KW-PEM1CSV Flashcards
When can you close a dog bite? (What does the wound look like, and what level of risk is it)
If the wound is superficial without presence of significant crush injury or tissue loss, primary closure is the best approach for cosmetic outcomes. (=low risk)
Which is most common and also THE WORST: ischemic vs non ischemic priaprism?
Ischemic
Whats the prob with ischemic (low flow priaprism)?
impaired relaxation
and
paralysis of smooth muscle
What’s the time cutoff to define PRIAPRISM?
> 4 hrs
What 2 tests can help determine priaprism type?
penile blood gas (acidotic = ischemic)
Doppler
pH = 7.25, PCO2 >/=60 what kind of priaprism is this?
Ischemic
When does penile damage occur?
@ 6 hrs
What rx for priaprism can you offer while u wait for Urology?
Physical activity
urination
Fluid
Ejaculation
ICE (except if SCD)
Pain management
What is Urology’s procedure?
Aspiration and Irrigation
In Priaprism, whats engorged and whats flaccid?
Cavernosum = ENGORGED
Glans and Spongiosum = Flaccid
What medication reccs are there for priaprism treatment?
1) AUA reccs phenylephrine
2) if < 10 yo, then epi in dilute soln
3) If these dont work, then surgical shunt
Whats the procedure
Injection at 2-3 o’clock midshaft of corpus callosum
Removal of 3-5 ml aliquots of blood until detumescence / red blood
Irrigation with normal saline
What are the consult indications for PARAphimosis
Answ
- Penile necrosis –dark color, firmness, elasticity
- Evidence of blood flow compromise
- Complete urinary obstruction
- Unsuccessful manual reduction
otherwise attempt MANUAL REDUX
What happens in penile fx?
Rupture of tunica albuginea (the layer surrounding cavernosum)
AKA “eggplant deformity”
What must you eval for in penile fx?
Urethral rupture
What is the treatment for penile fx?
URGENT/EMERGENT repair
-surgical
What is the treatment for zipper entrapment?
1) Mineral Oil extraction
2) Cut zipper cloth
3) Cut the median bar of the fastner
For girls with STRADDLE injuries—what is the common injury location? Why is this important?
Anterior/lateral to hymen
if hymen or posterior fourchette involved—>think of abuse
When should you consult for straddle injuries?
-Vaginal bleeding, large vaginal / vulvar lacerations
•Large testicular / scrotal hematoma; testicular rupture, torsion, dislocation, avulsion
•Scrotal laceration through the Dartos layer
•Concern for urethral disruption
Most torsion is due to ____ rotation
Medial
De-torse by lateral rotation (360-270 deg) “open the book”
What are the time delay cutoffs for testicle loss at 90%, 50% and 10%?
<6 hrs: 90% survival of teste
12 hrs: 50%
>24 hrs: < 10%
Tenderness of testicle that is POSTERIOR and SUPERIOR =
Epidymitis
spermatic cord twisting, altered testicular blood flow, increased size, altered echotexture
Torsion
swelling & structural heterogenicit
Epididymitis & TAT
Label the following
A) Dartos/fascia and skin
B) Tunica Albuginea
C) T. Vaginalis
D) Spermatic Cord
B
C
D
A
When do you need to discuss surgery for Hematocele?
> 5cm or expanding US (bc testicle may suffer comrpession)
What’s the formula for expected bladder capacity?
(Age + 2) x 3
What are common Urinary retention etiologies?
Urinary RTN is >12 hrs without UOP WITH enlarged bladder
UTI –urethritis and urethral edema
•Constipation –mechanical obstruction by distended rectum
•Medications –i.e.anticholingerics, sympathomimetics
•Neurologic disease –MS, myasthenia gravis, GBS, spina bifida, spinal cord disease (etiology in 3-17% of AUR cases)
•Urethral obstruction –paraphimosis, imperforate hymen, urethral stone
•Uretheralspasm
What are the 4 components of a complex febrile seizure?
Focality
>15 min
Occcur 2 or more times in 24 hrs
Todd Pareisis or other deficits present
Who gets imaging in febrile seizure?
Focal seizure
Neonates with seizures
Afebriles with seizure < 3
When should a patient return back to baseline following seizure (afebrile)?
2-3 hrs
What is 2nd line management for status epi? (> 4wks of age)
If seizures continue for 10 min after at least two injectons of benzos…
Then..give
Keppra
phenytoin/fospheny
Valproate
Define Status Epi
Lasts > 5 min
OR
Back to back seizures not allowing for postictal states
When do you consider pyridoxine rx for status epi?
In kids less than 1 yrs of age with refractory seizures
and
Isoniazid overdose
Dose for pyridoxine deficiency:
100 mg
For isoniazid OD: 70 mg/kg IV to start
What is the 3rd line/step in Status epi?
if lasting > 30 min despite benzos, 2nd line rx (KPFV)
then..
give continuous infusion of midaz, propofol, or pentobarb
What imaging is best to eval spinal epi abscess
MRI with IV gadolinium is the imaging method of choice for spinal epidural abscess and is superior to CT scan alone.
What is the treatment for congenital syphillis in newborn?
Treatment with aqueous penicillin G IV for 10-14 days is the preferred treatment for congenital syphilis
What are the features of Leimierre’s?
recent head or neck infection, internal jugular vein septic thrombophlebitis and the isolation of anaerobic pathogens, usually Fusobacterium necrophorum .
What is PID treatment?
Ceftriaxone IM and doxycycline PO. More specifically, this patient should receive ceftriaxone 250 mg IM (single dose) and oral doxycycline 100 mg BID for 14 days.
What is the treatment for rabies exposure?
