Part 8: Emergency and Crit Care Flashcards
1
Q
Children ____ have a higher % of injuries in the upper cervical spine than older children and adults
age
A
<9 y/o
2
Q
In trauma, pts who have neurologic symptoms but no apparent abnormalities in CT or XRay may have…
A
Spinal cord injury without radiographic abnormalities (SCIWORA) - though most abnormalities may be detected by MRI
3
Q
Severe spinal cord (C-spine) injuries will usually lead to ____ in pts who are breathing spontaneously.
A
Paradoxical Respiration - occurs when the diaphragm, which is innervated by the phrenic nerves with contributions from C3, C4, and C5, is functioning normally, but the intercostal musculature innervated by the thoracic spinal cord is paralyzed. In this situation, inspiration fails to expand of the chest wall but distends the abdomen.
4
Q
Mildest injury to the spinal cord
A
Transient quadriparesis
- evident for seconds or minutes with complete recovery in 24 hr. This injury follows a concussion of the cord and is most frequently seen in adolescent athletes.
5
Q
Significant spinal cord injury in the cervical region is characterized by
A
flaccid quadriparesis, loss of sphincter function, and a sensory level corresponding to the level of injury
6
Q
An injury at this spinal cord level can cause respiratory arrest and death in the absence of ventilatory support
A
C1-C2
7
Q
An thoracic injury at spinal cord level T10 or above may produce
A
paraplegia
8
Q
An thoracic injury at spinal cord T12-L1 level may produce
A
Conus medullaris syndrome
- loss of urinary and rectal sphincter control
- flaccid weakness, and
- sensory disturbances of the legs
9
Q
Higher risk wounds should be closed within _ hrs after injury, and low-risk wounds may be closed as late as _ ?
Time
A
6hours
12-24hrs
10
Q
Parts of the intracranial dyanamics
A
Brain parenchyma ~85%
Blood
CSF
11
Q
Further increases in ICP can ultimately displace the brain downward into the foramen magnum—a process called ?
A
Cerebral herniation
12
Q
Increases in CSF pH that occur because of inadvertent hyperventilation (which decreases PaCO2) can produce?
A
Cerebral Ischemia
13
Q
Hallmark of severe TBI
A
Coma (GCS 3-8)
14
Q
Moderate TBI
GCS score
A
GCS 9-12
15
Q
In the comatose child with severe TBI, the second key clinical manifestation is the development of ?
A
Intracranial HTN
16
Q
The development of increased ICP with impending herniation may be heralded by
A
- new-onset or worsening headache,
- depressed level of consciousness,
- vital sign changes (hypertension, bradycardia, irregular respirations), and
- signs of 6th (lateral rectus palsy) or 3rd (anisocoria [dilated pupil], ptosis, down- and-out position of globe as a result of rectus muscle palsies) cranial nerve compression.
17
Q
Significantly raised ICP (>20 mm Hg) can occur early after severe TBI, but peak ICP generally is seen at _ hr.
A
48-72 hr
18
Q
Fluid of choice for pts with severe TBI
A
Normal saline
19
Q
Treatment for cerebral herniation
A
- hyperventilate, with a fraction of inspired oxygen of 1.0, and
- intubating doses of either thiopental or pentobarbital, and
- either mannitol (0.25-1.0 g/kg IV) or hypertonic saline (3% solution, 5-10 mL/kg IV).
20
Q
Age-dependent cerebral perfusion targets:
A
- 2 - 6 y/o: 50mmHg
- 7 - 10 y/o: 55mmHg
- 11 - 16 y/o: 60 mmHg
21
Q
First-tier therapy for the management of increased ICP
A
- elevation of the head of the bed, ensuring midline positioning of the head, controlled mechanical ventilation, and analgesia and sedation (i.e., narcotics and benzodiazepines)
- osmolar agents hypertonic saline (often given as a continuous infusion of 3% saline at 0.1-1.0 mL/kg/hr) and mannitol (0.25-1.0 g/ kg IV over 20 min), given in response to ICP spikes >20 mm Hg or with a fixed (every 4-6 hr) dosing interval.
22
Q
Second tier therapy for refractory increased ICP
A
- Barbiturate infusion
- Decompressive craniectomy
- Mild hypothermia (32-34oC)
- Hyperventilation (PaCO2 25-30 mm Hg)
- Lumbar CSF drainage
23
Q
3 components for determining brain death
A
- Demonstration of co-existing irreversible coma with a known cause
- absence of brainstem reflexes
- apnea
24
Q
True or False
The presence of spinal cord reflexes—even complex reflexes—does not preclude the diagnosis of brain death.
