question

Leading cause of pediatric morbidity

answer

Falls. Most common from 0-14

question

Leading cause of pediatric morality

answer

MVA

question

Anatomic differences of kids

answer

1. more compact organs 2. relatively compact head 3. more elastic ligaments

question

kids response to shock

answer

Normal BP w/ early shock. Different baseline HR, BP Greater propensity for spinal cord injury without radiologic abnormality (SCIWORA) More heat loss (sa)

question

AVPU

answer

A= awake V=verbal stimulation response P= painful stimulation U= completely unresponsive

question

Wadell triad

answer

1. closed head injury 2. intraabdominal injury 3. mid-shaft femur fracture

question

What predicts intracranial injury risk (should CT)?

answer

Seizures, low CGS, scalp hematomas (parietal/temporal), altered mental status. NOT LOC.

question

SALTER-Harris

answer

severity scale based on epiphysis fx S=straight across A=above epiphysis L=low or beLow epiphysis T=Two or Through ER=erasure of growth plate or crush

question

Greenstick fx

answer

soft bones in which the bone bends and only partially breaks.

question

Buckle (torus) fx

answer

longitudinal force on kid bones. easier to see on lateral.

question

Boxer's fx

answer

4th or 5th metacarpal. Close fist and look at hand alignment and look for finger malrotation.

question

CRITOE

answer

Ossification centers of the elbow: C-capitellum=1yr, R-radial head=3yr, I-internal medial epicondyle=5yr, T-trochlea=7yrs, O-olecranon=9yrs, E-external (lateral) epicondyle=11yrs

question

Supracondylar fx

answer

FOOSH (fall on outstretched hand) Gartland 1: non-displaced Gartland 2: displaced but intact Gartland 3: displaced with disruption or ant/post periosteum. Neurovascular compromise/comapartment syndrome

question

Toddler fx

answer

Spiral or oblique fx through distal 3rd of tibia non-displaced. -Etiology: Often un-witnessed fall or minor trauma. -Sx: Limp. Pain with gentle twisting of LE or heel tap. -Tx: short or long leg cast for 3-4weeks

question

Avulsion fx

answer

sudden traction forces by muscles results in avulsion of apophysis (twisted ankle or ligaments/muscles attached)

question

Heat related illness

answer

Edema Tetany malaria rubra syncope cramps exhaustion

question

Cold related illnesses

answer

frostnip pernio-chillblains Kibe (chilblains on heel) Trench foot Surfer's ear Frostbite

question

Heat Stroke

answer

Core temp >40C w/ CNS dysfx in setting of environmental heat load

question

Drugs that cause heat stroke

answer

Diphenhydramine (Ach) phenothiazines (dopamine blockers) Ethanol Cocaine Ecstasy

question

Frostbite risk factors

answer

smoking, prolonged hand/arm vibration, chronic dz affecting vasculature

question

Frostbite - appearance -dx

answer

waxy, hard, insensate. Blisters containing blood or clear fluid. Don't rub affected areas. -dx: clinical, angiography, technetium99

question

Mild Hypothermia

answer

32-35C (89.6-95) Shivering, hyper-reflexia, cold diuresis

question

Moderate Hypothermia

answer

28-32 C (82.4-89.6) CNS depression, paradoxical undressing, cardiac dysrhythmias develop (sinus brady, afib), Osborn J waves.

question

Severe

answer

<28C (82.4) Pulmonary edema, oliguria, loss of reflexes, acidosis, hypotension, coma, ventricular fibrillation, asystole.

question

Passive external rewarming

answer

Remove wet garments, apply blankets, let them shiver

question

Active external rewarming

answer

heating pads, radiant heat lamps, warm baths

question

Active internal rewarming

answer

cardiopulmonary bypass, ECMO, warm pleural and peritoneal irrigation, arteriovenous rewarming, esophageal rewarming tubes, endovascular rewarming

question

Shock

answer

physiologic state characterized by inadequate oxygen delivery. Delivery isn't keeping up with demand

question

CO

answer

HR X SV

question

How does inadequate volume cause shock?

answer

Decreased preload (ex: hemorrhage, dehydration)

question

How does inadequate resistance cause shock?

answer

Inappropriate low SVR (ex: SIRS, anaphylaxis, burns, Addisonian crisis)

question

How does pump failure cause shock?

