Quiz #3 Flashcards
Peds larynx are more ??
superior/anterior position (C3 level)
Adults vocal cords are more?
perpendicular to trachea
Peds vocal cords are more?
slant anteriorly to trachea
How is pediatric tube sizes estimated?
ETT= (age + 16) / 4
What is ETT tube size age?
older 1 yr
What is more accurate at determining ETT?
resuscitation tapes
Formula for Depth of ETT insertion?
ETT x 3 = (cm)
What age doesn’t get a cricothyroidotomies?
<10-12yr
For children <10 what airway emergency do they get?
Needle translaryngeal ventilation
How long does a needle translaryngeal last?
~30 mins (30kg)
What is a problem with needle translaryngeal?
build up of CO2
What blade is used for <2yr?
straight blade (miller)
What tube is used for <6-8yr?
uncuffed tubes
What should be avoided when given oxygen to the child?
hyperventilation
What does hyperventilation cause?
air in the stomach
possible barotrauma
What method is used for fluid boluses?
4-2-1 method
For hypovolemia how should a bolus be admin?
rapidly as possible (20 min max)
What should be done after each bolus given?
reassess patient
In peds cardiac arrest is usually secondary to what?
respiratory arrest and shock
What are the 3 priorities in pediatric arrest?
airway, oxygenation, ventilation
Who has a poor outcome in ped arrest?
child in primary cardiac arrest
What are 6 airway emergencies?
stridor (obstruction) epiglottitis croup foreign body aspiration peritonsillar/ Retropharyngeal abscess Bronchiolitis
What are 4 signs of airway/ breathing difficulties?
stridor
intercostal and suprasternal retractions
tachypnea
cyanosis
Which child is in imminent danger of airway compromise?
Stridorous
What should not be done in a child that is having stridor?
DO NOT agitate or lay them down!
What is the txt for stridor?
begin intervention to correct cause ASAP
Dysphagia, drooling, distress?
Epiglottitis
The three D’s?
Epiglottitis
Tripod position
Epiglottitis
What is the txt for epiglottitis?
IV steroids and abx
oxygen
What is seen on a lateral neck x-ray in epiglottitis?
Thumb sign
What pathogen causes croup?
parainfluenza
What infection is seen in croup pts?
viral laryngotracheobronchitis
What are the classic s/s of croup?
nasal congestion
rhinorrhea
cough
low grade fever
Harsh barking cough worse at night
croup
What is the severity of symptoms in croup related to?
edema and inflammation of the airway
What is the txt and disposition for croup?
corticosteroids, +/- nebulized epinephrine
What is seen on a/p neck xray for croup?
steeple sign
What pathogen causes bronchiolitis?
RSV
What is the most common age for bronchiolitis?
<2y
What week are symptoms the worst in bronchiolitis?
1st week (out of 3)
What are the 6 symptoms in bronchiolitis?
URI symptoms, wheezing, fever, apneic episodes, cyanosis, poor feeding
What is the txt for bronchiolitis?
nebulized epinephrine
corticosteroids
nebulized hypertonic saline
What disorders are uncommon in emergency med?
unknown pediatric cardiovascular disorders
What are the majority of peds heart diseases seen in the ED?
valvular dysfunction
septal defects
vascular anomalies
Txt for peds cardio?
immediate cardio consulation
What makes peds heart defects worse?
oxygentation
When in doubt about cyanotic infants cardio txt?
admit to NICU for observation
Limping child w/ a hx of trauma or overuse, whats next?
imaging
Limping child w/ no trauma, whats next?
no systemic sx
systemic sx
Limping child w/ no systemic sx, what’s next?
imaging
Limping child w/ systemic sx, what’s next?
imaging
CBC, ESR, CRP
What things need to be r/o with a limping child?
Fractures SCPE AVN Osteomyelitis Septic Joint Cancer Deep abscess
What are the 3s rule for colic?
> 3hrs/day
3days/week
3 weeks
What are 3 non-accidental trauma?
bruising in different stages of healing
fractures in different stages of healing
odd story concerning injury
Most common complaint in >75yr pts
weak and dizzy
What is often used as a surrogate for fatigue?
weakness
Neurological deficit?
muscle weakness
What 3 things is lightheadedness often due to?
anemia, hypovolemia, or orthostatic hypotension
What is vertigo?
loss of balance or spinning room
What is a precursor to altered mental status?
malaise
What are 6 emergent concerns for generalized fatigue?
anemia heart failure inability to oxygenate systemic infection adrenal crisis myxedema coma
What is the txt for muscle weakness?
identify cause and attempt to reverse or limit progression
Get pt to specialist
Dysfunction of the brain or brain stem leading to misinterpretation of peripheral stimuli?
