ER Flashcards
cardiac arrest
1 cause = hypoxia 2/2 pulmonary prob. CPR. assess brachial artery in infants and carotid in kids. compressions for systole or bradycardia
shock classification
compensated- normal BP, adequate perfusion but maldistribution. compensate by tachycardia, vasoconstriction, incr heart contractility, incr venous tone, tachypnea.
decompensated: hypotension, low CO, inadequate perfusion
irreversible shock- cell death, refractory to med
hypovolemic shock
most common shock in kids. >25% volume loss –> decompensated shock
MSA, tachypnea, tachycardia, hypotension, cool extremities, oliguria
septic shock
hyper dynamic stage- normal or high CO, bounding pulses, warm extremities, wide pulse pressure
decompensated state- impatited mental status, cool extremities, diminished pulses
tx: boluses of fluid until good perfusion. may need interpose like epi or do to incr contractility and vasopressors to incr BP
distributive shock
pooling of fluid distally. due to anaphylactic or neurogenic shock (2/2 spinal transection, loss of distal sons CV tone + hypotension), meds, toxins. vasodialtion, incr capillary permeability, third space loss
sx of shock
severe N/V, trauma with hemorrhage, febrile illness in IC pt, CHF sx, allergic allergen exposure, SC injury
coagulation factors
evaluate for disseminated intravascular coagulation that may accompany shock. give FFP
trauma
1 cause of death in
pulseless electrical activity on ecg
cardiac tamponade. T PTX, profound hypovolemia
head trauma
- self limiting seizure
- open fontanelle/suture= susptive to subgaleal/ epidural/subdural hemorrhage = more tolerant of expansion. don’t need fracture or loc. subdural common in infancy & 75% b/l, worse prog than epidural
3) intracerebral hemorahge - frontal and temporal lobe. contrecoup injury= opp side of impact.
4) incr ICP: HA= 1st sx then pupillary and AMS is 1st signs.
bradycardia
1st sign of herniation in
signs of herniation
bradycardia. fixed and dilated pupils. cushion’s triad= late sign= bradycardia, HTN, irreg breathing. CL hemiparesis
treat incr ICP
mild hypervent, elevation of head, diuretic, neurosurgery
T PTX
distended neck vein, decr breath sounds, hyper resonance to percussion, displaced trachea, pulseless electrical activity shock
abdominal trauma
common bc unnerved abd muscle.
duodenal hematoma- 2.2 bicycle handle bar in RUQ
lap belt injury- chance fracture
spleen liver kidney in blent trauma
burns
2nd most common injury.
secondary burn
superficial partial thickness brun- epi + outer portion of dermis. moist, painful, red, blister +no scar
deep PTB: epi + lower part of dermis. pale whit, blister + scar
tx: opiates, debridement of dead skin, don’t remove bulla unless ruptured
first degree burn
red, blanching painful. epi
tx: moisturizer, analgesics
3rd degree burn
epi, dermis, part of subQ. dry, white, leathery. need skin graft bc nerve ending burn so insensitive to pain.
BSA
adolescent and adult- arm/head+neck=9 each, leg/anterior trunk/posterior trunk= 18 each
child- palm= 1%
burn management
1) resuscitation, endotracheal intubation of hot gas, pulse ox, IV through non burned skin
2) fluid resusitation
3) skin care
4) hospitalize if partial burn >10% or full burn >2%, overly J, hands, feet , circumferential, inhalation injury
near drowning
older infant/ toddler, + adolescent
drawing cause denaturing of surfactant, alveolar instability and collapse –> pul edema–> decr compliance - incr pul P, restricting gas exchange
penumonia in 24hr from aspirating mouth flora
slow deterioration of pul func in 12-24hr
neuro damage dep on time hypoxia
CV-dysrhythmia, MI
hemolysis and DIC
Renal failure may occur
drowning management
1) resuscitate ABC, remove wet cloth to prevent heat loss
2) intubate and mechnical vent PEEP if respiratory failure
3) rewarming with warm saline gastric lavage, bladder washing or peritoneal lavage if needed. conti resuscitation until 89.6- 32
4) attention- fluid and electrolyte imbalance
drowning prog
better in children bc dive reflex shunt blood to heart, brain, liver. but poor in 5min, resusitate delay >10min, CV resusitation needed, abn near, ph
abuse RF
abuse signs
metaphyseal fractures- bucket handle or corner fractures caused by torsional force or violent shaking. feature of posterior or first ribs, sternum, scapular, vertebral spinous process
abuse #1 and 2nd cause of death
head injury.
sudden infant death syndrome
poison
60% occur in
odor of poisons
bitter almond- cyanide. garlic- arsenic, organophosphate. acetone- salicylates.
skin v poison
cherry red- CO or cyanide. sweaty- organophosphate, sympathomimetics. dry- anti cool. gray cyanosis-methmoglobinema
eye v poison
miosis- opiate, phenyclidine, organophos, phenothiazine
mydriasis- tricyclic antidep, atropine
nystagmus- dilantin
retinal hemorrhage- CO, methanol.
