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129 Cards in this Set
- Front
- Back
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what is the initial goal of PALS?
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to rapidly classify patients into one of the following categories:
- stable - impending resp. failure - definite resp. failure or shock, compensated or uncompensated - cardiopulmonary failure - cardiopulmonary arrest |
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How long do we have to make our first initial PALS assessment to classify the patients status
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less than 60 seconds
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What is the first thing we want to evaluate in an acute ped?
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Airway! If alone, do 1 min of ABCs before activating EMS
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Once cardiopulmonary failure has occurred in a child how many will die?
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75-80% die!
if they survive >75% will have permanent injury |
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What is the MCC of cardiopulmonary arrest in a child?
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Respiratory failure
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do infants breathe through their nose or mouths?
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nose! be careful not to occlude nasal passages
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Is nasal intubation a good option to give infants oxygen?
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not really. they are easily obstructed with mucous
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in what position should you place an acute child to assess their airway?
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sniffing position. they have big heads to make sure to put padding under their shoulders not the occiput
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how do we determine the size needed for an uncuffed ET tube?
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Age/4 + 4
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How do we determine the size needed for a cuffed ET?
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Age/4 + 3
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What is the rough set. used for the size of a child ET tube?
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the size of their little finger (5th)
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what three things are we observing for when assessing Breathing in an acute child?
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1. Respiratory rate, low and high rates are dangerous
2. Mechanics - grunting, flaring, retractions, accessory mm use 3. Air entry - chest expansion, breath sounds, stridor, wheezing, paradoxical chest motion |
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when assessing a childs circulation what is more important BP or Heart rate?
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Heart rate!! BP will be maintained until all of a sudden will collapse so not good indicator of how the child is doing.
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What is the PALS algorithm for bradycardia?
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1. ABC's
2. O2 at 100% If continued cardioresp. compromise and HR <60 with poor perfusion then 3. CPR If patient continues to have bradycardia can follow with 4. Epinephrine 5. Atropine used less commonly and only for AV block with increased vagal tone |
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If a child is in pulseless arrest what would you shock him at?
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2J/kg then
2-4 J /kg then 4 J/kg |
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If child in pulseless arrest does not have a shockable rhythm how do you treat?
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CPR and then Epi and then CPR and epi etc
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how do we measure the lower limit of systolic blood pressure for kids 2-10 yo?
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70 + [ 2 x ( age in yrs)]
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what SPB is considered hypotention in <1 month old?
in a 1-12 month old? |
<60 for <1 month
<70 for 1-12 months |
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for kids >10 years old what SBP is considered hypotension?
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<90
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what are different types of shock syndromes seen in peds?
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"Chodd"
Cardiogenic hypovolemic Restrictive Dissociative Distributive |
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what are examples of things that can cause cardiogenic shock syndromes?
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MC = CHD (congential heart dz)
heart failure drug intoxication |
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what is the most common type of shock in peds?
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hypovolemic
due to decrease in circulating blood volume ex: GI loss, hemorrhage, burns |
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what are examples of things that can cause obstructive shock syndromes?
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tamponade (rare), pneumothorax
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what are examples of things that can cause dissociative shock syndromes?
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CO poisoning or methemoglobinemia
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What are examples of things that cause distributive shock syndromes
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due to maldistribution of blood flow
MCC = septic shock Anaphylaxis, CNS injury, intoxication |
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What is the algorithm or fluid resuscitation?
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20ml/kg of NORMAL SALINE over 15-30 minutes
Can be repeated up to 3x depending on the clinical situation |
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regardless of the type of injury to the child, be it CNS, or cardiogenic, restoration of what is always the highest priority?
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restoration of BP and cardiac output
want them to be perfusing first or else CNS and all the other systems will die regardless |
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where do we obtain venous access from in peds?
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very difficult to get venous access in kids
use small IV catheter often we may have to go interosseous or central line Saphenous line in baby may work) |
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What fluid maintenance formula gives us the hourly fluid maintenance rate?