A
True
25
Apnea is defined as absence of respiratory effort in response to an adequate stimulus. PaCO2 value >= _ and _ above baseline is sufficient stimulus
60mmHg
20mmHg
26
Brainstem reflex tests to determine brain death
* Pupillary Light reflex (CN II, II, midbrain)
* Oculocephalic reflex (Doll's eyes reflex; CN III, VI, VIII, midbrain, pons)
* Corneal reflex (CN III, V, VII, pons)
* Oculovestibular reflex (CN III, IV, VI, VIII, pons, midbrain)
* Gag and cough reflex (CN IX, X, medulla)
27
The most common cause of syncope in the normal pediatric population
Neurocardiogenic syncope (vasovagal syncope, fainting)
28
A phenomenon that can lead to syncope, but is usually very short, usually 30-60 secs, and occurs primarily with active standing, not passive upright tilt. BP may drop 30% of baseline at 10-20 sec of standing and may be assoc with tachycardia
Initial orthostatic hypotension
-usually happens after prolonged recumbence and when the individual stands
29
Define orthostatic hypotension
SUSTAINED decrease in the systolic BP of > 20mmHg or diastolic BP >10mmHg in the first 3mins upright
Rarely occurs in children
30
This is defined as relatively sudden change in autonomic nervous system activity that leads to a sudden decrease in BP, HR, and cerebral perfusion
Reflex syncope (vasovagal or neurally mediated)
31
In children, Postural Orthostatic Tachycardia Syndrome (POTS) is characterized by HR increase of __ beats/min during the 1st 10 min of upright tilt test without associated hypotension, (__ beats/min if >19 yr old) while replicating orthostatic symptoms that occur when upright. Improvement of symptoms in the supine position is expected.
> 40 bpm in children, >30 bpm if >19y/o
The diagnosis of POTS also requires daily orthostatic symptoms. In patients with POTS, the larger decline in cardiac stroke volume
32
Enumerate the various pathophysiologic mechanisms of POTS (4)
* Neuropathic POTS, an autonomic neuropathy impairing sympathetic venoconstriction in the lower extremities or splanchnic circulation, decreasing stroke volume, and consequently resulting in a tachycardia
* Hypovolemic POTS, a common contributor, often related to decreased aldosterone with reduced renin activity, resulting in a tachycardia caused by decrease blood volume
* Hyperadrenergic POTS, with norepinephrine levels rising 3-4–fold in the standing position (norepinephrine normally doubles on stand- ing), which may occur in norepinephrine transporter deficiency or strong stimulation of central baroreflex responses
* Autoimmune POTS, typically assumed based on a postviral chronology, but seldom proven; such a form may or may not exist.
33
The best measure for treating POTS
REgular aerobic exercise program
34
This is defined as any alteration of organ function that requires medical support for maintenance,
Multiple-organ dysfunction syndrome
35
This type of shock results from decreased cardiac output secondary to direct impediment to right- or left-sided heart outflow or restriction of all cardiac chambers
Obstructive Shock. Possible etiologies include: Tension pneumothorax Pericardial tamponade Pulmonary embolism
Anterior mediastinal
masses
Critical coarctation of aorta
35
Shock caused by inadequate vasomotor tone, which leads to capillary leak and maldistribution of fluid into the interstitium
Distributive shock. Possible etiologies: Anaphylaxis Neurologic: loss of
sympathetic vascular tone secondary to spinal cord or brainstem injury
Drugs
35
Criteria for CVS organ dysfunction
* Despite administration of isotonic intravenous fluid bolus ≥60 mL/kg in 1 hr: decrease in BP (hypotension) systolic BP <90 mm Hg, mean arterial pressure <70 mm Hg, <5th percentile for age, or systolic BP <2 SD below normal for age, or
* Need for vasoactive drug to maintain BP in normal range (dopamine >5 μg/kg/min or dobutamine, epinephrine, or norepinephrine at any dose), or
* Two of the following:
*Unexplained metabolic acidosis: base deficit >5.0 mEq/L
Increased arterial lactate: >1 mmol/L or >2× upper limit of normal
Oliguria: urine output <0.5 mL/kg/hr
Prolonged capillary refill: >5 sec
Core-to-peripheral temperature gap: >3°C (5.4°F)*
36
Criteria for Respiratory Organ dysfunction
* PaO2/FIO2 ratio <300 in absence of cyanotic heart disease or preexisting lung disease, or
* PaCO2 >65 torr or 20 mm Hg over baseline PaCO2, or
* Need for >50% FIO2 to maintain saturation ≥92%, or
* Need for nonelective invasive or noninvasive mechanical ventilation
37
Criteria for Neurologic organ dysfunction
* GCS score ≤11, or
* Acute change in mental status with decrease in GCS score ≥3 points from abnormal baseline
38
Criteria for Hematologic organ dysfunction
* Platelet count <100,000/mm3 or decline of 50% in platelet count from highest value recorded over last 3 days (for patients with chronic hematologic or oncologic disorders), or
* INR >1.5, or
* Activated prothrombin time >60 sec
39
Criteria for REnal dysfunction
* Serum creatinine >0.5 mg/dL, ≥2× upper limit of normal for age, or
* 2-fold increase in baseline creatinine value
40
Criteria for hepatic dysfunction
* Total bilirubin ≥4 mg/dL (not applicable for newborn)
* Alanine transaminase level 2× upper limit of normal for age
41
Septic shock is a combination of which types of shock?
