Exam 1, Deck 2 Flashcards
1
Q
What burn zone?
cells in this area receive maximum contact with heat source, necrosis occurs
A
zone of coagulation (site of injury)
2
Q
what burn zone?
decreased blood supply, high risk of burn wound progression without adequate fluid resus
A
Zone of stasis (area extending peripherally from site of injury):
3
Q
what burn zone?
cells sustain minimal injury, mild inflammation, spontaneous heals in 7-10 day
A
Zone of hyperemia (located furthest away from injury):
4
Q
Burns > __% TBSA have a larger systemic response
A
15%
5
Q
what happens in large TBSA burns that places the pt at risk for compartment syndrome
A
Fluid shifts
6
Q
Complications in Burns
A
Infection
Fluid shifts -risk for compartment syndrome
Rhabdomyolysis
Hypermetabolic response - 24-72 hours ->Gluconeogenesis, weight loss, negative nitrogen balance, decr in E stores, incr risk of infection
Body temp -> risk for heat loss (increased cortisol, glucagon and catecholamine secretion)
7
Q
most common cause burns in pediatric
A
Scalds
child maltreatment
8
Q
What degree burn
restricted to the epidermal layer
Sunburn
Erythematous, painful, absent of bullae
Heals 2-5 days without scarring
A
Superficial 1st degree
9
Q
what degree burn
extends into dermal layer – have bullae (fluid containing blisters) and very painful due to nerve ending exposure, assess cap refill
A
Partial Thickness (2nd degree)
10
Q
most frequent burn for which treatment is sought out
A
Partial Thickness (2nd degree)
11
Q
what degree burn
Entire epidermis and deeper dermis
Blistering
Dermal base is less
blanching, mottled pink or white, less painful than superficial partial thickness
Require excision and grafting
A
Deep partial-thickness (2nd degree):
12
Q
what degree burn
all layers of the skin — epidermis and dermis — are destroyed, and the damage may even penetrate the layer of fat beneath the skin.
A
full thickness
3rd degree
13
Q
what type of burn
Involved underlying fascia, muscle, or bone
May need reconstruction and grafting
A
4th degree burn
14
Q
Non-blanching wound is a ________ _____ wound
A
full thickness
15
Q
when should you suspect inhalation injury
A
facial burn
singed nose hairs
Carbonaceous sputum
Hoarseness
16
Q
Labs and imaging in burn
A
CBC, type/screen, coags, chem10, ABG, chest xray
Carboxyhemoglobin if inhalation exposure
Cyanide level: smoke inhalation with AMS
Burn >15% TBSA: BMP, BUN, Cr, prealbumin
Electrical: get UA (goal urine pH >6), myoglobin, ECG to eval for ST changes
17
Q
Care of wound pt
A
Nutrition must be assessed within first 24hr – needed to manage the hypermetabolic state
-High protein, high calorie
- Steroid-Oxandrolone (incr protein synthesis),
–propranolol (helps blunt hypermetabolic state), growth hormones (aid in wound healing)
Pain control, blood glucose control
Wound care
Topical antimicrobials: silver sulfadiazine (can cause kernicterus in peds, pancytopenia), bacitracin, mafenide cream (metabolic acidosis)
100% humidified O2 if hypoxia or inhalation suspected
18
Q
Silver sulfadiazine used as topical antimicrobial in burns can cause
A
Kernicterus in peds
Pancytopenia
19
Q
Mafenide cream used in burns can cause
A
metabolic acidosis
20
Q
Urine output goal in burn
A
<30kg: 0.5-1ml/kg/hr
>30kg: 1-2 ml/kg/hr
If UO too high, titrate LR infusion down by ⅓
If UO too low, titrate LR infusion up by ⅓
Reassess UO in 2hr and adjust as needed
21
Q
Parkland formula for TBSA >
A
15%
22
Q
Parkland formula
A
4ml x weight in kg x %TBSA burned = volume of LR to deliver in 24 hrs.
deliver first half of fluid in 1st 8 hrs
second half over the next 16 hrs
For pt <30kg: deliver MIVF (4-2-1 rule) with dextrose in addition to parkland fluid
23
Q
special considerations
chemical burns
A
cleanse immediately, do not alkalize, call poison control
24
Q
special considerations
eye burns
A
ophtho consult, erythromycin ointment
25
special considerations
Perineum burns
urinary drainage catheter, bacitracin
26
Bleed
injury to the middle meningeal artery or vein
Epidural
27
Bleed?