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4:2:1
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How does the 4:2:1 calculation for maintentance fluid work?
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4 ml/kg for first 10 kg
2 ml/kg for next 10 kg 1 ml/kg for every kg over 20kg |
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maintenance requirements for electrolytes are based on volume. what are they?
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Na = 3 meq / 100 ml
K = 2meq/100ml Cl = 4 meq/100ml |
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what electrolyte/ maintenance fluid would you use for a 12kg baby?
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4x10= 40
2x2 = 4 total 44ml/hr 44ml / hr D5 1/2NS + 20KCL/L |
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what's the electrolyte shortcut for children >10 kg?
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Use D5 1/2 NS
plus 20KCl/L after voiding |
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what is the electrolyte shortcut for children <10kg?
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Use D5 1/3 or 1/4 NS if available
plus 10 KCl/L after voiding |
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For MG, who should weigh 7kg, what would her maintenance fluids be if healthy?
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4ml/kg for first 10kg = 28ml/hr
<10kg so want to use 1/3 or 1/4 NS with 10KCl/L after voiding answer: 28ml/hr D5 1/4 NS + 10KCl/L |
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0.2%NaCl is the same as ____NS
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1/4 NS 34 meq/L of Na
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whats the urine ouput goal for children and infants?
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children 1ml/kg/hr
infant: 2ml/kg/hr |
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how are diarrhea losses replaced?
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1:1 NS every 4-6 hours
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how do we know how much fluids a child is losing if they have diarrhea?
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wight the dirty diaper for strict I/Os
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in general, how do we replace fluid deficit for someone without electrolyte abnormalities?
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50% of deficit over 1st 8hours and remainder of next 16 hrs
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for correcting hypertonic dehydration you need to calculate the ?
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water deficit (L) = [(current Na level - 145)/ 145] x 0.6 x kg
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We want to correct half the free water deficit in the first 24 hrs if Na is less than what?
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175 meq/L
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when treating hypertonic dehydration, the goal should be rate not more than?
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15meq/l per 24 hr , ideall 0.5 meq/hr because correcting too rapidly can be dangerous
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What can happen if we correct hypertonic dehydration too quickly?
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cerebral edema
Should be rate no more than 15meq/L/24hrs ideally 0.5 meq/hr |
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When correcting hypertonic dehydration (Na >150) how quickly should the rate be of decreasing Na?
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no more than 15meq/L/24 hrs
ideally 0.5 meq/ hr |
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when correcting the free water deficit do we give the fluids all within the first 24 hrs?
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no, only half of the FWD is given in the first 24hrs
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if giving free water replacement through IV what is the calculation?
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water deficit x [ 1/ 1(Na concentration in replacement fluid/1540]
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For hypernatremic dehydration, additional ____ will help draw water into cells
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K, pottassium
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If you have associated hyperglycemia, may want to do ...
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D 2.5
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in hypernatremic dehydration, where additional K will help draw water into the cells, you may want to consider giving what to infants and children?
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20 KCl to an infant or even
40 KCl to a child after voiding is established |
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if a patient clinically loos worse than you would expect would you suspect hyper or hyponatremia?
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Hyponatremia
happens a lot in MONO cases |
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when correcting for sodium deficiency you never want to exceed what rate?
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correction of 15 meq/L/24 hr
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for mild to moderate dehydration what route of rehydration is preferred?
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oral if possible
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when undifferentiated AMS is present what 2 things do we do immediately?
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check Dstick (glucose)
and give oxygen |
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if an adolescent comes in which acute poisoning we should assume what?
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that they are suicidal, until proven otherwise
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what should we include in our detailed physical exam in a child with suspected poisoning?
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1. full set of vitals
2. neurologic exam (pupillary, nerve palsies) 3. cardiovascular status 4. skin findings (wet, dry, lesions) 5. odor to breath or clothes? |
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What initial labs should we consider in child with suspected poisoning?