Hypovolemic shock from intravascular fluid losses occurs through capillary leak. Cardiogenic shock results from the myocardial-depressant effects of sepsis, and distributive shock is the result of decreased SVR.
42
What is an inflammatory cascade that is initiated by the host response to an infectious or noninfectious trigger?
systemic inflammatory response syndrome (SIRS)
This inflammatory cascade is triggered when the host defense system does not adequately recognize and/or eliminate the triggering event. The inflammatory cascade initiated by shock can lead to hypovolemia, cardiac and vascular failure, acute respiratory distress syndrome (ARDS), insulin resistance, decreased cytochrome P450 activity (decreased steroid synthesis), coagulopathy, and unresolved or secondary infection.
43
What are some examples of proinflammatory mediators?
IL-6, IL-10, interferon-γ, and macrophage migration inhibitory factor
44
What are some examples of anti-inflammatory mediators?
IL-10, transforming growth factor-β, and IL-4.
45
Hallmark of uncompensated shock
Imbalance between oxygen delivery and oxygen consumption.
46
Elevated levels of this reflect poor tissue oxygen delivery noted in all forms of shock
Blood lactate
47
Target blood sugar level in patients with septic shock
RBS <= 180mg/dl
48
In the surviving sepsis campaign care bundles, what must be completed within the first 3 hours? (4)
1. measure lactate level
2. obtain blood cultures before administration of antibiotics
3. Administer broad-spectrum antibiotics
4. Administer 30 mL/kg crystalloid for hypotension or lactate
≥4 mmol/L.
49
Treatment of choice for anaphlaxis
Epinephrine
50
Amount of fluid boluses to be given in pts with cardiogenic shock
5-10ml/kg
51
An inodilator, this drug may improve systolic function and decrease SVR w/o causing a significant increase in HR and has the added benefit of enhancing diastolic relaxation
Milrinone
52
Drugs that improve BP that should generally be avoided in pts with cardiogenic shock
Agents that improve BP by increasing SVR (and therefore increased afterload) e.g., norepinephrine and vasopressin
53
What may be considered to be given in pts with shock that is unresponsive to fluid resuscitation and catecholamines?
Corticosteroids
54
What can be used if shock remains refractory despite maximal therapeutic interventions?
Mechanical support with ECMO
55
This is defined as inability of the lungs to provide sufficient oxygen (hypoxic respiratory failure) or remove carbon dioxide (ventilator failure) to meet metabolic demands.
Respiratory failure
56
Lesions in these parts of the brain result in hyperpnea and tachypnea
Cerebral hemispheres, midbrain
57
This is characterized by alternate periods of rapid and slow breathing
Cheyne-Stokes breathing. - may result from lesions in the midbrain
58
This is characterized by prolonged inspiration with brief expiratory periods
Apneustic breathing - may result fom lesions on the pons
59
This is characterized by Rapid and irregular respirations with pauses
Biot's breathing - lesions on the pons and medulla
60
Metabolic disorders causing hyperammonemia cause what kind of acid base disorder?