AMUDPILES
causes of increased anion gap >16. alcohol, methanol, uremia, diabetic ketoacidosis, paraldehyde, iron and isoniazid, lactic acidosis, ethylene glycol, salicylates
CHIPE
radioopque substances on imaging of abd. chloral hydrate/calcium ,heavy metals iodine/iron, phenothiazine, enteric coated tablets
gastric decontamination
syrup of ipecac- induce emesis- if ingest
salicylate poisoning
pepto-bismol, oil of wintergreen. direct stimulation of respiratory center –> hyperventilate–> respiratory alkalosis. and uncouple oxidative phosphorylation producing lactic acidosis enhancing ketosis.
P: fever, diaphoresis, flushed appearance, tinnitus, vomititng, HA, lethargy, restlessness, coma, seizure, yperpnea, dehydration
lab: respiratory alkalosis with anion gap metabolic acidosis
hyperglycmeia to hypoglycemia
hypokalemia
tx: gastric lavage, activated charcoal, serum salicylate lvl q6h, done monogram, alkalization of urine with NaHCO3 to pH 7. dialysis
Iron
iron prenatal vitamins.
patho: direct damage to GI= hemorrhage, hepatic injury/necrosis, third spacing and pooling of blood= hypotension, interference with oxidative phosphorylation
P: 4 stages: 1) 500 or 300+ labs abn, can give test dose if urine is red or vin rose color then pos and start IV.
Lead
dirt, paint clay
P: abd prob, cns complaints (listlessness, irritbaility, seizure, encephalopathy, decr consiousness), microcytic anemia, basophlic stippling, RBC precursors, radiopacities, dense metapheasl bands on radiograph, lead lines on knees and wrist.
dx- elevated lead or erythrocyte protoporphyrin
management- dimercaprol, british anti-lewisite, or EDTA
Caustic acids
acids or alkalis with corrosive potential. damage mouth and esophagus
acids- coat necrosis- superficial damage.
alkalis- liquefaction necrosis- deep and penetrating.
P: burning with hysphagia, salivation, retrosternal pain, vomiting. obstructive airway edema (acid), gastric perforation (acid), esophageal perforation with mediasitnitis (base)
caustic agent management
don’t neutralize bc cause exothermic rxn- burn
CI: gastric lavage, ipecac, charcoal
endoscopy assess damage
household bleach - doesn’t need tx
CO
low lvl- flu like - nonspecific sx-HA, dizziness
high lvl- visual and auditory changes, vomiting, confusion, syncope, slurred, cyanosis, MI, coma, death
cherry red skin-venous blood has more O2 bc left shift= don’t release O2 to tissue. retinal hemorrhages, tackycardia/pnea. kid= GI>neuro sx. neuro delayed
dx- CO-Hb lvl, anion gap metabolic acidosis, low O2 sat though PaO2 may be normal. MI on ECG or leveled troponin.
hospitalize if COHb> 25% or >10%+ sx
dog bites
s. aureas. suture wound, and amoxicillin-clavulanic acid. tetanus prophylaxis
cat bite
P. multocida= often infected. cat scratch disease with regional lymphadenitis
punture wound
human bite
fist fight-metacarpophalangeal joint. - may penetrate avascular fascial layer- deep infection and tendonitis
high infection with mixed bacteria - strep viridian, s aureus, anaerobic bacteria. hep B, HIV, siphilis
amoxicillin-clavulanic acid
black widow
neurotoxin. severe HTN and cramps= pathonomongic
irrigate, tetanos prophylaxis, benzo relive M cramps, latrodectus antivenin
brown recluse spider
nrpwm vop;om sj[aed/ cytotoxic. painless bite then 8hr later a painful itchy papule incr in size and discolors over 3-4d. necrotic and ulcerative deep lesion. systemic run 1-2d with fever, chills, weakness, DIC, hemolysis, RF 2.2 myoglobinura.
steroid, skin grafting, dapsone, hyperbaric O2. no antivenin
pit viper snake
proteolytic enzyme. swelling and ecchymosis. paresthesias of scalp, weakness, metallic taste in mouth. coagulopathy, thrombocytopenia, hypotension and shock.
crotalidae polyvalent antivenin for all bites within 4-6hr. antivenin can cause serum sickness and anaphylaxis. can use crotalidae polyvalent immune Fab
coral snake
red, yellow, black. neurotoxic. severe system sx, diplopia, fascinations, respiratory depression. antivenin.
cardiac shock
rare in kids. due to severe CHF, dysrhythmias, cardiomyopathy, tamponade
sx: cool extremities, delay refill, hypotension, tachypnea, incr obtundation, decr urine output
gaining access
if peripheral line can’t be placed in 90s, intraosseous line is fastest way to get assess. insert needle in marrow cavity oblong bone
fever + petechiae
always think meningococcal sepsis. even if look well. need blood culture and antibiliotics until r/o. when dx, need to get all household contacts tx with ciprofloxacin for adults an rifampin for kids as prophylaxis.
complicaiton: hearing loss, neuro disability, digit or limb amputation, skin scaring.
10-15% fatality. 21%fatality in adolescents
toxic shock syndrome
fever, sunburn looking rash -sandpaper texture.
rocky mountain spotted fever
also cause fever and petechiae but isolated to pass and soles.
meningococcal conjugate vaccine
given to kids 11-18. IM. booster at 16yo.
