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KG - Pediatrics Exam 2 > Pediatric emergencies > Flashcards

Pediatric emergencies Flashcards

1
Q

Why are head injuries both dangerous and common in infants and toddlers?

A
  • large head:body ratio
  • weak neck muscles (prone to acc-dec injuries –> shearing forces –> inj to neurons and vasc structures)
  • thin skulls = poor brain protection
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2
Q

what are most common causes of head injuries in children >12 yrs old?

A
  • rec

- MVA (mostly male)

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3
Q

what are most common causes of head injuries in children < 1 yr?

A
  • falls

- abuse

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4
Q

name layers covering brain form most outer to inner

A 
scalp
periosteum
skull bone
dura mater
subdural space
subarachnoid space
(brain)
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5
Q

what bones make up the basal skull/skull base?

A
  • sphenoid bone
  • temporal bone
  • occipital bone
  • ethmoid bone
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6
Q

why must we worry extra if there is a basilar head injury?

A

because this is where great vessels enter/exit the skull - injuries here can be very significant

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7
Q

what are the critical components of a history in the event of suspected head injury?

A
  • who witnessed the fall/information from the witness?
  • from what height?
  • was there an immediate cry from the child? (this is a good sign if there was)
  • consolable? (if not, sign of something wrong)
  • vomiting?
  • time since injury?
  • arousable?
  • size of mass? (ie: if there is hematoma)
  • other injuries?
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8
Q

what should you check if parents are worried about child’s drowsiness post-head injury?

A
  • ask if this is “normal” nap time or bed time
  • concerning signs would be excessive sleepiness and if the child was hard to arouse, was vomiting, or was extra irritable
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9
Q

what is the primary survey for head injuries?

A

1) ABCs (airway, breathing, circulation)
2) neuro status (GCS, pupils, sucking reflex if infant, muscle tone)
3) vital signs (cushing’s triad? wide pulse pressure, bradycardia, abn respirations)
* **Also Glasgow Coma Scale #/15 pts

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10
Q

what is the secondary survey for head exams?

A

1) head/neck (c-spine alignment, fundoscopic exam for hemorrhaging, hematomas/step-offs/crepitus/lacerations/fontanels, basilar skull fracture
2) rest of body

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11
Q

head injury - diagnostics

A
  • bedside ultrasound
  • radiography = min. value bc doesn’t show injury to soft tissues/brain, ok for bony injury, air fluid levels in sinuses
  • CT = high dose radiation & not indicated for low risk patients (decision rules via PECARN, CATCH, CHALICE)
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12
Q

subdural hematoma

A
  • POOR PROGNOSIS
  • between dura & arachnoid membrane
  • usu associated w/ diffuse brain injury
  • tearing of bridging veins, low pressure bleed, dissects arachnoid from dura
  • usu associated w/ LOC, lingering sx, irritability, lethargy, bulging, fontanelle, vomiting
  • CT findings = crescent shaped, crosses suture lines
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13
Q

epidural hematoma

A
  • BETTER PROGNOSIS
  • rupture of arteries
  • common w/ football players
  • +/- underlying fx
  • typical hx = brief LOC, lucid per, followed by deterioration
  • elliptical shape, does not cross sutures
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14
Q

subarachnoid hemorrhage

A
  • parenchymal and subarachnoid vessels
  • small, dense “slivers” on CT (bc blood in cisterns, sulci, fissures, blood in CSF)
  • sx range from normal to LOC
  • may take time to visualize on CT (imp to get witness acct)
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15
Q

management of head injury - NO ICH, NO SKULL FX

A
  • head injury precautions
  • responsible caregiver monitors for behavior change, vomiting, decreased arousabiltiy, seizures, irritability
  • sleeping okay (if concerned, wake up q 2-3 hrs)
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16
Q

management of head injury - ICH +/- SKULL FX

A
  • neuro consult
  • admit (PICU?)
  • evacuation of ICH/surgery to repair fx or observation w/ repeat imaging
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17
Q

definition: concussion

cause?

A
  • traumatically induced alteration in mental status w/ or w/out LOC
  • cause usu blunt force (stretching/shearing of axons
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18
Q

symptoms of concussion

A
  • amnesia
  • confusion, blunted affect, distractability
  • delayed response
  • emotional lability
  • visual changes
  • repetitive speech changes
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19
Q

what could a witness tell a PA that would help during an exam of a patient who is suspected to have a concussion?

