Pediatrics Flashcards
1
Q
Initial approach to ped patient who “appears well”
Alert, engaged, calm
A
- 5 Vital signs
- (S) Focused history
- (O) Focused physical
- (A) Assessment and differential
- (P) Order appropriate labs and radio graphics as needed
2
Q
Initial approach to ped patient who “appears sick”
5 Key Interventions
A
Act first, talk later
- O2 and ventilation if needed
- Pulse Ox
- Cardiorespiratory monitor
- IV access
- CXR / EKG
3
Q
Primary Survey, ABCDE
A
Airway Breathing and ventilation Circulation Disability Exposure / Environmental control
4
Q
Easiest way to assess patent airway
A
Ask patient to talk: “What’s your name?”
- able to answer?
- sound of voice? (gargle, muffle, wheezing, stridor)
5
Q
Conditions that put patients at risk of developing airway compromise
A
Angioedema / allergy
Inhalation injury / burn
Facial trauma
Neck trauma
GSW or stab to neck
6
Q
Unique features of pediatric airway
A
Smaller (more prone to obstruction)
More anterior and cephalad in location
Shorter (right main stem intubation)
Funnel shaped in < 8yrs old (most narrow at sub glottis, just below vocal cords)
7
Q
Simple trick to help upen airway (esp considering large heads of toddlers)
A
Rolled towel under shoulders
plus “jaw thrust” to line up airways
8
Q
Maneuver to ensure sufficient seal in bag mask ventilation
A
“C” and “E”
9
Q
Ensure you see this during bag mask ventilation (so yo know it’s working)
A
Chest rise
10
Q
Excessive ventilation in bag mask may result in
A
Excessive ventilation increases risk of gastric air, regurgitation, and aspiration
May result in barotrauma (pneumothorax)
May increase intrathoracic pressure and impair venous return.
This in turn decreases cardiac output, cerebral blood flow, and coronary perfusion.
11
Q
Three signs to note while assessing work of breathing
A
Retractions
Nasal flaring
Grunting (ominous - resp failure)
12
Q
Two common pathways leading to pediatric cardiac arrest
A
Respiratory failure
Shock
(rarely cardiac origin / sudden)
13
Q
Three potential causes of respiratory failure, pediatrics
A
Intrinsic lung disease
Airway obstructions
Inadequate effort
Distress precedes failure
14
Q
Where do you assess central pulse in infants?
A
Brachial artery
15
Q
Where do you assess central pulse in older children?
A
Femoral artery
16
Q
Signs of poor perfusion
A
Mottled, cool skin
Delayed capillary refill
Tachycardia
17
Q
Pediatric blood pressure and shock: what to be careful of
A
Normal BP is maintained until over 30% of child’s circulating volume is lost
Hypotension is LATE finding in kids!!
18
Q
Formula for pediatric BP normal range
A
Mean systolic BP: 90 mmHg + (2 x age in yrs)
Lower limit: 70 mmHg + (2 x age in yrs)
19
Q
What is BP like in shock?
A
Can be normal, low, or high
20
Q
Fluid resuscitation in pediatrics
A
Isotonic fluids
20 ml/kg boluses until signs of improved perfusion, resolution of tachycardia
If shock due to hemorrhage, after 2 boluses give PRBC 10 ml/kg
21
Q
How to assess disability? (in ABCDE)
A
Quick neuro exam
Engaged?
Pupils?
Moving all 4 extremities?
Symmetric strength and sensation?
22
Q
AMPLE history
A
Allergies
Medications
PMH
Last meal
Events surrounding visit
23
Q
Review: overall assessment in ED
A
How does the patient look?
If sick → oxygen, pulse ox, monitor, IV access, CXR & EKG
ABCDs intact?
If not, address airway, breathing, circulation, and disability in that order
5 vital signs
AMPLE history
Secondary survey
24
Q
Review: overall assessment in ED
A
How does the patient look?
