ENPC With Correct Answers

ENPC Pediatric triangle - ANS appearance work of breathing circulation to skin General appearance considerations - ANS Tone Interactiveness: drawn to sounds or people. Wants to play Consolability Look/Gaze Speech/cry Work of breathing: - ANS Increased work of breathing evidenced by tachypnea, stridor, grunting, retractions, accessory musles, nasal flaring, head bobbing, abnormal positioning Circulation to Skin - ANS Observe palor mottling cyanosis Sick, Sicker, Sickest - ANS Sick: no disruption of any component of PAT but caregivers are concerned Sicker: one component of PAT is a concern Sickest 2+ concerns of PAT 2 leading causes of altered mental status in kids - ANS hypoxia hypoglycemia Blood pressure norms - ANS Hypotension: Less than 70 + (2 x age in years) Widening pulse pressure = increased ICP Narrowing pulse pressure = hypovolemic shock Crying child - ANS Vigorous = good weak = sick high-pitched = increased ICP "Fussiness" = red flag Respiratory distress indicated by: - ANS increased heart rate skin color changes incrased work of breathing wheezing diaphoresis abnormal airwa sounds Respiratory failure signs - ANS fatigue and become lethargic hypoxia hypercarbia General airway interventions - ANS Allow child to stay in most comfortable position Give O2 to maintain it above 92% O2 does NOT measure ventilation Croup - ANS 1-3 days of nasal congestion and fever with sudden onset of barky cough Treatment: dexamethasone and nebulized epi Discharge Teaching: oral hydration, get child to cool air or steamy bathroom Asthma interventions - ANS albuterol, duo neb and oral steroid Bronchiolitis/RSV - ANS Assessment: 1-3 days nasal congestion fever, cough, respiratory distress with wheezing and crackles. Dehydration and tachypnea interventions: nasla suctioning, fluids sever: heated, high flow nasal cannula O2 Discharge: lasts 2-3 weeks; nasal suctioning; monitor hydration treating hypoglycemia - ANS obtain glucose for anyone who is not awake and alert treat kids with 2-4ml/kg of D25W When to perform blood glucose test? - ANS When the child is not awake and alert or AMS is suspected Preventing Secondary brain injury in TBI - ANS prevent hypotension and hypoxia cuffed vs uncuffed tube - ANS uncuffed= (age in years/4) + 4 cuffed= (age in years/4) + 3.5 fluid bolus formula - ANS infant: 10ml/kg kid: 20ml/kg normal vitals - ANS pg 52 blood glucose normal ages 5-11 - ANS 72-140 Cardiac Assessment - ANS Trend pulse and pulse pressure palapate upper and lower extremity pulses symptoms of CHF - ANS poor feeding, irritability, fatigue easily with rapid resp rate, increased work of breathing Ass and Interventions similar to adults Myocarditis Assessment and treatment - ANS Assess: consider in anyone with recent viral infection; SOB and crackles; dysrhthmias; heart failure; syncope; elevated liver enzymes Treat: diuretics; BP support; ECMO; transplant Hypovolemic Shock - ANS Tachycardia, tacypnea; AMS; slight increaes in diastolic pressure Intervention: Stop bleed; give fluids and RBC; balanced therapy; offer pedialyte if not NPO Cardiogenic shock - ANS Intervention: expert consult; supportive care to decrease O2 and metabolism demands; slow fluids; treat hpotension while decreasing afterload; vagal maneuver; vasopressors Obstructive Shock - ANS Assessment: Cardiac tamponade- muffled heart sounds and pulsluss paradoxus; tension pneumo- asymmetrical chest rise and fall Intervention: pericardiocentesis; needle thoracentesis; antigoagulation or surgical intervention; treat ductal dependent lesion Anaphylactic Shock - ANS remove pathogen fluids epi Neurogenic - ANS spinal motion restriction vasopressors warming measures Septic - ANS Fluids antibiotics vasopressors OLD CARTS - ANS Onset Location Duration Characteristics Aggravating factors Relieving factors Treatment Severity Pain Scale and appropriate ages of use - ANS Numeric- 6-17 years Visual Analog: 5-17 Faces: 4-12 FLACC- nonverbal Evaluation of child maltreatment - ANS ask open ended questions use direct quotes Sex trafficing risk factors - ANS limited education runaway/homeless/foster care hx of abuse livining poverty family dysfunction disability substance abuse LBGT low self-esteem, depression, social isolation Human trafficang Assessment screening - ANS hx: pt doesn;t have ID; doesn't know home address; vague hx of illness; person accompanying is unwilling to leave pt. persistent/untreated STI trauma to vagina/rectum jaw/neck pain hyper startle reflex expensive items, clothing, hotel keys Increased ICP triad - ANS widening pulse pressure bradycardia bulging fontenel respiratory disress Febrile seizure - ANS Temp greater than 100.4 usually occurs after 24 hour onset if occurs after that 24 hr period consider meningitis give antipyretic to promote comfort and oral intake. Does not prevent seizures Avoid ice baths Seizure