Acute Care - 2019 Updated! Flashcards
A child was involved in a house fire 1 hour prior to arrival in your ER. He is in respiratory distress with an O2 sat 78% on FiO2 1.0. His response to bag and mask is inadequate and a decision is made to intubate. Despite previous ventilation in the field, his saturation is still poor on FiO2 1.0.
What would be your initial ventilator settings:
a) FiO2 1.0 – PIP 20 – PEEP 5 – rate 20
b) FiO2 1.0 – PIP 10 – PEEP 5 – rate 20
c) FiO2 1.0 – PIP 10 – PEEP 0 – rate 40
d) FiO2 0.5 – PIP 30 – PEEP 5 – rate 20
e) FiO2 0.5 – PIP 20 – PEEP 0 – rate 20 → wouldn’t choose this one PEEP is 0
a) FiO2 1.0 – PIP 20 – PEEP 5 – rate 20
13 year old girl who was sexually assaulted by a stranger at a party that night. Now in your emerg.
5 things in your management
- assess and treat for physical injuries
- psychological assessment and support
- pregnancy testing and offer emergency contraception (plan B)
- offer STI testing (HIV, Hep B, Hep C, VDRL) and treatment (hep B vaccine), consider HIV PEP if high risk assaulter, ceftriaxone and azithro empirically for chlamydia and gonorrhoea
- forensic evaluation (rape kit) - clothing, combed scalp and pubic hair, fingernail clipping, swabs
A teenage boy was brought in with methanol poisoning. His laboratory values are as follows: Na 140 K 4.4 Cl 96 Bicarb 11 Urea 4 Glucose 6 Serum osmolality 369
a. ) Calculate the anion gap.
b. ) Do you expect the osmolar gap to be abnormal? Yes - though gap will decrease as methanol is converted to its metabolites
c. ) What is the specific medication you would give for his methanol poisoning?
a) 33
b) Should be high, will decrease as methanol converts to metabolites
c) Fomepizole
CXR of a large cardiac silhouette. Patient has a several-day history of fever with chest pain relieved bending forward, elevated JVP, pulses paradoxus; what is your diagnosis?
Pericarditis complicated by cardiac Tamponade
Beck’s Triad - Pericardial Tamponade: Muffled heart sounds Distended neck veins Hypotension (typically have narrow pulse pressure) Can also get pericardial friction rub
3 indications for intubation in a trauma patient.
General reasons to intubate:
- unable to maintain effective airway
- unable to oxygenate
- unable to ventilate
Decreased level of consciousness such that patient cannot protect airway
Soft tissue injury/swelling raising concern for maintained airway patency
Injury to chest wall/lungs/heart leading to inability to maintain oxygenation or ventilation
Cardiorespiratory arrest
Secure airway for transportation
Need for diagnostic or interventional procedures that require patient cooperation
Regarding consent for organ donation, which is true:
a) It is possible to consent only to donation of specific organs
b) Can consent to donation of organs despite the absence of full brain death criteria
c) There are no absolute contraindications to organ donation
d) Some tissue donations do not require consent
a) It is possible to consent only to donation of specific organs
b) can consent to donation of organs despite the absence of full brain death criteria - since 2006 can consent after circulatory death
When is Charcoal CONTRAINDICATED
PHAILS
Pesticides - Petrolium Hydrocarbons, Heavy metals, >1h Acids, Alkali, Alcohols, aLOC, Aspiration Risk Iron, Ileus, Intestinal obstruction Lithium, lack of gag Solvent, Seizures
A boy is struck by lightning in a field. Most likely consequence?
a. liver failure
b. renal failure
c. cardiovascular collapse
c. cardiovascular collapse
Teenager, tall and lean, some chest pain. Has decreased air entry to left lung, his “vitals are stable”. Chest CT shows a left sided pneumothorax 10% volume. What is your management: 1 - needle the chest now 2 - insert chest tube 3 - observe 4 - insert chest tube and inject
- Observe
A 4 year old child suffers a severe accident in the periphery. He is intubated and brought to the emergency room. Which of the following would be your compression to ventilation ratio?
- Synchronous 15:2 -
- Synchronous 30:2
- Asynchronous 100:10
- Asynchronous 15:2
- Asynchronous 100:10 - Once advanced airway provide continuous compressions without pausing for breaths, with breaths every 6 seconds.
