secrets ER Flashcards
3 differences between smallpox and varicella
- distribution - smallpox - face and extremities vs varicella trunk
- stages - smallpox al in the same stage, varicella in different stages
- smallpox rash develops more slowly than varicella rash
symptoms of plague from bioterrorism
yersinia pestis -aerosolized, inhalation would result in presentations more typical of pneumonic plague with fever, chills, tachypnea, cough and bloody sputum, lympadenitis would be a later finding
nuclear power plant - family leaves nearby
potassium iodide - will inhibit uptake of radioactive iodine into thyroid gland (since kids are more likely to get thyroid cancer from this exposure)
chemical attack/exposure - what is your first step in management
initial decontamination - remove the patient’s clothing, can eliminate 90% of contaminants
Most common cause of severe head trauma (closed) in <1 year old
child abuse
Which of the following about retinal hemorrhage is false?
a) may be only sign in an infant of shaking injury
b) commonly caused by seizures
c) confirm by optho
d) should be followed by skeletal survey, head injury
b) false - almost never caused by seizures alone
may be the on
which imaging better for subarachnoid? CT or MRI?
CT better for subarachnoid and large extra-axial hemorrhages and mass effect (but can be false negative)
better for subdural?
MRI and also better for intraparenchymal lesions
may miss subarachnoid
Increased LFTs in child with suspected shaken baby syndrome?
may signify occult liver injury
Important historical indicators of possible child abuse
- lots of previous hospital visits for injuries
- history of untreated injuries
- cause of trauma not known or inappropriate for age or activity
- delay in seeking medical attention
- history incompatible with injury
- parents unconcerned or more concerned about unrelated minor problem
- abused siblings
- changing stories
Timing of X ray findings after fracture
1-7 days: soft tissue swelling, sharp fracture line
7-14 days: periosteal new bone formation, blurring of fracture line (earlier for infants)
14-21 days : more clearly defined callus forming
21-42 days: peak of hard callus formation
>60 days: remodelling of bone begins with reshaping of the deformity (up to 1-2 years)
fractures suggestive of abuse
- spinal fractures
- rib
- metaphyseal chip (from forceful jerking of extremity)
- vertebral/femoral/pelvic or scapular fractures
true or false - rib fractures commonly caused by CPR
secrets says almost never caused by CPR **discuss
If abuse is highly suspected and the first skeletal survey is noma what should you do?
follow up study in 2 weeks
age group where skeletal survey is most important?
AAP says mandatory until age 2, yield diminishes after that
Features of OI?
bone fragility fractures with low impact blue sclera ligamentous laxity osteopenia wormian skull bones dentinogenesis imperfecta family history of OI hearing loss
Types of burns suspicious for abuse
1 immersion burns
- geographic burns
- splash burns
After history and physical exam, what evidence should be collected (if kid consents) if suspected sexual abuse or assault of post pubertal female?
- pregnancy test
- sperm sample, acid phosphatase, prostate glycoprotein, blood troop antigens
controversial - hair, DNA testing - STI testing - cultures (better for court) PCRs can also be used
**advantage of PCR - can detect chlamydia earlier
when to repeat tests for syphilis and HIV?
6 weeks, 3 months and 6 months
what is the best predictor of gonorrhoea infection in <12 year old?
vaginal or urethral discharge (without discharge very unlikely to have gonorrhoea)
is BV strongly suggestive of sexual abuse?
nope, listed as inconclusive
when do you need immediate medical exam after sexual abuse?
- within 96 hours
- ongoing bleeding
- evidence of acute injury
most common P/E in sexual abuse
normal
3 date rape drugs
- flunitrazepam (rohypnol)
- GHB (gamma hydroxybutyrate)
- ketamine
* *lots of these can only be detected early, so need to check in urine/blood super early
Near drowning, mechanism of lung disease?
V/Q mismatch and hypoxemia
no longer thought to be different between fresh and salt water drowning
Physiological changes at different body temperatures?
31-32 C: increased HR, CO, BP, peripheral vasoconstriction, increased central vascular volume, normal ECG
28-31 C: diminished HR, CO and BP, ECG changes including PVCs, SVT, atrial fibrillation, T wave inversion
<28 C: severe myocardial irritability, V fib, usually refractory to electrical defibrillation, no pulse/BP, J waves on ECG
Consequences of warming hypothermic too rapidly?
- core temperature after-drop
- hypotension
- acidosis (lactic)
- dysrhythmias
How to rewarm mild hypothermic patient (32- 35 C)
passive rewarming, remove cold clothing, place patient in warm dry environment with blankets
CAN also use active external rewarming (blankets heated, hot-water bottles, overhead warmers)
When to not use active external rewarming?
chronic rewarming >24 hours
What are some rewarming techniques appropriate for patient with temperature <32 C?
