Exam 1

Question 1

Pressure related medical condition that compromised the tissue within a closed facial space

Answer 1

Compartment syndrome

Question 2

Compartment syndrome causes

Answer 2

Injury
Infection
Surgery
Burns
Bleeding disorder
Venomous bites
IV/IO infiltrates
Thromboembolic event
Vascular reconstruction

Question 3

Compartment syndrome is due to

Answer 3

Inadequate blood flow through the capillaries

Question 4

Most common causes of compartment syndrome

Answer 4

Acute high impact trauma
Long bone fractures (distal humerus and proximal tibia

Pediatric most common-
displaced supracondylar humerus fracture
Proximal/mid shaft tibia fracture
IV infiltrates

Question 5

Transient compartment syndrome cause

Answer 5

Heavy training
Due to muscle hypertrophy and increased intracompartmental pressure with exercise

Question 6

Pain disproportionate to injury
Think…

Answer 6

Compartment syndrome

Question 7

Early signs of compartment syndrome

Answer 7

Pain disproportionate to injury
Refusal to move affected area
Pain with a passive stretch

Question 8

Late signs of compartment syndrome

Answer 8

Paralysis
Pallor
Paresthesia
Pain
Pulselessness

Ps in Lipincott
Pain with passive stretch
Pain out of proportion to clinical situation
Paresthesia
Paralyiss
Pulses absent

Question 9

Compartment syndrome treat

Answer 9

Remove casts
Keep extremity at level of heart
Do not elevate or dangle (further restrict blood flow)
Administer oxygen
Pain meds

Use isotonic fluids for hypotension

Question 10

Devices to measure intracompartmental pressure in compartment syndrome

Answer 10

Mercury manometer system
Arterial line system
Stryker intracompartmental pressure monitoring system

Question 11

Compartment syndrome pressures that warrant surgical intervention

Answer 11

> 35 mmHg (slit or wick catheter)
40 (needle technique)

Another technique is measure the diff between diastolic BP and intracompartmental pressure - if diff is less than 30 - suggestive of compartmental syndrome

Question 12

definitive treatment for compartment syndrome

Answer 12

incisional fasciotomy

Question 13

preoperative antibiotic in compartment syndrome prior to incisional fasciotomy

Answer 13

cefazolin

Question 14

post incisional fasciotomy, a full recovery can be expected in what time frame

Answer 14

with early identification and quick treatment, within 6 months

the open wound is closed within a few days or a skin graft is placed

Question 15

Time period to surgical fasciotomy to regain normal function with compartment syndrome

Answer 15

6 hours

Question 16

The 3 As of compartment syndrome

Answer 16

Anxiety (increasing)
Agitation
Analgesic requirement

have been shown to precede the classic 5 Ps signs in children by several hours

5 ps
Paralysis
pallor
paresthesia
pain
pulselessness

Question 17

Ortolani maneuver identifies

Answer 17

a dislocated hip that can be reduced
A palpable clunk (not click) is felt as the hip reduces - positive Ortolani

Question 18

Galleazzi sign

Answer 18

hip dislocation sign
difference in femur length when hips and knees are flexed to 90 degrees

Question 19

Trendelenburg gait is seen when there is _____

Answer 19

weak abductor muscles of the hip seen when there is only one dysplastic hip

Question 20

A hip click without hip instability in newborn is

Answer 20

common and benign finding

Question 21

disorder that results from a temporary loss of blood supply to the proximal femoral epiphysis

Answer 21

Legg-Calve-Perthes disease

Question 22

cause of Legg-Calve-Perthes disease

Answer 22

not well understood
it has been suggested:
trauma
infection
inflammation
acetabular retroversion

Question 23

stages of Legg-Calve-Perthes disease

Answer 23

initial stage - begins with ischemic event
ossification is arrested
bone becomes sclerotic

second stage
“fragmentation stage”
bone is deformed and even fractured

third stage
healing stage or reossification stage where old necrotic bone is reabsorbed and new bone is formed

last stage
remodeling stage
residual deformity may be observed

Question 24

typical age range for Legg-Calve-Perthes disease

Answer 24

4-8 yrs old

Question 25

gender more affected in Legg-Calve-Perthes disease

Answer 25

male

Question 26

presentation of Legg-Calve-Perthes disease

Answer 26

pain on affected side persistent can start in hip and radiate to thigh or knee and not usually severe can even be chronic many patients have delayed skeletal maturation and are often shorter than normal

Question 27

what has better range of motion (typically) septic hip transient synovitis Legg-Calve-Perthes disease

Answer 27

Legg-Calve-Perthes disease

Question 28

a mild dysplasia of the proximal femoral epiphysis

Answer 28

Meyer Dysplasia - normal variation and is usually bilat

Question 29

labs and imaging for Legg-Calve-Perthes disease

Answer 29

CBC CRP ESR blood cultures Which are all typically WNL In some kids abnormal thyroid hormone levels and insulin-like growth factors have been noted X rays -Hip -Pelvis Anterior/posterior and frog leg views help in tracking the progression Bone scan or MRI can be useful in the early stages of the disease when x ray changes are difficult to detect

Question 30

goal of treatment in Legg-Calve-Perthes disease

Answer 30

keep the femoral head seated in the acetabulum promote good range of motion Mild cases -observe with normal activity Severe cases -need activity restriction -physical therapy -bracing to hold the head of the femur in proper position to optimize its functional shape

Question 31

infection of the bone that may occur by hematogenous spread from bacteremia

Answer 31

Osteomyelitis

Question 32

what causes osteomyelitis and most common cause in pediatrics

Answer 32

local invasion from contiguous infection or from direct inoculation from sustained trauma or surgical procedure most common: hematogenous - when blood borne organisms seed the metaphysis of the bone (can happen in transient bacteremia from ear infection or URI)

Question 33

what happens if osteomyelitis goes untreated

Answer 33

purulent material may extend through the cortex into the subperiosteal space. Once in the periosteal space, accumulation of purulent material increases and results in bone necrosis

Question 34

most common pathogens in osteomyelitis other common

Answer 34

S. Aureus other common: Streptococcus pyrogens Streptococcus pneumoniae K. kingae HIB MRSA

Question 35

reporting of K.kingae in osteomyelitis primarily affects children of what age

Answer 35

6 mos - 4 yrs of age

Question 36

Things to note on MRSA osteomyelitis

Answer 36

more virulent higher and prolonged fevers increased inflammatory markers more local tissue destruction longer hospital stays higher risk of complications such as DVT, septic pulmonary emboli and Septic thrombophlebitis

Question 37

presentation of osteomyelitis

Answer 37

localized pain - constant and increasing in severity may stop using upper extremity may walk with limp or refuse to walk Neonates, infants and nonverbal patients can present with -new onset irritability -poor feeding -change in sleep habits discrete tenderness at site of infection edematous erythema warm to touch

Question 38

labs and imaging in osteomyelitis

Answer 38

CBC with diff ESR CRP Blood cultures WBC elevated in 35% of children with osteomyelitis CRP and ESR more sensitive to infection ESR rises slowly and typically elevated (>20 mm/hr) within 48-72 hrs CRP >10 mg/L more quickly within 6 hours of infection. This number falls more quickly in response to effective management Plain x-rays to evaluate for other causes of limb pain such as fracture or tumor MRI is imaging of choice for strong suspicion of osteomyelitis

Question 39

Empiric antibiotics in osteomyelitis

Answer 39

cover for S. aureus - flucloxacillin and 1st gen cephalosporins k.kingae - good sensitivity to PCN and cephalosporins such as cefotaxime bc it also covers for GBS and enteric gram neg bacilli MRSA - vancomycin, clindamycin, daptomycin, linezolid

Question 40

when is surgical intervention warranted for osteomyelitis

Answer 40

presence of large subperiosteal, soft tissue or bone abscess or concurrent septic arthritis area of necrotic bone direct invasion of growth plate

Question 41

antibiotic route guidance in osteomyelitis

Answer 41

2-4 days of IV antibiotics before transitioning to oral antibiotics for 3 weeks criteria to transition to oral -clinical improvement as evidence by --lack of bony tenderness --normal temps --reduction of inflammatory markers - primarily CRP

Question 42

Treatment for children with MRSA osteomyelitis

Answer 42

4-6 weeks of abx with early oral abx acceptable if cultures show susceptibility to Clindamycin

Question 43

MRSA infection is associated with increased _______ (complication)

Answer 43

DVT

Question 44

risk factors for osteomyelitis associated with poor prognosis

Answer 44

MRSA S. pneumoniae pyomyositis abscess infection in hip younger age delayed treatment

Question 45

long term complications of osteomyelitis

Answer 45

limb-length discrepancy abnormal gait recurrent infection

Question 46

what happens in Chronic osteomyelitis

Answer 46

a segment of the cortex becomes devascularized to form a sequestrum or dead bone. An involucrum, which is new bone with a limited vascular supply may form. Treatment involves several surgical procedures and long term (4-6 months) antibiotic treatment

Question 47

vaccination to help reduce risk of infection in osteomyelitis

Answer 47

HIB - prevents osteo by HIB

Question 48

infection in the synovial space of a joint

Answer 48

septic arthritis

Question 49

joints most often affected by septic arthritis

Answer 49

knee hip ankle elbow

Question 50

osteomyelitis can lead to septic arthritis esp in

Answer 50

hip shoulder elbow ankle (due to intra-articular location of metaphyseal bone in these joints)

Question 51

Peak incidence of septic arthritis is

Answer 51

children younger than 3 yrs males twice as often as females

Question 52

risk factors for septic arthritis

Answer 52

prematurity immune compromised

Question 53

organisms associated with septic arthritis

Answer 53

S. aureus MRSA K. kingae (Moraxella)- more popular in children younger than 4 GBS occasionally in neonates other organisms -A. Streptococcus -S. pneumoniae -Salmonella -Neisseria gonorrhoeae -HIB not as common due to vaccinations -S pneumoniae rates are also on the decline

Question 54

presentation of septic arthritis

Answer 54

pain in affected joint may not use the affected extremity If the hip, knee or ankle is involved: child will limp or refuse to bear weight Neonates - irritable, can refuse to eat, might not spontaneously move the affected limb (pseudoparalysis) can have history of URI or skin/soft tissue infection joint painful to palpation likely red, warm and swollen range of motion is painful and limited If hip is affected - pt may prefer to lay with hip in external rotation, abduction and mild flexion bc it creates more space in the joint capsule Lipincott -Ill appearing -Fever >38 -Joint pain -•   History of recent viral illness, soft tissue or upper respiratory tract infection. • Insidious joint pain. •   Affected joint: painful to palpation, erythematous, warm, edematous; limited range of motion. •   If the hip, knee, or ankle are affected, refusal to bear weight. •   If hip, external rotation, adduction and mild flexion. Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1407). Wolters Kluwer Health. Kindle Edition.

