Pediatric Potpourri 200+ New CPEN Questions: Certified Pediatric Emergency Nurse Review (3rd Edition Supplement)

Potpourri

CHAPTER 12

So New... Who Knew?

Even More Pediatric Potpourri

Make no mistake about why these babies

are here - they are here to replace us.

- Jerry Seinfeld

When your first baby drops her pacifier,

you sterilize it. When your second baby

drops her pacifier, you tell the dog:

‘Fetch!’

- Bruce Lansky

1) A 12-year old with a history of severe developmental delay and cerebral palsy presents unresponsive, hypotensive, and with minimal respiratory effort to the ED. Upon rapid initial physical exam, she is found to have a small round metal device implanted under the skin of her lower abdomen. Her parents indicate the device is a Baclofen pump used to help manage her spasticity. The initial priority is:

A) Establishing an airway with ventilatory support

B) Administration of IV/IO Narcan (naloxone)

C) Disabling and preparing for surgical removal of the Baclofen pump

D) Labs for a full toxicology screen and initiation of the facility’s child abuse/endangerment protocol

A - This is an example of a complicated question with an uncomplicated answer. Remember your ABCs! Airway, airway, with a side of airway. The most important part of the child’s presentation is the minimal respiratory effort. That means she's barely breathing. So, picking an answer that reflects having a patent airway and adequate breathing is a great choice.

But, what about beyond the ABCs... What are the Basics of Baclofen?

Spasticity involves tight, stiff muscles that make movement, especially of the arms and legs, difficult or uncontrollable. It happens when there is an injury to a part of the brain or spinal cord that controls voluntary movements. Baclofen is a derivative of gamma-aminobutyric acid (GABA) and more importantly, is a muscle relaxant with anti-spasticity effects. In children with spasticity from cerebral palsy, multiple sclerosis, or spinal cord injuries, oral Baclofen is commonly tried first. However, when the oral route doesn’t bring about the desired effects or produces too many undesired side effects, the intrathecal spinal pump has been found to achieve good results.

The Baclofen pump continuously administers the medication directly into the spinal canal which not only treats the issue at the site but allows for a much lower dose. The intrathecal dose of Baclofen is 100-1,000 times less than the oral dose. Wow! But, as such, a little difference in dose can make a big difference in symptoms. Baclofen does cross the blood-brain barrier and the associated symptoms of toxicity or withdrawal are actually very similar to opiate overdose or withdrawal.

Too much Baclofen (muscle relaxant) results in children who are way too relaxed. So relaxed, in fact, that they may be unconscious and not breathing very well, if at all. Too little Baclofen results in children who are not nearly relaxed enough and leads to serious spasticity or seizure activity.

In this case, management of presumed Baclofen toxicity first involves what can be immediately treated. Start with ABC which means maintaining a patent airway, assistance with breathing, and circulatory support with fluids, pressors, etc. Then, once the ABCs are addressed, steps can be taken to temporarily disable and drain the pump. This is important, but not as important as airway management.

Narcan works great for opiate overdoses, but does not work for Baclofen overdoses. Obtaining labs may be helpful, but should never come before the ABCs, and nothing in this presentation indicates that there would be a high level of concern regarding abuse or maltreatment.

And always remember with healthcare ABCs, Breathing comes before Baclofen!

2) Which patient would be the best candidate for the application of a tourniquet?

A) 1-year old male with uncontrolled bleeding to the lower leg

B) 5-year old female with uncontrolled bleeding below the knee

C) 9-year old male with uncontrolled bleeding from a groin injury

D) 13-year old female with a deep thigh injury that is controlled with direct pressure

B –The 5-year old patient (regardless of gender) would be the best candidate, even with an injury near the knee. While tourniquets should not be applied directly over joints, the tourniquet can be applied above the knee for this patient.

The 1-year old is likely too small for a commonly available adult tourniquet to be effective and therefore, packing the wound and/or direct pressure would be more appropriate. The 9-year old has a groin injury and a traditional extremity tourniquet would not be able to be applied. The bleeding on the 13-year old patient is being controlled with direct pressure and therefore a tourniquet is not required.

3) You are providing care to a 5-year old with massive bleeding to the right upper leg after being hit by a car. The primary and initial way to help control bleeding in this patient is to:

A) Apply direct pressure to the wound

B) Apply a tourniquet

C) Press on the femoral artery

D) Stabilize using a splint

A – While tourniquet application is appropriate for children and found to be safe, in this question, it was asked what the primary/initial way would be to stop the bleed. Direct pressure should be initiated while someone else obtains and applies a tourniquet.

