Lecture 8 - Emergencies Flashcards
What is the leading cause of ED visits?
injuries
90% blunt
What are the expected vitals for a 2 month old?
0-3 months
100-150 HR
35-55 RR
65-85/45-55
What are the expected vitals for a 4 month old?
3-6 mo
90-120 HR
30-45 RR
70-90/50-65
What are the expected vitals for a 9 month old?
6-12 mo
80-120 HR
25-40 RR
80-100/55-65
What are the expected vitals for a 2 year old?
1-3 yr
70-110 HR
20-30 RR
90-105/55-70
What are the expected vitals for a 4 year old?
3-6 yr
65-110 HR
20-25 RR
95-110/60-75
What are the expected vitals for a 7 year old?
6-12 yr
60-95 HR
14 - 22 RR
10-120/60-75
What are the expected vitals for a 13 year old?
> 12yr
55-85 HR
12-18 RR
110-135/65-85
ABCDE
Airway Breathing Circulation Disability (Neuro scale) Exposure
AMPLE
allergies medications past medical hx last meal events leading to injury
What is the most common cause of death d/t traumatic injury?
MVA
What questions do you need to ask when you have an MVA pt?
event speed location seatbelt broken glass airbag deployment LOC
Definition of drowning
A process resulting in primary respiratory impairment from submersion or immersion in a liquid medium
Who has the highest prevalence for drowning?
Males AA 1-5 y/o Low SE status Southern states
What is the mechanism of drowning?
Panic —> breath holding —> reflex inspiratory effort —> hypoxemia —> end organ effects (icshemia)
Why is drowning worse in children?
High surface area:mass
Decreased subq fat
Limited thermogenic capacity
Moderate vs severe hypothermia
Moderate = 32-35 —> increases O2 consumption
Severe = <32C —> decrease cellular metabolic rate
What is the goal of prehospital drowning treatment?
Rapid restoration of oxygenation, ventilation and circulation
Is C-spine recommended for drowning pts?
No
Afterdrop
Initial drop in temp during initial warming of a drowning pt
What is the ED treatment for drowning?
Remove wet clothing, dry skin
External warming:
-warm blankets, plumbed garments, heating pads, radiant heat, forced warm air
Internal warming:
-warmed IV fluids or humidified oxygen via tracheal tub, heated irrigation of peritoneal and pleural cavities
Continue until core temp reaches 33-35
_____ min of hypoxemia = irreversible CNS injury
3-5 min
When should you suspect toxic exposure?
Acute onset of multi-organ system dysfunction AMS Respiratory/CV compromise Metabolic acidosis Seizure Questionable clinical picture
Suspect abuse if <1y/o
What are the most common ingestions in children?
Coins
Keep in mind the single load laundry packet
What is the phone number for poison control?
800-222-1222
What toxicology screens can we run?
Utox, serum acetaminophen levels, salicylate levels
If a child is having a seizure secondary to poisoning, what is the treatment?
benzos, then barbituates
benzos are also used to HTN and drug associated agitation associated with benzos
What is the antidote treatment for opioid poisoning?
Naloxone
What is the antidote treatment for acetaminophen poisoning?
n-acetylcysteine (mucomyst)
What is the antidote for insecticide poisoning?
atropine
What is the antidote for TCA poisoning?
sodium bicarb
What do you give a pt for GI decontamination?
activated charcoal
What do you do for a child who ingested button batteries?
surgical consult!
emergent
What do you do for a child who ingested magnets?
emergent
depends on if its single or multiple
Dx: serial x-rays
Tx: keep away from magnetic material until it passes
Endoscopic removal if possible
What do you do for a child who ingested sharp pointed objects?
straight pens, needles, straightened paperclip, bones, toothpick
Risk: perforation, retropharyngeal abscess
Dx: X-ray
Tx: watchful waiting, OR
Epi of bites
Dogs (60-90%)
Cats (5-20%)
Humans (2-3%)
20-35 deaths annually in the US
Animals - Pasterurella
Humans - Eikenella corrodens
What is the assessment for a bite wound?
LA
identify what type of injury it is: skin, muscle, tendon, NV
Xray/US: foreign body or deep bite near bone or joints
Head CT: head injury, <2 years
Infection concern: gram stain aerobic and anaerobic cultures before ABX
What is the management of a bite wound?
I and D Primary closure if: - cosmetically important (ex. facial) -clinically uninfected -<12 hours old, <24 hours on the face
When NOT to close:
- crush injuries
- hand or feet
- cat or human bites (unless on the face)
- immunocompromised
When are you NOT supposed to close a bite wound?