Question 55

what should be on your differential for a child with joint or bone pain

Answer 55

osteomyelitis poststreptococcal arthritis juvenile idiopathic arthritis leukemia Lyme disease accidental or inflicted trauma tuberculosis osteomyelitis and septic arthritis often occur together if hip is involved: SCFE LCPD myositis of obturator or psoas muscle transient synovitis of the hip (self limiting)

Question 56

Kocher criteria is for what and what does it include

Answer 56

septic arthritis temp >38.5 C (101.3) refusal to bear weight elevation of ESR (>40) or CRP and/or WBC > 12,000

Question 57

key labs for septic arthritis

Answer 57

CBC with diff ESR CRP Blood cultures WBC is usually elevated >12,000 but not invariably ESR and CRP will rise ESR (rises within 48-72 hrs) CRP (rises in 6 hours) purulent aspiration - culture

Question 58

imaging in septic arthritis

Answer 58

X rays - to look for trauma and noninfectious conditions finding of joint space widening suggests an effusion US to evaluate irritable joints (esp hip joints)- can detect distention of the joint capsule and effusion If fluid is found in joint, diagnostic aspiration should be done with US guidance MRI can also identify a joint effusion but most helpful in identifying concomitant osteomyelitis in an adjacent bone or myositis in the adjacent musculature. Technetium bone scans are indicated when infections are located in difficult to assess areas such as ankle and shoulder. Bone scans are esp beneficials for evaluating neonate because there may be more than one site of infection

Question 59

surgical irrigation and drainage in septic arthritis

Answer 59

smaller joints such as wrist are controversial bc they usually resolve with abx larger joints (esp hip and shoulder) irrigation and drainage should be performed emergently in the OR bc of potential for cartilage damage and compromised blood supply

Question 60

Abx for septic arthritis

Answer 60

parenteral abx begin as soon as blood and joint aspiration cultures are obtained Empirics should cover -S. aureus (MSSA and MRSA) -group A strep -K. kingae and if not immunized -HIB -S pneumoniae Combo of Vanc and 3rd or 4th gen cephalosporin (Cefotaxime, ceftriaxone, cefepime) infants younger than 2 months should get abx that cover for GBS, S aureus and Gram neg bacteria such as Vancomycin and Cefepime or Gentamicin Nafcillin or Oxacillin and cephalosporin (cefazolin) are preferred for MSSA Clindamycin or newer agents (Ceftaroline, linezolid) can be considered for susceptible MRSA (also Vancomycin) Group A Strep- Amp/Amox Strep pneumoniae - amp/amox, ceftriaxone/cefotaxime, vanc Kingella kingae - amp/amox, cefotaxime neonates - 3rd gen cephalosporins (Cefotaxime) 3-5 days of IV abx followed by 2-3 weeks of oral for uncomplicated cases of septic arthritis (no concomitant septic shock, osteomyelitis, abscess or marginal abx susceptibility switching to oral abx - needs to have clinical improvement - fever, pain, declining CRP to <10 and ability to tolerate oral abx

Question 61

a spinal fusion imitates

Answer 61

a fracture of a bone by decorticating (removing the outer layer of the bone) to mimic the need for bone healing The bone graft then acts as a scaffold for bone remodeling

Question 62

6 phases of bone remodeling

Answer 62

rest activation resorption reversal formation mineralization

Question 63

Bone remodeling is completely replaced in what time frame following mineralization of the bone

Answer 63

2-8 months

Question 64

another name for spinal fusion

Answer 64

spinal arthrodesis

Question 65

surgical procedure that joins one vertebra to an adjacent vertebra

Answer 65

spinal fusion

Question 66

what warrants urgent intervention for spinal fustion

Answer 66

spinal deformity, trauma, degenerative conditions, tumors and infections that cause spinal instability exposing neural contents making risk for injury

Question 67

what spinal deformities sometimes require spinal fusion

Answer 67

scoliosis kyphosis spondylolisthesis for most cases this is elective

Question 68

what degenerative spinal condition is seen during the adolescent period

Answer 68

lumbar disk degeneration most commonly related to strenuous physical activity, posttraumatic injury or congenital spinal deformity

Question 69

what conditions can cause loss of bone integrity compromising the structural integrity of the spine

Answer 69

fracture tumor invasion infective process

Question 70

the majority of spinal deformity procedures are performed through what type of approach

Answer 70

posterior

Question 71

what type of surgical approach for spinal fusion when fewer segments require fusion

Answer 71

anterior so that leaving normal motion over more segments of the spine

Question 72

what type of surgical approach for spinal fusion in case of a spinal tumor located in the vertebral body

Answer 72

anterior to remove the tumor and stabilize vertebra

Question 73

what type of surgical approach for spinal fusion in case of a spinal tumor located in the posterior elements of spinal column

Answer 73

posterior

Question 74

in spinal fusion a bone graft taken from the Pt iliac crest is ______

Answer 74

autologous

Question 75

in spinal fusion a bone graft taken from a cadaver donor is ______

Answer 75

autogenous

Question 76

what protein can be used in bone graft to facilitate fusion healing

Answer 76

Bone morphogenic protein (BMP)

Question 77

How often should a neuro assessment be performed following a spinal fusion surgery

Answer 77

every 2 hours for the first 24 hours to monitor for deficits

Question 78

Narcotics and muscle relaxers are needed after a spinal fusion surgery for how long

Answer 78

typically needed for the first 2-4 weeks after surgery

Question 79

what post op complications can occur following a spinal fusion

Answer 79

increased blood loss resp changes due to thoracic rib cage changes SIADH secondary to intraoperative volume replacement and spinal manipulation

Question 80

immobilization after spinal fusion

Answer 80

Sometimes Lumbosacral orthosis (LSO) or a thoracolumbar orthosis (TSO) will be required if it is determined that the spinal column requires additional support until the spinal fusion solidifies - approx 6 months

Question 81

postob mobility after spinal fusion

Answer 81

sitting within the first 24 hours walking within 48-72 hours prior to discharge they should be ambulatory with minimal assistance for the first month after - progressive walking program, mild upper and lower extremity strengthening and participation in activities of daily living No flexion, extension or rotation of the spine until fusion has healed

Question 82

What technique for invasive device used to monitor compartment syndrome? skin is opened and a catheter is placed into the compartment

Answer 82

Slit technique

Question 83

What technique for invasive device used to monitor compartment syndrome? a catheter with a wick is placed in the compartment

Answer 83

Wick technique

Question 84

What technique for invasive device used to monitor compartment syndrome? a straight or side-port needle is placed into the compartment

Answer 84

Needle technique

Question 85

local inflammation of the muscle

Answer 85

myositis

Question 86

symptoms of myositis

Answer 86

muscle pain, weakness, or difficulty performing tasks of daily living

Question 87

what causes Myositis who is it more common in

Answer 87

Viral Acute self-limited illness occurs during epidemics of flu A/B; also more predominant in males Suspected to be caused by invasion of the muscle tissue by inflammatory cells;

Question 88

presentation of myositis

Answer 88

viral symptoms such as fever anorexia muscle pains Myalgias: mild to moderate and muscle tenderness with calves most affected during the early phase of many acute viral infection Weakness: mild to severe Dark urine in those who develop rhabdo Benign self limiting conditon Bilateral muscle pain, tenderness, and something swelling during first week of flu illness with calf muscles most severely affected Child may refuse to walk or toe walk On exam, calves are tender Serum creatinine phosphokinase may be elevated Myoglobinuria with AKI rare→ when rhabdo develops it occurs

Question 89

Labs and diagnostics on myositis

Answer 89

CK may/ will be mildly elevated but no myoglobinuria or acute renal failure Muscle imaging and biopsy reserved for cases of weakness unrelated to acute pain, markedly elevated CK, or EMG abnormalities

Question 90

treatment for Acute/viral myositis

Answer 90

Most are self-limited and management is directed at relief of symptoms Analgesic agents such as tylenol or NSAIDs Usually resolve in 3-10 days

Question 91

Highlights on acute childhood myositis what is it symptoms prognosis

Answer 91

Accompany acute viral infections seen during flu epidemics Symptoms include marked pain and tenderness, localized to calves Occurs as acute illness is subsiding, usually 24-48 hours after resolution of presenting symptoms Child will refused to walk or will have difficulty walking due to pain or true muscle weakness Ankles held in plantar-flexion with resistance to dorsiflex Muscle enzymes elevated 20-30x normal, rhabdo is rar Muscle biopsy reveals muscle necrosis and muscle fiber regeneration Full recovery in 3-10 days with decrease in muscle enzymes within 3 weeks

Question 92

Childhood condition in which the proximal femoral epiphysis has a temporary interruption in blood supply, leading to bone necrosis and subsequent repair. Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (pp. 1395-1396). Wolters Kluwer Health. Kindle Edition.

Answer 92

Legg-Calve-perthes disease

Question 93

is osteomyelitis more common in adults or kids and why

Answer 93

more common in children bc of rich metaphyseal blood supply and thick periosteum

Question 94

Approximately 50% of osteomyelitis occur in children < ____ years of age

Answer 94

5

Question 95

Most common sites of osteomyelitis

Answer 95

femur tibia

Question 96

what disease processes increase risk of osteomyelitis

Answer 96

hemoglobinopathies such as sickle cell chronic renal disease type 1 DM compromised immune system

Question 97

________ is the most common organism in children (except neonates), 70% to 90% of Osteomyelitis infections. Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1399). Wolters Kluwer Health. Kindle Edition.

Answer 97

Staph Aureus Community acquired MRSA is becoming more prevalent Other agents Group A hemolytic strep Strep pyogenes Strep pneumoniae

Question 98

what is the most common organism in neonates causing osteomyelitis

Answer 98

Group B strep

Question 99

organism most common causing osteomyelitis associated with puncture wounds (esp of the foot)

Answer 99

Pseudomonas

Question 100

in osteomyelitis, what imaging is helpful in identifying abscess and areas of destruction

Answer 100

CT

Question 101

in osteomyelitis, what imaging is helpful in evaluating for abscess, though unable to image details of the bone

Answer 101

US

Question 102

Most common hip disorder in adolescence, typically associated with obese African American or Latino adolescents. Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1403). Wolters Kluwer Health. Kindle Edition.

Answer 102

Slipped Capital Femoral Epiphysis (SCFE)

Question 103

what gender and age is more common in Slipped Capital Femoral Epiphysis (SCFE)

Answer 103

Males ages 12-15

Question 104

Characterized by the separation of the growth plate in the proximal femoral head with the epiphysis slipping posteriorly with potential for complete dislocation. Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1403). Wolters Kluwer Health. Kindle Edition.

Answer 104

SCFE

Question 105

Etiology of SCFE

Answer 105

Unknown, but may be related to rapid growth, obesity, hypothyroidism, family history, trauma, or genetic conditions such as Trisomy 21. Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1403). Wolters Kluwer Health. Kindle Edition.

Question 106

Acute SCFE vs Chronic vs Acute on chronic SCFE

Answer 106

Acute: is a sudden exacerbation of < 3 weeks; a radiological shift in the epiphysis without a callus formation. Chronic: has a gradual onset of symptoms over 3 weeks with some remodeling of the bone. Acute on Chronic: involves symptoms for months, but exacerbated with injury. Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1403). Wolters Kluwer Health. Kindle Edition.

Question 107

symptoms for SCFE

Answer 107

•   Acute or chronic hip, thigh, or knee pain. •   Limited rotation and obligated external rotation of the hip. Pain can be severe with shortened stance of affected leg and Trendelenburg gait. Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (pp. 1403-1404). Wolters Kluwer Health. Kindle Edition.

Question 108

Ice cream slipping off cone appearance on X ray

Answer 108

SCFE

Question 109

SCFE management

Answer 109

•   Strict non–weight-bearing status until percutaneous pinning or in situ screw fixation of the femoral head through the growth plate has been placed. •   More severe dysfunction may require open osteotomy and internal fixation to secure the bones. •   Crutches are issued for 2 to 3 weeks postoperation for stable SCFE; 6 to 8 weeks for unstable SCFE. •   Team approach requires PT for gait training, hip precautions, and range of motion exercises. •   Sports and vigorous activity should be avoided until growth plates close. •   Overall care is provided by the primary care provider. Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1404). Wolters Kluwer Health. Kindle Edition.

Question 110

Parkland formula Burn pt

Answer 110

>15 % TBSA 4ml/kg 4ml x kg x % burn divide by 2 divide by 8 LR

Question 111

cafe au lait spots and lisch nodules are associated with what?

Answer 111

Neurofibromatosis type I

Question 112

café au lait spots and lisch nodules are associated with what?

Answer 112

Neurofibromatosis type I

Question 113

a purulent bacterial infection in the synovial fluid joint spaces; causes rapid destruction of the articulate cartilage. Considered a medical emergency Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1405). Wolters Kluwer Health. Kindle Edition.