Respiratory alkalosis (dec PaCO2 and inc pH) because ammonia stimulates the respiratory centers
61
Perfusion in excess of ventilation results in incomplete arterialization of systemic venous (pulmonary arterial) blood and is referred to as ?
Venous admixture
62
Perfusion of unventilated areas is referred to as ?
Intrapulmonary shunting
63
Ventilation that is in excess of perfusion and does not contribute to gas exchange is referred to as ?
dead space ventilation
64
Examples of diseases leading to venous admixture
Asthma, aspiration pneumonia
65
Examples of diseases leading to intrapulmonary shunting
lobar pneumonia, ARDS
66
Examples of diseases leading to impaired diffusion in the lungs
Interstitial pneumonia, ARDS, scleroderma, lymphangiectasia
66
Why is a lower SpO2 desired in pts with single-ventricle cardiac lesions or with large left to right shunts (eg, VSD, PDA)?
In these types of pathophysiologic situations, a lower SpO2 is desired to avoid excessive blood flow to the lungs and pulmonary edema from the pulmonary vasodilatory effects of oxygen, in the patient with a single ventricle, diverting blood flow away from the systemic circulation
67
FiO2 % calculation when using nasal cannula
FiO2 % = 21% + [Nasal cannula flow (L/min) x3]
68
FiO2 delivery using a simple mask
| range
30 - 65%
69
What provides preset FIO2 through a mask and reservoir system by entraining precise flow rates of room air into the reservoir along with high-flow oxygen.
VEnturi Mask
Oxygen flow rates of 5-10 L/min are recommended to achieve the desired FIO2 and to prevent rebreathing.
70
This type of masks have 2 open exhalation ports and contain a valveless oxygen reservoir bag.
Partial rebreather masks - can provide FIO2 up to 0.60, for as long as oxygen flow is adequate to keep the bag from collapsing (typically 10-15 L/ min)
71
This type of masks include 2 one-way valves, 1 between the oxygen reservoir bag and the mask and the other on 1 of the 2 exhalation ports. This arrangement minimizes mixing of exhaled and fresh gas and entrainment of room air during inspiration.
Non-rebreather mask - can provide FIO2 up to 0.95
72
This is a powerful inhaled pulmonary vasodilator. Its use may improve pulmonary blood flow and V̇/Q̇ mismatch in patients with diseases that elevate pulmonary vascular resistance, such as occurs in persistent pulmonary hypertension of the newborn, primary pulmonary hypertension, and secondary pulmonary hypertension as a result of chronic excess pulmonary blood flow (e.g., ventriculoseptal defect) or collagen vascular diseases.
inhaled nitric oxide (iNO) - adminis- tered in doses ranging from 5 to 20 parts per million of inspired gas
73
The proper internal diameter (ID) for the ETT can be estimated using the following formula
ID=(Age[yr] 4)+4
74
Mech Vent mode whereby the machine-delivered breaths are triggered by the patient’s inspiratory efforts
Synchronized intermittent mandatory Ventilation (SIMV) mode
75
In this mech vent mode, every patient breath is triggered by pressure or flow generated by patient inspiratory effort and assisted with either preselected inspiratory pressure or volume
Assist-control (AC) mode - cannot be used in the weaning process, which involves gradual decrease in ventilator support
76
Mechanical ventilation at supraphysiologic rates and low VT, and this improves gas exchange in a select group of patients who show no response to traditional ventilatory modalities, is known as?
high-frequency ventilation (HFV)
77
In a patient with relatively normal lungs, an age-appropriate ventilator rate and a VT of ____mL/kg would be appropriate initial settings.
7-10 mL/kg
78
Diseases associated with decreased TC (decreased static compliance; e.g., ARDS, pneumonia, pulmonary edema) are best treated with ____ VT and relatively ____ rates. Diseases associated with prolonged TCs (increased airway resistance; e.g., asthma, bronchiolitis) are best treated with relatively ____ rates and ____ VT.
small (6 mL/kg), rapid
slow, higher (10-12 mL/kg)
79
The alveolar pressure in excess of the set PEEP at the completion of the expiratory pause is measured as
auto-PEEP or intrinsic PEEP
80
The most objective means of assessing extubation readiness is a ...
spontaneous breathing trial (SBT)
81
this is the most common cause of extubation failure in children
postextubation upper airway obstruction
*Administration of intravenous corticosteroids (dexamethasone, 0.5 mg/kg every 6 hr for 4 doses before extubation) has been shown to minimize the incidence*
82
The altitude threshold where clinical illness may begin to occur is ____ meters. At this altitude a mild impairment in oxygen transport begins.