Inteventions - ANS turn pt on side provide safe environment check bedside glucose manage fever as a cause or a result if seizure lasts longer than 5 minutes consider benzos give antiboitcs for infection hyponatremia =3% sodium chloride Seizure medication - ANS 5 min: midazolam=intranasal, IM, IV 5-10 min: 2nd dose or phenytoin 15-30 min: phenobarbital, reassess airway, consider intubation When should the parent cal 911 in for a seizing child? - ANS child stops breathing parent cannot feel a pulse seizure lasts more tahn 5 minutes child has more than 1 seizure before fully awake VP shunt issues assessment - ANS changes in resp rate: apnea or irregular changes in BP: widening pulse pressure Changes in HR: bradycardia fever or signs of shock redness/edema Hydrocephalus interventions - ANS accurate head circumference for monitoring elevate HOB 30 degrees and maintian head allignment Give meds: anyipyretics, analgesic, antibiotics, meds to decrease ICP Difference between stroke and bells palsy - ANS Pt will be unable to raise an eyebrow or wrinkle the forehead on the affected size w/ bells palsy stroke usually only involves the lower face Stroke interetnions - ANS maintain glucose control BP meds: aspirin; anticonvulsants; antigocagulants (embolism) Symptoms of TBI (concusion) are organized into what four catagories? - ANS Thininking and remembering physical emotional/mood sleep Secondary impact syndrome - ANS 2nd brain injury before the first one is healed. Brain cannot auto regulate CPP Causes massive brain edema and herniation proper infnat/toddler head positioning with spinal percautions - ANS place padding under shoulders of infant to achieve neutral alignment have parent directly above pt so pt is not turning head reverse trandeleburg to reduce anxiety Neurogenic Shock - ANS Injury above T6 results in bradycardia, hypotension, and vasodilation, thermoregulatory instability Spinal shock - ANS flaccid muscle tone below thei njury and decreased sensation at and below the level of injury kids who do not need a spine board - ANS compliant child absence of distracting injury absence of alcohol GCS 15 absence of spine tenderness/neurologic findings Orbital fracture interventions - ANS topical vasoconstrictor to stop bloody nose avoid blowing nose analgesics ice elevate HOB LeFort I - ANS Edema of maxillary area lip laceraiton or fractured teeth edema maloccluiosn Le Fort II - ANS massive facisal edema nasal swelling with obvious fracture or deformity maloccluison CSF rhinorrhea Lefort III - ANS massive facial edema ecchymosis mobility and depression of zygomatic bones diplopia from nerve entrapment ma,occluison CSF rhinorrhea midface and nasal fracture interventions - ANS maintain airway delay surgery until swelling decreases avoid straining bending over heavy lifting blowing nose sleep with head of bed elevated for 3 nights mandibular fracture test - ANS have pt bite down on tongue blade attempt to pull tongue blade out if pt unable to continuously bite down -- could indicate mandibular fracture Hyphema interventiosn - ANS pt on bed rest with HOB at 35-45 degrees cover eye with shield steroids and tranexamic acid Globe injuries - ANS stabalize object with a shield assess for fluid leaks CT or MRI meds to prevent increase IOP -- prevent vomiting, agitation, pain, antibiotics Gastroenteritis Assessment and Interventions - ANS Assessment: increased freqency of loose, fould smelling stools, vomiting, fever/headache/malaise; ab cramping Intervention: oral rehydration; 2-5ml of oral rehydration solution every 2-5 minutes; increase if tolerated. Goal 50-100mg/kg over 2-4 hrs; ANTIDIARRHEAL MEDS ARE NT REOMMENDED colic baby comforting suggestions - ANS 1. Swaddle 2. Side position for digestion (left) 3. sushing sounds 4. swinging 5. Sucking Intussusception assessment and intervention - ANS Assessment: colicky abdominal pain; child inconsolable; draws legs to chest; bomiting and ab distention with palpable sausage-shapped mass Intervention: air or contrast enema to diagnose and treat -- not with signs of shock; Swallowing items - ANS -batteries are ideally removed within 2 hours -X-ray/CT/US use to diagnose -keep child NPO Esophageal Atresia/Tracheoesophageal fistula - ANS Assess: resp distress; drooling, choking episodes; reccurent resp infection Post repiar: GErD; resp. illness, dysphagia; feeding issues diagnosis by trying to insert a OG tube Rhabdomyolysis assessment and interventin - ANS Classic triad: muscle pain, weakness, dark urine Peds: muscle pain, fever, and fivral prodrome usually caused by infection (under 9yo) Diagnose: CK1000 Aggressive hydration; treat problem hemolytic uremic syndrome Assessment - ANS damage to kidenys so they can't filter usually form illness pallor/lethargy hypertension diarrhea (bloody); N/V edema oliguria/anuria w/ hematuria and proteinuria low hemoglobin adn hematocrit