Description of toxic shock syndrome with erythema, fever, low BP. Already received 2x20cc/kg. Slightly decreased LOC. Next?
bolus and inotropes.
Intubate and bolus
Epi
Blood
a) bolus and inotropes. (norepi best as distributive shock)
All are true of shaken baby syndrome except:
- homicide is the most common cause of death due to injury in kids <4y.o.
- external physical findings of shaken baby syndrome are not always present
- shaken baby syndrome does not occur after 3 years of age
- retinal hemorrhages are not always present
- homicide is the most common cause of death due to injury in kids <4y.o.
Babe in shock with Na 131, K 5.9. What is the BEST thing to do right now? (2009 MCQ)
a. iv hydrocortisone
b. NS bolus
c. D10W
d. D5W
a. IV hydrocortison
but if in shock - probably bolus first?
Shock + Hyponatremia + Hyperkalemia = Adrenal Insufficiency
Child brought to the emergency department by parents. They suspect he has taken an overdose, the child denies any ingestion.
On examination: T 38.2 o C, heart rate 132, blood pressure 150/90. The most likely drug is:
a) LSD
b) Cocaine
c) Cannabis
d) Barbiturates
b) Cocaine
HTN, hyperthermia and tachycardia Sx of sympathomimetic and anticholinergics. You’re diaphoretic when you take a sympathomimetic and dry skin when you take an anticholinergic.
LSD: hallucinogen. Delirium and psychosis (tacky, HTN, mydriasis, flushing, delusional, body distortion)
Cannabis: Injected conjunctiva, Tachycardia, orthostatic hypotension, hyperphagia, anxiety
Barbituates: Sedative (lethargy, confusion, ataxia, slurred speech, normal vitals)
A child comes in with stiffness, unable to open his mouth, rigidity. He has been having nausea and vomiting and his mother treated him with some anti-nausea medications, but does not remember what it is. What do you treat him with?
a) diphenhydramines
b) ativan
diphenhydramines (Benadryl)
OD on metoclopramide - > EPS symptoms.
8 year old with a significant closed head injury. You intubate the patient and give IV fluid. The patient has an O2 sat of 98% with oxygen applied. His blood pressure is 130/85 and a heart rate of 80. (No mention of pupils) What would be the next best step.
- Hyperventillation
- Mannitol
- CT head
Mannitol
But… Hamilton review would said to hyperventilate first - faster than mannitol ?
Toddler with gastroenteritis presents with lethargy, pallor and significant dehydration.
HR 120, BP 70/40, rapid respirations. Given 20 cc/kg normal saline bolus.
Nurse informs you that the child has stopped breathing.
Next step in management:
a) ventilate with 100% 02, fluid bolus, epinephrine
b) ventilate with 100% 02, dopamine, fluid bolus
c) dopamine, ventilate with 100% 02, fluid bolus
d) fluid bolus, ventilate with 100% 02, bicarb
a) ventilate with 100% 02, fluid bolus, epinephrine
10 year old 30 kg girl presents in DKA. pH<7.25, glucose 4(0?), 10% dehydrated. Current Na is 120.
A) What type of initial fluid would you give her? B) What would be the rate? C) What initial insulin
dose/type would you start her on?
A) Normal saline
B) Rate = 4cc/kg/h for kids over 20kg
C) once starting insulin (after running fluids for 1-2 hours) run novolin (short acting) at 0.1U/kg/h
Patient in an ice-water drowning, received 3 shocks, CPR started. Temp 26 degrees. He is getting CPR, what to do now?
a. amiodarone
b. lido
c. do nothing
d. asynchronous cardioversion at 4 J/kg
d. asynchronous cardioversion at 4 J/kg
Assuming they have a shockable rhythm (usually have brady arrest or PEA, but sometimes have v fib in which case should be shocked)
- shock may not be effective until temp >30 but still do it
Child found face down in pool. Resuscitation started at scene. At the hospital, his temp is 37.5, HR 100, RR 20, sat 95% in R/A. He is alert and oriented. What to do immediately?
