Emergency Flashcards
head injuries
-Range in severity from minor asymptomatic trauma without sequelae to fatal injuries
-Nonspecific symptoms: Headache, dizziness, N/V, disorientation, amnesia, slowed thinking, and perseveration
-Worsening symptoms in first 24 hours may indicate more severe TBI
-Obtain vital signs and assess child’s LOC by AVPU system or GCS
-PE:
-Detailed neurologic examination
-CSF or blood from ears or nose, hemotympanum, or later appearance of periorbital hematomas (“racoon eyes”) or bruising over mastoid process (“battle sign”) imply a basilar skull fracture
-Eval for associated injuries/C-spine
-Consider child abuse if injury is not consistent with history, developmental stage, and the injury mechanism
head injuries: imaging
-Close observation versus CT scan (PECARN score)
-In infants, normal neurologic exam does not exclude significant intracranial hemorrhage
-Consider imaging if large scalp hematoma or concerns of nonaccidental trauma in younger children
head injuries: complications
-CNS infection: Open head injuries, basilar skull fractures (allow direct entry of organisms)
-Acute intracranial HTN
-AMS, headache, vision changes, vomiting, gait difficulties, pupillary abnormalities
-Signs: Papilledema is cardinal sign
-> Others include stiff neck, cranial nerve palsies, and hemiparesis
-Cushing triad (bradycardia, HTN, and irregular respirations) is a late/common finding
-CT scan prior to LP to avoid herniation
-Tx: ABCs, supportive care (intubation), mannitol/hypertonic saline, neurosurgical consult
head injuries: prognosis and prevention
-Prognosis:
-Depends on severity of initial injury, presence of hypoxia or ischemia, development and subsequent management of intracranial HTN, and associated injuries
-Prevention:
-Helmets
-Over 50% of children fail to wear helmets when riding bicycles
-More stringent helmet use while playing contact sports now in place in child and high school sports programs
-Toppled TVs, dressers, and other unsecured furniture can also result in mild to severe head injuries in young children (anticipatory guidance should be provided)
thermal burns
-Common cause of accidental death and disfigurement in children
-Common causes include hot water/food, appliances, flames, grills, vehicle-related burns, and curling irons
-Associated with child abuse and preventable nature of burns constitute an area of major concern in pediatrics
thermal burns: clinical manifestations
-Superficial-thickness burns: Painful, dry, red, and hypersensitive (sunburn)
-Partial-thickness burns: Superficial or deep
-Superficial partial-thickness: Red, blisters
-Deep partial-thickness: Pale, edematous, blanch with pressure, decreased sensitivity to pain
-Full-thickness burns: Extend through all layers of skin, as well as into the underlying fascia, muscle, and possible bone
-Singeing of nasal or facial hair, carbonaceous material in the nose and mouth, and stridor indicate inhalational burns > critical airway obstruction
burns: physical abuse
-25% of burns in children may be due to physical abuse
-Symmetric immersion burns with glove and stocking distributions with sharp margins
-Buttock burns that spare center and result in a “doughnut appearance”
-Simultaneous deep burns of buttock, perineum, and both feet
-Burns with clear pattern of hot object (iron, cigarette lighter)
-Lower extremity burns that spare flexor surfaces
-Delay in seeking care, unknown or unwitnessed cause of burn, or burn pattern not consistent with mechanism
thermal burns dx and tx
-Labs
-Extensive partial-thickness and full-thickness burns: CBC, BMP, and CK (tracking infections, renal function)
-Inhalational injuries: ABG, carboxyhemoglobin levels
-Evaluation
-Burn extent classified as major or minor based on calculating total percent of body surface area (BSA) affected by partial-thickness or full-thickness burns
-Minor: < 10% BSA for partial-thickness; < 2% for full-thickness
-Major: Burns to hands, feet, face, eyes, ears, and perineum
-Tx:
-Superficial-Thickness and Partial-Thickness Burns
-Initial analgesia
-Saline irrigation followed by application of clear antibiotic ointment and nonadherent dressing -> Small blisters may be left intact under dressing; larger left intact versus drainage
-Protect wound with bulky dressing, re-examine in 48 hours and serially thereafter
-Cool compresses/pain control continued at home
-Full-Thickness, Deep or Extensive Partial-Thickness, and Subdermal Burns
-ABCS, artificial airway (oral/nasal burns), intubation (singeing of oro- or nasopharynx), NGT, bladder catheterization
-Primary/secondary surveys
-Fluid resuscitation: Based on weight and percentage of BSA with partial- and full-thickness burns
-Parkland formula
-4 mL/kg/% BSA burned for first 24 hours
-½ administered in first 8 hours, ½ in second 16 hours
-Maintenance fluids in addition
-Goal urine output is 1-2 mL/kg/hour
thermal burns disposition and complications
-Disposition:
-Burns > 10% in circumferential pattern, suspicious for abuse, associated with inhalational injury/explosions/fractures > admitted
-Admission for those requiring parenteral analgesia as well
-Burns > 20% > admission versus burn center
-Subdermal burns > burn center
-Complications:
-Deep partial-thickness and full-thickness burns are at risk for scarring
-Loss of barrier function predisposes to infection
-Damage to deeper structures may result in loss of function, contractures, and compartment syndrome (circumferential burns)
-Renal failure secondary to myoglobinuria from rhabdomyolysis
-Prognosis: Greater the BSA and depth of burn, the greater the risk of long-term morbidity and mortality
thermal burns: prevention
-Place hot liquids as far as possible from counter edges
-Panhandles turned away from stove edge
-Water heater thermostats turned to less than 120F
-Irons/electrical cords out of reach
-Barriers around fireplaces
-Protective clothing/hats outdoors
-Infant approved sunscreen for 6 months and older
electrical injuries
-Vary from exposure to low-voltage, high-voltage, or lightning strikes
-Children electrocuted with household current (low-voltage) who are awake and alert at time of evaluation are unlikely to have significant injury
-ECG unnecessary in these cases
-Brief contact with high-voltage source results in contact burn (treat accordingly)
-Infants and toddlers that bite cords may result in burns to the commissure of the lips > labial artery hemorrhage
-If current passes through the body, pattern of injury depends on path of current
-“Locking-on” effect: Alternating current causes tetany
-Extensive nerve and muscle injury, fractures, and cardiac arrhythmias, in addition to dermal burns are possible
-Lab evaluation (UA for rhabdomyolysis) as well as cardiac monitoring should be performed
-Lightning strikes may induce asystole and blast trauma: May not have physical injuries, but can present in cardiopulmonary arrest
heat related injuries