After local wound care, concurrent active and passive prophylaxis with rabies immune globulin (RIG) and rabies vaccine are indicated. Rabies vaccine should then be repeated on days 3, 7 and 14.
So give vax on Day 0, 3, 7, 14
What is the arm sequelae of compartment syndrome (forearm)
Volkmann’s contracture of the hand (i.e. “claw hand”). Forearm ischemic contracture is due to brachial artery injury and injury to the anterior interosseous branch of the median nerve. This affects the flexor digitorum profundus and the flexor pollicis longus, which leads to muscle contraction and scarring, and ultimately clawing of the fingers.
Forearm ____ contracture is due to _____ artery injury and injury to the anterior interosseous branch of the ___nerve.uestion…
ischemic
brachial
median
What structures are impacted in VOLKMAN’S CONTRACTURE
This affects the flexor digitorum profundus and the flexor pollicis longus, which leads to muscle contraction and scarring, and ultimately clawing of the fingers.
Hip pain, limp,good passive ROM, antalgic gait, no hx of fever
Get bilat hip XRAYS to eval for Legg-Calve-Perthes (LCP)
ddx includes transient synovitis
needs f/u
What is Leggs Calves Perthes?
osteonecrosis of the capital femoral epiphysis
including a small dense proximal femoral epiphysis and widening of the articular cartilage. In some patients, a subchondral fracture can be seen, which can be from a stress fracture after minor trauma, and may be the etiology of acute worsening of symptoms
What are the XR findings in Leggs Calve P.?
a small dense proximal femoral epiphysis and widening of the articular cartilage.
In some patients, a subchondral fracture can be seen, which can be from a stress fracture after minor trauma, and may be the etiology of acute worsening of symptoms
Walking age (just beginning), no pain with range of motion, but has limited abduction of the left hip and slight asymmetry of thigh muscles and labial folds
Consider:
developmental dysplasia of the hip
These findings are c/w…
abnormal hip abduction, abnormal gluteal/thigh/labial folds, and limb-length inequality
What is the work up (age dep) for <4-6 mos, >4-6mos
developmental dysplasia of the hip
US for < 4-6 mos (femoral epiphysis is NOT ossified)
XR for >4-6 mos
** follow up with an orthopedic surgeon once the diagnosis is made
Most common pathogen for septic joint, all ages
Staph Aureus
Synovial fluid WBC of (>/<) ______ cells per mm 3 is concerning for bacterial septic arthritis, although Lyme disease and noninfectious causes of arthritis (e.g., juvenile idiopathic arthritis) can also have elevated WBC in this range, while tuberculosis and Brucella infections may have lower WBC counts.
Synovial fluid WBC of >50,000 cells per mm 3 is concerning for bacterial septic arthritis,
** Lyme disease and noninfectious causes of arthritis (e.g., juvenile idiopathic arthritis) can also have elevated WBC in this range, while tuberculosis and Brucella infections may have lower WBC counts.
Septic Joint Empiric abx: Everyone, Neonates, >2mo up to 5 yrs, >5 yrs, sexually active
Treat with: Clindamycin alone
-S. aureus is the most common organism found in this condition for all age groups.
Neonates:Vanc, Cefotaxime
-group B streptococcus and Gram-negative bacilli are also causative organisms and should be treated with vancomycin and cefotaxime.
> 2mos-5 yrs: Clinda, +/- CTX
-still, clindamycin is recommended for empiric treatment and ceftriaxone should be added only if 1) the Gram stain is negative for Gram-positive cocci; 2) or the culture is positive for K. kingae; or 3) if the child is ill appearing
> 5 yrs: Clinda
- S. aureus and group A streptococcus would also be covered with clindamycin.
sexually active adolescents: CTX + Clinda
-Neisseria gonorrhoeae should also be considered as a causative organism; therefore, ceftriaxone, in addition to clindamycin, is recommended for empiric treatment .
Switch to an oral form for the duration of treatment, usually 2-3 more weeks.
Finger Felon Management:
1st: digital block,
2nd: I/D (palmar or lateral surface of the finger in the area of greatest fluctuance)
* The septae should not be divided as iatrogenic complications can occur, including skin sloughing, unstable fat pad, permanent sensory nerve damage with chronic pain and/or hypesthesia, and significant scarring
Felon complications
Osteomyelitis of the distal phalanx. septic arthritis, or suppurative flexor tenonsynovitis
The deep septal attachments in the finger pad within which the infection is contained are distal to the DIP joint, so infection spread to this structure and possible subsequent chronic arthritis are uncommon.
Why is it uncommon for bacteria to spread past distal phalanx in a felon?
The deep septal attachments in the finger pad within which the infection is contained are distal to the DIP joint, so infection spread to this structure and possible subsequent chronic arthritis are uncommon.
Abscess in the deep pulp space of the distal finger
Felon
*clinical dx, don’t need labs
refusal to walk, difficulty sitting upright, hip pain and/or abdominal pain, less than 25% have fever
discitis
Identify condition
Legg Calve Perthes
Discitis: Order the following test in order of sensitivity CT, MRI, XR, Bone Scan
Bone scan is the most sensitive and would show increased uptake at the level of the involved disc.
MRI can best differentiate discitis from vertebral osteomyelitis.
CT is less sensitive in demonstrating discitis.