- Admit for 24 hours
- Observe for 4 hours
- Call social work
- CXR
- IV antibiotics
- CXR
Observe for 6-8 hours minimum
1/2 of kids who are looking great go on to develop some resp distress and pulmonary oedema after 4-8 hours after submersion
CXR not necessarily needed for asymptomatic children, but some advocate for CXR prior to D/C from ED
2 year old in the ER with passage of bright red blood mixed in with his stool. Pale looking but otherwise okay. On rectal exam you find blood mixed with stool on your glove. Hemoglobin is 94.
Most likely diagnosis:
A) anal fissure
B) bleed from a peptic ulcer
D) Meckel’s diverticulum
D) Meckel’s diverticulum
2 year old with torticollis, neck pain and refusal to move neck. 3 things on the differential
Meningitis, RPA, PTA, cervical adenitis, trauma
Febrile 3 yo, seizing for 30 minutes. HR 180, RR 60, BP stable. Failed IV access. Next?
b) intranasal midazolam
What complication is associated with erythromycin use in infants?
Hypertrophic pyloric stenosis
Parents are worried about their 9 year old daughter; she has been snoring a lot
and having episodes overnight where she stops breathing. Polysomnography was done and shows episodes of significant, severe central apnea. What to do?
a) consult ENT
b) MRI brain
c) brainstem evoked auditory potentials
d) CPAP overnight
b) MRI brain
MVA, head injury, GCS 6, now intubated. How would you ventilate the child and explain why from a physiologic perspective.
Prevent hypoxia - 100% oxygen
Head of bed elevated
Neck midline
Hyperventilate/prevent hypercarbia to PCO2 35-40 (lower than this increases risk of ischemia and stroke)
Near drowning 2yr old in PICU. Mom wants prognosis. List 4 poor prognosis factors associated with pediatric near drowning.
Warm Water Prolonged immersion >10 mins Delay in bystander CPR by 25mins In ED: Deep coma Apnea Absent papillary responses, Hyperglycemia GCS ≤ 5
Child stepped on a nail that punctured the sole of his shoe and his foot. What is the most likely organism?
o Pseudomonas
You are on the phone with a doctor in a community hospital 2 hours away. Pt with varicella and now 12cm purple lesion on leg, very painful, and sick - what to suggest (4)
Varicella Gangrenosum or
Nec Fasc
IV access, put on monitors, cycle BP Fluid rescus/IV fluid maintenance IV broad spectrum Clox/CTX, Clinda, IV acyclovir, ± vanco Analgesia Prepare for transport
Child with head injury. Which of the following is a reason for why ketamine should not be used in this child?
a. it has sympathomimetic properties
b. it has negative inotropic properties
c. it causes respiratory suppression
a. it has sympathomimetic properties
Notes: - ketamine dissociates the connections between the cortex and limbic system
- in lower doses releases catecholamines (sympathomimetic action) which maintain BP and
cardiac function BUT per Nelson’s can also be associated with increased ICP
Child with pulseless wide-complex tach, got defibrillated x 1 and is receiving CPR. IV is in situ. What do you do next?
c. epinephrine 1:10000, 0.1 cc/kg
An 8 year sustained a severe head injury from which he has completely recovered.
The most likely long-term sequela is:
a. Epilepsy
b. Specific Learning Disability
b. specific learning disability
- Motor and cognitive (particularly executive function) sequelae result from TBI (but they benefit from rehab to minimize LT disabilities)
- Attention skills can remain impaired 10 years after the injury
What’s the SALTER classification?
I Separated II Above III beLOW IVThrough and Trough V eRammed
3yr old with miosis and seizure. Which toxin did he ingest?
a. insecticide
b. cocaine
c. beta blocker
a. insecticide
(organophosphate toxicity)
SLUDGE (muscarinic) and nicotininc effects
b. cocaine (seizures, mydriasis, high HR, HTN)
c. beta blocker (low HR, hypoTN, hypoglycaemia, decreased GCS)
Scenario of a mom who brings her infant in after he/she was at the sitters (age?), and the kid has burns of both hands, and a scald on his chest. She was told that he pulled the coffee pot down on himself.
What do you do? List 3 reasons why you would admit him.
