board review 6/7/2013. what is your favorite letter? a. c b. d c. e d. a e. b
TRANSCRIPT
Board Review 6/7/2013
Emergency Care
Test QuestionWhat is your favorite letter?A. CB. DC. ED. AE. B
Pediatric Head Injuries
Role of the PCP Assess a patient with head trauma and
determine if a significant intracranial injury (ICI) has resulted
Recognize an increase in intracranial pressure
Initial management of acute CNS trauma
Outpatient management of minor head trauma
Head Injury: 2 parts Primary injury
Mechanical damage to skull/tissue Shearing forces vessel rupture bleeds
Secondary injury Ongoing derangement to neuronal cells due to: Hypoxia, hypoperfusion (local or systemic shock), metabolic derrangements (hypoglycemia), expanding mass, increased pressure, edema
Assessment of a patient with a head injury ABCs first! History
Details of injury mechanism Fall: height and surface type MVC: Use of restraining devices, speed Action of victim (thrown, rolled, etc)
Timing of symptoms LOC, amnesia, confusion, seizure, vomiting,
headache, general behavior Risk factors:
Seizure d/o Adolescent: drugs/intoxication
Assessment of a patient with a head injury Physical Exam
Mental Status!! Use the Glasgow Coma Scale
Examine head for obvious evidence of trauma Severe brain injury/trauma may be present in
a patient who has NO external signs of trauma
Neurologic exam Look for focal findings Fundoscopic exam: look for retinal
hemorrhages
Question #1A patient presents with blood draining
from his ears, ecchymoses in the orbital area, and postauricular bruising. He likely has what type of fracture?
A. Basilar skull fractureB. Simple linear skull fracture C. Scapula fractureD. Depressed parietal skull fractureE. Femur fracture
Specific Injuries: Skull Fracture Basilar Skull Fracture
Ecchymoses in the orbital area Blood behind the TM Battle sign (postauricular bruise)
Temporal Bone Fracture Bleeding from the external auditory canal or
hemotympanum Hearing loss Facial paralysis Cerebrospinal fluid otorrhea
Intracranial injury (ICI) Has an ICI occurred?
Clear predictors: GCS ≤ 14 or altered mental status Focal neurologic abnormalities Skull fracture
Yet many people with ICI lack these features…when do we do imaging?
Consider children < 2 years old separately More difficult to assess, more easily injured
from short falls, higher incidence of asymptomatic injuries, more often victims of inflicted injury
Question #2What type of intracranial injury is this?A. Subdural hemorrhageB. Subarachnoid hemorrhageC. Epidural hemorrhageD. Cerebral ContusionE. Diffuse axonal injury
Intracranial Injuries (ICI) Focal Hemorrhage:
Epidural Lens-shaped; often has overlying fracture “lucid interval” common on Boards only Subtle signs: vomiting, headache, often asymptomatic can progress
rapidly Subdural
Crescent-shaped; can be bilateral Associated with underlying brain injury Present with LOC, AMS, lethargy Suspect NAT
Subarachnoid Rarely associated with mass effects Usually seen with other ICIs Present with LOC, headache, meningeal irritation
Cerebral contusion Brain bruise: can have coup and contrecoup (brain striking skull) Present with subtle signs: vomiting, headache, LOC, ?focal neuro
defect
Intracranial Injuries (ICI) Diffuse Injury
Diffuse axonal injury Injury to white matter due to shear forces
Acceleration/deceleration or rotational forces (MVC) Present in coma or less commonly like a
concussion CT scan with small areas of hemorrhage near
gray-white interface Cerebral edema
Severe head trauma May not be visible on initial imaging Present with marked depression or deterioation of
GCS Main threat: increased ICP
Signs of Progressive Increased Intracranial Pressure Headache, vomiting, depressed mental
status Posturing and vital sign deterioration
Bradycardia, hypertension, abnormal respirations Ultimately, can lead to brain herniation
Repeated fundoscopic examinations are important to look for papilledema Especially for patients with coma or seizure May not be present initially
Brain Herniation 4 possible types
Uncal herniation Innermost part of
temporal lobe moves over tentorium
Exerts pressure on the midbrain and CNIII Leads to ipsilateral
pupillary dilation
Question #3A 12-year-old boy is brought to the emergency
department after being struck by a car. On physical exam, he is unresponsive and has a large abrasion over his forehead. His heart rate is 100, respiratory rate is 8 breaths/min and shallow, and blood pressure is 130/80. His pupils are unequal. Of the following, the MOST appropriate INITIAL step is to:
A. Administer tetanus prophylaxis B. Infuse 20 mL/kg of 0.9% salineC. Obtain head computed tomography scanD. Provide assisted ventilationE. Administer mannitol
Acute Management of CNS injury ABCs FIRST! Cervical spine precautions Oxygen Ventilation as needed to keep pCO2 34-
45mmHg Hyperventilation has a limited role GCS<8 = intubate
Drugs Cardiovascular support Anticonvulsants for seizures Medications to decrease ICP
Mannitol Hypertonic saline
Acute Management of CNS injury Hospital admission
Any depressed skull fracture ICI Normal CT scan but persistent symptoms (persistent
vomiting, severe headache, abnormal mental status) Emergent Neurosurgical consultation
Depressed skull fracture and any ICI D/C home?