A
  • MOI
  • length of LOC
  • length of confusion/mental status change
  • seizure activity?
  • hx of previous concussions or other brain injuries
  • substance use? (if yes to this, imaging is a must bc neuro exam unreliable)
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20
Q

phys exam for concussion?

A
  • GCS rating, CN II-XII balance, gait, cognition/memory testing
  • head: hematoma, deformity, step offs, crepitus, mastoid
  • eyes: pupils, vis acuity, raccoon eyes
  • ears: hearing, hemotympanum
  • nose: CSF rhinorrhea, fracture
  • neck/throat: cervical spinous processes, neck ROM
  • chest: trauma
  • extremities: ROM, strength
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21
Q

what is the “ACE” tool used for?

A

concussion eval - good to use after pays exam and pt hx

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22
Q

prognosis for first concussion?

A
  • headache
  • mental fogginess
  • symptoms usu resolve 7-10 days
  • severe/prolonged/worsening HAs = emergent
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23
Q

what is “post-concussive syndrome?”

A

sx lasting 3+ months

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24
Q

what is “second impact syndrome?” (in relation to concussions)

A
  • 2nd concussion w/in weeks of prior concussion
  • brain swelling, herniation
  • can cause death
  • children at increased risk
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25
Q

concussion treatment?

A
  • NO SAME DAY RETURN TO PLAY
  • must be symptom-free to return & be evaluated by neuro
  • physical and cognitive rest (no cell phones, video games, get adequate sleep, noise reduction)
  • structured return to play protocol
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26
Q

what is the major difference between adult and pediatric bony anatomy?

A

presence of a cartilaginous growth plate (physics) in children

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27
Q

why are sprains less common in children?

A

the weak area at the end of long bones in children is more prone to damage than adjacent ligaments

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28
Q

what is the Salter-Harris Classification system used for?

A

to classify fractures of the epiphysis, physics, and metaphysis in children

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29
Q

define: Type I salter-harris classification

A

epiphyseal separation through physis

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30
Q

define: Type II salter-harris classification

A

fracture through portion of physics, but exiting across metaphysis

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31
Q

define: Type III salter-harris classification

A

fracture through physics, but exiting across epiphysis into joint

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32
Q

define: type IV salter-harris classification

A

fracture through metaphysics, physics, and epiphysis

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33
Q

define: Type V salter-harris classification

A

crush injury to physis

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34
Q

what is treatment for open fracture?

A
  • surgery

- IV antibiotics

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35
Q

a stress fracture is hard to see on X-rays… what would be the next test to do?

A

MRI

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36
Q

what happens to the bone in a compression fracture?

A

bone = crushed

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37
Q

what happens to the bone in an avulsion fracture?

A

tendon pulls off bone

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38
Q

what happens in a greenstick fracture?

A

bone buckles, very common in young kids

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39
Q

toddlers fracture

info & presentation

A
  • occurs when kids start walking 9 months - 3yrs
  • non-displaced spiral fx of tibia
  • sx vague: irritability, refusal to walk

***often signal of child abuse, unless story is pretty solid… can ask for “stat read” on X-rays

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40
Q

compound open fractures, fracture management

A
  • splint.dress
  • start IV antibiotics
  • ortho consult
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41
Q

non-displaced open fracture (overlying laceration) fracture management

A
  • start po antibiotics
  • repair laceration
  • splint
  • outpatient ortho follow up
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42
Q

what should you ALWAYS document before and after splinting/reduction/or other fracture interventions?

A

neurovascular status (always check to tingling, cap refill, etc)

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43
Q

grossly deformed/displaced fracture, fracture management

A
  • may compromise neuromuscular structures
  • will req closed/open reduction, possible fixation
  • ortho consult in ED
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44
Q

“other” fractures, fracture management

A
  • splint
  • pain control
  • ortho follow up
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45
Q

when should you suspect child abuse? (ie: when a child comes to ED w/ injury?)

A
  • inappropriate response by parents
  • delay in med attn
  • multiple healed fractures
  • inadequate hx of injury
  • MOI inconsistant w/ exam
  • neglect/failure to thrive
  • disturbed emotions/expressions
  • prior hx of suspicious events
  • parental substance abuse
  • “corner fracture” or “bucket fracture”(results from jerking/shaking limb)
  • posterior rib fracture
  • skull fracture > 3mm wide, complex, bilateral
  • acromion, spinous processes, femur injuries
  • spiral fractures of long bones
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46
Q

how does a child get a spiral fracture?

