Tom Emergency Medicine Flashcards
What is the appropriate ratio of breaths to compressions in paediatric CPR?
15:2
What is the appropriate dose for manual defibrillation in paediatric resuscitation?
4J/kg
In what scenarios might ‘3 stacked shocks’ from a defibrillator be appropriate?
When already attached to defibrillator and monitoring an a shockable rhythm is observed
1. cath lab
2. PICU post cardiac surgery
3. Other scenarios in which the above conditions are met
What is the appropriate defibrillation dose in haemodynamically compromised SVT?
0.5 - 1 J/KG
Describe the COACHED algorithm for defibrillation
Compressions continue
Oxygen away
All else away
Charge
Hands off
Evaluate rhythm
Defib or disarm
What receptor does noradrenaline primarily act upon?
Alpha 1
Primarily vasopressor
Used in septic shock
What receptors does adrenaline act upon?
Beta 1 and 2 at low does - chronotropy, inotropy, bronchodilation
At higher does has alpha 1 effects - vasopressor also
Anaphylactic shock, add on septic shock (although note that adrenaline now listed as first line option in RCH CPG)
What receptors does dopamine act upon?
Alpha 1 at high doses (vasoconstrictor)
Beta 1 at medium dose (heart)
D1 at low dose
What receptors does dobutamine act upon?
Primarily B1
Inotropy
Used in low output states/cardiogenic shock
2nd line in sepsis
What receptors does milrinone act upon?
Primarily B1/inotropic agent
Primarily a inotrope and vasodilator with little chronotropic activity
Milrinone selectively inhibits PEAK III cAMP (cyclic adenosine monophosphate) phosphodiesterase isozyme in cardiac and vascular muscle, leading to an increase in intracellular ionised calcium and contractile force in cardiac muscle.1,2 This activity results in left ventricular afterload reduction, with an increase in cardiac output and a reduction in total peripheral resistance.3
What is the pathology shown here?
Subdural
Crescentic
What is the normal ratio of soft tissue to vertebral body on lateral neck x-ray?
C2-3: soft tissues <1/3 of vertebral body width
C4-7 soft tissues <1 vertebral body width
https://emergencyeducation.org.au/paediatric-soft-tissue-neck-xrays/
What are the conditions necessary for the closure of a facial laceration with tissue glue?
Aponeurosis of frontalis muscle on view
<3 cm length
No flaps
Edges brought together without tension
https://pressbooks.bccampus.ca/advancedanatomy1sted/chapter/muscles/#:~:text=Epicranial%20Aponeurosis%20also%20referred%20to,bones%20to%20the%20lambdoid%20suture.
https://sjrhem.ca/rcp-scalp-lacerations-you-can-leave-your-hat-on/
A patient arrives shortly after GHB ingestion with GCS 3 requiring airway/ventilation support with bag and mask
What is the role for gastric lavage?
Rapidly absorbed so no role for gastric lavage or charcoal
An adolescent in out of home care presents reporting that they have ingested supratherapeutic doses of paracetamol everyday for the last 3 days, the last was immediately before presenting
Should you
a) measure levels immediately
b) start NAC immediately
c) wait 4 hours to take levels
Immediate NAC and ALT
Which toxidrome is most likely to be associated with the ECG pictured?
This ECG is classical for TCA overdose
There is:
- widening of the QRS complex (due to Na channel blockade in myocardium)
- QTc prolongation (K+ channel blockade)
- RAD
- Tall R wave in aVR
What is the Salter Harris Classification of the image shown?
II ‘above’ - the fracture starts above the physis
You see a 8 year old male who had FOOSH and now has a Salter-Harris II fracture of the proximal humerus with ~30% displacement and around 40 degrees of angulation
What will your management be?
he proximal physis contributes 80% of the length of the humerus. Due to the enormous remodelling potential, most of these injuries do not require reduction. There is no role for attempted reduction in the ED.
The older child with greater deformity may be treated with closed reduction. This is controversial and there are no agreed figures to guide closed operative reduction.
Approximate indications are:
5-12 years - accept 60 degree angulation and 50% displacement
>12 years - accept 30 degrees angulation and 30% displacement
Isolated greater tuberosity fractures with displacement in the adolescent are an exception group in which surgical reduction and fixation is usually required.
See x-ray
What is the management
This is a Gartland type 1 fracture (non-displaced)
Gartland 2 - displaced with intact posterior cortex
Gartland 3 - displaced with no cortical contact
A posterior fat pad and anterior sail sign are present, although a little difficult to see
There is also a visible anterior cortical breech
The anterior humeral line does not intersect the middle 3rd of the capitellum
The management would be with an above elbow back slab for 3 weeks
Which of the following is NOT true regarding the C1 vertebra?
a. no transverse process
b. bifid spinous process
c. superior facet joints articulate with the occipital condyles
d. contains a transverse ligament as part of the atlanto-axial joint
B = bifid spinous process is incorrect because C1/the atlas does not have a spinous process
A bifid spinous process is a unique feature of the C2-7 vertebra
A 15 year old male is in the front seat of a car, unrestrained, which then collides with a lane divider.
They present to ED with a bruise on their forehead and severe neck pain
What injury is shown?
This is a hyperextension injury causing a Hangman’s fracture
This consists of bilateral fractured C2 pedicles, horizontal tear in the C2/3 disc and subluxation of C2 on C3
What is the most common location for fracture of the odontoid peg in children?
Base of dens, body of axis not involved (type 2)
What fractures is the peg odontoid view useful for visualising?
Jefferson fractures
Peg odontoid fractures
Line 1Make sure the lateral masses of C1 (atlas) do not hang over the lateral masses of C2 (axis).
The rule of Spence would suggest that if there is more than a combined (total of both sides) overhang of 6.9 mm or more of the lateral masses of C1 in relation to the C2 lateral masses then there is concern for an injury to the transverse ligament and an MRI should be done.
Line 2
Make sure there is no asymmetry of the articular spaces between the lateral masses of C1 and the body of C2 (axis).
Line 3
Make sure there is no asymmetry of the articular spaces between the dens and the lateral masses of C1
A 16 year old dives headfirst into shallow water and has severe neck pain
The following XR is obtained
What fracture is shown?
Jefferson fracture
This is a burst fracture of C1 bony ring due to axial loading
Jefferson fractures are typically treated conservatively (hard collar immobilisation) provided the transverse atlantal ligament is considered intact (no widening of the atlantodental interval or intact ligament visualised on MRI).
In cases where the ligament is thought to be disrupted, the injury is considered unstable and more aggressive management is usually required 7. This includes halo immobilisation, posterior C1-C2 lateral mass internal fixation or transoral internal fixation.
What is commotio cordis?
in what resus scenario would it be inappropriate to give adrenaline?
CPVT
What condition is suggested by this rhythm strip?
Arrhythmogenic right ventricular cardiomyopathy
Epsilon wave present
https://litfl.com/arrhythmogenic-right-ventricular-dysplasia-arvd/
