key: cord-018111-5qx8tolv authors: Lanski, Steven L.; Naga, Osama title: Emergency Care date: 2015-03-28 journal: Pediatric Board Study Guide DOI: 10.1007/978-3-319-10115-6_5 sha: doc_id: 18111 cord_uid: 5qx8tolv Children less than 6 years have the greatest risk for accidental ingestion and poisoning. • Children less than 6 years have the greatest risk. • Jimson weed and deadly night shade produce anticholinergic toxins, e.g., atropine, scopolamine, and hyoscyamine • Common garden vegetables in the solanum genus, including tomatoes, potatoes, and eggplants. • Amygdalin is contained in seeds and produces hydrogen cyanide which is a potent toxin • Inhibition of cellular respiration and can be lethal • Ingestion of mushrooms also may have fatal consequences in species that harbor amatoxins (Amanita) and related compounds Products contain an aspirin • Baby aspirin • Regular aspirin at home includes: Anti-diarrheal medications, topical agents, e.g., keratolytics and sport creams • Refer to emergency departments for ingestions > 150 mg/kg • Ingestion of > 200 mg/kg is generally considered toxic, > 300 mg/kg is more significant toxicity, > 500 mg/kg is potentially fatal • Acute salicylism; nausea, vomiting, diaphoresis, and tinnitus • Tachypnea, hyperpnea, tachycardia, and altered mental status can be seen in moderate toxicity • Hyperthermia and coma are seen in severe acetylsalicylic acid toxicity • Classic blood gas of salicylic acid toxicity is respiratory alkalosis, metabolic acidosis, and high anion gap • Check serum level every 2 h until it is consistently down trending • Initial treatment is gastric decontamination with activated charcoal, volume resuscitation, and prompt initiation of sodium bicarbonate therapy in the symptomatic patients • Goal of therapy includes a urine pH of 7.5-8.0, a serum pH of 7.5-7.55, and decreasing salicylate levels • An R wave in lead aVR of > 3 mm is independent predictor of toxicity • Electrocardiography (ECG) parameter is superior to measured serum of TCAs • Stabilization of patient is the most important initial step specially protecting the airway, and ventilation support as needed, activated charcoal in appropriate patients • Obtain ECG as soon as possible • ECG indication for sodium bicarbonate therapy include: QRS duration > 100 ms, ventricular dysrhythmias and hypotension • Strong acid and alkalis < 2 or > 12 pH can produce severe injury even in small-volume ingestion • Patient can have significant esophageal injury without visible oral burns. • Wash all exposed skin with soap and water and immediately remove all exposed clothing • Laceration is a traumatic disruption to the dermis layer of the skin • The most common anatomic locations for lacerations are the face (~ 60 %) and upper extremities (~ 25 %) • An evaluation for life-threatening injuries is the first priority • Ongoing bleeding that may cause hypovolemic shock • Applying direct pressure usually is successful • Sphygmomanometer may be used for up to 2 h on an extremity • Ring tourniquet on a digit for up to 30 min to help control ongoing blood loss • Lacerations of the neck should be evaluated for deeper structural injuries • If developmentally appropriate, two-point discrimination at the finger pads provides the best assessment of digital nerve function • It is critical to identify foreign material within the laceration Anesthetics and anxiolysis • The use of the topical anesthetic LET (4 % Lidocaine, 1:2000 Epinephrine, and 0.5 %Tetracaine) has been shown to be effective and to reduce length of stay • LET usually is effective 20-30 min after application to a laceration site on the face but often needs twice that amount of time to be effective elsewhere • Blanching of the site after application most often indicates achievement of effective anesthesia • A local anesthetic also may be used to prepare for placement of sutures • Dermabond: It is critical that the laceration be dry and well approximated to avoid application below the epidermal surface, which may cause the wound to gape open or lead to a "Dermabond Oma" • Evenly spaced suture placement: The general rule is sutures should be spaced the same distance as they are placed from the wound edge. For irregular wound shapes, approximate the midpoint of the wound first and then work laterally • Lip laceration require special care if the injury crosses the vermilion border • It is essential to approximate the vermilion border with a suture. Failure to do so may result in a poor cosmetic outcome • An infraorbital or mental nerve block along the lower gum line may be considered to reduce tissue distortion for lip lacerations, including those through the vermilion border • It may be painful and produce anxiety for the child and parent • A digital nerve block should be applied to provide adequate analgesia for this injury • If the nail has been removed during the injury, the nail bed should be repaired with absorbable sutures by using a reverse cutting needle which they designed to protect • There is no benefit to administer antivenom to unrelated species due to risk of anaphylaxis and expenses as well • Surgical assessment focuses on the injury site and concern for the development of compartment syndrome • Fasciotomy is indicated only for those patients with objective evidence of elevated compartment pressure • Bitten extremities should be marked proximal and distal to the bite and the circumference at this