- gastric or colonic irrigation with warm fluids
- peritoneal dialysis
- pleural lavage
- extracorporeal blood rewarming with partial bypass
- heated IV fluids (43 C)
- warm, humidified O2 by face mask
What is heat stroke symptoms?
medical emergency
temperatures >41.5 C with multi system dysfunction
CNS: confusion, seizures, LOC
CVS: hypotension, peripheral vasodilation, myocardial dysfunction
Renal: ATN and renal failure with lytes abnormal
LVR: injury and dysfunction
Heme: abnormal hemostasis often with DIC
Rhabdomyolysis
What is the “critical thermal maximum”?
42 C
the body starts to fall apart ->cell death
Patient in house fire, signs of upper airway exposure?
- carbonaceous sputum
- singed nasal hairs
- facial burns
- resp distress
* **do NOT need resp distress as an indicator for ETT intubation, can progress rapidly to upper airway obstruction
What symptoms would you expect at blood carboxyhemoglobin level of 40%?
for 30-50%: severe headache, nausea, vomiting, increased HR and rests, visual disturbances, memory loss, ataxia
other levels:
0-1%: normal - smokers may have up to 5% -10%
10-30%: headache, exercise induced dyspnea, confusion
30-50%: severe headache, nausea, vomiting, increased HR and resp, visual disturbances, memory loss, ataxia
50-70% : convulsions, coma, severe CR compromise
70%: usually fatal
Hg: evaluate correctable anemia
arterial pH - for acidosis
urinalysis for myoglobin:
Treatment of CO poisoning?
100% O2 through non-rebreather mask until carboxyhemoglobin <5%
half-life of COHb 5-6 hours if the patient is breathing room air (at sea level) reduced to 1-1.5 hours if patient is breathing 100% O2
consider treating for cyanid poisoning if metabolic acids safer adequate O2
consider referral for hyperbaric oxygen
when to refer for hyperbaric O2
- coma, seizure, abnormal MS
- persistant metabolic acidosis
- neonate
- pregnancy
- HbCO?25% (even if neurologically normal)
How does CO shift the Hg O2 dissociation curve?
to the left - binds Hg more than O2, and also harder to release O2 into tissues , also binds to mitochondria and messes them up
Which burns are worse in the eye, alkali or acid?
alkali are worse - cause liquefaction necrosis (i.e. from Drano/lye)
worse than acid burns because the damage is ongoing, irrigation is important
which one gives more tissue damage lightening o high voltage wires?
high voltage wires more tissue damage more likely to lead to rhabdo
in household devices, which is worse, alternating or direct current?
alternating - harder to let go, therefore more prolonged injury
toddler gets full thickness burn after biting an electrical cord, complications?
eschar at the site- can detach and cause bleeding from the labial artery 1-3 weeks later
scarring can be extensive, plastics early on
3 risk factors for fatal anaphylactic reactions:
1 history of asthma
- delayed diagnosis
- delayed administration of epi
should you rub the area in frostbite
nope might injure more
rewarm in water 37-43 C, don’t rewarm if chance of refreezing
someone at your child’s soccer practice has avulsed a digit, what do you tell them about how to bring it to the hospital?
wrap in dry gauze then put in a plastic bag NOT liquid (tissue swelling) or ice (tissue necrosis)
Which lip lacerations should be referred to a specialist?
if they involve the lip margins (vermillion border)
eye lacerations that should be referred?
inner eyelid can damage the inner eyelid
Where should sutures stay longer
more as you move lower down the body (less blood supply)
face only 5 days, trunk 7-10 days
when to suspect digital nerve injury
abnormal sensation
abnormal autonomic function
diminished range of motion of finger
pulsating blood
Animals that have rabies in US
raccoons, skunks, foxes, coyotes and bats
Which animals to consider rabies vaccine and Ig for?
bites or scratches (or even exposure according to nelson ) from bats, or bites/scratches from skunks, raccoons, foxes and most other carnivores if they break the skin
bites from dogs and cats - don’t need prophylaxis if you can observe the animal for 10 days (and stays healthy)
when should you not use lidocaine with epi?
tissue viability/or where might produce schema - tip of nose, ear, finger, toe, penis
When should you not consider tissue approximation (i.e. glue)
jagged wounds
bite/puncture
deeper than 5 mm
hands/feet or joints (unless you can immobilize)
oral mucosal or other mucosal surfaces
conditions that may delay wound healing (DM or steroids)
Give examples of when you can use absorbable sutures?
