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Peds Exam 2 > Pediatric Emergencies > Flashcards

Pediatric Emergencies Flashcards

1
Q

Leading cause of childhood deaths

A

Injuries (counsel on safety at every well-child visit)

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2
Q

Head injuries in infants/toddlers because

A

large heads
weak neck muscles (acceleration-deceleration injuries –> shearing forces –> injury to neurons and vascular structure)
thin skulls
physically uncoordinated
lack cognitive ability to predict/understand danger

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3
Q

Causes of head injuries

A

MVA, falls, abuse, recreational activities

Bimodal dist:
>8: sports, MVA, ATV’s bikes, scooters
<1 Yo: walking, furniture, abuse

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4
Q

Diffuse axonal injury

A

smash one side of head and the other gets injured

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5
Q

Bones of the skull

A

frontal, parietal, occipital, temporal, sphenoid, ethmoid

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6
Q

Hx questions

A 
witnessed?
heigh
immediate cry
consolable
vomiting (more than 3x)
time since injury
arousable (is it nap-time)
size of mass
other injuries
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7
Q

parents worried about “drowsiness”

A

ask if “normal” nap or bed time

concerning signs: excessive sleepy or hard to arouse, vomiting, irritability

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8
Q

Exam for head injury 1st survey

A

ABC’s (airway, breathing, circulation)
Neuro status: Glasgow coma scale (GSC), pupils, sucking reflex, muscle tone
Vitals: Cushings triad

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9
Q

Glasgow coma scale (GSC)

A

checks for coma
15 - highest
<8 needs immediate resussitation

Evaluates:

  • eye opening
  • best verbal response
  • best motor response
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10
Q

Cushings triad

A

wide PP
bradycardia
abnormal respiration

(body’s response to increased ICP – typically showing hemorrhage or bleed, etc.)

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11
Q

Eval for head injury 2nd survey

A

Head/neck:

  • C-sline alignment, funduscopic exam, hematomas, step-offs, crepitus, lacerations, fontanels
  • basilar skull fracture: battle sign, periorbital ecchymosis (racoon eyes), hemotypanum, otorhea/rhinorrhea (CSF)
  • REST OF BODY
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12
Q

Basilar skull fracture

A

battle’s sign (behind ear)
periorbital ecchymosis (racoon eyes)
hemotympanum
otorrhea/rhinorrhea (CSF)

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13
Q

Dx of head injuries

A

X-ray (minimal value, body injury, air-fluid levels, no soft tissue (brain) visualization)

CT - high radiation, only for HIGH-RISK
- based on PECARN, CATCH, CHALICE tests

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14
Q

PECARN

A

most important/accurate

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15
Q

CATCH

A

CT based on irritability on exam

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16
Q

CHALICE

A

CT based on high-speed MVA (>40 mh)

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17
Q

Who gets CT?

A 
GCS <15 or acute mental status change
Fx signs
vomiting >3x
seizure
<2 YO
Hematoma- non-frontal scalp
LOC > 5 seconds
MOA - severe
"weird acting" or lethargic

“Guy with friendly voices start 2 make Lauren horny.”

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18
Q

How many who get scanned have TBI?

A

0.9%

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19
Q

Subdural hematoma prognosis

A

poor

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20
Q

What is a subdural hematoma

A

b/w the dura and arachnoid membrane– associated w/ diffuse brain injury

tearing of bridging veins – LOW PRESSURE BLEED, dissects arachnoid away from dura

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21
Q

Sx of subdural hematoma

A

LOC

Lingering sx – irritability, lethargy, BULGING FONTANELLE, vomiting

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22
Q

Dx of subdural hematoma

A

CT - crescent-shaped, usually parietal area

- CROSSES SUTURE LINES (KEY)

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23
Q

Epidural hematoma prognosis

A

better than subdural

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24
Q

What is epidural hematoma

A

rupture of the arteries +/- underlying fracture

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25
Q

Hx of Epidural hematoma

A

brief LOC

lucid period followed by deterioration!