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1. D stick
2. venous blood gas, CO level? 3. Blood: CBC, chemistries, LFTs, CK, coags, ABG, ammonia? lactate? 4. serum levels, acetaminophen, ASA, med level based on hx 5. Urine: UA, urine tox 6. Imaging: CXR, and xray 7. ECG |
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what sort of imaging would you want to get on a ped with suspected poisoning?
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Chest xray and abd xray
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what sort of blood work would you want on a ped with suspected poisoning?
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CBC
chemistries LFT CK lactate? coags ammonia? ABG serum levels for acetaminophe, ASA, med level based on hx |
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what mnemonic do we use to assess for metabolic acidosis and what does it stand for?
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MUDPILES
methanol, CO Uremia Diabetes Paraldehyde Iron, Isoniazid Lithium Ethanol, ethylene glycol Salicylates, starvation, szs |
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In calculating serum anion gap and osmolality you get a difference of 12, this strongly suggests?
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difference >10 strongly suggests methanol or ethylene glycol
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if a child ingested his mother's metformin what would hemost likely present with?
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hypoglycemia
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what substances can be toxic in kids and commonly present with hypoglycemia?
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"I need MO PIIE"
Metformin - oral diabetic meds Propranolol INH Insulin Ethanol |
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what substances can be toxic in kids and commonly present with hyperglycemia?
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Salycilates
Isoniazid Phenothiazines Iron Sympathomimetics |
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what substances can be toxic in kids and commonly present with hypocalcemia??
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Fluoride
Oxalate Ethylene glycol |
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what sort of substances are considered Anticholinergics?
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anti-depressants, anti-histamines, atropine, antipsychotics, nightshade, jimson weed, some shrooms
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what sort of substances are considered cholinergics?
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insecticides, meds for MG
organophosphates, carbamates (physostigmine) nerve agents and some shrooms |
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what are types of opioid/sedatives?
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Narcotics, barbiturates, benzo’s, opiates, ethanol
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Cocaine, MDMA, PCP, amphetamines, decongestants, caffeine, withdrawal
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sympathomimetic
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Anxiety
Tachycardia* Hypertension Dilated pupils/Blurry vision Urinary retention Seizures/Psychosis Nausea/vomiting Diaphoretic “gooseflesh” |
sympathomimetics = cocaine, MDMA, PCP, amphetamines, decongestants, caffeine, withdrawal
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Depressed MS
Constricted pupils Hypopnea Bradycardia, hypotension Ileus Hypothermia hyporeflexia |
Opioids = Benz's, barbiturates, narcotics, ethanol, morphine, vicodin
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what substances can we see in radiopaque KUB?
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B CHIPPED
Batteries Calcium, chloral hydrate, carbonate Heave metals (lithium, lead, zinc, barium, bismuth, arsenic) Iron Phenothiazines - insecticides Play-doh, potassium chloride Enteric coated pills Dental amalgam (fillings |
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what is our biggest concern when it comes to poisnonings with hydrocarbons?
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aspiration! more dangerous than ingestions can lead to chemical pneumonitits
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Do we get an xray for hydrocarbons ingestions?
Do we do GI decontamination? |
yes, along with observation for signs and sx of resp. distress/ systemic toxicity
no role for GI deconatmination |
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Systemic toxicity with hydrocarbons in uncommon except with which agents?
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" Toxic Carbons -- SH1T"
Trichloror's Camphor Spot removers Heavy metals Insecticides Toluene |
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the following hydrocarbons are nontoxic in 95% of the cases
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Asphalt, tar, motor oil, mineral or liquid petroleum, lubricants, baby oil
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what is the tx for lead poisoning?
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hypertonic phosphate enema for visible chips in intestine
chelation therapy for levels above 45 |
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what are sx for someone with lead level of 50?
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HA, anemia, irritability
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what are sx for someone with lead level of 82?