Answer 113

Septic Arthritis

Question 114

joints commonly affected in septic arthritis

Answer 114

hip knee elbow ankle

Question 115

age and gender for septic arthritis

Answer 115

less than 3 yrs males neonates and premature infants are at greatest risk due

Question 116

what family of snake? Rattlesnake

Answer 116

Crotalid

Question 117

What family of snake copperhead

Answer 117

Crotalid

Question 118

What family of snake Cottonmouth

Answer 118

Crotalid

Question 119

What family of snake? Coral snake

Answer 119

Elapid

Question 120

what family of snake is venomous? Crotalid Elapid

Answer 120

Crotalid

Question 121

characteristics of venomous snakes

Answer 121

elliptical pupil presence of retractable fang Triangular head Will have heat-sensing pit located between the nostril and eye (differentiates between bite of coral snake)

Question 122

Characteristics of non-venomous snakes

Answer 122

round pupils multiple small teeth instead of fangs Oval-shaped head

Question 123

what family of snake bites are most prevalent in US

Answer 123

95% in US are pit vipers (Crotalid)

Question 124

Pit vipers are what family and what does that include

Answer 124

Crotalid includes Rattlesnakes, copperheads and cottonmouths

Question 125

whats the snake venom rhyme

Answer 125

“red on yellow, kill a fellow; red on black, venom lack”

Question 126

what do coral snakes look like

Answer 126

black snout with alternating red, yellow, and black bands along the body

Question 127

what family is a king snake? Venomous? what does it look like?

Answer 127

Colubridae Non-venomous Red band bordered by black on each side

Question 128

black snout with alternating red, yellow, and black bands along the body

Answer 128

Coral snake

Question 129

Red band bordered by black on each side

Answer 129

King snake

Question 130

Crotalid venom contains 90% _____ by dry weight

Answer 130

protein

Question 131

what problems come from Crotalid snake bites

Answer 131

Local tissue destruction, edema, red cell extravasation -> platelet aggregation -> thrombocytopenia May also lead to shock Glycoprotein can cause reaction similar to DIC Intravascular fluid leaks through damaged membrane causing more edema and shock

Question 132

what happens in Mojave rattlesnake envenomation (also Timber rattlesnake - rare)

Answer 132

neurotoxic effects -> cranial nerve paralysis (ptosis, ophthalmoplegia) and flaccid paralysis -> may require intubation

Question 133

what happens in Elapids envenomation

Answer 133

Neurotoxin causes flaccid paralysis and myonecrosis

Question 134

___% of all snake bites occur in the pedi population

Answer 134

25%

Question 135

what time of year do snake bites happen more

Answer 135

warmer months of the year from April to October

Question 136

Gender bitten more

Answer 136

males

Question 137

what differentiates envenomation "DIC" from true DIC

Answer 137

the fibrin monomers are produced by the glycoproteins, rather than consumption or thrombin of activation of Factor XIII True clinical bleeding is rare

Question 138

Elapid venom exerts its effect through ___ and ___

Answer 138

neurotoxins Phospholipase A2 Direct neurotoxins bind the postsynaptic membrane of the neuromuscular junction, causing a flaccid paralysis, which can be long lasting. Phospholipase A2 causes myonecrosis

Question 139

Presentation of Crotalid envenomation

Answer 139

1st: immediate burning pain at the bite site 2nd: edema, erythema that will increase over next 8-10hr Ecchymosis or bullae (serous or hemorrhagic) may form at the site within hours and can lead to lymphadenopathy or lymphangitis Necrosis of extremity Compartment syndrome rare (bite directly into compartment) Local edema can cause airway compromise if bite is near neck/face Systemic signs Perioral paresthesia or metallic taste within minutes Weakness, N/V, diaphoresis, dizziness, syncope, tachycardia Rhabdo, pulm edema with resp failure, hypotension, shock, CV collapse, kidney failure Anaphylactic reactions

Question 140

Presentation of Elapid envenomation

Answer 140

Bites are unimpressive -> minimal pain and swelling and no puncture marks Systemic sxs take hours to develop Malaise and nausea, muscle fasciculation, ptosis, diplopia -> can progress to difficulty swallowing or talking with diaphragmatic paralysis -> resp failure

Question 141

Plan of care for Crotaline envenomation

Answer 141

CBC, type and screen, UA, coags, CMP, BUN, Cr, CK, fibrinogen, fibrin split products: check Q6 to monitor for systemic effects and treatment

Question 142

what labs do you need to draw for Elapid envenomation

Answer 142

None

Question 143

what does dry envenomation mean

Answer 143

no venom injected

Question 144

what category of envenomation Local signs adjacent to bite without progression of proximal edema Perioral paresthesia but will have normal lab studies

Answer 144

Mild

Question 145

what category of envenomation? Edema extending proximally from bite Systemic: N/V, diarrhea, dizzy, weak, diaphoresis Neurotoxicity: fasciculation Any coag abnormality is considered moderate -> incr PTT and PT, decr plt or fibrinogen, presence of fibrin split products

Answer 145

Moderate

Question 146

what category of envenomation? Edema extending proximally from bite Systemic: N/V, diarrhea, dizzy, weak, diaphoresis Neurotoxicity: fasciculation Any coag abnormality is considered moderate -> incr PTT and PT, decr plt or fibrinogen, presence of fibrin split products Impending resp failure or shock Significant (beyond gingival or mild epistaxis) bleeding Altered mental status Severely deranged labs

Answer 146

Severe

Question 147

Antidote for Crotaline venom

Answer 147

Crotaline Polyvalent Immune Fab (Crofab) – sheep derived

Question 148

You may have a reaction to Crofab if your are allergic to

Answer 148

latex papain papaya dust mites sheep products

Question 149

How is Crofab dosed? when do you treat?

Answer 149

in vials, not by weight - dosed by severity of the envenomation Pediatric dose is equivalent to pediatric dose Moderate to severe envenomation: Give 4-6 vials asap If hemodynamic instability or life-threatening toxicity -> initial bolus is 8-12 vials If after 1hr there is no improvement, repeat bolus dose Can give more boluses, but contact specialist if patient needs more than 2 rounds Sxs improvement: halt to edema progression, normal lab values (hemodynamic parameters), clear improvement in any neurotoxicity Maintenance dosing of antivenom once symptoms are controlled After 6hr of sxs control: 2 vials of antivenom are given Q6hr for a total of 3 doses (6 vials total)

Question 150

After using Crofab for envenomation, how long do you need to monitor

Answer 150

24 hours after initial control is achieved. If they develop new or worsening symptoms, repeat appropriate bolus dose based on severity of new symptoms

Question 151

What do you do if someone is allergic to crofab.

Answer 151

Call poison control. may use epi for anaphylaxis. May need to resume antivenom at slower rate

Question 152

what treatment for elapid envenomation

Answer 152

Might not be able to reverse symptoms with antivenom Antivenom to coral snakes has not been produced in US for decades Supportive care is the MAINSTAY – may need to intubation

Question 153

wound care for envenomation

Answer 153

Do not use tourniquets or compression bands -> may cause release of toxin once released Always search patient for multiple bites Wash with soap and water and search for remaining teeth/fangs Tissue necrosis -> debridement Tetanus prophy

Question 154

Action items on Crotaline envenomation

Answer 154

Immobilize extremity in comfortable position at or slightly below heart level Mark bite, measure circumference to follow progression of edema (take hourly until no more edema); leading border of edema should be marked and timed with each measurement Check distal pulses hourly -> if none are found, check compartment pressures to see if it is above 30 (fasciotomy is not recommended, give more antivenom) Leave bullae intact unless on the digits and they interfere with distal perfusion Pain control with narcotics if CV stable Skin grafting for large areas of tissue breakdown

Question 155

Latrodectus mactans

Answer 155

Black widow spider

Question 156

what is the neurotoxin released in a Black widow spider envenomation

Answer 156

A-Latrotoxin

Question 157

what happens with A-Latrotoxin

Answer 157

an excitatory neurotoxin that causes increased neurotransmitter release from presnyaptic neurons at the neuromuscular junction, sympathetic, and parasympathetic synapses.

Question 158

what gender of black widow can envenomate humans

Answer 158

Female (larger than males)

Question 159

true/false black widow is very aggressive

Answer 159

false not aggressive unless provoked or threatened

Question 160

what sensation is felt in a black widow envenomation followed by what presentation

Answer 160

small pinprick Severe cramping pain at the site of the bite begins within 15-60 minutes. Pain spreads from bite to rest of body. Chest and abdominal pain are prominent, but all muscles may be involved Abdominal pain may be accompanied with abd rigidity Diaphoresis, N/V, dizziness, ptosis, headache, irritability, dyspnea, dysarthria, facial swelling, and conjunctivitis HTN, increased ICP, or resp failure may see one or two fang marks

Question 161

Positive tap test

Answer 161

Black widow envenomation tapping at suspected bite site elicits pain

Question 162

treatment for black widow envenomations

Answer 162

1st responders should apply a cold pack to bite site and elevate site if possible In ED, perform wound care cleansing with soap and water and tetanus prophylaxis as indicated. CBC, coag studies, ECG, and urinalysis should be obtained and shoudnt come back abnormal. Start IVF Symptom control→ oral analgesic if mild and IV opoids/benzos for sereve cases Latrodectus antivenom used for high-risk pts or those with uncontrolled symptoms despite therapy. Symptoms may improve within 45 minutes of antivenom administration Asymptomatic pts or those with mild/local symptoms should be observed in the ED for 6 hours

Question 163

Loxosceles reclusa

Answer 163

Brown recluse

Question 164

Venom toxin in a Brown recluse envenomation what does it do?

Answer 164

Venom includes Sphingomyelinase D that damages cell membranes of RBCs, endothelial cells, and PLTs→ hemolysis, PLT aggregation, coagulation→ local tissue damage and occasional systemic toxicity

Question 165

where is the Brown recluse commonly found

Answer 165

Southern and midwestern USA

Question 166

what does the brown recluse look like and when are they dangerous. Where do they like to be?

Answer 166

They are brown and will only attack if provoked. They are usually found outdoors under rocks or woodpiles, but can be found indoors inside dark areas (closets).

Question 167

Presentation of Brown recluse envenomations

Answer 167

Local symptoms: pain at site of bite, usually within 3-4 hours. A white ring of tissue ischemia secondary to vasoconstriction can develop, followed by a pustule or blister. This pustule and ring of erythema gives a bull’s-eye appearance to the lesion. Over the next few days, the pustule will darken, become necrotic, and expand uo to 10-15 cm in diameter. The pustule then drains, leaving a dark/necrotic/ulcerated crater. Necrosis is usually worse in areas with increased subcutaneous fat Systemic symptoms: appear 24-48 hours after bite; hemolysis, thrombocytopenia, shock, jaundice, kidney failure, bleeding, or pulm edema

Question 168

Labs for Brown recluse envenomation

Answer 168

No definitive lab test. If the spider cannot be brought to ED and history is atypical, diagnosis can be challenging CBC, metabolic panel, coag studies, and urinalysis if showing systemic s/s

Question 169

treatment for Brown recluse envenomation

Answer 169

Systemic: Supportive since there is no available antivenom in the US Local: area should be washed with soap and water. The wounded extremity should be splinted and elevated with a cold compress at the site. As necrosis develops, surgical debridement may be beneficial. Large areas of necrosis may require skin grafting Tetanus prophylaxis given if indicated. Pts with suspected brown recluse bite with no symptoms can be discharged after 6 hours of observation in the ED

Question 170

Pts with suspected brown recluse bite with no symptoms can be discharged after __ hours of observation in the ED

Answer 170

6

Question 171

most common places eczema dermatitis is seen

Answer 171

Cheeks antecubital fossa posterior knee folds

Question 172

most common skin disease in children

Answer 172

Atopic dermatitis (20% of children)