- crush injuries
- hand or feet
- cat or human bites (unless on the face)
- immunocompromised
What is the treatment for bites?
cleanse with soap and/or virucidal agent with NS
tetanus if >5 years
ABX animal bites
-Augmentin 20mg/kg per dose BID for 3-5 days
ABX human bites
-Augmentin
-Unaysn (ampicillin -sulbactam)
50mg/kg per dose QID for 3-5 days
Rabies vaccine
Animal bite prophylaxis
4-1ml IM dose of HDCV or PCEC vaccine in deltoid or thigh
Days 0, 3, 7, 14
Rabies Immune Globulin (RIG)
Animal bite prophylaxis
full dose infusion around bite(s) if possible
remained IM from separate site than vaccine
Human bite prophylaxis
if blood in saliva:
HIV prophylaxis
if bitter +HbsAg
- initiate HB vaccine series in all unvaccinated
- -Hep B immune globulin
- -Hep B vaccine
What are signs and sxs of dehydration?
Tachycardia, hypotension
Poor skin turgor, delay in cap refill, deep respirations
cool and mottled extremities, frank shock
decreased OCP
increased thirst, decreased tearing, lethargy irritability
What labs do you draw for a pt with dehydration?
serum electrolytes serum bicarb <17mEq/L increased blood BUN serum sodium and potassium ADH secretion urine sodium, osmolality and specific gravity
What is the treatment for dehydration?
5ml/2min
Goal: 10ml/kg of body weight
IV crystalloid isotonic (0.9%) saline
never use hypo/hyper tonic crystalloids
added dextrose shows no benefit
What are the fluid rates for someone with severe dehydration?
rapid (bolus) infusion of 20ml/kg of isotonic 0.9% saline in 10-30 min
moderate dehydration - rapid rehydration of 60ml/kg vs 20ml/kg over an hour
How do you calculate the daily fluid requirement?
1st 10kg - 100ml/kg/day
2nd 10kg - 50ml/kg/day
remainder of bodyweight 20ml/kg/day
rate (ml/hour) = total daily requirement divided by 24
SIDS
sudden infant death syndrome
death of an infant <1yo, unexplained through case investigation, autopsy, and examination
What is the leading cause of infant mortality between 1 month and 1 year in US?
SIDS
peaks 2-4 months, 90% before 6 months
What are risk factors for SIDS?
maternal:
- younger, smoker, drug abuse, delayed prenatal care, UTI/STIs
neonatal:
-preterm, low weight for GA
infant:
- prone sleeping position, sleeping on soft surface or with increased accessories, bed-sharing, overheating, sibling of SIDS victim
What are preventative factors for SIDS?
room-sharing pacifier use breastfeeding fan use immunizations firm mattress
What analgesics are used in children?
acetaminophen (15mg/kg/dose Q4H)
Ibuprofen (10mg/kg/dose Q6H)
IN Fentanyl (1-2mcg/kg)
Ketoralac (Toradol)
(0.5mg/kg - max dose 30mg)
Morphine (0.2-0.5mg/kg, max 10 mg every 3-4 hours)
LET
lidocaine-epinephrine-tetracaine
topical anesthetic –30 min prior to procedure
What LAs can you use for children?
LET topical gel
Lidocaine
Bupivicaine
When do you NOT use lidocaine?
fingers, nose, penis, toes
What drug do we use for minimal sedation?
Midazolam (versed)
IN/PO/IV/IM
sedative ONLY
used prior to starting a procedure
onset of action: 1-3 min (IN)
IN dosing: 0.2mg/kg, max dose 10mg
What drug do we use for moderate sedation?
usually reserved for ortho reduction, tongue lacerations, extensive lacerations, MRI/CT
IV Ketamine
Analgestic + sedative
loading dose + maintenance PRN
SE: N/V, tachy, HTN, agitation, hallucinations, respiratory suppression
What is used for irrigation?
50-100mL/cm of laceration length
Normal saline > sterile water
When is the tetanus vaccine schedule?
2mon, 4mon, 6 mon, 15-18mon, and 4-6 years
if <3 doses Dtap or Tdap
if >3 doses vaccine if >5 years
When can kids get cough medicine?
no until after the age of 12 years
What do you do for a child complaining of a HA?
all get a neuro exam
record their BP
What must you be sure to keep in mind for a boy with abdominal pain?
testicular exam