4) When applying a tourniquet to a child in order to control massive hemorrhage, it is important to:

A) Ensure you don’t totally occlude bleed flow

B) Not cause additional pain to the injured extremity

C) Tighten until all the bleeding stops

D) Use only in uncontrolled arterial bleeding

C - Tourniquets are designed to stop ALL blood flow to the area, and can be applied to any major bleed on the extremities. Indications for tourniquet use include both venous and arterial bleeding. All bleeding must stop, not just the venous bleeding, otherwise the patient is at risk for continued hemorrhage. It is important to note that when properly applied and all blood flow ceases, tourniquets hurt! A lot! If you have taken the Stop the Bleed course and have had a tourniquet applied to yourself, you will never forget this. They hurt. But temporary pain is preferable to permanent death. Pain doesn’t mean that it was applied incorrectly or it’s not working, it just hurts. Be ready for this and anticipate the need for pain meds.

5) While doing community outreach at a local high school, a teacher asks you if, in an emergency, an improvised tourniquet should be used to stop bleeding. Which of the following would be the most appropriate response?

A) It would depend on what you were using. Belts are not generally effective, but a necktie, if available, is recommended

B) No, those only work in the movies. They should never be attempted on someone who has massive bleeding

C) They may be effective. You could try it, but it would be best to have a backup plan in case it doesn’t work

D) While you may hear about an improvised tourniquet working, research shows these are not reliably effective at controlling bleeding

D – The American College of Surgeons does not recommend the use of improvised tourniquets. The key here is the word improvised. While it is possible these could work, it is risky to try. They may stop some bleeding, but not all the bleeding. It may be tight enough to cut off venous bleeding (great), but not tight enough to stop arterial bleeding (not so great). If you do not have a commercial tourniquet available, it’s best to apply direct pressure and pack the wound if appropriate. Applying an improvised tourniquet can waste valuable time and has been shown NOT to be effective.

6) Stop the Bleed is an international program designed to teach the lay public the skills necessary to provide potentially lifesaving treatments in an emergency. This is based on the fact that:

A) Active shooter incidents are a leading cause of injury

B) If someone helps and has not been properly trained, they are legally at risk

C) Many EMS systems have slow response times

D) Uncontrolled bleeding is the leading cause of preventable death after injury

D – Uncontrolled bleeding is the leading cause of preventable death after injury, so being able to stop life-threatening bleeding can be incredibly important. While active shooter incidents are a horrible tragedy, they are not a leading cause of injury. There are many far more common causes of pediatric injuries, including falls, automobile vs. pedestrian collisions, and motor vehicle crashes. These can all cause life-threatening bleeding, which is the leading cause of preventable death after injury. This bleeding can occur within minutes, meaning someone needs to be able to provide immediate assistance while EMS is en route. Stop the Bleed saves lives!

7) If a teen is driving at 55 mph (89 kph) and takes her eyes off the road for five seconds to read/respond to a text message, how far has she traveled during those five seconds?

A) 1 yard (0.9 meters)

B) 25 yards (23 meters)

C) 50 yards (46 meters)

D) 100 yards (91 meters)

D - Five seconds of texting while driving translates to over 100 yards of driving essentially with your eyes closed. That’s more than the length of a football field. Wow! A lot can happen in that much space. Texting while driving causes a 400 percent increase in time spent with eyes off the road. Of all cell phone related tasks, texting is by far the most dangerous activity. In fact, texting while driving is six times more likely to cause an accident than driving drunk.

The following is reprinted with permission from DigitalResponsibility.org

Teens are the age group at the highest risk for texting-related accidents. On average, teens are the most inexperienced drivers out there, and they are also the most addicted to texting. That can be a lethal combination.

The risks:

•Want to become 23 times more likely to crash with just the flick of a finger? Text while driving. A Virginia Tech Transportation Institute study of commercial drivers revealed that texting while driving was the riskiest type of driver distraction, making drivers 23 times more likely of getting into a safety-critical event. (Virginia Tech Transportation Institute (VTTI) 2009)

•If you are driving at 55 mph and take your eyes off the road for the average amount of time it takes to text, five seconds, you will have zoomed the length of a football field without looking at the road. (VTTI) 2009)

•The CDC reports that a distracted driver was a factor in 18% of all injury-causing accidents in 2010.