Spine x-rays are usually normal initially, but then may demonstrate intervertebral disc space narrowing after 2-3 weeks
Bone Scan> MRI> CT> XR
Leggs Calve P. exam (maneuver) findings
restricted range of internal rotation and abduction
defect of the pars interarticularis of the vertebral body, which can occur due to an acute traumatic event or may develop more insidiously
Spondylolysis
-Most commonly L5-S1 = “anterior translation of L5 on S1”
Sinding-Larsen-Johansson
a traction apophysitis at the inferior pole of the patella at the infrapatellar tendon
SCFE
capital femoral epiphysis is displaced from the femoral neck through the physeal plate
=condition affecting the femoral head epiphysis
SCFE sx
chronic history of intermittent pain in the groin, medial thigh, or knee
knee b/c of referred pain down obturator
How do you dx SCFE?
The diagnostic test of choice for this condition is x-rays of the hips (AP and frog-leg views) = ED DXIC TEST OF CHOICE
which demonstrate displacement of the femoral neck from the acetabular wall, physeal plate widening, irregularity and decreased epiphyseal height in the center of the acetabulum.
SCFE Complications
Without early and appropriate surgical pinning, major complications of this condition include:
chondrolysis (acute dissolution of the articular cartilage) and osteonecrosis.
*Follow-up x-rays may demonstrate osteonecrosis with a subchondral lucency, fracture, sclerosis, or collapse of the femoral head, and cyst formation
Risk Factors in Sickle Cell for avasc necrosis
Hemoglobin (Hgb) SC disease compared to Hgb SS disease.
Other risk factors include a high baseline hematocrit and a history of frequent or severe pain crises.
Some pain with internal rotation of the right hip. When you passively flex the right hip, the thigh abducts and externally rotates, Atrophy of the thigh and gluteal muscle may be apparent from disuse with chronic symptoms.
SCFE exam findings
How do you estimate Severity in SCFE
Using the Klein line
What is this photo a depiction of
Klein line in SCFE
1) Evaluate the line along the superior margin of the femoral neck. This radiographic measurement, the Klein line, or Klein’s line, demonstrates the degree of displacement of the femoral head epiphysis from the femoral neck, which is found in the diagnosis of slipped capital femoral epiphysis.
With normal anatomy, this line intersects the lateral aspect of the epiphysis. With progressive displacement, this line may not intersect the epiphysis at all. Although the femoral head metaphysis may appear more laterally displaced from the acetabular wall, this measurement may not give the degree of displacement.
True/False: There are sclerotic changes in SCFE
Sclerotic changes and effusions are not seen with SCFEs
What are the KOCHER Criteria?
“There are just a FEWw Kocher”
They risk stratify a child with suspected septic arthritis using the following factors:
1) non-weight bearing on the affected side;
2) ESR > 40 mm/hr;
3) presence of fever; and
4) serum WBC > 12,000/mm 3 .
What are the associated probabilities for KOCHER criteria
With 4/4 criteria the probability of septic arthritis is 99%;
3/4= 93%,
2/4= 40%;
1/4= 3%; and
0/4=0.2%.
When should you perform athrocentesis for septic jt eval?
If the degree of clinical suspicion for a bacterial septic hip is high, it should be performed to obtain
synovial fluid for culture, Gram stain, and WBC.
If the fluid is purulent with a high WBC count or a positive Gram stain, operative intervention is necessary
When do you start abx in septic jt?
Empiric antibiotics would not be routinely given until synovial fluid cultures were obtained by aspiration or operative washout.
Symptoms: pain, swelling after activity, chronic
XRAY: crescentic-shaped defect within the subchondral bone of the distal left femur
consistent with osteochondritis dissecans
osteochondritis dissecans management hierchy
1st: conservative with rest
if no improvement
2nd: Casting for immobilization and non-weight bearing restrictions
Septic Joint due to suspected Lyme: management
- 8 years or older is oral doxycycline for 1 month.
-< 8 years, the preferred treatment is with oral amoxicillin for 1 month.
There is no indication for parenteral antibiotics or operative drainage for Lyme arthritis.…
DDx of Bony Tumor in femur with findings:lytic lesion with a thin cortex due to cortical destruction in the distal right femur
Ewing sarcoma, osteosarcoma, aneurysmal bone cysts
**specific diagnosis can’t be made on the x-ray, orthopedic follow-up with advanced imaging will be necessary.
Osgood Schlatter Dz
- apophysitis of the tibial tubercle caused by repetitive stress on the patellar tendon by overuse.
-The repetitive stress causes a series of microavulsions of the secondary ossification center and underlying cartilage of the patella.
The x-ray demonstrates a tibial tubercle avulsion fracture that can be associated with Osgood-Schlatter disease. n
-
What maneuvers can be used to dx O.Schlatter dz?
The diagnosis can be confirmed on PE with localized tenderness of the tibial tubercle. Maneuvers that stress the patella tendon elicit pain (e.g., patient in prone position flexes knee so heel contacts the buttocks).
What is complex regional pain syndrome type I (CRPS1
previously referred to as reflex sympathetic dystrophy.
This is a disorder characterized by pain, abnormal sensation and irregularities of the circulation.
This condition may develop after minor trauma, but not in all cases.
xrays aren’t needed to dx condition
When should Breast Milk Jaundice disappear?
Jaundice should be gone by 12 weeks
What are the nerves supplying A-G
A: Median only
B. Ulnar only
C. Median
D. Radial only
E.Median
F. Ulnar
G. Radial
The musculocutaneous nerve provides anesthesia for the ______.
Forearm
Where is the best posoition for a penile nerve block
2 and 10 position
What amts of lido and concentration are used for neonate and older kid penile block?
neo: 0.8 ml of 1 %
older: 1-4 ml of 1%
- hear a pop when passing thru buck fascia
What is the taping procedure of a “sucking chest wound”?
A temp occlusive dressings function as one-way flutter valves (until a thoracostomy tube can be placed at a site distant from the wound.)
The occlusive dressing material should be impervious to air, thin and flexible, unlikely to adhere to the skin, and pliable enough to allow air to flow underneath when applied over the wound.