If sick → oxygen, pulse ox, monitor, IV access, CXR & EKG
ABCDs intact?
If not, address airway, breathing, circulation, and disability in that order
5 vital signs
AMPLE history
Secondary survey
25
Most common cause of death and disability in children
Injury
>10 million children require care in ED for injuries each year
>10,000 children die from serious injuries each year in the US
Injury mortality surpasses deaths from all other childhood illnesses combined
**MVC most common cause of death in children**
26
Multisystem injury in pediatric trauma
Rule, rather than exception
Smaller body mass
Less fat and connective tissue
Closer proximity of internal organs
27
Head injuries in peds: anatomical differences
**Leading cause of death in pediatric trauma**
Large head relative to body > more torque
Less myelin > more shearing forces, greater neuronal injury
Soft cranium > may have intracranial injury without skull fracture
28
Types of head injuries in children
Contusions
Diffuse axonal injury
Subdural hemorrhage
Epidural hemorrhage
Subarachnoid hemorrhage
Intraparenchymal hemorrhage
29
Management of head injuries in children
Maximize Oxygen
Maintain BP
30
Signs of increased ICP, and what to do
(Pupillary / macular signs)
Elevate head of bed 30 degrees
Hypertonic saline (3%) 5ml/kg
Mannitol 0.5-1 mg/kg
31
Special considerations about chest injuries in children
Chest injuries serve as marker for other injuries
2/3 of children with chest injury will have other injuries as well
Significant thoracic trauma possible without rib fractures (ribs are very pliable in kids)
Mediastinum very mobile
Increased risk of pneumothorax
32
Two most vulnerable organs in abdominal injuries
Liver, spleen - lower, below rib cage, in children
33
If you see a "seatbelt sign" on a child from a MVC, what next step is warranted?
CT of abdomen
seatbelt sign = linear bruising in distribution of seatbelt)
34
Normal pediatric blood volume
70 ml/kg
Tremendous ability to compensate for blood loss by vasoconstriction
HYPOTENSION IS A LATE FINDING
Treat shock early to avoid sudden deterioration
35
Due to children having less fat and connective tissue, they are at higher risk of
Hypothermia
36
Hypothermia puts children at higher risk of
Coagulopathy and Acidosis
37
Reassuring signs and symptoms in children presenting with abdominal pain
Frequent watery diarrhea
Normal appetite (eating in the exam room)
Fever onset before pain
(*fever is late finding in appendicitis, once it's ruptured*)
The “JUMP TEST”
38
What area should always be checked for male ped presenting w abdominal pain
Groin area - testicles, hernia
39
What should always be tested in adolescent females w abdominal pain
Urine HCG and pelvic exam (**12 yrs old and up)
40
Beware of vomiting without diarrhea
May not be stomach virus - could be bowel obstruction, pregnancy, head injury
41
Two common conditions with referred abdominal pain in pediatrics
Lower lobe pneumonia
Strep pharyngitis (GAS)
42
Warning signs of abdominal emergencies in pediatrics
Bilious vomiting - obstruction
Vomiting WITH abdominal distention - bowel twist / obstruction
Pain BEFORE vomiting - appendicitis
Blood in stool of ill appearing infant - intussusception
Focal abdominal pain (esp + guarding) - appendicitis
Involuntary guarding
43
Blood in stool of ill appearing infant
Intussusception
44
Pain BEFORE vomitting might indicate ___ as opposed to ___
Appendicitis, viral
45
Neonates abdominal emergency DDX
Slide 6, peds abominal
Malrotation w/ volvulus
NEC
Intestinal atresias/stenosis
Hirschsprung disease
46
1-2 month abdominal emergency DDX
Pyloric Stenosis
47
6-10 month abdominal emergency DDX
Intussusception
48
Pre school / school age abdominal emergency DDX
```
Appendicitis
Intussusception
Testicular/ovarian torsion
Incarcerated hernia*
NAT with blunt abdominal trauma*
```
49
Adolescent female abdominal emergency DDX
```
Ectopic pregnancy
Ovarian cyst/torsion
Appendicitis
STD/PID
Tuboovarian abscess
```
50
Bilious emesis in a neonate is what kind of surgical emergency until proven otherwise
Intestinal malrotation with midgut volvulus
51
Risk of midgut volvulus is highest at what age
First month - 50-70%
90% in first year
52
Why is midgut volvulus a surgical emergency
Bowel necrosis can occur within hours
53
Study of choice for midgut volvulus
Upper GI series with contrast (CT?)
