Acute Care Flashcards
1
Q
1. Which of the following is not acceptable for long-term sedation? A. Intermittent lorazepam B. Midazolam infusion C. Propofol infusion D. Fentanyl infusion E. Morphine infusion
A
Propofol infusion
- Short onset <1min + duration 3-10min
- Activates central GABA receptors
- rapidly metabolized by liver, active metabolites renally excreted
- SE: low BP, burning at IV site
uncommon: bradycardia, arrhythmia, sz, myoclonus-like activity, infxn from contaminated vials
Propofol Infusion Syndrome
- high doses >4mg/kg/h + prolonged use >48H
1) Acute refractory bradycardia
2) Cardiac failure
3) Renal failure
4) Hepatomegaly
5) Hyperlipidemia
6) Rhabdomyolysis
7) Severe metabolic acidosis - Stop propofol + supportive care
2
Q
3 yo girl with history of URTI presents with stridor. Vitals normal and stridor present when crying. What is the best management?
a. Single dose of oral steroid
b. Racemic epinephrine
c. Nebulized steroids
d. Humidified oxygen
A
Single dose of oral steroid
Improvement in 2-3H, persists for 24-48H
For croup
a) Mild (w/o stridor or substantial indrawing): PO dex 0.6mg/kg
b) Mod (stridor or indrawing at rest w/o agitation): PO dex 0.6mg/kg, observe for 4H
c) Severe (stridor and sternal indrawing, assoc’d with agitation or lethargy): blow-by O2, neb epi, PO dex 0.6mg/kg, can repeat once
Admit to hospital if:
- rec’d steroids 4H ago and has
1) cont’d resp distress (w/o agitation or lethargy)
2) stridor at rest
3) chest wall indrawing
If recurrent severe episodes of agitation or lethargy, contact PICU
3
Q
4. Child presents in respiratory distress a few days after URTI with cough, tachypnea and fever. White out lung on CXR. What is your next test? A. Lateral decubitus x-ray B. Chest ultrasound C. Chest CT D. Diagnostic thoracentesis
A
Chest ultrasound
4
Q
- 14yo M with vesicular, very pruritic rash and work of breathing, tachypnea. Most likely cause:
A. Myocarditis
B. Pneumothorax
C. Varicella pneumonia
A
Varicella pneumonia
Usually 1-6d after onset of rash
CXR: multiple nodules (5-10mm)
Tx: 7d of acyclovir
5
Q
- 3 week old baby admitted with RSV proven bronchiolitis. Two days into his hospitalization he develops a fever to 39C. There is no change in his physical exam. He has been requiring 0.5L O2 since admission and remains tachypneic. A CXR is done after the fever and shows a small RML infiltrate. What is your management?
a) supportive care
b) amp gent
c) Ceftriaxone
d) Racemic Epi
A
Supportive care
More likely to be atelectasis. Less likely to be pneumonia if no change in O2 needs or exam.
6
Q
- Kid with stridor a few times this week and now drooling, fever, stridor. What to do
a) Lateral XR
b) Call ENT
c) Neb of epinephrine
A
Call ENT
If stable -> lateral neck
If unwell/unstable airway -> call ENT/plan for intubation
CPS: ENT for a/w evaluation if persistently severe despite Tx
Airway visualization with the intention of intubation should be promptly performed if the underlying cause of stridor in an acutely ill child is thought to be epiglottitis or bacterial tracheitis or highly likely foreign body → should be done by experienced clinicians
7
Q
- Asthmatic presents with history of increased cough and is in severe respiratory distress. Ventolin, ipratropium bromide and steroids have all been attempted with no improvement. What do you do next?
a. Give MgSO4
b. Intubate & ventilate
A
Give MgSO4
8
Q
- Baby in respiratory distress. RR12 and severe indrawing. Lots of wheeze on auscultation. What to do next
a. Bag and mask ventilation
b. Salbutamol inhalation
A
BMV
That RR is worrisome
9
Q
- Teen with tension pneumothorax, where do you put the needle?