- two or three 4 x 4 gauze sponges with an overlying covering of petrolatum gauze. The dressing is then applied over the chest wall with 1 to 2 inch margins beyond the wound edge, and then securely taped on 3 sides of the dressing with the nondependent edge left open.
Where do you put in a needle (thoracostomy)?
2 nd intercostal space at the midclavicular line.
Which splint:
unstsable forearm or wrist fracture
Sugar Tong
Which splint:metacarpal and proximal phalangeal fractures.
Gutter
Which splint:metacarpal and proximal phalangeal fracture of thumb
thumb spica is a gutter splint adapted for the thumb
Which splint: stable forearm fx
colles splints provide volar support , alternative for older children.
Which splint: stable injuries at or near the elbow.
Long arm
What are the steps for a successful IO placement?
1) IO needle should remain in the bone without support. Firm seating of the IO needle in the bone is the first indication of correct placement.
2) Aspiration of the bone marrow typically follows, providing additional evidence of correct placement of the IO needle and also providing blood that may be used for laboratory assays.
- If aspiration of bone marrow is unsuccessful, advancing the needle is not indicated, as it may result in puncturing both cortices.
3) After the firmly-seated needle is aspirated, with or without blood return, the next step should be infusion of saline through the IO needle.
-If the saline infuses without resistance or soft tissue fluid extravasation, this provides additional confirmation that IO placement is correct even if bone marrow aspiration was not successful.
What is the position for proper pigtail placement
Above the 5 th rib, anterior axillary line.
Appropriate placement for insertion of a pigtail thoracostomy catheter is between the anterior axillary and midaxillary lines in the 4 th to 6 th intercostal spaces.
Insertion at this location minimizes risk to blood vessels, muscle, and breast tissue.
*The ideal insertion site is to go above the inferior rib at the intercostal space to avoid injuring the neurovascular bundle.
When less invasive respiratory options have failed in patients with upper airway obstruction, what are your two choices? Which should be tried first?
Percutaneous transtracheal ventilation and surgical cricothyrotomy
Percutaneous transtracheal ventilation should always be considered first due to its ease, quicker procedural time and fewer complications.
Cuffed OR uncuffed: endotracheal tubes are safe and effective in children and recommended for pediatric intubations outside the neonatal period?
Cuffed
What’s the ETT size formula? uncuffed? cuffed?
uncuffed tubes—>age (in years)/4 + 4,
For traditional cuffed tubes, the ETT should be ½ size smaller, making 5.5 mm ETT appropriate.
large occiput may cause ___ flexion in the supine position obstructing visualization of the vocal cords during laryngoscopy in kids age ____ or less. Placing a small towel roll under the shoulders can create proper positioning of the airway during laryngoscopy.
Anterior
7 or less
Why is use of MILLER preferred in 7 and younger?
because of its ability to lift the epiglottis and improve visualization of the vocal cords.
Extruded permanent tooth: what do you do?
emergencies and require immediate repositioning and splinting for the best possible outcome. If unable to splint, repositioning followed by biting down on gauze is appropriate until splinting can be done.
An extruded ______ tooth should not be extracted; that would be appropriate treatment of an extruded ___ tooth.
permanent
Primary
when is dental cement use?
tooth fractures with pulp exposure,
Safe Liquids to place avulsed permanent teeth are:
suitable liquid medium such as commercially balanced salt solutions. If these are not available, the preferred solution is milk, followed by intraoral saliva and then physiologic saline.
What is the proper location of the femoral vein?
1 cm medial to the femoral pulse and 1 cm below the inguinal ligament.
The point of cannulation for a femoral vein catheter is 1 to 2 cm medial to the femoral artery and 1 to 2 cm below the inguinal ligament. When there is a weak or absent femoral pulse, then the femoral vein can be located by identifying the point halfway between the pubic tubercle and the anterior iliac spine.
Name the fx and the splint needeed:
Scaphoid
THumb spica
Where do you cut to avoid the. neurovasc bundle on toe?
incision can be made to cut the fibers on the lateral (3 o’clock or 9 o’clock) or dorsal (12 o’clock) location
ddx for empty gestational sac
1) anembryonic pregnancy, also known as a “blighted ovum”; 2) early intrauterine pregnancy (a yolk sac should be identifiable by transvaginal US by 5.5 weeks, which is 7-10 days earlier than by transabdominal US); 3) pseudogestational sac seen in ectopic pregnancies; and 4) gestational trophoblastic disease.
get HCG quant and radiology US
Transabdominal US can identify an intrauterine gestational sac when the serum hCG level rises to more than ____ mIU/mL, while transvaginal US can identify it levels of ___ to ____ mIU/mL.
6500
1000 to 1500
An early and viable IUP will typically have a doubling of the hCG every ____ hoursuestion…
48
What meds commonly give a false pos for HCG?
phenothiazines, anticonvulsants, methadone, or chlorpromazine
NOT cough meds
Sonographic findings for acute cholecystitis?
pericholecystic fluid or thickening of the gallbladder wall (measurement of the anterior gallbladder wall less than 0.3 cm on US is normal),
What other lung findings are associated with no lung sliding on US?
large consolidations, right main stem intubation, pulmonary contusion, pleural adhesions, atelectasis, acute respiratory distress syndrome, pulmonary fibrosis, and phrenic nerve palsy.
The US shows air bronchograms (arrows) within the consolidation that is consistent with _____ pneumonia.
bacterial
what bladder US findings are associated with adequate hydration in a child?