- facial lacerations
- lacerations under casts or splints
- closure of lacerations of the tongue or oral mucosa
- hand and finger lacs
- nail bed lacs
true or false - conscious sedation is appropriate for office settings
false - need to be prepared for airway problems - O2, bagging, suction
in conscious sedation should keep protective reflexes and appropriate responses to stimulation on verbal command, and patent airway
What type of tube should you use when intubating a 6 year old patient in Nunavut for transpot?
uncuffed i think - cuffed tube is safe for all beyond newborn period BUT in an inpatient setting, my understanding is that uncured is safer the middle of nowhere
type of tube to intubate newborn?
uncuffed
Times to especially consider cuffed tube?
large air leak
poor compliance
high airway resistance
size of ETT tube calculation
age/4 + 4 (uncuffed)
age/4 +3 (cuffed)
depth of ETT insertion (from gum line)
age/2 + 12
2 disadvantages of LMA vs intubation
less protection against aspiration
less stable
er drugs you can give through ETT tube
lidocaine epinephrine atropine naloxone **also vasopressin but absorption not super reliable, we give 10x more epi and 2-3 x dose of the other drugs when giving via ETT
types to use calcium in resus
DON't use routinely- does not improve survival or neuro outcome when to consider: 1. Ca channel blocker overdose 2. hyperkalemia with cardiac arrhythmia 3. hypocalcemia 4. hypermagnesemia 5. hyperkalemia
Contrandications to IO
- fracture bone
- dirty or infected skin
- bone disorders - i.e. osteoporosis, osteogenesis imperfecta
- repeat into the same bone - risk of extravasation through initial puncture site
Complications from IO
fluid extravasation superficial skin infections RARE - osteomyelitis - skin necrosis - bone fractures - compartment syndrome should switch to different access asap
estimate of weight
(age x 3) + 7
how long in SVT before CHF develops?
48 hoours 50 percent
rare after less than 24-48 hours
contraindications to resus - fixed and dilated pupils?
NO can be transient after 1min 45 sec
contraindications to resus
rigor mortis
corneal clouding
dependant lividity
decapitation
hypothermic patient - what temp to warm to before saying dead
36 for asystolic patient
when to stop resus
secrets says 20 min or 2x epi seems short to me
where is most of the blood in a child? (i.e. venous, capillary beds, arterial)
venous - 70%
capillary bed - 12%
8% within arterial side
What two cases should you consider steroids in septic shock in children?
- catecholamine resistant septic shock
2. clear evidence of adrenal insufficiency
Where should you give epi
IM into thigh
IF severe refractory symptoms and hypotension then consider giving IV
8 year old falls into swimming pool, HR 90 (NORMAL), hypotensive - 50/40 despite lots of luis, brain is okay
neurogenic shock
loss of sympathetic tone - therefore NOT expected sympathetic response
Vital signs in neurogenic shock
hypotension with bradycardia or normal HR despite fluid
may need vasopressors
How much blood loss does hypotension signify?
> 45% of circulating blood volume
Cases where bleeding into the brain can cause shock
infant with unfused cranial sutures with significant hemorrhage into subaleal or epidural space
may be associated with long bone and pelvic fractures
always look in the belly for the source of blood loss
Which meds can kill a toddler with 1-2 tabs/caps/teaspoonfuls
- TCAs
- antipsychotics
- antimalarials
- antiarrhythmics
- calcium channel blockers
- oral hypoglycemics
- opioids
- imidazolines
The toxicology time bombs (i.e. have toxicity later in the course)
- acetaminophen
- iron
- alcohols - methanol (delayed acidosis) and ethylene glycol(delayed nephrotoxicity)
- lithium
- anticonvulsants - phenytoin (dilantin), carbamazepine
- time release medications
child presents with unknown toxic ingestion and altered mental status
O2 through non rebreather
glucose evaluation - treat hypoglycaemia
hypoglycemia
consider nalxone (therapeutic and diagnostic ) if think opioids
drugs which cause hypoglycaemia
ethanol
betal blocker
oral hypoglycemic agents
what are some complications of gastric lavage, when might you consider it?
laryngospasm
esophageal injury
aspiration pneumonia
consider for patients with a life-threatening quantity of a poisonous ingestion within 60 minutes of evaluation whose airway is protected
What are icontrainndications for whole bowel irrigation?