levles elevated BUN and creatinine bruising, purpura AMS/seizures HUS interventions - ANS diagnosis made by triad of anemia, thrombocytopenia, and renal failure DONT give antibiotic IV hydration and electrolyte correction dialysis blood/platelet transfusion antihypertensives Long bone fracture assessment - ANS pain reluctance to use extremity deformity/shortening/rotation bony crepitus edema tenderness on palpation delayed cap refill, cool skin six Ps long bone fracture intervention - ANS extenal hemorrhage control monitor for fat emboli splint deformities -- use temp first pain managment immobilize injured extremity and joints above and below circulation is impaired = impaired alignment prepare for possible closed reduction amputation interventions - ANS use tourniquet for external hemorrhage if uncontrolled by direct pressure resus and stabilize consider splinting pain management antibiotic and tetnus care for amputated limb - ANS avoid excessive handling gently rinse with steril saline to remove dirt wrap in moist gauze and place in plastic bag place bag on ice interventions for compartment syndrome - ANS limb at level of heart loosen or remove any bandage or splints fasciotomy septic arthritis assessment - ANS 1 joint less than 3 mo: irritability, poor feeding, cellulitis, discomfort with diaper change, pseudoparalysis/fever older kids: fever/malaise/anorexia swelling, tenderness, and warmth of the affected joints limp or refusal to bear wt and decreased ROM Juvenile idiopathic arthritis assessment - ANS fever spikes about same time each day transient rash for a few hors morning stiffness and after inactivity edematous joints hepatosplenomegaly anemia and elevated WBC countpleural and pericardial effusions juvenile idiopathic arthritis interventions - ANS NSAIDs and steroid use psychological counseling academic counseling PT OT warm baths and heating pads Interventions for frost bite - ANS immediate rewarming over 15-30 minutes remove constricting, damp clothing and replace it with warm blankets avoid rubbing or causing frictin blood blisters are left intact; fluid extracted from clear blisters splint affected part Hair tournequet assessment and intervetion - ANS crying w/out associated fever or appearance of some loca reaction by redness and swelling treat pain tpoical antibiotic if skin breakdown wound care to open areas observation for return of circulation Burn intervetnions - ANS Stop burning process- remove clots, jewelry, diapers; cover with dry sheet; cool burns with room0eimp water prevent exposure: done PPE; brush off as much powder as possible clean minor burns with soap and water wound care as indicated: leave blisters intact; pain meds before debridement fluid replacement: 3mlxkg/% burn; use LR pt wt less than 30kg get 5% dextrose with LR monitor I&O G-tube for ventilatory effor cardiac monitoring for electrical burns opiods circumferential burns = excharotomy and montior for compartment syndrome Verbal De0escalation Techniques - ANS remain 2 arms lengths away keep hands visible and not clenched stand at angle to pt avoid folding arms across chest introduce self reassure pt you want to help them speak in simple, short sentences repeat expectations if needed set clear limits on which behaviors will be tolerated offer strategies to help pt calm down- oral meds; meal/blanket choices when available Emergency interventions for eating disorders - ANS rehydration correcting electrolyte and metabolic imbalances monitoring cardiac dysrhythmias and hypotension General psychosis interventions - ANS No hx of mental health = rule out physical issues 1st bedside glucose CBC and blood culture to rule otu onfectin electrolytes ammonia level drug screen, urinalysis, and urine culture Depression interventions - ANS ask direct questons about suicidal ideation thoughts about killing yourself compete physical exam further testing not indicated for kids with preexisting mental health issues, mornal physical and mental exam and normal vital signs obtain CBC and measure thyroid levles consult mental health professional Side effects of psych meds - ANS wt gain type 2 diabetes increased sedationdry mouth dizziness and nausea Extrapyramidal symptoms: dystonia (distorted posture, excessive blinking) dyskinesia: repetitive movement of face/lips akathisia: internal restlessness pseudoparkinsonism: tremors, stiffness, rigidity Autism interventions - ANS place pt in room that is protected from sound and away from main hallway ask caregivers for details on best techniques to gain cooperation increased aggression can mean pain consistent treatment team avid touch child explain procedures using visual cues move slowly Neutorpenia Interventions - ANS assess sepsis avoid rectal temps positive air pressure room hand hygiene! IV antibioitcs labs avoid NSAIDs Tumor lysis syndrome interventions - ANS Protect renal