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26
Q

Dx of epidural hematoma

A

eliptical shape – DOES NOT CROSS SUTURES

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27
Q

Subarachnoid Hemorrhage (SAH)

A

injury to the parenchymal and subarachnoid vessels

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28
Q

Sx of SAH

A

normal to LOC

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29
Q

CT findings for SAH

A

small, dense “slivers” on CT – blood in cisterns, sulci and fissures, blood in CSF, may take time to evolve and be visible on CT

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30
Q

Most common bleed

A

SAH

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31
Q

Management of head trauma- No ICH, no skull fracture

A

head injury precautions
Monitor for: behavior change, vomiting, decreased arousability, seizure activity, irritability

SLEEPING IS OKAY – if concerned, wake up every 2-3 hours

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32
Q

Management of head trauma w/ positive ICH +/- skull fracture

A

Neuro consult
Admit (PICU?)
Evacuation of ICH/surgery to repair fracture vs observation w/ repeat imaging

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33
Q

Concussion aka

A

mild traumatic brain injury

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34
Q

What is a concussion

A

traumatically induced alteration in mental status, with or without LOC

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35
Q

Phys behind concussion

A

direct blunt force –> stretching/shearing of axons

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36
Q

Sx of concussion

A

amnesia
Confusion and/or blunted affect, distractibility
delayed response
emotional lability
visual changes
repetitive speech pattern (repeating questions)

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37
Q

Types of amnesai

A

antigrade – new memories

retrograde – pulling up old memories

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38
Q

Hx for concussion

A

MOI
length of LOC
length of confusion/mental status changes
seizure?
movement of extremities at scene
hx of previous concussions or brain injury
Substance use - -ETOH or other

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39
Q

When to CT

A

ALWAYS IF THERE WAS SUBSTANCE USE INVOLVED (regardless of PE findings)

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40
Q

PE for concussion

A

Complete neuro exam: GCS rating, CN II-XII balance, gait, cogn/memory testing
Head: hematoma, deformiting, step off, crepitus, mastoid
Eyes: pupils, acuity, racoon eyes
Ears: earing, hemotypanum
Nose: CSF rhinorrhea? fx?
Neck/throat: cervical spinous process tenderness, neck ROM
Chest: trauma
Extremities: ROM, strength , reflexes

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41
Q

Concussion prognosis

A

h/a, mental fogginess, mild sx - resolve 7-10 days (90% w/i 30)
worsening h/a, vomit, deterioration in mental status = emergent
post concussive syndrome: sx lasting 3 months or longer
Second impact syndrome: 2nd concussion w/i weeks –> brain swelling, herniation, death
Chronic traumatic encephalopathy - multiple concussion, permanent change in mood, behavior, pain

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42
Q

Post concussive syndrome

A

sx last 3 months or longer

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43
Q

Second impact syndrome

A

2nd concussion w/i weeks –> brain swell, herniation and death

children at increased risk

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44
Q

What can multiple concussions lead to

A

chronic traumatic encephalopathy

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45
Q

Tx for concussion

A

NO SAME DAY RETURN TO PLAY

  • must be COMPLETELY sx free to return
  • consider NO SPORTS 1-2 weeks, depending on severity
  • slow advancement of activity after complete sx resolution

Physical and cognitive rest: no cell phone, video games, adequate sleep, NOISE REDUCTION for first 48 hours

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46
Q

return to play protocol stages

A

1-6

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47
Q

Stage 1 return to play

A

sx limited activity (aim)

daily activities that don’t provoke sx (activity)

Goal: gradual reintroduction to work/school

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48
Q

stage 2 return to play

A

light aerobic

walking/stationary cycle; no resistance training

goal: increase HR

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49
Q

stage 3

A

sport specific exercise

running or skating drills; no head impact activities

Goal: add movement

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50
Q

Stage 4

A

non-contact training drills

harder training (passing drills); start progressive resistance training

goal: exercise, coordination and increased thinking

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51
Q

Stage 5

A

full contact practicce

follow med clearance, participate in normal training activities

goal: restore confience and assess skills

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52
Q

Stage 6

A

return to sport

normal game play

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53
Q

Cervical spine injuries

A

VERY RARE IN PEDS

Causes: MVA
< 8 yo: falls (C2-4)
> 8 YO: sports (C5-C7)

adolescent typically have SCIWORA

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54
Q

SCIWORA

A

spinal cord injury w/o radiographic abnormality

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55
Q

test of choice for cervical spine injuries

A

MRI

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56
Q

Concerning sx for cervical spine injury

A

bilateral pain
neuro deficit
torticollis
bony abnormalities

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57
Q

Open fracture management

A

compound - splint/dress, start IV abx, ortho consult

non-displace (overlying laceration) – start PO abx, repair laceration, splint, outpatient ortho f/u

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58
Q

Managment of grossly deformed/displace fracture

A

may compromise neurovascular structures

will require closed/open reduction, possible fixation (ortho consult in ED)

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59
Q

Other fx management

A

splint, pain control, ortho f/u

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60
Q

Always do this w/ fractures

A

document neurovascular status BEFORE and AFTER splinting/reduction/any other intervention

