Trauma and Critical Care Flashcards
Trauma, PALS, NRP
What are PECARN criteria for pts >/= 2yo to determine if a child requires a CT scan?
- normal mental status
- No LOC
- no vomiting
- Non-severe mechanism
- No basilar skull fracture
- No severe headache
What are signs of a basilar skull fracture?
CSF rhinorrhea, raccoon eyes, hemotympanum, battle sign behind ears
How does PECARN define a severe mechanism of action in head trauma
MVC ejection, passenger death or rollover
auto vs pedestrian/bicycle
Fall to head (<2yo=3ft; >2yo=5ft)
Head struch by high impact object
Give a ddx for shock in the neonate
THE MISFITS Trauma/NAT Heart dz/hypovolemia Electrolyte disturbances Metabolic disturbances (CAH) Inborn errors of metabolism Sepsis Formula dilution Intestinal catastrophy Toxins Seizure
Whate basic milestones should you always remember when considering NAT?
4 mo rolls over
6mo sits unsupported
9mo cruises
12mo walks
In a cyanotic infant, what signs and symptoms point toward a cardiac etiology of cyanosis?
- SpO2 worsens with crying
- comfortable at rest
- <10% to SpO2 response to administering oxygen
- abnormal EKG
- Abnormal cardiac silhouette on CXR
In a cyanotic infant, what signs and symptoms point toward a pulmonary etiology of cyanosis?
- SpO2 improves with crying
- uncomfortable at rest
- > 10% to SpO2 response to administering oxygen
- abnormal CO2
What medication should you give to keep a PDA open?
If you are planning to give this medication, what contingency planning should you consider?
Prostaglandin
Prostaglandin can cause apnea, so consider intubation if prostaglandin administration is deemed necessary
At what heart rate should you begin PPV during neonatal resuscitation?
HR < 100
During neonatal rescuscitation, what should be done once the heart rate drops below 60 bpm?
- Start chest compressions at 3:1 ratio
- Intubate patient
- 100% FiO2
- Obtain IV access rapidly
- Give epinephrine every 3-5 minutes
- Consider fluid bolus vs blood
During cardiac arrest, how often should you be performing rhythm checks?
Every 2 minutes
What is the PALS dosing for epinephrine?
- IV-[1:10,000]=0.01mg/kg=0.1ml/kg with a max single dose of 1mg or 10mL
- ET tube-[1:1,000]=0.1mg/kg
What are the Hs to consider during cardiac arrest?
hypovolemia, hypoxia, hyperkalemia, hypoglycemia, H+ (acidosis), hypothermia
What are the Ts to consider during cardiac arrest?
tension pneumothorax, tamponade, toxins, thrombosis (MIs, PEs)
What rate of compression:ventilation should CPR occur at depending on 1 rescuer, 2 rescuers, or advanced airway?
- 1 rescuer-30:2
- 2 rescuers-15:2
- advanced airway-continuous compressions w/10 breaths/min
During pulseless arrest, which rhythms are considered shockable?
Defibrillation should be performed for ventricular fibrillation or pulseless ventricular tachycardia
How many jouls/kg should defibrillation be performed at?
2J/kg–>4J/kg–>10J/kg
- How should a wide complex tachycardia with a pulse be managed?
- What are the dosages for drugs to be used?
- Which drug should be used for WPW?
- If patient is unstable (AMS, hypotension, signs of shock) proceed directly to synchronised cardioversion
- If patient stable and no evidence of WPW try adenosine 0.1 mg/kg, max 6mg
- If stable patient is refractory to adenosine, consider expert consultation for amiodarone (5 mg/kg over 20-60 min) usage vs procainamide (15 mg/kg over 30-60 min) if WPW
How should SVT be managed?
- vagal maneuvers first
- adenosine if no evidence of WPW, QRS monomorphic
- Synchronised cardioversion if the above fails
What are the jouls/kg for synchronised cardioversion?
0.5J/kg–>1J/kg–>2J/kg
How should symptomatic bradycardia be managed?
- HR<60
- Start CPR
- Epi q3-5 mins
- Atropine if suspected AV block or increased vagal tone
What is the initial management of a burn patient?
Cool burn w/ cool water, monitor for hypothermia, remove clothing near burn, update tetanus vaccination, provide pain relief, IV fluids
What is the rule of 9s for burn body surface area estimation?
- Infant/Toddler-Head=18%; back=18%; chest+abdomen=18%; GU=1%; legs=14%
- adolescent/adult-Head=9%; back=18%; chest+abdomen=18%; GU=1%; legs=18%
- What is the Parkland formula for fluid resuscitation in burn patients?
- How should you give this fluid?
- 4mL of LR/kg per % body surface area=total fluid over next 24 hours
- 1/2 given over first 8 hours
- 2nd half given over the proceeding 16 hrs
Under what conditions should you consider a foley cath for burn patients?
Burns >15% BSA, or burns involving perineum
If broselow tape is unavailable what is a quick way to estimate a patient’s weight?
Starting at 10kg for age 1, go up by 5kg every odd age: 1yo=10kg 3yo=15kg 5yo=20kg 7yo=25kg
What is the formula for cuffed ET tube sizing?
3.5+(age/4)
What is the formula to estimate systolic BP of 5th %ile by age indicating hypotension if the patient’s BP is under?