most important for airway compromise
don’t usually cause electrolyte imbalance
may consider for toxic ingestions of sustained release/enteric coated meds, may help with iron or packs of drugs
when might you consider alkalization of urine
salicylate, barbituate or TCA overdose
potential complications of acidification/alkalinzation of urine
fluid overlad
academia
also use it less because now we have dialysis
antidote for anticholinergics
physostigmine
antidote for benzos
flmazenil
antidote for beta blocker
glucagon
antidote for calcium channel blocker
calcium
glucagon (for the hypoglycaemia)
antidote for digoxine
digibind (antidigoxin antibody)
antidote for iron
deferoxamine
CO poisoning antidote
hyperbaric iron
lead antidote
EDTA, DMSA
mercury antidote
dimercaprol, DMSA
antidote for methemoglobinemia
methylene blue
antidote for organophosphates
atropine, pradoxime
antidote for phenothiazines (dystonic reaction)
diphenhydramine
antidote for tricyclics
bicarbonate
antidote for warfarin
vitamin K
What are two classes/types of drugs that Narcan can be used as an antidote for?
opioids
clonidine
what ingestions are radio opaque on abdo X-rays
radioopaque - white on Xray
- chloral hydrate
- heavy metals (arsenic, iron,lead)
- iodides
- phenothiaxines, psychotropics (cyclic antidepressants
- slow releae capsules - enteric coated tables
Salicylate toxidrome
fever, hyperpnea, tachypnea, abnormal mental status, tinnitus, vomiting, oil of wintergreen door from methyl salicylate
Toxidrome for anticholinergics
mad as a hatter - delirium, visual hallucinations
fast as a hare - tachycardia, hypertension
red as a beet - flushed skin, facial flushing
dry as a bone (remember, can’t sweat!!!!)
blind as a bat - dilated sluggish pupils
full as a tick - urinary retention, decreased GI motility and hypoactive bowel sounds
hot as Hades - hyperpyrexia, inability to sweat
how long can a urine test for marijuana stay positive
for 3 days
false positive: ibuprofen PPIs
false negative - add vision to a urine specimen
alcohol in infants/toddlers
coma
hypothermia
hypoglycemia
treatment for methanol and ethylene glycol ingestions
ethanol or fomepizole (safer, easier to monitor, less likely to cause hypoglycemia/get the kid drunk)
formula for osmolar gap
2Na and glucose
2 salts and a sticky bun
drugs which cause nystagumus
barbiturates
ketamine
PCP
phenytoin
drugs with cause mitosis (small pupil)
narcotics organophosphates PCP clonidine phenothiaxines barbiturates ethanol
toxic dose of tylenol
150 mg/kg are unlikely to be harmful
a kid presents 20 hours after a tylenol overdose , there is a toxic serum level, should you start NAC or is it too late
start it
should use for any toxic tylenol ingestion within 24 hours
works best within 8 hours
if not clear history, start NAC
How does NAC work?
NAC replenishes glutathione so that the cytochrome P450 can convert the excess acetaminophen into mercaptopuric acid
gas in salicylate poisoning
metabolic acidosis and respiratory alkalosis
**salicylates directly stimulate the medullary resp drive centre -
lactic acidosis and ketoacidosis
why should you not use pep to bismol in influenza or chickenpox?
risk of Reye syndrome
pepto-bismol contains salicylates
classic ECG findings in TCA overdose
- increased QRS
- large R wave
**treat with Na bicarb if these are present
benadryl can mimic these findings in high doses
Lab findings of iron toxicity
increased iron level >300 Gi symptoms leukocytosis hyperglycemia may see radio opaque on Xray
what is the toxic dose of iron
20 mg/kg
if multi vitamins contain iron then need to take it seriously, since iron is toxic
suspected unknown dose - can observe (since calls GI symptoms at the beginning
no symptoms and normal exam after 4-6 hours can be d/c home
kid takes metoclopromide has dystonic reaction. 2 treatment options
- benadryl
2. benztropine (cogentin) in teens
what metal mimics Kawasaki
mercury
symptoms of mercury poisoning
acrodynia swelling and redness of the hands and feet sin rashes diaphoresis tachycardia hypertenion photophobia irritability with anorexia and insomnia weakness of hip and shoulder girdle
Which organs most affected by cyanide poisoning?
CNS
most affects the organs that are more metabolic active
which are 3 sources of cyanide poisoning
- suicide
- fires (with synthetic materials getting combusted)
- nitroprusside continuous infusion
disc battery what to do?
esophagus need to remove
controversy if it is further on
ways to remove: sole, foley extraction, bougineage (put into stomach)
What are symptoms of a blowout fracture
- pain on upward gaze
- diplopia on upward gaze
- enophthalmos
- loss of sensation over the upper lip and gums on the injured side
- compromised upward gas on the affected side
- creptus over the inferior orbital ridge
location (orbital floor or medial wall from trauma)
estimate weight
(age x 3) + 7 average baby newborn 3 kg at 1 year 10 kg at 5 year 20 kg
