It may cause death up to 72 hrs after near drowning accident. Caused because fresh water results in hemodilution from INGESTED water (electrolyte disturbance)
How do we treat someone who has been subject to secondary drowning?
Get O2 sats to 95% or higher, use mechanical ventilation; use warmed isotonic IV fluids and warming blankets; treat electrolyte abnormalities, monitor cardiac rhythm; CXR, repeat at 6 hours; admit for ventilation
What is a fever considered? What is the goal when you see a fever?
A rectal temp of greater than 100.4; seek for occult infections
What do you do for a child that presents with a “non-toxic” fever?
UA on all males less than 6 months, uncirced males less than 12 months, all females less than 24 months, and all older females with UTI sx; rapid viral testing for flu and RSV; Stool for WBCs and guaiac (if diarrhea)
What tests should be done for a “toxic” fever?
CBC with diff, CXR, UA, CSF analysis (LP), stool for WBCs and guaiac and rapid virus testing
What antibiotics are typically chosen for empiric antibiotics in treating neonatal fever?
Cefotaxime 50 mg/kg/dose
Ampicillin 50 mg/kg/dose
What disease are you trying to exclude on a fever of unknown origin?
Meningitis on children less than 12 months need full septic workup (blood culture, LP, CXR, UA)
What drug is administered to be used prophylactically at onset of fever to prevent seizure?
diazepam
What is the peak age for the incidence of SIDS? What time of day does it usually occur?
2-4 months old from the time of midnight to 8 am
