Peds Emergencies Flashcards
what are the elements of the glasgow coma scale?
Eye opening (out of 4)
Best verbal response (out of 5)
Best Motor Response (out of 6)
–> score of three is a brick, 15 is best
ratings for Eye opening component of glasgow coma
spontaneous = 4
to speech = 3
to pain = 2
no response = 1
ratings for Best verbal response in GCS?
oriented - infant babbles/coos = 5 confused - infant cries irritable = 4 inappropriate - infant cries to pain = 3 incomprehensible - moans to pain = 2 no response = 1
ratings for best motor response in GCS?
obeys (moves purposefully) = 6
localizes (withdraws to touch) = 5
withdraws to pain = 4
abnormal flexion (decorticate posturing) = 3
abnormal extension (decerebrate posturing) = 2
no response = 1
bones involved in the basal skull and why to be concerned if head injury occurs here
Bones: sphenoid, temporal, occipital, ethmoid
concern: lots of vessels here, worry about foramen magnum
what should primary PE of head injury consist of
1) ABC (airway, breathing, circulation)
2) neuro status - glasgow coma
3) vital signs - cushings triad (wide pulse pressure, bradycardia, abnormal respirations)
Secondary PE of head injury should be..
check head/neck:
- CS alignment
- eye exam for papilledema indicating hydrocephaly
- hematomas (stepoffs, crepitus, fontanels)
- basilar skull fracture (battle sign, ecchymosis, hemotympanum, ear/nose CSF d/c)
check rest of body
How to dx head injury?
bedside US emerging, radiography min value, CT is best but high radiation (decide with PECARN, CHALICE, CHART)
young child fell on his head and experienced LOC followed by irritability, lethargy, bulging fontanelle and vomiting. Upon seeing him in the ED you immediately you order a CT exam. Results indicates diffuse blood spread in crescent shape. Dx? and what is the etiology? concern?
dx: subdural hematoma
etiology: tearing of VEINS resulting in low pressure bleed that separates arachnoid from dura.
concern: Bad bc crosses suture lines so blood can spread, swell –> death, coma, LT effects if not treated. Poor prognosis
Football player comes in with head injury. He had been tackled, briefly lost consciousness but seemed alright after a bit. What might the CT reveal? dx?
CT: elliptical shaped blood due to rupture of ARTERIES, skull fractures
dx: epidural hematoma
* does not cross suture lines but admit for obs bc deterioration with time
Pt has “worst headache ever” following head injury. Small dense slivers are noted on a CT exam. what are these slivers and what is your dx?
slivers are blood in sulci, fissures, blood in CSF due to injury to parenchymal and subarachnoid vessels
dx: subarachnoid hemorrhage
* may take time to evolve and be visible on CT
what is a concussion
trauma induced alt in mental status w/ or w/o LOC
*the direct force causes shearing of axons
what do you want to make sure to find out from witness of concussion?
mech of injury, LOC length, confusion/mental status, seizure or mvmt, concussion hx, substance use (ALWAYS CT if used substance)
PE for concussion:
complete neuro exam including GCS, CN II-XII
check every inch, focal neural findings take precedence so put in C collar then if no acute findings to treat, clear ALWAYS clear CS
Concussion sx. Continuing issues?
HA, fogginess should improve 7-10 days
- Post concussive syndrome if sx 3mth or more
- Second impact syndrome = 2nd concussion w/in weeks can lead to brain swelling, herniation (children at risk)
Tx concussion?
no same day return regardless, must be symptom free and eval by neurologist
rest brain and body (no cell phones, video games etc) and slow return to play
why are sprains (torn ligaments) less common in children as opposed to ends of long bones?
cartilaginous growth plate - physis!
Salter Harris Type I
epiphyseal separation through physis often appears normal
Salter Harris Type II
fracture through portion of physis but exiting across metaphysis (goes up) (most common growth plate fx expecially in older children)
salter harris Type III
fracture through physis exiting down into joint
salter harris type IV
fracture through metaphysis, physis, and epiphysis
IV = ALL!!!