A
  • a forceful twisting injury, does not happen from a simply fall
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47
Q

nursemaid’s elbow

presentation/diagnosis/treatment

A
  • child holds arm in slightly flexed, prone position
  • child refuses to use arm
  • diagnose w/ hx, exam, X-rays normal
  • treatment = reduction
  • test = lollipop (hold out lollipop for child - if they grab for it, they’re ok… if not, something is wrong!)
  • prevent recurrence by parent education
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48
Q

describe supination-flexion reduction of nursemaid’s elbow

A

1) immobilize elbow, applying pressure to radial head
2) apply traction to wrist w/ pop hand, supinate forearm, flex elbow
3) should feel “pop” at radial head

-can also try pronation w/ elbow flexion if supination not successful

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49
Q

acute septic arthritis

info & presentation

A
  • entry bacteria into joint space, usu hematogenous spread, sepsis of joint
  • infants/kid = s. aureus, strep
  • teens = gonorrhea
  • fever, constant worsening joint pain, warm/swollen joint w/ pain on ROM
  • hold hips in flexion/external rotation
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50
Q

acute septic arthritis

diagnosis

A

lab studies

  • CBC
  • CRP
  • ESR
  • blood culture
  • joint aspiration
51
Q

acute septic arthritis

management

A
  • antibiotics (empiric, then targeted therapy)

- repeated aspiration for peripheral joints OR surgical (open) drainage of hips/shoulders

52
Q

osteomyelitis

info & presentation

A
  • hematogeous spread of infection to bone
  • most common males > females, under 5 yrs
  • long bones (femur, tibia, humerus)
  • s. aureus, s. pneu, s. pyogenes
  • fever, bone pain, swelling, redness, guarding of limb
  • focal tendering during exam
53
Q

osteomyelitis

diagnosis

A
  • xray (soft tissue swelling, then bone destruction w/ lytic lesions)
  • MRI = BEST STUDY FOR EVALUATION, marrow edema, abscesses
  • lab studies = CBC, CRP, ESR (look for high WBCs)
54
Q

osteomyelitis

treatment

A
  • IV antibiotics (empiric, then directed)
  • surgical drainage
  • surgical debridement
  • hyperbaric o2 therapy
55
Q

transient synovitis

info & presentation

A
  • common 18 months - 12 yrs)
  • etiology unknown, commonly follows URI, strep, or mild trauma
  • abrupt onset of pain to hip/thigh/knee, normal or slightly high temp, usu FROM
56
Q

transient synovitis

diagnosis

A
  • labs = WBC, ESR normal or slightly high
  • x rays
  • ultrasound may show effusion
  • **diagnosis of exclusion!
57
Q

transient synovitis

treatment

A
  • pain relief
  • observation
  • close follow-up
58
Q

legg-calvé perches disease

info & presentation

A
  • idiopathic avascular necrosis of femoral head
  • most common males 4-9 yrs old
  • limp = main symptom
  • little to no pain
  • nontoxic, insidious onset
  • hip held internally rotated, shows limited abduction
59
Q

legg-calvé perches disease

diagnosis & treatment

A
  • dx = xray (AP and frog-leg lateral hip), bone scan

- tx = urgent ortho referral

60
Q

slipped capital femoral epiphysis (SCFE)

info & presentation

A
  • femoral head “slips” - ice cream falls off cone
  • males 14-16 yrs > females 11-13 yrs
  • associated w/ obesity, taller, genital under development, pituitary tumors
  • acute/chronic hip or knee pain
61
Q

slipped capital femoral epiphysis (SCFE)

treatment

A
  • conservative - bed rest w/ traction
  • most req some surgery
  • usu try PT
62
Q

what is the phone # for poison control?

A

1-800-222-1222

63
Q

what are 4 main categories of items of toxic ingestion?

A

meds, cosmetics, cleaning supplies, plants

64
Q

what are the items we learned that were “deadly in a dose?”

A 
ASA
beta blockers
Ca channel blockers
camphor
chloroquine
clonidine
iron
lindane
methyl salicylate
methadone
nicotine
oils (hydrocarbons)
theophylline
tricyclic antidepressants
65
Q

what is a toxidrome? why is this important?