Normal CT scan (or no CT scan indicated) Resolution of symptoms
Child is easily aroused to light touch, normal baseline mental status; normal neurologic exam
If vomited: can now tolerate PO fluids Reliable caregiver No concern for inflicted injury
Outpatient management of minor head trauma Always review symptoms concerning for ICI!
Return for: persistent or worsening headaches, development of vomiting, change in mental status or behavior, unsteady gait or clumsiness/incoordination, seizure
Arrange follow up (even if by phone) in 24 hours Wake up?
For low-risk mechanism, no LOC or mental status changes, <1 episode of vomiting, no non-frontal scalp hematomas Observe, do not need to keep them awake, check them
periodically No data available for waking child up
If concerning mechanism or prolonged symptoms: Can wake up every 4 hours: child should be able to recognize
parent and surroundings and appear alert
Musculoskeletal Injury in Children
Nursemaid Elbow Subluxation of the radial head Typical patient:
Age < 6 years History of pull on the arm by caretaker, sibling, etc
Patient holds arm partially flexed and pronated **refuses to move it voluntarily**
Reduction is initially painful but discomfort quickly resolves and patient begins moving the arm voluntarily
If uncertain of diagnosis or if reduction is unsuccessful xray!
Question #4Name this type of fracture:A. Buckle fractureB. Greenstick fractureC. Nursemaid’s elbowD. Salter-Harris Type 1E. Salter-Harris Type 4
Fracture Patterns in Children Bones tend to BOW rather than BREAK Buckle (torus): compression fracture
Metaphyseal fractures Circumferential compression but no periosteal
rupture Greenstick
Incomplete fractures of diaphyseal or metaphyseal bone
Intact bridge of cortex and perisoteum on the compression side
Plastic deformation: in very young children, neither cortex may break
Growth Plate 20% of all childhood fractures occur at
the physis Can disrupt bone growth
S A L T R
Focus on… Clavicle fracture AC separation Injuries that affect vasculature
Question #5You are seeing a 5 yo boy who complains of right arm
pain after a fall while jumping on the bed. He is holding his right arm against his body and is unwilling to move it. He has no deformity or swelling of his right arm, but he does have a tender swelling in his mid-clavicle. You obtain a radiograph which shows a midshaft clavicle fracture. Of the following, you are MOST likely to advise the parents that:
A. Complications include ulnar nerve palsyB. He should be tested for osteogenesis imperfectaC. His right arm should be placed in a slingD. Surgical reduction will be neededE. The injury typically heals in 8 to 10 weeks which will
be done in foster care because you are reporting them to OCS
Clavicle Fracture Common fracture of childhood Majority are mid-shaft or distal Caused by fall or direct force onto
lateral shoulder (with arm adducted) Presents with pain, deformity, swelling,
unwilling to move arm Rare complications: brachial plexus injury
(more common with distal fracture) Treat:
Immobilization with either figure of eight bandage or sling
Acromioclavicular Separation Adolescent male athletes Fall onto shoulder with
arm adducted or direct blow to lateral shoulder
Ranges from partial to full separation
Swelling and tenderness over AC joint; pain with arm elevation and crossing over across chest
Treatment: Partial: immobilization Complete: surgery
Normal Shoulder
Supracondylar fracture 60% of elbow
fractures in children
High incidence of neurovascular injury Nerves: radial,
median or ulnar Vascular: brachial
artery More common with
posterolateral displacement of distal segment
Look for pallor and worsening pain
Other fractures associated with vascular complications Tibial fractures: watch for compartment
syndrome in the distal lower extremity Scaphiod fracture of the wrist: at risk for
ischemic necrosis Posteriod sternoclavicular dislocations:
dislocated proximal clavicle may compress the upper airway or subclavian vessels
ACUTE FEVER
Normal Body Temperature Prior to the development of various thermometers, a temperature of 98.6 became synonymous with “normal” body temperature