Answdequate urine catheterization samples are achieved with volumes of at least 2 mL. The volume can be estimated on US by measuring bladder width and depth. Measurements > 2.4 cm 2 yields at least 2 mL .er…
Min, Mod, Deep, Gen Sedation level?
not arousable, even by painful, repeated stimulation. Furthermore, the ability to maintain a patent airway and adequate ventilation is often impaired, and cardiovascular function may also be impaired.
GEN
Min, Mod, Deep, Gen Sedation level?
drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully after repeated verbal or painful stimulation.
Their ability to independently maintain their airway or ventilatory function may be impaired, but their cardiovascular function is usually maintained.
Deep
Min, Mod, Deep, Gen Sedation level?
aroused by verbal stimulation or light touch and should not require intervention to maintain a patent airway, ventilation, or cardiovascular function
Moderate
Min, Mod, Deep, Gen Sedation level?
(i.e., anxiolysis) would normally respond to verbal commands and would not be asleep. Cognitive function and coordination may be impaired, but the cardiovascular and ventilatory function is maintained.
Minimal
only be aroused with repeated painful stimulation, ohypoventilate
Moderate to deep. PSA was formerly called “conscious sedation
PSA Risk factors (6)
1) anatomic/physiologic issues that predispose the patient to upper airway obstruction; 2) active lower airway disease; 3) cardiac disease; 4) age < 3 months; 5) obesity with BMI > 30; and 6) metabolic disorders that affect sedative clearance.swer…
Flumazenil reverses ______.
Dose is ________.
How often can you repeat it? (its also the onset action time)
Duration?
Total amt you can use with repeat doses?
Benzos
is 0.01-0.02 mg/kg/dose IV/IM (maximum initial dose of 0.2 mg). The dose may be repeated every minute, to a maximum cumulative dose of 1 mg.
The onset of action is approximately 1 minute and duration between 30 and 60 minutes
Unlike naloxone reversal of opioid-induced respiratory depression, response to flumazenil to treat benzodiazepine-induced respiratory depression is variable: sometimes flumazenil will reverse respiratory depression, but not always.
Pain scale for <3yo? 3-18?
FLACC. Validated self-reporting pain scales exist for children as young as 3 years old. For children unable to use self-report pain scales (such as the younger preverbal child in the vignette), behavioral scales can be used; an example of a behavior scale is the Faces, Legs, Activity, Cry, and Consolability (FLACC) scale.
The Wong-Baker FACES® Pain Rating Scale is intended for children age 3-18 years of age, has been translated into > 10 languages, and is preferred relative to other pain scales by nurses and children.
Dose associated with FENTANYL wooden chest?
most often associated with doses greater than 15 mcg/kg but may also be seen with rapid infusions of smaller doses. However, it has not been reported in the low bolus doses of 1-2 mcg/kg recommended for procedural sedation.
Can you reverse fentanyl wooden chest?
Nope, naloxone wont work. You have to paralyze and intubate.
When are pt at highest risk of resp depression?
1) during the first 5-10 minutes after IV administration of medications and,
2)during the immediate post-procedure period, when painful stimuli have ceased.
Side effects of NALOXONE
hypertension, ventricular tachydysrhythmias, cardiac arrest, pulmonary edema, agitation, nausea, and vomiting.
What is the order of management for ketamine laryngospasm?
head tilt, jaw thrust»_space;BVM»paralytic, intubation
What is the procedural sedation history taking componentss?
This history should include:
= SHIP-MAMO
1) allergies (propofol is contraindicated with egg and/or soy allergies);
2) current medications;
3) prior problems or adverse reactions with sedation;
4) upper airway issues such as sleep apnea or snoring;
5) medical history (ketamine is relatively contraindicated when there is a history of psychosis);
6) impact of current illnesses or injuries (nitrous oxide is contraindicated in a patient with trapped gas pockets—as would be the case with a pneumothorax, pneumocephalus, or bowel obstruction); and
7) last oral intake
Name this pure sedative, can be given via oral or rectal routes. However, its slow onset of action, long duration of action, and possible side effect of paradoxical hyperactivity limit its usefulness
Chloral hydrate,
EMLA ( E utectic M ixture of L ocal A nesthetics)..contain __% of both ____ and ____.
2.5% of both lidocaine and prilocaine.
Side effect and at risk group for prilocaine (EMLA component)
When used on neonates, topical prilocaine can precipitate methemoglobin formation due to low levels of methemoglobin reductase. This rare complication is related to the duration of skin application and is most common in patients under 3 months of age.
A side effect of ____ causes _____ and nasal itching.
Fentanyl
facial pruritus and nasal itching
Safe dosage __ mg/kg for lidocaine without epi
5
The maximum dose of lidocaine with epinephrine for topical injection is 7 mg/kg.
1% lidocaine = _ g/100 mL = ___ mg/100 mL = __mg/mL
1
1000
10
Lido (with epi) calculation:
(1% lido)
If aA 20 kg child can receive a maximum dose of __ mg/kg = __ mg.
Given that the concentration of the anesthetic is __ mg/mL, the maximum recommended volume is
7, 140
10
14 ml
Lido (alone) calculation:
1%
If aA 20 kg child can receive a maximum dose of __ mg/kg = __ mg.
Given that the concentration of the anesthetic is __ mg/mL, the maximum recommended volume is
5, 100
10
5ml
What does the procedure prepping acronym, SOAP ME stand for?
can assist in remembering what to have in place before you begin the procedure:
S uction—source and catheters;
O xygen—source and meters;
A irway equipment—adjuncts and BVM device;
P harmacy—rescue and reversal drugs;
M onitors;
E xtra equipment (special equipment needed for a particular procedure). In the case of equipment, oxygen flow should be confirmed, and the BVM device should be tested.
