Emergencies Flashcards
What is the leading cause of childhood death in the US?
Injuries
Why do head injuries occur more often in kids?
Larger head to body ratio
Weak neck muscles (acceleration-deceleration injuries)
Thin skulls
Physically uncoordinated
Lack cognitive ability to predict/understand danger
Critical components of history with head injuries
Witnessed fall, height of call, immediate cry, consolable, vomiting, time since injury, arousable, size of mass, other injuries
Concerning signs with head injury
Excessively sleep or hard to arouse
Vomiting
Irritability/behavior changes
Primary exam that needs to be done with head injuries
ABCs
Neuro status (GCS, pupils, sucking reflex, muscle tone-<8 is immediate resuscitation)
Vital signs
What is Cushing’s triad and what does it indicate?
Wide pulse pressure
Bradycardia
Abnormal respirations
Indicates increased intracranial pressure
What are signs of a basilar skull fracture?
Battle’s sign
Periorbital ecchymosis (raccoon eyes)
Hemotympanum
Otorrhea/rhinorrhea (CSF)
When is CT not indicated in head injuries?
For low risk pts with low risk injuries
How do you decide when to do a CT with a head injury?
PECARN (primary one)
CATCH (irritability is involved)
CHALICE (has the speed of the MVA)
Who gets a CT in head injuries?
GCS<15 or acute mental status change Signs of skull fracture Vomiting >3 times Seizure Less than 2 Nonfrontal scalp hematoma LOC<5 sec Severe mechanism "Not acting right" or lethargic
Where does a subdural hematoma occur?
Between the dura and arachnoid membrane (associated with diffuse brain injury)
**crosses the suture lines
How does a subdural hematoma occur?
Tearing of bridge veins so a low pressure bleed that dissects the arachnoid away from the dura
How might a pt act with a subdural hematoma
LOC/lingering sxs (irritability, lethargy, bulging fontanelle, vomiting)
CT findings in subdural hematoma
Crescent shaped, usually parietal area
What has a better prognosis, subdural or epidural hematoma?
Epidural
How does an epidural hematoma occur?
Rupture of arteries (usually meningeal)–may have an underlying fracture
**does not cross sutures!
History seen in an epidural hematoma
Brief LOC
Lucid period followed by deterioration
CT findings for epidural hematoma
Elliptical shape
How does a subarachnoid hemorrhage occur?
Injury to parenchymal and subarachnoid vessels
CT findings of a subarachnoid hemorrhage
Small dense slivers-blood in cisterns, sulci and fissures
Blood in the CSF
May take hime to be visible on a CT tho
Most common bleed with a head injury
Subarachnoid hemorrhage
Management for a head injury with no ICH or skull fracture
Head injury precautions (monitor for behaviors, vomiting, decreased arousal, seizure irritability)
Sleeping is ok
Management for a head injury with an ICH and +- skull fracture
Neuro consult
Admit (evacuation of ICH/surgery to repair fracture)
Repeat imagin
Sxs of a concussion
Amnesia Confusion and/or blunted affect, distractibility Delayed response Emotional lability Visual changes Repetitive speech pattern
What must you do when a pt is found to have a substance abuse problem and has a concussion?
Must CT!
When does the HA, fogginess and other mild sxs usually resolve with a concussion?
7-10 days (Can go up to a month)
What is emergent after a concussion?
Severe, prolonged or worsening HA, vomiting or deterioration
What is post-concussive syndrome?
Sxs lasting 3 mos or longer
What is second impact syndrome?
2nd concussion within weeks (brain swelling, hernation or death)
Kids are at increased risk
What is chronic traumatic encephalopathy?
Multiple concussions
Permanent change in mood, behavior, pain
Tx for concussion
No same day return to play (regardless if sxs resolve)
Physical and cognitive rest
Slow advancement of activity after sxs resolve
Causes of cervical spine injuries <8
Often MVAs but can be falls
C2-4
Causes of cervical spine injuries >8
Often MVAs but can be sports
C5-C7
Test of choice for cervical spine injuries
MRI (adolescents can have SCIWORA that is not picked up on CT so use this)
What is concerning with a cervical spine abnormality?
Bilateral pain
Neuro deficits
Torticollis
Bony abnormalities
Management of a compound open fracture
Splint/dress, start IV abx, ortho consult
Management of non-displaced open fracture with overlying laceration
Start PO abx, repair laceration, splint, outpt ortho f/u
Management of grossly deformed/displaced fracture
May compromise neurovascular structures so require closed or open reduction and maybe fixation
What must you always remember with an intervention for fractures?
Always document neurovascular status before and after!!
Cellulitis vs erysipelas
Both skin infections, bacterial entry and all other signs
Cellulitis is deeper dermis and subcutaneous fat
Erysipelas is upper dermis and superficial lymphatics
Tx for cellulitis or erysipelas
Warm wet compress
Bactroban topical
Keflex or bactrim orally
Most often cause for osteomyelitis
Hematogenous spread of infection to bone (sinus infection, dental etc)
S. aureus, strep pneumoniae, strep pyogenes
Where does osteomyelitis occur?
Long bones
Presentation of osteomyelitis
Fever, bone pain, swelling, redness guarding
Focal tenderness during exam
What is seen on an x-ray in osteomyelitis?
