Board Review 6/7/2013

1. Board Review 6/7/2013 Emergency Care

2. Test Question What is your favorite letter? • C • D • E • A • B

3. Pediatric Head Injuries

4. 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

5. 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

6. 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

7. 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

8. Question #1 A patient presents with blood draining from his ears, ecchymoses in the orbital area, and postauricular bruising. He likely has what type of fracture? • Basilar skull fracture • Simple linear skull fracture • Scapula fracture • Depressed parietal skull fracture • Femur fracture

9. 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

10. 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

13. Question #2 What type of intracranial injury is this? • Subdural hemorrhage • Subarachnoid hemorrhage • Epidural hemorrhage • Cerebral Contusion • Diffuse axonal injury

14. 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

15. 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

16. 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

17. Brain Herniation • 4 possible types • Uncalherniation • Innermost part of temporal lobe moves over tentorium • Exerts pressure on the midbrain and CNIII • Leads to ipsilateralpupillary dilation

18. Question #3 A 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: • Administer tetanus prophylaxis • Infuse 20 mL/kg of 0.9% saline • Obtain head computed tomography scan • Provide assisted ventilation • Administer mannitol

19. 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

20. 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

21. 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

22. Musculoskeletal Injury in Children

23. 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!

25. Question #4 Name this type of fracture: • Buckle fracture • Greenstick fracture • Nursemaid’s elbow • Salter-Harris Type 1 • Salter-Harris Type 4

26. 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

27. Growth Plate • 20% of all childhood fractures occur at the physis • Can disrupt bone growth

28. S A L T R

29. Focus on… • Clavicle fracture • AC separation • Injuries that affect vasculature

30. Question #5 You 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: • Complications include ulnar nerve palsy • He should be tested for osteogenesisimperfecta • His right arm should be placed in a sling • Surgical reduction will be needed • The injury typically heals in 8 to 10 weeks which will be done in foster care because you are reporting them to OCS

31. 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

32. 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

33. Normal Shoulder

34. 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

35. 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 • Posteriodsternoclavicular dislocations: dislocated proximal clavicle may compress the upper airway or subclavian vessels

36. Acute fever

37. 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

38. 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

39. 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

40. Question #6 You 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? • 4 mo F with otitis media • 4mo F with urinary tract infection • 4 mo F with fever of unknown origin (FUO) • 4mo F with thermometer malfunction • 4mo F with fever without a source

41. 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 havebacterial illness • UTI, meningitis, sepsis, bacteremia, osteomyelitis, septic arthritis, PNA • Pathogens: GBS, Listeria, Salmonella, E. coli, Staph aureus

42. 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

43. Question #7 You 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? • Ibuprofen or another NSAID • Acetaminophen (Tylenol) • Both Ibuprofen and Tylenol alternating with each other q3 hours • Neither…give the baby an ice bath • Neither…wipe the baby down with alcohol

44. 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

45. 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.

46. burns

47. Question #8 This is a _________ degree burn. • First degree • Second degree • Third degree • Fourth degree • Fifth degree

48. 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

49. Burn Classification • Third degree burn • Most serious • Appears pearly white, charred, hard, or parchmentlike • Dead skin (eschar) • Superficial vascular thrombosis can be observed • PainLESS

50. Burn Classification