Safe dosage __ mg/kg for lidocaine with epi
7
TRUE/FALSE: Assuring compliance with American Society of Anesthesiologists (ASA) NPO guidelines is mandatory for PSA in the ED
FALSE
—ED is a place where the risks of potential complications from a non-fasted status should be balanced against those from delaying procedural sedation.
Criteria for discharge following PSA
stable vital signs,
well-controlled pain,
return to baseline level of consciousness,
adequate head control and muscle tone to maintain a patent airway,
adequate hydration and controlled nausea/vomiting.
In most cases, patients may be discharged when they are beyond the period of significant adverse effects and are awake enough to tolerate oral hydration. For most commonly used agents, this occurs within 60-120 minutes after medication administration.
Only topical non-liquid anesthetic approved to be put on OPEN skin
LET (Lidocaine, Epinephrine, Tetracaine). LET is the only anesthetic agent listed specifically designed for use on non-intact skin such as lacerations, as well as mucous membranes
LMX (lido 4%), EMLA: only for intact skin
Duration of disassociation for given Ketamine dose:
ketamine (0.5-2 mg/kg IV) = disassociation time of _ to _
Higher IV doses or ketamine given via IM route (3-5 mg/kg) can prolong the duration to _ to _ minutes.
10-15 min
————–
prolongs 12-25 min
NAME THE ASA CLASS:mild systemic illness without functional limitation (asthma, no active wheezing)
TWO (II)
NAME THE ASA CLASS: normal, healthy patient
ONE (I)
NAME THE ASA CLASS: severe systemic disease with definite functional compromise (e.g. obesity, asthma and is actively wheezing)
THREE (III)
NAME THE ASA CLASS: severe systemic disease that is a potential or constant threat to life
FOUR (IV)
NAME THE ASA CLASS:moribund patient who is not expected to survive without the procedure.
FIVE (V)
complications of bacterial rhinosinusitis
periorbital or orbital cellulitis, orbital subperiosteal abscess, septic cavernous sinus thrombosis, meningitis, osteomyelitis of the frontal bone associated with a subperiosteal abscess (aka Pott’s puffy tumor), epidural abscess, subdural abscess, and brain abscess.
Surgical emergency, forehead swelling and tenderness usually associated with headache and fever, and often photophobia, vomiting, and lethargy
Pott’s Puffy Tumor
What is parinaud syndrome?
downward deviation of the eyes or “sun setting,” lid retraction, convergence-retraction nystagmus
Wilms Tumor Presentation
abdominal mass, and does not usually have neuro signs/symptoms
Neuroblastoma Presentation
-Refusal to walk, constipation
-spinal cord involvement —>possible spinal compression sx. In older patients, symptoms of spinal cord compression will usually begin with back pain and progress to weakness, sensory abnormalities, gait disturbance, urinary retention, and fecal incontinence.
Name the condition associated with these sx:
Beck’s triad (jugular venous distension, distant heart sounds, and hypotension with narrow pulse pressure) and pulsus paradoxus which is defined as a > 10 mmHg drop in systolic blood pressure during inspiration
Cardiac Tamponade
What is the process for pericardocentesis?
Insertion of a 20 gauge spinal needle below the xiphoid process at a 45º angle toward the left shoulder.
EKG changes will happen as the needle hits myocardium (elevation of ST), so withdraw the needle a bit
________ effusions (defined as opacification of more than ¼ of the thorax or occupying >__ cm on lateral decubitus radiography) and _____ effusions (defined as opacification of more than ½ of the thorax) should be considered for a diagnostic and therapeutic thoracentesis often guided by US or CT scan.
Moderate effusions, >1 cm
large effusions
when is a VATS reccommended in pleural effusions?
reserved for complicated effusions (loculated) unresponsive to chest tube management with or without fibrinolytic therapy
What size needles is needed for decompression of PTX?
20-g catheter-over-needle
chest location for PTX decompression
over-the-needle catheter perpendicularly into the 2 nd intercostal space at the midclavicular line until a rush of air is obtained. The patient will ultimately need a thoracostomy tube, but the life-threatening situation should be addressed first with needle decompression, which can be performed more rapidly than thoracostomy.
Epistaxis, hypotension, tachycardia, failed compression/packing attempts: Next step
1st: Isotonic saline
Epistaxis, hypotension, tachycardia, failed compression/packing attempts: 2nd step
RBC’s
FFPs follow
Kiesselbach Plexus Epistaxis Management
1) direct pressure on the bleeding site for 5 to 10 minutes by external compression of the nares between 2 fingers.
PLUS
A cotton roll may be placed under the upper lip to compress the labial artery.
Providers can also soak gauze in a few drops of 1:1,000 epinephrine or topical thrombin and pack the anterior aspect of the nose to further help achieve hemostasis.
2) If a bleeding vessel is identified, cautery with a silver nitrate stick may be attempted; still, silver nitrate is less effective when the bleeding is active and brisk.
If others fail…insertion of an expandable nasal tampon may be required.
fever, stiff neck, lymphadenopathy, drooling, and occasionally stridor. Inflammation surrounding the abscess may lead to neck stiffness without meningismus;
RPAs a lateral and/or parapharyngeal abscess may present similarly and may be missed on plain radiographs
IN THIS CONDITION: a lateral and/or parapharyngeal abscess may present similarly and may be missed on plain radiographs
RPA
If high clinical suspicion of RPA, get this imaging
CT with IV contrast
lateral neck x-ray would likely reveal widening of the prevertebral space, is highly suggestive of which condition?
