Emergency Medicine Final Exam- Bens
ACEP recommendations for use of backboards and cervical collars
"Backboard should not be used as a therapeutic intervention or as a precautionary measure either inside or outside the hospital or for interfacility transfers" "Spinal motion restriction should be considered for patients who meet validated indications such as the NEXUS criteria or the Canadian C-Spine rules"
Hangman's fx
- C2 bilateral pedical fracture - due to *hyperextension* injury - hanging chin on dash - leading to the body of C2 being anteriorly displaced on C3
bilateral facet dislocation
- complete anterior dislocation - disruption of the posterior ligament complex and the anterior longitudinal ligament - *hyperflexion* results in rupture of the posterior ligamentous complex - allows the superior facets to pass up and over the inferior facts
central cord syndrome
- corticospinal and spinothalamic tracts affected - loss of movement and sensation in upper extremities, incomplete loss in lower body
anterior cord syndrome
- damage to corticospinal and spinothalamic paths, *preservation of posterior column* - loss of motor, pain and T distally, preserves vibration and position
C1 Jefferson Fracture
- due to axial load - occipital condyles forced downward - fx of anterior and posterior arches of C1 - displacement of lateral masses - disrupted transverse ligament
Brown-Sequard Syndrome
- hemi-section of the cord - ipsilateral loss of *motor, proprioception, and vibration* - contralateral loss of *pain and temperature* - best prognosis for recovery
flexion tear drop fx
- hyperflexion and compressive forces, diving - push fragments into the spinal canal - when occurring at C4, can lead to apnea
chalazion (internal hordeolum)
- infected Meibomian gland (acute or chronic)
Stye (external hordeolum)
- infected oil gland at the lid margin
bronchiolitis
- most common cause of hospitalization in children < 5 y - MC in winter, through May - can last weeks - fever, noisy breathing, cough, drooling
atlanto-occipital disassociation
- pure flexion C1, C2 - +/- associated odontoid fx
ketamine
- sedative effecs on NMDA receptor (blocks Na+ channels of CNS) - antagonist to histamine - antagonist to acetylcholine - beta sympathomimetic
aspiration pneumonitis
Chemical injury to the lungs that may occur with regurgitation and aspiration of acidic gastric secretions. - due to impaired swallowing mechanisms and compromised airway protection
H. influenzae type B
MC organism for epiglottitis
parainfluenza
MCC of croup on children, characterized by seal-like barking cough and tracheal obstruction
0.1 mg/kg
dose of epipen or peds?
1:1000
epipen concentration
3 doses max (q3-5 min)
how frequent for peds epipen?
IM
how is epipen administered?
IVFs and pressors
how to treat neurogenic shock?
asymmetric or unilateral
how will wheezing be described with a foreign body and respiratory distress?
supportive care and time - steroids don't work!
management for RSV bronchiolitis?
- high flow oxygen - subQ epinephrine - Albuterol or Ipatropium - systemic steroids - IV MagSulfate - CPAP mask (infuse albuterol/epi through this) - sedate w/ IV ketamine
medical management of severe asthma exacerbation
T6
neurogenic shock occurs if there is a spinal cord injury at the level of _______ or higher
only once they have a full complemented teeth and can chew
only when should kids have the "commonly aspirated foods?"
enhance cAMP - target levels of 10-20 mcg/mL
phosphodiesterase drugs assist to do what?
spinothalamic (lateral and anterior)
spinal pathway - nociceptive pain
dorsal column
spinal pathway - touch, pressure, kinesthesia
lateral/sagittal view
what Cervical spine view assesses alignment of spine and looks for disruptions in the cortex?
Cefepime (or can use Vancomycin)
what abx is used for treatment of febrile neutropenia with risk for sepsis?
-Not comfortable -Restricts respirations -Does not fit all patients -Induces anxiety -Can cause pressure ulcers -Difficulty with airway protection -Lack of evidence
what are disadvantages of backboards?
- AMS - labored effort - speaking in short word strings - diaphoresis - cyanosis - marked fatigue - combativeness
what are red flags of respiratory distress? (7)
- hypotension and bradycardia - loss of sympathetic tone - injury to T6 or higher
what are signs of neurogenic shock?
PDA, VSD, ASD
what are some heart defects causing shunting of blood flow and overloading of 1 side? (3)
holes, malformed valves, obstructions, and misplacements
what are some lesions that can cause congenital heart disease? (4)
- infectious - vascular inflammation (Kawasaki) - Drugs (chemo) - tachyarrhythmias and heart block
what are some non anatomical causes of CHF due to myocardial contraction being impaired? (4)
hypoplastic ventricle, aortic stenosis, coarctation of aorta
what are some obstructive heart defects? (3)
- etomidate - propofol - midazolam - ketamine
what are some sedative/hypnotic drugs?