Findings:
Trace contrast passes in corkscrew configuration
Abnormal position of duodenum
54
Malrotation / midgut volvulus management review
```
IV fluid resuscitation
NG tube to intermittent suction
Call your surgeon
Upper GI series
Laparotomy
```
55
Ultrasund / CT findings for intussusception
"Target sign" or "Crescent sign" of bowel within bowel
Bull's eye" or "Coiled spring" on ultrasound
56
Most common abdominal emergency in early childhood
Intussusception
57
Why is it common for children to have a viral infection before intussusception?
Virus causes inflamed lymphatic tissue in gut - Hypertrophy of Peyer patches in terminal ileum can serve as lead point
58
Most common area of intestine for intussusception
Ileo-colic
59
"Classic" presentation of intussusception
sudden onset of intermittent, severe, crampy abdominal pain
Toddlers and infants may “draw up legs” toward abdomen
Episodes occur ~20 min intervals
Classic triad of pain, palpable sausage shaped mass, currant jelly stools occurs < 15% of the time
60
Management of Intussusception
ABCs
Resuscitate with IVF
If frequent vomiting, decompress stomach with NGT
Consider IV antibiotics if concern for perforation
Notify surgery early
Abdominal xrays (including left lateral decub) to exclude perforation w/ free air prior to air enema reduction (and exclude constipation)
Air enema reduction
61
Preferred treatment for intussusception
Nonoperative reduction
Air enema or water-soluble contrast enema
Study of choice in typical presentation
Diagnostic and therapeutic
Success rate 75-90% in ileo-colic intussusception
Perforation risk is small, less than 1%
62
Contraindicatons for nonoperative reduction for intussusception
Prolonged symptoms (> 3 days)
Signs of peritonitis
Evidence of free air on plain x-ray
63
Indications for surgical treatment of intussusception
when nonoperative reduction fails or is incomplete
64
Ovarian torsion
Presentation is non-specific
Difficult to differentiate from other causes of abdominal pain in children
Classic presentation in children:
Sudden onset of unilateral lower abdominal pain
Right side > left side (3:2)
Nausea and vomiting (70-80%)
65
Management of ovarian torsion
Pain control
IVF
US with doppler - STAT!
Emergent operative intervention
Prolonged symptoms does not preclude possible ovarian salvage
May have intermittent torsion
66
Managing pediatric seizure
Assess ABCs
Place patient on his/her side
O2, O2 sat, monitor, IV access, bedside glucose
Intervene medically if needed for seizure > 3 min
67
Best medications for seizures
Intervene medically if needed for seizure > 3 min
Lorazepam (0.05-0.1 mg/kg) IV or IM
Diazepam (0.3-0.5 mg/kg) IV or PR
Midazolam (0.2 mg/kg) IV/IM or intranasal
68
Pre-seizure history questions
```
Well prior to event
History of prior seizures
History of fever, recent infections
Recent antibiotics
Recent trauma
Adult Rx medications, toxic ingestions
```
69
Seizure history questions
Eye deviation, blank stare, drooling, cyanosis, incontinence
Generalized vs focal
Duration
Responsive or unresponsive
70
Post Seizure history questions
Single or multiple
Mental status after event
EMS observations at time of arrival
71
Physical Exam for seizure
Vital signs (rectal temp)
General appearance and mental status
Focused exam:
- Focal neurologic deficits
- Signs of increased ICP (bulging fontanelle, papilledema)
- Skin lesions (Ashleaf spots, shagreen patch, café au lait)
- Nuchal rigidity
- Poor perfusion
- Altered motor tone
- Prolonged post-ictal lethargy
- Generalized petechiae
72
Categories of febrile seizures
Simple and complex
73
Qualifications for a Simple Febrile Seizure
Last less than 15 minutes
Generalized
No focal features
Does not recur within 24 hrs
74
Qualifications for a Complex Febrile Seizure
Last more than 15 minutes
Focal features or postical paresis (Todd’s paralysis)
Recurrence within 24 hrs
75
Evaluation and Management of Febrile Seizure, Peds
Stabilize the patient
Focused history & physical
Categorize the seizure (simple vs complex)
Determine probability of intracranial infection and acute bacterial meningitis
Determine need for diagnostic studies
Establish disposition
76
First time simple febrile seizure - labs / imagining?