a. needle over 3rd rib, in the second intercostal space at the midclavicular line
b. needle over 5th rib, in the fourth intercostal space midclavicular line
c. needle in 2nd IC space, anterior axillary line
- ———— - Site for needle decompression of suspected pneumothorax
a. 3rd ICS AAL
b. 3rd ICS MCL
c. 5th IC AAL
d. 5th ICS MCL
A
Needle in 2nd ICS, midclavicular line
OR
5th intercostal space, anterior axilliary line
Above the rib
10
Q
- Baby with severe bronchiolitis, wheezing, severe retractions, lethargy. HR 160, RR 12, Sats 82% what is the next step.
a. Give racemic epi
b. Give salbutamol
c. Give steroids
d. Bag-mask ventilation
A
BMV b/c of impeding respiratory failure
Needs O2!
11
Q
- You have a child with asthma and a pneumothorax that you are about to transport. What is appropriate management prior to transport?
a. Chest tube only if >10% pneumothorax
b. Chest tube in affected side
c. Needle thoracotomy in 2nd interspace on affected side
d. Chest tube if symptomatic
————–
You are called about an asthmatic with a unilateral pneumothorax. In arranging medical air transport to your intensive care unit, you suggest:
a. insert a chest tube on the affected side
b. insert a chest tube if the pneumothorax is greater than 10%
c. insert a needle into the 2nd intercostals space, midclavicular line
d. transfer without intervention
A
Chest tub in affected side
During transport, increased altitude, atmospheric pressure decreases, so gases expand
Need to decompress PTX with needle decompression or chest tube and NG placed for ileus
12
Q
- Child with severe stridor. There is no improvement with 2 rounds of racemic epinephrine and dexamethasone. What should be done next?
a. Heliox
b. Intubate
c. Humidified air
A
Intubate
13
Q
- A child presents to the emergency room with shortness of breath and wheezing. This occurred suddenly after playing with older sibling. What should be the next management step after a CXR?
a. Broncoscopy
b. Ventolin via nebulizer
c. Racemic epinephrine
A
Bronchoscopy for FB
14
Q
15. Kid with a tracheostomy desaturates and is cyanotic. The nurse has tried to suction without improvement. What do you do next? A. Intubate B. Provide 100% oxygen C. Change tracheostomy D. Try suction the tracheostomy yourself ------------- 84. Child with tracheostomy becoming blue and in respiratory distress. Nurse suctions with no improvement. You do: a. change trach b. attempt intubation
A
Change trach
15
Q
3. A boy put his finger in an electrical socket and has the rhythm below. He’s in Emerg receiving CPR and sats are 100%. What’s the next step? (looks like VF a) Intubate b) IV/IO epinephrine c) Synch 1J/kg d) Defibrilate 2J/kg
A
Defibrillate 2J/kg for VF
16
Q
- 14y boy has a witnessed collapse on the basketball court. He is pulseless. What is the next immediate step in management? [cps]
a. Defibrillate
b. Start CPR
c. Administer an EpiPen IM
d. Start artificial ventilation
A
Start CPR
17
Q
Child with PEA in an outside hospital, now with wide complex QRS, tachycardia, shocked x 1 in ER, still wide complex tachycardia. CPR ongoing. Next step: a. defib 2J/kg b. defib 4J/kg c. Epi 0.1 ml/kg d. Amiodarone --------------- 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 2 J/kg b. shock 4 J/kg c. epinephrine 1:10000, 0.1 cc/kg d. lidocaine
A
Defib 4J/kg
Second shock for Vtach
18
Q
- 10 y.o boy with URTI x 10 days, presents to ER looking unwell. On exam, petechial rash, Gr 2/6 murmur with gallop. What is the most likely diagnosis.
a. viral myocarditis?
b. acute rheumatic fever (rash is erythema marginatum)
c. SLE (malar or discoid rash, photosensitivity skin changes)
d. SBE (Osler’s nodes)
————–
7 y with viral URTI 2 weeks ago. Now presents in CHF and a maculopapular rash. What is the most likely diagnosis?
a. Viral myocarditis?
b. Acute rheumatic fever
c. Subacute bacterial endocarditis
A
Viral myocarditis
Murmur with gallop suggests CHF
CHF is unlikely for ARF
Rash
- ARF = erythema marginatum
- SLE = malar + discoid rashes
- SBE = Osler node, Janeway lesions, splinter hemorrhages
Most common pathogens for viral myocarditis:
- enteroviruses e.g. coxsackie
- influenza
- adeno
- EBV/CMV
- parvo
Presentation
- fever, tachycardia, hypotension, gallop rhythm, murmur, resp distress
- acute or chronic heart failure or chest pain
- if decompensated heart failure, then hepatomegaly, peripheral edema, wheeze + rales
Diagnosis
- Cardiac MRI is standard for Dx!
