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)
You are treating a 2 year old with otitis media with amoxicillin. He returns to you with a high fever, erythema behind the right ear and the right pinna appears pushed forward.
a. What is the diagnosis?
b. What are 3 complications of this condition?
c. What medications will you use to treat?
a) Mastoiditis
b) FN palsy or 6th nerve palsy Venous sinus thrombosis Meningitis Subperiosteal abscess Hearing loss
c) Ceftriaxone
Child present to ED with viral URTI symptoms, stridor, no significant respiratory distress, FiO2 approx. 95% (assuming this is SpO2). What do you do?
A) One dose of dex
B) Neb epi and dex
a) One dose of dex
No distress
A teenager is brought into the ER after taking 4 pills consisting of a white powder. He is comatose with hypertension, muscle rigidity, myoclonic jerks, and nystagmus.
a) Cocaine
b) Psilocybin (= mushrooms)
c) PCP
d) LSD
e) Amphetamines
c) PCP
Hallucinogen = dissociative, adrenergic, agitation, paranoia, nystagmus, dystonic posturing, muscle rigidity, myoclonus
Cocaine = sympathomimetic = psychosis, agitation, mydriasis, tachycardia, HTN, Hyperthermia, DIAPHORETIC
Amphetamines - same as cocaine
LSD: Hallucinogen (serotonigeric) - mydriasis, tachycardia, HTN, diaphoresis, increased respiratory rate
Girl submerged in icy water. AED used at scene. In hospital, temp 26 C and VFib
Do nothing
Lidocaine
Amiodarone
Defibrillate
Defibrillate
there is a max number of tries though - chest Ham Review
First line treatment of a child with pulseless Ventricular tachycardia.
Defibrillation
first shock 2J/kg, second shock 4 J/kg, subsequent shocks >=4Jkg, max 10J/kg or adult dose
List 3 treatments for hyperuricemia.
Allopurinol (decrease production of uric acid)
Alkalinize urine
Hydration
Diuresis
Rasburicase (enzyme that degrades uric acid)
A patient with septo-optic dysplasia presents hemodynamically unstable. He is mottled and has a low
blood pressure. WBC is normal, Na 138, K 6.1. After fluid resuscitation, what is your next management
step?
a) give IV hydrocortisone
b) start antibiotics
c) give hypotonic saline
d) start Kayexalate
a) give IV hydrocortisone
Could have panhypopit causing secondary adrenal insufficiency (means not enough ACTH).
Adrenal crisis.
Picture of Bell’s palsy- what is diagnosis and 2 treatments and prognosis
Bell’s palsy (upper and lower parts of face are paretic)
Tx: Prednisone 1 mg/kg/day x 1 week, then taper 1 week
Acyclovir
> 85% will recover without facial weakness
Remember - Ramsay Hunt (zoster in auditory canal)
Hutchinson sign - varicella on nose - precedes ophthalmic herpes zoster.
4 yo with drowning injury. GCS 6, no spontaneous breathing. How long of no improvement of GCS signifies almost nil chance of survival without sequelae
A) 6 h
B) 12 h
C) 24 h
D) 48 h
D) 48 h
A 4 month old infant presents in shock with a temperature of 41.8C. In the ICU on
ventilator, spontaneous bleeding occurs and the pupils are sluggish.
The most likely diagnosis is: a. E. coli meningitis b. Hemorrhagic shock and encephalitis syndrome (HSES) c. Reye syndrome
b. Hemorrhagic shock and encephalitis syndrome (HSES)
- occurs in previously healthy 3-8 month olds in context of high fever
- encephalopathy, shock, severe DIC, renal and liver failure
Organophosphate overdose antidote
Atropine (muscarinic effects) Pralidoxime (nicotinic effects)
Benzos for seizures
Decontaminate! Take off clothing. Scrub skin.
List 3 serotonergic symptoms/side effects from an SSRI.
- irritability/restlessness
- insomnia
- diaphoresis
- behavioural activation
An infant presents to the ER with significant irritability and you find the following on examination. Shown a picture of bilateral burns to lower limbs suggestive of immersion injury.
What are the 4 important factors in this patients management.
Fluid resuscitation
Analgesia
Wound Care - consult plastics
Consider NAI - careful documentation of Hx and PE
3 yo trauma patient with depressed skull fracture is unstable with desaturation and hypotension.
What is your next management step?
urgent CT
intubate
give mannitol
b) intubate
A child who has ingested iron has AXR showing concretions. He is started on desferoxime. He is otherwise alert. What is your management?
a) Gastric lavage
b) Whole bowel irrigation
c) Activated charcoal
d) No additional management
b) Whole bowel irrigation
Child with pulseless wide-complex tach, got defibrillated x 1 and is receiving CPR. IV is in situ. What do you do next?
a. Shock 2J/kg
b. Shock 4J/kg
c. Epinephrine 1:10000, 0.1cc/kg
d. Lidocaine
b. Shock 4J/kg
PALS:
pVT algorithm: shock x2 then and epi
1:10000 Epi 0.1ml/kg = 0.01mg/kg q3-5min
Repeat assessment for shockable rhythm would be q2min.
Child had a URTI a week ago. He now presents with bloody diarrhea, abdo pain and a petechial rash. What is his diagnosis?
HSP - 1/2 of cases are preceded by viral URTI; can have bloody diarrhea (bowel hemorrhage or necrosis, though rare)
Also consider HUS, BUT does not typically follow viral illness. Do have bloody diarrhea and TCP though
3 yo with trauma, skull and femur fracture and has already received 3 boluses of 20 cc/kg. HR 160, low BP – unchanged Next step:
mannitol/lasix
intubate and give another bolus
inotropes and packed RBC
intubate and blood
inotropes and packed RBC
EMS brings shocky 7yr kid to ER. BP 70/40. Tachycardic. Running IV maintenance
a) Does this kid need a change in fluid management & explain.
b) List 3 criteria for intubation in pediatric trauma patient
a) Yes- needs bolus fluids
b) Can't maintain airway patently Can't oxygenate Can't ventilate Needs sedation Rapidly deteriorating
Child with flexion response to pain, incomprehensible moaning, eyes don’t open. GCS?
