secrets ER2 Flashcards
A child presents with sudden inability to see after getting punched in the eye, the eye looks shrunken and the pupil looks tear shaped. What is the diagnosis and what do you do?
ruptured globe inability to see after eye trauma eye sunken - decreased IOP anterior chamber may be flattened or shallow may see tear shaped pupil
management of globe rupture
emergency, cal optho
Sterile dressing and shiled
Antiemetics (to protect against increased pressure)
NPO to prepare for surgery
Tetanus shot
Analgesics (parenteral or oral NOT topical)
Sedation (if not other contraindications) should be given
What are contraindications to pupil dilatation drops
- need neuro exams
- increasing ICP with herniation is possible
- acute angle glaucoma- moderate eye pain, decreased vision, cloudy cornea, asymmetric pupil size, poor pupillary reaction)
to avoid systemic absorption, should put pressure on the medial can thus
A two year old loses a tooth after falling on the playground. What should you do?
a) re-implant it
b) leave it and refer to dentist
b)
don’t replant baby teeth because it can damage the nerve root or cause dental ankylosis (solid fixation of the tooth to the bone)
A 10 year old year old loses a permanent tooth after falling on the playground. What should you do?
a) re-implant it
b) leave it and refer to dentist
a)
for secondary teeth, should repair as soon as possible
early insertion after gentle rinsing
disturb the root as minimally as possible
if you can’t (because patient rowdy, etc) then transport in cold milk or saliva or under parent’s tongue, reimplant temporarily until definitive dental care can be obtained
Persistant nasal bleeding, 3 management options
- pressure
- topical vasoconstrictors
- cauterization
- anterior or posterior nasal packing
A child has there nasal septum bulging into the nasal cavity. What are two risks if this goes untreated?
septal hematoma,
if we don’t treat (i.e. drain) risk of abscess formation or pressure necrosis
Clear fluid leaking from nose of a child after a head injury. What should you think of?
could be a CSF leak from cribriform plate, suborbital ethmoid, phenoid sinur or frontal sinus fracture
CT scan etc to figure it out
how to tell if clear fluid from the nose is CSF or just fluid?
check glucose
CSF: higher glucose than nasal mucous (should be 0)
to remember, snot is not sweet
When should you reduce a broken nose in a child?
within 4-5 days if causing asymmetry
frontal scalp hematoma in otherwise well 1 year old after minor trauma, do you need a CT?
nope, other scalp hematomas are an indication
also need to look at the mechanism of injury and the patient’s status (check the Canadian CPS statement for the best answer for our exam)
What is the risk of lethal malignancies from cranial CT in childhood?
1/1000-1500 based on one study
very important not to order too many CTs
true or false - papilledema is apparent as soon as increased ICP occurs
false - takes 24-48 hours to get papilledema
3 different types of herniation
- tentorial herniation - ipsilaterl third nerve findings - dilated pupil, ptosis, loss of medial gaze; contralateral hemiparesis and decerebrate posturing (temporal lob herniating through ridig tentorium)
- cerebellar tonsils through foramen magnum - abnormalities of tone, bradycardia, hypertension, progressive respiratory distress
- subfalcine herniation - herniation of cerebral hemisphere beneath the flax - get leg weakness and bladder abnormalities
what type of cervical spinal fracture more likely in younger kids?
higher in younger kids, lower in older kids, based on head size/neck muscles
What is SCIWORA?
spinal cord injuries without radiographic abnormality
most are younger than 8 years old
have symptoms of spinal cord injury but normal x ray and CT
MRI can help
with these symptoms need to keep evaluating the spine and get further evaluation
How many view to clear a c spine
at least 3 views: 1. AP (include C7-T1 and C1-C7) 2. lateral 3. open mouth (odontoid) if symptomatic but these are negative then consider CT and MRI oblique are controversial
A child sustains a punch to the stomach at school and complains of pain in the left shoulder , what injury should you consider?
Kehr sign - referred pain from blood under the diaphragm
suggests injury to abdominal organ
most commonly spleen
can elucidate with LUQ palpation or trendelenburg (since it shifts the blood closer to the diaphragm)
a 5 year old has ethimosis of the lear abdomen after a car accident, what injury should you suspect
lap belt injury
kids who are to young or too small
lap elt rests high
1. lumbar spine injuries - especially flexion disruption (chance)
2. bowel/bladder perforations/distruptions
proven pelvic fracture what test should you do?
worry about urethral injury
do a retrograde urethrogram
contraindications to foley ?