RPA
in this condition:
pain is more commonly exacerbated by lateral neck movement as seen in torticollis. Symptoms may also clinically mimic epiglottitis, but less abrupt
RPA
an abscess + inflammation with neck stiffness that IS NOT meningismus
RPA
fever, stiff neck, lymphadenopathy, drooling, and occasionally stridor. ; pain is more commonly exacerbated by lateral neck movement as seen in torticollis
RPA
Name this condition:
-poor dental hygiene,dysphagia,odynophagia, trismus, andedema of the upper midline neck and the floor of mouth.
-Clinical examination reveals edema of the upper neck and swelling of the floor of the mouth
ludwig anigna
When are EGDs performed for patients with s/o burns/perforations in the esophagus or stomach?
12-24 hours after event
deep purple discoloration as well as parchment-paper appearance of the skin
non-tubercular mycobacterium (NTB),
When NTB is suspected, a CXR should be obtained and a PPD planted. Patients with NTB typically have normal CBC and CRP results, and have positive or partially positive PPD tests
Question…
uricular perichondritis can occur in the setting of seemingly minor trauma to the ear and diabetic patients are at greater risk. Without appropriate treatment, this can lead to permanent deformity of the ear cartilage. The most likely causative organism is Pseudomonas aeruginosa with the preferred therapy being quinolone antibiotics. It is important to keep in mind that the FDA cautions the use of fluoroquinolones in children and encourages the use of alternative therapy when available. However, in this case, there is no other oral option that is effective against Pseudomonas. If outpatient options are limited, admission for IV ceftazidime should be considered
Question…
In hypernatremic hypovolemia, the goal of therapy is restoration of extracellular fluid and correction of serum sodium. In order to reduce the chance of developing cerebral edema, serum sodium levels should be decreased slowly at a rate of no more than 10-12 mEq/L per 24 hours. The goal of therapy is to bring the sodium to a level below 155 mEq/L, so this should be achieved over 48 hours. Of the possible choices, only D5 ½ NS at 1.5 times maintenance would be expected to achieve this goal. The use of more hypotonic fluids, such as D5 ¼ NS or D5W, especially at high rates, could lead to the development of cerebral edema
E3 (of 4)
Eye opening to speech
E2 (of 4)
Eye opening to pain
what’s the verbal score?
confused kid
irritable, cries infant
V4 (of 5)
what’s the verbal score?
inappropriate words
cries in response to pain (infant)
V3 (of 5)
what’s the verbal score?
incomprehensible sounds
moans in response to pain
V2 (of 5)
what’s the motor score?
localizes pain stim
or
Withdraws in response to touch (infant)
M5 (of 6)
what’s the motor score?
withdraws in response to pain
M4 (6)
what’s the motor score?
abnormal flexion/flexion in sresponse to pain
Decorticate posturing (abnormal flexion) in response to pain
M3 (6)
PALS Brady (<60)
Epi dose and concentration? (iv, IO)
0.01mg/kg —>0.1ml/kg
1:10, 000 concentration
PALS Brady (<60)
Epi dose and concentration? (ETT)
0.1 mg/kg—>0.1ml/kg
1:1000
PALS Brady (<60)
Atropine dose? max single dose?
0.02mg/kg,
0.5 mg
PALS Brady (<60)
Atropine dose: how many times can you repeat it?
Once. (“a TROP ine)
PALS Brady (<60)
What are the 4 treatment options if Bradycardia persists?
Epi
Atropine (for increased vagal tone or primary AV block)
Consider transthoracic or transvenous pacing
Treat underlying causes
PALS Brady (<60)
How often can you give epinephrine?
Every 3-5 min
PALS Brady (<60)
If child responded to epi, and has persistent brady, what should you consider?
continuous infusion of epi (0.1-0.3 mcg/kg/min)
what are the reversible causes of bradycardia?
Hypoxia
Acidosis
HyperK
Hypothermia
Heart block
Tox/poison/drugs
Trauma
Name the AV block
Prolonged PR interveal representing slowed conduction thru the AV node
First Degree
Name the AV block
Occurs AT the AV node
Progessive prolongation fo PR interval until an atrial impuslse is NOT conducted to ventricles.
What happens to the P
2nd degree Mobitz type I (wencke), P wave is NOT followed by QRS
Name the AV block
Occurs BELOW the AV node
Nonconduction of some atrial impulses to ventricle withotu change int he PR interval of conducted impulses
COnsistent ratio of atrial to ventricular depolarizations (typically 2 atrial depols to 1 ventricular depol)
2nd degree mobitz type II,
3rd degree AV block
none of atrial impulses conducts to ventricles, may be referred to as complete heart/av block
What arrythmias do you SYNCHRONIZE shock?
hemodynamic unstable SVT, atrial flutter, VT with pulse
and with cards for stable SVT, atrial flutter, VT
What’s the initial Adenosine dose? max?
0.1mg/kg (6mg max)
What’s the 2nd dose of Adenosine?
0.2mg.kg (12 max)
When is amiodarone use?
-wide range of atrial/ventricular tachyarrythmmias
-hemodynamically stable SVT that is refractory to vagals, adenosine
-hemodynamically UNSTABLE VT
True/False: Amiodarone decreases the QT interval.
False. It PROLONGS it.
So beware of it causing torsades (polymorphic VT)
What dose of amiodarone for poor persusion + Supraventricular and ventricular arrythmias?
Load: 5mg/kg over 20-60 min (max dose 300)
How should amiodarone be adminsitered?
SLOW, b/c it can cause hypotension and bradycardia
If giving repeat amiodarone, what’s the max and whats’ the dose?
Give same as initial, 5 mg/kg, can repeat up to a max of 15 mg/kg per day or 2.2 g)
What’s the MOA for procainamide?
blocks sodium channels so it prolongs effective refractory period of both the atria and ventricles and depresses conduction velocity within the conduction system —>prolongs QT, QRS, PR
what’s the procainamide loading dose?