7
child has been vomiting mother giving suppositories unknown what kind, child comes into ER with recurrent tonic spasms but not unconscious, mouth open most of the time, what do you administer:
a. diazepam
b. benadryl
c. naloxone
b. benadryl
Intravenous diphenhydramine, 1-2 mg/kg/dose, may rapidly reverse the drug related dystonia.
Teenaged boy who has just had orthopedic surgery. Has been in the casts and on bedrest for 11
days. Suddenly develops anorexia, polydipsia and polyuria. Glucose is normal on admission, BMI 29.
What is the diagnosis?
What one test can give you the diagnosis (1).
What is the management?
- immobilization hypercalcemia (from increased bone resorption)
- ionized calcium
- IV fluids at 1.5-2x maintenance; lasix to increase excretion of calcium
Reversible causes of cardiac arrest?
- H’s: hypovolemia
- hypoxia
- hydrogen (acidosis)
- hyper/hypokalemia
- hypoglycemia
- hypothermia
- T’s: tension pneumo
- tamponande
- toxins
- thrombosis (pulmonary or coronary)
- unrecognized trauma
5 year old fever 38.5 degrees, had a recent URTI. Hip was externally rotated and child not weight-bearing. ESR was 40. Diagnosis? a) transient synovitis b) JIA c) septic arthritis
c) septic arthritis
Dog bite 2 hours ago on the dorsum of the hand. Both the child’s and dog’s vaccinations are up-to-date. On exam, full ROM of hand with mild edema.
Appropriate management:
a) irrigate with antibiotic solution
b) irrigate with saline
c) irrigate with saline and cover with topical antibiotics
d) irrigate with saline and treat with clavulin prophylactically
e) swab wound for culture and treat with IV clindamycin while awaiting result
d) irrigate with saline and treat with clavulin prophylactically
- remove FB
- XRAY if suspected bony injury
All wounds: irrigate with saline
Indications for prophylactic antibiotics:
- Moderate or severe bite wounds, especially if edema or crush injury is present
- Puncture wounds, especially if penetration of bone, tendon sheath, or joint has occurred
- Face, hand, foot, and genital bites
- Wounds in immunocompromised and asplenic persons
- Wounds with signs of infection
Side effect of marijuana in adolescents
a. gynecomastia
b. decreased testicular volume
c. tachycardia
c. tachycardia
Some evidence of decreased testosterone and spermatogenesis in chronic users
12 yr old male in MVA. Closed head injury. In peripheral hospital, no ct no neuro surgery.
Pt is intubated and has IV in situ. Give three immediate interventions .
- Continuous monitoring of vital signs (if possible EtCO2)
- Ventilation to maintain normal oxygen and CO2
- Maintain normothermia
- Provide sedation/analgesic
- Fluids to maintain normovolemia and avoid hypotension
- elevate head of bed
Child in MVA 24h ago discharged home after brief observation. Returning today with decreased U/O
of orange urine. Cr is rising and is unresponsive to fluids. Why?
a. Renal contusion
b. Renal artery thrombosis
c. Rhabdomyolysis
c. Rhabdomyolysis
16 y M had been agitated and aggressive earlier in the evening. Brought in unconscious, but rouses intermittently showing rigidity and hyper-reflexia.
What has he ingested?
e. Cocaine
f. PCP
g. Heroine
f. PCP
Coma of PCP may be distinguished from that of opiates by the absence of respiratory
depression, presence of muscle rigidity and hyperreflexia and nystagmus, and lack of response
to naloxone
5 week baby with pyloric stenosis. Labs show a bicarb 34. What solution would you use for rehydration (1) and why (3)
- Initial NS boluses
- D5NS + 20mEq/L KCl
- correct alkalosis, will likely have hypokalemia, restore hydration
- chloride will correct alkalosis
- better to correct lytes and acid-base status pre-op for better post-op outcome
15 year old with right eye pain, scleral injection and watery discharge. (He may have had fever; don’t remember) Visual acuity is 20/20 in left eye and 20/200 in right eye. What 3 diagnoses should you consider?
Orbital Cellulitis Anterior uveitis Keratitis Foreign body Glaucoma Bacterial conjunctivitis Trauma Retinal detachment
Child comes in with acute onset over 24 hours of fever and diffuse erythroderma. In your ED is hypotensive and complaining of myalgia. There is renal and liver dysfunction on bloodwork.
What diagnosis is this most consistent with:
Stevens-Johnson syndrome
Kawasaki’s disease
Staphylococcal toxic shock
Staph TSS
Major Criteria (ALL req):
Fever >38.8
Hypotension
Rash
Minor (Need 3+) Mucous membrane inflam. Vomiting, diarrhea Liver abn Renal abnormalities Muscle Abs (myalgia or CK 2x normal) CNS (aLOC w/o focal signs) Thrombocytopenia
Which is used to treat a methanol overdose
- Fomepizole
- Physostigmine
- Flumazenil
- Naloxone
- Pralidoxime
Answer: Fomepizole (methanol usually from windshield washer fluid) - if not available or allergic, give ethanol; may need dialysis
PLUS: thiamine, folic acid and pyridoxine
- Physostigmine (anticholinergic)
- Flumazenil (benzos)
- Naloxone (opioids)
- Pralidoxime (cholinergic - specifically organophosphates and nerve gas)
Small pupils overdose: what is it. (2010 Ottawa)
a) nicotine
b) insecticide
c) cocaine
b) insecticide
Organophosphate (Cholinergic)
DUMBBELS:
Diarrhea, urination, MIOSIS, bronchorrhea, bradycardia, emesis, lacrimation, salivation
Tx: Atropine, Pralidoxime, Benzos for seizures
A 10-year-old boy has a temp 39.3, RR 44 on 100% O2, HR 140, and BP 60/P. There is a diffuse erythematous rash on his body and one lesion that looks like impetigo. He is given a 20 cc/kg bolus of saline with no improvement. How do you proceed:
a) bolus again – intubate – penicillin
b) bolus again – inotrope – cloxacillin
c) bolus again – ceftriaxone – intubate
d) inotrope – intubate – cloxacillin
e) intubate – bolus again – penicillin
b) bolus again – inotrope – cloxacillin
Doesn’t say decreased LOC. Do not need to intubate.