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encephaolopathy, increase ICP, seizure
Clues are basophilic stippling on cbc and risk factors |
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what is the tx for caustic ingestions
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both acidic and alkaloic use dilution and neutralization
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how will a patient with caustic ingestion present?
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dysphagia, epigatric pain +/- oral mucosal burns, low grade fever
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Present with dysphagia, epigastric pain, +/- oral mucosal burns, low grade fever
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caustic ingestion
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what is the leading cause of fatal poisoning in children?
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iron ingestion
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When do we see significant iron toxicity if more than what?
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20mg/kg of elemental iron was ingested or if patient is symptomatic
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How do we make dx of iron ingestion?
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2-6hr afer ingestion serum iron
Abd, xray to count pills |
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describe the 5 stages of iron poisoning
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Stage 1: (0-6 hrs) -- vomiting, hematemesis, abd. pain, hematochezia, diarrhea
Stage 2: (6-24 hrs) -- asymptomatic Stage 3 : severe heaptotoxicity - hepatic failure, shock, szs, coagulopathy Stage 4 (4-6wks) - gastric outlet or intestinal stricture |
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what system do we use in pediatric trauma that eliminates math, memorization, promotes standardization, provides redundancy and universality and overall reduces errors?
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broselow/Hinkle system
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for trauma, ABCs become ABCDE's what does it stand for?
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A - airway + assess cervical spine
B - breathing + assess major thoracic injuries C - circulation + control any bleeding D - disability, assess and monitor neurologic status E - exposure, undress the child completely and address any thermal issues |
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who are more likely to be susceptible to hypothermia? adults or children?
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children
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what is included in the initial trauma lab evaluation
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1. Hematology: CBC, platelets, type and cross match
2. Urinalysis : gross and micro 3. Chemistry's : LFTs, amylase, lipase, 4. Radiology: C spine films, CXR for fx, CT scans where indicated for head, chest, abd. trauma. |
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children suffer more blunt trauma, esp. blunt abdominal trauma. Most frequently injured organs in order are:
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spleen> liver> GU tract > stomach > intestine
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_____ is method of choice for hemodynamically stable children with intra-abdominal trauma
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CT
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Pain at tip of left shoulder or left chest with resp. distress, nausea, vomiting
Positive Kehr sign what abd. organ? |
spleen
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abdominal trauma to this organ accoutns for 40% of all deaths
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liver
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Pain in right shoulder or RUQ; hypotension
what abd. organ? |
liver
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how do we want to tx abdominal trauma to the spleen and liver?
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non-operative management if possible with serial CT or US assessment and ICU care
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abdominal trauma to this organ can be missed on CT, need to have a high index of suspicion
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intestine
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What will UA show for renal damage?
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blood and increased protein
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What is diagnostic for renal damage?
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IVP (intravenous pyelogram)
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______ occurs in up to 20% of patients with severe intrabdominal injury
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pneumoperitoneum (air or gas in the peritoneum, abdominal cavity)
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head injury is present in _____ of patients with multiple traumas
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80%
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In pediatric cases what is the most severely affected part of the body when dealing with trauma situations?
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the head
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What is part of our rapid neurologic assessment on a head trauma?
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Examine the pupil size and reactivity
Do a mental status assessment - GCS |
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Awake, alert children who have headaches, sleepiness or vomiting
are classified as head injury with |
no neuro deficit
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Imaging may not be necessary for head injury/trauma if the following:
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1. neuro exam is normal
2. consciousness is preserved |
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Imaging should be done for head trauma if:
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1. presistent worsening HA
2. Vomiting 3. neuro changes 4. any skull fx of physical exam signs suspicious of skull fx |
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what are physical exam signs suspicious of skull fx?
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localized bogginess/pain
battle signs racoon eyes hematoympanum CSF rhinorrhea otorrhea |
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when assessing burns, what criteria would make you want to hostpiatlize the child?
