Emergency Flashcards
What is the AVPU score?
A - alert
V - voice
P - pain
U - unresponsive
What is warm shock?
Hyperdynamic shock
High cardiac output, low peripheral resistance
What is cold shock?
Hypodynamic shock
High systemic vascular resistance and low cardiac output
Why do patients have a narrow pulse pressure in cold shock?
Systolic: low due to low CO
Diastolic: high due to catecholamines that increase systemic vascular resistance to increase venous return
Why do patients with warm shock have a wide pulse pressure?
Lowered diastolic BP
Cytokines increase vascular permeability and cause systemic vasodilation, lowering the systemic vascular resistance
Which vasopressor is used for cold shock?
Adrenaline
Strong B1 activity - increases CO
Given if fluid resuscitation is inadequate
Which vasopressor is used for warm shock?
Noradrenaline
Acts on alpha 1 and beta 1 receptors, producing potent vasoconstriction and a modest increase in cardiac output
Given if fluid resuscitation is inadequate
Is cold or warm shock more common in infants/neonates?
Cold shock
What is the difference between SJS and TEN?
Extent of spread
<10% SJS
>30% TEN
What is the most common cause of SJS?
Drugs (80%)
Antibiotics (sulfonamides), corticosteroids, antiepileptics, alllopurinol, antiretrovirals
What is the pathophysiology of SJS?
Delayed type IV hypersensitivity
Cytotoxic t cells → keratinocyte damage
How does mucous membrane involvement differentiated SJS from staphylococcal scalded skin syndrome?
Involved in SJS
How is SJS treated?
Cease offending drug
Supportive
How is Kawasaki disease diagnosed?
Fever + 4 of
- Fever lasting > 4 days
- Bilateral conjunctival injection (non-exudative)
- Erythematous rash
- Dry/red fissured lips or strawberry tongue
- Oedema of hands/feet
- At least once cervical lymph node > 1.5cm
How are the points in the GCS distributed?
Eye - 4
Verbal - 5
Motor - 6
How are eye responses scored for the GCS?
4 - spontaneous
3 - verbal command
2 - pain
1 - no eye opening
How are verbal responses scored for the GCS?
5 - orientated
4 - confused
3 - inappropriate words
2- incomprehesible sounds
1 - no verbal response
How is motor response scored for the GCS?
6 - obeys commands
5 - localises pain
4 - withdraws from pain
3 - flexion to pain
2 - extension to pain
1 - no motor response
How is DIC from meningococcal treated?
Antithrombin
(thrombotic/organ failure type)
Antithrombin inhibits thrombin and other coagulation factors
What is the empirical treatment for suspected meningococcal sepsis?
Benzylpenicillin IV or IM
How is adrenaline dosed in childhood?
10 micrograms/kg
0.01mL/kg of 1:1000
What doses are children defibrillated with?
4 J/kg
What is the definition of hypoglycaemia in a child?
BGL < 2.6 mmol/L
What fluid type is given for resuscitation/bolus?
0.9% NaCl
How is a child’s fluid bolus calculated?
20mL/kg
0.9% NaCl
How are a child’s replacement fluids calculated?
Weight x % deficit x 10mL
(only replace to 5% in the first 24 hours)
How do you calculate a child’s daily fluid requirements for maintenance?
What % body weight loss corresponds with mild, moderate and severe dehydration?
3% mild
5% moderate
10% severe
When is supplemental oxygen used in an asthma attack?
SaO2 < 94%
Maintain > 94%
When is Ipratropium used for acute asthma?
Include timing and dose
Severe +/- moderate asthma
Every 20 minutes x 3 with salbutamol
< 6 years: 4 puffs
6+ years: 8 puffs
What is third space loss?
Too much fluid moves from the intravascular space into the interstitial space
- Three spaces:*
- intracellular*
- intravascular*
- interstitial*
What BSL should be maintained in DKA treatment before insulin is infused?
10-15
So insulin can be administered and resolve ketoacidosis
What serum potassium level is a contraindication to insulin in DKA?
< 3.3 mmol/L
How fast should BSL fall in DKA management?