Mgmt:
- fluids
- abx: antistaph (clox) and antitoxin (clinda)
Name 4 clinical signs or symptoms of a tension pneumothorax.
Where would you insert a needle and
what size needle would you use.
In one line describe the purpose of a Heimlich or flutter valve.
Clinical signs of a tension pneumothorax:
- respiratory distress with tachypnea and increased work of breathing
- tracheal deviation toward contralateral side
- hyperresonance of affected side
- hyperexpansion of affected side
- diminished breath sounds on affected side
- pulsus paradoxus (decrease in SBP by >10mmHg during inspiration)
Mgmt: 18-20 gauge for neonates, 14-16 for kids. Needle and catheter over the top of the third rib (second intercostal space) in
the midclavicular line
Heimlich: - one way valve mechanism within a thoracostomy tube or tube drainage system that allows air and fluid to exit the pleural space, but prevents air or fluid from entering the pleural cavity from the outside (now we use water seal instead)
Description of child with serum sickness day 10 of abx for URTI, joint pain, anemia, rash, hematuria. Management:
a) Pulse pred
a) IVIG
b) high dose NSAIDS
c) plasmapheresis
b) high dose NSAIDS
Remove triggering drug
steroids can be used for severe symptoms
Newborn term, Appropriate GA baby, cried at birth, Apgars 9 and 9.
Few hours later found to be in respiratory distress. RR 80, HR high. Cap refill 4-5 seconds, BP 48/32. Hyperinflated chest with minimal indrawing. Cannot hear breath sounds on left, cannot hear heart sounds.
Baby is turning cyanotic. What
investigation do you do (1)? What is your possible diagnosis (1)
Baby’s heart rate is now 80 and is more cyanotic. What one investigation do you want to do (1)
Transillumination. 2 nd choice: CXR
● False (+): ELBW, subcutaneous air or edema, PIE
● CXR would confirm but is clinical diagnosis
Tension Pneumothorax, DDX: Congenital Diaphragmatic Hernia.
● CC: sudden deterioration with O2 desat/increased O2 need
● Tachycardia, fall in BP
● Circulatory compromise due to mediastinal shift (pressure on RA= lower preload and CO) =
bradycardic due to hypoxemic
Treatment: Needle Decompression
● Butterfly needle (23 gauge if > 32 GA or > 1500g) + 3 way stop cock and syringe
● Insert into 2nd intercostal space mid-clavicle line (just above 3 rd rib)
● Advance while aspirating until pull air back; and shoot out through different port; repeat
A 6 year old boy present to your ED with acute onset of headache. In the waiting room he suddenly loses consciousness and is brought into your resuscitation room. He begins to have decorticate then
decerebrate posturing on the right side. You assess his ABCs and they are stable.
What is the next step in your management:
CT head
Mannitol
Dilantin
Mannitol
Note: clinical signs of impending herniation, including alterations in the respiratory pattern (e.g.,
hyperventilation; Cheyne-Stokes respirations, ataxic respirations, respiratory arrest), abnormalities of pupil size and reactivity, loss of brainstem reflexes, and decorticate or decerebrate posturing.
Child with ASA overdose.
Classic lab findings
- Classic early finding is respiratory alkalosis, metabolic acidosis later
- hypokalemia, hypocalcemia
- early hyperglycaemia, later hypoglycaemia
Tx:
Gastric Decontamination with activated charcoal
NaHCO3 if symptomatic - ALKALINIZATION of urine
Consider hemodialysis
What are the cardinal features of serum sickness?
rash, fever, polyarthritis (thin serpiginous bands of erythema)
- presents in 1-2 weeks after starting triggering agent (contains animal serum - foreign serum protein)
Young child presents to the emergency room looking unwell with a sodium of 132 and potassium of 6.2. What is the diagnosis?
Adrenal insufficiency
15 year old with hypertensive emergency.
List two medications that you can use to lower BP acutely.
For each medication, list one side-effect (not including hypotension).
IV medications
- labetolol: bradycardia, bronchospasm in asthmatics, hypoglycemia, vertigo
- nicardipine: tachycardia, hypokalemia, flushing
- sodium nitroprusside: dizziness, cyanide toxicity (if malnourished or hepatic impairment)
- Hydralazine - agranulocytosis, lupus like syndrome, tachycardia
15 year old boy comes in agitated, flailing limbs and speaking incomprehensibly. Pupils are dilated,
skin is flushed. HR 115, BP 110/70, afebrile. How do you manage?
A) Supportive
B) Naloxone
C) Flumazenil
D) Atropine
A) Supportive
B) Naloxone (Opioids)
C) Flumazenil (Benzos)
D) Atropine (Organophosphates)
Mgmt of anticholinergic: patients with moderate toxicity can be treated with physostigmine IV (note can induce sz and worsen arrhythmia in patients with conduction issues); seizures and agitation can be treated with benzos
Ibuprofen ingestion – list 3 blood tests you would perform
Toxic dose: usually <200mg/kg is okay, >400mg/kg more likely to have toxic effects
BUN, Cr, gas, CBC (for platelets), screen for coingestion (acetaminophen, salicylate level)
List 4 signs of recent marijuana use
- Sympathomimetic effects: tachycardia, hypertension
- Neurologic abnormalities: nystagmus, ataxia, dysarthria
- Nausea, vomiting
- Conjunctival injection
- Increased appetite
- Elation, euphoria
- Impaired short-term memory, poor performance of tasks requiring divided attention, loss of critical judgment, decreased coordination, distortion of time perception, social withdrawa
A child is brought into ER unresponsive without a pulse. According to the latest AHA guidelines, what
is the ratio of compression to breaths that should be provided?