1,500 m
83
Fluid homeostasis often shifts at altitude, resulting in ... as manifested by ...
a generalized fluid retention and redistribution into intracellular and interstitial spaces, manifested by peripheral edema, decreased urine output, and impaired gas exchange.
84
Most healthy, unacclimatized visitors to high altitude will not experience a significant drop in SaO2 (<90%) until they reach elevations above ____m
2,500m
85
The most important response to acute hypoxia is ?
an increase in minute ventilation
86
What is the primary symptom of acute mountain sickness (AMS)?
High-altitude headache - proposed to be caused by both mechanical and trigemiovascular system.
87
What is commonly prescribed as prophylaxis against AMS because of its ability to stimulate respiration and increase alveolar and arterial oxygenation?
Acetazolamide (2.5mg/kg q 12h, max 125mg/dose)
88
This drug used as prophylaxis against AMS acts a carbonic anhydrase inhibitor that induces what process, and consequently what effect?
Acetazolamide induces a renal bicarbonate diuresis, causing a metabolic acidosis that increases ventilation and arterial oxygenation.
89
When does symptoms of AMS reach maximum severity?
Between 24 and 48hrs
90
What is an effective treatment for all forms of altitude illness and should be tailored to the individual response?
Descent (500-1,000 m, ~1,600-3,300 ft)
91
High altitude cerebral edema (HACE) is differentiated from severe AMS by the presence of ?
Neurologic signs (most often ataxia and altered mental status, including confusion, progressive decrease in responsiveness, and eventually coma. Less common signs are focal cranial nerve palsies, motor and sensory deficits, and seizures.)
92
What is the deadliest of the high-altitude illnesses?
High-altitude pulmonary edema (HAPE)
93
Describe briefly the pathophysiology of high-altitude pulmonary edema (HAPE).
Hypoxic pulmonary vasoconstriction is a normal physiologic response to optimize ventilation/perfusion (V̇ /Q̇ ) matching by redistributing regional pulmonary blood flow to areas of highest ventilation, thereby optimizing arterial oxygenation. Under conditions that result in widespread alveolar hypoxia, extensive pulmonary vasoconstriction will lead to significant elevations in pulmonary arterial pressure; uneven pulmonary vasoconstriction can result in localized overperfusion, increased capillary pressures, distention, and leakage in the remaining vessels.
94
Symptoms of HAPE generally develop when?
within 24-96hrs of ascent
95
The minimum criteria to diagnose HAPE include ?
* recent exposure to altitude, dyspnea at rest,
* radiographic evidence of alveolar infiltrates, and
* near-complete resolution of both clinical and radiographic signs within 48 hr after descent or institution of oxygen therapy.
96
Finding these in portable ultrasonograms is useful in to diagnose HAPE.
Comet tails - artifacts created by microreflections of the ultrasound beam within interlobular septa thickened by interstitial and alveolar edema
97
What is the treatment of choice for HAPE?
Descent with supplemental oxygen, rapid descent of at least 1,000 m (~3,300 ft) usually results in rapid recovery
98
What drug can be used in emergency situations when treatment of choice for HAPE is not available/possible?
Nifedipine - 0.5 mg/kg orally every 4-8 hr and titrated to response (maximum, 10 mg/dose), although its use has not been studied in children for treatment of HAPE
99
Travel to high altitude with young infants is generally safe after ____, when circulatory changes have occurred, breastfeeding is established, and congenital abnormalities may have been detected.
4-6 wk
100
Drowning rates are highest in what age group and followed by which age group?
highest in 1-4 y/o, followed by older adolescents, aged 15-19 y/o
101
Most of the drowning deaths in children <1 y/o occur where?
in the bathtub. next major risk factor is the large (5-gallon) household bucket
102
What is the most common cause of mortality and long-term morbidity in drowning victims?
CNS injury
103
Submersions ____ min are associated with a favorable prognosis, whereas those ____ min are generally fatal.
< 5mins
>25mins
104
At body temperatures ____oC, extreme bradycardia is usually present with decreases in cardiac output, and the propensity for spontaneous ventricular fibrillation or asystole is high
<28oC
105
With this level of hypothermia, loss of consciousness leads to water aspiration. Progressive bradycardia, impaired myocardial contractil- ity, and loss of vasomotor tone contribute to inadequate perfusion, hypotension, and possible shock.