Body temperatures vary depending on multiple factors Method of assessment (axillary, oral, rectal,
tympanic) Mean range of 97.5-98.6
Time of day: lowest in morning, peak in early evening Individual factors
Age (slightly higher in younger infants) Sex Physical activity
Ambient air temperatures
Temperature Measurement There are various methods used to measure body temperature…consistency is important
Axillary Skin temperature lags behind core temperature,
especially early Low sensitivity, often inaccurature and imprecise
Oral method Safe and comfortable in kids > 5 years Less lag time and more accurate than axillary
measurements Affected by temperature of recently consumed
foods or by evaporative effects of mouth breathing
Temperature Measurement Rectal temperature Has long been accepted as the gold standard of
indirect measurement Standard of care in febrile neonates
Less deviation by environmental factors Uncomfortable Associated with cross-contamination
Infrared tympanic membrane thermometry Quick, comfortable, cost-effective Blood supply to the TM is similar to that of the
hypothalamus, so measurement is thought to be closer to core body temperature
Accuracy remains debatable
Question #6You are evaluating a 4 month old baby
with fever up to 101.5 for one day. On ROS and physical examination, there are no localizing signs for the fever. What is your problem definition?
A. 4 mo F with otitis mediaB. 4mo F with urinary tract infectionC. 4 mo F with fever of unknown origin
(FUO)D. 4mo F with thermometer malfunctionE. 4mo F with fever without a source
Fever Without a Source Fever without localizing signs on the physical exam Both the differential diagnosis and the management
differ depending on the age of the child Infants < 3 months
Immature immune response and may no be able to contain certain infections
Do not consistently show signs of a “localized” cause for fever, so they often undergo lab evaluation < 28 days = FULL septic evaluation
70% have infectious cause identified, majority are viral 10-12% of febrile infants have bacterial illness
UTI, meningitis, sepsis, bacteremia, osteomyelitis, septic arthritis, PNA
Pathogens: GBS, Listeria, Salmonella, E. coli, Staph aureus
Fever Without a Source 3-36 months Most common age for febrile illness, but up to
60% have a “localized” bacterial or viral cause 40% of cases do have fever without a source
Primarily viral that requires only reassurance and careful follow-up
Occult bacterial infections are still present but less common Bacteremia…depends on immunization status UTI
Prevalence from 2-9% More common in young girls, least common in
circumcised males If suspected…obtain catheterized urine culture
Pneumonia
Question #7You are telling mom how to treat your 4mo
patients fever at home (once you determine that she is at low risk for serious bacterial infection and that she likely has a virus). What antipyretic agent do you recommend?
A. Ibuprofen or another NSAIDB. Acetaminophen (Tylenol)C. Both Ibuprofen and Tylenol alternating with
each other q3 hoursD. Neither…give the baby an ice bathE. Neither…wipe the baby down with alcohol
Management of Fever Should begin with restoring the nutrients and
water lost during the onset of the febrile phase Proper hydration Comfortable environment
Sponge bathing with tepid water only provides marginal temperature reduction and often causes discomfort and shivering
Cold water or rubbing alcohol should NOT be used because it leads to vasoconstriction…which does not allow for heat dissipation Alcohol can be absorbed through the skin and
leads to toxicity
Management of Fever Acetaminophen
10-15 mg/kg every 4-6 hours NSAIDs (most commonly Ibuprofen)
5-10 mg/kg every 6-8 hours Do NOT use in children < 6 months of age due to
the risk of interstitial nephritis Similar safety and analgesic effect for moderate-
severe pain Ibuprofen is a more effective antipyretic and
provides a longer duration of antipyresis. No current evidence indicates that alternating
drugs is either safe or more efficacious than single-drug therapy.