Central vertigo
Dysfunction of the inner ear or vestibular nerve creating incorrect stimuli that is sent to brain?
Peripheral vertigo
What are 3 symptoms of central vertigo?
associated Cranial nerve deficits
Vertical nystagmus
Ataxia
CVA?
associated Cranial nerve deficits
Vertical nystagmus
Ataxia
What are 5 symptoms of peripheral vertigo?
unilateral hearing loss Tinnitus Fatigable on repeat testing S/s usually more tense Positional in nature
What is positive on a Dix- Hallpike maneuver?
Latency (peripheral vertigo)
What is the txt for central vertigo?
activate stroke if < 4hrs from onset
Call neurology/admit if > 4hrs from onset
What imaging is done in central vertigo?
brain CT w/o contrast
brain MRI to evaluate cerebellum
What maneuver is done in peripheral vertigo to txt?
Epley Maneuver
What medicines are given for peripheral vertigo if the epley maneuver doesn’t work?
Antiemetics (meclizine)
Anticholinergics (scopolamine)
Benzodiazepines (diazepam)
“Passing out”
presyncope
Loss of consciousness AFTER a psychologically stressful event
vasovagal syncope
What is the patho of vasovagal syncope?
Stress increases vagal tone > causes bradycardia >
hypotension > lack of brain perfusion > unconsciousness
Loss of consciousness NOT RELATED to psychological stress event
syncope or presyncope
What 2 things should be done in a syncopal pt?
check fingerstick glucose and pregnancy
preform detailed PE
CHESS?
San Francisco Syncope Rule
What does CHESS stand for?
Congestive Heart Failure Hematocrit < 30% E KG abnormality Shortness of breath SBP <90mmHg
What is the criteria to r/o a serious outcome for CHESS?
if “No” to all
What is the Canadian Syncope Risk Score used for?
a +/- to score risk of serious adverse event
What are the 4 first steps in txt a pt w/ syncope?
Supplemental O2
IV
Vitals
EKG
Syncope + Headache
subarachnoid or ICH
hemorrhage
Syncope + Neuro Deficit
CVA/TIA or ICH
Syncope + Confusion
Seizure
Syncope + Chest pain
MI, PE, or Aortic Dissection
Syncope + Back/Abdominal pain in older patient
Abdominal Aortic Aneurysm (AAA)
Syncope + Positive HCG
Ectopic Pregnancy
What is the disposition for syncope?
D/C w/ PCM follow if low risk
otherwise ADMIT
What are some precautions to give a syncope pt?
no exercise until evaluated and cleared
NO driving or swimming, shower w/ a chair or w/ someone nearby
What is a level I trauma center?
all essential specialties and services available in house 24/7/365
What is the No 1 cause of death in 1-37 y/o
Trauma
Most specialties available in house 24/7/365?
Level II
What level has transfer capability with level I and Level II
Level III
What is vital to successful trauma resuscitation?
a team
What should be performed in the first 1-2 min of arrival?
100% O2 2 large bore IVs Vitals, pulse oximetry Removing all clothing and jewelry Applying EKG leads Limb splints Obtaining O neg titer or type specific blood for transfusion
What is the first and only drug to actually decrease mortality rates?
Tranexamic acid
Use for pts with significant bleeding reduces mortality by 1.5% w/o increasing thromboembolic events?
Tranexamic acid
When imaging done?
after ABCDEs
What imaging is done in trauma?
CXR
Pelvic
X-table lateral C-spine
EARLY CT
What is the 5 primary trauma survey?
Airway Breathing Circulation/ Control of bleeding (C2) Disability Exposure
What should ALWAYS be protected in inline immobilization?
C- spine
For a midfacial trauma what two things can be done to protect the airway?
orotracheal or cricothyrotomy
For severe head trauma in c-spine injuries what can be used for intubation?
pretreatment w/ lidocaine or fentanyl
Consider a dose of depolarizing paralytic (vecuronium)
Where is needle decompression in adults done?
between the fourth or fifth intercostal space mid axillary line
What is the drug of choice for intubation?
Ketamine
What non-depolarizing paralytic is used?
Vecuronium
What is FAST?
