EMS/ADMIN/Psych Flashcards
4 components to the pediatric trauma score
- Weight
- Airway
- Systolic BP
- CNS / Mental status
- Open wound
- Skeletal
*scores assigned a 2, 1 or (-)1
*score < 8 = referral to trauma center
Injurity Severity Scale (trauma) - how to calculate
Combine AIS for 3 most seriously injured regions
(AIS = 1 to 5 (survival uncertain) for injuries within 6 body regions: head/neck, face, chest, A/P, extremities, skin)
What does ISS predict?
Valid predictor of mortality, length of stay and cost of trauma care
5 reasons to activate trauma team? (9)
- Trauma mechanism with unstable VS
- Penetrating injury to head, neck, torso
- Head injury with GCS < 14
- Pediatric trauma score < 8
- Gunshot wound victim
- Two or more proximal long bone fractures
- Severe maxillofacial injuries w/ airway compromise
- Evidence of spinal cord injury w/ paralysis
- At discretion of trauma / ED physician
6 things to include in brochure for playground safety?
- Use age appropriate equipment
- Hold onto protective barriers/guardrails
- Use vertical rather than horizontal bars (to discourage climbing)
- Active supervision is important
- Discourage climbing on guardrails
- Ensure appropriately protective surfacing under and around play equipment
2 things required of quality assurance program?
- Process for monitoring a specific procedure or process to ensure it is meeting the standard
- Need known standard / measureable outcome
- Need continuous review of processes
4 steps of a quality improvement program?
- Plan - create team, define objectives and questions, plan data collection
- Do - carry out plan, collect data
- Study - analyze data, compare to predictions
- Act - plan next cycle, decide whether to implement change
2 factors that reflect quality in asthma management
- Number of admissions/hospitalizations
- Number of return ED visits
4 requirements for a continuous quality improvement program
- Structure - people / technology
- Process
- Output
- Outcome
CTAS Primary Modifiers (4)
- Level of consciousness
- Respiratory - RR, SpO2, effort
- Hemodynamic - HR, BP, perfusion
- Pain
- Temperature (> 38.5 for pts 3 mo - 3 yrs, > 38 for pts > 3 yr)
JUMP START Triage System
Minor (Green) = walking wounded
Black (expectant) = No spontaneous breathing with positioning of airway or 5 rescue breaths if has a pulse
Red (immediate) = Spontaneous breathing with airway positioning, RR <15 or > 45, no pulse or PU on AVPU
Yellow (delayed) = unable to walk but breathing, RR 15-45, (+) pulses, AV on AVPU
10 things that measure quality assurance in peds ED
- Length of stay
- Pain intervention at triage
- Patient satisfaction
- Hand hygeine
- ED admissions within 8 hours
- Left without being seen rate
- 48-72 hour returns
- Specimen ID errors
- Cultural sensitivity
- Time to abx in sepsis
CTAS levels - name and time guidelines
Level 1: Resuscitation - immediate
Level 2: Emergent - 15 minutes
Level 3: Urgent - 30 minutes
Level 4: Semi-urgent - 60 minutes
Level 5: Non-urgent - 120 minutes
Three offline (indirect) roles of EMS Medical Director
- Training of EMS: certification, CME
- Protocol development: standing orders
- Quality assurance: field assessments, medical simulation, audits/review of care
- Authorization of clinical practice
- Serving as a liason within medical community
- Promotion of research
Examples of Direct Medical Oversight
- Physician-directed care
- Direct patient care on scene
- Patient care delivery suggestions: radio, phone, videp
- Provider advocacy: physical/scene safety, PPE
List 2 advantages of a cohort study
- Less expensive and time consuming than RCT
- Can estimate relative risk (incidence)
List 2 disadvantages of cohort study
- Challenging for rare disease/outcomes
- Controls may be difficult to obtain
- Does not account for all potential confounders
What factor is important in determining pre-test probability?
Prevalance of disease
What factors (3) influence post-test odds?
