CCP Fall 2013 - Week 6

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jmork
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249190
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CCP Fall 2013 - Week 6
Updated:
2013-12-02 19:17:21
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Critical Care Paramedic
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Trauma Management and Hematology - Parts I & II, Pediatric and Neonatal Emergencies - Parts I & II
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  1. What are the Signs & Symptoms of Tension Pneumothorax?
    • Agitation/Anxiety
    • Severe respiratory distress/dyspnea
    • Decreased or absent breath sounds
    • Tracheal Shift
    •   Late sign on external exam
    •   Early sign on radiographic
    • SQ air
    • JVD
    • Cyanosis
  2. What are the landmarks for the acceptable needle thoracostomy sites?
    • 2nd intercostal space, mid-clavicular or
    • 4th or 5th intercostal space, mid-axillary line
  3. What are the landmarks for tube thoracostomy placement?
    4th intercostal space anterior axillary line
  4. What should be delayed as long as possible when pt is potentially experiencing a tension pneumothorax?
    • ETI
    • PPV
  5. What are the signs & symptoms of massive hemothorax?
    • Hypovolemic shock
    • Altered mentation
    • Decreased/absent breath sounds
    • Midline trachea
    • Flat neck veins
  6. How do you treat a massive hemothorax?
    • Tube thoracostomy
    • Crystalloid replacement
    • Blood replacement
    • Intubate
  7. What are the signs & symptoms of an open pneumothorax?
    • Sucking chest wound
    • Respiratory distress
    • Tachypnea
    • Grunting
    • Shock
  8. What is the treatment for an open pneumothorax?
    • Occlusive dressing
    • Placed upon end exhalation
    • Taped on 3 sides only until tube thoracostomy accomplished
    • Seal 4th side post-chest tube
  9. What are the signs & symptoms of flail chest?
    • Paradoxical movement
    •   Uncommon in spontaneous breathing
    •   Common w/NMBA’s
    • Respiratory distress
    • Tachypnea w/grunting
    • Accessory muscle use
    • Cyanosis
    • C/O severe chest pain
  10. What are the treatments for flail chest?
    • Attempt to stabilize flail segment
    • Consider intubation w/peep
    • Injured side down
    • Limit fluids as able
    • Opioids for pain PRN
  11. What are the signs & symptoms of early tamponade?
    • Sinus tachycardia
    • Pulsus paradoxus
  12. What are the signs & symptoms of late tamponade?
    • Severe hypotension
    • Beck’s triad
    •   Muffled heart tones
    •   JVD
    •   Narrowed pulse pressure
  13. What is the treatment for early tamponade?
    • Force fluids
    • Anticipate tamponade progression
  14. What is the treatment for late tamponade?
    Pericardiocentesis
  15. What are the signs and symptoms of aortic rupture?
    • Severe Chest/Mid-scapular pain
    • Dyspnea
    • HTN in the upper extremities
    • Harsh systolic murmur
    • CXR findings: Widened Mediastinum
  16. Describe the treatment of aortic rupture
    • Supportive: If caval or liver lac suspected, est IV access above & below the diaphragm
