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GreenC2 ER, Toxicolo

Board Review

Who gets poisoned, how many substance involved and the most common managment? 50% <6yo (peak 1-2yo); 90% involve 1 substance, 72% managed at home Majority occur at home
Most common pediatric poisons cosmetics, analgesics, cleaning substance, foreign bodies, topicals, vitamins, antihistamins, cold/cough preps, pesticides, plants
Most common adolescent ingestions 25% intentional, pharmaceuticals more common: acentaminophen, barbituates, stimulants, antidepressants, and alcohol
When do you discuss storage of poisons? 6 month well child check
What has decreased the mortality of unintentional ingestions by 45%? childproof caps
What is the average swallow of a young child? 5-10cc, most kids take a swallowful
What is the average swallow of an older child or adolescent? 10-15cc
What aspects of a physical/ are important in analysing a poisoning case? HR, RR, BP, Neuro status, pupillary findings, breath odor, skin (temp, color, diaphoresis)
Poisoning: FAST heart rate causes Freebase cocaine, Anticholingergics, Sympathomimetics, Theophyline,
Poisoning: slow heart rate causes PACED Propanolol, Anticholinesterase drugs, Clonidine, Ethanol, Digoxin,
Examples of anticholinesterase drugs Carbamates (physostigmine, neostigmine), edrophonium-short duration, organophosphates, THC, Galantamine
Poisons that cause Miosis- COPS Cholingerics, Clonidine; Opiates, Organophosphates; Phenothiazine, Pilocarpine; Sedative (barbituates);
Poisons that cause Mydriases- AAAS Antihisatamine, Antidepressant, Anticholingerics, Sympathomimetics (amphetamine, cocaine, PCP)
Poisons that cause diaphoretic skin- SOAP Sympathomimetics, Organophosphates, ASA (salicylates- aspirin or peptobismal), PCP (phencyclidine)
Poisons that cause red skin- ABC Anticholingerics Boric acid, Carbon monoxide
Poisons that cause blue skin Methemoglobinemia agents
Toxidrome: Anticholinergic (antihistamine, phenothiazines) BLIND as a BAT (mydriasis), HOT as a HARE (hyperhermia), RED as a BEET (flushing), DRY as a BONE (dec UOP, dec sweating), MAD as a HATTER (delirium, hallucinations)
Radiolucent pill fragments (COINS) Chloral hydrate, calcium; Opium packets; I \ron, other heavy metals; Neuroleptic agents; Sustained-relese or enteric-coated agents
Cardiotoxic drugs and EKG finding tricylic ingestions: prolonged QRS
Drug screens and other testing- confirmatory testing after H&P Drug levels: acetaminophen, salicylate, ethanol; Also chech CBC, renal panel, LFTs, osmolality
What ingestions cause hypoglycemia? (HoBBIES) Hypoglyceimic oral agents, Beta blockers, Insulin, Ethanol, Salicylates
Osmolar gap equation Osmolar gap= (measured-calculated osmoles); (2 x Na)+(BUN/2.8)+(glucose/18)
Osmolar gap >10 alcohol ingestions
Anion gap equation Anion Gap= Na-(Cl + HCO3)
Anion gap >12 (MUDPILES) Methanol, uremia, DKA, phenols, iron, INH, lactate, ethanol, ethylene glycol, salicylates
Approach to the Poisoned patient ABCs, DONT (Dextrose, Oxygen, Naloxone, Thiamine), and Decontaminate (remove clothing, wash skin with soap and water, irrigate eyes with 1000cc normal saline sln, get into fresh air)
Absorption time for ingested liquids 30 minutes
Absortpion time for ingested solids 1-2hrs
Ipecac- GI decontamination Rare hosp use, NO home use, ineffective, may help in extremely large, recent, toxic, long-acting ingestions without other therapy
Activated charcoal- GI decontamination action, and when best to use adsorbs the ingested substance which dec bioavailability, best within 1hr of ingestion, may need to repeat doses
Complications of Activated Charcoal pulmonary aspiration, emesis, constipation
Contraindications of Activated Charcoal hydrocarbons, corrosives, illeus, compromised airway
Charcoal is ineffective with: (CHEMICaL CamP)- mostly things found in the garage Cyanide, Hydrocarbon, Ethanol, Metals, Iron, Caustics, Lithium; Camphor, Phosphorus
Gastric Lavage- use only within 30-60min of a life-threatening ingestion, older children and adults only
Gastric Lavage- contraindications hydrocarbons, acids, alkalis, sharp ingestions, and altered mental status
Gastric Lavage- complication pulmonary aspiration
Cathartics- GI decontamination actino and use decreases GI transit time? never used alone- often used in combo with activated charcoal, use only one dose
Acetaminophen peak plasma level 1hour
Acetaminophen toxicity mechanism metabolized in liver using glutathione, glutathione stores are overwhelmed and toxic metabolite accumulate
Acetaminophen acute toxic dose 150mg/kg minimum dose, 7.5gms teens/adults
Acetaminophen chronic toxic dose 150mg/kg/day > 2days OR 4gm/day >2day
Acetaminophen overdose symptoms- 1st 48hrs 0-24hrs: GI irritation (N/V, nl LFTs); 24-48hrs: Latent period (asymptomatic, RUQ pain, LFTs may increase)
Acetaminophen overdose symptoms- after 48hrs 48-96hrs: Hepatic Failure (peak s/s) AST>20,000 with prolonged PT, death is from hepatic failure or coagulopathy. 4day-14days: Recovery or Death
Acetaminophen overdose management prevent absorption- activated charcoal; check acetaminophen levels
Rumack-Matthew nomogram used in managing acetaminophen overdose, and used only for single dose ingestion.