location should be monitored every 15 min to monitor for progressive edema and compartment syndrome • Black spider with bright-red or orange abdomen • Neurotoxin acts at the presynaptic membrane of the neuromuscular junction, and decreased reuptake of acetylcholine and severe muscle cramping • Pricking sensation that fades almost immediately • Uncomfortable sensation in the bitten extremity and regional lymph node tenderness • A "target" or" halo" lesion may appear at the bite site • Proximal muscle cramping, including pain in the back, chest, or abdomen, depending on the site of the bite • Almost painless bite, and only rarely is a spider recovered • Erythema, itching, and swelling begin 1 to several hours after the bite • Central ischemic pallor to a blue/gray irregular macule to the development of a vesicle • The central area may necrose, forming an eschar • Induration of the surrounding tissue peaks at 48-96 h • Lymphadenopathy may be present • The entire lesion resolves slowly, often over weeks to months • Tetanus status should be assessed and updated • Signs of cellulitis treated with an antibiotic that is active against skin flora • Treatment is directed at the symptoms Background • The only scorpion species of medical importance in the USA is the Arizona bark scorpion ( Centruroides Sculpturatus). • Toxins in its venom interfere with activation of sodium channels and enhance firing of axons. • Local pain is the most frequent symptom • Usually no local reaction • In small children -Uncontrolled jerking movements of the extremities -Peripheral muscle fasciculation, tongue fasciculation, facial twitching, and rapid disconjugate eye movements -May misdiagnosed as experiencing seizures • Severe reaction -Agitation -Extreme tachycardia -Salivation -Respiratory distress • Maintenance of a patent airway and mechanical ventilation in severe cases • Victims may be managed solely with supportive care: -Analgesia and sedation -Airway support and ventilation -Supplemental oxygen administration • Antivenin therapy also may obviate or reduce the need for airway and ventilatory support • Status epilepticus (SE) is defined as a seizure that lasts more than 30 min • Treatment of SE should be based on an institutional protocol, such as the following: • Initial management -Attend to the ABCs before starting any pharmacologic intervention -Place patients in the lateral decubitus position to avoid aspiration of emesis and to prevent epiglottis closure over the glottis -Make further adjustments of the head and neck if necessary to improve airway patency -Immobilize the cervical spine if trauma is suspected -Administer 100 % oxygen by facemask -Assist ventilation and use artificial airways (e.g., endotracheal intubation) as needed -Suction secretions and decompress the stomach with a nasogastric tube -Carefully monitor vital signs, including blood pressure -Carefully monitor the patient's temperature, as hyperthermia may worsen brain damage -In the first 5 min of seizure activity, before starting any medications, try to establish IV access and to obtain samples for laboratory tests and for seizure medications -Infuse isotonic IV fluids plus glucose at a rate of 20 ml/ kg/h (e.g., 200 ml D5NS over 1 h for a 10-kg child) -In children younger than 6 Fig. 3 , p. S888) • Bradycardia-most common pre-arrest rhythm in children with hypotension, hypoxemia and acidosis (Fig. 3 ) -Sinus bradycardia • Maybe non-pathologic in case of well conditioned individuals like athletes • Causes include: hypothermia, hypoglycemia, hypoxia, hypothyroidism, electrolyte imbalance, toxic ingestion, head injury with raised ICP • Treatment-identify cause and treating that condition • HR < 60 bpm in a child who is a well-ventilated patient, but showing poor perfusion, chest compression should be initiated • If HR remains below 60 despite adequate ventilation and oxygenation, then epinephrine or atropine (0.02 mg/kg-0.1 mg min and 0.5 mg max) should be given • Symptomatic bradycardia unchanged by above may require pacing • AV mode blocks -First degree-prolonged PR interval • Generally asymptomatic -Second degree-2 types • Type 1-Wenckebach ▪ Progressive PR prolongation until no QRS propagated • Type 2-regular inhibition of impulse ▪ Usually every other P results in QRS -Third degree-complete dissociation between P and QRS -Reversible causes of cardiac arrest (Fig. 4) • Fig. 4 Pediatric advance life support bradycardia algorithm. ROSC return of spontaneous circulation, IV intravenous, IO intraosseous, CPR cardiopulmonary resuscitation. (Kleinman ME et al. American Heart Association guideline for cardiopulmonary resuscitation and emergency cardiovascular care, part 14. Circulation 2010, 122, suppl 3, pp. S876-S908, Fig. 1 , p. S885) Toxic plant ingestions. Wilderness medicine Nelson Text book of pediatrics Rattlesnake bites in southern California and rationale for recommended treatment Clinical presentation and treatment of black widow spider envenomation: a review of 163 cases Clinical presentation and outcome of brown recluse spiderbite Envenomation by the scorpion Centruroides Sculpturatus Epilepsy Foundation of America's Working Group on Status Epilepticus. Treatment of convulsive status epilepticus. Recommendations of the Epilepsy Foundation of America's Working Group on Status Epilepticus Total burn care Golden hour: handbook of pediatric advanced life support Pediatric advanced life support