    • Rapid transport to thoracic surgeon
  17. Describe the clinical presentation of diphragmatic rupture
    • Dyspnea
    • Bowel sounds in chest
    • Cyanosis
    • Scaphoid abdomen
  18. Describe the treatment of diaphragmatic rupture
    • NGT / OGT
    • Strict NPO
    • ETI / PPV PRN
  19. Describe the presentation of tracheobronchial disruption
    • Continuous air leak or persistent pneumothorax
    • Rapidly progressing subcutaneous emphysema
    • Pneumomediastinum
  20. Describe the treatment of tracheobronchial disruption
    • Supportive
    • Consider mainstem intubation trial
  21. Describe the clinical presentation of esophageal perforation
    • Hematemesis
    • Dysphagia
    • Dyspnea
    • Fever
    • Shock
  22. Describe the treatment of esophageal perforation
    • Supportive
    • NGT / OGT
    • Antiemetics
    • Antibiotics
  23. What is Newton’s 1st Law?
    An object in motion will remain in motion and an object at rest will remain at rest, unless  acted upon by a force
  24. What is Newton’s 2nd Law?
    F = MA
  25. What is Newton’s 3rd Law?
    For every action there is an equal and opposite reaction
  26. Describe injuries common to head-on collisions w/an up-and-over path of the body
    • Head injuries
    • Axial loading on the neck
    • Chest injuries from steering wheel
    • Pelvis injuries from belt
  27. Describe injuries common to head-on collisions w/an down-and-under path of the body
    • Acetabular fx
    • Femur fx
    • Pelvic fx
    • Low back injuries
    • Chest & facial injuries from steering wheel
  28. Describe predictable injury patterns suffered in rear end collisions
    • T12-L1 back injuries
    • Femur fx
    • Tib/Fib fx
    • Ankle Fx
    • C2 fx of neck
    • Evaluate for 2nd impact injuries
  29. What are the 2 most common spinal injuries?
    • Lumbar
    • Cervical
  30. What type of collision causes the most lethal injuries?
    Rollover collisions
  31. What is indicative of adequate oxygenation in trauma management?
    SpO2 > 90%
  32. How do you assess for adequate ventilation in trauma management?
    Monitor ETCO2
  33. Which VS is more more likely to alter 1st in the trauma patient?
    HR - BP won't fall until EBL > 30-40%
  34. Describe reasons for increased risk pattern in farming accidents
    • Delayed arrival of medical care & extrication often increase mortality
    • High potential for HAZMAT involvement
  35. Describe why tractor (farm) accidents raise the index of suspicion for MOI
    • Tractors are much heavier than autos
    • Tractors have a high center of gravity making them prone to rollovers
    • End over end rollovers have a greater potential for pt entrapment
  36. What age groups statistically suffer more falls?
    Primarily in adults & children under 5
  37. What part of a child's body will impact 1st in a fall?
    Impact on their head
  38. How do adults injure themselves in a fall?
    “Lover’s Leap”: Victim impacts on feet then falls backwards landing on buttocks & outstretched hands
  39. What injuries are common d/t the sequence of impacts often suffered in falls by adults?
    • Fx of feet/legs
    • Hip & pelvic injuries
    • Axial loading to the lumbar & cervical
    • spines
    • Vertical deceleration forces on organs
    • Colle’s fxs of the wrists
  40. What are general areas of concern in impalements / stab wounds?
    • Area of body penetrated
    • Blade length
    • Angle of penetration / attacker sex
  41. What are general areas of concern in GSWs?
    • Type of weapon
    •   Caliber, handgun vs long gun
    •   Distance from weapon
    • Bullet construction
    • High velocity bullets travel @ > 2000 fps
  42. How many distinct injury profiles can a victim experience from a blast?
    3: Primary, Secondary & Tertiary
  43. Describe the injury pattern seen in a Primary Injury from a Blast
    Result of Initial air blast, causes Injuries to air containing organs
  44. What causes the injury pattern seen in a Secondary Injury from a Blast?
    Victim struck by projectiles launched by blast force
  45. What causes the injury pattern seen in a Tertiary Injury from a Blast?
    Victim impacting the ground or another object
  46. What is the primary concern in a burn patient?
    Airway early
  47. What common byproducts of combustion complicate burn management?
    • Carbon Monoxide
    • Cyanide
  48. The combustion of what material results in the release of cyanide gas?
    Petroleum products, esp household carpet
  49. What is the goal of fluid resuscitation in the adult (child) burn patient?
    Urinary output of 30-50 ml/hr (1-2 ml/kg/hr in peds)
  50. What is the Parkland Burn Formula?
    • 4 mL*kg*%BSA burned = VTBI
    • Give 1/2 over the 1st 8 hrs post burn
    • Give the remaining 1/2 over the following 16 hrs
  51. What is the Consensus Formula for burn pt fluid resuscitation?
    2-4 mL*kg*%BSA burned
  52. How do you calculate burn mortality?
    • Age ÷ % BSA Burned = Mortality %
    • Add 20 if respiratory involvement
  53. What is the treatment paradigm for hydrofluoric acid burns?
    • Copiuos water
    • 10% Calcium Gluconate
  54. What is the treatment paradigm for alkali metal burns (Na & K)?
    • Water reactive
    • Absorb heat w/oil
  55. What process generally limits the depth of acid burns?
    Coagulative necrosis
  56. Describe the mechanism of alkali burns
    Alkalis dissolve protein & collagen causing dehydration & saponification
  57. Define saponification
    • Conversion into soap. It is the hydrolysis or the splitting of fat by an alkali yielding glycerol & 3 molecules of alkali salt of the fatty acid, the soap.
