Final Exam Flashcards
Do not treat ___________ children with STI prophylaxis. However, _____ prophylaxis should be considered.
prepubertal
HIV
Prophylactic treatment of STIs for adolescents
Ceftriaxone PLUS
Azithromycin PLUS
Metronidazole OR
Tinidazole
Diagnostic of sexual abuse: ________, _________, _________, _________
Gonorrhea
Syphilis
HIV
Chlamydia
High suspicion of sexual abuse: ________, _______ _______
Trichomonas
Genital herpes
Suspicious of sexual abuse: _________ ________
Anogenital warts
Inconclusive of sexual abuse: ________ _________
Bacterial vaginosis
When a pediatric patient is well appearing:
5 vital signs
S, O, A, P
When a pediatric patient is sick appearing (5 things):
- Oxygen (assist ventilation if needed)
- Pulse ox
- Cardiorespiratory monitor
- IV access
- CXR/EKG
Normal blood pressure is maintained up over _____% of a child’s circulating volume is lost. Therefore hypotension is a late finding in ______
30%
Shock
Signs of shock/poor tissue perfusion in a pediatric patient (3):
- Cool or mottled skin
- Tachycardia
- AMS
Fluid resuscitation for the pediatric patient in shock
20 ml/kg boluses NS or LR until signs of improved perfusion and resolution of tachycardia
Fluid resuscitation for the pediatric patient in shock due to hemorrhage
2 boluses of NS/LR 20 ml/kg
After, PRBC 10 ml/kg
Treatment if signs of increased ICP with herniation in pediatric patient
- Elevate HOB 30 degree
- Hypertonic saline (3%)
- Mannitol
Seatbelt sign
High probability of abdominal injury; CT of abdomen warranted
Pain before vomiting in children is typical of ____________
Appendicitis
Abnormal rotation of mesentery during embryonic development
Intestinal malrotation
Management/treatment of intestinal malrotation
- IV fluid resuscitation
- NG tube w/ intermittent suction
- Call your surgeon
- Upper GI series
- Laparotomy
Preferred imaging and classic image of intussusception
Ultrasound
Coiled spring or bullseye
Management of intussusception
- ABCs, resuscitate with IVF
- NGT if frequent vomiting
- IV abx if concern for perforation
- Notify surgery early, abdominal x rays to exclude perforation with free air
- Air enema reduction
Contraindications to air enema for intussusception
- > 3 days
- Signs of peritonitis
- Evidence of free air on plain X Ray
A WBC count of less than _______ and an absolute neutrophil count of less than _______ makes appendicitis much less likely
9,000
7,000
Management for appendicitis
- IV Fluids
- IV pain meds and antiemetics
- IV ABX (ancef or zosyn if concern for perforation)
- Call surgeon
Classic presentation of sudden unilateral lower abdominal pain, nausea and vomiting with a palpable mass
Ovarian Torsion
In ovarian torsion, the ______ side is more commonly affected than the _______ side
Right
Left
Management of ovarian torsion
- Pain control
- IV Fluids
- US with doppler
- Emergent operative intervention
What to do when patient is having a seizure:
- Assess ABCs
- Place patient on his/her side
- O2, pulse ox, IV access, bedside glucose
- If longer than 3 minutes: lorazepam, diazepam, midazolam
PMH details to watch for in pediatric seizures
- Neurosurgical procedures (shunt for hydrocephalus)
- Prematurity or developmental delays
- History of meningitis, CNS infections
- Hx of head trauma
- Hypercoagulable state (sickle cell)
- Immunosuppression
- TB exposures/access to INH
- Formula mixing
Signs of increased ICP in pediatric patients
- Bulging fontanelle
2. Papilledema
2 important questions to always ask after a pediatric seizure:
- Vaccination status (DTP/MMR)
2. Recent ABX (can be masking signs/symptoms of meningitis)
Lumbar puncture is an option in a post-seizure child that is:
- Deficient in immunizations OR
2. Pretreated with ABX
Lumbar puncture is clearly indicated in a post-seizure child that has:
- Status epilepticus
AND - Fever
____% of children will experience recurrent febrile seizures
33
Preferred imaging modalities for children in epilepsy evaluation
EEG
MRI
2 tests that should be ordered right away for a child in suspected DKA
- Accucheck
2. Urinalysis
Definition of DKA
Hyperglycemia > 200 mg/dL AND Venous pH < 7.30 OR Bicarbonate < 15 mmol/L
Physical exam findings of a child in DKA