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61
Q

Skin infections

A

cellulitis

erysipelas

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62
Q

Sx of skin infection

A 
erythema
warmth
tenderness
induration
\+/- fever, n/v/d
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63
Q

Cellulitis

A

involves deeper dermis and subcutaneous fat

64
Q

erysipelas

A

involves upper dermis and superficial lymphatics

65
Q

Tx of skin infection

A

warm wet compress
Bactroban- topical
Keflex/Bactrim- oral

66
Q

Skin infection that fails outpatient tx

A

admit
labs
IV abx

67
Q

Osteomyelitis cause

A

hematogenous spread of infection to bone –> bone destruction

68
Q

Epidemiology of osteomyelitis

A

under age 5
M>F
long bones, including femur, tibia, humerus

69
Q

Pathogens of osteomyelitis

A

Staph aureus (most common, poss MRSA)
S. pneumo
S. pyogenes

70
Q

Presentation of osteomyelitis

A 
fever
bone pain
swelling
redness
guarding
focal tenderness during exam
71
Q

Dx of osteomyelitis

A

x-ray: early: soft tissue swelling, 10-14 days later: bone destruction w/ lytic lesions

MRI: BEST STUDY FOR EVAL: marrow edema, abscesses

labs: CBC, CRP, ESR, lactic acid, wound culture, blood culture (before abx)

72
Q

Best study for osteomyelitis

A

MRI

73
Q

Tx for osteomyelitis

A

supportive
IV Abx (empiric, then directed)– vanco, clinda, rocephin
Surgical drainage if needed
debridgement
hyperbaric oxygen therapy: change w/ 100% oxygen

74
Q

Deadly in a dose

A 
ASA
BB
CCB
Codeine
Camphor
Chloroquine
Clonidine
Iron
Lindane
Methyl Salicylate
Methadone
Nicotine
Oils (hydrocarbons)
theophylline
Tricyclic antidepressants
75
Q

Hx for toxic ingestion

A

substance (ingredient, concentration/strength)
route
quantity (count pills left in bottle)
long b/w exposure and eval
progression of sx since exposure
home tx administer (induced vomiting meds)
underlying med conditions

76
Q

Toxidromes

A

sx that occur w/ specific substances: helpful in establishing dx when exposure not well defined

77
Q

Anticholinergic presentation

A

delirium, flushed skin, dilated pupils, urinary retention, decreased BS, memory loss, seizures (hot as a har, dry as a bone, red as a beet, blind as a bat, mad as a hatter)

Tachycardic, hyperthermia, hypertension

78
Q

Anticholiergic agents

A 
antihistamines
scopolamine
jimson weed
angel trumpet
benztropine
TCA's
atropine
79
Q

Cholinergic presentation

A

confusion, weakness, salivation, lacrimation, defecation, emesis, diaphoresis, muscle fasciculations, miosis, seizures

bradycardic, hypothermic, tachypnea

80
Q

Cholinergic agents

A

organophosphates
carbamates
muschrooms

81
Q

Hallucinogenic presentation

A 
disoriented
hallucination
visual illusions
panic reaction
moist skin
hyperactive BS
seizures

tachycardic, tachypnea, hypertension

82
Q

Hallucinogenic agents

A

amphetamines
cannabinoids
cocaine
phencyclidine (PCP)

83
Q

Opiate/narcotic presentation

A

altered mental status
unresponsive
miosis, shock

shallow resp
slow RR
bradycardia, hypothermia, hypotension

84
Q

Opiate agents

A

opiates
propoxyphene
dextromethorphan

85
Q

Sedative/hypnotic presentation

A

coma, stupor, confusion, sedation
progressive deterioration of CNS function

apnea

86
Q

Sedative agents

A

barbiturates
benzos
ehtanol
anticonvulsants

87
Q

Sympathomimetic

A

delusion, paranoia, diaphoresis, piloerection, mydriasis, hyperreflexia, seizures, anxiety

tachycardic, bradycardia (if pure alpha agonist)
hypertension

88
Q

Sympathomimetic

A 
cocaine
amphetamines
meth
phenylpropanolamine
ephedrine
pseudoephedrine
albuterol
ma Huang
89
Q

Tachycardic

A

anticholinergic
hallucinogen
sympathomimetic

90
Q

bradycardia

A

cholinergic

opiate

91
Q

apnea

A

sedative/hypnotic

92
Q

Tx for toxin ingestion

A

(ABC-DDD)