    • Hydrolysis of an ester into its corresponding alcohol & acid (free or in the form of a salt).
  58. Generally, which causes more severe burns, acids or alkalis?
    Alkalis
  59. What are the 2 modes of EMS @ a HazMat scene?
    • Fast Break
    • Long-Term decision making
  60. Describe the "Two-Step" Decon process
    • Usually at a fast break scenario
    • Remove all clothing, shoes, jewelry
    • Wash & rinse patient w/soap & water making sure they do not stand in runoff
    • Reposition out of runoff & repeat a 2nd time
  61. What byproduct of massive muscle damage 2° to electrical injury will result in ATN & renal injury failure?
    Myoglobinuria
  62. Describe the clinical management of myoglobinuria 2° to electrical injury
    • Maintain urine output of a MINIMUM 100 ml/hr w/fluids
    • Osmotic diuretics
    • Alkalinize the urine w/bicarb solutions
  63. Describe the Respiratory assessment for START Triage
    • Immediate: Abnormal rate, WOB or respiratory distress
    • Delayed: Normal respiratory pattern or agonal
    • Dead: Apneic
  64. Describe the Perfusion assessment for START Triage
    • Immediate: Cap Refill > 2 sec
    • Delayed: Normal Cap Refill
    • Dead: Pulseless
  65. Describe the Mentation assessment for START Triage
    • Immediate: Altered LOC
    • Delayed: Conscious, A&O x 3
    • Dead: Injuries incompatible w/life
  66. How long should a START Triage assessment take for each pt?
    15-30 seconds
  67. What can you do in START Triage if patient is apneic?
    • Reposition the head once
    • If spontaneous resps resume, pt is triaged immediate
    • If spontaneous resps do NOT resume, pt is triaged dead
  68. How is penetrating trunk trauma classified according to START Triage?
    Immediate
  69. An emergency responder is injured at the scen of an MCI. According to START Triage, what is their designation?
    • Immediate
    • All responders injured at an MCI are triaged immediate
  70. Where is cap refill assessed in START Triage?
    Centrally
  71. How are Erythrocytes listed on lab reports?
    RBC
  72. How are Leukocytes listed on lab reports?
    WBC
  73. How are Thrombocytes listed on lab reports?
    Plt (Platelets)
  74. How is Hemoglobin listed on lab reports?
    • Hgb
    • Hemoglobin is the O2 binding protein in RBCs
  75. How is Hematocrit listed on lab reports?
    • Hct
    • Hematocrit is the percentage of blood that is not fluid
  76. Describe plasma
    • Fluid part of the blood
    • 91% is H2O
    • 7% are proteins (Primary is Albumin @ 60%)