When is the peak concentration of acetaminophen on the Rumack-Matthew nomogram? 4hrs post ingestion
What percentage of patients will develop hepatic toxicity if they are above the "probable hepatic toxicity line" on the Rumack-Matthew nomograms? 60%
Acetaminophen antidote? N-acetylcysteine (NAC) given IV or acetylcysteine (Mucomyst)
What is the timeframe for acetaminphen antidote admninistration? give within 8hrs of ingestion
What labs do you follow in an acetaminphen overdose managment? AST, ALT, PT, PTT
How often do you check drug levels for acetaminophen overdose managment? Once, the initial toxicity level is all that is needed. Consider co-ingestions though!
Examples of anticholinergics: diphenhydramine (benadryl), atropine, OTC antispasmodics, mushrooms, jimson weed, deadly nighthsade, TCA
Symptoms of anticholinergic toxicity HOT as HARE (hyperthermia), BLIND as a BAT (mydriasis), DRY as a BONE (dec sweat/UOP), RED as a BEET (flushing), MAD as a HATTER (aggitation, seizures)
Treatment of anticholinergic toxicity Activated charcoal, supportive care, Physostigmine use is controversial
Clonidine ingestion (antihypertensive)- importance children are very sensitive- small amount is very toxic (0.1mg)
Clonidine- how does it act centrally acting antihypertensive, in 24hrs
Clonidine toxicity signs (similar to opioids) apnea, bradycardia, hypotension, lethargy, miosis (COPS), transient hypertension
Treatment of Clonidine toxicity supportive care only- intubation, atropine, dopamine, naloxone?
What do you check with Clonidine toxicity ECG and blood gases
Age limits for use of cold meds in kids AAP- no use in <6yo, FDA- no use in <2yo, drug manufacturers- no use in <4yo
Reasons for age limits in cold meds usage lack of evidense for efficacy, toxicity
Ingredients often used in OTC cold meds Decongestants (pseudoephedrine, phyenlephrine), Antitussive (dextromethorphan), Antihistamines (diphenhydramine, chlorpheniramine, brompheniramine), Expectorants (guaifenesin)
Adverse effects of decongestants (pseudoephedrine, phyenylephrine) tachycardia, restlessness, insomnia, anxiety, tremors, hypertension, irritability, anorexia, lethargy, headaches, dysrhytmias, hallucinations, dystonic rxns, seizures
Adverse effects of antitussives (dextromethorphan) constipation, dizziness, drowsiness, N/V, depression, apnea, palpitations, possible serotonin syndrome with SSRIs
Adverse effects of antihistamines anticholinergic toxicity; drowsiness, headache, dry mouth, dry eyes, paradoxic exictability, respiratory depression, hallucinations, tachycardia, arrythmias
Adverse effects of expectorants (guaifenesin) nausea, diarrhea, dizzines, headache
Complimentary-Alternative Medicine: Herbals little FDA regulation, difficult to determine toxicity due to lack of standards
How much Ibuprofen can lead to toxic levels? >400mg/kg doses
Ibuprofen toxicity signs N/V, epigastric pain, drowsiness, lethargy, ataxia
Serious complicatons of Ibuprofen toxicity renal failure, coma and seizures are rare
Treatment of Ibuprofen toxicity activated charcoal, supportive care
What to monitor in Ibuprofen toxicity renal function and acid-base status
Iron ingestion sources prenatal vitamins, iron supplements
Pathophysiology of iron toxicity corrosive to gastric mucosa and intestinal mucosa, causes mitochondrial/cell dysfxn, capillary leak lead to hypotension
What is the toxic dose of elemental iron? >50mg/kg dose
How much iron causes just GI symptoms? >20mg/kg
Phases of iron toxicity (IRON acronym) 1. Indigestion, 2. Recovery, 3-4. Oh my Gosh!, 5. Narrowing
Phases of iron toxicity- Phase 1 GI stage (30min-6hrs): N/V, diarrhea, abd pain, hematemesis, bloddy diarrhea
Phase 2 of iron toxicity Stability for 6-12 hrs
Phase 3 of iron toxicity Systemic toxicity (within 48hrs): CV collapse, severe metabolic acidoses- high Anion Gap (MUDPILES)
Phase 4 of iron toxicity Hepatic toxicity (2-3 post ingestion)- hepatic failure
Phase 5 of iron toxicity GI/pyloric scarring seen in 2-6wks post ingestion.