  1. Stabilize pt (ABC)
  2. Contact poison center
  3. DDD (disability, drugs, decontamination)
93
Q

ABC

A

airway
breathing
circulation

94
Q

Ocular decontamination

A

test pH
copious normal saline lavage until pH normal: flush at least 15 min before re-eval

remove contacts
optho consult STAT

95
Q

Skin decontamination

A

copious NS and water

follow w/ soap to concentrated lipid-soluble toxins

96
Q

GI decontamination

A

activated charcoal, cathartics, whole bowel irrigation

97
Q

Blood stream decontamination

A

antidote

98
Q

GI decontaminates

A
  1. Ipecac- helpful w/i 30 minutes, not recommended
  2. Gastric lavage- no longer used
  3. Cathartics - not helpful
  4. Whole bowel irrigation - sustained release med (poop alot)
  5. Activated charcoal – GO TO!
  6. simple dilution- mild toxins
99
Q

Activated charcoal not used with

A 
salicylates
hydrocarbons
lithium
strong acids/base
metals
EtOH
100
Q

Charcoal used wi

A 
carbamazepine
barbiturates
dapsone
quinine
theophylline
digoxin?
phenytoin?
101
Q

Enhancing elimination

A

activated charcoal (bind toxins)
urine alkalization (inc. urination)
diuresis
dialysis/hemoperfusion

102
Q

Antidote for acetaminophen

A

acetylcysteine

103
Q

antidote for anticholinergics

A

physostigmine

104
Q

*benzodiazepine antidote

A

Flumazenil

105
Q

Beta blocker antidote

A

glucagon

106
Q

CCB antidote

A

Calcium

107
Q

Digoxin antidote

A

Digibind

108
Q

heavy metal antidte

A

chelating agents

109
Q

narcotics antidote ***

A

Naloxone

110
Q

Labs for toxin ingestion

A 
salicylate level
acetaminophen level*
UDS (urine drug screen)
digitalis, theophylline, methemoglobin levels
lithium level
PT/INR (warfarin)
CO level
CMP, coags, ABGs - standard

cardiac monitor

administer antidotes

111
Q

FB lodges in what narrow spaces

A

cricopharyngeal narrowing-upper esophageal sphincter
tracheal bifurcation
aortic notch
lower esophageal sphincter (LES)

112
Q

FB concerns

A

sharp/irregular edges

if lodged in esophagus: airway obstruction, stricture, perforation

perforation: result of direct mechanical or chemical erosion

aspirated vegetable matter can cause intense pneumonitis, often difficult to remove

113
Q

Aspirated vegetables cause

A

intense pneumonitis

114
Q

Esophageal FB presentation

A 
refuse to eat
vomiting
choking, cough, stridor
neck/throat pain, inability to swallow
increased salivation
FB sensation in chest
115
Q

PE for esophageal FB

A 
red throat
palatal abrasions
anxiety/distress
wheezing
decreased BS
fever
peritoneal signs
.... OR NONE
116
Q

FB work up

A

patency of airway

radiograph of neck, chest, abdomen ( - XR does not mean - ingestion)

117
Q

Tx for FB

A

esophagus - endoscopy

trachea - bronchoscopy

118
Q

When to consult for FB

A 
sharp/elongated objected
multiple (magnets)
button batteries
perforation evidence
FB > 24 hrs
airway compromise
coin at cricopharyngeus
above cricopharyngeus - ENT
below cricopharyngeus - GI
below esophageal sphincter - leave it
119
Q

Esophageal button battery

A

MEDICAL EMERGENCY

120
Q

Problem w/ esophageal BB

A

extremely rapid action of the alkaline substance on the mucosa, pressure necrosis, residual charge

burns to esophagous in as few as 4 hours, perforation at 6 hrs

121
Q

How soon til BB burns esophages

A

4 hours

122
Q

perforation timing of esophagus from BB

A

6 hours

123
Q

Worse outcome of BB

A

lithium battery

124
Q

Mercuric oxide batteries

A

heavy metal poisonin gb/c they fragment

125
Q

When to obtain blood and urine mercury levels

A

if cell is observed to split in GI tract

126
Q

Tx for BB ingestions

A

emergent removal if lodged in esophagus

if passed esophagus: no need to remove if asymptomatic UNLESS not passed through pylorus after 24-48 hours

GI s/sx = immediate surgical consult

127
Q

BB usually excreted w/i

A

48-72 hours

128
Q

mechanism of drowing

A

respiratory impairment from submersion in liquid– liquid prevents indiv from breathing oxygen