  77. What is a normal lab value for RBC?
    5
  78. What is a normal lab value for Hgb?
    15
  79. What is a normal lab value for Hct?
    45
  80. What is a normal lab range for WBC?
    5k - 10k
  81. What is a normal lab range for Plt?
    150k - 400k
  82. What is a normal lab range for Na+?
    135 - 145
  83. What is a normal lab range for K+?
    3.5 - 5.0
  84. What is a normal lab range for Cl-?
    95 - 107
  85. What is a normal lab value for BUN?
    10
  86. What is a normal lab value for Creat?
    1
  87. Blood loss is replaced by isotonic crystalloid by iv @ what ratio?
    3 : 1
  88. At what value should MAP be maintained w/fluids?
    80-90 mmHg
  89. Describe the process of bleeding control
    • Vessel spasm upon injury to tissue themselves  
    • Platelet plug development (primary hemostasis)
    •   Platelets attach to exposed collagen vi von
    • Willebrand’s factor (vWF)
    • Clotting cascade activation by platelets triggered secretion of thromboxane A2 (TXA2) [location of ASA & NSAID interference]
    •   Extrinsic
    •   Intrinsic
    •     Clot formation occurs (secondary hemostasis)
    •       Clot retraction closes vessel approximately 20 min to 1 hr later
  90. How is the intrinsic pathway of clotting cascade activated?
    • Triggered by endothelial damage w/collagen
    • exposure
    • Vessel damage
  91. How is the extrinsic pathway of clotting cascade activated?
    • Triggered by tissue damage w/tissue thromboplastin release
    •   Highest quantities in
    •     Brain
    •     Placenta
  92. What mineral is essential at several steps along the clotting pathway?
    Calcium essential at numerous steps along the pathway
  93. Describe Disseminated Intravascular Coagulopathy (DIC)
    • Sepsis, massive tissue trauma &/or hypoxia causes systemic activation of clotting cascade by overwhelming release of tissue thromboplastin (tissue factor).
    • Problem resides w/clotting ultimately.
    • MODS & death result from entire systems losing blood flow d/t mass micro emboli occlusion.
  94. How is DIC diagnosed?
    • Diagnosis is based on clinical presentation
    •   History
    •   + D-Dimer
    •   Low clotting factors (fibrinogen) & platelets
    •   High PT, aPTT, INR & FSPs
  95. How do we treat DIC?
    Focus on treating the precipitating event
  96. When should PRBCs be administered?
    Given to ⇧ O2 carrying capacity of blood ONLY
  97. Above what Hgb level are PRBCs NOT indicated?
    > 10 mg/dl
  98. Below what Hgb level are RBCs indicated?
    < 6 mg/dl
  99. At what Hgb level should pts receive PRBCs prior to proceeding to altitude (flight)?
    8 mg/dl
  100. How fast SHOULD PRBCs be given?
    • Over 2-4 hrs
    • Can be given fast emergently, but RBC lysis increases under pressure
  101. Are ABO antigens a concern when administering PRBCs?
    Yes, watch for acute hemolytic reactions (temp & back px)
  102. What blood type is considered the universal donor?
    O-
  103. What blood type is considered the universal recipient?
    AB+
  104. What is the volume of 1 unit of PRBCs?
    ~330 cc
  105. What is the pediatric dosing for PRBCs?
    10 cc/kg
  106. When does citrate toxicity become a concern?
    • Multiple units &/or fast push (4 units  < 20 min)
    • [> 1 ml/kg/min]
  107. How much will 1 unit of PRBCs impact a patient's H&H?
    Raise it by 1 & 3
  108. How is temperature a concern when administering PRBCs?
    • Need to re-warm the PRBCs. 
    • Every unit PRBCs given @ storage temp will drop core temp 0.25°C
    • Hypothermic pts don't clot!
  109. What should be administered concurrent with PRBCs?
    Equal volumes of NS
  110. What concerns re K+ arise during blood admin?
    • Admin rates > 90-120 ml/min can cause clinically significant hyperkalemia & arrest
    • Watch ECG for Δs, if seen stop blood immediately & consider NaHCO3-, Dextrose & Insulin as appropriate