- call CPS - infant probably can’t pull coffee pot down on self
- estimate percentage of BSA involved and fluid resuscitate
- indications for admission: burns affecting >10% BSA
- burns to face, hands, feet, genitals, major joints
- suspected child abuse or neglect
- Infant with skull fracture, suspect SCAN. What is the most likely bleed?
a. subdural
15 kg child with tachycardia, dry mucous membranes and a history of vomiting and diarrhea. What is the most appropriate rehydration regimen?
a. 400 mL of ORS per hour, for 4 hours
b. 100 mL of ORS per hour, for 4 hours
c. rehydrate with apple juice
d. start IV fluids
a. 400 mL of ORS per hour, for 4 hours (1600ml = ~100ml/kg)* this is the answer
(b. 100 mL of ORS per hour, for 4 hours (400ml = 26ml/kg = too little)
Can try ORT for anything but severe dehydration (mild = 50ml/kg over 4h, moderate = 100ml/kg over 4h)
14 year old girl was found in a field by her friends. She was agitated and disoriented. On examination she was found to have jimson weed on her, with a few the seeds from the plant. This is known to be an isomer of atropine.
What are 4 signs that you might find on examination?
What are two things you should do for management?
Anticholinergic toxidrome:
- tachycardia
- dry red skin
- mydriasis
- urinary retention
- hyperthermia
- hallucinations
- decreased bowel sounds
Mgmt: benzos for delirium, agitation or seizure
- charcoal if in tact LOC and protecting airway
- physostigmine if normal ECG
- screening tests: ECG, look for coingestion (acetaminophen, salicylate)
List 4 signs/symptoms of serotonin syndrome
- myoclonus
- hyperreflexia
- delirium
- hyperthermia
- tachycardia
- agitation/confusion
- diaphoresis
All are needed to declare brain death except:
- EEG
- 2 physicians are required to declare brain death
- No spontaneous respiration despite hypercarbia
- Absent corneal reflex
- Absence of hypothermia
- EEG
The 3 key components of clinical brain death diagnosis are demonstrations of coexisting irreversible coma with a known cause, absence of brainstem reflexes, and apnea.
A 6 year old boy is seen with abdominal pain of 24 hour duration that he now rates as an 8/10. He is afebrile. HR 150, BP 120/80, RR 30.
On examination she has a diffusely tender abdomen and is guarding. You call general surgery to consult. In the meantime, what is your priority in management:
- Blood C&S and IV antibiotics
- 20 cc/kg IV bolus and IV analgesia
- 20 cc/kg IV bolus and CT abd
- 20 cc/kg IV bolus and IV antibiotics
20 cc/kg IV bolus and IV analgesia
Child with a diffuse erythematous rash, sick in the ICU with strep pneumonia sepsis. Got his first dose of Pen G, then developed rash and hypotension. Also HR 200, decreased LOC. What does this scenario describe? (2009 MCQ)
a. uncompensated hypovolemic shock
b. compensated cardiogenic shock
c. uncompensated distributed shock
d. uncompensated obstructive shock
c. uncompensated distributed shock
Uncompensated because he is hypotensive
Increased intracranial pressure occurs in all EXCEPT:
(a) TCA overdose
(b) Reye’s syndrome
(a) TCA overdose
In Reye syndrome get death secondary to raised ICP and herniation
A teenager is brought into the ER. He is hypertensive, tachycardic, and agitated. Management:
a) physical restraints
b) activated charcoal
c) chlorpromazine
d) diazepam
d) diazepam
Likely ingestion is amphetamines
- benzo treats hypertension and possible arrhythmias
Young child presents to the emergency room looking unwell with a sodium of 132 and potassium of 6.2. What is the diagnosis?
Hyponatremia + Hyperkalemia = primary adrenal insufficiency (insufficient cortisol)
Also have pigmented skin, metabolic acidosis, weakness, fatigue, weight loss, myalgia, arthralgia, nausea, vomiting, abdo pain, diarrhea, salt craving
*treat with hydrocortisone
A child who is known to be allergic to peanuts presents to emergency after having eaten some 30 minutes ago. He is very itchy and has hives all over his body. His vitals including BP are stable and there is no wheezing.
Which of the following is correct?
a) IV epinephrine would be the preferred medication
b) Benadryl can be given IV, IM or PO
c) ventolin and Pulmicort should be administered
d) hydrocortisone does not prevent the late onset effects
e) desensitization therapy should be undertaken
b) Benadryl can be given IM, IV, or PO
Succinylcholine is contraindicated in which of the following ?
