Pediatric emergencies Flashcards
Why are head injuries both dangerous and common in infants and toddlers?
- 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
what are most common causes of head injuries in children >12 yrs old?
- rec
- MVA (mostly male)
what are most common causes of head injuries in children < 1 yr?
- falls
- abuse
name layers covering brain form most outer to inner
scalp periosteum skull bone dura mater subdural space subarachnoid space (brain)
what bones make up the basal skull/skull base?
- sphenoid bone
- temporal bone
- occipital bone
- ethmoid bone
why must we worry extra if there is a basilar head injury?
because this is where great vessels enter/exit the skull - injuries here can be very significant
what are the critical components of a history in the event of suspected head injury?
- 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?
what should you check if parents are worried about child’s drowsiness post-head injury?
- 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
what is the primary survey for head injuries?
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
what is the secondary survey for head exams?
1) head/neck (c-spine alignment, fundoscopic exam for hemorrhaging, hematomas/step-offs/crepitus/lacerations/fontanels, basilar skull fracture
2) rest of body
head injury - diagnostics
- 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)
subdural hematoma
- 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
epidural hematoma
- 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
subarachnoid hemorrhage
- 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)
management of head injury - NO ICH, NO SKULL FX
- head injury precautions
- responsible caregiver monitors for behavior change, vomiting, decreased arousabiltiy, seizures, irritability
- sleeping okay (if concerned, wake up q 2-3 hrs)
management of head injury - ICH +/- SKULL FX
- neuro consult
- admit (PICU?)
- evacuation of ICH/surgery to repair fx or observation w/ repeat imaging
definition: concussion
cause?
- traumatically induced alteration in mental status w/ or w/out LOC
- cause usu blunt force (stretching/shearing of axons
symptoms of concussion
- amnesia
- confusion, blunted affect, distractability
- delayed response
- emotional lability
- visual changes
- repetitive speech changes
what could a witness tell a PA that would help during an exam of a patient who is suspected to have a concussion?
- 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)
phys exam for concussion?
- 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
what is the “ACE” tool used for?
concussion eval - good to use after pays exam and pt hx
prognosis for first concussion?
- headache
- mental fogginess
- symptoms usu resolve 7-10 days
- severe/prolonged/worsening HAs = emergent
what is “post-concussive syndrome?”
sx lasting 3+ months
what is “second impact syndrome?” (in relation to concussions)
- 2nd concussion w/in weeks of prior concussion
- brain swelling, herniation
- can cause death
- children at increased risk
concussion treatment?
- 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
what is the major difference between adult and pediatric bony anatomy?
presence of a cartilaginous growth plate (physics) in children
why are sprains less common in children?
the weak area at the end of long bones in children is more prone to damage than adjacent ligaments
what is the Salter-Harris Classification system used for?
to classify fractures of the epiphysis, physics, and metaphysis in children
define: Type I salter-harris classification
epiphyseal separation through physis
define: Type II salter-harris classification
fracture through portion of physics, but exiting across metaphysis
define: Type III salter-harris classification
fracture through physics, but exiting across epiphysis into joint
define: type IV salter-harris classification
fracture through metaphysics, physics, and epiphysis
define: Type V salter-harris classification
crush injury to physis
what is treatment for open fracture?
- surgery
- IV antibiotics
a stress fracture is hard to see on X-rays… what would be the next test to do?
MRI
what happens to the bone in a compression fracture?
bone = crushed
what happens to the bone in an avulsion fracture?
tendon pulls off bone
what happens in a greenstick fracture?
bone buckles, very common in young kids
toddlers fracture
info & presentation
- 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
compound open fractures, fracture management
- splint.dress
- start IV antibiotics
- ortho consult
non-displaced open fracture (overlying laceration) fracture management
- start po antibiotics
- repair laceration
- splint
- outpatient ortho follow up
what should you ALWAYS document before and after splinting/reduction/or other fracture interventions?
neurovascular status (always check to tingling, cap refill, etc)
grossly deformed/displaced fracture, fracture management
- may compromise neuromuscular structures
- will req closed/open reduction, possible fixation
- ortho consult in ED
“other” fractures, fracture management
- splint
- pain control
- ortho follow up
when should you suspect child abuse? (ie: when a child comes to ED w/ injury?)
- 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
how does a child get a spiral fracture?
- a forceful twisting injury, does not happen from a simply fall
nursemaid’s elbow
presentation/diagnosis/treatment
- 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
describe supination-flexion reduction of nursemaid’s elbow
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
acute septic arthritis
info & presentation
- 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
acute septic arthritis
diagnosis
lab studies
- CBC
- CRP
- ESR
- blood culture
- joint aspiration
acute septic arthritis
management
- antibiotics (empiric, then targeted therapy)
- repeated aspiration for peripheral joints OR surgical (open) drainage of hips/shoulders
osteomyelitis
info & presentation
- 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
osteomyelitis
diagnosis
- 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)
osteomyelitis
treatment
- IV antibiotics (empiric, then directed)
- surgical drainage
- surgical debridement
- hyperbaric o2 therapy
transient synovitis
info & presentation
- 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
transient synovitis
diagnosis
- labs = WBC, ESR normal or slightly high
- x rays
- ultrasound may show effusion
- **diagnosis of exclusion!
transient synovitis
treatment
- pain relief
- observation
- close follow-up
legg-calvé perches disease
info & presentation
- 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
legg-calvé perches disease
diagnosis & treatment
- dx = xray (AP and frog-leg lateral hip), bone scan
- tx = urgent ortho referral
slipped capital femoral epiphysis (SCFE)
info & presentation
- 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
slipped capital femoral epiphysis (SCFE)
treatment
- conservative - bed rest w/ traction
- most req some surgery
- usu try PT
what is the phone # for poison control?