  111. What is the pathology of a hemolytic reaction?
    ABO incompatibility
  112. Describe the signs & symptoms of a hemolytic reaction?
    • Fever
    • Chills
    • Back pain
    • Dyspnea
  113. How quickly will a hemolytic reaction develop?
    Shortly after transfusion
  114. What is the treatment for a hemolytic reaction?
    • Stop transfusion
    • Supportive care
  115. What is the treatment for an anaphylactic reaction to blood transfusion?
    • Stop transfusion
    • Epi
    • Steriods
  116. What is the treatment for a febrile reaction to blood transfusion?
    Stop transfusion
  117. What is the treatment for circulatory overload secondary to blood transfusion?
    • Stop transfusion
    • Lasix
  118. What percentage of acute hemolytic reactions will develop DIC?
    30-50%
  119. Describe the treatment of acute hemolytic reaction
    • Treatment focuses on:
    • Support hemodynamics w/fluids & pressors
    • Maintain renal perfusion & function w/fluids & diuretics
    • Prevention of DIC: Maintain pressure & oxygenation
  120. What are the indications for FFP administration?
    • Coumadin therapy reversal
    • DIC
    • Antithrombin III deficiency
    •   S/P extended heparin therapy
    • Dilutional coagulopathy (> 1 blood volume of replacement [10 units of PRBCs]
    •   Commonly given 1:4 w/PRBCs until 10 units of PRBCs then 1:1
    • May be given as a volume expander or for coagulation factors
  121. What is platelet infusion indicated for?
    • Platelet deficiency
    • ASA Guidelines: “platelet transfusion is rarely indicated when platelet count is greater than 100,000 and is usually indicated w/a count below 50,000”
  122. What equipment requirements are there for platelet administration?
    Use a filter w/a 19 ga or larger needle
  123. How much will 1 unit increase the platelet count?
    ~5-10k
  124. Cryoprecipitate has high levels of what?
    Fibrinogen
  125. When is cryoprecitiate given?
    • DIC
    • Hemophilia A
    • von Willebrand Disease (vWD)
    • Stop tPA induced bleeding
  126. What is the normal infusion rate for cryoprecipitate?
    10 ml/min
  127. What is the normal adult dose for cryoprecipitate?
    10 units
  128. What are the most common indications for emergent cryoprecipitate administration?
    • Massive PRBC infusions
    • tPA related bleeding
  129. What components make up cryoprecipitate?
    • Factor VIII:C
    • Factor XIII – Fibrinogen stabilizing factor
    • von Willebrand factor
    • Fibrinogen
  130. How is the rib cage of a child different than an adult?
    More elastic & flexible
  131. How does a child's lung tissue compare to n adult's?
    More fragile
  132. Compare the mediastinum of a child to that of an adult
    The child's mediastinum is more mobile
  133. Compare the bones of the skull of a child to that of a patient older than 5 YOA?
    Soft & separated by cartilage until 5 YOA
  134. When do the fontanelles close in a child's skull?
    • Anterior closes @ 12-18 mos
    • Posterior closes by 2 mos
  135. Compare the liver & spleen of a child to an older patient
    • Proportionally larger
    • More vascular
  136. How are the bones of a child different than those of an older patient?
    They are softer
  137. Compare the cardiac output of a child to that of an adult
    • Higher
    • HR ⇧ SV ⇩
  138. At what point will hypotension present in the case of a child with acute blood loss?
    Children will not demonstrate hypotension until acute blood loss totals ~ 25% of the circulating blood volume