70+(age*2)
What vital sign changes occur with hypovolemia?
1st is tachycardia
2nd is narrow pulse pressure
last is hypotension
-Hypotension is a late finding of hypovolemia in pediatrics as children have a high sympathetic tone which allows kids to remain normotensive until 30% of their circulating blood volume is gone
What are indications to CT a patient with abdominal trauma?
abnormal vitals, abnormal exam (AMS, peritoneal signs, surgical abdomen), significant pain, seatbelt sign, abnormal labs, hematuria
What are peritoneal signs?
abdominal pain, distension, fever, N/V, decreased appetite, diarrhea, decreased UOP, thirst, fatigue, inability to pass gas
What are the Nexus criteria for clearing C-spine in children >/= 8yo?
- No midline cervical tenderness, no focal neuro deficit, normal alertness, no intoxication, no painful or distracting injury
- Children who underwent a severe mechanism of injury or who are inconsolable or altered will need imaging
What imaging should be obtained to clear c-spine?
- X-ray is appropriate.
- Due to ligamentous laxity children are at high risk of ligamentous injury. So if clinical suspicion is high but xray is negative the next best imaging modality is MRI
What are the most likely type of injuries in a pediatric chest trauma?
tracheobronchial tree injury, pulmonary contusions, tension pneumothorax
How would you estimate the size of chest tube needed to evacuate a hemothorax?
Chest tube size= 3-4 * ETT size
What structure should you worry about injuring in a posterior palate trauma?
carotid arteries!
What are red flags in posterior palate trauma?
-severe mechanism of action, AMS, drooling, neck swelling, torticollis, chest pain (could be mediastinal free air), evidence of remaining foreign body
How should posterior palatal trauma be managed?
- If no red flags but 1-2 cm of mucosal injury DC with antibiotics
- If red flags obtain a CT angiogram of the neck and carotids-DC w/ abx if negative
- If CT positive-NSGY/ENT/Vascular consults, consider anticoagulation with aspirin vs heparin
What are potential complications of posterior palatal trauma?
carotid pseudoaneurysm, carotid dissection, carotid thrombosis, CVA, retropharyngeal infxn, mediastinitis, internal jugular infection
- What is the dose of atropine for use during symptomatic bradycardia?
- Minimum dose?
- maximum dose?
-0.02mg/kg IV/IO with a minimum dose of 0.1mg and a maximum dose of 0.5mg
- How is adenosine dosed for SVT?
- What are the max doses?
- Can try a second dose if the first fails as follows
- First dose-0.1mg/kg, maximum first dose of 6mg
- Second dose-0.2mg/kg with maximum of 12mg
How often should you be doing pulse and rhythm checks during a pulseless arrest?
-Every 2 minutes
Describe the PALS algorithm for Vfib/pulseless Vtach
- Start CPR and attach defibrillator. If rhythm is shockable (Vfib/pulseless Vtach, shock 2J/kg then pulse rhythm check. If no circulation return–>CPR. Obtain IV access and prepare epinephrine. After 2 mins CPR perform pulse/rhythm check. If still no pulse give epi and shock again 4J/kg. Pulse rhythm check, resume CPR. Obtain advanced airway. At next pulse check give amiodarone vs lidocaine vs mag(if torsades).
- Can give epi every 5 minutes.
- Should consider your Hs and Ts of reversible causes the whole time
- If at any point the rhythm is not shockable proceed to PEA algorithm.
What is the most common cause of pediatric cardiac arrest?
respiratory arrest
- At what age should you be attaching an attenuating device if available to an AED for defibrillation?
- Are attenuators necessary in the event they’re unavailable?
- Anyone <8yo
- The energy dose needed to produce histologic damage to myocardium is many times greater than that needed to defibrillate. Thus, a standard AED without a dose attenuator is acceptable for infants and younger children, if it is the only device available.
What is the most common organ injury following a handlebar type bicycle injury?
-Duodenal hematoma
- What is the most commonly injured abdominal organ in pediatric blunt trauma?
- What are other commonly injured abdominal organs in blunt trauma?
The spleen is the most commonly injured organ in blunt trauma, followed by the liver, kidney, GI tract and pancreas in descending order
At what minimum level of microscopic hematuria should radiographic evaluation be initiated in suspected genitourinary trauma in children?
In adults, there is a relatively higher threshold of hematuria combined with clinical status in determining the need for radiographic evaluation of suspected renal injury. In children, however, the threshold is much lower, generally recommended at 20 RBC/hpf. There are some experts/studies that recommend imaging with any degree of microscopic hematuria.
- What thoracic injury classically occurs in the absence of rib fracture in children?
- Are rib fractures common in pediatrics who have thoracic trauma?
- How often is thoracic trauma associated with organ system injuries?
- How should suspected diaphragmatic injuries be definitively excluded?
- The classic thoracic injury in children is a pulmonary contusion in the absence of an overlying rib fracture, due to the incompletely calcified pediatric bone and the increased pliability of the chest wall.
- A rib fracture in children is less common than adults and implies significant force.
- More than 2/3 of thoracic injuries in children are associated with other organ system injuries.
- Laparoscopy is needed to definitively exclude suspected diaphragmatic injury.