E) 30:2
F) 5:1
G) 15:2
H) 5:2
G) 15:2
What are two life-threatening acute presentations of a teenage boy with an anterior mediastinal mass?
State the acute presentation, and describe why it is life-threatening
Risks (compression)
o Airway compromise (airway obstruction/ respiratory failure)
o Cardiac tamponade (obstructive shock)
o Vascular Obstruction (SVC syndrome) (obstructive shock)
Morphine
a. Only one receptor
b. IM route preferred over IV
c. Analgesic effect on subjective perception of pain and decreased emotional response
c. Analgesic effect on subjective perception of pain and decreased emotional response
2 yo found screaming in cottage bedroom under covers. Bat is flying around the room. On exam there are no marks on the child or saliva and PE is normal. What treatment do you offer if any
CDC has recommended that rabies PEP be considered after any physical contact with a bat OR when a bat is found in the same room as a person who cannot give a reliable history (e.g. young children), or is upset (suggestive of contact with bat)
Tx: tetanus prophylaxis if break in skin
- passive immunization with rabies Ig - 20IU/kg - inject around bite site and then into distant limb IM
- immunization with inactivated vaccine at 0, 3, 7, 14 days
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. 100ml 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
Mild Dehydration - Do ORS 50 ml/kg over 4 hours + ongoing losses
Moderate Dehydration:
ORS 100 ml/kg over 4 hours
+ ongoing losses
Severe >10% Give bolus 30-40ml/kg NS
then reassess
Child had sore throat, improved then had fever, difficulty in swallowing and locked jaw. What is the Dx.
Peritonsillar abscess
Trismus in ⅔
RPA - trimus in 20%, has ++ neck pain
What are 5 causes of mediastinal mass?
Etiology (5Ts- thymoma, terrible lymphoma, teratoma, ectopic thyroid, dilated thoracic aorta)
Fire, sat 89% How to believe it?
a) overestimate
b) underestimate
c) accurate
a) overestimate – sats would be an overestimation of actual oxygen delivery in carbon monoxide poisoning …
18 month old with unknown amount of TCA ingested. Drowsy, HR 180, BP 85/45, ECG QRS 130 ms. Mgmt?
a. activated charcoal
b. sodium bicarbonate
c. phenytoin
b. Sodium bicarbonate
Indications for Sodium bicarbonate in TCA overdose: hypotension, ventricular dysrythmias, QRS>110ms.
TCA - similar questions, asked about Amitriptyline and Imipramine
What must be present to diagnose concussion? A) Headache B) Dizziness C) Amnesia D) Vomiting E) Phalange fracture
Technically none of the above - HA present 93% of time
What medication should be used for sedating a 2-year old child for a CT scan?
(a) oral midazolam (b) chloral hydrate (c) propofol
c) propofol - short acting sedative-hypnotic
Avoid in soy/egg allergy
2 year old swallows a 8 mm coin battery 2 hours ago. Stable. On x-ray, it is found in the stomach. What is the next step in management?
a. Consult for endoscopic removal
b. Wait for 48 hours, follow serially with x-rays
c. Wait for 10 days, follow serially with x-rays
D. Reassess if it does not appear in the stool
D. Reassess if it does not appear in the stool
Gastric and Beyond Batteries
- If < 5 years AND BB > 20 mm and stable then remove within 24-48hrs
- If > 5 and/or BB <20mm and stable then outpt monitoring, do XR at 10-14 days if failure to pass
Boy found in garden shed with cholinergic symptoms. Tx:
a. atropine
b. pralidoxime
c. physiostigmine
a. atropine
b. pralidoxime (in combination with atropine if severe - especially profound weakness and muscle twitching)
Kid with kawasaki disease. Received IVIG and asa. Now has hemolysis. Massive hematuria. Low haptoglobin. GN picture. High bili and LDH and liver enzymes
1) renal vein thrombosis from thrombocytosis
2) hemolysis from IVIG
3) ASA mediated platelet dysfunction
4) Kawasaki mediated GN
2) hemolysis from IVIG - occurs in 10% of people getting IVIG
- increased bill, LDH and low haptoglobin all in keeping with hemolysis
What prognostic feature is associated with worst neurological outcome in drowning injury?
a. increased length of submersion
b. GCS < 7 on arrival to ER
c. poor quality CPR at scene
d. cardioresp arrest at scene
a. increased length of submersion
Submersion >5 minutes is most critical factor in prognosis
Other bad prognostic factors: >10 minutes to effective BLS
- resusc for more than 25minutes
- persistent apnea and CPR in ED
Child with headache, nausea, father admitted with CO poisoning.
First step in management?
100% oxygen at normal atmospheric pressure via non-rebreather facemask (enhances elimination of CO)
- if syncope, seizure, coma, MI consider hyperbaric oxygen to even further increase rate of CO elimination
Which of the following are criteria for brain death?
A. 2 exams 24 hr. apart B. absent DTRs C. hypoventilation despite hypercarbia D. Isoelectric EEG E. Angiography F. Consult neuro
C. hypoventilation despite hypercarbia
2 examinations separated by an observation period
24 hr for neonates from 37 wk gestation to term infants 30 days old
12 hr for infants and children older than 30 days
3 year old with severe hypotension secondary to meningoccocemia. You have started an IV, given a
few boluses and the child still is hypotensive.
What 3 things will you do for management (3) of his
hypotension?