Question 173

who is at higher risk for atopic dermatitis

Answer 173

Most common skin disease in children, 20% of children have it Urban areas, higher socioeconomic classes Lower risks: area where industrial pollution is less, eosinophil-mediated infections (helminth) are endemic Atopic march: will get atopic dermatitis with allergic rhinitis and allergy (asthma occurs in 50%)

Question 174

in eczema, what bugs cause secondary infections most often

Answer 174

Staph, strep pyro HSV eczema herpeticum – life threatening Varicella zoster virus Coxsackievirus Smallpox (eczema vaccinatum) – life threatening Molluscum contagiosum Fungal infections

Question 175

circumscribed and well defined borders, scale or hyperkeratosis is thicker/greasy/yellowish, located on scalp/eyebrow/perinasal region/upper chest/back (dandruff and cradle cap)

Answer 175

Seborrheic

Question 176

localize on elbow/knee/lower back/scalp, lesions are salmon colored at the base with an overlying hyperkeratosis that is thick with silver coloration, well demarcated/oval or round/thick plaques

Answer 176

Psoriasis

Question 177

distribution limited to one area of the body corresponding to contact with the allergen, lesion is well demarcated, bizarre, linear, square, or angulated (poison ivy, diaper rash)

Answer 177

Allergic contact dermatitis

Question 178

contact sensitization to nickel in metals, occurs on areas of the body where nickel or other metal are

Answer 178

Nickel dermatitis

Question 179

Mainstay treatment for dermatitis

Answer 179

Topical corticosteroids Class I: highest potency (typically avoided in younger children or areas of thin skin) Class VII: lowest potency

Question 180

eczema care

Answer 180

KEY: Frequent liberal use of bland moisturizers to restore skin barrier, avoidance of triggers of inflammation, use of topical anti-inflammatory medication Control of pruritus and infection If topical is not working, systemic therapy with immunosuppressive agents or UV light therapy can be used Daily short bath with warm (not hot) water Moisturizing cream/ointment to entire body immediately after to trap moisture, apply topical medications immediately after bath as well Avoid common triggers of inflammation: rubbing/scratching, contact with saliva or acidic foods, soaps/detergents, wool or other harsh material, fragrances, sweat, chlorinated pools, low humidity, tobacco smoke, dust mite, animal dander, environmental pollen, mold

Question 181

How do you enhance penetration for topical corticosteroid application for dermatitis

Answer 181

use wet wraps with topical corticosteroid application

Question 182

difference in ointment, creams, lotions and spray, foam and gels in dermatitis

Answer 182

OINTMENT PREFERRED: increased efficacy, occlusive nature, tolerability Creams: better for older patients for cosmetic reason and in warmer climates Lotion: cause irritation Spray, foam, gel: good for hair-bearing areas Everything but ointment will be irritating to open skin and should be avoided

Question 183

How often do you apply corticosteroids in dermatitis

Answer 183

BID

Question 184

systemic effects of topical corticosteroid applications

Answer 184

adrenal suppression or cushing -> can happen with application to large area or occluded area (diaper, bandages) at risk for enhanced penetration

Question 185

immune modulators in Atopic dermatitis

Answer 185

Topical calcinerurin inhibitors (immune modulators): Tacrolimus, pimecrolimus No potential for skin atrophy -> good for face or genital lesions Approved as second line for mild to moderate dermatitis

Question 186

atopic dermatitis treatment

Answer 186

Topical Corticosteroids Topical calcinerurin inhibitors (immune modulators): Tacrolimus, pimecrolimus -No potential for skin atrophy -> good for face or genital lesions -Approved as second line for mild to moderate dermatitis Sedating antihistamines (Benadryl): mild effect on pruritus but can improve sleeplessness due to scratching (non-sedating are of little benefit during day) Systemic corticosteroids is rarely used and should be tapered when given and be aware of rebound dermatitis UV light: moderate to severe cases in older children 2-3 times weekly Potential for skin CA Systemic immunosuppressives: cyclosporin methotrexate, azathioprine, mycophenolate – severe cases

Question 187

most common secondary skin infection found in atopic dermatitis

Answer 187

Impetigo with Staph group A Strep also common

Question 188

treatment for impetigo

Answer 188

Topical mupirocin for local lesions; widespread lesions require PO 1st gen ceph Cephalexin

Question 189

Pustules, erythema, honey crusting, flare of disease, lack of response to adequate anti-inflam therapy

Answer 189

Impetigo

Question 190

Multiple, pruritic, vesiculopustular lesions occur in disseminated pattern ( on normal skin and areas of dermatitis) Rupture and form crusted umbilicated papules and punched out hemorrhagic erosions Irritability, anorexia, fever

Answer 190

Eczema herpeticum after HSV infection – serious complication

Question 191

Tzanck test

Answer 191

scraping of skin lesion and staining, can also send vesicle fluid test for Eczema herpeticum after HSV infection

Question 192

How to prevent atopic dermatitis

Answer 192

Avoid triggers of inflammation and apply moisturizer Breast feeding for at least 4 months can decrease risk Extensively hydrolyzed casein based formula Early intro of peanuts in children at high risk for allergy (have severe eczema, egg allergy, or both) may decr risk of getting the peanut allergy

Question 193

contact dermatitis is what type of hypersensitivity disorder

Answer 193

Type IV or delayed hypersensitivity

Question 194

what type of contact dermatitis ill-defined, scaly, pink or red patches and plaques

Answer 194

Irritant

Question 195

what type of contact dermatitis form of irritant derm

Answer 195

Diaper dermatitis

Question 196

where is irritant contact dermatitis is usually seen

Answer 196

dorsal surface of hands, often from repeated hand washing or exposure to irritating chemicals

Question 197

diaper dermatitis is a form of

Answer 197

irritant dermatitis

Question 198

diaper dermatitis is caused by irritation to

Answer 198

urine/feces

Question 199

what secondary infection can complicate diaper rash

Answer 199

Candida albicans or bacterial infection

Question 200

what type of dermatitis is Poison ivy and poison oak

Answer 200

Acute allergic contact Rhus (or Urushiol induced) dermatitis

Question 201

describe the rash associated with Poison ivy/Poison oak

Answer 201

Bright pink, pruritic patches, linear or sharply marginated bizarre configurations Inside the patches are clear vesicles and bullae

Question 202

Bright pink, pruritic patches, linear or sharply marginated bizarre configurations Inside the patches are clear vesicles and bullae

Answer 202

Poison Ivy Poison Oak

Question 203

timeline of exposure to rash for Poison ivy/poison oak

Answer 203

Sxs of disease may be delayed 7-14 days after first exposure, subsequent exposures will occur within hours and are more severe

Question 204

what type of dermatitis is nickel

Answer 204

Chronic Allergic nickel dermatitis

Question 205

what do the lesions look like for Chronic Allergic nickel dermatitis

Answer 205

Lesions are pink, scaly, pruritic plaques that mimic atopic derm

Question 206

Lesions are pink, scaly, pruritic plaques that mimic atopic derm

Answer 206

Chronic Allergic nickel dermatitis

Question 207

what is distribution of Rhus dermatitis

Answer 207

lower legs, distal arms + linear configuration of lesions

Question 208

what is distribution of Nickel dermatitis

Answer 208

derm of ears, wrists, periumbilical

Question 209

Treatment for contact dermatitis

Answer 209

Topical corticosteroids for allergic and irritant High potency and short course of PO may be necessary for severe reaction to allergic contact derm Oral antihistamine to control itching Candia diaper rash: topical nystatin or topical azole antifungal + low potency topical corticosteroid

Question 210

Seborrheic Dermatitis in infant is what

Answer 210

cradle cap or dermatitis in the intertriginous areas of the axillae, groin, antecubital and popliteal fossae, umbilicus

Question 211

what does Seborrheic Dermatitis look like in adolescents

Answer 211

Dandruff

Question 212

what causes Seborrheic Dermatitis

Answer 212

Malassezia species in sebaceous rich areas such as Scalp, eyebrow, eyelid, nasolabial fold, external auditory canal

Question 213

How long does Cradle cap last

Answer 213

begins during first month and lasts through first year

Question 214

koplic spots

Answer 214

Measles

Question 215

Maculopapular rash with lymphadenopathy

Answer 215

Rubella

Question 216

Rash + koplik spots

Answer 216

Measles

Question 217

Rash + lymphadenopathy

Answer 217

Rubella

Question 218

Rash involving cheeks

Answer 218

Erythema infectiosum or Fifth disease

Question 219

Rash after the fever

Answer 219

Roseola

Question 220

Sandpaper like rash

Answer 220

Scarlet fever

Question 221

rash of different stages

Answer 221

chicken pox

Question 222

rash involves hand foot mouth

Answer 222

Hand foot mouth disease

Question 223

thick, greasy and waxy, yellow-white scaling and crusting of the scalp

Answer 223

cradle cap

Question 224

German measles is also called

Answer 224

Rubella

Question 225

Roseola is also called

Answer 225

Sixth disease

Question 226

How do you differentiate between cradle cap and tinea capitis

Answer 226

Fungal culture and potassium hydroxide

Question 227

Treatment for Seborrheic Dermatitis

Answer 227

Asymptomatic and does not require any treatment Cradle cap: oil may be gently massaged into scalp and left on for few minutes before brushing out the scale and shampooing Daily shampoo with ketoconazole, zinc pyrithione, selenium sulfide, salicylic acid shampoo Seborrheic derm with inflamed lesions -> low potency steroids 2x/day

Question 228

ordinary measles is called

Answer 228

Rubeola

Question 229

Roseola infantum is also called

Answer 229

Exanthum subitum

Question 230

symptoms of rubeola

Answer 230

conjunctivitis cough coryza fever koplik spots on buccal mucosa rash starts at hairline and spreads cephalocaudally over 3 days

Question 231

Herald patch

Answer 231

Pityriasis Rosea

Question 232

when does Pityriasis Rosea occur (age)

Answer 232

adolescence

Question 233

Solitary 2-5cm pink oval patch with central clearing

Answer 233

Herald patch in Pityriasis Rosea

Question 234

Progression of Pityriasis Rosea

Answer 234

Solitary 2-5cm pink oval patch with central clearing = herald patch = 1ST MANIFESTATION, found on trunk or thigh · 1-2 weeks later a general eruption occurs on torso and proximal extremities · 0.5-2cm oval red or tan macules with fine, bran like scale arranged parallel to skin tension lines = Christmas tree pattern · Pruritus present in 25% of cases · Lasts 4-14 weeks · Residual hypopigmentation or hypopigmentation can take months to clear

Question 235

treatment for Pityriasis Rosea

Answer 235

Self limiting can use oral antihistamine or low potency topical corticosteroid for itching

Question 236

Christmas tree rash

Answer 236

Pityriasis Rosea

Question 237

Well-demarcated, erythematous scaling papules and plaques · Occurs at all ages, chronic and relapsing

Answer 237

Psoriasis

Question 238

what things can exacerbate psoriasis

Answer 238

Infection (strep pyogenes) stress trauma medications may exacerbate

Question 239

psoriasis vulgaris is also called

Answer 239

Plaque type psoriasis

Question 240

Auspitz sign

Answer 240

Plaque-type psoriasis (psoriasis vulgaris) Lesions are localized or general o Round, well demarcated red plaques measuring 1-7cm with micaceous scale = thick, silvery appearance with pinpoint bleeding points revealed on removal of scales (Auspitz sign) Lesions in psoriasis have distinct distribution involving extensor aspect of elbow/knee,

Question 241

Lesions in psoriasis

Answer 241

Lesions are localized or general o Round, well demarcated red plaques measuring 1-7cm with micaceous scale = thick, silvery appearance with pinpoint bleeding points revealed on removal of scales (Auspitz sign) Lesions in psoriasis have distinct distribution involving extensor aspect of elbow/knee, Lesions in psoriasis have distinct distribution involving extensor aspect of elbow/knee, posterior occipital scalp, periumbilical region, lumbosacral, intergluteal cleft · Children will have facial lesions · Nail plate: pitting, onycholysis, subungual hyperkeratosis, oil staining (reddish, brown color) · Guttate = numerous small papules and plaques diffusely distributed on torso · Erythrodermic = covering large body surface areas · Inverse = moist red patches affecting body folds · Pustular ·

Question 242

Treatment Psoriasis

Answer 242

Topical corticosteroid – least potent as possible to avoid AE o Do not use oral -> can induce pustular psoriasis o Phototherapy, vit D analog, salicylic acid o Immune suppressive meds may be needed for severe cases

Question 243

what type of psoriasis? numerous small papules and plaques diffusely distributed on torso (teardrop-shaped)

Answer 243

Guttate

Question 244

what type of psoriasis? red covering large body surface areas

Answer 244

Erythrodermic

Question 245

plaque psoriasis is symmetrical or assymmetrical

Answer 245

symmetrical

Question 246

most common psoriasis

Answer 246

Plaque psoriasis

Question 247

Plaque psoriasis is worse during what season

Answer 247

winter

Question 248

Guttate psoriasis classically preceded by what infection

Answer 248

psoriasis classically follows a preceding streptococcal infection, typically pharyngitis or perianal streptococcus.