Focused Assessment with sonography in trauma
What is RUSH?
Rapid ultrasound for Shock and Hypotension
What should you be doing when checking the neck and throat?
feeling and looking
Ensure adequate decompression of the chest and eliminate tension pneumothorax
finger thoracostomy
What is the txt for losing blood loss?
Stop obvious bleeding
2 large bore IVs
16 Ga minimum
FAST/RUSH exam
Where should a 16 Ga be performed?
long bone
What administrated for shock and control of hemorrhage?
Pneumatic antishock garments (PASG)
What are contraindications to PASG?
Pulmonary edema Pregnancy Evisceration Thoracic injury w/ hemorrhage Diaphragm injury Impaled objects
What line is used for fluid resuscitation in children?
intraosseous line
More than ??? of crystalloid fluid has been associated w/ increased mortality
1.5 L
How fast should tranexamic acid be given?
within 3 hours
When a 1g dose is given in prehospital setting, where should the other dose be admin?
in the ER
Beck’s Triad is a indication for?
percardiocentesis or thoracotomy
For pregnant pts what side should they be positioned to relieve uterine pressure on the IVC?
left lateral decubitus
What use to be superior to tourniquets?
pressure
If bleeding diathesis what should NOT be done?
removing gauze (add more gauze and continue to apply pressure)
In a uncontrolled extremity hemorrhage what should be use?
tourniquets above the area of injury
What 3 body cavities should be checked in internal bleed?
thorax
abdomen
retroperitoneum
When should neurologic status be performed?
BEFORE sedation/intubation
What is the rapid neurological assessment (AVPU)
Awake
Verbal response
Painful response
Unresponsive
What is HNSCASPER?
Head Neck Shoulders Chest Abdomen Spine Pelvis Extremities Reassess
What is MARCH?
Massive hemorrhage Airway Respiration Circulation Head injury/ Hypothermia
What is most paramount in a mass casualty event?
scene and provider safety
Once a tourniquet has been applied what shouldn’t be done?
DO NOT loosen it
What can be used as a temporary measure in massive hemorrhage?
direct pressure w/o hemostatic agents
If not treated promptly what can a tension pneumothorax progress to?
shock and traumatic cardiac arrest
Where should a needle NOT be inserted?
medial to the nipple line
A tourniquet should NOT be taken down after?
6 hours
When should a tourniquet be converted?
2 hrs
Less than how many hours is a STROKE ALERT?
<4hrs
What is Glasgow coma scale usually used for?
trauma only… (but used in all emergency medicine)
What score is normal on a Glasgow coma scale?
15
What score is dead on a Glasgow coma scale?
3
What are the 3 categories of a Glasgow coma scale?
eye opening, verbal response, motor response
What is the first imaging that is done in a neuro ed workup?
Head CT
What are 3 focal neurological deficits of acute onset?
movement
sensation
cognition (responsiveness)
In a stroke like s/s pt what is the first thing that should be determined?
attempt to determine time patient “ last known well”
What are all focal neuro deficits treated as?
STROKE (until either improve or other cause identified)
What is the first order of business to help differentiate ischemic vs. hemorrhagic stroke?
CT w/o contrast
What is seen on CT for a ischemic stroke?
focal deficit with NON-HEMORRHAGIC
What lab should be done on all neuro pts?
fingerstick glucose
Dx imaging for cerebellar stroke?
emergent brain MRI
How many degrees should the bed be elevated in ischemic stroke management?
30
What should the glucose be kept at for ischemic stroke?
140-180
When should BP ONLY be lowered ?
SBP > 220mmHg
OR
DBP > 120mmHg
What percent is Bp lowered in the first 24hr period?
15%
What 3 meds are used to lower bp?
Nicardipine, labetalol, esmolol (IV titratable)
What are the good and bad of thrombolytics in ischemic stroke?
can reverse deficits and allow for complete recovery
can cause the patient to die
When should thrombolytics not be given?
SBP > 185 or DBP > 110
Active bleeding
Acceleration deceleration injury sheering veins and more common in elderly due to atrophy
Subdural
Thunderclap HA, worst HA of life, neck stifness?
Subarachnoid
Hypertensive emergency, bleeding mass, trauma
Intracerebral
LOC w/ blow to the head, followed by lucid period and mental decompensation?
Epidural
Dx of hemorrhagic stroke?
Brain CT w/o contrast
What should the SBP be reduced to in hemorrhagic stroke?
