Emergency Care Flashcards
Patient presented at the ER with 2 days of gradually worsening cough and dyspnea, with air hunger and drooling. What is your priority?
a. Secure the airway
b. Secure IV access
c. Get ABG
d. Start antibiotics
a. Secure the airway
In establishing intraosseous access, what is to be done:
a. empiric antibiotics
b. only isotonic solutions are to be given
c. only IV fluids are to be given and not medications
d. May be maintained for up to 3 days
a. empiric antibiotics
NTP Chapter on Pediatric Emergencies and Resuscitation: Once the patient has received initial drug and fluid therapy through the IO line, every effort should be made to obtain more conventional central venous access and remove the IO line as soon as possible, to minimize risk to the bone. Because such needles are often inserted in haste, consideration should be given to empirical antibiotic coverage after the needle is placed and the patient stabilized.
Diagnosis of acute abdomen like acute appendicitis A. History and PE B. Xray C. Ultrasound D. CT scan
NTP19 Ch 335 Acute Appendicitis Diagnostic Approach The diagnosis of appendicitis occasionally humbles even experienced clinicians. A diagnosis of acute appendicitis is made in only 50-70% of children at the time of initial assessment, and delay in diagnosis and treatment leads to substantial increases in morbidity, length of hospitalization, and cost. When patients have perforation due to late presentation, missed diagnosis, or delay in diagnosis, they require longer hospitalizations, often other invasive procedures such as percutaneous drainage of abscesses, and longer courses of antibiotics, and they are at higher risk for the complications of appendicitis including abscess formation, peritonitis, sepsis, wound infection, and small bowel obstruction. The cost of treatment for cases of perforated appendicitis is approximately double the cost for nonperforated cases. Traditionally, early surgery in equivocal cases was the standard because complications and morbidity rise dramatically in appendicitis after perforation. Negative laparotomy rates of 10-20% were common and were deemed acceptable to keep perforation rates low. Many authors have criticized these high negative laparotomy rates, citing the risks and expense of unnecessary surgery. National databases have become an important resource for benchmarking and standardization of care. The Pediatric Health Information System (PHIS) was created by the Child Health Corporation of America (CHCA) as a national database to support the evaluation and improvement of clinical care in children’s hospitals. A review of data collected from this source demonstrated substantial variation in practice patterns and resource utilization in the evaluation and management of appendicitis. Overall rupture rates for appendicitis varied from 20% to 76%, with a median of 36%. The median overall negative laparotomy rate (normal appendix) was 2.6%, significantly lower than traditionally reported rates of 10%-20%. The lack of consensus in management approach is reflected by the fact that the use of diagnostic imaging in cases of suspected appendicitis varied from 18% to 89%. The diagnostic challenges are many, including the rapid escalation of appendicitis from subtle malaise to perforation (often within 36-48 hr), variable abilities of medical centers and experience among clinicians, and fear of malpractice suits for missed diagnosis. Several reports have described clinical scoring systems and computer-assisted decision-making models incorporating specific elements of the history, physical examination, and laboratory studies designed to improve diagnostic accuracy in acute appendicitis (see Table 335-1). To date, none has demonstrated improved accuracy over experienced clinical judgment. Some clinicians remain steadfast to the primacy of a careful history and physical examination and rarely order imaging studies. The initial assessment, along with the history and physical examination, may include a complete blood count with differential, urinalysis, and plain films (chest and abdominal series). If the initial assessment leads to a high level of suspicion for appendicitis, pediatric surgical consultation should be the next step, with the likelihood of prompt appendectomy without further studies. If the initial evaluation suggests a nonsurgical diagnosis and a low concern for appendicitis, the child may be discharged with advice to the family to return for repeat evaluation if the child is not improving on liquids and a bland diet in the next 24 hr. This approach has demonstrated high sensitivity and specificity (>90%) at certain institutions, but collective data from many centers have not been able to reproduce this degree of accuracy. In equivocal cases, some clinicians or centers proceed with a plan of active observation. Many reports substantiate improved diagnostic accuracy by observation and serial examination over a period of 12-24 hr, simplifying the eventual decision to proceed with appendectomy, discharge the patient, or proceed with imaging studies, and report no correlation between surgical morbidity and timing of surgery. The child may be observed with intravenous fluids and planned repeat CBC and physical examination in 6-12 hr. At the end of a period of observation, the clinician should decide to discharge the patient based on improved clinical status, proceed to appendectomy, or proceed to further imaging evaluation. Further imaging in this equivocal group hopefully can minimize the negative laparotomy rate without increasing the perforation rate (missed or delayed diagnosis). Less than 2% of children’s appendices perforate while under observation. This approach is cost effective, often avoids radiologic imaging, and is optimized if an observational unit is available that avoids admission costs for the period of observation. Most centers demonstrate improved diagnostic accuracy for appendicitis in children when using radiologic imaging as an adjunct to history and physical examination, and some have even recommended imaging in all atypical cases to minimize unnecessary surgery (negative appendectomy) and avoid the complications of missed appendicitis, including perforation with abscess formation and peritonitis, sepsis, wound infection, and small bowel obstruction. The consequence of missed appendicitis substantially increases morbidity, length of stay, and cost. With selective imaging, the PHIS review of pediatric centers had an overall negative appendicitis appendectomy rate of 2.6%. It seems likely that if imaging studies are obtained in all patients with equivocal presentations and a brief duration of illness (<24 hr), the false-negative rate of the imaging studies will increase. Maximum benefit and effectiveness of imaging is obtained when it is used selectively in children for whom the diagnosis is equivocal after careful history and physical examination by an experienced clinician and who are not too early in the temporal evolution of the illness. A thoughtful approach in equivocal cases of appendicitis is to begin with ultrasound if it is readily available and the hospital has experience with ultrasound for possible appendicitis. Ultrasound in one study decreased the need for CT scan in 22% of patients. CT scan is used if ultrasound is unavailable or inconclusive, or as the first-line test in obese patients, in cases of probable advanced or perforated appendicitis, or when there is gaseous distention of the bowel. This approach has proved highly accurate and cost-effective. Practice guidelines have decreased both length of stay and cost without increasing complications. One such guideline employing clinical judgment and selective imaging attained a positive and negative predictive value for appendicitis of 94% and 99%, respectively.
Chest compression:ventilation relationship in a 5 year old child is: a. 3:1 b. 5:1 c. 7:1 d. 15:2
B. (p. 280, Nelson’s). 3:1 C:V ratio is for neonates; 5:1 is for 1-8 years old; 15:2 is for >8y/o.