Question 249

what type of psoriasis can be life threatening

Answer 249

Pustular psoriasis

Question 250

Psoriasis with sudden onset with leukocytosis, malaise, fever and hypocalcemia

Answer 250

Pustular psoriasis

Question 251

what electrolyte imbalance is associated with pustular psoriasis

Answer 251

hypocalcemia

Question 252

Triggers for pustular psoriasis

Answer 252

Pregnancy withdrawal of oral glucocorticoids

Question 253

what type of psoriasis Head to toe generalized erythema

Answer 253

erythrodermic

Question 254

Psoriasis that has issues with sepsis and fluid loss due to issues with barrier protection

Answer 254

Erythrodermic psoriasis

Question 255

symptoms for rubella

Answer 255

Headache low grade fever sore throat coryza Forchheimer spots on soft palate Lymphadenopathy Rash begins on face and spreads cephalocaudally

Question 256

Forchheimer Spots

Answer 256

Rubella

Question 257

Caused by Human Herpes virus 6

Answer 257

Roseola infantum

Question 258

Exanthem subitum

Answer 258

Roseola infantum

Question 259

S/S Roseola

Answer 259

Abrupt high fevers After fever subsides, a rash develops, starting on neck and trunk and spreads to face and extremeties

Question 260

age for roseola

Answer 260

6-36 months old

Question 261

Pityriasis Rosea is caused by

Answer 261

HHV-6 and HHV-7

Question 262

How long before methotrexate reaches peak concentration

Answer 262

2-3 months

Question 263

How often do you give methotrexate vs Humira

Answer 263

Methotrexate is weekly Humira is every 2 weeks

Question 264

Black box warning for Humira

Answer 264

Males with IBD have increased risk of Lymphoma

Question 265

An acute immune-immediated mucocutaneous disorder characterized by distinctive target-like lesions on the skin. Typically accompanied by oral, genital, and/or ocular mucosal erosions

Answer 265

Erythema Multiforme

Question 266

age/gender for Erythema Multiforme

Answer 266

Slight male predominance Can occur at any age

Question 267

have been linked to the development of EM

Answer 267

infections, medications, malignancy, autoimmune disease, immunizations, radiation, poison ivy, and UV sunlight exposure

Question 268

Erythema Multiforme is what type of reaction

Answer 268

hypersensitivity reaction

Question 269

what is the most common infections trigger for Erythema Multiforme other causes?

Answer 269

HSV Other viral causes Varicella Parapoxvirus EBV CMV Influenza HIV Mycoplasma Pneumoniae Chlamydia mycobacterium TB Histoplasmosis

Question 270

EM with high fever in infants can be a sign of

Answer 270

Kawasakis

Question 271

Rash in EM appears in crops over ___-___ days and resolves when?

Answer 271

3-7 days and resolve in over 1-2 weeks

Question 272

Rash in EM is found where, spread how and looks like what?

Answer 272

Symmetric Any part of the body→ palms, soles of feet, and exterior surfaces of arms/legs are most commonly affected Spread in a centripetal fashion, but the trunk is usually less affected Lesions start as dusky red macules or red wheals that evolve into target lesions (hallmark sign). Compared to SJS/TEN, bullae develop less than 2% of the time May be asymptomatic or may have burning/itching

Question 273

Target lesions

Answer 273

EM

Question 274

Presentation of EM

Answer 274

Rash mucosal involvement - usually border of lips mild systemic - fever, malaise and myalgias

Question 275

Answer 275

Erythema Multiforme

Question 276

Answer 276

Erythema Multiforme

Question 277

skin lesions that are well circumscribed, red wheals, and plaques but lack the central dusky zones

Answer 277

Urticaria

Question 278

dusky, red plaques with or without central necrosis. Compared to EM, there are fewer lesions and the lesions recur in the same spot within hours of ingestion of offending agent. Clinical findings are hard to differentiate from EM….

Answer 278

Fixed drug eruption

Question 279

initially presents with mucosal erosions and atypical target lesions. distinct in that it’s widespread epidermal + mucosal membrane necrosis and sloughing of the skin.

Answer 279

SJS

Question 280

HX of eruption + target-like lesions with or without mucosal involvement is the most important infor to DXs

Answer 280

EM

Question 281

In severe cases of EM, what labs can you look like

Answer 281

Elevated sed rate CRP WBC and liver enzymes

Question 282

treatment for EM

Answer 282

self limiting, resolves in 4 weeks if caused by Medication -> stop that med If caused by HSV - give PO acyclovir - 25mg/kg/day divided BID for 10 days. For recurrent HSV-associated EM 5-10mg/kg/day for 6-12 months Mostly supportive Topical emolient, systemics antihistamines, and NSAIDs for burning or itching Oral antiseptic washes or local anesthetic solutions for painful oral lesions EM with severe functional impairment→ prednisolone 0.5-2 mg/kg/day divide BID for 3-5 days should be considered despite controversy of increase risk of infection

Question 283

What meds can cause EM

Answer 283

Barbiturates Hydantoins Nonsteroidal anti-inflammatory drugs Penicillins Phenothiazines Sulfonamides seizure meds such as lamictal NSAID, sulfonamide, anticonvulsants (lamotrigine, pheno), antibiotics, Can also be d/t viral/bacterial, syphilis, fungal Mycoplasma pneumoniae may have new distinct disease form (mycoplasma pnemonia is seen in school age children- previous test question) cmv

Question 284

Acute hypersensitivity reactions characterized by cutaneous and mucosal necrosis Inflamatory infiltration of the epidermis that leads to skin cell death as well as keratinocyte apoptosis

Answer 284

SJS/TEN

Question 285

Nikolsky sign

Answer 285

(mild skin friction results in dermal exfoliation; basically skin falls off) SJS/TEN

Question 286

whats worse SJS or TEN

Answer 286

TEN

Question 287

S/S SJS/TEN

Answer 287

Proceed HIGH fever, malaise, URI 1-14days before onset of cutaneous lesions Vomitting, diarrhea Target lesions on face and trunk→ bullae and vesicles with central necrosis Erythema, edema, and pain typically precede development of ulcers Red macules appear suddenly -> coalesce into large patches -> occur over face and trunk Nikolsky sign (mild skin friction results in dermal exfoliation; basically skin falls off) 2 mucosal surface involvement -Genitalia, -respiratory tract and -eyes -urinary tract, -gastrointestinal tract) Atypical targets may be present at first -> can cause confusion with EM but this target does not have the 3 zones SJS: epidermal detachment of <10% of BSA SJS/TEN overlap: 10-30% BSA TEN: >30% BSA and 1 severe mucosal erosion progressing to diffuse, generalized detachment of the epidermis

Question 288

How do you dx TEN vs SJS

Answer 288

SJS: epidermal detachment of <10% of BSA SJS/TEN overlap: 10-30% BSA TEN: >30% BSA and 1 severe mucosal erosion progressing to diffuse, generalized detachment of the epidermis

Question 289

treatment for SJS/TEN

Answer 289

supportive therapy 1)Fluid and electrolyte imbalances occur due to water loss from the affected dermis and decrease oral intake in patients with mucositis → strict I/Os and fluid replacement initiated to prevent shock. In the first 24 hours, fluid replacement should be 2 mL/kg/BSA percent affected and then titrated to achieve urine output goal of 0.5 to 1 mL/kg/hr. 2) Wound Care: Surgical: the detached epidermis is removed by manual scrubbing, debridement, or whirlpools and an allograft subsequently applied Non-surgical approach: the detached epidermis is left in place and cleansed with sterile water or diluted chlorhexidine prior to the application of a non-adhesive dressing. The wound should be cleaned and redressed every 7 days to promote healing and prevent infection. 3) Infection prevention and management: At a higher risk for infection Monitoring for signs and symptoms of infection → altered mental status, hypothermia, hypotension, tachycardia, and decreased urine output Repeat wound and blood cultures every 48 hours Broad-spectrum antibiotics should be initiated if have s/s of infection of (+) BC 4)Nutritional support: Caloric requirement of 20 to 25 kcal/kg/day during the catabolic phase 25 to 30 kcal/kg/day during the anabolic phase Mucosal involvement→ NGT 5)Temperature control: Room temperature should be kept at 82 to 90 degrees and a bear hugger utilized to prevent excessive caloric expenditures. 6)Pain Control Early involvement of eye doctor due to ocular complications Management of TEN -Burn unit for wound care -Resp support because of tracheal sloughing -Fluid management due to insensible losses

Question 290

what are the 2 categories of vascular anomalies and treatment

Answer 290

Tumors Malformations

Question 291

The most common pneumonia seen in school aged children

Answer 291

Mycoplasma pneumonia

Question 292

Breach in the corneal epithelium

Answer 292

Corneal abrasion

Question 293

s/s corneal abrasion

Answer 293

Pain, redness, tearing, photosensitive, blurred vision, foreign body sensation

Question 294

most important risk factor for corneal abrasion

Answer 294

contact lens use

Question 295

if corneal abrasion is vertical......

Answer 295

foreign body may be imbedded under the upper eye lid

Question 296

corneal abrasion treatment

Answer 296

topical abx drops/ointment 4x/day NEVER give STEROID (will increase risk of infection) NEVER give TOPICAL ANESTHETIC (will impair healing)

Question 297

corneal abrasion takes how long to heal when to follow up

Answer 297

1 week f/u within 2 days to eval healing and presence of developing infection Corneal whitening is a sign of infection

Question 298

corneal whitening is a sign of

Answer 298

infection....look for corneal ulcer (medical emergency)

Question 299

eye foreign body.....need to make sure of what?

