Acute Care

Question 1

Croup - epi

Answer 1

<1% severe, <6% presentations to ED need hospitalization

Question 2

Croup - viruses

Answer 2

mainly parainfluenza type 1 and 3, also influenza, adeno, RSV, HMPV

Question 3

Croup - symptoms, time course

Answer 3

rapid onset, barky cough, insp stridor, hoarseness, resp distress
symptoms 3-7 days, most cough gone <48h

Question 4

Croup - ddx & when to consult ENT

Answer 4

bacterial tracheitis, RPA, peritonsillar abscess, epiglottitis, FBA, allergic rxn

ENT if recurrent, severe, or atypical age

Question 5

Croup - treatment (general)

Answer 5

General - keep comfortable, don’t frighten, don’t use mist tents, antipyretics
Dex 0.6 mg/kg PO or IM for all kids w croup - helps within 2-3h, lasts 24-48h
Epinephrine neb for mod-severe (lasts 1-2h, so watch 2-4h post treatment)
Heliox for severe to avoid ETT

Consult ENT if severe or if recurrent/atypical age

Question 6

Croup - treatment (by severity)

Answer 6

Mild (no sx at rest) - PO dex and home
Moderate (stridor or indrawing at rest) - PO dex and observe, if no improvement by 4h consider admit
Severe (stridor, indrawing, agitation/lethargy) - minimize intervention, blowby, epi neb, PO dex, if no recurrent sx at 2h then DC home, if recurrent symptoms repeat epi and continue to observe, if poor response PICU consult

Question 7

MCC of gastro?

Answer 7

Rota + noro

Question 8

Pharmacologic class of ondansetron, and how long until it reaches peak plasma concentration?

Answer 8

5-HT3 receptor antagonist

1-2h

Question 9

Should you screen electrolytes/ECG before giving ondansetron?

Answer 9

no evidence for routine screening

Question 10

Name some antiemetics and their s/e

Answer 10

Promethazine, metoclopramide, dimenhydrinate, domperidone

Drowsiness, hallucinations, EPS, convulsions, NMS

Question 11

Who should get oral zofran, details of how to give?

Answer 11

6m - 12y with mild-mod dehydration that have failed trial of oral rehydration

single dose

start ORS 15-30 mins after dose of ondansetron

Question 12

MC side effect of ondans

Answer 12

diarrhea

Question 13

dosing of ondans?

Answer 13

0.15mg/kg

OR
8-15kg: 2mg
15-30kg: 4mg
>30kg: 6-8mg

Question 14

ITP triggers

Answer 14

virus
immune cause

usually no trigger found

Question 15

Classic ITP presentation

Answer 15

Child 2-5 years

Usually mild bruising and petechiae
Mild mucocutaneous lbeeding in 3%
ICH very rare (0.17-0.6%)

Question 16

Red flags for diagnosis other than ITP with plts <100

Answer 16

History:

• constitutional symptoms
• bone pain
• recurrent thrombocytopenia
• poor response to treatment

Physical:

• LAD
• HSM
• Unwell appearing
• Signs of chronic dx

Labs:

• Low Hb
• Abnormal total WBC or ANC
• High MCV
• abnormal cellular morphology on smear

Question 17

Treatment for mild ITP (no or mild bleeding)

Answer 17

Observation

2nd line: steroids, IVIG

Consider family opinion, pt activity level, social issues

Question 18

Treatment for moderate ITP (and definition)

Answer 18

Mucosal lesions, epistaxis, menorrhagia

IVIG 0.8-1.0 g/kg

• s/e: HA, NV, fever, rash, hemolysis, IV placement, in hospital, $$$
• usually plts increase within 24h, peak 2-7d

STEROIDS 4 mg/kg/day div BID-QID x 4 days (max 150mg/day) WITHOUT taper, or 2 mg/kg/day for 1-2wks WITH taper

• s/e: mood changes, increased appetite/weight, gastritis, HTN, poor taste
• increased plts within 48h

anti-D only for Rh+ kids, not considered firstline

Question 19

Severe bleeding in ITP, definition and treatment

Answer 19

Prolonged epistaxis, GI bleeding, or ICH

• Admit
• IV steroids AND IVIG
• TXA as adjunct: 25 mg/kg/dose TID-QID to max 1500mg/dose
• plt transfusion if acute, life-threatening bleeds or in children requiring immediate surgery

Question 20

Relapse in ITP (how many and when)

Answer 20

1/3

within 2-6 weeks

Question 21

Sepsis definition

Answer 21

Systemic inflammatory response to presence of suspected or proven infection
Classic features: Tachycardia, tachypnea, hyperthermia

Question 22

Septic shock definition

Answer 22

Severe infection leading to cardiovascular dysfunction (hypotension, need for vasoactive medication, or impaired perfusion)

Question 23

Biochemical signs of adrenal insufficiency

Answer 23

Hyponatremia, hyperkalemia, hypoglycemia

Question 24

Patients at risk for adrenal insufficiency in the setting of septic shock - and what to do?

Answer 24

Kids with

• Purpura fulminans
• Waterhouse-Friederichsen syndrome
• Steroid therapy for chronic illness
• Pituitary or adrenal abnormalities

Give stress dose - 50 mg/m2, then 100 mg/m2 div TID or QID

Question 25

Heart rate by age

Answer 25

AWAKE

• neonate: 100-205
• infant: 100-180
• toddler: 98-140
• preschooler: 80-120
• school-aged child: 75-118
• adolescent: 60-100

ASLEEP

• neonate: 90-160
• infant: 90-160
• toddler: 80-120
• preschooler: 65-100
• school-aged child: 58-90
• adolescent: 50-90

Question 26

RR by age

Answer 26

• infant: 30-53
• toddler: 22-37
• preschooler: 20-28
• school-aged child: 18-25
• adolescent: 12-20

Question 27

Hypotension cutoffs by age

Answer 27

• term neonates <28d: 60
• infants 1-12m: 70
• children 1-10y: 70 + (agex2)
• children >10: 90

Question 28

You’ve given 60 cc/kg for a child who has tachycardia, low BP, and poor peripheral perfusion. What’s next, and what’s the goal?

Answer 28

Epinephrine 0.05 mcg/kg/min

Titrate upward by increments of 0.02mcg/kg/min as required

OR

Dopamine 10 mcg/kg/min

GOAL: Treat myocardial dysfunction and low cardiac output

Question 29

You’ve given 60 cc/kg NS for a kid who has tachycardia, flash cap refill, bounding pulses, and flushing as well as hypotension. What’s next, and what’s the goal?

Answer 29

Norepi 0.05 mcg/kg/min
Titrate upward by increments of 0.02 mcg/kg/min

GOAL: Increase SVR

Question 30

You’ve given 60/kg of NS to a child with tachycardia, poor peripheral perfusion, and NORMAL blood pressure. What’s next?

Answer 30

Consider epi 0.03-0.05 mcg/kg/min

Consider adding vasodilator (dobutamine or milronone) in specific cases