BURNS
Question #8This is a _________ degree burn.
A. First degreeB. Second degreeC. Third degreeD. Fourth degreeE. Fifth degree
Burn Classification First degree burns
Superficial Dry Painful to touch Heals in < 1 week Ex: prolonged exposure to sunlight
Second degree burn Partial thickness Pink or mottled red Bullae or frank weeping on the surface Usually painful unless classified as “deep” Heals in 1-3 weeks Ex: commonly caused by scald injuries, brief
exposure to heat
Burn Classification Third degree burn
Most serious Appears pearly white, charred, hard, or
parchmentlike Dead skin (eschar) Superficial vascular thrombosis can be
observed PainLESS
Outpatient Management A superficial burn wound that extend to less than 10% of the TBSA can usually be treated on an outpatient basis UNLESS abuse is suspected Apply cotton gauze occlusive dressing
Protects damaged skin from bacterial contamination Eliminates air movement over the wound (decreases
pain) Decreases water loss
Change dressings daily Topical antibiotic before dressing is placed for
prophylaxis Most common = silver sulfadiazine
Daily clinical inspection and wound culture, if necessary, should determine when the wound is healed Typically within 2 weeks
Inpatient Management More extensive or severe burns require
inpatient management, typically at a specialized burn center
Initial management Initial assessment and removal from the scene Aggressive fluid resuscitation Nutritional support Airway management
Prevention and treatment of complications Sepsis is major cause of mortality Burn shock and burn edema Hypermetabolism
Electrical Burns Pediatric electrical burns are typically related to contact
with household, low-voltage sources like electric cords and wall outlets (110 Volts)
Burns Direct contact burns Flash contact = current strikes skin but doesn’t enter the
body, associated with soot Arc-exposure = body becomes part of the electrical current
Associated with deep tissue burns and internal organ involvement
Extent of injury may be underestimated Complications (more likely with high-voltage…>1000V)
Infection…so MUST ensure immunization status Arrhythmia (asystole and ventricular fibrillation) Compartment syndrome, rhabdomyolysis, renal damage
WOUNDS
Wound Cleansing Decontamination of the wound is the most important
step in preventing infectious complications Tap water, sterile water, and sterile saline are all safe
and effective Pressure irrigation
4-15 psi using a syringe and splash guard 100mL/cm of wound Effective at removing most bacteria and foreign material
Removing foreign material is essential to minimize the risk of infection Wound should be explored for retained foreign bodies Heavily contaminated wounds (“road rash”) should be
scrubbed. Anesthesia may be required to achieve satisfactory
cleaning.
Wound Dressing Once the wound has been evaluated,
decontaminated, and repaired, an appropriate dressing should be applied.
Wounds heal best under slightly moist conditions Application of topical antibiotic ointments
(bacitracin) and an occlusive dressing Dressing can be left in place for 24-48 hours Change once or twice daily
Wounds that cross joints may require splinting or bulky dressings to minimize movement and tension on the wound
Question #9You are evaluating a teenage patient with extensive
dog bites to the left lower leg and foot as well as the right hand…he got these when breaking up a dog fight with his friend. He is unsure of his immunization status, and his parents are on vacation out of the country, so he can’t ask them. What do you need to do for tetanus prophylaxis?
A. Nothing…you aren’t worried about tetanus at all.B. Tetanus immune globulin onlyC. Tdap vaccination onlyD. Both Tdap and tetanus immune globulin injectionE. Call a consult to ID…you have no idea! (Both Dr.
Begue and Dr. Seybolt are on vacation…ahhhhh!!!)