Bridging vein rupture
Subdural
28
Bleed?
Tearing of small vessels in the pia matter
Subarachnoid
29
Which bleed has a lucid interval
Epidural
30
which bleed is from shaken baby
Subdural
31
Bleed?
result from direct trauma or rotational forces from vigorous shaking
Subdural
32
Bleed?
Sudden, severe HA due to rupture of intracranial aneurysm
Subarachnoid
33
acceleration/deceleration forces that result in shear trauma at the interface of grey and white matter
diffuse axonal injury
34
Secondary Brain injury is
local and systemic events triggered by primary injury
-Posttraumatic energy failure and excitotoxicity
-Axonal injury
-Cerebral edema with increased ICP
35
Mild TBI has GCS of
13-15
36
Moderate TBI has GCS of
9-12
37
Severe TBI has GCS of
<8
38
Cushing Triad
Bradycardia
Hypertension
Irregular resp
39
Secondary impact syndromes
repeated concussions carry r/o permanent brain injury
40
ICP > ____= poor outcome
>20
41
CPP =
MAP-ICP
42
CPP Infant
children
adolescent
Infant >40-50
Children >50-60
Adolescent >60
43
Physical abuse fractures
-Long bone fracture in non-ambulatory child
-Rib fracture (needs a lot of force to fracture)
-Grabbing baby and squeezing chest
-Fractures of sternum, scapula or spinous process (needs a lot of force to fracture)
-Multiple fractures in various stages of healing
-Digital fracture in child < 3 years old
-Complex skull fracture
-Metaphyseal corner and bucket fractures
- Bone shaved off
44
Baby GCS
Eye opening
spontaneous - 4
speech - 3
pain- 2
none - 1
Verbal
coos, babbles - 5
irritable cries - 4
Cries to pain - 3
moans to pain-2
none- 1
Motor
Normal - 6
withdraw touch-5
withdraws pain 4
abnormal flexion -3
abnormal extension 2
none 1
45
GCS
eyes
spontaneous 4
to command 3
to pain 2
none 1
verbal
oriented -5
confused-4
inappropriate words-3
incomprehensible sounds - 2
None-1
Motor response
obeys commands -6
localizes pain-5
withdraws-4
abnormal flexion-3
abnormal extension-2
none-1
46
maintenance fluid for SJS
2ml/kg x TBSA
for 24 hours
47
maintenance rhabdo
2xs maintenance
48
Hypotension formula
70 + 2(age)
systolic
if systolic is this number. Lower limit for hypotension
49
for children 1-4 yrs old what is the leading cause of death?
drowning
50
for children less than 1 yr what is the leading cause of death
suffocation
51
Highest death rate across all age groups cause of death is
MVC
52
leading cause of nonfatal injuries
falls
53
pediatric anatomy differences
Larger head with shorter neck
Occiput causes neck to flex while laying flat
Posterior pharynx can buckle anteriorly without proper shoulder support
Large floppy tongue and tonsils can obscure view
Funnel shaped larynx allows secretions to accumulate
54
Gather medical history, allergies, medications, last food/fluids and events surrounding incident
Primary or secondary survey?
secondary
55
Trauma
hemoptysis
subcutaneous emphysema
Tension pneumothorax with mediastinal shift
What type of injury should you be thinking about
Tracheobronchial tree injury
56
Trauma with the following symptoms
> 2 ribs fractured in 2 or more places
Abnormal chest wall movement
Crepitus of ribs
Pulmonary contusion.
Ventilation/Oxygenation
what are you thinking?
Flail chest
57
what type of pneumothorax has neck vein distention and tracheal deviation
Tension pneumothorax
58
What type of pneumothorax requires needle decompression and chest tube
Tension pneumothorax
59
Symptoms of cardiac tamponade
Becks Triad:
1)Hypotension is the first sign, but it is not related to hypovolemia
2)Jugular venous distention is often noted as the veins begin to back up
3) Lastly muffled heart sounds are heard
Other signs include Pulsus Paradoxus:
A decrease of at least 10 mm Hg in arterial blood pressure when the patient inhales
Electrical Alternans
60
signs of Tension pneumo
Hypotension
JVD
Absent breath sounds
61
what type of bleed?
Caused by tears in bridging veins that rupture across the subdural space
Blood gathers between the dura mater and the brain
Subdural bleed
62
When does a subdural bleed need surgical decompression
if 5mm midline shift or greater
63
What type of bleed?