Not needed - no benefit
Only workup should be for underlying cause of fever (UA, chest X-ray, etc)
77
Questions to ask in assessing risk of CNS infection
Vaccination status?
Antibiotics taken recently?
- can mask signs of meningitis
78
Concerning exam findings in pediatric (febrile) seizures
```
Focal neurological deficits
Altered motor tone
Nuchal rigidity
Poor perfusion
Generalized petechiae
```
79
Status epilepticus + fever indicates >>
Bacterial meningitis
**LP indicated**
80
Clear discharge instructions for parents (peds w seizures)
```
Safe place
Place child on his/her side
Nothing in mouth
Chin lift/jaw thrust
When to call EMS
```
81
Indications for admission in febrile seizures
```
Prolonged postictal phase
Complex febrile seizure
Age < 6 months
Social concerns
Inability of caretakers to provide appropriate observation
Prolonged distance to medical care
```
82
Absent staring with/without eyelid flutter
Absence Epilepsy
ethosuximide, valproic acid, lamotrigine, levetiracetam
83
Myoclonic Jerks (> in AM)
Onset adolescence
Precipitated by stressors
May have tonic-clonic and absence seizures as well
Juvenile Myoclonic Epilepsy
valproic acid, topiramate, levetiracetam
84
Somatosensory changes (numbness/tingling), speech arrest, facial twitching, drooling, may have tonic clonic seizures at night, often during sleep
Benign Epilepsy of Childhood with Centrotemporal Spikes (BECTS/Rolandic)
**may not need treatment - may outgrow**
85
Sudden flexion, extension or mixed movements of trunk and proximal muscles
Treated differently and with more urgency
Infantile Spasms **
ACTH, steroids, zonisamide, topiramate, vitamin B-6
86
Onset at 3-5 years
Mixed seizure types
Most children have severe developmental delay
Lennox Gastaut
87
Evaluation of Infantile Spasms
Need urgent EEG, MRI, and metabolic evaluation with neurology consultation
Mortality as high as 15-20%
Only 5-10% or children with infantile spasms have normal intelligence
88
Treatment for Infantile Spasms
ACTH, steroids, zonisamide, topiramate, vitamin B-6
89
Lab Evaluation of Seizures Without Epilepsy
```
Electrolytes, glucose, Ca, Mg, Phos
Ammonia, Lactic Acid
Metabolic syndrome suspected
Drug Screen
Possible toxin exposure
```
LP plus Antibiotics
Only if meningeal signs or sustained AMS
90
Preferred neuroimaging study for seizure
MRI (usually)
EEG
91
Indication for EEG
All first time, non febrile seizures
92
When to admit for non febrile seizures
```
Age (< 6 months)
Etiology of seizure
Seizure control
Social concerns
Inability of caretakers to provide appropriate observation
Prolonged distance to medical care
```
93
Categories of DKA
Mild pH < 7.30, bicarbonate < 15 mmol/L
Mod pH < 7.20, bicarbonate < 10 mmol/L
Severe pH < 7.10, bicarbonate < 5 mmol/L
94
Symptoms of Hyperglycemia
```
Polyuria: increased volume and freq of urination
Polydipsia: increased thirst
New urinary incontinence
Weight loss
Muscle cramps
```
95
Symptoms of Acidosis
```
Abdominal pain
Vomiting
Shortness of breath
Headache
Confusion
Altered mental status
```
96
PE findings in DKA
Kussmaul respirations
Dehydration (sunken eyes, dry mucous membranes)
Tachycardia
Delayed capillary refill
Abdominal tenderness (nonfocal or epigastric)
97
Why do kids with DKA have electrolyte imbalances?