How do you diagnose iron ingestion? Xray- however, liquid preps and chewable vitamins are not visible. Serum levels. "Vin rose" urine is an unreliable indicator.
When do you obtain serum levels for iron overdose management? 4hrs post ingestion
What are the important serum levels for iron toxicity? <300mcg/dL: minimal toxicity; >500mcg/dL: severe toxicity
Treatment of iron toxicity deferoxamine (IV)- chelation therapy in moderate to severe symptoms regardless of drug levels
other treatments for iron toxicity whole bowel irrigation, endoscopic pill removal
What NOT to use with iron toxicity Ipecac, gastric lavage (large tabs), activated charcoal- does not bind iron, oral bicarb, oral deferoxamine
Opiates- examples morphine, heroin, methadone, propoxyphene, codeine, meperidine
Opiate toxicity symptoms drowsiness to coma, mood change, decreased GI motility, analgesia, N/V, respiratory depression, abdominal pain (due to inc colonic and biliary tone)
Opiate overdose signs Miosis, resp depression, coma, decreased GI motility, hypotension from histamine release, NO change in HR
Opiate poisoning signs respiratory and CNS depression with pinpoint pupils
Salicylate- sources Aspirin, Oil of Wintergreen, antidiarrheal products (Pepto Bismal)
Salicylate action uncouples oxidative phosphorylation
Salicylate- toxic dose >150mg/kg
Acute signs of Salicylate poisoning N/V, tinnitus, hyperventilation- resp alkalosis (not always though), dehydration and hypokalemia --> metabolic acidosis
Serious salicylate toxicity hyperthermia, agitation, confusion, coma, renal failure. Death from pulmonary or cerebral edema, electrolyte imbalance, CV collapse.
Monitoring salicylate toxicity serial levels q2-4hrs: ABG, electrolytes, and Coags
Treatment of salicylate toxicity activated charcoal (drug may form a bezoar in stomach)- consider mult. doses; agressive fluid rehydration; replace bicarb and K; raise urine pH with IV bicarb (enhanced exretion); hemodialysis
TCA- tricyclic antidepressants toxicity onset symptoms within 2hrs, major complications within 6hrs
TCA- symptoms of toxicity CNS effect more prominent in children- lethargy, agitation, seizures, coma; CV- tachycardia, hypertension, hypotension, ECG changes
ECG change in TCA toxicity widened QRS and prolonged QT, multiple differnet cardiac defects may occur late
TCA- toxicity symptoms: triC A Coma, Convulsions, Cardiac dysarhythmias, Acidosis
Workup of TCA ingestion: BMP (hypokalemia), ABG, ECG, urine pregnancy test, urine drug screen for co-ingestion
Danger of perscribing TCA ingestion of younger sibling
Treatment of TCA overdose ABCs, activated charcoal/gastric lavage, alkalinize serum with sodium bicarb (pH 7.45-7.55) prevents dysrhythmias, ECG monitoring
Treatment of dysarrthymia from TCA overdose with lidocaine (use of phenytoin is controversial)
DO NOT tx TCA overdose with ipecac (risk of aspiration) or physostigmine
What are your environmental toxins? Carbon monoxide, caustic agents, esophageal foreign bodies, hydrocarbons, ethanol, ethylene glycol, organophosphates, and plants
Carbon Monoxide- what is it? colorless, odorless gas- car in the garage with the engine on, space heater in an enclosed home
Action of carbon monoxide CO binds reversibly to one of Hgb 4 binding sites, this "carboxyhemoglobin: impairs oxygen release at the other 3 sites. This shifts the dissociation curve to the left. O2 carrying capacity and availability to the tissues is impaired
Symptoms of carbon monoxide poisoning headache, dizziness, nausea, malaise (Flu like symptoms). Visual changes, weakness, syncope, vomiting, ataxia, seizures, coma, and death. Cherry red skin is not of diagnostic value.
Labratory finding in carbon monoxide poisoning Carbon monoxide concentration, note: pulse ox will most likely be normal.
