Exam 1, Deck 2 Flashcards
What burn zone?
cells in this area receive maximum contact with heat source, necrosis occurs
zone of coagulation (site of injury)
what burn zone?
decreased blood supply, high risk of burn wound progression without adequate fluid resus
Zone of stasis (area extending peripherally from site of injury):
what burn zone?
cells sustain minimal injury, mild inflammation, spontaneous heals in 7-10 day
Zone of hyperemia (located furthest away from injury):
Burns > __% TBSA have a larger systemic response
15%
what happens in large TBSA burns that places the pt at risk for compartment syndrome
Fluid shifts
Complications in Burns
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)
most common cause burns in pediatric
Scalds
child maltreatment
What degree burn
restricted to the epidermal layer
Sunburn
Erythematous, painful, absent of bullae
Heals 2-5 days without scarring
Superficial 1st degree
what degree burn
extends into dermal layer – have bullae (fluid containing blisters) and very painful due to nerve ending exposure, assess cap refill
Partial Thickness (2nd degree)
most frequent burn for which treatment is sought out
Partial Thickness (2nd degree)
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
Deep partial-thickness (2nd degree):
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.
full thickness
3rd degree
what type of burn
Involved underlying fascia, muscle, or bone
May need reconstruction and grafting
4th degree burn
Non-blanching wound is a ________ _____ wound
full thickness
when should you suspect inhalation injury
facial burn
singed nose hairs
Carbonaceous sputum
Hoarseness
Labs and imaging in burn
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
Care of wound pt
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
Silver sulfadiazine used as topical antimicrobial in burns can cause
Kernicterus in peds
Pancytopenia
Mafenide cream used in burns can cause
metabolic acidosis
Urine output goal in burn
<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
Parkland formula for TBSA >
15%
Parkland formula
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
special considerations
chemical burns
cleanse immediately, do not alkalize, call poison control
special considerations
eye burns
ophtho consult, erythromycin ointment
special considerations
Perineum burns
urinary drainage catheter, bacitracin
Bleed
injury to the middle meningeal artery or vein
Epidural
Bleed?
Bridging vein rupture
Subdural
Bleed?
Tearing of small vessels in the pia matter
Subarachnoid
Which bleed has a lucid interval
Epidural
which bleed is from shaken baby
Subdural
Bleed?
result from direct trauma or rotational forces from vigorous shaking
Subdural
Bleed?
Sudden, severe HA due to rupture of intracranial aneurysm
Subarachnoid
acceleration/deceleration forces that result in shear trauma at the interface of grey and white matter
diffuse axonal injury
Secondary Brain injury is
local and systemic events triggered by primary injury
-Posttraumatic energy failure and excitotoxicity
-Axonal injury
-Cerebral edema with increased ICP
Mild TBI has GCS of
13-15
Moderate TBI has GCS of
9-12
Severe TBI has GCS of
<8
Cushing Triad
Bradycardia
Hypertension
Irregular resp
Secondary impact syndromes
repeated concussions carry r/o permanent brain injury
ICP > ____= poor outcome
> 20
CPP =
MAP-ICP
CPP Infant
children
adolescent
Infant >40-50
Children >50-60
Adolescent >60
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
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
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
maintenance fluid for SJS
2ml/kg x TBSA
for 24 hours
maintenance rhabdo
2xs maintenance
Hypotension formula
70 + 2(age)
systolic
if systolic is this number. Lower limit for hypotension
for children 1-4 yrs old what is the leading cause of death?
drowning
for children less than 1 yr what is the leading cause of death
suffocation
Highest death rate across all age groups cause of death is
MVC
leading cause of nonfatal injuries
falls
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
Gather medical history, allergies, medications, last food/fluids and events surrounding incident
Primary or secondary survey?
secondary
Trauma
hemoptysis
subcutaneous emphysema
Tension pneumothorax with mediastinal shift
What type of injury should you be thinking about
Tracheobronchial tree injury
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
what type of pneumothorax has neck vein distention and tracheal deviation
Tension pneumothorax
What type of pneumothorax requires needle decompression and chest tube
Tension pneumothorax
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
signs of Tension pneumo
Hypotension
JVD
Absent breath sounds
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
When does a subdural bleed need surgical decompression
if 5mm midline shift or greater
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)
leading cause of TBI and mortality in children
Skull fractures
what skull bone is most frequently involved in skull fx
Parietal bone
Type of skull fracture most common
Linear fx
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
symptoms of TBI with Herniation
Altered MS
Hypotension with tachycardia
Retinal hemorrhage
Unequal pupils
Seizures
Altered respiratory rate
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
SCTWORA
traumatic myelopathy will have spinal cord injury without any radiographic abnormality
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
Cervical x rays
Cross table lateral
AP of lower cervical column
Atlanto-axial AP (Open mouth)
BL supine oblique views
40% of children under 7 yrs of age show anterior displacement of C2 on C3 which is called a
Pseuosubluxation
what kind of burn?
with hot fluid such as coffee, tea or soup
scald burn
what kind of burn?
when touch hot object such as stove, iron, grill or muffler
contact burn
what kind of burn
friction with treadmill, rope, or pavement
mechanical burn
what kind of burn?
contact with fire
flame burn
what kind of burn?
when electrical current travels from the contact site into body
electrical burn
what kind of burn
contact with strong acids (drain and toilet cleaners) or strong alkalis (fertilizers, detergents, oven cleaners)
chemical burn
what kind of burn?
from hot gases or smoke
inhalation burn
Burns increase risk of
infection
hypothermia
metabolic acidosis
how long does it take for a 2nd degree burn to heal
7-10 days
how long does it take for a deep partial thickness burn to heal
2-3 weeks
how long does it take for a full thickness burn to heal?
