PAEDIATRIC EMERGENCIES Flashcards
Paediatric emergencies
List 4
• Acutely Raised Intracranial Pressure
• Shock
• Respiratory failure
• Status Epilepticus
Raised intracranial pressure
Definitions:
• Intracranial pressure (ICP) is the __________ exerted by ________________________ (blood, brain and CSF) within the intracranial cavity
• Usually less than ____mmHg
• Raised ICP: A clinical condition in which this pressure is raised.
pressure ; intracranial contents
10mmHg
Pathophysiology of raised ICP
• Intracranial contents are in a state of delicate equilibrium
• Intracranial contents: _______,_______,_________
• The brain is ____________________ so any increase in ICP will __________ and/or ________________________
blood, CSF, brain
non compressible
reduce CSF
cerebral blood flow
Pathophysiology of raised ICP
• Pressure increases __________ with increases in volume up to a point; thereafter pressure increases __________
slightly ; steeply
Cerebral perfusion pressure (CPP) is the effective pressure that results in
___________ in the brain
• CPP = ______ – _______
blood flow
MAP – ICP
Cerebral autoregulation: _______ changes in BP produce ___________ changes in cerebral blood flow
Large
Only Small
Predisposing factors to raised ICP
• _____________
• _____________
• _____________
• Brain oedema
• _____________ to CSF flow
• _____________
• _____________
Infections
Space occupying lesions
Trauma
Obstructions to CSF flow
Cerebrovascular accidents
Seizures
Predisposing factors to raised ICP
• Infections: __________ , __________, cerebral __________
• Space occupying lesions: __________, __________
• Trauma: intracranial ________ and __________
• Brain oedema: toxins, cerebral hypoxia, encephalopathies (hepatic, hypoxic ischaemic, _______ syndrome)
• Obstructions to CSF flow: ____________
meningitis, encephalitis, cerebral
abscess
tumors, cysts
intracranial bleeds and hematomas
Reye’s ; hydrocephalus
Clinical features of raised ICP
• ___________
• Early ________ ________
• ________ vision
• Seizures
• Cranial nerve palsy : CN _____
• ________ consciousness
• ________ consciousness
• Localizing signs: hemiparesis, hypertonia
• Cerebellar signs: ________, ________
Headaches ; morning vomiting
Blurred vision ; CN VI
Altered consciousness
Loss of consciousness
ataxia ; nystagmus
Clinical features of raised ICP
• Sluggish or absent ____________
• ____________: late sign
• Increase in ____________
• ____________ and tense ____________
pupillary light reflex
Papilledema ; head size
Bulging ; fontanels
• Cushing triad of ICO
???
– Hypertension
– Bradycardia
– Waxing and waning respiration with apnoea
Complications of raised ICP
• Brain ____________
• ________________
• Global cerebral ____________
• ____________
• ____________
• Death
• Brain herniation
• Status epilepticus
• Global cerebral ischaemia
• Coma
• Stroke
• Death
Management of raised ICP
• Emergency management
– Optimizing ________ , ________, ________ and ________ level
• Positioning: ________ the head to about _____ degrees
• Respiratory care: ________ +/- ________
• ________ control
• ________ control
• Treatment of ________
• ________ control
• Sedation and analgesia
• Prophylactic hypothermia
airway ; breathing ; circulation
sugar level ; Elevate
30 degrees ; suctioning
intubation ; Fever ; Blood pressure
anaemia ; Seizure
Management of raised ICP
• Investigations:
– _______ count
– Electrolytes urea and creatinine
– Blood _______
– Cranial imaging: _______, _______
– _______ studies
– _______
– Lumbar puncture for CSF analysis
Full blood count
Blood sugar
CT scan, MRI
Toxicology studies
– Blood culture
Management of raised ICP
• Ventilatory support: heavy __________ and paralysis
• __________
• Hyperosmolar therapy: __________, hypertonic saline
• Steroids: __________
• __________ coma
• Surgical management: __________ of tumors, __________ of abscesses, __________, ______________________
heavy sedation and paralysis
Hyperventilation
mannitol ; dexamethasone
Barbiturate coma
resection; drainage
ventriculostomy ; ventriculo-peritoneal shunt
Shock is an __________ syndrome, characterized by inadequate _________________________ , so that the ___________________ of vital organs and
tissues are not met.
acute ; circulatory supply of oxygen
metabolic demands
Morbidity and mortality of shock
• Leading cause of morbidity and mortality in children
• Can be a progressive process due to the continued presence of the initiating factor with exaggerated and potentially harmful neurohomural, inflammatory and intracellular responses.