- push repeated boluses 20ml/kg NS
- vasopressor support (epinephrine for hypotensive cold shock)
- consider steroids if hypotension is fluid refractory (2mg/kg hydrocortisone)
- Obviously start antibiotics but won’t help the hypotension any time soon
Reason why we remove esophageal foreign bodies that have been sitting for >24 hours
a. esophagitis
b. risk of aspiration
c. risk of esophageal perforation
c. risk of esophageal perforation
Burn Patient.
Indications to admit?
Burn >10% BSA Full thickness Face, hands, feet, perineum, genitals, major joints Electrical burn by high-tension wires or lightning Chemical burns Inhalation injuries Suspect abuse / neglect Other injuries Pregnant
Retropharyngeal abscess with very poor x/ray (soft tissues neck).
a. ) List 2 X-ray findings compatible with retropharyngeal abscess.
b) What makes the xray adequate?
a. ) Increased width of retropharyngeal space
- Air fluid level in retropharyngeal space
- Gas in soft tissue
b) What makes the xray adequate?
- neck extended
- film taken during inspiration
- good penetration
- not rotated
What is the best early indicator of mild dehydration?
- Tachycardia
- Capillary refill of 4-5 seconds
- Hypotension
- Tachycardia
What toxic ingestion is suggested by a relative afferent pupillary defect?
methanol - 18-24h after ingestion have decreased vision and feeling of seeing through a snow storm
Which of the following is most consistent with compensated shock? (2008 MCQ)
a. N BP, cool extremities, decreased LOC. Delayed cap refill
b. brady, HTN, apnea
c. N BP, N LOC, increased CO2, decreased PO2, N urine output
d. N BP, tachy, unresponsive, normal pulses
N BP, cool extremities, decreased LOC. Delayed cap refill
16 yo F with purpuric rash, fever x several days, presents lethargic to ER. Has received 60cc/kg NS boluses. Now BP 65/45, HR 150, tachypnea, continues to be lethargic, bounding pulses, cap refill < 2 seconds. What is your next step?
- Epinephrine
- Norepinephrine
- Dobutamine
- Dopamine
Norepi
Surgeon asks for a consult on two of his patients for elective surgeries next morning.
Please give fluid type and rate for:
A) 14 y.o. boy (50 kg) NPO from midnight for inguinal hernia repair
B) 2 mos boy (5 kg) NPO from midnight for inguinal hernia repair
a) - D5NS with 20 meq KCL at 90 ml/hr.
b) D5NS with 20 meq KCl at 20 ml/h
Matching Question:
Asystole Bradycardia SVT V. tach with pulse V. tach without pulse PEA
Epi High dose Epi Atropine Adenosine Amiodarone Lidocaine
Asystole: epi
bradycardia: epi or atropine (if increased vagal tone)
SVT: adenosine
V tach with pulse: Adenosine (consider Amiodarone or Procainamide)
Pulsesless V tach: defib, then epi (repeat), then amiodarone
PEA: epi
A 10kg child is brought into the ER unconscious. There is a rhythm on the monitor but no pulse. Which medication should you administer? A) Atropine 1 mg B) Atropine 0.1 mg C) Epinephrine 1/1000 1ml D) Epinephrine 1/10 000 1ml
D) Epinephrine 1/10 000 1ml
Epi 0.1ml/kg for PEA
0.01 mg/kg of 1:10,000
(this is 0.1 mL/kg)
Adolescent in the ER after an MVA. He is comatose. His breath smells of alcohol.
a) attending physician can take a blood alcohol level without patient’s consent
b) attending physician should talk to police about possible alcohol ingestion
c) parents can refuse alcohol level
d) police can look at medical files
a) attending physician can take a blood alcohol level without patient’s consent
Emergent situation - to rule of EtOH or other cause.
3 week old with pyloric stenosis, severe metabolic alkalosis (bicarbonate 34). What to do:
- Give hydrochloric acid IV
- OR immediately
- Give large amounts of chloride IV
- Give 5mmol/kg of KCl IV bolus
- Give ascorbic acid IV
- Give large amounts of chloride IV
Child in poor perfusing SVT (but pulses present but weak). Weight 8kg. HR 300. Electricity choice:
Synchronized cardioversion 4J
Synchronized cardioversion 16J
Unsynchronized cardioversion 4J
Unsynchronized cardioversion 16J
Synchronized cardioversion 4J
From PALS
Synchronized cardioversion: start at 0.5 - 1 j/kg
List 3 clinical signs of increased ICP in an 8 month old baby with vomiting for 5 days.
- decreased level of consciousness
- bulging fontanelle
- hypertension, bradycardia (Cushings)
- Sunset eyes
- CN VI palsy
- Papilledema
Child who is seizing IN hospital with IV access in place list the steps in managing the seizure (be specific)
Manage ABCS – ensure airway is protected
IV Lorazepam 1st line (can repeat dose x 1 within 5 minutes) 0.1mg/kg
Fosphenytoin/Phenytoin 2nd line (usually preferred over Phenobarb because it causes less respiratory depression) - 10-20mg/kg in NS over 20 min
If still seizing after 5 min, give whichever drug not used first
If still seizing at this point - refractory status – need to intubate, call PICU and progress through algorithm – midazolam infusion, thiopental, pentobarbital
A child playing a sports game has a head injury with transient loss of consciousness. What to do:
- Have him do mental tasks. If he succeeds, have him return to game
- Sit out for 1 week
- Sit out for 15 minutes
- Sit out for 1 week
“only after symptom free 7-10 day and fully returned to school can begin medically
supervised return to play”
Which is used to treat a methanol overdose:
a) Fomepazole
b) Physostigmine
c) Acetylcholinesterase
d) Flumazenil - benzos
e) Naloxone
f) Pralidoxime
a) Fomepazole
FOMO about the etoh
Scenario of child head trauma. GCS 6 intubated and ventilated. To CT scan (CT of epidural
hematoma). Posturing and pupil blown in CT scan.
What is the diagnosis?
What next 3 things are in your
immediate management.