- succinylcholine - rocuronium - vecuronium - cisatracurium
what are some skeletal muscle paralytic drugs?
- hypoxemia - hypovolemia - hypoglycemia - hypothermia
what are the 4 deadly H's of Pediatrics?
- no midline cervical *tenderness* - no *painful* distracting injuries - *altered* mental status - *intoxication* - *neurological* deficits
what are the NEXUS criteria/Canadian rules that line up with the acronym "T-PAIN"?
- make injuries worse - restrict airway management - can increase ICP
what are the adverse effects of cervical collar? (3)
- aortic stenosis - dextrocardia - hypoplastic left heart - tetralogy of fallot - transposition of great arteries - VSD
what are the common congenital cardiac malformations?
- *vital signs* - cardiac monitor - oxygen - IV access - nasopharyngeal suction - NS fluids
what are the first things we want to do if a kid is brought in with respiratory distress?
- age >65 - dangerous MOI - paresthesias in extremities
what are the high risk factors according to Canadian rules? (3)
- simple rear end MVC - sitting position in ED - ambulatory at any time - delayed onset of neck pain - absence of midline cervical tenderness
what are the low risk factors for Canadian rules? (5)
- hot dogs - grapes - nuts - raisins - jelly beans - corn - hard candy - popcorn
what are the most commonly aspirated foods?
- tachypnea - retractions - head bobbing
what are the physical manifestations of respiratory distress? (3)
- lateral/sagittal view - odontoid view
what are the two views we focus on for cervical spine radiology?
- Jefferson fx - bilateral facet dislocation - odontoid - atlanto-occipital disassociation - Hangman's Fx - Teardrop Fx
what are the unstable C-spine fractures? (6) *Jefferson Bit Off A Hangman's Tongue*
Canadian C-spine
what can be used to rule out a patient who has C-spine tenderness?
RSV
what causes bronchiolitis?
oral flora anaerobes
what do we want to cover for antibiotics with aspiration pneumonitis?
history
what is 90% of making the diagnosis for eye complaints?
oral, IM, IV dexamethasone 0.6 mg/kg (max 12 mg) - 40% O2/60% Helium
what is inpatient management of CROUP??
supportive care - NPO, O2, IVFs, suction - Beta 2 nebs, empiric abx - intubation and ventilator if severe
what is management for hydrocarbon ingestion?
cool humidified air, hydration, antipyretics - *NO OTC cough/cold products*
what is outpatient treatment for CROUP?
respiratory failure
what is the #1 cause of cardiac arrest in babies and young children?
visual acuity
what is the FIRST part of the exam for eye complaints?
30
what is the average RR of a 1 yr old?
17
what is the average RR of a 14 yr old?
25
what is the average RR of a 3 yr old?
19
what is the average RR of a 6 yr old?
18
what is the average RR of an adult?
40
what is the average RR of newborn?
increase CO2
what is the cause of combativeness with respiratory distress?
7 mL/kg
what is the desired tidal volume in a child?
bag/mask ventilation
what is the first intervention in an apneic patient?
- assess the adequacy of the films
what is the first step in interpretation of the cervical spine imaging?
prevent secondary injury
what is the goal of placing a C-spine prehospital?
10-20 mL/kg
what is the starting volume of NS fluids for someone in respiratory distress?
- warm compress - erythromycin ointment 7-10 days - PLUS doxycycline in refractory cases - *refer to optho for persistent cases*
what is the treatment for infections?
- warm compresses - erythromycin ointment for 7-10 days
what is treatment for stye?
ciliary
what part of red eye is deeper?
visualize the dens and lateral masses
what would be considered adequate with odontoid view?
all cervical vertebrae and the top of T1
what would be considered adequate with the lateral/sagittal view?
only *after* hemorrhagic shock is ruled out
when can neurogenic shock only be diagnosed?
once oxygen is <80%
when does cyanosis become visible with pO2?
only if you can see it
when should you remove a foreign object with your finger?
dextrocardia
when the heart is on the opposite or right side of the chest
only when there is an absence of air movement
when would we do the heimlich maneuver on children?
subcostal, intercostal, and suprasternal/clavicular
where do we look for retractions when assessing breathing in kids?
face mask w/ reservoir
which breathing apparatus gives them the best oxygen administration?
odontoid view
which cervical spine view assesses alignment of C1 and C2 and looks for Dens and Jefferson Fractures?
conjunctival
which part of red eye is superficial?
increase the heart rate and maintain CO when intubating, because peds tend to tank their HR when being intubated
why is atropine used in peds code for intubation?
FiO2 (fraction of inspired oxygen)
The percent of O2 a client receives
Hypoplastic Left Heart Syndrome
underdevelopment of the left side of the heart, usually resulting in an absent or nonfunctional left ventricle and hypoplasia of the ascending aorta