Tetanus Prophylaxis
Puncture Wounds Clinical Manifestations
Most are plantar surface wounds from nails Infected puncture wounds that result from a
nail through a tennis shoe should be evaluated for possible Pseudomonas aeruginosa infection
Punctures also occur in other parts of the extremities, trunk, and head
Particular attention should be paid to wound depth, possible retained foreign bodies, and risk of infection
Puncture Wound Evaluation Inspect and remove superficial debris
Neurovascular evaluation Copious irrigation
High pressure irrigation is contraindicated because it may trap bacteria or debris deep within the puncture site
Radiographic evaluation for retained foreign body X-ray Ultrasound: highly sensitive CT scan
Puncture Wounds Higher risk of infection
Older than 6 hours Occur from bites, particularly mammalian
bites Cat >> human > dog Should heal by secondary intention
Retained foreign body or vegetative debris Extend to a significant depth Human bites on a clenched fist (inoculation of
the MCP joint capsule)
Puncture Wound Management Most can be managed in the outpatient setting with antibiotic dressings and warm soaks.
Oral antibiotics only for puncture wounds with a high risk of infection Augmentin OR Clindamycin and Bactrim if PCN
allergic for bites to the hands or feet Close follow-up
Any fever, wound redness, swelling, pain, or pus should prompt re-evaluation to rule out persisted foreign body or infection Staph aureus Strep pyogenes Pasteurella multocida and other anaerobes
(mammal bites)
Puncture Wound Management More serious infections may need additional imaging and IV antibiotics Cellulitis Abscess Osteochondritis Osteomyelitis
Surgical consultation for potential debridement or retained foreign body removal should be considered for wounds that are refractory to medical management
Question #10Two very brilliant past pediatric residents (Dr. Kathy and Dr.
Adrienne) walked into the room of a patient with a forehead laceration that extends slightly to the bridge of his nose. They decide to use tissue adhesive to repair the small wound. What could they have done to prevent gluing their patient’s eyelids together and having to remove a few eyelashes to get them apart??!! They wish they didn’t have to worry about getting sued by the patient’s dad…who is a lawyer!
A. Hook the patient up to an EKG to monitor for arrhythmiaB. Consult their co-residents Dr. Chelsey and Dr. Nicole to help
pry the eyelids apart.C. Try to rinse off the adhesive with some tap waterD. Apply petroleum jelly or vaseline to the eyebrow and
eyelashes beforehand to prevent the adhesive from stickingE. Repeat their 3rd year of residency!
Lacerations Evaluate the laceration for foreign material and
for any signs of neurovascular damage Anesthetics
Topical LET Subcutaneous injection of lidocaine through
the opening of the wound edge No epinephrine for fingers, toes, penis,
pinna, nose Regional nerve blocks
Anxiolysis Benzodiazepines (PO or intranasal Versed) Distraction techniques
Lacerations Timing of closure
Face: within 24 hours Anywhere else: within 6-8 hours
Tissue adhesives Less painful, reduced procedure time,
comparable cosmetic outcomes Recommended for
Linear lacerations Low tension < 4cm in length
Simple interrupted repair “Rule of ones” Removal: 3-5 days for face and scalp; 10 days
elsewhere
Lacerations Lip lacerations
Require special care if the injury crosses the vermilion border
Technique Approximate the vermilion border with a
non-absorbable or “stay” suture. Failure to do so will result in a poor
cosmetic outcome
An infra-orbital or mental nerve block along the lower gum line may be considered to reduce tissue distrotion for lip lacerations
Complications Occur in up to 8% of children with cutaneous
wounds Delayed healing Poor cosmetic outcome Potentially serious morbidity
Wound dehiscence Tension on a wound overcomes the tensile
strength of the repair Can be minimized by splinting high tension
wounds and the appropriate choice of material for repair
Wound infection Higher risk
Extremities, joints >12-24 hours old Crush, tear, bite, and puncture wounds
EXTRA
BitesPlease see the Morning Report PowerPoint
entitled “Bites” on the Chief Resident Webpage. It covers most of the additional content specifications for management of
animal and insect bites in detail.
•Hymenoptera stings • Life-threatening reactions include hypotension,
wheezing, laryngeal edema, and other signs of anaphylaxis
• If a patient has one anaphylactic reaction to hymenoptera, he should be reffered to AI (and given an epipen, of course)
• Immunotherapy with insect venom is 98% effective in preventing subsequent reactions
WE’RE DONE THANK YOU FOR A WONDERFUL YEAR!!!
WE LOVE YOU GUYS