Moderate (30 - < 34oC)
106
A deep coma, with fixed and dilated pupils and absence of reflexes at very low body temperatures (____°C), may give the false appearance of death.
<25 - 29oC
107
In drowning victims with suspected airway foreign bodies, what are preferable maneuvers?
**Chest compressions or back blows**
Abdominal thrusts should not be used for fluid removal as it may increase the risk of regurgitation and aspiration.
108
This is usually the initial drug of choice in drowning victims with bradyasystolic cardiopulmonary arrest.
Epinephrine (IV dose is 0.01 mg/kg using the 1 : 10,000 [0.1 mg/mL] solution given every 3-5 min, as needed)
109
Most pediatric drowning victims should be observed for at least____, even if they are asymptomatic on presentation to the ED.
| time / duration
6-8 hr
110
What should be prevented at all times in the acute recovery period (at least the 1st 24-48 hr) in comatose drowning victims resuscitated from cardiac arrest?
Hyperthermia (core body temp > 37.5oC)
111
Active rewarming should be limited to victims with core body temperatures ___.
<32°C
112
Poor outcome is highly likely in pedia drowning patients with submersion durations ____, and with failure of response to CPR given for ___.
| time / duration
> 10mins,
25mins
113
In pediatric drowning, what is the best predictor of outcome?
Submersion duration
114
The leading cause of burn in children 5-14 y/o
Flame injury
115
What s the fabric most resistant to ignition by small flame source?
Polyester. It does burn deeply as it melts, but it self-extinguishes when the flame source is removed. It also melts downward, sparing the face and respiratory tract
116
What is the most commonly injured sites with deep 2nd-degree friction injury/burns?
The hands
117
What is the major cause of morbidity and mortality in house fires?
Anoxia
118
Give indications for hospitalization for burns.
* Burns affecting >10% of BSA
* Burns >10–20% of BSA in adolescent/adult
* 3rd-degree burns
* Electrical burns caused by high-tension wires or lightning
* Chemical burns
* Inhalation injury, regardless of the amount of BSA burned
* Inadequate home or social environment
* Suspected child abuse or neglect
* Burns to the face, hands, feet, perineum, genitals, or major joints
* Burns in patients with preexisting medical conditions that may
complicate the acute recovery phase
* Associated injuries (fractures)
* Pregnancy
119
Children with burns ____ of BSA require intravenous (IV) fluid resuscitation to maintain adequate perfusion.
>15%
120
All high- tension and electrical injuries require venous access to ensure ____ in case of muscle injury to avoid myoglobinuric renal damage.
Forced alkaline diuresis
121
Fluid of choice for initial infusion in burn patients
Lactated Ringer's Solution (10-20ml/kg), but NSS may be used if LRS is not available
122
# True or False
Burns < 10% BSA do not require tetanus prevention, whereas burns >10% need tetanus immunization.
True
123
For burn patients requiring tetanus prophylaxis, what should be used for children < 11 y/o? > 11 y/o?
< 11 y/o, Dtap
> 11 y/o, TdaP
124
What is the Parkland formula and how is it given?
Guideline for fluid resuscitation (4 mL lactated Ringer solution/kg/% BSA burned) for burn patients. Half the fluid is given over the 1st 8 hr, calculated from the time of onset of injury; the remaining fluid is given at an even rate over the next 16 hr.
| This is in addition to the maintenance fluid.
125
Oral supplementation may start as early as ____ after the burn
48 hours
126
What is the pediatric age group wherein the rule of 9s in estimating BSA for a burn can be used?
> 14 y/o
127
What may be required for children with burns > 20% BSA if 0.5% silver nitrate is used as the topical antibacterial dressing for burn injury?
Oral sodium chloride supplement of 4 g/m2 burn area/24 hr is usually well tolerated, divided into 4-6 equal doses to avoid osmotic diarrhea. The aim is to maintain serum sodium levels >130 mEq/L and urinary sodium con- centration >30 mEq/L.
IV potassium supplementation is supplied to maintain a serum potassium level >3 mEq/dL.
128
What is a very effective broad- spectrum topical agent with the ability to diffuse through the burn eschar and is the treatment of choice for burn injury to cartilaginous surface, such as the ear?
Mafenide acetate (also a sulfa-containing agent)
129
What is a common adverse reactions to sulfur-containing agents that is transient, self-limiting, and reversible?
