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Paediatric Emergency Medicine > PEM - CVS, environmental, surgical, neonatal, trauma > Flashcards

PEM - CVS, environmental, surgical, neonatal, trauma Flashcards

CVS, environmental, genitalia, neonatal, trauma

1
Q

Major trauma activation criteria

A

Mechanism:
- Motorcyclist, cyclist or pedestrian impact > 30 km/hr
MVA > 60 km/hr
- Ejection, roll over, fatality in same vehicle or extraction > 30 min
- Fall > 3 m or twice childs height
- Explosion and suspected inhalation burns

Injury

  • Serious or suspected serious injuries to head, neck or torso
  • Injury to 2 or more body areas
  • Burns > 20 %
  • Two or more long bone fractures
  • Evisceration, severe crush injury, amputation, suspected spinal injury or pelvic fracture

Signs

  • RR < 10 or > 30
  • SBP < 75 mmHg
  • GCS 15
  • O2 sat < 90%
Interventions 
- Intubation, airway manoeuvres, assisted ventilation, chest decompression 
Failure to control bleeding 
Interhospital transfer 
Significant comorbidity
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2
Q

Circulating blood volume of

  • neonate
  • infant
  • child
  • adult
A
  • neonate 85-90 mls/kg
  • infant 75-85 mls/kg
  • child 70-75 mls/kg
  • adult 65-70 mls/kg
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3
Q

Indications for CTB in paediatric head injury

A

Definite (RCH)

  • Signs of base of skull fracture
  • Focal neurological deficit
  • Suspected open or depressed skull fracture
  • Any GCS < 8 or GCS persistently < 13
  • Suspected NAI
  • Seizures > 2 min post impact

Consider - persistent headache, irritability, confusion or drowsiness

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4
Q

Central cord syndrome: causes and deficits

A

Hyperextension injury.
Motor deficit arms > legs, distal > proximal
Variable sensory change

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5
Q

Indications for CT abdomen in paediatric trauma

A
  • Abdominal tenderness / peritonism
  • Reduced conscious state and high risk of injury
  • External evidence of abdominal injury (bruising, handlebar injury, haematoma)
  • Positive FAST, falling HCT or elevated LFT
  • Macroscopic haematuria
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6
Q

Describe fluid therapy in burns

A 
Indication > 20% BSA 
- Resus: Parkland formula: BSA burnt x weight (kg) x 4 = mls of resus fluid to be given over 24 hrs, half in first 8 hrs (from time of injury) 
- Maintenance fluid 
- Subtract any resus boluses. 
Aim, urine output 0.5-1 ml/kg/hr
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7
Q

Indications for paediatric burns unit admission

A

Required

  • Partial thickness burns > 20%
  • Full thickness burns > 5-10%
  • Smoke inhalation or airway burn suspected
  • Child abuse suspected

Consider

  • Burns to hands, feet, face, perineum or joints
  • Other concern: age < 12 months, parental coping
  • Comorbidity
  • Other significant injuries
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8
Q

Indications for tetanus toxoid or immunoglobulin

A

Toxoid:
- < 3 doses, uncertain, > 10 yrs since vaccination, or 5-10 years with large / contaminated wound
- At risk: 9-11/13 yrs and > 16-18 yrs
Immunoglobulin: < 3 doses or uncertain with large/dirty wound. HIV positive. 250 IU if < 24 hrs, 500 IU if > 24 hrs.

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9
Q

Characteristics of a benign paediatric murmur

A

Asymptomatic (no chest pain, breathlessness, cyanosis)
Systolic, short
Soft
Well localised.

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10
Q

Serious differentials for paediatric chest pain

A 
Pneumothorax, PE
Arrhythmia, Cardiomyopathy 
Myocarditis 
Coronary arteritis (kawasaki) 
Ingested FB (button battery)
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11
Q

Cyanotic heart disease - 5 causes

A 
Transposition of great arteries 
Tetralogy of fallot 
Total anomalous pulmonary venous return 
Truncus arteriosus 
Tricuspid atresia 
(pulmonary atresia, hypoplastic LV)
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12
Q

Findings in Tetralogy of Fallot

A

VSD
Overriding aorta
Pulmonary stenosis (subpulmonary)
RVH

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13
Q

Causes, timing and treatment of duct dependent cardiac lesion

A 
Causes 
- pulmonary atresia / stenosis 
- Transposition of great arteries 
- coarctation of aorta, interrupted aortic arch 
- critical aortic stenosis 
- hypoplastic left heart 
1-3 weeks of age