  139. Compare the surface area to volume ratio of a child to that of an adult
    • Larger ratio of surface area to volume: This
    • influences heat loss primarily
  140. What are the 3 components of a pediatric assessment?
    • LOC
    • Perfusion Status
    • Work of Breathing
  141. How does the tongue in a child's mouth differ than that of an adult?
    A child's tongue takes up more room in the mouth
  142. Describe the epiglottis of a child in relation to the airway
    Short, narrow & angled away from the long axis of the trachea
  143. Describe the anatomical differences in a child's airway
    • Larynx is higher
    • Short chin gives more anterior relationship
  144. Where is the narrowest portion of the airway in a child < 10 YOA?
    @ the cricoid cartilage
  145. Compare O2 consumption in an infant to that of an adult
    O2 consumption in infants = 2x that of an adult
  146. What size tube should be used to intubate a pre-term infant?
    2.5 - 3.0
  147. What size tube should be used to intubate a term infant?
    3.0 – 3.5
  148. What size tube should be used to intubate a 3 MOA - 1 YOA infant?
    4.5 - 4.0
  149. What formula solves for the size tube used to intubate a pediatric patient > 1YOA?
  150. What is the depth of insertion when intubating a pre-term neonate < 1000 gm in mass?
    6 cm
  151. What is the depth of insertion when intubating a pre-term neonate btn 1000 gm & 2000 gm in mass?
    7 - 9 cm
  152. What is the depth of insertion when intubating a term neonate?
    10 cm
  153. What is the depth of insertion when intubating a 1 YOA child?
    11 cm
  154. What is the depth of insertion when intubating a 2 YOA child?
    12 cm
  155. What is the formula for determining depth of insertion when intubating a child older than 2 YOA?
    • 3 x ETT Size or
    • (Age/2)+ 12
  156. Describe the anatomical presentation of Pierre Robin
    • Short Chin
    • Antero/superior glottis
    • Arched cleft palate common
  157. Describe the anatomical presentation of Treacher-Collins
    • Short chin
    • Dental malformations
  158. Describe the anatomical presentation of Hurler’s Syndrome
    • Macrocephalic
    • Short neck
    • Scoliosis common
  159. Describe the anatomical presentation of Goldenhar Syndrome
    • Facial asymmetry
    • Small mouth/limited opening
  160. What is the bolus dose for a child?
    20 mL/kg then reassess, repeat PRN
  161. What is the IV bolus dose for an infant/neonate?
    10 mL/kg then reassess, repeat PRN
  162. What is the Estimated Blood Volume (EBV) of a child > 1 YOA?
    70 mL/kg
  163. What is the Estimated Blood Volume (EBV) of a child 3 mos - 1 YOA?
    70-80 mL/kg
  164. What is the Estimated Blood Volume (EBV) of a term neonate?
    80-90 mL/kg
  165. What is the Estimated Blood Volume (EBV) of a premature neonate?
    90-100 mL/kg
  166. What is the formula to calculate Maximum Allowable Blood Loss in a child?
  167. What is the minimum acceptable Hct for the flight environment?
    28
  168. Describe the formula for calculating IV Maintenance Infusion rates for children
    • 4 /2 /1 System
    • 4 ml/kg for the 1st 10 kgs of mass
    • 2 ml/kg for the 2nd 10 
    • 1 ml/kg for every kg over 20
  169. Describe continuous monitoring guidelines for pediatric patients
    • Continuous skin temp monitoring recommended, esophageal / rectal probe optimal
    • Continuous SPOmonitoring: “Standard of care”
    • Glucose monitoring PRN
  170. What is considered hypoglycemia in a neonate?
    • < 30 mg/dl
    • Use D10 to correct
  171. What is considered hypoglycemia in a child?
    • < 40 mg/dl
    • Use D25 to correct
  172. What is the optimal IV fluid for children < 2 YOA?
    • NS
    • Kidneys are better able to deal w/excess Na+
  173. What is the pediatric dose for synchronized cardioversion?
    0.5-1.0 J/kg
  174. What is the pediatric dose for defibrillation?
    2 J/kg then 4 J/kg
  175. What is the pediatric dose of adenosine?
    0.1-0.2 mg/kg rapid IVP
  176. What is the pediatric dose of atropine?
    0.02 mg/kg IV min 0.1 mg max 0.5 mg
  177. What is the pediatric dose of dobutamine?
    2-20 mcg/kg/min IV gtt
  178. What is the pediatric dose of dopamine?
    2-20 mcg/kg/min IV gtt
  179. What is the pediatric dose of epinephrine?
    • 0.01 mg/kg IV 1:10,000
    • 0.1 mg/kg ET 1:1000
    • Infusion: 0.1-1.0 mcg/kg/min IV gtt
  180. What is the pediatric dose of lidocaine?
    1 mg/kg
  181. What is the pediatric dose of naloxone?
    • < 20 kg: 0.1 mg/kg IV
    • > 20 kg: 0.4-2.0 mg IV
  182. What is the pediatric dose of sodium bicarbonate?
    • 1 mEq/kg IV or
    • 0.3 mg x kg x base deficit IV
  183. Describe Wadell's Triad
    • Common Injuries when a child is struck by a motor vehicle: 