- ECG + ECHO: non-specific
Supportive care
- Inotropes (esp milrinone), use but with caution
- Diuretics
- IVIG + steroids are controversial
19
Q
- 11 month-old infant with ECG showing some electrical activity but no pulses on exam. What do you give?
a. Epi 1 mL of 1:1000
b. Epi 1 mL of 1:10000
c. Atropine
————-
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
————– - 11 month old with PEA, how do you treat? (No weight given, you have to estimate on your own)
a. Atropine
b. Epinephrine IV 1 mL 1:10,000
c. Epinephrine IV 1 mL 1:1000
d. Epinephrine ETT 1mL 1:10,000
—————
1 year old is in septic shock, he weighs 9 kg. You assess him and find that he is hypotensive and extremities are shut down and not responsive. Cardiac monitor shows sinus rhythm but when you assess his pulses, you cannot feel them. What do you give him?
a. Atropine
b. Epinephrine 1/1000 , 1ml
c. Epinephrine 1/10,000, 1 ml
A
Epi 1 mL in 10,000 IV
Epi 0.01mg/kg (0.1mL/kg of 0.1mg/mL (previously 1:10,000)) Q3-5min
20
Q
3. A 5 y.o boy is hurt in a MVA. At the scene, EMS note that he does not open his eyes, moans incomprehensibly, and extends his arms to painful stimuli. Vitals: HR 110 RR 14 BP 120/85. He has a c-spine collar in place. What should be your next step? A. Give mannitol B. Hyperventilate C. Intubate D. Urgent CT head ------------------- 83. Kid in an MVC. On scene no verbal response, extensor posturing to deep pain, moaning incomprehensibly to pain. On arrival in ED HR 95, bp 130/75, RR 14. Pupils are 4 bilaterally and reactive. Best initial management: a. Arrange for urgent CT b. BMV c. IV Mannitol d. Rapid sequence intubation ------------------ 29. 3 yo trauma patient with depressed skull fracture is unstable with desaturation and hypotension. What is your next management step? a. urgent CT b. intubate c. give mannitol
A
Intubate
E1, V2, M2 = 5
No signs of increased ICP
21
Q
- A child is involved in an MVC. He was sitting in the back seat with a seat belt on at the time. He now presents with ecchymosis around the area of the lap belt. He has not voided since the accident and can’t move his legs. What is the most likely diagnosis?
a. Kidney rupture
b. Fracture of L1-L2
c. Bleeding into his spine
c. Pelvic fracture
—————– - Child in MVC. No booster seat, wearing lap belt. No urine output, not moving lower limbs. Cause?
a. Chance # L1-L2
b. intraspinal hemorrhage
c. urethral injury
—————-
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?
a. Intraspinal bleed
b. Chance fracture at L1-L2
c. Bladder rupture
d. Pelvis fracture
A
Fracture of L1-L2
Seat belt syndrome
Classic triad
1) abdo wall bruising
2) internal abdo injury - high risk for duodenal perf, mesenteric disruption, pancreatic, bladder injuries for compression
3) spinal # - compression # of L1L2 is most common (Chance #)
22
Q
16. A 4 year old girl is seen in the emergency department after a motor vehicle collision. She is diagnosed with splenic rupture, and receives a large volume transfusion of packed red blood cells. Which is the most likely to occur as a result? A) Peaked T waves on ECG B) Decreased urine output C) Hypotension D) Seizure
A
Peak T waves on ECG
Massive transfusion defined as
- transfusion of >50% of total blood volume w/in 3H
- > 100% of total blood volume in 24H
- transfusion to replace ongoing blood loss of >10% of total blood volume per min
SE
- Dilutional coagulopathy if only getting pRBCs
- Hyperkalemia
- Hypocalcemia +/ hypoglycemia due to infused citrate in preservative
- Hypothermia
23
Q
17. 4yr old boy victim of MVC. At the scene, wouldn’t open eyes, moans incomprehensibly, flexes legs with painful stimuli. What is his GCS? 5 6 7 8
A
E1V2M3 = 6
DeCORticate
- damage to corticospinal tract
Decerebrate
- damage to upper brain stem (midbrain or pons)
24
Q
- Alcohol-related MVC. Police wants a blood EtOH level. you
a. give it
b. ask for warrant
c. call CMPA
d. wait for patient to wake up for consent
———————
Teenager driving and hit a pedestrian. You are treating the teen driver who smells like alcohol. Police ask you for the blood alcohol level result on your patient. What do you do?