- Prevalance of the disease in catchment population
- Patient-specific patient risk factors
- Diagnostic test itself (likelihood ratio)
Post-test odds = pre-test odds x likelihood ratio
Post-test probability
Post-test probability = post test odds / 1 + post-test odds
Post-test probability is the proportion of patients that test positive that truly have the disease (same as positive predictive value)
Levels of Evidence / “Quality categories” (5)
Level 1: atleast one proper RCT
Level 2: Well designed controlled trial w/o randomization
Level 2b: Well design cohort, > 1
Level 3: Descriptive or observational studies, case control
Level 4: Expert opinion, case reports
8 elements of informed consent for participation in pediatric clinical research trial
- Description of clinical investigation - purpose, duration, procedures
- Risks or discomforts
- Benefits
- Appropriate alternative treatments/procedures
- Confidentiality
- Compensation and medical treatment in event of injury
- Contact information
- Voluntary
- Should consider assent in pediatric cases
Prevalence
Prevalence = # of people with disease / population at same time x 100
Total number of cases of disease existing in a population at a given time
Incidence
Incidence = # of new causes of disease in specific time / size of population at start of study period x 100
probability of being diagnosed with a disease during a given period of time
Regression analysis
set of statistical processes for estimating the relationship between a dependent variable (outcome) and one or more independent variable
2 types of Regression Analysis
- Simple linear regression - continuous or ordinal data, only one independent variable
- Multiple linear regression - more than one independent variable used; analyze whether the variable significantly contributes to the model
Relative Risk
Risk/probability og event (disease) in the exposed group vs control group
RR = (A/A+B) / (C/C+D)
4 Ethical Principles of Human Research
- Beneficience - apply evidence based care to children
- Nonmalificience - avoid harmful therapies extracted from adult data
- Respect for informed consent
- Distributive justice - allow research benefits to be available to all populations
- Respects confidentiality and privacy
3 criteria for authorship on scientific paper
Substantial contributions to all of the following:
- Concept, design, analysis and/or interpretation of data
- Writing/ revieweing drafts
- Approving final version of manuscript for publication
- Agree to be accountable for all aspects of work
- Identify which coworkers did what
What amount of risk is acceptable in healthy children participating in a study?
Minimal risk –>risk that is equivalent to that ordinarily encountered in daily life or during the performance of routine physical or psychological tests
- any harms during procedure will be transient and reversible in consideration of the nature of the harm
3 indications to break confidentiality with patient
- suicidal / homicidal ideations
- child abuse/neglect
- public health concerns
4 quality indicators in RCT (6)
- Randomization
- Allocation concealment
- Blinding
- Eligibility defined
- Sample size calculation
- Intention to treat analysis
5 things to do when applying physical restraints
- Attempt de-escalation techniques first and consider chemical restraints prior to physical restraints
- Regular reassessments: < 9 yo - 1 hr, 9-17 yo - 2 hr, adults - 4 hrs
- Ensure constant supervision
- Require 5 staff to apply restraints (one / limb plus head)
- Regularly record VS / behavior changes
5 common historical features in Munchausen by Proxy
- Diagnosis does not match objective findings
- Inconsistent histories from different observers
- Caregiver insists on invasive or painful procedures and hospitalizations
- Sibling has had an unusual illness or death
- Failure of the child’s illness to respond to normal treatments
- Use of multiple medical facilities
- Sensitivity to multiple environmental substances
6 common risk factors for suicide in teenagers
- History of mental illness
- Prior history of self harm or SI
- Substance abuse
- Parental mental illness or family hx of suicide
- Family conflict or poor child-parent communication
- Lack of psychosocial support or follow-up
- Hx of impulsivity (aggression, risk taking behavior)
Methods of verbal de-escalation (4)
- Introduce yourself
- Simplified language, soft voice, slow movements