Ketoacids bind Na+ and K+ and they are excreted in the urine
Hyponatremia and hypokalemia result
98
DKA Precipitants (I's)
Remember the “I”s
Insulin lack
Indiscretion (dietary)
Infection
Impregnation or other stressors
99
Treatment of DKA
Correct dehydration - IV Fluids
Correct acidosis and reverse ketosis - Insulin, DRIP! not bolus
Restore normoglycemia
Correct electrolyte imbalances - Na, K
Avoid complications of treatment -
*Cerebral Edema from rapid fluid resuscitation*
Identify and treat precipitating event - infection, etc
100
ED Management of DKA
```
ABCs, cardiac monitor, vital signs, accucheck
IV access (2 is best, one for fluids, one for insulin drip)
```
BMP, VBG, UA, +/- CBC
Consider EKG
Accucheck every 1 hr
VBG every 1-2 hr
BMP every 4 hr
Neurologic checks every hr
Consultation with endocrinology & critical care
101
Step 1 DKA treatment
IV hydration
Initial bolus: NS bolus or LR (Lactate Ringer) bolus 20 ml/kg over 1 hour
Next: LR at 2x MIVF rate
102
Step 2 DKA treatment
(After initial IVF bolus)
Insulin infusion 0.05-0.1 U/kg/hr regular insulin
**No insulin bolus in children!!! (may increase risk of cerebral edema)**
Ideally don’t want glucose to fall more than 100 mg/dl per hour
Switch to D5NS when glucose is < 300 mg/dL
103
Step 3 DKA treatment
Next 4-6 hours
NS with 40 mEq/L K+ (20mEq/L KCl and 20 mEq/L KPhos)
Rate is 2x maintenance rate
After 4-6 hrs: Switch to 0.45% saline with electrolytes
104
K+ and DKA
Total body K+ is depleted in DKA
It is excreted in the urine when it binds to the ketoacids
Also once you start giving insulin and correct the
acidosis, this drives the K+ into the cells lowering your K+ levels further
105
Bicarb and DKA?
Multiple downsides
- Paradoxical CNS acidosis
- Rapid correction can worsen hypokalemia
- May increase hepatic ketone production
Selected benefit: Only if arterial pH < 6.9 or if there is hypotension, shock, arrythmia, severe hyperkalemia
**Must give cautiously NaHCO3 at 1-2 mEq/kg over 60 minutes**
106
Most serious complication / cause of mortality in children w DKA
Cerebral Edema - 60-90% of all DKA deaths
107
Signs/Symptoms of cerebral edema
Headache
Gradual decrease in LOC
Slowing of HR inappropriately with increase in BP
Change in pupils
*Onset 4-12 hours after treatment initiated, but may be present before tx begins*
108
Cerebral Edema treatment
Reduce rate of IVF infusion
Mannitol 0.5-1 g/kg over 20 min
3% saline 5-10 ml/kg over 30 min
Consider intubation if cannot protect airway
109
Other complications of DKA
```
Hyponatremia
Hypokalemia
Acute renal failure (pre-renal, low perfusion)
Rhabdomyolysis
Rarely ARDS and pulmonary edema
```
110
Cushing's triad
irregular respirations, decreased heart rate with increased BP