answer

Contractility or HR (ex: acute MI, arrhthymias, late sepsis)

question

Normotensive Shock

answer

SBP40mmHg drop fro baseline. It's not about the pressure it's about the O2 demand

question

Cryptic Shock

answer

Normotensive + high lactate = profound tissue hypoxia. SBP >90 or MAP >65. Lactate >4.

question

SIRS criteria

answer

-Temp: 100.4 - HR: >90 - RR: >20 or PCO2<32 - wbc: 12 or bands >10%

question

Severe Sepsis:

answer

Sepsis + Organ dysfunction (elevated Cr, INR, altered mental status, elevated lactate, hypotension that responds to fluids)

question

Septic Shock

answer

Severe sepsis + hypotension. Hypotension does NOT respond to fluid (30cc/kg bolus)

question

Early Goal-Directed Therapy (EGDT):

answer

Early antibiotics + resuscitation minimizes mortality in septic shock.

question

Confusion

answer

Alteration in higher cerebral functions (memory, awareness, attention). Sx, not a dx

question

Etiology of widespread cortical dysfunction --> confusion

answer

1. Primary intracranial disease 2. Systemic dz that affect CNS 3. Exogenous toxins 4. Drug withdrawl

question

Coma

answer

complete failure of the arousal system with no sponatenous eye opening

question

Coma causes?

answer

Brainstem dysfx and/or bilateral cortical dz

question

Minimally conscious state

answer

inconsistent but discernable evidence of consciousness. Altered state. Able to follow commands/purposeful behaviors/simple commands

question

Obtundation

answer

Awake but NOT alert. Psychomotor retardation

question

Stupor

answer

Awaken with stimuli but little motor or verbal activity when aroused.

question

Delerium

answer

Severe confusion associated with 1. Motor restlessness 2. Transient hallucinations 3. Disorientation 4. Delusions

question

Delerium v Dementia

answer

Delerium always has an organic cause.

question

Dementia

answer

stable course of confusion, slow onset, irreversible, progressive, no impairment of consciousness, alert, normal vitals

question

Critical Life threatening AMS not to miss

answer

o Hypoxia/diffuse cerebral ischemia (CHF, MI, shock) o Systemic process: hypoglycemia o CNS infx o HTN encephalopathy o Elevated ICP

question

Coma etiologies NOT to miss

answer

CNS: hemorrhage, stroke Infx: meningitis, sepsis Metabolic: hypoglycemia, DKA, HHNK

question

"Big-Five" life threatening causes of chest pain

answer

1. ACS/MI 2. PE 3. PTX 4. Aortic dissection 5. esophageal rupture

question

Spontaneous pneumothorax risk factors

answer

tall, young, thin, smoker

question

PE risks

answer

long trips, pregnancy/OCP, cancer risks, virchow's triad (venous stasis, hypercoagability, endothelial damage) -- #1 risk factor= prior DVT/PE

question

PE dx (ecg, xcr)

answer

- Ddimer: rule-in - ECG: sinus tachy! - XCR: normal or atelectasis. Wedge shaped infarcts hampton's hump and westermark's sign- pathopneumonic

question

Aortic Dissection

answer

intimal tear with entry of blood into the media "dissects" between the intima and adventitia.

question

Expressive aphasia, stroke (carotid ischemia), pain radiates to back, CXR: widened mediastinum

answer

Aortic dissection clinical picture

question

Stanford classification (aortic dissection)

answer

A: involves Ascending aorta (w or w/o descending) 80% of dissections - older pts w/ HTN B descending aorta only - mar fan's, ehler Danlos, pregnancy

question

Aortic Dissection physical exam

answer

unequal decreased or absent peripheral pulses, aortic insufficiency murmur

question

Aortic Dissection treatment goals

answer

Fluid and BP control (beta blockers, nitroprusside)

question

Cocaine-Related Chest pain -cause -tx

answer

-cause: coronary vasospasm - tx: benzodiazapem (NO beta blockers)

question

Stable angina

answer

Transient, episodic chest discomfort that is predictable and reproducible

question

Unstable angina (plaque rupture)

answer

Angina that is new in onset occurs at rest or is similar but somewhat "different".