129
Q

Drowning ages

A

Children <4 YO

Young adults 15-24 YO

130
Q

Secondary drowning classifications

A

wet drowning
dry drowning
near-drowning
secondary drowning

131
Q

Problems from impaired ventilation:

A

hypoxemia
acidosis - metabolic and/or respiratory
most drowning victims aspirate <4 mL of liquid

132
Q

CNS impairment

A

from hypoxemia during drowning and subsequent:

  • arrhythmia
  • ongoing pulmonary injury
  • reperfusion injury
  • multi-organ dysfunction (secondary injury)
133
Q

Dry drowning

A

laryngospasm –> hypoxia – LOC

NO FLUID IN LUNGS

134
Q

Wet drowning

A

more common
aspiration of water into lungs

dilution and washout of surfactant –> diminished gas transfer across alveoli –> atelectasis –> ventilation-perfusion mismatch

135
Q

near-drowning

A

survival >24 h post-event (severe brain damage 10-30% of peds nonfatal drowning victims)

136
Q

Sx of near-drowning

A

alert or mildly obtunded at ED presentation (may experience full recovery)

comatose, receiving CPR en route to ED, fixed and dilated pupils and no spontaneous respiration (poor prognosis): 35-60% die, 60-100% survivers have long-term neuro damage

137
Q

Poor prognosis associated with:

A 
subermesion > 5 min 
time to effective BLS >10 in
resuscitation duration >25 min
age >14 YO
GCS <5 (comatose)
persistent apnea and requirement of cardiopulmonary resuscitation in the ED
Arterial blood pH < 7.1 on presentation
138
Q

When to consider child abuse in near-drowning

A

less than 6 mo

toddlers w/ atypical presentation

139
Q

Secondary drowning

A

may cause death up to 72 hours after near drowning incident

140
Q

Mechanism of secondary drowning

A

fresh water drowning results in hemodilution from ingested water –> if large enough volume aspirated –> significant hemolysis and cardiac arrhythmias (electrolyte disturbance)

141
Q

Tx of secondary drowning

A

pre-hsopital care is CRITICAL

ED focus:

  • assist ventilation
  • warmed isotonic VI fluids and warming blankets
  • address any associated injuries; treat electrolyte abnormalities; monitor cardiac rhythm
  • get initial CXR, repeat in 6 hrs
  • admit for observation (maintain ventilation and prevent neuro injury)
142
Q

Fever w/o source is considered

A

rectal temp >38 C (100.4)

143
Q

Goal of fever w/o source

A

identify OCCULT SYSTEMIC BACTERIAL INFECTION: pnemonia, UTI, bacteremia, Herpes virus 6, meningitis

144
Q

Workup for unknown fever

A

“septic workup”

145
Q

septic work up based on

A

age: <3 mo (neonates), 3 mo-3yr: infants and young children
Appearance
Risk factors: birth hx, exposures, vaccination status, immune deficiencies

146
Q

Infants <3 mo w/ fever w/o source

A

DO WORKOUT REGARDLESS OF APPEARANCE

incidence of serious bacterial infection (SBI)

147
Q

Birth hx for fever

A 
premature
STD exposure
PROM
fetal hypoxia
maternal peripartum infections
other fetal loss

(5-10% w/ GBS sepsis also have meningitis)

148
Q

Sx of infection w/ neonatal fever

A 
irritability
decreased activity
poor feeding/lack of weight gain
lethargy
change in sleep patterns
v/d
hypothermia
149
Q

Management of neonatal fever

A 
septic workup:
CBC w diff
UA (cath)
CXR
LP
Blood cultures

early administration of empiric abx
admission pending culture results

150
Q

Management of 3mo-36 mo fever ill-appearing

A 
labs
UA
Cultures: blood, urine, CSF, stool
CXR: if tachypnea or leukocytosis (>20,000)
parenteral abx
admit
151
Q

well appearing, not completely immunized fever

A

CBC w diff
blood culture if WBC >15,000
UA (girls <24 mo, uncircumcised boys <12 mo, circumcised boys <6 mo)
CXR - leukocytosis >20,000

152
Q

who gets UA if well appearing and not immunized

A

girls <24 mo
uncircumcised <12 mo
circumcised <6 mo

153
Q

when to give CXR in well appearing, not immunized

A

leukocytosis >20,000

154
Q

Well appearing, immunized management

A

UA and C&S

Girls >24 mo, uncircum >12, circum >6 = no routine labs, no abx, just UA and CS

155
Q

Fever >39 + abnormal UA

A

treat for UTI

Peds Exam 2 (3 decks)

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