Carbon monoxide poisoning treatment Oxygen- high flow mask, immediately, Cardiac monitoring, Correct any anemia, treat metabolic acidosis, ?use of hyperbaric therapy (pregnant and neonatals may benefit)
House fire, chemicals that can poison Carbon monoxide and cyanide
What is the half-life of carbon monoxide? 5hrs in room air, 30-90 minutes on 100% Oxygen.
Caustic agents can be alkali or acidic household items
Alkali products in the home- tasteless oven cleaner, drain cleaner, hair relaxer, bleach, automatic dishwasher detergent
Household bleach (5%) usually only a mild irritant alkali
What type of necrosis do alkali products make? liquefaction necrosis- severe and deep
Acidic products in the home- bitter toilet bowl cleaner, grout cleaner, rust remover, metal cleaners (gun bluing)
What type of necrosis do acidic products make? coagulation necrosis- superficial because mucosa is resistant
Hydrochloric acid or sufuric acid are unique in that they can cause severe gastritis without significant oral or esophageal burns
Caustic agents- s/s ingestion drooling, refusal to drink, vomiting, oral burns, dysphagia, stridor/resp distress, chest or abd pain, hypotension, metabolic acidosis, DIC
If there are no oral lesions you can still have severe esophageal or stomach injury
If there are no symptoms with a Caustic ingestion = little or no injury
Caustic ingestions workup cbc, lytes, BUN, creatinie, CXR, AXR
Caustic ingestions treatment remove contaminated clothing/rinse, early intubation for resp distress or stridor, acutely dilute with water or milk, IVFs, analgesia, upper endoscopy, observe for complications, steroids are usually not helpful
When do you want to do Endoscopy in a caustic injuries case? in 12-48hrs if there are severe oral burns or symptoms
DO NOT do this with caustic injuries neutralize, induce emesis. NO gastric lavage or activated charcoal.
Burn complications of caustic injuries necrosis, esophagitis, perforation, late stricure formation
Complications specific to Hydrochloric/Sulfuric acids severe gastritis, perforation or peritonitis, late stricture.... all without severe mouth or esophageal burns!!!
Esophageal foreign bodies commonly occur in what age? 6mo to 3yo
Most common esophageal FB coin
Lodging places in the esophagus upper esophageal sphincter, aortic arch, lower esophageal sphincter
S/S esophageal foreign bodies 30% asymptomatic; drooling, dysphagia, choking, gagging, vomiting, cough, stridor, wheeze, dyspnea. pain in neck/throat/chest
Coin flat on AP film, location? located in esophagus
Coin on edge on AP film, location? located in trachea
When is endoscopic removal necessary? urgently if respiratory symptoms, sharp object, button batteries, no movement past LES in >24hrs
Other methods of detection of FBs CT scan, contrast esophagram, or metal detectors
Other methods of removal of FBs balloon catheter under flouroscopy, push into stomach using bougie dilator
Button Batteries- what's the danger? needs immediate removal due to caustic leakage and electrical current can cause burns, can get mucosal injury in 1hr, full thickness injury in 4hrs
Radiographic finding of button battery double ring
What do you do if a button battery is in the stomach? monitor stools, repeat xrays q3days
How dangergous is a button battery in the nose or other orifice (ear canal)? Same danger as esophagus- needs immediate removal.
Ethanol- what products are in the home? Besides liquor cabinet, mouthwash, perfume, vanilla extract for baking
Ethanol- what is the danger in young kids <5yo? Hypoglycemia: ethanol inhibits hepatic gluconeogenesis leading to hypoglycemia in 10-22% in <5yo. Its the kid who is in hypoglycemic crises the morning after his parents had a party.
Ethanol signs and symptoms CNS depression (esp in young kids), N/V, slurred speach, ataxia, resp depression, seizures, coma, hypothermia
Ethanol ingestion- diagnosis Ethanol level, Increased osmolar gap (>10 gap identifies unknown alcohol ingestion)
Treatment of ethanol intoxication ABCs, IVFs, treat hypoglycemia and hypokalemia, hemodialysis is rare, rewarm
Do you use activated charcoal for ethanol ingestion? Not for ethanol ingestion alone, consider if necessary for another substance that was co-ingested.
What can happen when there are other co-ingestions with Ethanol? Toxicity from other substances can be masked by the symptoms of toxicity from ethanol ingestion.... always screen for others.
What is Ethylene Glycol? What is the toxicity? antifreeze found in radiator fluid and coolants, it tastes sweet. Metabolites are toxic.
What are 3 stages of Ethylene Glycol toxicity and when do they occur? Stage 1 (1-12hrs): N/V, drowsiness, slurred speech, lethargy. Stage 2 (12-36hrs): tachypnea, cyanosis, pulmonary edema, ARDS, death. Stage 3 (2-3days): cardiac failure, seizure, cerebral edema, RENAL FAILURE
How do you diagnosis Ethylene Glycol toxicity? Increased osmolar gap (>10 identifies unknown alcohol ingestions), Increased anion gap (>12 MUDPILES), urine may flouresce under Woods lamp.