Salter harris type V
crush injury to physis
V = COMPRESS/CRUSH
2 yr old pt is irritable and refuses to walk. Her radiograph reveals non-displaced spiral fx of tibia. Dx and what to be on the watch for
dx: toddler’s fracture (9mth to 3 yr)
suspicious of child abuse/non accidental injury
tx of open compound fx
splint/dress, IV antibio, ortho consul
tx open nondisplaced fx
PO antibiotic, repair laceration, splint, ortho FU
deformed/displaced fx tx?
make sure to check neurovascular structures, will require closed/open reduction, possible fixation (ortho ED consult)
standard tx for all fx?
always document neurovascular status before and after splinting or reduction to any fx (cap refill, nerve sensation)
splint, pain control, ortho f/u
common fx to suspect child abuse
spiral fracture of long bone, femur fracture, spinous processes, acromion, skull fracture greater than 3 mm, posterior rib fracture, corner fracture or bucket handle from jerking/shaking (metaphyseal fracture)
child comes in guarding arm, holding it in slightly flexed prone position and will not use the arm even to grab candy. Normal radiographs. dx and tx?
dx: nursemaids elbow
tx: reduction by immobilizing elbow, applying pressure to radial head, supinating forearn and flexing elbow - should feel pop
* do not reduce without xray clearance
Acute septic arthritis presentation, cause, labs
presentation: fever, constant worsening joint pain, arm swollen joint pain with ROM *hip typically flexion/external rotation
cause: adolescent = N gonorrhea, kids = s aureus or strep
Lab: CBC< CRP, ESR, blood culture, joint aspiration
tx for acute septic arthritis
if not treated, this may lead to?
- antibiotics (empiric then targeted)
- repeated aspiration if peripheral joints or surgical drainage for hips/shoulders (ususal**)
untreated –> osteomyelities
Kid comes in with fever, bone pain, swelling, and is guarding limb that began over a week ago. Pain in leg upon palpation. Xray (2 wks after initial onset) reveals bone destruction. MRI (the best study in this scenario) reveals marrow edema, abscesses. Dx, etiology, tx?
Osteomyelitis
etiology: hematogenous spread of infection into BONE cause bone destruction in long bone
tx: IV antibiotic (empiric then targeted), surgical drainage, debridement, hyperbaric O2 (to help with tissue healing)
this disease commonly affecting 18mth to 2 yrs has unknown etiology, but commonly follows URI, strep or trauma. Sx include abrupt onset pain to hip/thigh or knee, temp but FROM. WBC and ESR is normal and Xray shows some effusion. Dx, tx?
dx: transient synovitis
tx: pain relief, obs, f/u
*dx of exclusion, comes on quickly
6 year old BOY is limping and holds hip internally rotated with limited abduction but has little to no pain. How to dx and likely dx? etiology, tx?
Legg Calve Perthes disease
dx: xray (AP and frog leg lat), bone scan, ortho referral URGENT
etiology: idiopathic avascular necrosis of femoral head (no blood supply, bone dies), slow onset
**think frog LEGG calve
this disease has similar presentation as Legg Calve Perthes but affects males 14-16 more freq. Associated with obesity, increased ht, genital underdev, pituitary tumors. Sx are acute or chronic hip/knee pain and xrays reveal ice cream falling off cone.
dx: SCFE (slipped capital femoral epiphysis)
- -> femoral head slips and exposes anterior/superior aspects of femoral neck
tx: bed rest with traction but most require surgery
toxidromes are helpful in categorizing reactions. Name the main ones
Anticholingeric (hot as haire, dry as a bone, red as a beet, blind as a bat; tachycardia) - benadryl is pink and could look like candy
cholinergic (bradycardia), hallucinogenic,
opiate/narcotic, sedative/hypnotic, sympathomimetic
poison control phone number
1-800-222-1222
what is the most important thing to know! deadly in a dose (1-2 tab can kill)
the substance!