• Mortality is increased significantly by the presence of _________________
(____% if only 1 organ system involved, _______% in 2 organ systems, >_____% if 3 or more organ systems)
multiple organ dysfunction
25%; 60%
> 85%
Aetiology of shock
• Reduced blood in the circuit
– ______________
– Dehydration from ___________, ___________
– ______________
– Maldistribution due to ‘______________’ – many causes including anaphylaxis)
• Pump failure
– Sepsis
– ______________/ ______________
– ______________
• Inadequate oxygen carrying capacity
– ______________
– __________ poisoning
Haemorrhage ; diarrhoea
vomiting; Sepsis
‘third spacing ; Cardiomyopathy/ myocarditis
Arrhythmias
– Anaemia
– CO poisoning
Classification of shock
List all
• Hypovolaemic
• Distributive
• Cardiogenic: Obstructive
• Dissociative
• Septic
Hypovolemic shock
• Pathophysiology:
– Loss of ____________________ leading to reduced ________with resultant reduced ______________
intravascular volume ; Preload
cardiac output
Most common type of shock in children is??
Hypovolemia shock
Hypovolemic shock
• Aetiology
– Hemorrhagic: _________ bleed, _______ with concealed blood loss (liver/spleen injuries, long bone fractures),
____________ hemorrhage
– Non-hemorrhagic: __________ /__________, heat stroke, __________, __________________
GI ; trauma
vomiting/diarrhea ; burns
diabetic ketoacidosis
Hypovolemia shock
• Classically, ___________ and ___________ without signs of ____________________ are seen in the patient.
hypotension ; tachycardia
congestive heart failure
Distributive shock, Pathophysiology:
– Loss of _______________________ (________) results in abnormal distribution of blood flow
– Loss of _________ due to release of endotoxin, vasoactive substances, complement cascade activation, and microcirculation thrombosis leads to loss of preload with blood volume _________ in the periphery.
Systemic Vascular Resistance
afterload; vascular tone
pooling i
Distributive Shock
Aetiology: Sepsis, anaphylaxis, envenomation, spinal
cord injury and drug reaction (barbiturates,
antihypertensives, phenothiazines)
Distributive shock
• Aetiology: _________ , ___________ , envenomation, __________ injury and drug reaction (barbiturates, antihypertensives, phenothiazines)
Sepsis ; anaphylaxis
spinal cord injury
Cardiogenic shock
Pathophysiology:
– The underlying process here is _________________ (______ failure) i.e. Low ______________ in the presence of high systemic vascular resistance
– Subsequent increase in LV ______, LV _________, and cardiac _______________
– Cardiac output decreases and ultimately results in volume retention, ____________ , and ______________________ failure
impaired contractility ; pump failure
Cardiac output ; afterload
work ; oxygen consumption
pulmonary edema ; Right
ventricular
Cardiogenic Shock
Aetiology: ____________ , ___________ lesions, __________, myocarditis, cardiac ____________
Cardiomyopathy
obstructive
arrhythmias
tamponade
Septic shock
• SEPTIC SHOCK is not an entirely different entity, but is a clinical syndrome that can include features of both ___________ and ___________ shock.
cardiogenic
distributive
Septic Shock
• _______% presentation – classic “_______ shock” with _______ extremities, _______ pulses _______cardia, _______pnoea,
_______ urine output and mild metabolic _______
– This is characterized by _______ CO, _______ SVR.
• 20%
warm ; warm
bounding ; tachycardia!; tachypnoea,
adequate ; acidosis
High; low
Septic shock
• ____% presentation – “_____ shock” with _______ extremities, _________ pulses, _________ capillary refill, _________
respiration and _________ urine output
– This is characterized by ______ CO, ________ SVR
• A small percentage present with mixed pictures.
60% ; cold ; cold
thready ; prolonged ; shallow
inadequate ; Low; high
Clinical features of shock
• Early signs
– Fussy, _________
– Reduced _________
– Sinus _________cardia, small volume /_________ pulse
– _________ capillary refill
age in years)
irritable; urinary output
tachycardia ; thready
Delayed
Clinical features of shock
• Late signs
– ______cardia
– _________ _________ status (lethargy, coma)
– _______tonia, ______eased deep tendon reflexes
– _________ breathing
– ______________ is a very late sign
Lower limit of SBP = _______ + (_____ x _____________)
Bradycardia ; Altered mental status
Hypotonia ; decreased
Cheyne-Stokes ; Hypotension
70 + (2 x age in years)
Management of shock
• Immediate identification of life - threatening conditions (primary survey)
– GET ____________ IN EARLY
• Rapid Correction of _________ compromise
• Maintain adequate _________________
• Eliminate underlying cause
OXYGEN ; circulatory
perfusion pressure
Management of shock
Airway
• The ability to speak or cry without stridor generally indicates a __________ airway.