- Reduce environmental stimulation
- Offer food/drink
- Reassure child that your job is to keep them safe
- Listen and empathize
- Offer distracting toys / sensory modalities
- Find things for the child to control (choice of drink)
4 common signs/symptoms of adolescent depression
S - sleep changes
I - loss of interest
G - feelings of guilt or worthlessness
E - lack of energy / fatigue
C- impaired concentration
A- change in appetite
P - psychomotor agitation/retardation
S - suicide/death preoccupation
Diagnostic Triad for School Refusal
- Vague physical symptoms
- Normal physical exam and lab findings
- Poor school attendance
5 Behavioral Manifestations that go along with school refusal
- Anxiety
- Mood disorder - depression
- Anger / aggressive behaviors
- Arguing / defiance
- Learning disorders, tics, nightmares
- Somatization
4 physical signs of Bulimia Nervosa
- Dental enamel erosions
- Enlarged parotid glands
- Callused knuckles/fingers
- Xerosis / dry skin
2 serious complications of bulimia nervosa
- Electrolyte derangements/ dehydration- hypokalemia, metabolic acidosis/alkalosis
- Arrhythmia –> prolonged QTc
- Mallory Weiss tear
3 comorbidities associated with school phobia
separation anxiety
major depressive disorder
adjustment disorder
social phobia / simple phobia
conduct disorder
Precipitating factors for suicide
vital role in interaction with predisposing RF for suicide
- access to means (firearms)
- alcohol/drug use
- exposure to suicide (fhx)
- social stress / isolation
- emotional / cognitive factors
4 reasons to put a patient in physical restraints
- threat to themselves
- threat to others
- failure of verbal deescalation and chemical restraint
- unable to give chemical restraint (allergy or C/I)
Emancipated minor (4)
- Pregnant or already a parent
- Married
- Enlisted in armed forces/military
- Legally / economically self supporting
Exceptions to consent in minors
- Emergency or life-threatening situation
- STI
- Pregnancy
- Alcohol / substance use
- Mental health treatment
- Sexual / physical abuse
- Emancipated minor
Sensitivity formula
A / A+C
Rule OUT
Type 1 error
conclude that there is a difference between groups when one does not exist (incorrectly reject the null hypothesis)
Type 2 error
conclude that there is no difference in outcomes but a difference does exist
(minimize by recruiting adequate sample size)
CRAFT screening for alcohol use
- C = have you been in car alone with someone using
- R = do you use it to relax
- A = do you use it alone
- F = have friends/family told you to cut down
- F = do you forget things
- T = has it gotten you in trouble?
If > 2 yes = needs assessment for substance use/dependence
2 features of a good SCREENING test
- Sensitive
- Inexpensive or cost effective
2 requirements for a minor to give consent
- Capacity: be considered a mature minor and/or must comprehend information
- Informed and voluntary: be able to understand risks/benefits without coercion from provider
Advantages of case-control study
Can study rarer diseases/conditions or those have a long lag from exposure
Disadvantages of case control study
- Recall/recording bias
- Does not account for possible confounding variables
- Usually have smaller sample size
4 principles of informed consent
Must have decision-making capacity
Medical provider must disclose information on treatment, test or procedure including risk, benefits and likelihood that the benefits/risks will occur
Pt/parent must comprehend information
Must be voluntary
Reasons to use physical restraints
Threat to themselves (not responding to meds / deescalation)
Threat to others
Patient refusing chemical restraint or continued aggression despite chemical restraint
Unable to give chemical restraint
Complications of physical restraints
Feelings of shame
PTSD
Asphyxiation
MSK injury if improperly restrained
Rhabdomyolysis
4 quality indicators in RCT
Random allocation to groups
Allocation concealment
Blinding
Sample size calculation
Intention to treat analysis
2 things to consider when evaluating allocation
Were groups comparable at start
Were groups randomized appropriately
Were allocation groups concealed beforehand
Reasons to stop resuscitation in field
Decapitation or other non-survivable injury, ex 100% TBSA burns
Valid DNR / SDM confirming such at scene
Prolonged downtime, no bystander CPR and no ROSC 20 minutes of ALS care