Management

  • Prostaglandin E1 infusion, 5-60 ng/kg/min.
  • End organ perfusion: IV fluid bolus, adrenaline, optimise Hb
  • PEEP (offload LV)
  • Reduce O2 demand: support breathing, reduce fever
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14
Q

Management of tetralogy spells

A

Aim: increase PVR and decrease Pulmonary Blood flow.
- knees to chest
- O2
- Morphine / fentanyl / ketamine (abort crying, reduce tachypnoea).
- inrcrease preload 5-10 mls/kg IV saline
Then PICU/cardio: propranolol/esmolol, metaraminol.

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15
Q

Causes of acyanotic cardiac disease

A

Increased pulmonary blood flow: VSD, ASD, PDA, AV canal

Ventricular outflow obstruction: coartation of aorta, aortic stenosis, pulmonary stenosis

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16
Q

Causes, timing and treatment of congestive heart failure

A

VSD, PDA, congenital arrhythmia or valve disease
4-12 weeks of age.
Post viral cardiomyopathy 3-6 months.

Management

  • oxygen
  • diuresis
  • support ventialtion
  • inotropes (adrenaline if hypotensive)
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17
Q

Acute rheumatic fever diagnostic criteria

A

Modified Jones criteria

  • 2 major criteria
  • 1 major and 2 minor criteria
  • Preceding GAS infection (positive throat swab, elevated/rising ASOT)

Major manifestations

  • Heart: Carditis
  • Joint: polyarthritis, aseptic monoarthritis, arthralgia (very high risk only)
  • Brain: Chorea
  • Skin: erythema marginatum, subcutaneous nodules

Minor manifestations

  • Fever
  • ESR > 30 (Aus) or CRP > 30
  • Heart: Prolonged PR
  • Joints: monoarthralgia (high risk) or polyarthralgia (NZ, lower risk)
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18
Q

Diagnostic criteria for infective endocarditis

A

Modified Duke criteria

  • definite: 2 major criteria, 1 major and 3 minor, 5 minor criteria
  • Possible: 1 major and 1 minor, or 3 minor
  • Rejected: clear alternative diagnosis, or resolution with antibiotic therapy for 4 days

Major

  • typical microorganism (strep viridans/bovis, HÁČEK, staph aureus) in 2 cultures or one of coxiella
  • positive cultures > 12 hours apart of typical organisms, or for skin contaminant organisms 3 cultures
  • Evidence of endocardial involvement
  • Echo confirming IE (intracardiac mass, periannular abscess, partial dehiscence of valve)
  • New valvular regurgitation on echo

Minor

  • Predisposing factor, history of IVDU or Congenital heart disease
  • Fever > 38
  • Vascular phenomenon - arterial emboli, pulmonary infarcts, mycotic aneurysm, intracranial haemorrhage conjunctival haemorrhage, Janeways lesions
  • Immunological phenomenon - GN, oslers nodes, Roth spots, RF positive
  • Positive blood cultures / serology not meeting major criteria.
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19
Q

Antibiotic management of infective endocarditis

A

Community acquired:
Benzylpenicillin Q4H
Flucloxacillin 50mg/kg to 2g Q4H
Gentamicin 4-6 mg/kg stat

Hospital acquired / prosthetic valve / MRSA:
Vancomycin 1.5g IV BD
Gentamicin 4-6 mg/kg IV

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20
Q

Diagnosis of Kawasaki Disease

A

Fever of 5 days, without other cause, plus
4 of:
- bilateral bulbar conjunctival injection
- Enanthem: dry/cracked/injected lips, oropharyngeal injection, strawberry tongue
- Rash: polymorphous
- Peripheral changes: erythema or oedema of Palms/soles, desquamation in 2/3rd week
- Cervical adenopathy (one node > 1.5 cm diameter)

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21
Q

Treatment of Kawasaki disease

A

IVIG 2g/kg over 10-12 hrs
Aspirin 3-5 mg/kg/day
Possible methyprednisolone 2mg/kg.kday in 3 doses

22
Q

Differential diagnosis of ataxia developing flaccid paralysis

A 
Snake bite 
Pesticide exposure 
Toxins / poisons (antiepileptic, lead)
Tick bite paralysis 
ADEM, GBS
23
Q