Answer 299

that foreign body does not fully penetrate the cornea (open globe)

Question 300

Plan of care for foreign body in eye

Answer 300

CT scan if suspect globe penetration document visual acuity and a seidel test (fluorescein and woods lamp)

Question 301

seidel test

Answer 301

Fluorescein and woods lamp

Question 302

signs of open globe

Answer 302

peaked pupil flat anterior chamber

Question 303

what would an open globe look like on seidel test

Answer 303

fluid leaking from anterior chamber will appear green (aqueous humor leaking)

Question 304

treatment for foreign body removal

Answer 304

Topical anesthetic applied, foreign body removed with irrigation or cotton-tipped applicator 4th gen fluoroquinolone or cipro 4x/day to affected eye until healed NEVER USE STEROIDS, NEVER USE TOPICAL ANESTHETIC Pain medication will not be helpful Can have sxs before and after foreign body is removed until the cornea heals (1 week)

Question 305

Inflammatory rxn causing chemotaxis of leukocytes and leakage of proteins into the anterior chamber called iritis

Answer 305

Traumatic iritis

Question 306

most common cause of traumatic iritis

Answer 306

being struck by or against an object MVC Falls

Question 307

Traumatic Iritis s/s

Answer 307

redness photosensitive tearing blurred vision positive history of blunt trauma withing 72 hours

Question 308

Physical findings in traumatic iritis

Answer 308

conjunctival hyperemia with constricted and poorly reactive pupil Pain in affected eye when light is shown in the unaffected eye = consensual photophobia – pain is originating from iris contraction (uveitis) Slit lamp exam: anterior chamber cellular reaction will be present

Question 309

treatment for traumatic iritis

Answer 309

Cycloplegic eye drops If significant inflammation- use steroid eye drops Healing within 1-2 weeks; ophtho follow up in 3-5 days

Question 310

Disruption of arterial vessels of the iris or ciliary body that causes hemorrhage

Answer 310

Hyphema

Question 311

most common cause of hyphema

Answer 311

being struck by or against an object, MVC, falls

Question 312

s/sx hyphema

Answer 312

Pain, redness, blurred vision, eccymosis, subconjunctival hemorrhage

Question 313

physical exam findings for hyphema

Answer 313

PE: layered blood in the anterior chamber when sitting up (area between cornea and iris) Blood that fills entire chamber and is black = “eight ball hyphema” = see ophtho asap with high suspicion of ruptured globe

Question 314

plan of care for hyphema

Answer 314

Sickle cell prep test on all African Americans if status unknown CT scan if MOI unknown – looking for foreign body or orbital fracture Seidel Test if suspicion of open globe (peaked pupil) Visual acuity test

Question 315

TX for hyphema

Answer 315

Cycloplegic and intraocular pressure-lowering drops should be started (may need IV intra-ocular pressure lowering meds) AVOID CARBONIC ANHYDRASE INHIBITORS in sickle cell (will increase sickling of RBC) Shield eye with metal shield 24 strict bed rest – do not want another bleed, very important to educate on this and admit if they cannot do bedrest at home HOB at 30 Ophthal consult asap Biggest risk: secondary hemorrhage within 1 week (greatest risk in first 4 days) Wash out surgery if pressure lowering meds don’t work Poor outcomes: vision of 20/200, have a greater than 1/3 anterior chamber hyphema, delayed presentation to eye doctor (may have glaucoma later in life)

Question 316

Orbital floor blow out fracture - what happens

Answer 316

Occurs when large object strikes the orbit, causing sudden increase in orbital pressure Bones of orbital floor are weakest – most common site of fracture

Question 317

etiology of orbital floor blow out fx

Answer 317

struck by object falls

Question 318

S/sx Orbital blow out fx

Answer 318

Pain with diplopia, blurred vision PE: eyelid edema, ecchymosis, subcutaneous/conjunctival emphysema, enophthalmos (sunken globe) Bradycardia occurs with eye movement secondary to oculocardiac reflex in setting of muscle entrapment = immediate surgical intervention

Question 319

Plan of care orbital blow out fx

Answer 319

CT through maxillary sinus with bone windows Seidel test if concern for open globe (peaked pupils

Question 320

Tx orbital blow out fx

Answer 320

Cephalexin (or broad spec) PO abx PO prednisone (multidose pack) Avoid nose blowing If muscle entrapment – surgical emergency Cold packs in first 48hr can decrease swelling, bruising, and pain

Question 321

open globe in younger than 9 is at risk for

Answer 321

amblyopia in injured eye

Question 322

signs of peritonitis

Answer 322

guarding rebound tenderness abd wall rigidity abd wall discoloration in infants

Question 323

in the setting of abd trauma what does a CBC evaluate?

Answer 323

Hemorrhage

Question 324

in the setting of abd trauma what does ABG/VBG evaluate?

Answer 324

pH base deficit serum electrolytes h/h estimates degree of shock acidosis need for blood products

Question 325

in the setting of abd trauma what does a CMP/AST/ALT evaluate?

Answer 325

elevated AST/ALT may suggest liver injury - CT image warranted

Question 326

in the setting of abd trauma what does a amylase/lipase evaluate?

Answer 326

May be indicative of pancreatic injury if elevated 24 hours after trauma or upward trending values Amylase high -Pancreatic pseudocyst -Parotid gland injury

Question 327

in the setting of abd trauma what does a hematuria indicate?

Answer 327

>5 RBCs indicates need for further abd eval High sensitivity for injury but non-specific gross hematuria - evaluate for renal injuries

Question 328

when should you obtain pregnancy test

Answer 328

all females above 10yo

Question 329

in the setting of abd trauma what does a PT/PTT/INR evaluate?

Answer 329

Abnormal in hemorrhaging pt or pt who has been resuscitated with large volumes of crystalloid or RBCS alone

Question 330

in the setting of abd trauma what does a chest or pelvic x ray evaluate?

Answer 330

Pneumo, hemothorax, mediastinal widening, traumatic diaphragmatic hernia and pneumoperitoneum Pelvis fractures/ SI widening- cause of blood loss

Question 331

Preferred diagnostic modality for most intra-abdominal injuries in children

Answer 331

CT

Question 332

Contrast CT for abdominal injuries to see what

Answer 332

Must use IV contrast to determine bleeding PO contrast is not to be used risk of aspiration, not tolerating

Question 333

free fluid on abdominal CT - think

Answer 333

Hollow viscus or mesenteric injury

Question 334

Abd CT is used in trauma to evaluate

Answer 334

Hematomas, free fluid or air and retroperitoneal, pelvic, or solid organ injury Grade solid organ injuries Pelvis and spine Must use IV contrast to determine bleeding Diaphragmatic, bowel and pancreatic injuries often not detected via initial CT scan If free fluid= hollow viscus or mesenteric injury

Question 335

Abd trauma CT What is often not detected on initial scan

Answer 335

Diaphragmatic, bowel and pancreatic injuries

Question 336

What does FAST stand for

Answer 336

Focused abdominal sonography for trauma ultrasound

Question 337

what 4 areas are examined in a FAST exam

Answer 337

Hepatorenal fossa (Morrison pouch) Splenorenal fossa Pericardial sac Pelvis (pouch of douglas)

Question 338

FAST exam can see fluid collections of what amount

Answer 338

100 ml and >

Question 339

Trauma Exam findings for pelvic fx

Answer 339

Blood at the urethra and or bruising/swelling/open lacerations to the perineum/vagina/rectum High-Riding Prostate Gland Avoid manual manipulation of the pelvis!

Question 340

In traumas, what diaphragm is more commonly injured

Answer 340

Left hemidiaphragm

Question 341

In diaphragm injury, what is the x ray finding

Answer 341

Blurring of hemidiaphragm, hemothorax or an abnormal gas shadow obscures the hemidiaphragm confirmed with laparotomy, thoracoscopy or laparoscopy

Question 342

what abdominal organ is the most commonly injured in children

Answer 342

spleen

Question 343

what abdominal organ is the second most commonly injured in children

Answer 343

liver

Question 344

s/s spleen lac

Answer 344

Left UQ Pain Left shoulder pain (Kehr’s Sign) Abdominal pain/distention Bruising/abrasions to LUQ Abd pain with inspiration possibly hypotension and tachycardia

Question 345

s/s liver lac

Answer 345

Right lobe injured > left RUQ Abdominal pain Right shoulder pain Elevated Transaminases ecchymosis or abrasions to R torso R sided rib pain or tenderness possibly hypotension and tachycardia

Question 346

what is located in the peritoneum

Answer 346

stomach spleen liver 1st and 4th parts of the duodenum, jejunum, ileum, transverse and sigmoid colon

Question 347

what is located in the retroperitoneal space

Answer 347

Aorta kidneys ureters second and third parts of the duodenum, ascending and descending colon adrenal glands

Question 348

eval for splenic lac

Answer 348

CBC, CMP, coag, amylase, lipase, and possible blood gas. FAST- not always conclusive in pedi CT abdomen with IV contrast blush/ extravasation of contrast can represent ongoing bleeding or arterial bleed May need serial CT scanning, angiography, or surgery

Question 349

non surgical treatment for splenic lac

Answer 349

NOM (splenic salvage)- for hemo stable pt to Prevent emergent operation and preserve immune fx -Bed rest -NPO -Heme monitoring -serial abdominal examinations -Serial H/H -Blood products prn -IVF -Incentive spirometry -Judicious pain control to -avoid atelectasis -Diet titrated dependent on hemostability

Question 350

surgical treatment for splenic lac

Answer 350

In the unstable pt with splenic lac -repair, partial splenectomy or total splenectomy

Question 351

splenectomy has what complication risk

Answer 351

Removal has large risk of infection, 50% mortality rate Strep pneumoniae, Haemophilus influenza, meningococcus, E. Coli, staph aureus Postsplenectomy vaccinations -Pneumococcal, H. influenzae, and meningococcal vaccines consider at 14 days Prophylaxis ABX -Before age 5 daily -Prior to any future surgical or dental procedures

Question 352

what grade splenic injury? Laceration <1 cm Subcapsular hematoma <10% of surface area

Answer 352

Grade I

Question 353

what grade splenic injury? Laceration 1-3 cm subcapsular hematoma 10% -50% of surface area

Answer 353

Grade II

Question 354

what grade splenic injury? Laceration >3 cm subcapsular hematoma >50% of surface area

Answer 354

Grade III

Question 355

what grade splenic injury? Ruptured subcapsular or parenchymal herniation

Answer 355

Grade III

Question 356

what grade splenic injury? Segmental or hilar vascular injury Devascularization >25% of spleen

Answer 356

Grade IV

Question 357

Shattered spleen Hilar injury

Answer 357

Grade V

Question 358

What grade liver injury? Capsular tear < 1 cm deep subcapsular hematoma <10% surface area

Answer 358

Grade I

Question 359

What grade liver injury? Capsular tear 1-3 cm deep, <10 cm long subcapsular hematoma 10-50% surface area Intraparenchymal hematoma <10 cm

Answer 359

Grade II

Question 360

What grade liver injury? Capsular more than 3 cm deep subcapsular hematoma >50% surface area parenchymal hematoma >10 cm or expanding

Answer 360

Grade III

Question 361

what liver lobe is injured more often

Answer 361

Right

Question 362

plan of care liver injury

Answer 362

CBC, CMP, transaminases, coagulation studies, amylase, lipase, and possible blood gas FAST US and CT- primary diagnostic modalities for stable pt.