DMD
Hypothyroidism
Increased ICP
DMD
Absolute contraindications: DMD CP with paralysis Extensive crush injury with rhabdo Peronsal Hx or Fx malignant hyperthermia
What are the Kocher criteria for septic arthritis?
T>38.5 WBC >12 ESR >40 CRP >23 inability to weight bear
Which of the following is true about management of postoperative pain in children aged 6-10 years:
a. use BP and HR as a guide for when to give pain medications
b. give regular doses of pain meds in the first 24 hours as they cannot reliably report pain
c. they can assess pain meds as required using self report
d. use a visual analog pain scale
d. use a visual analog pain scale
Should also give routine analgesia post-op, but not because the child cannot reliably report pain, more because you anticipate they will have pain and want to stay on top of it
Child presents with an ammonia level in the 400-range. What 3 things would you do in your management?
- Sodium benzoate to bind ammonia and allow excretion
- give arginine (supplies the urea ammonia cycle)
- provide adequate fluids, electrolytes and calories IV, but minimize protein
- dialysis if the above does not work sufficiently
*high ammonia is toxic to CNS
Infant with skull fracture, suspect child abuse. What is the most likely bleed? (2009 MCQ)
a. subdural
b. epidural
c. intraventricular bleed
a. subdural
What are four clinical signs that would be considered a contraindication for a lumbar puncture?
Signs of raised ICP:
- decreased LOC
- hypertension
- bradycardia
- focal neurologic defect or seizure
- petechiae (suggest TCP)
- overlying infection (cellulitis)
- spina bifida
4 absolute contraindications to ketamine (believe it or not!)
Hypersensitivity Age < 3 months Schizophrenia Major oropharyngeal procedures (as there is already baseline risk of laryngospasm and hypersalivation) Thyrotoxicosis Intraocular trauma or glaucoma Severe HTN
Critically ill (may cause hypotension and bradycardia)
13 y/o male with intermittent testicular pain. 3 things on your ddx.
- torsion (testicular or appendix testis)
- hernia
- epidydimitis
- trauma (ruptured testis)
- testicular vasculitis
- renal stone (referred)
Teenager in a motor vehicle accident a day before and was observed in ER. Now presents with orange urine and his creatinine has tripled. What is the diagnosis?
a. renal vein thrombosis
b. rhabdomyolysis
c. glomerulonephritis
b. rhabdomyolysis
Child with 15% blood loss after MVA. ETA to ER is at least 1 hour. Which of the vital signs most represents the patient upon arrival to ER.
- P 120, RR 30, BP 90/60
- P 130, RR irregular, BP 100/70
- P 220, RR 36, BP 60/40
- Pulse thready, RR 36, BP not obtainable
a. pulse 120, RR 30, BP 90/60
- Can lose up to 30% of blood before BP decreases
- 15% is between very mild to mild hemorrhage
Which of the following fracture is most suggestive of abuse?
Spiral fracture of the tibia
Supracondylar fracture
Posterior rib
posterior rib fractures
A child ingests paint thinner (hydrocarbon). What to do:
- Gastric lavage
- Activated charcoal
- Observe and treat symptomatically
- Discharge home
- Observe and treat symptomatically
Charcoal doesn’t bind hydrocarbon, gastric lavage increases risk of aspiration, need to observe for pneumonitis
A 3 year with 5 days low grade temperature, rhinorrhea, occasional cough. On exam he looks well, has green crusted nasal discharge. Mom has been giving acetaminophen 6 to 7 x/day. Next test:
a) Sinus x-rays and treat if fluid level present
b) treat with amoxil
c) consult with ENT
d) counsel on Tylenol dosing and risk of too much acetaminophen
d) counsel on Tylenol dosing and risk of too much acetaminophen
Toxic dose of acetaminophen: 150mg/kg
8yr male from Kenya. Severe chest pain. Diaphoretic and pale. Tachycardic. Jaundiced. Hgb 40.
a. Underlying diagnosis?
b. 4 management strategies
a. SCD with acute chest
b. O2, Transfusion, Pain mgmt, Antibiotics (Cefotax and Azithro), bronchodilators
± IVIG
What are 4 clinical signs that are suggestive of an inhalation injury in the setting of an acute burn?