Epidural hematoma with raised ICP Mgmt: 1. Head of bed to 30 degrees 2. hyperventilate with 100% O2 3. 3% hypertonic saline IV bolus (5ml/kg) or mannitol 4. Call neurosurgery
Teenage girl listening to music with friends. Develops double vision then coma. Acidotic (wide gap?) glucose 2.5.
Why?
a) Ethanol
b) Insulin overdose
c) Benzos
a) Ethanol
WAGMA - Methanol Uremia DKA Paraldehyde Iron, IEM Lactic acidosis Ethylene glycol Salicylates
The following scenarios can be seen in a child with meningitis. For which one of the following children would you order a head CT?
a) 4 month old with a persistent fever 24 hours after admission
b) Neonate with irritability and hypothermia
c) 5 year old with generalized tonic-clonic seizures on presentation
d) 15 year old with confusion for 24 hours after admission
e) 5 month old with decreased serum sodium 24 hours after admission
d) 15 year old with confusion for 24 hours after admission
Indications for neuroimaging in the setting of confirmed bacterial meningitis:
- Focal neurological signs - increasing head circumference, prolonged obtundation, irritability, or seizure (> 72 hours after start of therapy)
- Persistently positive CSF cultures
- Persistently high CSF neutrophils
- Recurrent meningitis
- GN organisms in an infant
Child submerged in icy water for 6 minutes. On arrival, T28 degrees celsius. Vitals absent. CPR started early. Resusc goes on.
Can they stop resus at 15 minutes?
Why or why not and justify (4 lines given).
No
- resuscitation should continue until patient’s temp 34 degrees
- even if not hypothermic should run resusc for 25-30 minutes
- this patient has some positive prognostic factors (submerged <10 minutes, CPR started early)
Site for needle decompression of suspected pneumothorax
3rd ICS AAL
3rd ICS MCL
5th IC AAL
5th ICS MCL
2nd OR 3rd ICS MCL
3 yo has ingested 6 tablets of older sibling’s SSRI. Mom calls you for advise on what to do. What do you advise? (1 line)
Name 3 side effects of SSRI overdose.
What is the treatment for SSR overdose (1 line).
- take child to ED for assessment
- decreased LOC, tachycardia, QT prolongation
- supportive management, hydration, gastric decontamination, may be a role for benzos and
cyproheptadine depending on severity of ingestion
A 10 months child has frequent vomiting and just vomited up his ORT. He has a dry mouth, but is well perfused. His vitals are stable. Per the current guidelines, what do you do?
a) keep NPO and give IV fluids
b) ondansetron
c) breastfeed
b) ondansetron
CPS statement: ‘Oral ondansetron therapy, as a single dose, should be considered for infants and children age six months and older who present to the ED with vomiting related to suspected acute gastroenteritis, and who have mild to moderate dehydration or who have failed oral rehydration therapy.’
List 3 reasons to image a child with headaches.
- abnormal neuro exam (focal, raised ICP, altered LOC)
- seizures
- recent onset of severe, change in type, or neurological dysfunction
A child was involved in a house fire. He is alert and oriented, with soot coating his nostrils and mouth. He has mild stridor and indrawing.
What is your management?
a) Observe since he is likely to improve
b) arrange for urgent intubation
c) racemic epinephrine
d) parenteral steroids
e) IV antibiotics
b) arrange for urgent intubation
A mother calls you and tells you that her 4 year old has taken 5 tablets of her paroxetine.
A) What advice do you give her
B) Name 3 features of an
C) What is the treatment for this overdose (1 line)?
A) Bring to ED for evaluation (although good side effect profile, and generally safe in overdose)
Citalopram has greatest potential for serious toxicity compared to other SSRIs
B) Hyperthermia, tachycardia, hypertension or hypotension (autonomic instability), vomiting, diarrhea
Agitation, confusion, coma
Dilated pupils, diaphoretic, increased bowel sounds
Neuromuscular hyperexcitability: clonus, rigidity, tremor, hyperreflexia (lower extremities > upper extremities)
C) Benzos, Oxygen, IV Fluids
If temp >41 - sedation, paralysis, intubation
Mom wants to know where her 18 month old daughter acquired perineal warts. You tell her from:
a. perinatal acquisition
b. sexual abuse
c. day care
d. from bathing with her older sister
e. from dad changing diapers
a. perinatal acquisition
Vertical transmission reasonable until 3 years of age and most likely
- could also have come from dad or sister
Neonate with BPD being treated with furosemide. List 4 side effects.
Side effects of Lasix · Ototoxicity · Nephrocalcinosis, hypercalciuria · Electrolyte abnormalities: Hypokalemia, hyponatremia, hypocalcemia · Contraction alkalosis · Dehydration · Cholelithiasis
Kid with AKI and a potassium of 8. Not getting any K supplements.
4 ways to treat hyperkalemia
(doses not required).
- calcium gluconate to stabilize myocardium
- ventolin neb
- insulin (with glucose)
- kayexalate
- bicarb
- lasix
- dialysis
Description of a child holding their arm flexed and pronated. He refuses to move
the arm. There is no history of trauma.
What is the diagnosis?(1 line) What do you do?(2 lines)
Pulled elbow
o Rotation of forearm into supination while applying pressure to radial head OR hyperpronation
16 yo female on surgical ward in traction for femoral fracture and splenic rupture. She develops sudden onset CP, cough and O2 sats 84%.
Give 3 of the most likely causes of the sudden distress.
Give 3 investigations to do to confirm diagnosis.