question

MI (occlusion) or NSTEMI

answer

Sub-sternal chest discomfort > 15 min associated with dyspnea, diaphoresis, light-headedness, palpitations, n/v (12.5% of MIs are clinically silent)

question

Atypical MI symptoms

answer

old people feel weak inferior wall MI; only with N/V - not chest pain

question

Cardiac markers and sensitivities

answer

CK-MB: Sensitive >90% for MI 5-6 hrs after sx Troponin-I: Sensitive, duration for days Troponin-M: less sensitive, duration for days

question

Chest pain immediate goals tx

answer

1. ABC/Stabilization/resuscitation ("Oh MY": IV, O2, monitor, pulse-ox) 2. ECG 3. +/-CXR

question

Healing timeline

answer

Initial epitheliization: 24-48h Peak collagen synthesis 5-7d Strength of wound: 5% at 2 weeks, 35% at one month

question

Contaminated wounds

answer

saliva, stool, dirt, wood or other organic matter. No visual debris

question

Kraissel's lines

answer

lines of minimal tension. Important for wound contractures

question

Regional block (amides: lidoaine, bupivicaine)

answer

large areas: when needed to avoid tissue distortion. Areas where infiltration is painful (ex: digital block, plantar surface)

question

Lidocaine with epi. -don't use it? -treatment

answer

-ears, nose, penis and toes -phentolymine

question

Wound preparation steps

answer

1. Cleansing (saline under pressure 8psi) 2. Debridement is critical 3. Exploration is critical

question

Non-absorbable sutures

answer

Type: Monofilaments Subtypes: Ethilon (nylon,black) Prolene (polypropylene, blue, springy)

question

Absorbable

answer

Types: Monofilaments Subtypes: Vicryl Dexon

question

Tdap

answer

Once, 20-65 yo. Pregnant women after 20weeks.

question

dT

answer

Every 10 years or booster. Okay in pregnant women

question

TIG

answer

if not full immunized and current (within last 10 years)

question

Abx prophylaxis

answer

Generally not necessary, except cat bites, certain hand injuries, foot punctures

question

Gas permeable dressings

answer

Abrasions, burns, road rash, ulcers

question

Difficult sutures

answer

Palms Shins Joint involvement vermillion border

question

When to close? Golden hour.

answer

Depends on clinical scenario. 8-12hrs

question

Primary closure

answer

Clean wound

question

Delayed primary closure

answer

wound infx concerns

question

Healing by secondary intention

answer

Dirty wound. Least favorable will make a big scar.

question

Wound lecture pearls

answer

NO absolute golden hour, tap water is as good as NS, do NOT soak in betadine, non-sterile gloves ok, hand wounds less than 2cm> big, bulky dressings as good as sutures

question

Wound lecture pitfalls

answer

always remember ABC, look for assoc injuries, don't miss high pressure injuries, always assess for foreign body, abx v delayed primary closure for high risk wound and or co-morbid conditions

question

Primary EMBU applications

answer

1. Cardiac/IVC/Shock 2. FAST and pneumothorax 3. Aorta 4. Gallbladder and biliary 5. First trimester pregnancy and female pelvis 6. Evaluation for urterolithiasis and acute renal failure 7. Procedural guidance 8. Devaluation for DVT 9. Ultrasound of lungs and pleurae 10. Musculoskeletal and soft tissue evaluation

question

CT objective

answer

Id of specific organ injury and or free fluid and/or retroperitoneal andmusculoskeletal injury → IR or OR

question

DPL objective

answer

id of abnormal presence of blood, intestinal contents - old school

question

Supine watersheds

answer

RUQ: 4 spaces LUQ: 4 spaces Subxiphoid:1 Suprapubic:1

question

RUQ and LUQ spaces

answer

1. Pleural 2. Subphrenic 3. Splenorenal/hepatorenal (morrison's pouch) 4. Inferior pole

question

Subxiphoid space

answer

pericardial space

question

Suprapubic space

answer

retrovesicular (P of Douglas)

question

Metabolic causes of AMS

answer

Hypoglycemia Hepatic encephalopathy Thyroid dyxfx Alcohol withdrawal

question

CV causes of AMS

answer

HTN, enceophalopathy MI, CHF, PE Hypoxia Hypercarbia

question

Infection causes of AMS

answer

Pneumonia UTI Sepsis Meningitis

question

Neurological causes of AMS

answer

Siezure Stroke CNS mass

question

Urospesis tx

answer

abx and fluid resuscitation, admission (River protocol for goal directed therapy)

question

Occlusive Stroke -etiology -dx -tx

answer

-embolus from heart -dx: stat CT (rule out hemorrhage) -tx: tPA within 4hrs

question

Anterior infarct sx

answer

lower extremity weakness> upper

question

MCA infarct sx

answer

upper extremity> lower extremity; aphasia (left side), right sided hemi-paresis and sensory loss, left hemi anopsia, gaze preference toward the stroke.