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1. >10% BSA
2. electrical burn 3. smoke inhalation 4. social or medical problems |
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what fluids do we give peds with burns?
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lactate ringers bolus instead of NS
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what are the first 4 steps in inital burn management?
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1. cover surface with sterile sheet
2. relive pain and anxiety (will be easier to tx them) 3. debridement 4. cover with silver sulfadiazine or neosporin |
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any time an infant has decreased responsiveness and there are no sources (or confirmed sepsis) what do we want to look at?
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the head. maybe even order a CT scan!
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what is the usual age group for shaken baby syndrome?
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up to 8 mo sometimes older
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name the sign:
sparing area of buttocks in contact with bottom of bath a type of submersion burn |
donut sign
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submersion burn:
sapring popliteal fossa |
zebra sign
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what are3 types of submersion burns?
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donut sign, zebra sign, stocking/glove
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which one of these scenarious would you not be suspicious of child abuse?
1. acute abdomen in a very young child 2. torn frenulum in a 4 mo old 3. bruise on the forehead 4. bruising on the lower back |
3. bruise on the forehead may be normal for kids as well as on the tibia and bony prominences
the other ARE suspicious for child abuse |
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any fx can be the result of abuse and no fx is pathognomic of abuse. however, there are some fx that have great specificity for abuse. what are they?
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1. rib fx, especially posterior
2. CMLs (bucket handle and avulsion fx) 3. scapular fractures 4. spinous process fx 5. sternal fx |
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what are 4 metaphyseal lesions of child abuse?
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1. metaphyseal lucency
2. bucket handle appearance 3. corner fx appearance 4. thicker bucket hand |
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when doing a case of child abuse your hx should encompass the following:
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1. obtain separate hx from adults, witnesses and child
2. record direct quotations 3. AVOID disqualifiers 4. find out social specifics |
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when doing a case of child abuse what should you include in the physical portion?
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1. list bruises by size, shape and color
2. check retina, eardrums, oral cavity, teeth and genitals. Completely undress the child 3. check bones/joints for tenderness, crepitus ROM 4. color photographs from near and far away 5. RECORD, RECORD, record 6. include pertinent negatives |
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when doing a child abuse evaluation what labs and imagingins studies should you consider?
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focused on occult injuries as well as on r/o underlying conditions (causes):
1. skeletal survey for children under 2 yo when abuse is suspected 2. CBC, platelet, PT, PTT, vit k, d dimer when bruising is present 3. Vit D (25OH) Ca, phosphorus, PTH, alk phos (copper, vit. c RPR) when fx are present 4. Low threshold for LFTSs, amylase, lipase and amino acids |
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when doing a child abuse evaluation what labs should you order if bruising is present?
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CBC, platelets, PT, PTT, vit k. d dimer
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when doing a child abuse evaluation what tests should you order if fractures are present
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Vit D (25OH), Ca, Phosphorus, PTH, alk phos (copper, Vit. C, RPR)
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what test can we do determine whether its impetigo or a cigarette burn?
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culture will yield organisms and help establish dx. You can rapid strep; especially ecthyma
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what is the cultural practice that does therapeutic burning called?
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Mauqua
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name 5 findings suspicious for sexual abuse
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1. abrasions or bruising of genitalia
2. acute or healed tear in posterior aspect of hymen that extends to or nearly to the base of the hymen 3. markedly decreased Amt. of hymenal tissue or absent hymenal tissue in posterior aspect 4. injury to or scarring of the posterior fourchette, fossa navicularis, or hymen 5. anal bruising or lacerations |
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when doing an evaluation of child sexual abuse what must we remember to check?
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check other orifices such as the mouth!
Culture orohparynx make sure to check for syphilis! |
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little johnny was sexually assaulted by his uncle who do we call?
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report to DCF. DCF will contact poilice and arrange forensic exam if family member
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little johnny was sexually assaulted by the next door neighbor, who do we call?
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the police
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