L6: Basic pediatric emergencies Flashcards
Cushing’s triad (increased ICP)
wide pulse pressure
bradycardia
abnormal respirations
Battle sign
basilar skull fracture:
bruise behind ear
Periorbital ecchymosis
basilar skull fracture:
raccoon eyes
Hemotympanum, otorrhea/rhinorrhea (CSF)
other signs of basilar skull fracture
Basal skull/skull base is
sphenoid + temporal + occipital + ethmoid bones
Concerning head injury signs
excessively sleepy or hard to arouse
vomiting
irritability
What can a head xray tell you
no brain visualization
air-fluid levels in sinus
PECARN algorithm (for when to CT) group A
- CT recommended for:
GCS=14 or lower, other signs of AMS, palpable skull fracture, - Observation vs CT for: occipital, parietal, or temporal scalp hematoma, LOC > 5 secs, severe MOI, not acting normally
PECARN algorithm (for when to CT) group B
- CT recommended for:
GCS=14 or lower, other signs of AMS, signs of basilar skull fracture - Observation vs. CT for:
History of LOC, vomiting, severe MOI, severe HA
GCS less than __ always gets a CT
14
“the reality” guideline for CT
GSC <15 or AMS Skull fracture Vomiting > 3 times, seizure < 2 years old Non-frontal scalp hematoma LOC > 5 secs Severe MOI Not acting right/lethargic
Most common bleed
subarachnoid hemorrhage
CT of subdural hematoma
Crescent-shaped, usually parietal area
Crosses suture lines
CT of epidural hematoma
Elliptical shape
Does not cross suture line
CT of subarachnoid hemorrhage
Small, dense “slivers”
Blood in cisterns, sulci, and fissures
Blood in CSF
May take time to evolve and be visible on CT
bleed with the worst prognsosis
subdural hematoma
Can kids sleep if they’ve got a head injury?
Yes, if they’re not bleeding and don’t have a fracture.
Monitor: behavior change, vomiting, decreased arousability, seizures, irritability
Management for a head injury associated with bleeding or skull fracture
Neuro consult
Admit to PIC
evaluation for surgery vs. observation with repeat imaging
Concussion definition
Traumatically induced alteration in mental status, with or without LOC
Direct blunt force→ stretching/shearing of axons
Concussion symptoms
amnesia confusion blunted affect distractibility delayed response emotional lability visual changes repetitive speech pattern
How long does it take for a concussion to resolve?
7-10 days
Post-concussive syndrome
sx >3 months
Chronic traumatic encephalopathy
Multiple concussions → permanent change in mood, behavior, pain
Second impact syndrome
2nd concussion within weeks → brain swelling, herniation, death
Children at increased risk
Concussion management
No same day return to play: must be completely symptom free to return, no sports 1-2 weeks
Physical and cognitive rest
Slow advancement, structured return-to-play protocols
Who to CT with a concussion?
Severe/prolonged/worsening HA
Vomiting
deterioration in mental status → Emergent CT
ETOH/substance
Are C spine injuries common in peds?
NO
most commonly from car crashes
<8 years old c-spine injuries
falls
C2-C4
SCIWORA: Spinal Cord Injuries Without Radiographic Abnormalities
More commonly seen in adolescents
> 8 years old c-spine injuries
sports
C5-C7
Concerning symptoms for C-spine injuries
Bilateral pain
Neuro deficits
Torticollis (neck muscles contract on one side)
Bony abnormalities
Cervical spine injuries imaging of choice
MRI
When managing fractures make sure to
always document neurovascular status (pulse, sensation) before and after interventions
Management of a compound, open fracture
splint/dress
IV abx
ortho consult
Management of a non-displaced open fracture
repair laceration
splint
PO abx
outpatient ortho follow up
Management of a grossly deformed fracture
may compromise neurovascular structures → ortho consult in ED → closed/open reduction, possible fixation w/plates/screws
Cellulitis/erysipelas management
Warm wet compress
Topical: Bactroban
Oral: Keflex or bactrim
Failed outpatient treatment: admit, labs, IV abx
Cellulitis
deeper dermis and subcutaneous fat
Erysipelas
upper dermis and superficial lymphatics
Both cellulitis and erysipelas have similar pathophysiology:
Breaches in skin→ bacterial entry→ skin infection → erythema, warmth, tenderness, induration, +/- fever, N/V/D
Osteomyelitis
Hematogenous spread of infection to bone→ bone destruction
Osteomyelitis is most common in
males <5
long bones: femur, tibia, humerus
most common causes of osteomyelitis
**Staph aureus (most common, MRSA)
Strep pneumoniae
Strep pyogenes
Osteomyelitis presentation
Fever bone pain swelling redness guarding focal tenderness during exam