1-800-222-1222
what are 4 main categories of items of toxic ingestion?
meds, cosmetics, cleaning supplies, plants
what are the items we learned that were “deadly in a dose?”
ASA beta blockers Ca channel blockers camphor chloroquine clonidine iron lindane methyl salicylate methadone nicotine oils (hydrocarbons) theophylline tricyclic antidepressants
what is a toxidrome? why is this important?
- 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
presentation of anticholinergics?
"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
name important points of pt hx to get if toxic ingestion suspected
- 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
what is the standard treatment when toxic ingestion suspected?
1) stabilize patient - ABCs
2) contact poison control 1-800-222-1222 & do what they say
3) DDD - disability, drugs (antidotes), decontamination
decontamination - ocular exposure
- test pH
- saline lavage until normal pH
- flush for 15 min before reveal
- make sure contacts removed
- acidic vs. alkali (alkali worse)
- consult ophthalmology
decontamination - skin
- copious NS
- follow w/ soap/water if exposed to lipid soluble toxins
decontamination - GI
- lavage, charcoal, cathartics, bowel irrigation
- enhance elimination
decontamination - blood stream
antidote
when to use ipecac for detox?
- only helps if given within 30 min of exposure
- gen not recommended
when to use gastric lavage for detox?
- rarely indicated
- used for TCAs, CCBs, iron, lithium, EtOH
when to use cathartics for detox?
usu not helpful
how exactly do you achieve whole bowel irrigation for detox?
- sustained release meds
when to use charcoal for detox?
- 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
when to use simple dilution for detox?
mild toxins that only cause irritation/corrosion
what are methods of enhanced elimination?
- charcoal
- urine alkalization
- diuresis
- dialysis
- hemoperfusion
antidote for ACETAMINOPHEN?
acetylcysteine
antidote for ANTICHOLINERGICS?
physostigmine
antidote for BENZOS?
flumazenil
antidote for BETA BLOCKERS?
glucagon
antidote for CALCIUM CHANNEL BLOCKERS?
calcium
antidote for DIGOXIN?
digibind
antidote for HEAVY METALS?
chelating agents
antidote for NARCOTICS?
naloxone
what is you don’t know what substance a child ingested? (what labs to run? what antidotes?)
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
foreign body ingestion - where are these most common?
- cricopharyngeal narrowing
- tracheal bifurcation
- aortic notch
- LES
when is a foreign body ingestion a concern?
- 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
FB ingestion
presentation
- refusal to eat
- vomiting
- choking, coughing, stridor
- neck/throat pain
- neck pain, inability to swallow
- increased salivation
- fb sensation in chest
FB ingestion
exam findings
- red throat
- palatal abrasions
- anxiety/distress
- wheezing
- decreased BS
- fever
- peritoneal signs
- or nothing at all!
what would you do in a work up for a FB ingestion?
- 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
what are the indications for consultation in ingestion of FB?
- 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
Why are button batteries such a major problem when ingested?
- 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
button battery ingestion treatment?
- 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
peak incidence of drowning?
< 4 yrs
15-24 yrs
define: drowning
liquid prevents individual from breathing o2
what are two primary problems related to impaired ventilation, as a result of drowning?
- hypoxemia
- acidosis
(most drowning victims aspirate < 4mL liquid)
what complications can occur post-drowning?
- CNS damage due to hypoxemia (primary injury)
- arrhythmias
- ongoing pulmonary injuries
- reperfusion injury
- multiorgan dysfunction (secondary injury)
in a case of near-drowning, what are the survival rates/outcomes?
- 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)
when should you consider child abuse in near drowning situations?
- when victim is < 6 months old or toddlers w/ atypical presentation
define: dry drowning
- when laryngospasm –> hypoxia –> LOC
- no fluid in lungs
define: wet drowning
- 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
define: secondary drowning
- 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)
treatment for drowning
- 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
what workup do you do to figure out what is causing a fever when you don’t know the source?
- 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
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?
- 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)
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?
- CBC w/ diff
- CXR
- UA cath
- CSF analysis (LP)
- stool for W- stool for WBCs + guaiac (if diarrhea)
- rapid virus testing
what is management for a fever for a child 2 months - 3 yrs w/ NON-TOXIC cause?
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
what is management for a fever for a child 2 months - 3 yrs w/ TOXIC cause?
- admit
- begin empiric antibiotics pending culture results
- supportive care
what should be done with infants 38 deg Cel?
- 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
symptoms of infection w/ neonatal fever
- irritability
- decreased activity
- poor feeding/weight gain
- lethargy
- change in sleep patterns
- vomiting/diarrhea
- hypothermia
management of neonatal fever
- 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
febrile seizures, general info
- 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
simple febrile seizures
- lasts < 15 min
- isolated
- pt o/w neurologically intact before seizure
complex febrile seizures
- lasts > 15 min or multiple in rapid succession
- pt o/w neurologically intact before seizure
causes of seizures that are NOT fever related
- CNS related (+/- fever)
- withdrawal from drugs
- alcohol withdrawal
- toxins
- hypoxic-ischemic injury
- vascular accidents (AVM)
- trauma
- child abuse
- metabolic disorders
- idiopathic epilepsy
initial intervention for seizures
- 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)
phys exam w/ febrile seizures
- 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
prevention of febrile seizures
- 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)
SIDS
- 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
SIDS risk reduction
- 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