Treatment of Ethylene Glycol toxicity Gastric decontamination (not charcoal), Na Bicarb for metabolic acidosis, IV calcium for symptomatic hypocalcemia. Consider Antidote. Consider hemodialysis if severe.
Antidote for Ethylene Glycol toxicity IV ethanol or Fomepizole (fewer side effects, easier dosing but costly)
What are hydrocarbons and what makes it toxic? kerosene, gasoline, lamp oil, mineral spirits, some pesticides. Low viscosity fluid that leads to pulm aspiration. Metabolite carbon tetrachloride is liver toxic. Inhaled propellants- refigerants, toluene can sensitize to cardiac arrythmias.
What are the clinical finding of hydrocarbon ingestion? What are the lab findings? coughing, choking, gagging, tachypnea, wheezing, resp distress, mild CNS depression, fever. Lab findings are leukocystois, CXR may have 24hr delay in findings.
Treatment of Hydrocarbon ingestion: Dermal decontatmination (remove clothes, wash skin), observe for at least 6hrs. If symptomatic then supprotive care, airway control and ARDS treatment.
What not to do in Hydrocarbon ingestion: Ipecac, gastric lavage- except with very large or very toxic ingestion, activated charcoal, steroids, prophylactic abx, epinephrine (v-fib)
Where would you have Organophosphate exposure? Pesticides on a farm that contain diazinon, malathion. Bioterroism attack?
What is the method of action for organophosphate and recovery potentional? Bonds permanently to cholinesterase leading to excess acetylcholine for 2-3 days. It takes weeks to months to regenerate enzymes
Organophosphate toxicity signs are for cholingeric crisis: DUMBELS Diarrhea, Urination, Miosis, Bronchorrhea/Bronchspasm, Emesis, Lacrmiation, Salivation
What are the other signs of organophosphate toxicity (nicotinic effects + others) and what is specific to kids. Nicotinic effects: Twitching, Weakness, Resp weakness. Confusion, coma, convulsions, slurred speech. Kids are more likely to present with AMS and muscle weakness (which is not your classic cholingergic crisis)
What show up on labs for organophosphate toxicity? decreased RBC cholinesterase activity confirms diagnosis
How do you treat organophosphate poisoning? and the health care workers helping a victim? protect all caregivers with protective clothing (surgical mask and latex gloves are not effective). ABCs, decontaminate clothing and skin, Antidote, Benzodiazepine for CNS symptoms. May require weaks of treatment.
What is the antidote for organophosphate? Atropine- large dose and may need repeated doses. Pralidoxime (2-PAM)- use with atropine, works before bond ages.
Resource for plant exposure toxicities. Poison control
Side effects of this plant: Peace lily GI irritation and burning
Side effects of this plant: Pokeweed irritation of skin and GI tract
Side effects of this plant: Dieffenchachia, philodendron (houseplants) oral pain
Side effects of this plant: poinsettia, mistletoe, holly mild GI symptoms
Side effects of this plant: foxglove, oleander, lily of the valley digitalis-like toxicity
Side effects of this plant: Jimson weed, Angels trumpet anticholingeric poisoning
Side effects of this plant: lethal mushrooms delayed symptoms- liver toxicity
What animal bites are a concern for Rabies? bat, raccoons, skunk, foxes (major carriers). Sometimes Dogs and Cats are reservoirs.
What animal bites are NOT a concern for Rabies? Rodents: squirrels, rabbits, rats
What is considered Bat exposure? bite, exposure to fluids, founds sleeping in a room with a bat, bat in close proximity to a child.
What do you do with the domestic vs wild anmial when you are concerned about Rabies? observe the domestic animal, euthanize if becomes ill. Euthanize all wild animals for testing (brain is source for testing).
What is Rabies therapy? how do you give? HRIG (Rabies Immune Globin)- inject as much as possible into the wound, the rest is given IM. Rabies vaccine- 4 doses on Day 0, 3, 7, and 14 (do not give in gluteus).
What is the most common type of snake bite? 95% are Pit viper (rattlesnakes, cottonmouths, and copperheads)- triangular head, elliptical eyes, pit between eye and nose.
What does Pit viper vemon do? cause tissue necrosis, vascular leak, coagulopathies and neurotoxicity. Children are susceptible due to low body mass. s/s develop in 2-6hrs with severe pain, N/V, weakness, muscle fasciculations, coagulation abnormalities.
What is the treatment of Pit viper vemom? ID the snake (?antidote). Immobilize extremity and apply wound pressure (DO NOT ice or "suck and spit"). IVFs, pain meds. Give tetanus booster if needed (Tdap if >7yo, DTap if <7yo).