Transient leukopenia - mostly noted with the use of silver sulfadiazine cream when applied over large surface areas in children < 5 yr old. No sulfa-containing agent should be used if the child has a history of sulfa allergies.
130
When is inhalational injury suspected?
* patient confined to a closed space (building)
* with a history of an explosion or a decreased level of consciousness, or
* with evidence of carbon deposits in the oropharynx or nose, singed facial hair, and carbonaceous sputum.
131
Signs and symptoms of carbon monoxide poisoning.
* mild ( < 20% HbCO): with slight dyspnea, headache, nausea, and decreased visual acuity and higher cerebral functions;
* moderate (20–40% HbCO): with irritability, agitation, nausea, dimness of vision, impaired judgment, and rapid fatigue; or
* severe (40–60% HbCO): producing confusion, hallucination, ataxia, collapse, acidosis, and coma
132
Treatment for CO poisoning.
100% oxygen
Significant CO poisoning requires hyperbaric oxygen therapy
133
What medications can be given prior to a procedure (dressing changes, debridement) in burn patients?
Oral and IV morphine (analgesics), and Lorazepam (IV or PO) or midazolam (IV)
134
What is necessary to reduce hypertrophic scar formation, which consists of a variety of prefabricated and custom-made garments that are available for use in different body areas?
Pressure therapy. These custom-made garments deliver consistent pressure on scarred areas, shorten the time of scar maturation, and decrease scar thickness, redness, and associated itching.
135
This category of electrical burn occurs particularly at high-voltage installations, such as electric power stations or railroads; children climb an electric pole and touch an electric box out of curiosity or accidentally touch a high-tension electrical wire.
high-tension electrical wire burn (> 1,000 V)
136
What remains the key to effective management of the electrically damaged extremity?
Aggressive removal of all dead and devitalized tissue, even with the risk of functional loss.
137
What is characteristic of lightning injury?
Feathering / arborescent pattern
138
Pathophysiology of cold injuries (3)
* Ice crystals may form between or within cells, interfering with the sodium pump, and may lead to rupture of cell membranes.
* Further damage may result from clumping of red blood cells or platelets, causing microembolism or thrombosis.
* Blood may be shunted away from an affected area by secondary neurovascular responses to the cold injury; this shunting often further damages an injured part while improving perfusion of other tissues.
139
What results in the presence of firm, cold, white areas on the face, ears, or extremities and what is its treatment?
Frostnip.
Treatment consists of warming the area with an unaffected hand or a warm object before the lesion reaches a stage of stinging or aching and before numbness supervenes. Rewarming in a water bath (40-42.2°C [104-108°F]) is effective.
140
What occurs in cold weather when the feet remain in damp or wet, poorly ventilated boots, and what is its treatment?
Immersion Foor (Trench Foot)
Treatment includes drying the foot, gentle rewarming and nonsteroidal antiinflammatory drugs (NSAIDs) for pain.
141
This is characterized by initial stinging or aching of the skin progressing to cold, hard, white anesthetic and numb areas. Clear or hemorrhagic vesicles may develop over the exposed areas. On rewarming, the area becomes blotchy, itchy, and often red, swollen, and painful.
Frostbite
Treatment: Warming the damaged areas, NSAIDs, warm water bath (42oC), vasodilating agents, keeping the rewarmed area dry, open, and sterile provide optimal results
142
In patients with severe hypothermia with VT/ VF / shockable rhythm, how should the shock be given?
One shock at max power. Warm 1-2oC prior to additional shocks.
No vasoactive drugs until 30°C or above. From 30–35°C,
increase dosing interval to twice as long as normal.
143
What level of potassium in a serevely hypothermic patient is an indication to terminate CPR?
potassium > 12
144
What is a form of cold injury in which erythematous, vesicular, or ulcerative lesions occur?
Chilbain (pernio).
The lesions are presumed to be of vascular or vasoconstrictive origin. They are often itchy, may be painful, and result in swelling and scabbing. The lesions are most often found on the ears, the tips of the fingers and toes, and exposed areas of the legs. The lesions last for 1-2 wk but may persist for longer.
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A common, usually benign injury, ____ occurs on exposure to cold air, snow, or ice and manifests in exposed (or less often covered) surfaces as red (or less often purple to blue) macular, papular, or nodular lesions.
cold-induced fat necrosis (Panniculitis).
Treatment: NSAIDs
