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

Burn Classification

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