15 mg/kg
What arrythmias can you use procainamide for?
SVT, VT
-hemodynamically stable SVT
Afib, aflutter
*talk to expert when using it
SVT therapies: maneuvers, meds, electricity
Vagal maneuvers
Sync’d CV
Adenosine, AMio, Procainamide, Verapamil
VT WITH palp pulses therapies: maneuvers, meds, electricity
no maneuvers
VT with palp pulses
-(Sync’d CV)
-with an expert—>Amio, Procainamide
-lido
What’s the QRS cutoff for wide and narrow?
0.09
whats the energy dose for SYNC cardioversion—initial? subsequent? (for unstable SVT, VT)
0.5-1 J/kg
2 J/kg
What’s another name for 2nd degree AV block?
Mobitz type 1 and II
What’s the other name for Mobtiz I AV block
Wenckebach
When is a thoracotomy indicated?
Loss of pulses in front of you with penetrating trauma
widening of pelvis > 2.5 cm is defined as a _____ pelvic fracture
unstable
Name the most sensitive and specific diagnostic test to identify significant intra-abdominal and pelvic injuries and is currently considered the “gold standard” and the preferred diagnostic modality in children
CT scan of the abdomen and pelvis with IV contrast
Diag peritoneal lavage shows _____ or _____ in duodenal injury
elevated amylase in the effluent or the obvious presence of enteric contents.
Question…
Answer…
who (abd injury) gets an emergent ex laporoscopy
- unstable despite aggressive crystalloid and blood infusion
- perforation of a hollow viscous injury with pneumoperitoneum,
- increasing abdominal tenderness with peritoneal sign
- solid organ injury with uncontrolled bleeding, or
- ductal disruption of the pancreas.
Other indications for emergent laparotomy include hemodynamic instability, evisceration, left-sided diaphragmatic injury, intraperitoneal air, gastrointestinal hemorrhage (blood from NGT, emesis, rectal or vaginal bleeding), and implements that are embedded.
Match test with condition:
Torsion
Urethral injury
intra/retroperitoneal injury
urethral trauma
———
CT of abd pelv
Retrograde urethrogram
US with doppler
UA
Testicular ultrasound with Doppler best delineates the structures of the testes and vascular integrity. A UA is useful in the evaluation of concomitant urethral injury but does not exclude testicular injury. CT scan of abdomen and pelvis is best for the evaluation of intraperitoneal/retroperitoneal organs. A retrograde urethrogram is indicated for suspected urethral trauma.
Who gets a skeletal survey?
Less than 2 yo
“Less than two mr. skeletal survey will get you”
low risk criteria for blunt abdominal injury based on PECARN criteria of:
(1) no evidence of abdominal wall trauma or seat-belt sign; (2) a GCS score > 13;
(3) no abdominal tenderness;
(4) no evidence of thoracic wall trauma;
(5) no complaints of abdominal pain;
(6) no decreased breath sounds; and (
7) no vomiting.
Because pediatric bones are more pliable and contain a thicker periosteum than adults, pelvic fractures usually involve ___ ring or are avulsion fractures
one
multiple fractures of the pelvic ring confers ___ incidence of _____ trauma.
there is an increased incidence of associated urogenital trauma
grade II splenic laceration (yellow arrow) as defined as
a subcapsular hematoma of 10-50% surface area, intraparenchymal hematoma of < 5 cm diameter or a capsular laceration tear 1-2 cm in parenchymal depth not involving a trabecular vessel.
a subcapsular hematoma of _to 50% surface area, intraparenchymal hematoma of < _ cm diameter or a capsular laceration tear 1-2 cm in parenchymal depth not involving a trabecular vessel describes a
10
5
grade II splenic lac
Grade _ renal injury as defined by completely shattered kidney or avulsion of renal hilum with de-vascularized kidney (arrow)
5 (think of the #5 as a broken apart shattered kidney)
Grade _ splenic injury as defined by a completely shattered spleen or hilar vascular injury with complete devascularization
5
trauma associated billious emesis
duodenal hematoma or pancreatic injury, both of which can have a delayed presentation
grade ____ liver laceration as defined by
- a subcapsular hematoma > __ % surface area or expanding,
- ruptured subcapsular/parenchymal hematoma;
- an intraparenchymal hematoma >___ cm or expanding;
- a laceration > __cm parenchymal depth
grade III
> 50 %
>10 cm or expanding;
> 3cm
PICU admission is recommended for those with grade ___ liver injuries
4-6
liver lacs _____ are high-grade injuries often require ____ intervention.
4-6
surgical
Next step in management for:
compensated shock(BP is norm) with tachycardia and a tender, distended abdomen 2/2 trauma
NS bolus (why? Its part of your primary survey)
Bonus: Then what?
Labs
A triple (IV, oral and rectal) contrast abdominal/pelvic CT is the study of choice to evaluate
the bowel and renal system in management of penetrating stab wound
Question…
Answer…
What is the Parinaud Ocular Glandular Syndrome?
What causes it?
Conjunctivitis (unilateral), unilateral LAD, fever
—>will not improve with usual abx—>need azithro
It is an uncommon manifestation of
Bartonella henselae
Bx of lymph node reveals necrotizing granuloma
Question…
Answer…
Question…
Answer…
What’s the 2nd line for someone with true penicillin and ceph allergy?
Azithro
When does SNAP not appropriate?
<2
Shigella
Rx
RMSF TrT
Doxy
Tularemia
Answer…
Pencillin treats this rat dz: maculopap rash with fever and swollen big joints
Streptobacillus, srillum minus
