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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

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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
Q

Management of anaphylaxis

A 
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
Q

Risk factors for fatal anaphylaxis

A

Adolescence
Nut and shellfish allergy
Poorly controlled asthma
Delays to administration of adrenaline / emergency services
Preexisting cardiac and respiratory conditions

27
Q

Causes of PUO (>10 days)

A

Juvenile idopathic arthritis, IBD, Malignancy
Infection
- Viral syndromes (EBV)
- LRTI, CNS, Bone
- TB, abscess, endocaridtis, enteric (typhoid fever)
- Kawasaki disease

28
Q

Antibiotic cover for meningitis

A

3rd generation cephalosporin

Plus

  • age < 2 months: benzylpenicillin (GBS, listeria)
  • Penicillin-resistant pneumococci: vancomycin 15mg/kg (to 500mg) IV Q6H
29
Q

Contact prophylaxis for neisseria meningitidis or haemophilus influenza

A

Rifampicin. Neisseria - 10mg/kg BD, Influenza - 20mg/kg daily

30
Q

Antibiotics for pre-septal cellulitis

A

Amoxycillin/clavulanate, 22.5 mg/kg amoxycillin PO BD

Flucloxacillin and ceftriaxone if IV

31
Q

Antibiotics for peritonitis

A

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
Q

Antibiotics for pyelonephritis or UTI < 6 months

A

Benzylpenicillin 60mg/kg Q6H

Gentamicin 7.5mg/kg (360mg) if < 10yrs, or 6mg/kg IV if > 10 yrs.

33
Q

Antibiotics for epiglottitis

A

Ceftriaxone 50mg/kg IV

Add dexamethasone

34
Q

Management of otitis media

A

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
Q

Antibiotic management of pneumonia

A

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
Q

Antibiotics for necrotising fascitis

A

Vancomycin 15mg/kg IV Q6H
Meropenem 25 mg/kg IV Q8H (1g)
Clindamicin 15mg/kg IV Q8H (600mg)

37
Q

Sepsis < 2 months - causative agents

A 
GBS 
E. coli and gram negatives 
Listeria 
Haemophillus influenza 
Plus: strep pneumoniae, neisseria meningitidis, staph aureus, GAS
38
Q

Sepsis < 2 months - treatment

A

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
Q

Sepsis > 2 months - causes

A 
Strep pneumoniae 
N. meningitidis 
S. Aureus 
Group A strep 
Gram negatives
40
Q

Sepsis > 2 months - treatment

A

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
Q

Febrile neutropaenia

A

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
Q

Differntial diagnosis acute scrotum

A
  • 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
Q

Causes of erythroderma

A

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
Q

Causes of collapsed neonate

A

THEMISFITS

Trauma 
Heart disease 
Endocrine - CAH, hypothyroidism
Metabolic - BSL 
Inborn errors of metabolism 
Sepsis 
Formula mishaps 
Intestinal catastrophe - volvulus, NEC, intusussception
Toxins 
Seizures
45
Q

Presentation and management of congenital adrenal hyperplasia

A

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
Q

Causes of neonatal seizures (after 48 hrs)

A
  • 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
Q

Differential of neonatal seizures and differentiating features

A

Benign sleep myocolonus: during sleep, not stimulus sensitive, UL>LL, bilateral or unilateral
Jitterinesss: symmetrical, stimulus sensitive, no eye movements, supressible.

48
Q

Management of neonatal seizures

A

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
Q

Indications for neuroimaging in seizures

A
  • focal seizure
  • 3rd line antiseizure medicine
  • children < 6 months
  • signs of raised ICP
  • bleeding disorder / anticoagulation
  • not returned to baseline mentation
50
Q

Medications and dosing in neonatal resus:

  • adrenaline
  • naloxone
  • dextrose
  • saline
A

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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