Early: soft tissue swellig
10-14 days later: bone destruction with lytic lesions
Best study for eval of osteomyelitis
MRI (marrow edema or abscesses)
Tx for osteomyelitis
Supportive IV abx (empiric at first-vanco, clinda, rocephin) Drainage Debridement Hyperbaric O2 therapy
Important history with toxic ingestion
Substance Route Quantity How long since Progression of sxs Home txs? Underlying med conditions
Tx for toxic ingestion
Stabilize pts (ABCs) contact poison center Disability Drugs Decontamination
Decontamination for ocular exposure
Test pH Copious normal saline lavage until normal pH Flush at least 15 min before re eval Make sure contacts removed Consult opthamo
Decontamination for skin exposure
Copious NS and water
Follow with soap to concentrate lipid soluble toxins
Decontamination for GI exposure
Activated charcoal, cathartics, whole bowel irrigation
Enhance elimination
Decontamination for blood stream exposure
Antidote
What is ipecac?
For GI decontamination
Only helps if given within 30 mins of exposure
Not recommended usually
When might activated charcoal be used?
Caramazepine, barbiturates, dapsone, quinine, theophylline
Digoxin or phenytoin
Not with salicylates
NOT FOR hydrocarbons, lithium, stong acid/base, metals, EtOH
When is simple dilution used?
For mild toxins that only cause irritation or corrosion
What is used for enhanced elimination of ingestin?
Activated charcoal
urine alkalization
Diuresis
Dialysis/hemoperfusion
Antidote for acetaminophen
Acetylcysteine
Antidote for benzos
Flumazenil
Antidote for narcotics/opiods
Naloxone (narcan)
What happens if a foreign object passes the pylorus?
Continues to rectum and is passed in stool without complications
Concerns with foreign object ingestion
Sharp or irregular edges
If lodged in esophagus (airway obstruction, strictures, perforation)
Aspirated veggies can cause intense pneumonitis
Presentation of esophageal FB
Refusal to eat Vomiting Choking, coughing, stridor Neck or throat pain, inability to swallow Increased salivation FB sensation in chest
Procedure of choice to remove FB
Esophagus (endoscopy)
Trachea (bronchoscopy)
When should you consult with a FB?
Sharp or elongated Multiple Button batteries Perf Longer than 24 hrs Airway compromise Coin at level of cricopharyngeus muscle (below or above)
What is esophageal button battery?
An emergency!!
What happens with a button battery?
Extremely rapid action of alkaline substance on mucosa, pressure necrosis, residual charge
(lithium is worst, mercuric oxide can cause heavy metal poisoning)
Tx for button battery
Emergent removal if in esophagus
If past it then dont remove unless not pass pylorus after 24-48 hrs
Surgical consult if Gi sxs
2 primary problems in drowning
Hypoxemia and acidosis
What can hypoxemia from drowning lead to?
CNS damage and arrhythmias, pulm injury, reperfusion injury, multi organ dysfunction
What is dry drowning?
When laryngospasm leads to hypoxia that leads to LOC
No fluid
What happens in wet drowning?
Dilute and washout surfactant, lose gas transfer, atelectasisi and VQ mismatch
What is near drowning?
Survival past 24 hrs (can see severe brain damage)
alert or mildly obtunded at ED presentation but may see full recovery
What has a poor prognosis with near drowning?
Comatose, getting CPR or have fixed and dilated pupils and no spontaneous respirations
Poor prognosis in drowning
Submersion over 5 mins Longer than 10 mins to get BLS Longer than 25 min resuscitation Ager over 14 GCS<5 Persistent apnea and CPR in ED Arterial blood pH<7.1
When should child abuse be considered with near drowning?
Less than 6 mos
Toddlers with atypical presentation
What is secondary drowning?
Death up to 72 hrs after near drowning incident
Fresh water drowning results in hemodilution from ingested water
Can have hemolysis or arrhythmias is large enough water
Most critical tx for drowning
Pre hospital care
What is a fever without a source?
Rectal temp over 38C (100.4)
Must ID occult bacterial infections (pneumonia, UTI, bacteremia, herpes, meningitis)
What does the workup in a fever based on>
Age (<3 mo is neonate and 3 mo-3 yr is infant)
Appearance
Risk factors (birth history, travel, exposures, vaccinations, immune deficiiences)
Workup for kid <3 mos with temp over 38C
Workup regardless of appearance
Sxs of infection with neonatal fever
Irritability, decreased activity, poor feeding and no weight gain, lethargy, change in sleep, vomiting, diarrhea, hypothermia
Management of neonatal fever
Full septic workup
Empiric abx
Admission after culture results
Managment of ill appearing 3 mo old to 3 yr
Labs UA Cultures CXR is tachypnea or leukocytosis Parenteral abx Admit
Well appearing kid not immunized with a fever with management
CBC with diff
BLood culture if WBC>15000
UA if girl <2 yr, uncircumcised <1 yr or circumcised <6 mo
CXR is leukocytosis >20000
Well appearing immunized kid with fever management
UA and culture if girl <2, uncircumised <1 and circucised <6 mo
If older than no routinelabs, no abx therapy but do need UA C&S
Fever >39C and abnormal UA should be treated for UTI