boggy high riding prostate
blood at the urethral meatus
when to do abx in shock
within 1 hour start antibiotics
comes before inotropes
principles of opioid
rigmorphine, hydrator is regarded as first choice
use PCA/NCA to avoid need for PRNs , ght dose is the right dose that prevents pain
assess side effects
if >1 week taper to avoid withdrawal
PCA/NCA avoid infusion to avoid the need for pen decision
switch from IV to po morphine give 3x dose oral
All of the following are therapeutic measures in TCA overdoses EXCEPT
hemodialysis does not work for TCA because TCA has a really wide distribution into the tissues, dialysis won’t help because it is already in your tissues and cells
bound to your receptors
nelson says does not work
phenytoin - don’t use in TCA/general overdoses because most bad medicines cause sodium channel blockage and can worsen arrythmias
alkalinize urine
sodium bicarb
norepi will make your heart rate worse - more selective on alpha receptors, may worsen potential arrythmias ->use if hypotensive
how long to monitor for TCA overdose: 6 hours
Can give more than one dose than activated charcoal if you think the med slowed down their gastric emptying
indications for Na HCO3 in TCA overdose
arrythmias
QRS >100 ms
QRS matters not QT
CPS statement on acute bacterial meningitis
indications for imaging after LP done
- focal neurological
2. failure of sterilization of CSF
pulled elbow
subluxation of the annular ligament (not the radial head)
4 stages of tylenol ingestion
stage 1: first 30 min-24 hours, get anorexia, n/v, diaphoretic, metabolic acidosis
stage 2: 24-72 hours get tummy pain, elevated LFTs, nephrotoxicity, pancreatitis, prolongation of PTT
stage 3: 72-96 hours death usually occurs, peak LFT abnormalities, more anorexia/nausea/vomiting
stage 4: 96 hours to two weeks - slowly recover or get massive liver failure
parrafin oil
in makeup and lamps
pancreatitis, hepatitis and thrombocytopenia
valproic acid - pancreatitis
Most common side effect of cephalosporin
rash
diarrhea
anaphylaxis
1-19% have diarrhea
1-3% have rash
eosinophila -1-10%
methanol diagnosis
metabolic acidosis and increased serum osmolality
osmolar gap x 3.2 = estimated concentration of methanol
treatment NOT charcoal
give fomepizole
what to do for drowning kid that comes in looking good but with sats of 95%
observe for 6-8 hours even if asymptomatic
50% experience some resp distress even if otherwise well
most go to baseline within 8 hours
resp distress will be between 6-8 hours
when to do OR right after blunt abdominal trauma?
- unstable
- perforation of hollow viscus
- bleeding>1/2 blood volume (will also have vital instability)
tension pneumo
tachycardia resp distress deviated trachea hypotension jugular venous distension
side effects of SSRi overdose
tachycardia tremor sedation clonus diaphoresis occasional hyperthermia DONT get cardiac abnormalities or seizures
Which SSRI can cause cardiac conduction abnormalities?
huge doses of citalopram
serotonin syndrome
shaking/hyperactivity
altered mental status
autonomic instability
treatment for SSRi overdose
suppotive care
ciproheptadine - antagonist of serotonin receptor can be used
16 year old post op femoral fracture and splenic rupture
pulmonary embolism
fat embolism
pneumonia ?
ARDS ?
inv: Xray, spiral CT, V/Q scan, D dimer (but will be high anyways post op)
bat in room - 2 year old
give rabies prophylaxis
rabies immunoglobulin and vaccine
5 doses in total
administer directly into the wound - remainder you give IM
contraindications to ketamine
- previous anaphylaxis
- uncontrolled hypertension
- CRAZY (will make them more crazy)
(increased ICP used to be a contraindication)
retropharyngeal abscess with lateral neck x ray , 2 findings compatible with retropharyngeal abscess
- increased pre vertebral space
2. air fluid level
child in icy water for 6 minutes, no vitals but temp is 28 C, continuing resus
need to warm and dead
carbon monoxide poisoning what to do?
100% O2 through non rebreather
delayed neuropsychiatric symptoms - 3 days to 250 days later, degree of cognitive deficit and personality change
if anemic need to transfuse them
hyperbaric O2 chamber
jimson weed how to treat
physostigmine for anti-cholinergic toxidrome
complication of erythromycin
pyloric stenosis
lasix side effects in neonates
- metabolic alkalosis
- hypo natremia
- nephrocalcinosis
- ototoxic
- hypokalemia
6 clinical signs of gravol overdose
Anticholinergic toxidrome **
neonate with PDA treated with indomethacin
- platelet dysfunction - don’t work that well, lasts 7-10 days
- renal - increased BUN/Cr
- increased risk of NEC - slight mesenteric vasoconstrictor
- hypoglycemia and hyponatremia, hypokalemia
3 serious side effects of risperidone
- prolonged QT
- acute dystonic reaction
- neuroleptic malignant syndrome
weight gain, metabolic syndrome, diabetes, hepatotoxicity
tension pneumo investigation what to do
transillumination then needle
anthracyclins
doxorubicin
causes cardiomyopathy
myeloid depression
secondary malignancy (AML/myelodysplastic syndromes)
5 contraindications to succinylcholine
- hyperkalemia
- neuromuscular
- history of malignant hyperthermia
- hypersensitivity
- glaucoma/eye injury (can increase the ICP more)
steroids inhaled for asthma, effect on height
no effect on final height (CPS statement asthma)
most common fracture in children
buckle fracture - less displacement in pediatric fractures
labs in Kawasaki
- What lab abnormalities would you find in Kawasaki.
a) neutropenia
b) thrombocytopenia
c) hypoalbuminemia
other lab abnormalities: thrombocytosis super high a few days after sterile pyuria LFTs high Normocytic anemia Increased ESR/CRP (unaffected by IVIG) Neutrophilia Decreased lipids hyponatremia pleiocytosis in CSF