- facial burns
- soot in the mouth or nose (carbonaceous sputum)
- singed nasal hairs/eyebrows
- edema/blistering of oropharynx
- stridor/hoarse voice
Neonate with PDA treated with indocid. List four side effects of indocid.
Indomethacin is an NSAID
- GI bleed
- Gastritis / ulceration
- Intestinal perforation / NEC
- Transient renal dysfunction / oliguria
- Decreased cerebral, mesenteric, renal blood flow
- Altered platelet function
Teenager overdosed on imipramine. Presents with decreased LOC. What do you do?
a. Give phenytoin
b. Sodium bicarbonate
c. Activated charcoal
c. Activated charcoal
Phenytoin for arrhythmias (and may be questionable)
NaHCO3 for QRS>110, ventric arrhythmia or hypotension
Concerning complete AV block, all are true EXCEPT:
a) may be a cause of syncopal episodes
b) ventricular rate of 30-60 bt/min
c) if you hear a systolic murmur then it is associated with a congenital heart lesion
d) diagnosis is confirmed by ECG
e) may be present in infants born to mothers with SLE
c) if you hear a systolic murmur then it is associated with a congenital heart lesion
A 15 year old child is being transferred to your centre after an MVC in which he sustained a closedhead injury.
Which of the following is likely to occur on transport and will cause significant sequelae?
(a) hypoxia (b) hypercarbia (c) hypoglycemia (d) hypotension (e) hyperglycemia
Hypotension
Child presents with first diagnosis of DM1 and in DKA. Is 10% dehydrated but N vital signs incl BP.
Give initial fluid to give (1), the rate (1).
Then to write your initial insulin order (1).
NS bolus 10 ml/kg over 1 hour
Insulin 0.1 unit/kg/hr, start 1-2 hours after initial fluids
Child with vomiting and diarrhea who was fed a home concoction of enteral feed. Now is lethargic and seizing. Na 115, creatinine elevated. Ur Na 12, Bicarb 18, glucose 3.5.
Which is the best next step:
- Administer 3% NaCl at a rate to increase Na by 2mEq/L/hr.
- Give Lasix to increase urine output
- Give bicarb
- Give bolus of D5W0.45 20cc/kg
- Administer 3% NaCl at a rate to increase Na by 2mEq/L/hr.
● If severe hyponatremia (<120) and CNS symptoms)
o 3% NaCL 3-5 cc/kg IV push with hyponatremia induced seizures
o Rate of increase should not exceed rise of > 2 mEq/L/hour to prevent central pontine
myelinolysis
Child on Risperdol for Tourette’s syndrome has frequent syncopal episodes with exertion. What is the cause?
a) Hypoglycemia
b) prolonged QT
b) Prolonged QT
Toxic child with high fever, respiratory distress. White-out on 1 side of the lung on CXR. What to do?
b. chest ultrasound
Notes: Whiteout Hemithorax DDx: large pleural effusion, empyema, hemothorax, complete lung collapse,
community acquired pneumonia, pleural masses
Kid with vomiting and diarrhea. Mom feeding glucose water. Comes in with sodium 108. Not seizing. How do you manage? a. correct Na with 3% NaCl over 4-6 hrs b. correct to 135-140 in 24 hrs c. correct to 118 -120 in 24 hrs
c. correct to 118 -120 in 24 hrs
Not more than 0.5meq/h (12meq/day)
3% NS only for severe hyponatremia (<120 AND seizing)
EKG kid in vfib/ maybe early torsades?. Patient has CPR being performed already intubated. Has IV.
Give the interventions and drugs that will be administered for his cardiac care in the first 5 minutes of
resuscitation.
CPR Shock CPR Shock CPR Epi CPR Shock Amiodarone or Lidocaine \+/- Mag Sulf if TDP (from long QT)
Which drug has the most amnestic effect? (2010 Ottawa)
a) midaz
b) ketamine
c) fentanyl
d) chloral hydrate
b) ketamine
A 10 year boy hurts his ankle while playing soccer. He is able to weight bear in the emergency with significant pain. Which of the following would make you more inclined to do an ankle x-ray?