140-160mmHg
What is the txt of intracranial pressure in hemorrhagic stroke?
mannitol and hypertonic saline
What should NOT be done in the txt of hemorrhagic stroke?
hyperventilate
What is the PaCO2 goal in hemorrhagic stroke?
30-35
Why is the PaCO2 kept between 30-35?
to prevent cerebral vasoconstriction
What is used as a immediate txt by a neurosurgeon for evacuation in hemorrhagic stroke?
burr hole
What is the 5th most common symptom presenting to the ED?
Headaches
You AVOID opiate meds in what two things?
Migraines and tension headaches
In a approach to a dizzy pt what must be differentiate?
central from peripheral vertigo
In a approach to a pt “passing out” what must be differentiated?
syncope vs. presyncope
Trauma Primary Survey
Airway Breathing Circulation/ Control of bleeding (C2) Disability Exposure
What is a big red flag in medication use for headaches?
Anticoagulants
What is a red flag in findings use for headaches?
Papilledema
What is the dx for headaches w/ red flags?
CT brain w/o contrast
A head CT is 100% sensitive within what timeframe?
6hrs of SAH onset
After 6hrs hours what is necessary to r/o a SAH?
Lumbar puncture
What two things should be seen on a LP?
RBC count clearing and xanthochromia
Migraine Cocktail (Phase I)
IV Fluid 1L Toradol IV Tylenol PO Reglan (Metoclopramide) IV Benadryl IV
What must be r/o with Toradol IV admin?
ICH
What 3 drugs are given in Phase II?
Magnesium IV
Solu-Medrol IV
What is the time that thrombolytics are ok to give to a ischemic pt?
<4.5 hrs
What should always be ran before admin thrombolytics?
a thrombolytic checklist
How are anticoagulants reversed in hemorrhagic stroke?
reversal agent or by replace clotting factors
What becomes “Veterinarian Medicine”?
workup for altered mental status
Seizures are most commonly due to?
known epileptic patient not taking medications
1st seizure w/ no other symptoms or inciting event in a non-epileptic patient
r/o toxicity or metabolic issues and d/c home to follow up with PCP
2nd seizure w/ no other symptoms or inciting event in a non-epileptic patient?
Refer to neurologist
A secondary seizure can be a indication of what?
trauma, infection or severe metabolic derangement
6-60 months, generalized, last less than 15 mins, and do not recur within 24hrs?
Febrile seizures
Seizures in preggo?
Eclampsia (until proven otherwise)
Post- Trauma seizure?
Intracranial hemorrhage (until proven otherwise)
Txt for uncomplicated seizure (non-status)
Oxygen IV access Vitals monitor Fingerstick glucose Check seizure medication Rule out conditions
Txt for status epilepticus 5-10min?
Lorazepam or diazepam IV + phenytoin or fosphenytoin
Consider intubation
Txt for status epilepticus for >10min?
Versed IVP w/ drip + propofol or ketamine + phenoarbital
Intubate, Continuous EEG
A head injury that does not require neuroimaging or has no diagnostic neuroimaging findings
concussion
What two algorithms are used in adults to make decisions neck injuries?
Pediatric Cervical Spine Clearance Working Group
NEXUS
Canadian C-spine Rule
Concussion algorithm used for <18 yo for head trauma?
PECARN
Concussion algorithm used for >16 yo for head trauma
Canadian CT Head Injury
Disposition in concussion w/ no intracranial injury?
d/c home, FU w/ PCM
Txt for a concussion w/ no intracranial injury?
Physical and cognitive rest
Acetaminophen prn for 2days
Ondansetron prn for 2 days
Beware of 2nd head injury
Has replaced rapid sequence intubation (RSI)?
Drug assisted intubation
What is the new location for needle decompression?
fourth or fifth intercostal space mid axillary line
What is the best method for adequate decompression of the chest and eliminates tension pneumothorax?
finger thoracostomy
More than ??? liters of crystalloid fluid has been associated with increased mortality?
1.5
What should be used for external bleeding?
Tourniquets
How should tourniquets be placed?
above the area of injury in uncontrolled hemorrhage
What should be included in AMPLE hx of a disable person?
Allergies Medications PMHX Last meal Events (leading up to trauma)
What does AVPU stand for? (used as a alternate to GCS)
Awake
Verbal response
Painful response
Unresponsive
What does MARCH stand for in massive casualty event?
Massive hemorrhage Airway Respiration Circulation Head injury/ Hypothermia