Often located in temporal or parietal region
Results from tear in Middle Meningeal Artery
Usually causes midline shift of brain matter
Common for patient to have “lucid event” from time of injury to deterioration
Epidural bleed
(requires immediate surgical decompression)
64
leading cause of TBI and mortality in children
Skull fractures
65
what skull bone is most frequently involved in skull fx
Parietal bone
66
Type of skull fracture most common
Linear fx
67
skull fx signs
Bogginess to palpation of scalp
Skull bone depression or “Step-Off”
Periorbital bruising (raccoon eyes)
Bruising behind ears (battle’s sign)
CSF leakage from the nose or ears
Paralysis of the face
Hearing loss
68
symptoms of TBI with Herniation
Altered MS
Hypotension with tachycardia
Retinal hemorrhage
Unequal pupils
Seizures
Altered respiratory rate
69
Treatment for TBI with herniation
Prevent hypotension and hypoxia
Intubation with mechanical ventilation
Maintain SBP 90mmHg or >
Hyperventilation PaCO2 35+/-3
Sedation
Avoid fluid overload
70
SCTWORA
traumatic myelopathy will have spinal cord injury without any radiographic abnormality
71
what does a cervical spine assessment include
No midline cervical tenderness
No focal neurological deficits
Normal mental status/alert
No intoxication
No painful, distracting injury
72
Cervical x rays
Cross table lateral
AP of lower cervical column
Atlanto-axial AP (Open mouth)
BL supine oblique views
73
40% of children under 7 yrs of age show anterior displacement of C2 on C3 which is called a
Pseuosubluxation
74
what kind of burn?
with hot fluid such as coffee, tea or soup
scald burn
75
what kind of burn?
when touch hot object such as stove, iron, grill or muffler
contact burn
76
what kind of burn
friction with treadmill, rope, or pavement
mechanical burn
77
what kind of burn?
contact with fire
flame burn
78
what kind of burn?
when electrical current travels from the contact site into body
electrical burn
79
what kind of burn
contact with strong acids (drain and toilet cleaners) or strong alkalis (fertilizers, detergents, oven cleaners)
chemical burn
80
what kind of burn?
from hot gases or smoke
inhalation burn
81
Burns increase risk of
infection
hypothermia
metabolic acidosis
82
how long does it take for a 2nd degree burn to heal
7-10 days
83
how long does it take for a deep partial thickness burn to heal
2-3 weeks
84
how long does it take for a full thickness burn to heal?
> 1 month
85
what chart to determine TBSA
Lund and Browder chart or palmar surface
86
management of superficial partial thickness burns
Xeroform (petroleum gauze infused with 3% bismuth tribromophenate)
Mepilex AG: (silver impregnated antimicrobial dressing that lasts 5-7 days)
87
Management of deep partial thickness burns:
Mepitel
and
Acticoat: silver impregnated rayon/polyester/polyethylene mesh. Active release of antimicrobial silver ions into burn wound when moistened. Lasts 3-7 days but antimicrobial activity lasts up to 96 hours
88
Management of full thickness burns
Silver sulfadiazine 1% cream - absorbs into epidermis and dermis. Bactericidal against gram positive and gram neg organisms, fungi and some viruses
skin grafting
89
Burns need what immunizations
Tetanus
Booster if >5 yrs since last
<7 years for DTaP
>7 years: Tdap or Td if child has already received one Tdap.
90
what burns need hospital admission
Partial thickness burns 10-20% and full thickness burns >5%
91
Burns > ___% require IV fluids, Burs greater than ___% should be resuscitated using parkland formula
10%
15%
92
greatest risk for submersion injuries are < __ yrs
5
another peak at 16-24 yrs
93
pH imbalance in submersion
metabolic acidosis
94
submersion injury
indications for intubation
unconscious child, peripheral arterial carbon dioxide (PaCO2) levels >50 mmHg, inability to maintain peripheral arterial oxygen (PaO2) >90% with supplemental oxygen. Positive end-expiratory pressure should be used to prevent atelectasis and overcome intrapulmonary shunting.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1032). Wolters Kluwer Health. Kindle Edition.
95
needle aspiration for tension pneumo location
Second intercostal space mid-clavicular line
96
Thoracostomy tube is placed
4th, 5th or 6th intercostal space midaxillary line and connected to water seal or suction
97
Injury to lung parenchyma with edema and hemorrhage without associated pulmonary laceration.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1037). Wolters Kluwer Health. Kindle Edition.