A
  • grouped, physiologically based abnormalities that are known to occur w/ specific classes of substances
  • helpful to establish diagnosis when exposure to substance not well defined
66
Q

presentation of anticholinergics?

A 
"hot as a hare"
"dry as a bone"
"red as a beet"
"blind as a bat" 
(only ones in red on slide 56 of per emergency ppt)

also:

  • delirium
  • flushed skin
  • dilated pupils
  • urinary retention
  • dec. bowel sounds
  • mem loss
  • seizures
67
Q

name important points of pt hx to get if toxic ingestion suspected

A
  • substance ingested (active ingredient, strength)
  • route (oral, mucosal, inhalation, eyes)
  • quantity (count pills left in bottle)
  • how long between exposure and eval?
  • progression of sx since exposure
  • home treatments administered
  • underlying medical conditions
68
Q

what is the standard treatment when toxic ingestion suspected?

A

1) stabilize patient - ABCs
2) contact poison control 1-800-222-1222 & do what they say
3) DDD - disability, drugs (antidotes), decontamination

69
Q

decontamination - ocular exposure

A
  • test pH
  • saline lavage until normal pH
  • flush for 15 min before reveal
  • make sure contacts removed
  • acidic vs. alkali (alkali worse)
  • consult ophthalmology
70
Q

decontamination - skin

A
  • copious NS

- follow w/ soap/water if exposed to lipid soluble toxins

71
Q

decontamination - GI

A
  • lavage, charcoal, cathartics, bowel irrigation

- enhance elimination

72
Q

decontamination - blood stream

A

antidote

73
Q

when to use ipecac for detox?

A
  • only helps if given within 30 min of exposure

- gen not recommended

74
Q

when to use gastric lavage for detox?

A
  • rarely indicated

- used for TCAs, CCBs, iron, lithium, EtOH

75
Q

when to use cathartics for detox?

A

usu not helpful

76
Q

how exactly do you achieve whole bowel irrigation for detox?

A
  • sustained release meds
77
Q

when to use charcoal for detox?

A
  • may help in selected poisonings
  • carbamazepine, barbituates, dapsone, quinine, theophyline, ingestions
  • some evidence for use w/ digoxin and phenytoin
  • little evidence for use w/ salicylates
  • not indicated w/ hydrocarbons, lithium, strong acids/bases, metals, EtOH
78
Q

when to use simple dilution for detox?

A

mild toxins that only cause irritation/corrosion

79
Q

what are methods of enhanced elimination?

A
  • charcoal
  • urine alkalization
  • diuresis
  • dialysis
  • hemoperfusion
80
Q

antidote for ACETAMINOPHEN?

A

acetylcysteine

81
Q

antidote for ANTICHOLINERGICS?

A

physostigmine

82
Q

antidote for BENZOS?

A

flumazenil

83
Q

antidote for BETA BLOCKERS?

A

glucagon

84
Q

antidote for CALCIUM CHANNEL BLOCKERS?

A

calcium

85
Q

antidote for DIGOXIN?

A

digibind

86
Q

antidote for HEAVY METALS?

A

chelating agents

87
Q

antidote for NARCOTICS?

A

naloxone

88
Q

what is you don’t know what substance a child ingested? (what labs to run? what antidotes?)

A

labs:

  • salicylate level
  • acetaminophen level **
  • UDS
  • digitalis, theophylline, methemoglobin levels
  • lithium level
  • PT/INR (warfarin)
  • CO level
  • CMP, coags, ABGs standard **

and. .. administer antidotes empirically as indicated by exam
- naloxone/narcan – if opiate, will wake up
- flumazenil
- etc

89
Q

foreign body ingestion - where are these most common?

A
  • cricopharyngeal narrowing
  • tracheal bifurcation
  • aortic notch
  • LES
90
Q

when is a foreign body ingestion a concern?

A
  • if object is sharp or has irreg edges
  • if lodged in esophagus can result in airway obstruction or perforation
  • perforation can occur from direct mechanical or chemical erosion
  • aspirated vegetable matter can cause intense pneumonitis
91
Q

FB ingestion

presentation

A
  • refusal to eat
  • vomiting
  • choking, coughing, stridor
  • neck/throat pain
  • neck pain, inability to swallow
  • increased salivation
  • fb sensation in chest
92
Q

FB ingestion

exam findings

A
  • red throat
  • palatal abrasions
  • anxiety/distress
  • wheezing
  • decreased BS
  • fever
  • peritoneal signs
  • or nothing at all!
93
Q

what would you do in a work up for a FB ingestion?