function -- hydrate to produce urine at 100mL/m2/hr hydration therapy = 2-4x normal amount consider loop diuretics administer hypouricemic agents correct severe hyperkalemia (ainsulin, glucose, sodium bicarb) inhaled albuterol; IV calcium gluconate to prevent dysrhythmias 4 components of pediatric prioritization process - ANS 1. PAT 2. focused assessment 3. focused hx 4. acuity rating Steps in neonatal resuscitation - ANS 1. warm the infant 2. Maintian airway 3. Maintain breathing 4. adequate ciruclation 5. vascular access 6. administer meds 7. intervene if positive pressure ventilation fails 8. volume expansion and vasopressor supprot decominsated shock definition - ANS When blood pressure drops Hypoglycemia levels and assessment ifndings - ANS Less than 40 in a newborn Less than 60 in a child abnormal mental status irritability difficulty speaking ataxia paresthesia headache hypoglycemia interventions - ANS Mild symptoms: give oral carbohydrates followed by protein/starch snack unconscious pt: 5-10mL/kg D10W or 2-4mL/kg D25W vomiting common following glucogon DkA diagnostic criteria - ANS Blood glucose greater than 200 pH less than 7.3 serum bicarb less than 15 ketonemia and ketonuria Assessment for DKA - ANS polyphagia, polyuria, poydipsia, wt loss, fatigue N/V/anorexia abdominal pain signs of dehydration: tachycardia/dry AMS kussmaul repirations acetone or fruity odor to breath DKA focused interventin - ANS vascular access bedside glucose labs + Blood cultures if signs of infection hemodynamically unstable = 10-20mL/kg fluid bolus hemodynamically stable: correct fluid over 24 hrs continuous infusion of insulin after initial fluid continue drip until pH greater than 7.3 or bicarb greater than 15 glucose less than 300, add 5%glucose to iV fluids anticipate hypokalemia, hyponatremia and hypophosphatemia Acetominophen overdose treatment - ANS Charcoal if present within 1 hr of ingestion Acetylcysein given within 8 hrs of ingestion Alcohols overdose treatment - ANS monitor blood glucose and treath hypoglycemia with dextrose IV hydration and alkalization hemodialysis folic acid some alcohols limit metabolism of other alcohol Cyanid poisoning - ANS tissue hypoxia with high pulse O2 reading tachypnea/ bradypnea/apnea tachycardia AMS seizures hyptension dysrhthmias cardiovascular collapse cyanid treatment - ANS hemodynamic instability with hx of fire in enclosed space indicates empiric treatment with hydroxocobalamin Serotonin syndrome - ANS 1. AMS 2. Neuromuscualr abnormalities 3. hyperactive autonomic nervous system Treat: sedate with benzos, active cooling, stopping all serotonergic medications Meningitis Assessment findings - ANS fever headache/N/V nuchal rigidity and bulging fontanel opisthotonos (muscle spasms of head/back/neck which cause arching spine) seizures photophobia DIC coma petechiae and purpura weak central pulse and decreased cap refill Meningitis Diagnostic and intervention - ANS Give antibiotics as soon as IV access is obtained full septic work up lumbar puncture if ICP increased -- get CT fluid bolus and vasopressor as indicated Halmark sign of measels - ANS koplik spots rash that progresses downward and outward (starts at hairline) Allergic reaction Interventions - ANS maintain airway supplemental O2 prepare for bag-mask ventilation administer epi and IV isotonic crystalloid fluid resus consider ET tube Antihistamines and alergic reactions - ANS DO NOT halt progression of anaphylaxis relieve symptoms such as hives or itching Drowning interventions - ANS positive airway pressure intubate and deliver high pressure ventilation manage hypothermia remove all wet clothing and wrap in warm blanket active warming for temp less than 28-32 degrees extarcorporeal membraen O2 for rewaarming 20ml/kg bolus of warm fluids caridac monitoring with life support measures as indicated monitor glucose NG/OG to remove H20 from stomach antibiotics for pneumonia bronchoscopy urinary catheter w/ temp probe ABG Heat stroke assessment - ANS hx of heat stress/exposure rectal temp greater than 104 central nervous system dysfunction such as disorientation/seizures/coma heat stroke interventions - ANS cooling to a temp of 100.4 spray pt with water ice packs to the neck, axille, and groin cold water immersion IV cooling catheters or administration of cool IV fluids Meds: DO NOT give tylenol or ibuprofen benzos for shivering during cooling hypothermia - ANS Neuro: mild=confusion, ataxia, impaired judgment cardiovascular: mild= tachycardia; increase blood pressure, cold diureis -- then bradycarida/pnea and hypotension hematologic: coagulation issues renal: rhabdomylysis; cold diuresis Rewarming - ANS passive: remove cold clothes; wrap in warm, dry blankets. active: start with trunk. use warmed IV fluids, IV catheter rewarming; heated inspired ari; gastric, periotneal, bladder, and thoracing clavage, and ECMO