PUlmonary contusion
98
what injuries in children are almost always associated with a pulmonary contusion
flail chest
scapular fractures
99
when does symptoms peak in pulmonary contusion. when do they resolve?
peaks 24-48 hours after injury and resolves within 7 days
100
chest x ray may not show changes in pulmonary contusion until how long after injury
4-6 hours and may not reflect extent of injury
101
imaging for pulmonary contusion
CT
102
management of pulmonary contusion
supportive
Close monitoring for >24-48 hrs after injury
oxygen for hypoxia
pulmonary toilet
fluid mgmt
pain control
Fluids -judicious
-too little -> hypovolemia and hypoxemia
too much -> pul edema
No benefit for abx or corticosteroids
prone positioning may help with perfusion
103
complications of pulmonary contusion
pneumonia
ARDS
104
a bending of the bone which causes a small fracture that does not cross the bone. Most common in the ulna.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1044). Wolters Kluwer Health. Kindle Edition.
plastic deformation
105
fracture on the tension side of the bone near the softer metaphyseal bone; crosses the bone and buckles the harder bone on the opposite side, causing a bulge.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1044). Wolters Kluwer Health. Kindle Edition.
buckle (torus) fx
106
Bone is bent with an initial fracture which does not go through bone.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1044). Wolters Kluwer Health. Kindle Edition.
greenstick fx
107
fracture that involves total width of bone
complete fx
108
fx that occurs from a rotational or twisting force
spiral fx
109
fx that viewed diagonally across the diaphysis
Oblique
110
fx that is usually diaphyseal
transverse fx
111
fx that is through the physis or growth plate
Epiphyseal fx
112
immobilization for most fractures is < __ weeks
12
113
simple fractures that are closed and nondisplaced can heal enough to be free from immobilization within __ weeks
3
114
injury to a ligament resulting from excessive stretching force
sprain
115
grade that sprain
minimal discomfort, minimal or no loss of function
grade I
116
grade the sprain
ligaments are partially torn with tenderness, swelling, and ecchymosis with mild-to-moderate loss of function.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1046). Wolters Kluwer Health. Kindle Edition.
grade II
117
grade that sprain
completely torn ligament with unstable joint, significant tenderness, swelling, and ecchymosis with loss of function.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1046). Wolters Kluwer Health. Kindle Edition.
grade III
118
Ottawa ankle rules
rules for when to x ray sprain
-point tenderness on lateral or medial malleolus and the distal 6cm of posterior edge of tibia or fibula
or inability to bear weight
or
take 4 unassisted steps in exam room
119
how long does Sprain take to heal
4-6 weeks
120
foreign body in eye
what abx should be given
4th gen fluoroquinolone or ciprofloxacin drops 4 times a day until healed
no steroids
121
Quadriplegia is now known as
Tetraplegia
122
spinal cord injury at what level increases risk for neurogenic shock
T6
123
In neurogenic shock
How do you treat the bradycardia and hypotension
Bradycardia - Atropine
Hypotension- fluids
keep MAP 80-85
124
Temp loss of sensory, motor, autonomic and reflex function below level of injury. Flaccid paralysis -> venous pooling -> hypovolemia
spinal shock
125
inappropriately strong sympathetic response to triggers that occur below the level of injury. Patients develop vasoconstriction, hypertension, and reflexive bradycardia. flushing to face, headache Triggers may include bladder and bowel distention.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1051). Wolters Kluwer Health. Kindle Edition.
Autonomic dysreflexia
use urinary catheter and bowel regimen to prevent
126
Autonomic dysreflexia usually happens if injury is ___ or above
T6
127
most sensitive imaging to evaluate spinal cord, surrounding ligaments and soft tissues
MRI
128
GI complication in spinal cord injury
ileus
gastric decompression is recommended to prevent emesis and aspiration
129
____ and ____ perpetuate secondary spinal cord injury
hypotension
hypoxia
130
the first ___ after spinal cord injury are crucial for therapeutic interventions
24 hours
131
pneumonic for risk of person at risk for suicide
IS PATH WARM
Ideation
substance abuse
purposelessness
anxiety
trapped
hopelessness
withdrawal
anger
recklessness
mood changes
132
what risk category for suicide
* History of serious or nearly lethal attempts or planning.
* Recently institutionalized for a psychiatric disorder or recent psychiatric disorder.
* Persistent suicidal ideation, psychosis, or history of aggression and impulsive acts.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1055). Wolters Kluwer Health. Kindle Edition.
High
133
what suicide risk category
* Under medical care of a psychiatric specialist. * Suicidal ideation without plans or attempts. * No other identified signs.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (pp. 1055-1056). Wolters Kluwer Health. Kindle Edition.