Pulmonary venous thromboembolism
Pulmonary fat embolism
Pneumothorax
ARDS
- U/S of legs with doppler flow to look for DVT
- d-dimer (good sensitivity, poor specificity)
- Spiral CT with IV contrast
- ECG: S1Q3T3 in PE (deep S wave in lead I, Q wave in lead III, inverted T wave in lead III)
A child is in the ICU with a severe head injury. The social worker thinks that the father inflicted the injuries. What to do.
a) despite accusation of abuse, decision to withdraw care must be made in communication with the parents
b) courts are to decide on withdrawal of care (unless parent’s rights taken away)
c) police must be notified before withdrawal
d) MD can make decision about withdrawal of care
a) despite accusation of abuse, decision to withdraw care must be made in communication with the parents
6 month old with hx of dev delay is brought in to ER and needs resusc . Is now stable. What would you need to help make diagnosis: A) CT scan B) Lactate, carnitine, ammonia C) Serum organic acids D) Urine amino acids
B) Lactate, carnitine, ammonia
Acidopathies and organic acidurias present earlier than 6 months
Dx likely carnitine-acylcarnitine translocase deficiency - fatty acid oxidation defect (show up when kids start to have longer periods of fasting between feeds)
A 4-year-old with CP is involved in an MVA. He has been in the ICU for 1 week with a GCS of 4.
There is no improvement despite aggressive management and mechanical ventilation.
Parents approach you regarding the withdrawal of treatment.
a) if two EEGs done 24 hours apart show isoelectric background, then withdraw
b) do cerebral angiography to document no blood flow to confirm brain death
c) obtain a neurology consult to substantiate brain death
d) discuss the options again with the parents, and if they remain certain about the decision then proceed with withdrawal
Discuss the options again with the parents, and if they remain certain about the
decision then proceed with withdrawal
Notes: 3 components (2 examinations at separate times of 12-24h) o Irreversible coma with known cause o Absence of brainstem reflexes o Apnea
Which fracture is most commonly seen in children? Colles Torus Supracondylar Salter harris #2
Tores
Buckle #
A 10 year old boy is brought in with a history of a severe headache today and progressive decreasing level of consciousness.
In your emergency department he has a GCS of 6. After assessing and stabilizing the ABCs, you perform a CT scan with the following result (tumour in left temporal area). Which of the following is least important in his management:
a. Controlling fever
b. Analgesia and sedation
c. Hyperventilation
d. Hyperosmolar fluid
a. controlling fever
… but this is also important for ICP
?we answered analgesia and sedation b/c we said he was already comatose
Child presents to the emergency room with a traumatic brain injury.
What are 4 factors that can
cause secondary brain injury?
Hypoxia, Hypo/hypercarbia, Hyperthermia, Hypotension,
Hypoglycemia
10 month had private swimming lessons x 45 min. 1 h after lesson is found lethargic and brought to
ER. Has GTC Sz. BP 120/80. RR normal. No external signs of head injury. Lungs are clear.
What is the most likely etiology. E) Chlorine intoxication F) Closed head injury G) Near drowning H) Water intoxication
Water intoxication: rare complication, not clear this is a real thing
What are 5 reasons to perform a CT head after minor head injury in a 5 year old?
CATCH CT Rule
Minor Head injury (GCS 13-15) plus any one of:
High Risk
Worsening HA
Irritibility
GCS <15 at 2 hr post injury
Medium Risk
Skull fracture sings, basal
Dangerous mechanism
Hematoma, large and boggy
GCS =< 14 Signs of basilar skull fracture Signs of AMS ( Agitation, Somnolence, Repetitive questioning or slow to response to verbal communication ) Loss of Consciousness Vomiting Severe HA Severe mechanism (though in the stem they state minor head injury) MVC with pt ejection Death of another passenger Pedestrian or bicyclist w/o helmet struck by motorized vehicle Fall from >5 feet Head struck by high impact object
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. Initial way to assess adequate ventilation:
a) chest motion – capnography – SaO2
b) chest motion – auscultation – SaO2
c) chest motion – auscultation – capnography
d) auscultation – capnography – SaO2
e) auscultation – venous gas – capnography
c) chest motion – auscultation – capnography
Teenager took overdose of Gravol and Tylenol.
List six clinical signs of Gravol overdose.
Anticholinergic presentation
- tachycardia
- dry red skin
- mydriasis
- urinary retention
- hyperthermia
- hallucinations
- decreased bowel sounds
An 8 month old baby presents with an abdominal mass, thrombocytopenia, systolic murmur and a murmur over the liver. Ultrasound shows a 3 cm mass in the liver. What would you do?
a. DIC work-up
b. Bone marrow
c. Pulmonary imaging
d. Liver function tests
a. DIC work-up -
? Kasabach-Merritt syndrome. This is thrombocytopenia and consumptive coagulopathy in the setting of a tufted angioma and kaposiform hemangioendothelioma. These are typically cutaneous, but KHE can be retroperitoneal. Rare reports with liver hemangiomas. Will have low fibrinogen and high D-dimer
Ibuprofen Ingestion - 3 blood tests to perform
ACETAMINOPHEN level
Electrolytes (do anion gap)
VBG or ABG with glucose + lactate
Renal function
Coags
CBC (look at plts)
Child in status asthmaticus who has been given inhaled beta agonists, ipratroprium bromide and iv steroids. Heʼs still in trouble.
What are FOUR other medications that can be tried?
IV Ventolin/epinephrine
Magnesium Sulfate
Heliox
Theophylline
Kid with mixed partial and full thickness burns to 20% BSA. Wt 20kg. Using the parkland formula what would your initial rate of replacement fluids be?
60ml/h
90ml/h
100ml/h
120ml/h
100 ml/hr
Parkland Formula =
4ml RL x weight (kg) x % BSA
Give ½ over first 8 hrs, remaining over 16 hours
Remember it’s 4ml because PARK has 4 letters. First half over 8 hours because PARKLAND is 8 letters.