•The 2012 NHTSA study on distracted driving classified drivers as distraction-prone or distraction-averse. Fewer than half of respondents under 35 qualified as distraction averse, while the majority of those over 35 fit that category.

•According to the VTTI, teens are four times as likely to get into crashes or near misses due to cell phone distractions than older drivers.

The following is reprinted with permission from ArriveAliveTour.com

Texting While Driving Facts for Teens

•40% of teens say they have been a passenger in a vehicle where the driver was texting and driving.

•Every day, 11 teens die from texting while driving accidents.

•According to a AAA poll, 94% of teen drivers acknowledge the dangers of texting and driving, but 35% admitted to doing it anyway.

•A teen driver with only one additional passenger doubles the risk of getting into a fatal car accident. With two or more passengers, they are five times as likely.

•Teen drivers are four times more likely than adults to get into car crashes or near-crashes when talking on their cell phone or texting while driving.

•Of all the teen drivers involved in fatal accidents, 21% of them were distracted by their cell phones.

•Peer pressure? 90% of teens expect a response to their text message within five minutes, so if someone is driving and gets a text, then they feel the need to respond quickly and texting while driving issues arise.

•75% of teens say their friends text and drive.

•77% of teens say their parents text and drive.

8) A 3-year old is being discharged from outpatient surgery after a tonsillectomy. A common, easy-to-follow, recommendation for Tylenol® (acetaminophen) and/or Motrin® (ibuprofen) pain medication dosing is:

A) Alternate Tylenol ® every 6-8 hours and Motrin ® every 4-6 hours prn for 3 days

B) Alternate Tylenol ® and Motrin ® every 3-4 hours around the clock for 3 days followed by alternating every 3-4 hours prn

C) Alternate Tylenol ® every 6-8 hours and Motrin ® every 4-6 hours for 3 days followed by the same dosing prn for 10 days

D) Alternate Tylenol ® and Motrin ® every 3-4 hours around the clock for 3 days beginning 7 days post-op

B – Alternating Tylenol® and Motrin® every 3-4 hours around the clock for 3 days followed by alternating every 3-4 hours prn is a very common recommendation for children post-tonsillectomy. This type of question requires careful analysis and thorough reading of all of the options that seem to be overflowing with numbers. Options A and C have the normal frequencies reversed and would require a complex schedule of administration and the question does suggest that the answer would be easy to follow.

It should be easy to rule out option D, as decades of studies have shown that babies and kids, just like adults, feel pain and should receive appropriate post-op analgesics right away (not a week post-op). Pediatric tonsillectomy is one of the most common pediatric surgical procedures performed and it is also one of the most painful. With that in mind, here are a few things to help ensure the kids (and parents) post-procedure experiences are much more pleasant:

•Remember, pain is expected, especially during the first week post-op. For most children, the pain is gone by 2-3 weeks. The day after surgery is bad, but the next 2-3 days tend to be even worse. That’s really important for parents to know. After 3 days, the honeymoon phase kicks in and the pain tends to get a whole lot better. But right around the corner are days 7-10 when the scab falls off. Though usually not nearly as painful as the initial post-op period, when the scab falls off, it can hurt, and it’s important for parents to know about, and anticipate, this second period of pain.

•The throat is not the only place that hurts! Ear pain, especially with swallowing, is common. This is not due to an ear infection, but is referred pain from the surgery.

•For the first few days after surgery, Tylenol ® and/or Motrin ® are recommended. In many cases, especially for the first day or two, some sort of liquid narcotic analgesic is prescribed as well. When it comes to Tylenol ® and/or Motrin ® , many ENT surgeons recommend these medications be alternated and given every 3 hours around the clock for 3 days. That translates to each medication every 6 hours, which is a very good combination/compromise between Tylenol ® which is commonly given every 4-6 hours and Motrin ® which is commonly given every 6-8 hours. Trying to calculate medication times is difficult enough in the best of times, and even worse by a stressed parent. To help with these situations, some facilities now have templates for a variation of the Tylenol ® /Motrin ® Clock. This way, when a parent is home at 3 AM, they don’t have to try to remember what med to give. They can just look at the clock. The clock helps with avoidance of accidental overdoses as well.