Moderate
134
What suicide risk category
* Mild suicidal ideation, but without attempt. * Social support. * No previous attempts.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1056). Wolters Kluwer Health. Kindle Edition.
low
135
After a TBI, keep ICP <___mmHG with optimal CPP for age
<20mm Hg
136
behavior/response scale used to evaluate the state of consciousness through interaction of the pt with the environment or response to stimuli
Rancho Los Amigos Scale
137
Acute presentation of sexual abuse is within ____ hours
72
138
fractures concerning for child abuse
posterior rib fx
fx in a child <1 yr
classic metaphyseal lesions
139
eye finding in abuse
retinal hemorrhages found in 65-80% of pt with abusive head trauma
140
what rancho los amigos level?
a generalized response with inconsistent and nonpurposeful reaction to stimuli in a nonspecific manner. Responses may be delayed and include physiologic changes, gross body movements, and/or vocalizations.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1078). Wolters Kluwer Health. Kindle Edition.
level II
141
Rancho los amigos level?
no response to stimuli
Level I
142
Rancho los Amigos level?
when the response to stimuli is more localized, such as withdrawal from painful stimuli or inconsistent following of simple, one-step commands.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1078). Wolters Kluwer Health. Kindle Edition.
Level III
143
rancho los amigos level?
exhibits automatic but appropriate responses although “robotic-like” and demonstrates decreased safety awareness and impaired judgment.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1078). Wolters Kluwer Health. Kindle Edition.
Level VII
144
rancho los amigos
Purposeful and modified independent
Level X
145
injury to L frontotemporal where Broca is located may result in
motor aphasia or dysarthria
may understand but have difficulty expressing thoughts
146
The wernicke area is located in the parietal temporal area and is responsible for
language comprehension and receptive speech
may have fluent aphasia where they can express their thoughts fluently in nonsensical speech pattern
147
primary catalyst for secondary injury in drowning victim
Hypoxemia
148
incomplete Spinal cord injury in which some degree of sensory and/or motor fx is preserved up to 3 vertebrae below the level of injury
sacral sparing
149
Silver dressings should not be applied where?
face, so moisturizers without alcohol are sufficient
150
following grade III liver lac, how long does he need to maintain strict bed rest
2 nights
1 day for grades I and II, 2 days for grades III and IV
151
Salter Harris III fx is considered a fracture involving what area of the bone?
Epiphyseal
152
fracture through growth plate
Salter Harris?
Type I
153
Fracture through growth plate and metaphysis
salter harris?
Type II
154
Fracture through growth plate and epiphysis
salter harris?
type III
155
Fracture through growth plate, metaphysis and epiphysis
salter harris?
type IV
156
crushing of growth plate
salter harris?
Type V
157
most common symptom in a fabricated illness
apnea
158
which venomous spider triggers inflammatory cascade...can develop into tissue necrosis
Brown recluse (Loxosceles reclusa)
159
which venomous spider triggers intense pain via catecholamine release affecting neurotransmitters
Black widow (Latrodectus mactans)
160
which venomous spider may present with fang marks or target sign
Black widow
161
a ring of white tissue ischemia may develop, followed by a blister or pustule and then a bulls eye appearance
brown recluse
162
Local symptoms after a brown recluse bites begins how long
3-4 hours
163
Severe envenomation of brown recluse occurs ___ - ___ hours after bite and presents with what symptoms
24-72 hours
fever
chills
nausea
vomiting
signs of kidney injury
can lead to thrombocytopenia
hemolysis
shock
kidney failure
bleeding
pulmonary edema
164
what venomous spider
sudden onset of acute pain, swelling, muscle spasms, tachycardia, htn, pain, agitation
increased ICP, HTN, resp failure
positive tap test
Black widow
165
black widow antivenom derived from ___ serum
horse
166
___ __ spider bite presentation can be similar to an early community acquired staph aureus infection
Brown recluse
167
Black widow mild cases...how long do you monitor for
6 hours
168
Black widow muscle cramps can be treated with
Benzodiazepines
opioids
dantrolene
169
Wasps vs Bees after they sting
wasps can sting multiple times
Bee dies after stinging
170
Bee and wasp stings - systemic reactions occur as a result of massive ___ - mediated hypersensitivtity reaction to envenomation
IgE-mediated hypersensitivity
171
wound eval
maroon color intact skin close to sacrum
what best describes this skin ulcer
deep tissue injury