> 1 month
what chart to determine TBSA
Lund and Browder chart or palmar surface
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)
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
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
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.
what burns need hospital admission
Partial thickness burns 10-20% and full thickness burns >5%
Burns > ___% require IV fluids, Burs greater than ___% should be resuscitated using parkland formula
10%
15%
greatest risk for submersion injuries are < __ yrs
5
another peak at 16-24 yrs
pH imbalance in submersion
metabolic acidosis
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.
needle aspiration for tension pneumo location
Second intercostal space mid-clavicular line
Thoracostomy tube is placed
4th, 5th or 6th intercostal space midaxillary line and connected to water seal or suction
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
what injuries in children are almost always associated with a pulmonary contusion
flail chest
scapular fractures
when does symptoms peak in pulmonary contusion. when do they resolve?
peaks 24-48 hours after injury and resolves within 7 days
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
imaging for pulmonary contusion
CT
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
complications of pulmonary contusion
pneumonia
ARDS
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
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
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
fracture that involves total width of bone
complete fx
fx that occurs from a rotational or twisting force
spiral fx
fx that viewed diagonally across the diaphysis
Oblique
fx that is usually diaphyseal
transverse fx
fx that is through the physis or growth plate
Epiphyseal fx
immobilization for most fractures is < __ weeks
12
simple fractures that are closed and nondisplaced can heal enough to be free from immobilization within __ weeks
3
injury to a ligament resulting from excessive stretching force
sprain
grade that sprain
minimal discomfort, minimal or no loss of function
grade I
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
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
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
how long does Sprain take to heal
4-6 weeks
foreign body in eye
what abx should be given
4th gen fluoroquinolone or ciprofloxacin drops 4 times a day until healed
no steroids
Quadriplegia is now known as
Tetraplegia
spinal cord injury at what level increases risk for neurogenic shock
T6
In neurogenic shock
How do you treat the bradycardia and hypotension
Bradycardia - Atropine
Hypotension- fluids
keep MAP 80-85
Temp loss of sensory, motor, autonomic and reflex function below level of injury. Flaccid paralysis -> venous pooling -> hypovolemia
spinal shock
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
Autonomic dysreflexia usually happens if injury is ___ or above
T6
most sensitive imaging to evaluate spinal cord, surrounding ligaments and soft tissues
MRI
GI complication in spinal cord injury
ileus
gastric decompression is recommended to prevent emesis and aspiration
____ and ____ perpetuate secondary spinal cord injury
hypotension
hypoxia
the first ___ after spinal cord injury are crucial for therapeutic interventions
24 hours
pneumonic for risk of person at risk for suicide
IS PATH WARM
Ideation
substance abuse
purposelessness
anxiety
trapped
hopelessness
withdrawal
anger
recklessness
mood changes
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
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
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
After a TBI, keep ICP <___mmHG with optimal CPP for age
<20mm Hg
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
Acute presentation of sexual abuse is within ____ hours
72
fractures concerning for child abuse
posterior rib fx
fx in a child <1 yr
classic metaphyseal lesions
eye finding in abuse
retinal hemorrhages found in 65-80% of pt with abusive head trauma
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
Rancho los amigos level?
no response to stimuli
Level I
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
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
rancho los amigos
Purposeful and modified independent
Level X
injury to L frontotemporal where Broca is located may result in
motor aphasia or dysarthria
may understand but have difficulty expressing thoughts
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
primary catalyst for secondary injury in drowning victim
Hypoxemia
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
Silver dressings should not be applied where?
face, so moisturizers without alcohol are sufficient
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
Salter Harris III fx is considered a fracture involving what area of the bone?
Epiphyseal
fracture through growth plate
Salter Harris?
Type I
Fracture through growth plate and metaphysis
salter harris?
Type II
Fracture through growth plate and epiphysis
salter harris?
type III
Fracture through growth plate, metaphysis and epiphysis
salter harris?
type IV
crushing of growth plate
salter harris?
Type V
most common symptom in a fabricated illness
apnea
which venomous spider triggers inflammatory cascade…can develop into tissue necrosis
Brown recluse (Loxosceles reclusa)
which venomous spider triggers intense pain via catecholamine release affecting neurotransmitters
Black widow (Latrodectus mactans)
which venomous spider may present with fang marks or target sign
Black widow
a ring of white tissue ischemia may develop, followed by a blister or pustule and then a bulls eye appearance
brown recluse
Local symptoms after a brown recluse bites begins how long
3-4 hours
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
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
black widow antivenom derived from ___ serum
horse
___ __ spider bite presentation can be similar to an early community acquired staph aureus infection
Brown recluse
Black widow mild cases…how long do you monitor for
6 hours
Black widow muscle cramps can be treated with
Benzodiazepines
opioids
dantrolene
Wasps vs Bees after they sting
wasps can sting multiple times
Bee dies after stinging
Bee and wasp stings - systemic reactions occur as a result of massive ___ - mediated hypersensitivtity reaction to envenomation
IgE-mediated hypersensitivity
wound eval
maroon color intact skin close to sacrum
what best describes this skin ulcer
deep tissue injury