Osteomyelitis xray
Early: soft tissue swelling
10-14 days later: bone destruction with lytic lesions
Best imaging for osteomyelitis
MRI
shows marrow edema, abscesses
Empiric abx for osteomyelitis
vancomycin
clindamycin
rocephin
change meds once culture and sensitivity comes back
other management of osteomyelitis
Surgical drainage, debridement
Hyperbaric oxygen therapy (100% O2 chamber)
eye toxic exposure requires
pH testing, flushing, retest until normal
lipd-soluble toxins and skin exposure
follow flushing with soap
compounds for enhanced elimination of toxins
Activated Charcoal
Urine Alkalization
Diuresis
Dialysis/hemoperfusion
if a patient ingested sustained release medication
whole bowel irrigation
Ipecac
has to be used within 30 mins for GI toxins
not recomended
if a patient has ingested mild toxins that only cause irritation/corrosion
simple dilution
activated charcoal is effective for the following poisonings
carbamazepine barbiturates dapsone quinine theophylline \+/- digoxin and phenytoin
Sites of foreign body obstruction (narrowings)
cricopharyngeal narrowing to upper esophageal sphincter
tracheal bifurcation
aortic notch
lower esophageal sphincter
If a foreign body passes the pylorus
it usually continues to rectum without complications
an aspirated vegetable could lead to
intense pneumonitis
With esophageal foreign bodies, make sure of
patency of the airway
Consult if an esophageal foreign body is…..
Sharp/elongated Button batteries Perforation >24 hours Airway compromise
Ingested magnets can cause
volvulus and bowel perforations
appear as multiple foreign bodies
Does a negative chest, neck, abdomen xray rule out esophageal foreign body?
no
Coin above cricopharynxgeus muscle
consult ENT
Coin below cricopharynxgeus muscle
consult GI
Coin below esophageal sphincter
leave it
what kind of batteries have the worst outcome
lithium batteries
Mercuric oxide batteries have a risk of
fragment → heavy metal poisoning
Why is a button battery dangerous
Extremely rapid action of alkaline substance on mucosa, pressure necrosis, residual charge → esophageal burns and perforation in hours
Button battery management
EMERGENT removal if in esophagus
Passed esophagus→ observe→ remove if hasn’t passed pylorus after 24-48 hours
Usually excreted within 48-72 hour
Observed to split in GI tract→ blood and urine mercury levels
Which age groups are most at risk of drowning?
<4 years
15-24 years
How much liquid is aspirated in a drowning?
<4 mL
Drowning MOA
impaired ventilation: 1. Hypoxemia 2. Metabolic and/or respiratory acidosis
Hypoxemia → CNS damage → arrhythmias, ongoing pulmonary injury, reperfusion injury, multi-organ dysfunction
Dry drowning
no fluid in lungs.
Laryngospasm→ hypoxemia → LOC
Wet drowning
more common, fresh or saltwater.
Aspiration of water into lungs → dilution/washout of surfactant→ diminished gas transfer across the alveoli → atelectasis → V/Q mismatch
Near drowning
survival 24 hours post event
Severe brain damage occurs in 10-30% of peds
Consider child abuse in a near drowning if….
<6 months or toddlers with atypical presentation
Poor prognosis after a near drowning
*** Submersion > 5 mins Time for life support > 10 mins Resuscitation duration > 25 mins >14 years Glasgow coma scale <5 Apnea + cardiopulmonary resuscitation Arterial blood pH <7.1 ***
Non-primary drowning
follows primary event such as: seizures, head/spine trauma, cardiac arrhythmias, hypothermia, alcohol and drug ingestion, syncope, apnea, hyperventilation, suicide, hypoglycemia
Secondary drowning
may cause death up to 72 hours after near drowning incident
Fresh water drowning→ ingestion→ hemodilution
Large volume of water aspirated:
Significant hemolysis
Electrolyte disturbance→ cardiac arrhythmias
Near drowning treatment
Pre-hospital care is critical Assist ventilation→ O2 95% Warmed isotonic IV fluids, warming blankets CXR and repeat at 6 hours Admit for observation Address injuries
Fever without a source is defined as
Rectal temperature >38 C/100.4
Who to work up with a fever without a source regardless of appearance
Infants < 3 months
Who gets a urinalysis if they have a fever without a source?
girls <24 months
circumcised boy <6 months
uncircumcised <12 months
Ill-appearing children 3months-3 years
All children < 3 months
Treat for a UTI if
> 3 months, completely immunized, Fever >39, and abnormal ultrasound
when to do a CXR on a ill appearing child 3 months-3 years
tachypnea or leukocytosis (>20,000)
when to do a CXR on a well-appearing child >3 months
leukocytosis (>20,000)