4 mmol/L to prevent cerebral oedema
What is the proposed pathophysiology of cerebral oedema with DKA?
Hyperglycaemia → hyperosmolality
Insulin → reversal of osmolality → fluid moves intracellularly → cerebral oedema
What are the clinical features of cerebral oedema in the management of DKA?
Headache, vomiting, irritability, lethargy, elevated BP, altered mental status, incontinence, focal neurological deficits
During basic life support, for how long do you attempt to feel a pulse before commencing chest compressions?
10 seconds
Which pulses are most reliable for palpation in children?
Carotid, femoral, brachial
What is the COACHED approach to defibrillation?
C - compressions continue
O - oxygen away
A - all else clear
C - charging
H - hands off/I’m safe
E - evaluate rhythm
D - defibrillation or disarm and dump
How much energy should be given in a shock from a defibrillator?
4J/kg
What is unstable bradycardia?
HR < normal PLUS signs of shock
HR < 60 bpm in infants
How should unstable bradycardia be managed in a responsive patient?
- Bag and mask ventilation with high flow oxygen
- Volume expansion 20ml/kg 0.9% NaCl
- Consider atropine 20mcg/kg IV or IO if vagal cause
What gas flow rate should be set for neonates on the neopuff?
10L/min
What maximal pressure should be set for neonates on the neopuff?
50cm H2O
What PEEP should be set for neonates on the neopuff?
5-8 cm H2O
What PIP should be set for neonates on the neopuff?
30cm H2O (term)
20-25 cm H2O (preterm)
What does a small amount of PEEP do?
Prevent end-expiratory alveolar collapse
What are 3 paediatric insertion sites for an IO access?
- Distal femur
- Proximal tibia
- Distal tibia
- Proximal humerus
Where is the IO insertion site on the proximal tibia?
2cm below the tibial tuberosity
1cm medially
Where is the IO insertion site on the distal femur?
1-2cm above the superior border of the patella with the leg in extension
Where is the IO insertion site on the distal tibia or fibula?
1-2cm superior to the melleoli in the bone’s axis
Where is the IO insertion site on the proximal humerus?
Greater tubercle
What are the clinical features of an effective cough?
Crying or talking
Loud cough
Able to take a breath before coughing
Fully responsive
Mild airway obstruction
What are the clinical features of an ineffective cough?
Unable to cry to talk
Quiet or silent coug
Unable to breathe
Cyanosis
Decreased level of consciousness
How is an ineffective cough managed in a conscious patient?
Call for help
5 back blows, 5 chest thrusts
Assess and repeat
What is the effect of adenosine on the heart?
Slows heart rate
Suppresses SA node activivation and slows conduction through the AV node
How is stable SVT managed?
- Vagal manoeuvre - ice pack to the face
- IV adenosine 0.1mg/kg
How is the shocked patient with SVT managed?
Synchronised DC cardioversion
1 joule/kg
What do the 4 H’s and 4 T’s describe?
Reversible causes of cardiac arrest
What is involved in a septic workup?
- Blood cultures
- CXR
- Lumbar puncture
- Urine culture
Over what period of time is the fluid deficit in DKA corrected?
48 hours
The aim is the achieve sufficient perfusion to avoid acute tubular necrosis but keep the patient relatively hydrated while the metabolic defect is corrected
What is the ABCDE approach to a sick child?
A - airway
B - breathing
C - circulating
D - disability
E - exposure
(F - fluids)
(G - glucose)
What dose of salbutamol is given via a nebuliser in severe asthma?
(nebulised not given in mild/moderate)
1-5 years: 2.5 mg
6+ years: 5 mg
What dose of nebulised ipratropium is given to children with a severe asthma exacerbation?
(Ipratropium + nebulised bronchodilators are not used in mild/moderate asthma)
1-5 years: 250 mcg
6+ years: 500 mcg
What are the features of a severe asthma exacerbation?
Intercostal/subcostal recession or tracheal tug
Unable to complete sentences in one breath
Obvious respiratory distress
Oxygen saturation 90–94%