A
  • assure potency of airway
  • radiograph of neck/chest/abdomen
  • PROCEDURE OF CHOICE for removing FB in ESOPHAGUS = ENDOSCOPY
  • PROCEDURE OF CHOICE for removing FB in TRACHEA = BRONCHOSCOPY
94
Q

what are the indications for consultation in ingestion of FB?

A
  • sharp/elongated objects
  • multiple FBs (ie: magnets)
  • button batteries
  • evidence of perforation
  • coin at level of cricopharyngeus muscle
  • presence of FB more than 24 hrs
95
Q

Why are button batteries such a major problem when ingested?

A
  • extremely rapid action of alkaline substance on mucosa, pressure necrosis, residual charge
  • burns esophagus in as little as 4 hrs, perfs as soon as 6 hrs
  • lithium most adverse outcomes (mercuric oxide greater concern is heavy metal poisoning)
  • blood/urine mercury levels should be measured if split in GI tract
  • can see ID numbers on an xray
96
Q

button battery ingestion treatment?

A
  • emergent removal mandatory if in esophagus
  • is passed esophagus, no need to remove if assymptomatic, unless has not passed pylorus after 48 hrs
  • excreted 48-72 hrs
  • if GI signs/symptoms, immediate surgical consult
97
Q

peak incidence of drowning?

A

< 4 yrs

15-24 yrs

98
Q

define: drowning

A

liquid prevents individual from breathing o2

99
Q

what are two primary problems related to impaired ventilation, as a result of drowning?

A
  • hypoxemia
  • acidosis
    (most drowning victims aspirate < 4mL liquid)
100
Q

what complications can occur post-drowning?

A
  • CNS damage due to hypoxemia (primary injury)
  • arrhythmias
  • ongoing pulmonary injuries
  • reperfusion injury
  • multiorgan dysfunction (secondary injury)
101
Q

in a case of near-drowning, what are the survival rates/outcomes?

A
  • survival > 24 h post-event
  • severe brain damage in 10-30% peds near-drowning victims
  • patients who are alert/mildly obtunded at ED may have full recovery **
  • patients who are comatose/get CPR in route/have fixed or dilated pupils and no spontaneous respirations have POOR PROGNOSIS **
  • 35-60% individuals needing continued CPR in ED die (if so, 60-100% of survivors have neuro damage)
102
Q

when should you consider child abuse in near drowning situations?

A
  • when victim is < 6 months old or toddlers w/ atypical presentation
103
Q

define: dry drowning

A
  • when laryngospasm –> hypoxia –> LOC

- no fluid in lungs

104
Q

define: wet drowning

A
  • more common
  • aspiration of water into lungs
  • dilution and washout of surfactant –> diminished gas transfer across alveoli –> atelectasis –> ventilation-perfusion mismatch
  • fresh water = hypoosmolar shift
  • salt water = hyperosmolar shift
105
Q

define: secondary drowning

A
  • may cause death up to 72 hrs after near drowning incident
  • fresh water drowning results in hemodilution (from ingested water)
  • if enough volume aspirated, significant hemolysis & cardiac arrhythmias (electrolyte disturbances)
106
Q

treatment for drowning

A
  • pre-hospital care is critical

ED focus

  • assist ventilation (goal O2 saturation 95% or higher
  • mechanical vent if needed
  • warmed isotonic IV fluids and warming blankets
  • address associated injuries/treat electrolytes/monitor card rhythms
  • get initial CXR, repeat at 6 hrs
  • admit for observation (serial CXR), maintain vent & prevent neuro injury
107
Q

what workup do you do to figure out what is causing a fever when you don’t know the source?

A
  • thorough hx & PE, complete septic workup
  • workup based on age (< 2 months, 2 months - 3 yrs)
  • appearance
  • risk factors (birth hx, travel, exposures, vaccination status, immune deficiency
108
Q

to figure out if a fever is non-toxic or toxic, what tests would you do in a child 2 months - 3 yrs to check for NON-TOXIC causes?