a. Give police the result
b. Call CMPA
c. Wait for patient to wake up and ask him
d. Refuse unless police produces a warrant/court order
A
Ask for warrant
25
85. 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
rhabdomyolysis
Elevated CK
Proximal muscle pain
Myoglobinuria
26
115. Boy post MVA with multiple injuries, initially very hypotensive (50/20) but recovered with multiple boluses of Ringer’s lactate. Now creatinine markedly increased, passed 5L of urine, and urine positive for blood. What is the cause?
a. Fat embolus
b. Renal vein thrombosis
c. Diabetes insipidus
d. High output acute renal failure
AKI - ATN
```
Fat embolus:
- fat globules in pulm circulation
- long bone orthopedia truma
classic triad
1) hypoxemia, 2) neuro abN, 3) petechial rash
```
Renal vein thrombosis
- hematuria, proteinuria, anuria, hypovoemia, vomiting, thrombocytopenia
- nephrotic syndrome + renal transplant
DI
- polyuria, polydipsia, nocturia, high sodium
27
8. Child with concussion. When can she return to play?
a) Back at school full time with no symptoms and no accommodations
b) After symptom free for 7 days
Back at school full time with no Sx and no accommodations
28
56. Trauma head injury question GCS 7, what is most likely to cause secondary injury on transport?
a. Hypoxia
b. Hypotension
c. Hypercarbia
---------------------
89. 7 year old with closed head injury to be transported. What is most likely to occur on transport that will affect long term prognosis
a. hypoxia
b. hypercarbia
c. hyperglycemia
d. hypotension
-----------------
A 15 year old child is being transferred to your centre after an MVC in which he sustained a closed head injury. Which of the following is likely to occur on transport and will cause significant sequelae?
a. Hypoxia
b. Hypercarbia
c. Hypoglycemia
d. Hypotension
--------------------
121. A 3 y.o. with a severe head injury is being prepared for transport to hospital. What would most likely occur during transport that would be most damaging to this child?
a. hypoxia
b. hypotension
c. hypoglycemia
----------
Closed head injury - which would likely occur during transport and cause the most brain damage?
a. hypoxia
b. hypercarbia
c. hypoglycemia
d. hypotension
Hypotension
29
77. Child brought by EMS with severe head injury with HR 95, RR 14, BP 95/70 and is not responsive to name. Not opening eyes. He does have extensor posturing to pain. Pupils are 4mm and equally reactive. Next step is:
a. Hyperventilation
b. Mannitol
c. Intubate
d. CT head
Intubate
E1V<5M2 = 8 at the highest
No Cushing's triad
30
96. 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.
a. Hyperventilation
b. Mannitol
c. CT head
Hyperventilate
| HTN, lower HR.