– __________ airway
– +/- mechanical ventilation
– Assess mental state using __________ criteria (__________, response to __________, response to __________, __________) during the initial survey of
the patient.
Breathing
– __________ of breathing
– Check ______________ with pulse oximeter.
patent ; oropharyngeal
AVPU ;Alert, response to Verbal command
response to Painful stimulus
Unresponsive
work ; oxygen saturation
Management of shock
• Circulation
– Heart rate, pulses, blood pressure.
Remember ____________ (relative to age norm) is key sign of shock even before blood pressure is reduced.
___________ is a late sign.
– Capillary refill– to assess perfusion to organ systems
– Vascular assess should be obtained early either through a _______________ or _______________ route can be used after _____ failed attempts at venous cannulation. There is no place
for the lengthy nature of the procedure.
TACHYCARDIA
BRADYCARDIA
large bore vein ; intra-osseous
2
Management of shock
• Dextrose/Drugs?
- Do ____________ level and if necessary correct using 2-4ml/kg of ____% __________.
Random blood sugar level
10% Dextrose.
History/ examination and investigations
in shock
• Brief medical history should be obtained while resuscitation is on-going focusing on
– __________ events, recent __________ or __________
– __________ History
• Allergies & exposure to ________
– Focused physical examination
• __________ System: _______ status using __________
• Cardiovascular System: HR, perfusion, ? __________ ? __________
• Respiratory system: __________, __________
• Investigations: ______,_______,_________ and __________
Preceding events ; illness ; trauma
Past Medical History ; toxins
Central Nervous System ; mental status
Glasgow Coma Scale
?gallop; ?murmur
crackles ; wheezing
CBC, EUCr, Group and crossmatching
Management of shock
• Fluid resuscitation:
– Fluids: __________ , ____________
– Volume: _____mls/kg
– Duration: as quickly as possible
– Repeat if required
• Inotropes:
• Usually used early in septic shock
• Used after failure to respond to ____ml/kg fluid
in first hour
• Include: _________ , _________, _________,
noradrenaline, milrinone, vasopressin
Normal saline ; Ringer’s lactate
20mls/kg ; 40ml/kg fluid
dobutamine, dopamine, adrenaline,
Summary: Shock
• Recognize shock quickly - ____________ IS THE FIRST SIGN, __________ IS LATE.
• _________ remains your first step in initial care
• Gain access quickly - if needed use IO.
• If patient is not responding the as quickly you expect, broaden your differential; think about other types of
shock.
• The on-going management of the shocked child will depend on the specific cause and may include
interventions such as _________ , _________ antibiotics, _________ support and _________ intervention.
TACHYCARDIA ; HYPOTENSION
ABCD
ventilation ; broad spectrum
antibiotics ; inotropic
surgical
Respiratory Failure
Definition
• A clinical condition which occurs when the ___________________________________________________ is unable to match the body’s metabolic demands
• An important cause of morbidity and mortality
in children
rate of gas exchange (oxygen delivery and carbon dioxide removal) between the atmosphere and the blood
Respiratory failure
• PaO2 <_____mmHg and PaCO2> ____mmHg on room air
60
50
Respiratory failure
• Respiratory distress (can or cannot?) occur without respiratory disease
• Respiratory failure (can or cannot?) occur without respiratory distress
can
can
• Respiratory failure can be acute or chronic
Chronic causes include: bronchopulmonary dysplasia, ___________ , ___________
cystic fibrosis
obstructive sleep apnoea
Aetiology of respiratory failure
Lower airway obstruction
List 4
• Bronchial asthma
• Bronchiolitis
• Aspiration pneumonia
• Meconium aspiration
Aetiology of respiratory failure
Lung/interstitium
List 3
• Pneumonia
• ARDS/ RDS
• Pulmonary oedema
Aetiology of respiratory failure
Thoracic cage
• Chest wall deformities: _________
• Diaphragmatic _____________
•_______ chest
• Abdominal distension
kyphoscoliosis, pectus
herniation/eventration
Flail
Management of respiratory failure
• Emergency care: ________
• Investigations:
– _______ , ________ , ________,
– Imaging: CXR, neck /post nasal space xray, brain imaging
• Treat underlying cause
• Adequate __________
– Bag and mask ventilation
– Supplemental oxygen: face mask, nasal prongs,
– ________________________
• Adequate ventilation
– __________ with mechanical ventilation
ABCD
CBC, EUCr, ABG,
oxygenation
Continuous Positive Airway Pressure
Intubation
Aetiology of respiratory failure
Upper Airway obstruction:
List 5
• Adenoidal hypertrophy
• Choanal atresia
• Foreign body aspiration
• Epiglottitis
• Laryngotracheobronchitis
• Anaphylaxis
Aetiology of respiratory failure
Brain and spinal cord
• ___________ injury
• CNS ___________/___________
• CNS ___________
• Intracranial ___________
• ______________
• Transverse myelitis
• ___________
• ___________ of ___________
Trauma/head injury
depressants/sedatives
infections
Intracranial bleed
Raised ICP
Poliomyelitis
Apnoea of prematurity
Aetiology of respiratory failure
Neuromuscular
•________ nerve palsy
• Infant __________
•_____________ syndrome
• Myaesthenia gravis
•___________________ poisoning
Phrenic
botulism
Gullain Barre
Organophosphate
Clinical features of respiratory failure
• Increased _______________
• Tachypnoea
• Dyspnoea
• _____________ (_______________, _______________, _______________)
• _______________
• _______________
• Irregular respiration
• _______________
• Altered mental status
work of breathing
Retractions (intercostal, subcostal, suprasternal)
Grunting; Nasal flaring
Apnoea
Status epilepticus
• Definition
– ________ seizure lasting more than ______________
– __________ seizure occurring without ____________
May be __________ or ___________
Single ; five minutes
Multiple ; full recovery
convulsive ; non convulsive
Identifying a child with respiratory failure
Key signs: 2R,2C,1A
???