A
  • UA (cath) (all males < 6 months, uncirc males < 12 months, all females < 24 months, all older females w/ UTI sx)
  • rapid viral testing (for flu, RSV)
  • stool for WBCs + guaiac (if diarrhea)
109
Q

to figure out if a fever is non-toxic or toxic, what tests would you do in a child 2 months - 3 yrs to check for TOXIC causes?

A
  • CBC w/ diff
  • CXR
  • UA cath
  • CSF analysis (LP)
  • stool for W- stool for WBCs + guaiac (if diarrhea)
  • rapid virus testing
110
Q

what is management for a fever for a child 2 months - 3 yrs w/ NON-TOXIC cause?

A

d/c home if:

  • pt was healthy prior to onset of fever
  • pt fully immunized
  • pt has no significant risk factors
  • pt otherwise healthy
  • pt’s caregivers appear reliable
  • 24 hr PCP f/u
111
Q

what is management for a fever for a child 2 months - 3 yrs w/ TOXIC cause?

A
  • admit
  • begin empiric antibiotics pending culture results
  • supportive care
112
Q

what should be done with infants 38 deg Cel?

A
  • incidence SBI 6-10%
  • WORKUP REGARDLESS OF APPEARANCE
  • need pertinent birth hx (prematurity, STD exposure, PROM, fetal hypoxia, maternal peripartum infections, other fetal loss)
  • 5-10% of its w/ group B strep sepsis also have meningitis
113
Q

symptoms of infection w/ neonatal fever

A
  • irritability
  • decreased activity
  • poor feeding/weight gain
  • lethargy
  • change in sleep patterns
  • vomiting/diarrhea
  • hypothermia
114
Q

management of neonatal fever

A
  • full septic workup (CBC w/ diff, UA (cath), CXR, LP, blood cx)
  • early admin of empiric antibiotics, even if all tests neg (cefotaxime, ampicillin)
  • admit pending culture results
115
Q

febrile seizures, general info

A
  • occur in 2-5% of children
  • possibly genetic component
  • 6 months - 5 yrs
  • simple & complex
  • pts usu experience post-ictal period
  • generally benign unless prolonged per of compromised ventilation/perfusion or aspiration
116
Q

simple febrile seizures

A
  • lasts < 15 min
  • isolated
  • pt o/w neurologically intact before seizure
117
Q

complex febrile seizures

A
  • lasts > 15 min or multiple in rapid succession

- pt o/w neurologically intact before seizure

118
Q

causes of seizures that are NOT fever related

A
  • CNS related (+/- fever)
  • withdrawal from drugs
  • alcohol withdrawal
  • toxins
  • hypoxic-ischemic injury
  • vascular accidents (AVM)
  • trauma
  • child abuse
  • metabolic disorders
  • idiopathic epilepsy
119
Q

initial intervention for seizures

A
  • ABCs - maintain airway, use artificial airway or suctioning as necessary, recovery position
  • immobilize C-spine if any hx of trauma
  • consider ET intubation
  • IV access
  • if seizure > 10 min, give benzo (IV vs. pr)
120
Q

phys exam w/ febrile seizures

A
  • head to toe
  • full neuro exam
  • check for signs of meningeal irritation (nuchal rigidity, irritability)
  • exclude meningitis w/ septic work up
  • children < 12 months need full septic work up
  • IF IN DOUBT, CHECK IT OUT!
  • 12-18 months a grey zone
121
Q

prevention of febrile seizures

A
  • abt 1/3 will have at least 1 recurrence
  • antipyretics during febrile illness (educate parents act dose)
  • offer reassurance on benign nature of febrile seizures
  • in some cases, rectal diazepam may be used prophylactically at onset of fever
  • rarely use maintenance drug (unless multiple seizures)
122
Q

SIDS

A
  • usu few wks - 6 months, peak 2-4 months
  • usu occurs midnight to 8 am
  • male:female = 3:2
  • risk factors = low SES, minorities, teen moms, maternal smoking/drug use, sleeping prone, overheating, co-sleeping
123
Q

SIDS risk reduction

A
  • supine sleeping
  • avoid cigarette smoke
  • breast feeding
  • avoid overheating
  • avoid unsafe sleep conditions (soft bedding, pillows, waterbeds, sheepskins, sofa, sleeping with parents)
  • apnea and bradycardia monitors are not effective

KG - Pediatrics Exam 2 (3 decks)

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