Question 363

treatment liver lac

Answer 363

NOM is the most common approach to liver injury Adjunctive hepatic artery embolization in pt with blush increase success rate of NOM Hemodynamically unstable pt. -Emergency surgical consultation and possible exploratory laparotomy -Hemorrhage due to Surgical manipulation of venous injuries often results in death

Question 364

what complications are associated with poor outcomes in liver lac

Answer 364

Recurrent bleeding Haemobilia (upper GI bleeding from biliary tract) Biliary fistula intra abdominal abscess

Question 365

Pancreatic injury is associated with trauma to ___ and ___

Answer 365

duodenum and liver

Question 366

presentation of pacreatic injury

Answer 366

soft tissue contusion in upper abd handlebar marking in epigastric region Tenderness to the lower ribs and costal cartilage Epigastric tenderness out of proportion to finding of the abd exam concomitant lower thoracic spine fx signs of peritonitis (rebound tenderness, guarding or abd wall rigidity) Hypotension and tachycardia vomiting Late findings: -abd pain -palpable abd mass -persistently elevated amylase levels

Question 367

labs in pancreatic injury

Answer 367

CBC, CMP, coag, amylase, lipase, blood gas Repeat serum amylase >3 hours postinjury or trending higher over time, may not be high initially

Question 368

serum amylase may be elevated in what other type of trauma besides abd

Answer 368

facial trauma to parotid gland

Question 369

imaging in pancreatic injury

Answer 369

Fast exam not reliable CT scan is not helpful to determine pancreatic trauma after injury, CT should be repeated in pt with persistent abdominal pain, fever, and elevated amylase levels. Repeat CT with IV and oral contrast

Question 370

treatment for pancreatic lac

Answer 370

Nom is approriate for grades I, II, sometimes III injuries Bed rest, bowel ret, nasogastric decompression, PN, enteral feedings distal to the duodenum or octreotide therapy May need surgery or drainage if duct is disrupted Surgical intervention for high grade injury to reduce risk of pseudocyst

Question 371

after discharging a pt with pancreatic injury. What should they watch out for and what can it indicate

Answer 371

Early satiety and colicky abd pain pancreatitis or pseudocyst formation

Question 372

what grade pancreatic hematoma? minor contusion without duct injury

Answer 372

Grade I

Question 373

what grade pancreatic hematoma? Major contusion without duct injury or tissue loss

Answer 373

Grade II

Question 374

what grade pancreatic lac? superficial laceration without duct injury

Answer 374

Grade I

Question 375

what grade pancreatic lac? Major laceration without duct injury or tissue loss

Answer 375

Grade II

Question 376

what grade pancreatic lac? distal transection or parenchymal injury with duct injury

Answer 376

Grade III

Question 377

what grade pancreatic lac? Proximal (to right of superior mesenteric vein) transection or parenchymal injury

Answer 377

Grade IV

Question 378

what grade pancreatic lac? massive disruption of pancreatic head

Answer 378

Grade V

Question 379

presentation of kidney/bladder injury

Answer 379

Contusion, hematoma, ecchymosis to the back, flank or lower abdomen Abdominal or flank tenderness Hematuria Palpable flank mass Tenderness in the flank, costovertebral angel or back Stab wounds posterior to the anterior axillary line Difficulty or inability to urinate Urine leaking from vagina Blood at the urethral meatus

Question 380

Labs for kidney/bladder injury

Answer 380

CBC, CMP, coag, amylase, lipase, UA, blood gas

Question 381

is fast exam helpful in evaluating kidney/bladder injury

Answer 381

no

Question 382

imaging for kidney/bladder injury

Answer 382

CT with IV contrast IVP (intravenous pyelogram intraoperatively to evaluate kidney fx

Question 383

Treatment for kidney/bladder injury

Answer 383

NOM for lower grade injury Bed rest until gross hematuria resolves, H/H, IV hydration, blood press monitoring Higher grade injuries- within 24 to 48 hours to evaluate kidney perfusion, hematoma size, and urinoma formation High grade injuries can be managed with nonsurgical interventions- stenting, percutaneous drainage, and angiographic embolization Surgical intervention -Hemodynamic instability and penetrating injuries rather than injury grading Intraperitoneal bladder ruptures -Surgical repair with urethral or suprapubic catheter for two weeks -Usually be removed within 2 weeks Extraperitoneal ruptures -Urethral catheter kept in place until follow up shows no further leak

Question 384

what should be monitored in bladder/renal injury

Answer 384

HTN UA for resolution of hematuria F/U CT scans or US

Question 385

What grade? Trauma renal injury scale Contusion- Microscopic or gross hematuria Urologic studies normal Hematoma-Subcapsular, nonexpanding without parenchymal laceration

Answer 385

Grade I

Question 386

What Grade? Trauma renal injury scale Hematoma- Nonexpanding perirenal hematoma confined to renal retroperitoneum Laceration: Less than 1 cm parenchymal depth of renal cortex without urinary extravasion

Answer 386

Grade II

Question 387

What Grade? Trauma renal injury scale Laceration: Greater than 1 cm parenchymal depth of renal cortex without collecting-system rupture or urinary extravasation

Answer 387

Grade III

Question 388

What Grade? Trauma renal injury scale Laceration: Parenchymal lac extending through the renal cortex, medulla and collecting system Vascular: main renal artery or vein injury with contained hemorrhage

Answer 388

Grade IV

Question 389

What Grade? Trauma renal injury scale Laceration: Completely shattered kidney Vascular - Avulsion of renal hylum that devascularizes the kidney

Answer 389

Grade V

Question 390

Hollow viscus injury involves

Answer 390

Bladder and intestines

Question 391

Presentation of Hollow viscus injury

Answer 391

Abd wall ecchymoses or abrasion Abd tenderness Seat belt sign Associated injuries such as presence of lumbar distraction fracture (Chance fracture T12-L2) and solid organ injury Signs of peritonitis (rebound tenderness, guarding or abd wall rigidity) handlebar marks

Question 392

CT finding in Hollow viscus injury

Answer 392

Free fluid, thickened bowel, extraluminal air, mesenteric fat streaking, mesenteric hematoma, and vascular or luminal extravasation of contrast

Question 393

treatment in Hollow viscus injury

Answer 393

NOM- nasogastric decompression, PN, enteral feeding beyond hematoma Exploratory laparotomy with focus on higher risk injuries and controlling bleeding Repeated abdominal explorations be be required in days following injury

Question 394

presentation of abd compartment syndrome

Answer 394

Life Threatening complication Contents of confined body space begin to exceed the space available within that compartment Bowel swelling Ascites Blood Bowel distension May develop after laparotomy- third spacing, hemoperitoneum and bowel edema develop Worsening abdominal distension, decreased urine output, poor lower extremity perfusion with edema, increased peak pressures in ventilated patients

Question 395

plan of care in abd compartment syndrome

Answer 395

Intra abdominal pressure is monitored indirectly by monitoring urinary bladder pressure ACS pressure: 15-35mmHG Intubation, sedation, chemical paralysis, diuresis Immediate decompression of abdomen needed

Question 396

Post op complications in abd compartment syndrome

Answer 396

Prolonged ileus, small bowel obstruction, malabsorption from extensive small bowel resection (intestinal failure)

Question 397

diaphragm injury is a marker of severity of trauma and can lead to

Answer 397

obstruction of intestine sepsis death

Question 398

presentation of diaphragm injury

Answer 398

May be asymptomatic, delaying diagnosis dyspnea/ orthopnea Chest pain Referred scapular pain Decreased breath sounds Flail chest Localized or diffuse severe abdominal tenderness Guarding Rebound tenderness Progressive abdominal distention Anxiety Increased oxygen demand Tachycardia Bilious emesis initial x ray is normal in 50%

Question 399

plan of care in diaphragm injury

Answer 399

Need for a chest tube has to be carefully assessed prior to placement to prevent injury to herniated organs Upper GI study and barium enema- herniated colon within the thoracic cavity Definitive diagnosis- laparoscopy, laparotomy, thoracoscopy Isolated asymptomatic diaphragm injuries should be repaired prior to discharge Typically repaired in hemo unstable patients when repairing other injuries NG tube inserted with care and not forced

Question 400

discharge in diaphragm injury

Answer 400

Prevent postoperative pneumonia- IS etc. Follow up chest x-ray for several years Complications- recurrent herniation

Question 401

presentation of pelvic fx

Answer 401

Ecchymosis over iliac wings, pubis, labia, or scrotum Deformity Abnormal movement Pain on palpation of pelvic ring Hematoma to scrotum or vulva Lacerations or palpation of bone fragments on rectal or vaginal exam High riding prostate or blood at the urinary meatus Abnormal peripheral pulses Leg length discrepancy Asymmetry in rotation of the hips

Question 402

plan of care pelvic fx

Answer 402

Anteroposterior AP pelvic xray CT Orthopedics consult Can produce significant hemorrhage- control and fluid replacement- bedsheet or pelvic binder to control bleeding Angiography can be needed to diagnose and control bleeding when hemo unstable Immature pelvis is less likely to require surgical intervention Unstable fractures in pedi patient or adolescents with mature pelvis should follow adult surgical guidelines Surgical benefits- hemorrhage control, wound therapy, deformity prevention, improved mobility and decreased risk of growth disruption

Question 403

complications in pelvic fx

Answer 403

DVT, limb discrepancy, neurologic deficits, acetabular growth disturbance, hip subluxation, urologic disorders, and sexual dysfx

Question 404

discharge info for pelvic fx

Answer 404

Early PT, xray one week post Weight bearing status and gradual return to activity 4-6 weeks healing About 6 months to return to normal

Question 405

spinal injury ...look for what sign increased risk for what?

Answer 405

seat belt sign increased risk for lumbar spinal fx

Question 406

in pediatric pt facial trauma is unlikely why

Answer 406

large cranium and prominent forehead

Question 407

Causes of facial trauma in pediatric

Answer 407

MVC falls sports injury physical abuse animal bites

Question 408

What LeFort fx type? transverse maxillary fracture, teeth are usually contained in detached portion of maxilla

Answer 408

Type I

Question 409

What LeFort fx type? pyramidal fracture, results in a floating maxilla and nose with possible cribriform plate fracture

Answer 409

Type II

Question 410

what leFort fx type? complete separation of facial bones from their cranial attachments, “dishface” deformity

Answer 410

Type III

Question 411

How to evaluate for facial trauma

Answer 411

Craniofacial CT Plain x ray is unreliable in pedi population

Question 412

When should facial lacs be repaired (timeline)

Answer 412

within 8-12 hrs from injury if the edges clean, can repair up to 24 hrs after

Question 413

facial trauma plan of care

Answer 413

Pedi is handled more conservatively: observation, full liquid diet, bedrest, analgesics Peds have an accelerated rate of healing -> fracture reduction becomes difficult if care is delayed because of early bone healing Fracture reduction and fixation should be performed as soon as possible

Question 414

suture removal facial trauma

Answer 414

Sutures may remain in place for 5days – 2 weeks (some get reabsorbed and others have to be removed so follow up is necessary)

Question 415

diet for oral trauma

Answer 415

recommended soft food diet and avoidance of foods that can burn or sting, such as orange juice or hot, spicy foods.

Question 416

danger of dental trauma

Answer 416

can obstruct airway

Question 417

Category of dental trauma treatment? Tender to touch but has normal mobility

Answer 417

concussion Least problematic Close clinical observation

Question 418

Category of dental trauma? Treatment? Has not been displaced but has increased mobility

Answer 418

Subluxation TX: observation, soft toothbrush and rinsing with chlorhexidine May consider soft diet

Question 419

Category of dental trauma? Treatment? Removed from bone socket

Answer 419

Avulsion Primary vs. permanent for treatment Primary: not replanted Area cleansed and evaluated for foreign bodies or fractured roots Permanent Considered emergency Cleansed and replanted with splinting, being careful not to disrupt the cementum 15 minutes have an excellent prognosis If out of the mouth for 60 minutes in dry storage it will most likely not survive long term. Transport: cold storage solution, hanks balanced salt solution or cold milk or saliva, saline or water Consider tetanus prophy and antibiotics

Question 420

Tooth transport

Answer 420

cold storage solution, hanks balanced salt solution or cold milk or saliva, saline or water

Question 421

Tooth is broken but remains in the socket

Answer 421

Tooth fracture

Question 422

treatment for tooth fracture

Answer 422

depends on location Fragment removal may be possible otherwise tooth is extracted

Question 423

fracture that Involves the alveolar bone and could extend into the adjacent mandible

Answer 423

Alveolar fx

Question 424

tx Alveolar fx

Answer 424

Soft tooth brush, liquid diet, chlorohexidine mouthwash Consult oral surgery, dentistry, oral-maxillofacial surgery or plastic surgery.