A teen comes to ER about 1 hour after taking a diazepam overdose. She is awake, but slightly drowsy. The best management option is:
a. charcoal and gastric lavage
b. gastric lavage only
c. ipecac
d. immediate dose of naloxone
e. intubate and then charcoal and gastric lavage
d. immediate dose of naloxone
Naloxone for coingestion (flumazenil is benzo antidote)
Never ipecac, rarely gastric lavage (aspiration risk), AC within first hour
-> we said: intubate then AC and GL… I think this was wrong (too close to >1hr, don’t do GL). Plus for solitary benzo ingestions AC/GL has not shown to be effective (from UpToDate)
What is the appropriate ETT tube size for a 2 year old? (1)
Uncuffed= (2/4) + 4= 4.5
(age in years/4+4)
Cuffed: age/4 + 3.5 = 4
2 diagnostic criteria for ARDS.
- within 1 week of known clinical insult or new or worsening resp symptoms
- bilateral opacity on CXR not explained by effusion, collapse or nodules
- resp failure not explained by cardiac failure or fluid overload
- Oxygenation issues (PaO2/FiO2 less than 300 with PEEP 5 or more)
A teenager is seen in the ER with shortness of breath. He has distended neck veins, hepatomegaly and an S3 and an S4.
What are two abnormalities on this CXR?
What are two possible diagnoses?
- Cardiomegaly and Left pleural effusion ?perivascular markings
Causes heart failure in adolescent - Myocarditis
- Acute hypertension (glomerulonephritis)
- Genetic or metabolic cardiomyopathy
- Thyrotoxicosis
Child gets a tooth knocked out while playing. What are two things to do in your
management?
Management (permanent teeth)
- Find tooth
- Rinse tooth (don’t scrub or touch the root)
- Insert tooth into socket or in cold cows milk/isotonic solution
- Go directly to dentist
- (evaluate for other head/facial trauma)
Kid presenting from a party. Aggressive and punched a wall at the party. Hypertensive, tachycardic, pupils dilated. Comes with bloody nose and blood/cuts on his hand. Asked for management
- Haloperidol
- Lorazepam
- Phentolamine
- Naloxone
- Lorazepam
6 year old Greek girl with RR42, 38.8 degrees, RUQ pain, slight tenderness but no guarding. Abdo U/S normal.
a. First presentation of Familial Mediterranean Fever
b. Pleurodynia (Bornholm’s disease)
c. Bacterial pneumonia
d. Appendicitis
c. Bacterial pneumonia
List 6 clinical signs of early hypovolemic shock in a 3 year old who is dehydrated.
- low urine output
- orthostatic hypotension
- delayed capillary refill
- tachycardia
- dry mucous membranes
- decreased skin turgor
- sunken eyes
- Decreased energy
Child with blunt abdominal trauma, gross hematuria, positive Diagnostic Peritoneal Lavage. What’s
next:
- Abdo CT
- AXR
- Abdo U/S
- Transfuse pRBC
- Insert foley
- Transfuse pRBC… and
5. Insert foley?
Child presents to ER with vomiting, lethargy and is found to be hypoglycemic, hyponatremic, hyperkalemic. He also has 2 small patches of vitelligo on skin.
What condition that you would need to treat are you worried about?
Adrenal insifficiency/addison’s
Babe in shock with Na 131, K 5.9. What is the BEST thing to do right now?
b. NS bolus
List 3 symptoms of hypernatremia.
- polyuria
- increased thirst
- irritability/lethargy
- weakness
- seizures/coma
- nausea
- fever
All of the following are therapeutic measures in TCA overdoses EXCEPT:
a) alkalinization of the urine
b) phenytoin for arrhythmias
c) repeated doses of activated charcoal
d) hemodialysis
e) norepinephrine for hypotension
d) hemodialysis (most correct answer - also do not use in Digoxin or CCB overdose)
UTD also does not recommend phenytoin for arrhythmias, or repeat doses of activated charcoal.
Infant with temp 40C, BP 70/30, HR 160. Diffuse skin erythema. Refractory to 20 cc/kg bolus normal saline X 3. Slightly decreased LOC. Next step?
a. Intubate and Re-bolus
b. Inotropes and re-bolus
c. Ceftriaxone and transfuse PRBC’s
d. Something else and PRBC’s
b. Inotropes and re-bolus
What is the Parkland formula?
IV fluid requirement for the first 24 hours (*add maintenance to the rate you end up with) body weight (kg) x percentage of TBSA burned x 4 - half volume is given in first 8 hours, next half given over next 16 hours
Kid fall from tree, hypotensive, tachycardic, (?pale?) severe left shoulder tip pain, xrays N; diagnosis and next test to do?
Splenic Laceration
FAST U/S
CT would be good if stable
Unless sounds more like Pneumothorax? Do needle decompression
Patient with 10% pneumothorax about to be air transported to hospital. Best treatment of pneumo?
Chest tube
Needle in 2nd intercostal space, mid-clavicular line
Leave pneumo
Only insert chest tube if under tension
Chest tube
How to calculate AG?
Causes of metabolic acidosis with increased?
Cause of metabolic acidosis with normal AG?
Na - Cl - HCO3
WAGMA - Methanol, uremia, DKA, paraldehyde, Iron, Lactic acid, Ethanol, ASA
NAGMA - HARDUP Hypercholoremia Hyperalimentation (TPN) Acetazolamide RTA Diarrhea Uroenteric fistula Pacreaticoduodenal fistula
In an overdose with a tricyclic antidepressant, all of the following would be present
EXCEPT: a) tachycardia b) urinary retention c ) increased bowel sounds d) mydriasis e) seizures
c ) increased bowel sounds
TCA messy drug but has anticholinergic effects (mad as hatter, blind as bad, hot as hell, dry as bone, stuffed as pipe)
4 “medical reasons” why brain dead patient may not be able to be an organ donor.
Contraindications:
- active CMV, Hep B or Hep C infection
- active extracranial malignancy
- severe, untreated systemic sepsis
- AIDS
- viral encephalitis
- risk of rare viral or prion protein illness like Creutzfeld-Jakob
- active West Nile virus or rabies
- active disseminated TB
- Prematurity <32 weeks