ASA, Ca chan blockers, oils, clonidine, iron (vit, birth control), chloroquine, methadone, nicotine, TCA, lindane, methyl salicylate
tx
stabilize ABC, contact poison control, DDD (disability/supportive car, drugs/antidotes, decontaminate)
Decontamination - ocular, skin, GI, blood stream
ocular (IRRIGATE saline lavage, flush till pH normal via litmus paper, alkali is worse than acidic);
skin (normal saline flush),
blood stream (antidote)
GI (lavage, charcoal, cathartics, whole bowel irrigation, enhance elim - diuretics, dialysis, hemoperfusion, urine, charcoal)
GI decontamination methods
Ipecac only if within 30 min, gen not rec
Gastric lavage - rarely; use for TCA CCB, iron, EtOH
cathartics - not usually
whole bowel irrigation - sustained release med
charcoal - deox
simple dilution for mild toxin
antidote for: acetaminophen
acetylcysteine
antidote for: anticholinergic
physostigmine
antidote for: benzodiazepine
flumazenil
antidote for: beta blocker
glucagon
antidote for: ca channel blocker
calcium
antidote for: digoxin
digibind
antidote for: heavy metals
chelation
antidote for narcotics/opiates
naloxene/narcan
if you don’t know what poison was ingested..
draw lab for acetaminophen bc worse
C metabolic panel (electrolyte level, kidney function, liver), coags (liver function), ABG, protein
administer antidotes empirically as indicated by exam; you will do less harm by administering antidotes then letting the kid just be
places where foreign body often lodges; when is it clear to go
circopharyngeal narrowing, tracheal bifurcation, aortic notch, LES
*clear once passes pylorus
when to consult for foreign body aspiration
sharp/elongated objects, multiple foreign bodies, button batteries, evidence of perforation, coin at cricopharyngeus muscle level, if present more than 24 hr
button battery in esophagus.. what is the worry?
alkaline battery on mucosa, pressure necrosis, residual charge; burns can occur in as little as 4 hours, perforation in 6, lithium is worst, mercuric oxide worry about fragmenting - measure blood and urine levels or contact national button battery ingestion hotline
tx button battery
emergent removal if in esophagus, if passed esophagus, no need to remove if asymp UNLESS doesn’t move through pylorus after 24-48 hr
if any GI sx, immediate surgical consult
near drowning outcomes
survival > 24 post event, but severe brain damage in 10-30% victims
if come to ED comatose, needing CPR, fixed and dilated pupils, no resp = poor prog (30-60% die, 60-100% neuro complication)
when to worry about child abuse and drowning
if less than 6 mth or in toddlers with atypical presentation
*fences could prevent most drowning events
dry drowning
laryngospasm –> hypoxia –> LOC
*no fluid in lungs
wet drowning
more common, aspiration of water into lungs
dilution and washout of surfactant –> diminished gas transfer across alveoli –> atelectasis –> ventilation perfusion mismatch
- fresh vs salt water
secondary drowning - what is it and why is it dangerous
may cause death up to 72 hours after near drowning bc…
freshwater ingested during near drowning dilutes blood –> hemolysis and cardiac arrythmias if enough water ingested
tx drowning
pres hospital care is critical
in ED: ventilation, warmed isotonic IV fluids, address injuries, CXR and repeat at 6 hr, obs by neuro
Fever without a source
Rectal temp >38 deg c
goal is to identify occult infections: pneumonia, UTI, bacteremia/sepsis, herpes-virus, meningitis
how to manage fevers?
decide how to manage based on age and risk factors, appearance
<2 mth is neonate, 2 mth-3 yr is infant/young children
risk: birth hx, travel, exposures, vaccination, immune def
2 mth to 3 yr: non toxic management
UA cath, rapid viral testing (flu, RSV), stool for WBC and guaiac if diarrhea
*if all these things are negative and they appear okay, are fully immunized, etc you can send them home –> f/u 24 hr with PCP
2 mth to 3 year: toxic management (judge based on appearance)
CBC with diff, CXR, UA cath, CSF analysis via lumbar puncture, stool for WBC and guaiac, rapid virus testing
*admit for obs and begin empiric antibiotics while waiting for culture results
toxic management for infants less than 2 mth temp > 38 deg C
workup regardless of appearance; get pretinent birth hx (premature, STD exposure, PROM, fetal hypoxia, in NICU at all?)
neonatal fever: sx of infection, management
irritability * be careful with this documentation
management: full septic workup, early administration of empiric antibiotics (cefotaxime, ampicillin) till culture results
febrile seizures age range and types
6mth to 5 yr
simple febrile: less than 15 min, isolated
complex febrile: > 15 min multiple in rapid succession
usually benign unless prolonged aspiration, compromised ventilation/perfusion