    • Head
    • Trunk
    • Extremities
  184. What is the single largest cause of pediatric traumatic death?
    Motor vehicle related accidents
  185. What is the most common non-accidental-trauma pediatric injury type?
    Skin
  186. What system is injured the most in non-accidental-trauma?
    Integumentary
  187. What type of injuries best demonstrate long term abuse?
    Skeletal
  188. What injuries are sustained during sexual abuse of a child?
    Genitourinary
  189. Describe a comminuted fracture
    Bone is broken into fragments
  190. Describe a compound fracture
    Bone is broken & piercing the skin
  191. Describe a compressed fracture
    One bone is forced against another
  192. Describe a displaced fracture
    The ends of the bone are not aligned
  193. Describe a greenstick fracture
    Periosteum divided on only 1 side
  194. Describe a pathological fracture
    Occurs because of a bone defect
  195. Describe a simple fracture
    Fracture is straight & in good alignment
  196. Describe a spiral fracture
    Fracture resulting from twisting motion
  197. Isolette use is recommended in what group of patients?
    < 10 lbs or 30 days (corrected age)
  198. What neuro Δs can you expect w/temp Δs?
    • Hot: Fussy
    • Cold: Obtunded
  199. What perfusion status Δs can you expect w/temp Δs?
    • Hot: Tachycardic
    • Cold: Bradycardic & hypotensive
  200. What physiologic changes occur w/each ° ⇧ in temp?
    • HR ⇧ 20 bpm
    • RR ⇧ 10 rpm
  201. Is ASA an acceptable febrile therapy for children?
    No, d/t Reye's syndrome
  202. Describe techniques to keep children warm
    • Pre-heat the ambulance
    • Keep dry, head covered
    • Warm gases via ETT
    • Caution w/commercial heat packs
    • Plastic or aluminum foil use: Around towel or cellophane wrap
    • Warmed saline gauze over open defects
    • Fluid warmer
  203. Describe standards of care when mechanically ventilating an infant
    • Pressure targeted ventilation
    • SpO2 & ETCO2 monitoring
  204. What are the vent settings for an infant?
    • FiO2:                        100%
    • Inspiratory Time (IT): > 0.5 sec
    • Rate:                       16 – 40
    • PEEP:                       0 – 5 cm
    • PIP:                         15 – 20 cmH2O
  205. Describe standards of care when mechanically ventilating a child
    • Volume targeted ventilation typical after 6 mos of age
    • SpO2 & ETCO2 standard of care
  206. What are the vent settings for a child?
    • FiO2:                   100%
    • Tidal Volume (Vt): 6 – 12 mL/kg
    • Rate:                   16 – 24
    • PEEP:                   0 – 5 cm
    • PIP:                     < 30 - 40 cmH2O
  207. What are common causes of pediatric seizures?
    • Hypoglycemia
    • Febrile
  208. Are tonic-clonic seizures common in the pediatric pt population?
    Rarely seen d/t immaturity of nervous system
  209. Describe subtle seizures as seen in the pediatric population
    • Repetitive mouth/tongue movement
    • Bicycling
    • Eye deviation
    • Repetitive blinking
  210. Describe clonic seizures as seen in the pediatric population
    Repetitive jerky movements of limbs
  211. Describe tonic seizures as seen in the pediatric population
    May resemble posturing or tonic extension seen in older pts
  212. Describe myoclonic seizures as seen in the pediatric population
    Multiple jerking motions, usually of the upper extremities
  213. Describe the clinical treatment for neonatal diaphragmatic hernia
    • Intubation for resp distress; PPV as indicated
    • OGT w/suction
    • NPO
  214. What is the essential issue with choanal atresia?
    Nasopharynx obstructed
  215. What is the treatment for choanal atresia?
    • Provide oral airway access
    •   OPA
    •   ETT w/o ventilation possible but pressure support may be needed
  216. What are the concerns w/neonatal aspiration pneumonia?
    • Meconium staining
    • ET suctioning acceptable but discouraged unless lethargic
    • Consider risk of TEF: Minimize PPV
    • If brisk, monitor only
  217. What are the 2 classes of Congenital Hert Disease?
    • Acyanotic Lesions
    • Cyanotic Lesions
  218. Describe Acyanotic Lesions
    • Blood returning to the RA has passed through the lungs like normal
    • Many of these present w/pulmonary overload & CHF / Pulmonary edema symptoms
  219. Name some Acyanotic Lesions
    • PDA: Anticipate in low birth weight neonates, delayed closure in premies
    • Coarctation of the Aorta
    • ASD
    • VSD
    •   Very common in Down’s Syndrome, ESP males
    •   Commonly coexistent w/Coarcs & PDAs
    •   The most common CHD
    • AVSD
    • Aortic Stenosis: More common in males
    • Pulmonary Stenosis
  220. Describe Cyanotic Lesions
    Any condition w/true “mixing” of oxygenated & unoxygenated blood. Commonly causes a cyanotic appearance.