question

Tip of the basilar stroke sx

answer

locked in syndrome

question

Acute Bacterial Meningitis bugs

answer

young people: strep pneumo and neisseria meningitis old people: listeria

question

Acute Bacterial Meningitis -dx -tx

answer

-dx: lumbar puncture (careful not to herniate) -tx: abx and dexamethasone

question

Subarachnoid hemorrhage -sx -dx

answer

-sx: worst HA of life -dx: head CT/LP

question

AAA surgery indication

answer

3cm=aneurysmal 5.5 cm elective surgery recommended

question

AAA RF

answer

over 50yo, atherosclerosis, peripheral vascular disease (PVD), first degree relative with AAA

question

AAA classic triad

answer

(1) abdominal pain (2) hypotension (3) syncope (more in thoracic)

question

Arterial occlusive Acute Mesenteric Ischemia -etiology -sx -dx -tx

answer

-origin of the SMA -sx: pain out of proportion to exam -dx: angiography "thumbprinting" -tx: heparin, glucagon, intraarterial papaverine, laporatomy

question

Venous occlusive Acute Mesenteric Ischemia -etiology -sx -tx

answer

-etiology: Starts in venous arcades and progresses to SMV -sx: slower onset than arterial -tx: Heparin, IV thrombolytics, thrombectomy

question

Non-Occlusive acute mesenteric ischemia -etiology -sx -tx

answer

-etiology: "intestinal angina" after eating. -sx: Anorexia in elderly people or critically ill -tx: difficult. vasodilation, anticoagulate

question

Melenemesis

answer

coffee ground emesis, partially digested blood

question

UGIB causes

answer

PUD, gastric erosions, variceal bleeding, Mallory-weiss tear, esophagitis, duodenitis, aortoenertic fistula, renal disease

question

UGIB high risk (re-bleed, mortality)

answer

Hgb: 110-120 BPM Age >60 Coagulopathy Co-morbidities such as cancer

question

UGIB dx

answer

NG lavage: EXCEPT known esophageal varices, active PUD, Mallory-weiss tears, gastric bypass surgery Endoscopy: 12-24 hours if bleeding stops

question

LGIB dx

answer

Anoscopy: localizes lesion to rectum Colonoscopy: procedure of choice, difficult to perform without bowel prep or if active bleeding Nuclear red blood cell scan Angiography

question

Define fever in kids

answer

>38C (100.4F) - infant 38.5 (101.3F) -older kids

question

Reasons for fevers

answer

Host defense Endogenous pyrogens (IL-1, IL-6): rheumatic disease, Exogenous pyrogens: LPS, cocaine, anti-cholinergics

question

Hyperpyrexia

answer

extreme elevation of body temp ≥ 41.5°C due to high set point

question

Hyperthermia

answer

results from uncontrolled temperature regulation (e.g. heat stroke), body temp rises above set point

question

Febrile infant (<2yrs) agents

answer

E. coli, Group B strep, listeria monocytogenes, HSV 1, HSV 2

question

Fever without source

answer

temp >39, normal physical exam (well appearing, no obvious bacterial illness, petechiae -- occult)

question

Occult bacteremia

answer

this is rarely happens anymore because of vaccines (h flu, strep pneumo)

question

Occult UTI -agents -rf

answer

-agents: E coli, gnr, enterococcus -RF: age < 12mos, duration of fever 2+days, uncircumsized males

question

Fever Unknown Origin (FUO)

answer

elevated temperature but despite investigations by a physician no explanation has been found

question

Septic workup in kids

answer

CBC, UA, CSF, CXR

question

Febrile infant (29-56 days) mgmt

answer

Complete septic workup 28-56d: admission "Low risk" criteria: withhold abx "High risk" criteria: abx