•Drink, drink, and then drink: Not surprisingly, post-tonsillectomy kids don’t want to drink because their throat hurts. But dehydration is what will really get these kids into trouble. So, many ENT surgeons simply recommend that whatever the kid will drink (as long as it’s not red in color) is great. Can they have all the juice they want? Sure. (Apple or white grape are probably your best bets because it’s a good idea to avoid orange or grapefruit as the citrus juices may hurt). Can they have all the ice cream they want? Sure. Can they have all the non-red popsicles they want? Sure. Can they have all the Kool-Aid, or even better, Gatorade, they want? Sure. Can they have all the slushies they want? Sure. If it melts to a liquid at room temperature and it’s not red in color, go for it!

•Medicate before you hydrate: Giving the child pain meds 30-minutes or so prior to trying to eat or drink just makes sense.

•Cold packs on the neck and/or forehead can be helpful for throat pain, while a heating pad on the ear can be helpful for referred ear pain.

Did you know that tonsillectomies have been performed for over 3,000 years? Wow! We can be pretty sure that they hurt a lot back then, and we know that they hurt a lot now. But, if you can keep the pain under control and keep the patients drinking (anything cool and not red), you’re helping make the situation more tolerable.

Additional Insights from a Pediatric Post-Anesthesia Care Unit (PACU) & Peds ER Nurse: There are several other CPEN questions and rationales that specifically address post-tonsillectomy bleeding. For the test, but more importantly, for your patients, please, please remind parents that anything more than a teaspoon of bleeding is worth an immediate call to 911 or a trip to the ER. This is one time that it is far better to overreact than to wait. Post-op tonsillectomy bleeding is one of anesthesia’s nightmare scenarios. Scared kid + stomach full of swallowed blood + potential hypovolemia from blood loss and poor PO intake + active bleeding in the same place they want to place an endotracheal tube = the perfect storm for an airway nightmare!

9) An infant has been brought in by parents due to being inconsolable for several hours. When considering the mnemonic, IT CRIES. what does the C stand for?

A) Colic

B) Cold

C) Cardiac disease

D) Colon distention

C – The mnemonic, IT CRIES can be helpful when evaluating the inconsolable child. The mnemonic stands for:

I = Infections

T = Trauma

C = Cardiac disease

R = Reaction to meds, reflux (gastric), or rectal fissure

I = Intussusception

E = Eyes

S = Strangulation, surgical processes

Colic is always a possibility, but shouldn’t be the automatic go to diagnosis – you might miss something important! The key to an inconsolable infant is a really good head to toe examination. Remember that caring for babies has best been described as being similar to veterinary medicine. The patients are unable to verbalize and can’t describe what hurts, how it feels, what makes it better or worse, etc. Crying is their only language. So in a truly inconsolable infant, IT CRIES is a great way to rule out reasons why IT CRIES!

TIM’S CRIES from Life in the Fast Lane (litfl.com)

T - Trauma (accidental and non-accidental injuries) and bites (e.g. insects), tumours

I - Infections (otitis media, herpes stomatitis, urinary tract infection, meningitis, osteomyelitis)

M - Maternal/ parental stress, anxiety or depression

S - Strangulation (hair/fiber tourniquet)

C – Cardio-respiratory disease

R - Reflux, reactions to medications, reactions to formulas, rectal (anal fissures)

I - Intracranial hypertension, immunizations, intolerance of lactose or cow’s milk allergy

E - Eye (corneal abrasions, ocular foreign bodies, glaucoma, retinal hemorrhages)

S - Surgical (volvulus, intussusception, inguinal hernia, testicular torsion)

10) In the emergency nursing care of a child with Duchene's Muscular Dystrophy, the priority assessment should be:

A) Deep tendon reflexes

B) Pulmonary function

C) Cardiomegaly

D) Swallow study

B – Pulmonary failure is a primary driver of morbidity in patients with Duchene’s Muscular Dystrophy (DMD). Care should be centered on assessing and providing adequate support for their ability to breathe. Deep tendon reflexes are lost in these patients at an early age and will no longer be a useful assessment tool once the child is confined to a wheelchair. While cardiac complications, including cardiomyopathy and cardiomegaly are a significant concern and increasingly a primary cause of death for these patients, airway (and breathing) is the greater priority in the emergency department. These children will eventually have decreased oral intake necessitating a gastronomy tube, but a swallow study is not a priority assessment in the ER. Remember, the American Lung Association slogan... If you can’t breathe, nothing else matters!

11) A 16-year-old male with a history of Duchene’s Muscular Dystrophy presents to the emergency department. After the initial assessment is complete, the patient is found to have suffered a right ulnar fracture as a result