    • Commonly PDA dependent
    • These lesions can cause a Right ⇨ Left shunt w/systemic hypoxia
    • Typical SaO2 is 75-85%
  221. Name some Cyanotic Lesions
    • Transposition of the great vessels
    • Tetrology of Fallot
    • Total Anomalous Pulmonary Venous Return (TAPV)
    • Truncus Arteriosus
    • Tricuspid Atresia
    • Hypoplastic Left Heart Syndrome
  222. Describe the therapeutic approach to treating Cyanotic Lesions
    Minimize/avoid any stimulus to cough (suctioning, pain, acidosis etc) to prevent pulmonary hypertensive crisis & subsequent increased right ⇨ left shunting
  223. What is the most common Congenital Heart Disease?
    Ventricular Septal Defect (VSD)
  224. Identify transport considerations for pts w/CHDs
    • Pressurized cabin is essential
    • Specialty teams should be utilized whenever
    • possible
    • For longer transports Nitric Oxide should be considered / available
    • NO air in IV lines
    • Monitor SpO2, EtCO2 & electrolytes as closely as able
    • Specific repairs (i.e. Blalock Taussic Shunt, aka BT Shunt) prevent use of affected arm for BPs & IVs
  225. Describe the normal closure of a patent ductus arteriousus (PDA)
    Functionally closes at birth, anatomically closes by 21 days old
  226. Describe the effect of a patent ductus arteriousus (PDA)
    • Creates Left ⇨ Right shunt
    • Potential for gross pulmonary edema & resp failure
  227. Describe therapy to close a PDA
    • O2
    • Indomethagin (PGE1 inhibitor)
  228. Describe therapy to maintain a PDA
    Prostaglandin (PGE1)
  229. Describe "Transposition of the Great Vessels"
    • Aorta & the Pulmonary Artery are reversed
    • Cyanotic heart disease
  230. Patients with Transposition of the Great Vessels are dependent for their survival on at least 1 other CHD. What other CHDs support this condition?
    • Foramen ovale
    • PDA
    • VSD
  231. Ventricular Septal Defects (VSDs) may have an audible murmur. What information may the murmur reveal?
    Murmur amplitude may indicate size (inverse relationship)
  232. What mechanism reverses the left ⇨ right shunt of a VSD?
    Hypoxic Pulmonary Vasoconstriction Response (HPVR)
  233. Describe treatment of a VSD
    • Pre-load reduction
    • Diuresis (furosemide [Lasix®] utilized most often @ 0.5 – 1.0 mg/kg)
  234. Describe Coarctation of the Aorta
    • Narrowing of the aortic arch typically just distal of the left subclavian bifurcation, commonly @ aortic hiatus of diaphragm
    • Acyanotic Heart Disease
    • Decreased aortic flow results in increased LV pressures & ultimately failure
    • Commonly associated w/VSD
  235. Describe treatment of Coarctation of the Aorta
    • Minimize SVR as able
    • Prevent valsalva
    • Treat symptoms
    • Monitor SpO2 on right hand for accuracy
  236. What 4 defects make up the Tetrology of Fallot?
    • VSD
    • PA Stenosis
    • RV Hypertrophy
    • Rightward displacement of aorta exploited by VSD
  237. Describe the pathophysiology of Tetrology of Fallot
    • Right ⇨ Left shunt
    • Cyanotic heart disease
  238. Describe the treatment of Tetrology of Fallot
    • PGE1 for PDA patency management
    • “Tet Spell” management
    •   Knee-chest positioning
    •   O2: Careful, PDA management
    •   MSO4

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