Increased Respiratory rate
Increased Work of breathing
• Colour change (cyanosis)
Decreased Consciousness change
Decreased Air entry
Status Epilepticus
Risk of complications increases with ____________
Mortality rate up to ____%
duration
10%
Status epilepticus may be the first presentation of a seizure
T/F
T
Pathophysiology of status epilepticus
• ___________ and persistent __________________
• Ineffective recruitment of ___________ neurons
• Excitatory neurotransmitters: ___________, ___________, ___________
• Inhibitory neurotransmitter: ___________
• Associated ___________, ___________, ___________ and ___________ exacerbate neuronal damage
Excessive ; excitation of neurons
inhibitory neurons; glutamate,
aspartate ; acetyicholine ; GABA
hypoxia ; hypotension
acidosis ; hyperpyrexia
Investigation of status epilepticus
• Labs
– EUCr: Na, Ca, Mg, PO4 , glucose
– CBC, blood cultures, urinalysis, MP
– Arterial blood gases
– Liver function tests, ammonia
– Serum anticonvulsant level
– Toxicology
Tired
Morbidity and mortality of shock
Morbidity may be wide spread and involve multiple organs with effects such as
________ failure,
________ damage,
________ ischemia,
________ failure,
________ ________,
________ (DIC),
________(ARDS),
________ failure, and
death.
renal failure,
brain damage,
gut ischemia,
hepatic failure,
metabolic derangements,
Disseminated Intravascular Coagulation (DIC),
acute respiratory distress syndrome (ARDS),
cardiac failure, and
death.
Management of status epilepticus
Principles
• Ensure adequate vitals, systemic and cerebral __________
• _________ seizure activity
• Prevent seizure __________
• Establish the diagnosis and treat the
underlying disorder
oxygenation
seizure activity
recurrence
Investigation of status epilepticus
• Lumbar puncture
– Always defer LP in ________ patient, but never ____________________ if indicated
• CT scan
Indicated for _______ seizures or deficit, history of ________ or __________ disorder
• EEG: especially in _______________ SE
unstable
delay antibiotic/antiviral medication
focal ; trauma ; bleeding
non convulsive
Management of status epilepticus
• Abort seizures:
– 1st line: ______ acting ___________ (_________ , ___________), repeat if seizure continues
– 2nd line: ______ acting ___________: ___________, ___________
– 3rd line: IV ________________, levetiracetam
– ICU care with elective ___________ and ___________ if airway compromised or no response to 3rd line agents
– Midazolam infusion
– ________________ : ___________ or ___________ on _____ monitoring
Short ; benzodiazepine
Diazepam ; Lorazepam
Long ; anticonvulsants
Phenytoin ; Phenobarbitone
sodium valproate ; intubation
mechanical ventilation
Barbiturate coma ; pentobarbital
thiopental ; EEG
Management of status epilepticus
• Relevant history (after _________)
– Description of the event
– ________ or ________ seizure
– Associated symptoms
– Anticonvulsant medications (previous use/ type/change/adherence)
– Trauma
– Fever
– Ingestions
• CNS examination: Coma scale, Pupillary light reflex, CNS examination
stabilization
Previous ; first time seizure
Complications of status epilepticus
• _________ __________
• Focal neurological deficits
• _________ disorders
• Chronic _________
Mental retardation
Focal neurological deficits
Chronic epilepsy