Describe a Black Widow spider and where are they found? Red/orange hourglass markings on the abdomen. Found in barns, woodpiles and nests.
What are the symptoms of Black Widow spider bite and how do you treat? pain around site, muscle cramping, chest tightness, vomiting, malaise, sweating, abdominal pain (mimics appy or MI), agitation and hypertension. Treat pain, benzodiazepines, antivenom in severe cases, IV calcium is ineffective. Resolves in 24-48hrs.
Where is a Brown Recluse spider found and what is the hallmark lesion? basements and attics. Venom causes an ulcer due to lyses of cell walls. Think "U" in ReclUse=ulcer.
What are the symptoms of Brown Recluse spider bite and how do you treat? initially painless then pain around the site, hemorrhagic blister to large ulcer. Systemic symptoms (fever, chills, N/V) are rare but admit for these. Otherwise provide hydration and local wound care.
What is the most common spider bite? MRSA- trick question, not really a spider
What is the 2nd major cause of unintentional pediatric death? burns
What types of burns are there? fire, scalds, flame, electrical, chemical
What percentage of burns are due to abuse? 18%
Some safety tips to prevent burns? keep matches out of reach, electrical plug protectors, fireworks safety, set water heater to 120 F
Burn First Aid Extinguish flames, ABCs, remove clothing, wash off chemicals, cover burn with clean dry sheet- apply cold/wet compressess (careful with large burns and a small child- can get hypothermic). Do not apply grease, butter or ointment.
Burn classification: superficial redness, minor swelling, pain, resolves in 1 week First- degree
Burn classification: blisters or blebs, redness, painful, tissue underneath still perfused, takes 1-3 wks to heal Second- degree
Burn classifcation: dry, leathery, waxy, no pain, requires grafting or healing from edges in small burns Third- degree
Burn Surface Area- Rule of nine (>9yo) Head and neck total 9%, Each upper limb total 9%, Thorax and abd front 18%, Thorax and back 18%, perineum 1%, each lower limb total 18%
Burn Surface Area- Rule of palm (<9yo) use in small burns, child's palm (not including fingers) = 0.8-1% BSA
Minor Burn Care: First-degree pain control
Burn Care: partial thickness burn clean with soap/water daily, leave blisters intact- debride when ruptured, Abx ointment (silver sulfadiazine or bacitracin), pain control, update tetanus, re-evaluate every 2-3 days- burn can progress, avoid sunlight
Do you need to cover Facial burns? No, they may be left open to heal
Burn Care: major burns ABCs- consider carbon monoxide or cyanide poisoning, IVFs if >15% BSA, pain control
What is the Parkland formula for IVFs in burn managment? What fluid do you use? 4mls/kg/%burn first 24hrs (burn has 4 letters). Use Ringers lactate. 1/2 volume in first 8hrs, the rest in next 16hrs. Add MIVFs rate to this volume.
How much fluid for a 10kg child with 20% burn? 4mL/kg/%burn = 4x10x20= 800mL. Give 400mL in first 8hrs, then 400mL over next 16hrs. Add this on top of MIVFs.
When do you refer a burn? >15% BSA, full thickness burns >2%, inhalation injury, larger burns of hands/feet/face/perineum, concern for abuse
When are minor electrical burn injuries concerning? Extension cord bite injuries must be referred to a burn surgeon due to oral commissure burns. Superficial burns may otherwise just require cleaning and abx cream.
What to do with high-tension electrical wire burns? What is the injury and why the concern? Admit all, they are serious due to concerns for deep-muscle injury, arrhythmias, seizures, brainstem paralysis, ocular damage, fractures and renal failure. You may have little surface damage with deep-tissue burns.
Who drowns- biggest age group and gender? Where do they drown? 40% <5yo, M>F. Bathtubs, pools, open bodies of water.
How can you prevent drowning? sourrounding stand-alonge fencing, self-closing gates, locked gates, pool alarm, pool cover, close supervision (even at a party)
Pathophysiology of drowning and how much time do you have? Laryngospasm when you swallow water, LOC, Vomiting/aspiration in 90%, hypoxia/terminal apnea, circulation fails in 3-4minutes, CNS injury in 3-5minutes
Near drowning most common cause of death? CNS injury- hypoxic ischemic injury (cerebral edema) with hyperglycemia exacerbating brain injury
Freshwater vs Saltwater drowning managment? managed the same way
Hypothermia in a near drowning victim- when is it protective? Survivors (10-150min) drowned in freezing water (<5 C) and had a core body temp of (<30 C/ 86 F). Note cold water that isn't icy is NOT protective.