- Kussmaul respirations
- Tachycardia
- Dehydration (sunken eyes, dry mucous membranes)
- Delayed capillary refill
- Abdominal tenderness
Electrolyte imbalances in kids with DKA
Hyponatremia
Hypokalemia
The 4 I’s of DKA
- Insulin lack
- Indiscretion
- Infection
- Impregnation
Management of pediatric DKA
- ABCs, cardiac monitor, vital signs, accucheck
- IV access
- BMP, VBG, +/- CBC, +/- EKG
- Accucheck every hour
- VBG every 1-2 hours
- BMP every 4 hours
- Neurological checks every hour
Treatment of DKA: Step 1
NS/LR bolus 20 ml/kg over 1 hour
Next: LR at 2x MIVF rate
Treatment of DKA: Step 2
Insulin infusion -.05-0.1 U/kg/hr
No insulin bolus in children
Switch to D5NS when glucose is < 300 mg/dL
Treatment of DKA: Step 3
Next 4-6 hours, NS with 40 mEq/L K+
After, switch to 0.45% saline with electrolytes
Most serious complication of DKA and its treatment
Cerebral Edema Treatment: 1. Reduce rate of IVF 2. Mannitol 0.5-1 g/kg over 20 minutes 3. Hypertonic saline (3%) 4. Consider intubation
In the event of spinal cord injury, ___________ should be given if within ____ hours
High dose steroids
8 hours
Most commonly injured organ in blunt trauma
Spleen
Second most commonly injured organ in blunt trauma
Liver
Glasgow Scale for mild TBI
13-15
Glasgow Scale for moderate TBI
9-12
Glasgow Scale for severe TBI
8 or less
Canadian CT Head Rules for mild TBI
- GCS score < 15 at 2 hours after injury
- Suspected open or depressed skull fracture
- Any sign of basal skull fracture
- Vomiting > 2 episodes
- Age > 65 y/o
Medium Risk
- Amnesia before impact > 30 minutes
- Dangerous mechanism
Cushing’s Reflex
Triad of intracranial hypertension
Systolic BP increase
Bradycardia
Irregular respirations
Fastidious gram-negative rod. Can cause bacteremia and fatal sepsis after animal bites, especially in asplenic patients, chronic alcohol abusers or those with underlying hepatic disease
Capnocytophaga canimorsus
Organism responsible for cat scratch disease
Bartonella henselae
Diagnostic testing for animal bites
Blood cultures prior to abx
X Rays AP and lateral (if deep or markedly infected wounds)
Criteria for closure of dog bite wound
- Clinically uninfected
- Less than 12 hours old (24 hours on the face)
- NOT located on the hand or foot
Kanavel sign
Flexor Tenosynovitis
- Finger held in slight flexion
- Fusiform swelling
- Tenderness along the flexor tendon sheath
- Pain with passive extension of the digit
Treatment of flexor tenosynovitis (infectious)
Surgical drainage
Consult hand surgeon
Rabies postexposure prophylaxis
- Wound cleansing (soap/water or povidone/iodine solution)
- RIG infiltrated around wounds
- Vaccine - IM in deltoid area
Days 0, 3, 7, and 14
All ______ bites require antibiotic prophylaxis
Human
Bacteria commonly found in human bites
Streptococci, staph aureus, eikenella, fusobacterium, peptostreptococcus, prevotella, and porphyromonas species
Treatment for human bites
Amoxicillin clavulanate (Augmentin) and Moxifloxacin Cellulitis 10-14 days 3 weeks for tenosynovitis 4 weeks for septic arthritis 6 weeks for osteomyelitis
Medications for insect bite rxns
- Epinephrine (DOC)
- Antihistamines (H1 blocker - diphenhydramine; H2 blocker - Ranitidine)
- Corticosteroids (methylprednisolone)
Diagnostic testing for snake bites
- CBC, electrolytes, creatinine, blood urea nitrogen
- Serum creatinine kinase - indicative of rhabdo
- PT and PTT/INR, fibrinogen, UA (rhabdo), EKG
_______ prophylaxis should be given for all snake bites
Tetanus
Dosing for CroFab
Not weight-based
Initial dose is 4-6 vials
After 1 hour, determine is initial control has been reached. If yes, 2 vials every 6 hours for 18 hours
If no, repeat initial dosing of 4-6 vials
Complications of snake bites
Coagulopathy
Compartment Syndrome
Indications for intubation in post-drowned patients
- Inability to protect airway
- PaO2 < 60 mmHg or O2 saturation < 90% on high-flow O2
- PaCO2 > 50 mmHg
Water-borne pathogens that commonly cause pneumonia in post-drowning survivors
Pseudomonas Proteus Pseudallescheria boydii (fungus)
Pseudallescheria boydii
Fungus found in contaminated water such as floods
How does cold diuresis work in a post-drowning survivor?