question

Febrile young child (2mos-3yrs) mgmt

answer

Well appearing: urine dip, UCx Ill-appearing non-toxic: CBC, urine dip Toxic appearing: septic work-up, immediate abx

question

Febrile child (3+yrs)

answer

Similar to adolescents and adults

question

Croup

answer

laryngotracheobronchitis always caused by a virus (paraflu) in pharyngeal epithelium that spread to larynx and produce mucus and edema. Sx: Seal-barking cough, steeple sign on xcr

question

Croup tx

answer

1. cool mist/hot shower 2. dexamethasone 3. racemic epinephrine nebulized

question

Asthma

answer

airway hyperresponsiveness --> dead space ventilation. hypercapnea & respiratory acidosis, end-expiratory wheeze

question

Asthma tx

answer

Albuterol (beta 2 agonist) Ipratroprium (anticholinergic agent) Corticosteroids: use in ALL acute attacks Magnesium sulfate Terbutaline/Epinephrine: parenteral beta-agonists

question

Bronchiolitis

answer

RSV invades nasopharyngeal epithelium cell-cell transfer to lower airway and cause mucus plugging, and edema sx: grunting, nasal flaring

question

Bronchiolitis tx

answer

-Supportive care: O2, hydration, nasal suctioning, pulmonary toilet, ventilator -Albuterol, maybe? -Racemic epinephrine - Corticosteroids

question

Pneumonia

answer

aspiration or hematogenous spread to lungs of organsism that cause exudative inflamm response, fibrin deposition. Sx: pleuritic chest pain

question

Foreign body aspiration

answer

younger children into R main-stem bronchus, ball-valve effect sx: classic triad: wheezing, sudden cough, choking, diminished unilateral breath sounds

question

Opioid drugs

answer

morphine derivatives (hydrocodone, methadone, meperidine, propoxyphene, fentanyl) tx: narcan/naloxone

question

Opioid-like drugs

answer

tramadol, clonidine, imidazolidines

question

Opioid toxidrome

answer

Pinpoint pupils, respiratory depression, lethargy to coma, bradycardia, hypothermia, borderline, hypotension

question

Anticholinergic toxidrome

answer

block acetylcholine transmission Mad as a hatter, blind as a bat, red as a beet, hot as a hare, dry as a bone, full as a tick

question

Anticholinergic drugs

answer

Benadryl diphenhydramine (OTC cold, sleep meds), antiparkinson, anticholinergic meds, benzotropine, Jinsom weeds, atropine tx: neostigmine

question

Sympathomimetic toxidrome

answer

tachycardia, elevated bp, dilated pupils, hyperactive bowels, diaphoresis

question

Sympathomimetic drugs

answer

Cocaine, amphetamines, anorectics, otc stimulants, herbal, PCP (nystagmus)

question

Cholinergic toxidrome

answer

DUMBELS D: Diarrhea, diaphoresis U: urination M: miosis B: bradycardia, bronchorrhea E: emesis L: lacrimation S: salivation, seizures

question

Cholinergic drugs

answer

organophosphates/carbamate pesticides, carbamate medicinals (donepezil, physotigmine, pyridostigmine), nerve gas agents

question

Certified First responders

answer

first on scene firefighter, police etc. 45hrs of training. CPR, AED, splint and bleeding control.

question

EMS curriculum

answer

Set by the Federal Department of Transportation

question

EMS scope of practice

answer

set by each state

question

EMS length of training

answer

minimums set by the DOT, but overseen by the states

question

EMS certification

answer

states with local credentialing

question

Emergency Medical Dispatcher

answer

24hrs of training. Provide "pre-arrival instructions" Medical priority dispatch.

question

EMT-basic

answer

120+ hours of training. All CFR skills. O2 admin, basic extrication skills. Assist with patient's meds (NTG, MDI)

question

EMT-I (intermediate)

answer

80-1000hrs (vary by state). IVs, some medications, advanced airway skills (ET, combi-tube)

question

EMT-paramedic

answer

EMT-B training plus 1000+ hrs of training. Clinical rotations in ED, ICU, CCU, labor & delivery and anesthesia. Strict CME requirements. ET intubation, surgical airway, chest decompression, EKG

question

EMS personnel

answer

EMT-B EMT-I EMT-P

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