Complication of pulmonary aspiration in a near drowning victim? aspiration is usually small but can cause ARDS or pulmonary edema
Near drowning treatment ABCs, protect c-spine if a diving injury or abuse, apply cricoid pressure- vomiting is common, NG tube, warmed IVFs and O2, warmed gastric/bladder lavage.
What core temperature must be obtained in a freezing-water drowning vicitim? resuscitate until core temp is 32 C
How long do you observe near-drowning victims? >12 hrs because you may have an initial recovery period followed by ARDS (resp s/s develop by 8hrs)
What else is associated with an adolescent who has a head injury? drug and alcohol abuse
S/S head injury, vomiting, lethargy, headache, irritability, behavioral changes, altered mental status (GCS), scalp swelling/??stepoff, pupillary changes
Basilar skull fracture signs Raccoon eyes (bruising under the eyes) & Battle's sign (postauricular bruise) take hours to develop. Also hemotympanum, hearing loss, facial paralysis, CSF otorrhea
When does papilledema develop in a head injury? hours to weeks, it is a late sign of intracranial hypertension
What to think in an infant with retinal hemorrhages. ABUSE- shaken baby, there does not have to be significant external signs to have a significant brain injury
What is Cushing's triad? impending herniation causes bradycardia, irregular respirations and hypertension.
What is the best modality for studying intracranial contents in a head injury? CT w/o contrast
Who do you CT in a head injury? evidence of skull fx, altered level of alertness, neurologic deficit, persistent vomiting, presence of scalp hematoma, abnormal behavior, coagulopathy
Skull radiographs may benefit (less radiation) in minor head injuries, palpable depression, Battle's sign, hemotympanum, infants
When do you intubate in a head injury case? GCS <8
Treatment of head injuries ABCs, control C-spine, mild hyperventilation, support BP with IVFs, Mannitol/ 3% saline if s/s herniation, CT scan for potential surgical lesions
Subdural hematoma- description bleeding is from bridging veins, blood accumulates in the outermost meningeal layer, between dura mater (which adheres to skull) and the arachnoid mater (which covers the brain)
Epidural hematoma- description blood from tears in arteries with build up of blood between dura mater and skull
Signs of concussion confusion, LOC, vision disturbance, loss of equilibrium, amnesia, headaches, dizziness
Neuro exam in concussion ask about the game vs name and phone number
Concussion definition traumatic alteration in mental status with or without LOC
Second-impact syndrome head injury before full recovery from a previous concussion can cause loss of autoregulation of cerebral blood flow with rapid development of increased ICP. The younger the child the more sensitive to concussion
Concussion guidelines Player MUST be asymptomatic before returning to play. 6 step-wise progression where they get to do a little more each day.
Player with LOC <5min, when to return to play out 1 week after symptom free- follow 6 day step-wise progression
Player with LOC >5min, when to return to play out at least 1 month
Multiple concussions managment longer time for return to play, MRI may be useful in evaluation
How do you clean a laceration? irrigate with normal saline under mild pressure
Scalp laceration- can you use top adhesives? No
Who do you call for a complex vermillion border laceration? plastic surgeon
Who do you call for a clenched fist hand laceration? Hand surgeon, there is a high risk of infection
Who do you call for an eyelid laceration if tear duct needs repair? Ophthalmologist
What are the complications of laceration repair? tendon laceration with loss of fxn, arterial or vascualr compromise, infection (staph, strep or Pseudomonas- nail thru tennis shoe), joint involvement, limited flexibility, cosmetic concerns with scarring or keloid formation
Puncture wounds- concerns high risk for infection and foreign body. May need to Xray, US or CT
Treatment of puncture wound superficial irrigation only, do not repair, prophylactic abx only if dirty wound, update tetanus
Growth Plate Fracture classification Salter-Harris Classifcation
Salter-Harris Classification (SALTS) I Separated, II Above (metaphysis), III Lower (epiphysis), IV Together/thru (metaphysis and epiphysis), V Smashed (compressed growth plate)
Which Salter-Harris fxs need Ortho? III and IV
Which Salter-Harris fx is most common? II
Which Salter-Harris fxs are difficult to see on radiograph? I and V
When in doubt about a fracture splint/cast then repeat xray later to look for healing callous
Greenstick Fracture description and prognosis cortex is fractures on the tension side and there is a plastic deformity on the compression side, fracture is not complete. Heals well
Clavicle Fracture- who gets them, common type, injury associated Common in kids <10yo, 80% are in the middle 3rd portion of the clavicle. Fall on outstretched arm or direct trauma.
Clavicle Fracture- diagnosis and treatment physical exam/radiograph. Sling for comfort x 2weeks. Heals in 3-6wks
Buckle fracture compression of bone produces a torus fracture, most common in distal radial metaphysis. Heals well after 3 weeks immobilization
Spiral fracture curvilinear course, common in toddlers, think abuse if child is not walking
What is the most common elbow fx? Supracondylar Fracture
Method of injury in a distal humerus fx? fall on outstretched hand or elbow, monkey bars
Complication in Supracondylar fx of the humerus? brachial artery, median nerve or radial nerve damage in a displaced fx. Monitor neurovascular status closely.