- Pt is hypothermic, so blood is shunted to the core
- Central volume receptors sense fluid overload
- ADH is decreased
- Diuresis and hypovolemia occur
- Body goes into hypotension and shock
Symptoms of heat exhaustion
Moist and clammy skin, dilated pupils, normal or subnormal body temperature
Symptoms of heat stroke
Dry hot skin, constricted pupils, very high body temperature (>104)
Vital signs of a pt undergoing heat stroke
Elevated core body temp Tachycardia Tachypnea Widened pulse pressure Hypotension
Physical exam signs of a patient undergoing heat stroke
Flushing Crackles Excessive bleeding Altered mentation Slurred speech
Management of heat stroke patient
- ABCs
- Rapid cooling
- Intubation often necessary
- Fluid resuscitation for hypotension
Cooling methods for heat stroke patients
Evaporative cooling methods are best (moistened skin with fans across patient)
Immersion in ice water is rapid and effective in young patients with exertional heat stroke
Rules for collecting urine culture via bladder catheterization in a child
All males < 6 mo and all uncircumcised males < 12 mo
All females < 24 mo and older female children if symptoms of UTI
Fever workup in the toxic child (labs)
Rapid testing for viruses
CBC (looking for bandemia)
Blood cultures, CXR, obtain stool for WBCs and guaiac if diarrhea is present
Lumbar puncture
4 types of shock
- Cardiogenic
- Obstructive
- Distributive
- Hypovolemic
Clinical manifestations of shock
Hypotension Tachycardia Oliguria Mental status changes Cool, clammy, cyanotic, mottled skin Metabolic acidosis
Shock patients may need as much as ______ L of fluid for resuscitation
4-6
Inadequate blood volume to maintain supply of oxygen and nutrients to tissue
Hypovolemic
Hypotension unresponsive to fluid resuscitation, metabolic acidosis, encephalopathy, oliguria and coagulation disorders
Distributive or Septic Shock
Clinical signs of septic shock
Hyperthermia or hypothermia Tachycardia Wide pulse pressure Low blood pressure (SBP < 90) Mental status changes
Treatment of septic shock
2 large bore IVs - NS bolus 1-2 L wide open
Supplemental oxygen
Empiric antibiotics: Zosyn and ceftriaxone OR imipenem
Treatment for hypotension if no response after 2-3 L IVF
Start a vasopressor (norepinephrine, dopamine)
Anaphylactic Shock Treatment
- ABCs
- IV, cardiac monitor, pulse ox
- IVFs, oxygen
- Epinephrine
- Second line: corticosteroids, H1/H2 blockers
Epi pen dosage
0.3 mg IM of 1:1000 in the thigh
Repeat every 5-10 minutes as needed
Occurs after acute spinal cord injury, results in hypotension and bradycardia
Neurogenic shock
Neurogenic Shock Treatment
- ABCs (c-spine precautions)
- Fluid resuscitation - keep MAP at 85-90 mmHg for first 7 days. If crystalloid is insufficient, use vasopressors
- For bradycardia, atropine or pacemaker
- Methylprednisolone - high dose therapy for 23 hours, must be started within 8 hours
Treatment for cardiogenic shock due to MI
Aspirin Beta blocker Morphine Heparin IV fluids if no pulmonary edema If pulmonary edema: dopamine, dobutamine