Question 425

Prevention of dental injury

Answer 425

Mouth guards face shields

Question 426

imaging of dental injury

Answer 426

Panorex or CT with 3D imaging

Question 427

Pediatric assessment triangle and ABCDE

Answer 427

Appearance Work of breathing circulation to skin Airway Breathing Circulation Disability/neurologic evaluation Exposure

Question 428

categories of vascular anomalies

Answer 428

Tumors Malformations

Question 429

most common soft tissue tumor of infancy

Answer 429

infantile hemangioma

Question 430

Color differences of superficial vs deeper infantile hemangiomas

Answer 430

When deeper they have blue discoloration superficial red can be both superficial and deep

Question 431

risk factors infantile hemangiomas

Answer 431

female low birth weight infant

Question 432

when does infantile hemangiomas present

Answer 432

55% present at birth, rest develop in first weeks of life

Question 433

superficial hemangioma reach max size by

Answer 433

6-8 months

Question 434

deep hemangioma grow for __ - __ months then spontaneous resolution by ___ -____

Answer 434

12-14 months 3-10 years

Question 435

complications of infantile hemangiomas

Answer 435

ulceration - painful, increased risk of infection, hemorrhage and scarring

Question 436

periorbital hemangioma has risk of

Answer 436

vision disruption Amblyopia ->will cause obstruction of the visual axis or pressure on the globe, resulting in astigmatism · Get eye doctor involved to prevent vision loss

Question 437

subglottic hemangioma risk and symptoms

Answer 437

Hoarseness + stridor -> progression to resp failure may be rapid

Question 438

Symptomatic airway hemangioma develop in 50% of infants with _____________ on the chin and jaw (beard distribution) What needs to happen? ·

Answer 438

extensive facial hemangiomas Urgently refer for a laryngoscopy

Question 439

Cervicofacial hemangioma associated with: posterior fossa malformation, hemangiomas, arterial anomalies of the cerebrovasculature, coarctation of aorta/cardiac defects, eye abnormalities

Answer 439

PHACE Syndrome

Question 440

Occult spinal dysraphism with/without anorectal and urogenital anomalies

Answer 440

Lumbosacral hemangioma

Question 441

imaging for Lumbosacral hemangioma

Answer 441

MRI of spine: get if large midline cutaneous hemangioma in lumbosacral area

Question 442

Treatment for Lumbosacral hemangioma

Answer 442

Most resolve spontaneously · If treatment is needed: PO propranolol or topical timolol = mainstay

Question 443

Acquired, benign vascular tumor · Initially, the lesions appear as pink-red papules that arise after minor trauma, growing rapidly over a period of weeks into a bright red, vascular, often predunculated papule measuring 2-10mm Lesion has appearance of granulation tissue and very friable

Answer 443

Pyogenic granuloma

Question 444

Most common location for pyogenic granuloma

Answer 444

Head neck and extremities

Question 445

what can happen when a pyogenic granuloma is traumatized

Answer 445

may bleed profusely -> requires emergency medical attention

Question 446

Treatment for Pyogenic granuloma

Answer 446

surgical excision is mainstay Pulsed dye laser can be used for small lesions

Question 447

Small vessel vasculitis with a leukocytoclastic response

Answer 447

Urticarial Vasculitis

Question 448

what distinguishes urticarial vasculitis from normal urticaria

Answer 448

Lesions last longer than 24hr, may be tender, and leave behind skin pigmentation skin biopsy needed to confirm

Question 449

what is it that causes purulent exudate or pus in abscess

Answer 449

Bacterial cause Leukocyte accumulation and formation of the purulent exudate

Question 450

who is at highest risk for abscess

Answer 450

immunosuppressed

Question 451

Presentation difference of cutaneous abscess vs internal abscess

Answer 451

Cutaneous abscess: erythema, tenderness, pain, warmth, induration, fluctuance, drainage Internal abscess: fever, malaise, fatigue -> sxs become more specific to the area as the abscess progresses (fever, elevated WBC, pain

Question 452

recent flu infection with pain specific to calf....normal labs....what are you thinking

Answer 452

myositis - esp with calf pain. workup should be done to r/o rhabdo

Question 453

complicated laceration in which the tissue is pulled away from the body, creating a flap-like appearance (foreign body can be hidden under flap)

Answer 453

Avulsion

Question 454

Puncture wounds are prone to what

Answer 454

deep wound infection

Question 455

Most common cause of puncture would

Answer 455

Dog Bite

Question 456

leading cause of lacerations Population risk

Answer 456

cutting and piercing tools, falls, MVC, 4-7 yo males

Question 457

Most common method of foreign body induction into soft tissue:

Answer 457

metal glass ceramic

Question 458

Cleaning wounds - what should you use and what should you not use

Answer 458

Using antibacterial agents hydrogen peroxide, or iodine is contraindicated -> can do damage to healthy tissue

Question 459

what happens in pressure injuries (short patho)

Answer 459

Hypoxia occurs at a pressure point that forms the epicenter of injury Edema and ischemia occur, leading to progressive hypoxia -> necrosis

Question 460

Effects of pressure injury in kids:

Answer 460

compromised skin protection increasing risk of infection, altered thermoregulation, metabolic deficiency, compromised immunity, decreased sensation

Question 461

risk factors for pressure injury

Answer 461

terminal illness, sedation, hypotension, sepsis, spinal cord injury, impaired mobility, paralysis, cardiopulmonary bypass, vasopressors, young age, prolonged length of critical care stay, traction device

Question 462

risk assessment tools in pressure injury

Answer 462

Braden Q scale = best for critically ill patients (includes tissue oxygenation and perfusion) Neonatal Skin Risk Assessment Scale

Question 463

Pressure injury wound staging what stage? non-blanchable erythema of intact skin Color changes do not include purple or maroon discoloration -> deep tissue pressure injury

Answer 463

stage 1

Question 464

Pressure injury wound staging what stage? partial-thickness skin loss with exposed dermis Wound bed viable, pink or red, moist Can have intact or ruptured serum-filled blister Adipose and deeper tissue not visible Granulation tissue, slough, eschar are not present

Answer 464

Stage 2

Question 465

Pressure injury wound staging what stage? full-thickness skin loss Adipose is visible in the ulcer Granulation tissue and epibole (rolled wound edges) Slough and eschar may be present If slough or eschar obscures the extent of tissue loss = UNSTAGABLE Depth of tissue damage varies by location Undermining and tunneling occur Fascia, muscle, tendon, ligament, cartilage and bone NOT EXPOSED

Answer 465

Stage 3

Question 466

Pressure injury wound staging what stage? full-thickness skin and tissue loss Exposed fascia, muscle, tendon, ligament, cartilage, bone in the wound Slough/eschar visible If slough or eschar obscures the extent of tissue loss = UNSTAGABLE

Answer 466

Stage 4

Question 467

Pressure injury wound staging what stage? obscured full-thickness skin and tissue loss Extent of tissue damage cannot be confirmed because it is obscured by slough or eschar If slough removed, stage 3 or 4 will be revelaed Stable eschar (dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed

Answer 467

Unstageable

Question 468

Pressure injury wound staging what stage? persistent non-blanchable deep red, maroon, or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red/maroon/purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister Pain and temperature change often proceed skin color changes Results from intense/prolonged pressure and shear forces at the bone-muscle interface If necrotic tissue, subq tissue, granulation tissue, fascia, muscle, are visible = full thickness pressure injury (3, 4, unstageable)

Answer 468

Deep tissue pressure injury:

Question 469

Wound care solution for pediatric and neonate what other solution is safe

Answer 469

NS in Pedi Sterile water neonate Hypochlorous acid solution – safe

Question 470

whats wrong with using hydrogen peroxide to clean a wound

Answer 470

highly cytotoxic – do not use

Question 471

Wound care Sodium hypochlorite (Dakin solution): caution with

Answer 471

use with caution at a concentration no greater than 0.025%

Question 472

In wound care, when is culture needed?

Answer 472

only when infection is present to get susceptibility testing

Question 473

Topicals for wound care

Answer 473

Mupirocin (nasal tx), polymyxin B, bacitracin Silver sulfadiazine: contraindicated due to toxicity If you need antimicrobial therapy, get wound nurse involved

Question 474

Wound care: Silver sulfadiazine: contraindicated due to

Answer 474

toxicity

Question 475

aggregation of microbial cells enclosed in a polysaccharide matric material that forms thin film or patchy layer of varying thickness that is not removed by gentle rinsing and traditional wound cleansing techniques

Answer 475

Biofilm

Question 476

Benefits to Biofilm

Answer 476

Gives bacteria protection Adheres to wound surface, prolongs inflammation, erodes tissue, disables skin barrier function Recalcitrant to topical or systemic antibiotics Will cause complicated wound healing and increased risk of infection Studies being done now to figure out how to get rid of this

Question 477

What factors do you need to consider when picking a dressing in wound care

Answer 477

condition of wound bed, amount of exudate, presence of infection, granulation tissue, slough or eschar, overall condition of patient, comorbidities

Question 478

Negative pressure wound therapy benefits

Answer 478

Increased granulation formation, improved tissue perfusion, exudate management, reduced tissue edema Controlled suction through custom cut sponge -> evacuates excess wound fluid, provides moist healing environment, prevents maceration, decreases bacterial count Only changed 3x/week

Question 479

contraindications to negative pressure wound therapy

Answer 479

presence of necrotic wound tissue, untreated osteomyelitis, malignancy of wound site, coagulopathy, nonenteric and unexplored fistulas, exposed blood vessels/organs/nerves

Question 480

Hydrocolloid dressing description? does what? when should you not use?

Answer 480

bound to foam, impermeable to bacteria; minimal to moderate absorption Facilitates autolytic debridement not to be used in wounds with significant drainage difficult removal; use caution with delicate skin

Question 481

Sheet and amorphous hydrogels description? does what?

Answer 481

WAter based and non-adherent; Maintains a moist environment Nonadherent; no risk for skin irritation with removal; may require secondary dressing for reinforcement

Question 482

Transparent films description? does what?

Answer 482

Polyurethane with porous adhesive layer; allows escape of moisture and exchange of oxygen Allows for easy wound inspection; impermeable to external fluids; nonabsorbent; may adhere to wound

Question 483

Hydrocolloid description? does what?

Answer 483

Hydrophilic polyurethane coated foam, nonadherent, absorptive Nonadherent; trauma free removal; absorptive; not recommended for nondraining wounds

Question 484

when is gauze not recommended

Answer 484

for moist wound treatment

Question 485

Name that dressing bound to foam, impermeable to bacteria; minimal to moderate absorption

Answer 485

Hydrocolloid dressing

Question 486

Name that dressing WAter based and non-adherent; Maintains a moist environment

Answer 486

Sheet and amorphous hydrogels

Question 487

Name that dressing Polyurethane with porous adhesive layer; allows escape of moisture and exchange of oxygen

Answer 487

Transparent films

Question 488

Name that dressing Hydrophilic polyurethane coated foam, nonadherent, absorptive

Answer 488

Polyurethane foam

Question 489

Tetraplegia is injury in

Answer 489

one of 8 cervical regions

Question 490

Paraplegia is injury in the

Answer 490

thoracic, lumbar, or sacral segments

Question 491

incomplete vs complete spinal injury ? Residual motor or sensory function more than three segments below the level of injury

Answer 491

Incomplete

Question 492

incomplete vs complete spinal injury ? sensation or voluntary movement in the lower extremities

Answer 492

incomplete

Question 493

Sensation around the anus/ voluntary rectal sphincter contractions/ or voluntary toe flexion

Answer 493

Sacral sparing in incomplete spinal injury

Question 494

Clonus, muscle spasticity or bladder involvement -Typically a lesion in the middle or upper parts of the spinal cord or in the brain

Answer 494

Long tract signs in incomplete injury

Question 495

complete or incomplete spinal injury No preservation of motor/ and or sensory function more than three levels below the level of injury…the persistence of a complete lesion beyond 24 hours can be prognostic that function is unlikely to recover

Answer 495

complete

Question 496

In spinal shock, flaccid paralysis and loss of rectal tone and reflexes leads to

Answer 496

Venous pooling and slight hypovolemia

Question 497

Triad in neurogenic shock

Answer 497

Vasodilation (hypotension) Hypothermia Bradycardia less likely with injury below T6

Question 498

what happens in autonomic dysreflexia

Answer 498

Reflexes return after neurogenic shock, now more sympathetic below injury than parasympathetic Massive arterial vasoconstriction and reflex HTN Severe HA from the vasodilation above the level of injury Parasympathetic responses Sweating and skin flushing, bradycardia develops to control the HTN