Radiographic sign in an elbow fx? Posterior fat-pad
Complication in tibial fx? Compartment syndrome (swelling and vascular injury lead to ischemia). This is an emergency.
Compartment Syndrome signs pain out of proportion to the fracture, pulses may be normal, pain remote to fracture site. This is due to compromised tissue blood flow.
Gait disturbance in a young kid, occult fx not evident on radiograph, what do you do? Treat as if fractured and repeat radiographs- signs of healing fx will show up.
Subluxation of the Radial Head term, age and mechanism of injury Nursemaids elbow, 6mo-5yo, occurs due to traction on a pronated wrist- annular ligament slides over the radial head.
Nursemaids Elbow- exam and treatment Extrimity is held limply to the side, no TTP at elbow but pain with elbow movement. DO NOT Xray. Reduce by supination of the forearm with flexion at the elbow (or pronated the foreamr). Return to fxn in 15min.
Athlete/Teen falls on adducted shoulder and has tenderness over the AC joint, what injury? Acromioclavicular separation
Shoulder is swollen with deformity anteriorly, what injury and what is best imaging? Dislocated shoulder- best seen on Y view of shoulder radiograph, rare in prepubertal kids- they usually fx
How do you treat a shoulder dislocation? pain control first then traction/countertraction, sling and swathe
Sprain in a 5yo most likely a fracture- ligaments are stronger than growth plates in these little ones
Common sprains in older children ankle and finger
Uncommon sprains in older children wrist and elbow
Treatment of ankle sprain based on severity Grade 1: rest 7-10days, Grade 2: 2-4wks, Grade 3: 5-10wks
Severe lateral malleolus tenderness- what should you think of Salter Harris 1 fracture
Fussy infant corneal abrasion- check w/ fluorescein dye and a slit lamp or Woods lamp
Signs and treatment of corneal abrasion pain, tearing, photophobia, decreased vision. Tx with topical abx ointment, topical pain drops (cycloplegic- in office only)
How do you handle a penetrating globe injury in the field? protect eye with a styrofoam cup, minimal manipulation, call ophtho
Hyphema, what does it look like and what to do? presence of blood in anterior chamber of the eye from blunt of perforating injury. Tx with bed rest but elevate head to 30-45 degrees.
Kid hit in the eye with baseball (or other blunt trauma), now has limitation of upward gaze. fracture of the orbital floor with eye muscle entrapment
Chemical (alkali or acidic) burn to cornea, how long to irrigate with NS? Mild case: 30min or 2L NS, Severe case: 2-4hrs or 10L NS, CHECK OCULAR pH
Chemical burn to the eye, now has corneal opacification- what kind of chemical? Alkali
Mild acid or alkali burn to the eye causes mild corneal erosions
(PALS) Establishing an airway- same no matter what age head tilt/chin lift, jaw thrust if trauma
(PALS) Choking infant back blows and chest thrusts
(PALS) Choking child/adolescent abdominal thrusts
(PALS) Initial breaths- no matter what age 2 breaths
(PALS) Breathing rate/ No CPR, infant and child 12-20 breaths/min
(PALS) Breathing rate/ No CPR, adolescent 10-12 breaths/min
(PALS) Breathing rate when doing CPR, no matter what age 8-10 breaths/min
(PALS) Where do you check for circulation? Infant: brachial or femoral, Child/Adolescent: Carotid
(PALS) CPR technique- infant 2 thumbs w/ encircling hands at lower 1/2 of sternum
(PALS) CPR technique- child and adolescent heel of one hand, other hand may be on top
(PALS) Rate of chest compressions- no matter the age 100/min
(PALS) Ratio of breaths to compressions- infant and child 15:2
(PALS) Ratio of breaths to compressions- adolescent 30:2
Pediatric Bradycardia with a Pulse- no CV compromise ABCs, O2, observe
Pediatric Bradycardia with a pulse, HR<60 and CV compromise ABCs, O2, CPR, Epinephrine- repeat q3-5min. Atropine (0.02mg/kg- min dose of 0.1mg), may repeat. Continue CPR
Pediatric Pulseless Algorithm: V-fib or V-tach Shock 2J/kg, Shock 4J/kg, Epinephrine, Shock 4J/kg, Amiodarone/Lidocaine (repeat)
Pediatric Pulseless Algorithm Asystole/PEA CPR, Epinephrine- repeat every 3-5min
Epinephrine dose IV or IO 0.01mg/kg
Epinephrine dose for endotracheal tube 0.1mg/kg
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