Factors associated with poor prognosis in drowning

A

Duration of hypoxia
-Duration of submersion (>5 min = poor)
-Time to institution of effective CPR (>10-20 min poor)
-Time to first spontaneous gasp
Response to resuscitation
-Arrive conscious in ED - excellent outcome
-Lack of response, coma on arrival to ED - poor outcome
-GCS 5 or less on arrival to ED - dismal outcome
-Lack of pupillary response in ED (unless severe hypothermia).
-25 min of ALS, if non-hypothermic, without response,- poor outcome (but case reports of long donwtimes)

24
Q

Complications of hypothermia

A 
Cardiac arrhythmia / arrest 
Haematological - platelet dysfunction, thrombocytopaenia, DIC 
Pulmonary: pneumonia, PO, ARDS 
Infection: immune complex supression 
Renal: ATN, rhabdomyolysis 
GIT: pancreatitis 
Biochemical / metabolic derrangements.
25
Management of anaphylaxis
``` Remove allergen Lay child down Administer adrenaline: 0.01 mls/kg of 1:1000 (10 mcg/kg) - maximum 0.5 ml - repeat in 5 min if not improving Adrenaline infusion 0.05 - 5 mcg/kg/min - 1 ml adrenaline 1:1000, in 1L saline, at 5 mls/kg/hr (0.1 mcg/kg/min) IV fluid bolus 20 mls/kg saline ```
26
Risk factors for fatal anaphylaxis
Adolescence Nut and shellfish allergy Poorly controlled asthma Delays to administration of adrenaline / emergency services Preexisting cardiac and respiratory conditions
27
Causes of PUO (>10 days)
Juvenile idopathic arthritis, IBD, Malignancy Infection - Viral syndromes (EBV) - LRTI, CNS, Bone - TB, abscess, endocaridtis, enteric (typhoid fever) - Kawasaki disease
28
Antibiotic cover for meningitis
3rd generation cephalosporin Plus - age < 2 months: benzylpenicillin (GBS, listeria) - Penicillin-resistant pneumococci: vancomycin 15mg/kg (to 500mg) IV Q6H
29
Contact prophylaxis for neisseria meningitidis or haemophilus influenza
Rifampicin. Neisseria - 10mg/kg BD, Influenza - 20mg/kg daily
30
Antibiotics for pre-septal cellulitis
Amoxycillin/clavulanate, 22.5 mg/kg amoxycillin PO BD Flucloxacillin and ceftriaxone if IV
31
Antibiotics for peritonitis
Ampicillin/amoxycillin 50mg/kg IV Q6H Gentamicin 7.5mg/kg (360mg) < 10 yrs, or 6mg/kg > 10 yrs Metronidazone 15mg/kg (1g) stat, then 7.5mg/kg IV Q8H
32
Antibiotics for pyelonephritis or UTI < 6 months
Benzylpenicillin 60mg/kg Q6H | Gentamicin 7.5mg/kg (360mg) if < 10yrs, or 6mg/kg IV if > 10 yrs.
33
Antibiotics for epiglottitis
Ceftriaxone 50mg/kg IV | Add dexamethasone
34
Management of otitis media
Red flags: OAM in only hearing ear, cochlear implant, indigenous child. Immunosupressed. No red flags - analgesia for 48 hrs Red flags / immunocompromised / very unwell / not improving at 48 hrs: - amoxycillin 30-45 mg/kg/dose BD for 5 days Ongoing in 48 hrs with abx: change to amoxyclav Amoxyclav if amoxycillin in last 30 days or history of resistance.
35
Antibiotic management of pneumonia
Amoxycillin 25 mg/kg (500 mg) PO Q8H add: benzylpenicillin 60mg/kg (2g) IV Q6H if moderate Severe: flucloxacillin 50mg/kg IV Q6H and cephalosporin
36
Antibiotics for necrotising fascitis
Vancomycin 15mg/kg IV Q6H Meropenem 25 mg/kg IV Q8H (1g) Clindamicin 15mg/kg IV Q8H (600mg)
37
Sepsis < 2 months - causative agents
``` GBS E. coli and gram negatives Listeria Haemophillus influenza Plus: strep pneumoniae, neisseria meningitidis, staph aureus, GAS ```
38
Sepsis < 2 months - treatment