1) Inability to weight bear immediately after the injury
2) Pain at the anterior edge of the lateral malleolus
3) Pain at the posterior edge of the medial malleolus
4) Swelling
3) Pain at the posterior edge of the medial malleolus
A 3 year old child arrives in your ED with a history of seizing for 30 minutes. HR is 220, respirations are difficult to assess, BP is 150/80. You are unable to get IV access. What do you do:
Sodium nitroprusside
Rectal benzodiazepine
Intubate
IM dilantin
Rectal benzodiazepine
Don’t give Phenytoin (dilantin) IM (only IV or IO). You can give FOSphenytoin IM.
9 year old boy comes into your ER with severe abdominal pain and bilious vomiting. He has presented in a similar manner on 3 previous occasions in the past 2 years. List the most likely underlying diagnosis [1 point] and one investigation you would do in about 1 week when he is feeling well [1 point].
Malrotation with intermittent Volvulus- UGI
2 week old with Hypotension, RR 70, HR 210, on 50% oxygen sats 95%. What is your next step after fluid bolus?
a. IV abx
b. Bag Mask
c. Intubate
a. IV abx
Late onset sepsis
8 year old boy plays soccer competitively. He crashed into another player was confused and amnesic afterwards.
Now asymptomatic. He has practices every day for two weeks and then the playoffs start.
What do you tell him regarding his play (2)?
● no activity is step 1
● each step min. 24h and progression only if symptom free
● if symptoms recur then rest until resolve (24-48h) before trying again at last step where
asymptomatic
● only after symptom free 7-10 day and fully returned to school can begin medically supervised
return to play
Child fatigued and tanned, K 5.2, Na 132, glucose 2.6, shocky, vomiting and has
diarrhea. What is used to treat the underlying condition?
a. D5 0.25NS
b. nothing - just observe
c. NS 20 cc.kg
d. iv hydrocortisone
d. iv hydrocortisone
Which of the following is least associated with increased intracranial pressure?
- TCA Overdose
- Reye’s Syndrome
- Meningitis
- Encephalitis
- Intracranial bleed
TCA overdose
(Reye - reversible severe non-inflammatory encephalopathy and fatty degeneration of liver. High ICP secondary to cerebral edema (hyperammonemia))
Blunt abdominal trauma.
One reason to take patient to OR for laparotomy.
- Perforation from a hollow viscous injury as demonstrated by pneumoperitoneum (i.e. bowel
perforation) - Intra-abdominal bleeding
24hr hx esotropism of left eye. Dx:
a. Increased ICP
b. Atypical Guillan-Barre -
c. MS
d. Lyme disease
a. Increased ICP - Most common cause of abducens nerve palsy in children is increased ICP from compressing tumors (45%).
15% from other causes of increased ICP
Give 4 clinical manifestations of cocaine abuse?
Acute: Pupillary dilation Tachycardia, HTN Hyperthermia CP due to coronary vasopasms
Chronic:
Loss of smell, nosebleeds, chronic rhinorrhea, perforation of nasal septum
Anxiety
Psychosis
You are asked to assess a 5 year old kid who had surgery and has been receiving 20 mg/kg acetaminophen q4h for 5 days. He now has decreasing LOC. Which is true?
h) Acetaminophen is not a good drug for post-op pain management
i) he needs to be worked up for hepatic toxicity
i) he needs to be worked up for hepatic toxicity
A 5 year old boy is the back seat during a serious MVC. He is wearing a lap belt and shoulder belt. On arrival he has no urine output and cannot move his lower limbs. Which of the following is the likely cause?
- Intraspinal bleed
- Chance fracture at L1-L2
- Bladder rupture
- Pelvis fracture
- Chance Fracture at L1-L2
Seatbelt lays incorrectly - injuries to viscera, head, spine (chance) often with paraplegia
15 year old boy comes in with decrease LOC, GCS 11, flailing limbs and speaking incomprehensibly.
Pupils are dilated, skin is flushed. HR 115, BP 110/70, afebrile.
Which of the following is most likely what he ingested:
a. Imipramine
b. Jimson weed
c. Morphine
b. Jimson weed
Anticholinergic toxidrome
Organophosphate OD - signs/symptoms.
SLUDGE (Cholinergic)
Salivation Lacrimation Urination Defication GI cramps Emesis
(fluids from every orifice)