Benzylpenicillin 60mg/kg IV Q12H / 6H (1-4 weeks) / 4H 3rd generation Cephalosporin Skin: Flucloxacillin 50mg/kg IV Q12H (first week) / 8H (1-4 weeks) / 6H (>4 weeks) Abdominal: Amoxycillin/ampicillin 50mg/kg IV AND Gentamicin 5mg/kg IV (<1 week) then 7.5mg/kg AND Metronidazole 15mg/kg IV
39
Sepsis > 2 months - causes
``` Strep pneumoniae N. meningitidis S. Aureus Group A strep Gram negatives ```
40
Sepsis > 2 months - treatment
Flucloxacillin 50mg/kg IV Q6H (2g) Cephalosporin 3rd gen Central line or suspected MRSA: Vancomycin (alt to flucloxacillin) Gram positive TSS: Add clindamicin and IVIG
41
Febrile neutropaenia
Piperacillin / Tazobactam 100mg/kg (4g) IV Q6H AND Amikacin 22.5 mg/kg (1.5g) IV daily (< 10 yrs) / 18mg/kg > 10 yrs Add vancomycin 15mg/kg IV (500mg) Q6H for line infection
42
Differntial diagnosis acute scrotum
- Testicular torsion, adolescent and neonates, abnormal lie. - Torsion of appendix testis, upper pole tenderness, blue dot. few days. - Epididymoorchitis. Infants and 10-12 yr olds. - Idiopathic scrotal oedema. Scrotal skin thickened. - Testicular tumours. Scrotal enlargement + trauma. - Irreducible inguinal hernia. - Testicular rupture. - Acute hydrocele. Intercurrent illness - increase peritoneal fluid. Not painful.
43
Causes of erythroderma
Causes - Inflammatory: psoriasis, eczema, pityriasis, diffuse cutaneous mastocytosis - Ichthyoses - Immudeficiency: SCID, DiGeorg,GVHD - Drug Reaction - Metabolic: acrodermatitis enteropathica, organic acidemia - Infection: staph scalded skin, staph toxic shock, syphilius , HSV
44
Causes of collapsed neonate
THEMISFITS ``` Trauma Heart disease Endocrine - CAH, hypothyroidism Metabolic - BSL Inborn errors of metabolism Sepsis Formula mishaps Intestinal catastrophe - volvulus, NEC, intusussception Toxins Seizures ```
45
Presentation and management of congenital adrenal hyperplasia
ambiguous genitalia (F) or enlarged penis (M) 1-2 weeks of age with salt loosing crisis. Hyponatraemia, hypkerkalaemia and hypoglycaemia. IV hydrocortisone - 5mg/m2 Q8H
46
Causes of neonatal seizures (after 48 hrs)
- CVA: extra-axial, periventricular, sinovenous thrombosis - Biochemical: hypoglyaemia, hypocalcaemia, hypernatraemia - Meningoencephalitis: bacterial (GBS, E coli, listeria, Staph), viral (HSV, enterovirus) - Withrdrawal (opioid, SSRI) - NAI - Inborn errors of metabolism - Seizure syndromes: benign and malignant - Malformations/tumours
47
Differential of neonatal seizures and differentiating features
Benign sleep myocolonus: during sleep, not stimulus sensitive, UL>LL, bilateral or unilateral Jitterinesss: symmetrical, stimulus sensitive, no eye movements, supressible.
48
Management of neonatal seizures
Phenobarbitone 20 mg/kg IV or IM Levitiracetam 20mg/kg IV BD Intubation & midazolam - 0.15 mg/kg over 5 min, infusion 60-400 mcg/kg/hr Phenytoin 15-20 mg/kg IV over 30 min Pyridoxine 100 mg IV if unclear cause not responsive to other therapies
49
Indications for neuroimaging in seizures
- focal seizure - 3rd line antiseizure medicine - children < 6 months - signs of raised ICP - bleeding disorder / anticoagulation - not returned to baseline mentation
50
Medications and dosing in neonatal resus: - adrenaline - naloxone - dextrose - saline
Adrenaline 0.1-0.3 mls/kg 1:10,000 (10 mcg/kg) Naloxone 0.1 mg/kg IV or IM Dextrose 10% slow IV, 2 mls/kg Saline 10 mls/kg over 5 min

Paediatric Emergency Medicine (2 decks)

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