31
119. Which of the following would do the LEAST in child with severe head injury (might have also been seizing)?
a. Control fever
b. Hyperventilate
c. Sedate and analgesia
d. Mannitol
--------------
Kid with excruciating headache this morning. Collapsed in the ER. CT shows big goober in L hemisphere with midline shift. Which of the following would be least helpful in management:
a. analgesia & sedation
b. hyperventilation
c. Mannitol
Mannitol
32
119. Child presents to ED with decreased level of consciousness, starts to posture decerebrate but then quickly progresses to decorticate posturing. What should you do?
a. Mannitol
b. CT scan
c. Phenytoin
--------------
6 y o with severe headache collapses and has progressive posturing. After intubation, what would you do?
a. mannitol IV
b. urgent CT scan
Urgent CT scan
Decorticate to decerebrate posturing is often indicative of uncal (transtentorial) or tonsillar brain herniation
33
119. Child presents to ED with decreased level of consciousness, starts to posture decerebrate but then quickly progresses to decorticate posturing. What should you do?
a. Mannitol
b. CT scan
c. Phenytoin
--------------
6 y o with severe headache collapses and has progressive posturing. After intubation, what would you do?
a. mannitol IV
b. urgent CT scan
Urgent CT scan
Decorticate to decerebrate posturing is often indicative of uncal (transtentorial) or tonsillar brain herniation
34
```
5. Toddler with dehydration. 12 kg. Irritable, no tears. What is your management?
1200 cc ORT over 4 hours
600 cc ORT over 4 hours
IV fluids
----------------
51. Dry mucous membrane, irritable, no tears, 12kg [CPS]
a. 1200 cc over 4h
b. 600 cc over 4h
```
1200cc ORT over 4H
For all dehydration
- replace ongoing losses with ORS
- age appropriate diet after rehydration
```
Mild dehydration (<5%):
- ORS 50mL/kg over 4H
```
```
Moderate dehydration (5-10%)
- ORS 100mL/kg over 4H
```
Severe dehydration (>10%)
- IV NS or RL 20-40mL/kg for 1H
- Reassess and repeat if necessary
- ORS once stable
Rehydration + replace ongoing losses + maintenance
35
35. Ondansetron is proven effective in
a) 6mo-12yr moderate dehydration
b) 3mo-12yr old with moderate dehydration
c) 3m-12y with severe dehydration
d) 6m-12y with severe dehydration
6mo-12y with moderate dehydration
Ondasetron
- 5HT3 receptor antagonist
- PO peak 1-2H
- SE: diarrhea (mild + self-limiting)
- single dose PO ondans reduces freq of vomiting + IVF admin to 6mo-12yo who present to ED with mild-mod dehydratin who have failed trial of ORT
- GIve ORT 15-30min after ondans
36
11. 4 year old girl presents to emerg with 48 hour history of vomiting and diarrhea. She can’t keep water down, and she just vomited her ORT. Her HR is 95 with BP 100/65. Normal cap refill, alert. Her tongue is dry. What’s the best course of action?
a) Oral ondansetron
b) D5 NS with 20KCL at maintenance
c) IV metoclopramide
d) PO Gravol
Oral ondansetron
37
54. Child with gastroenteritis, develops thirst and poor skin turgor. He has normal vital signs. What type of rehydration in would you provide?
a. 300 cc/kg over 4h
b. NS bolus 20cc/kg
-------------
80. Child with 24 hours of diarrhea and vomiting, moderately dehydrated. How to rehydrate
a. 100 cc/kg ORT over 4 hours
b. 60 cc q5 min x 24 hours
c. IV NS
d. IV D5/45 + K
------------
66. Oral rehydration in kid with mod dehydration
a. 100cc/kg over 4h
b. 50cc/kg over 4h
c. NS bolus 20cc/kg
--------------
13 kg child with gastroenteritis, with K 2.5, Na 138. Physical findings… management?
a. 300 ml/hr ORS over 4 hrs
b. give D5 ½ NS
Moderate dehydration
100mL/kg over 4H
If 13kg = 1300mL over 4H = 325mL/hr
38
Child with gastroenteritis, decreased skin turgor, sunken eyes. K = 2.9, pH = 7.33, HCO3 = 13, BE -7. Vitals are normal. What do you give?
a. ORF 100ml/kg
b. ORF 5cc q5min
c. NS bolus 20cc/kg
- ------------
112. 5 yo Kid with gastro now mod dehydration. VS normal. K+ 2.9, HCO3 12, pH 7.3. what next step?
a. ORS 300cc/h x 4 h
b. ORS 5 cc/hr x 24 h
c. IVF D5 ½ NS
d. IVF NS bolus
- ------------
79. Kid with fatigue, 13 kg, decreased skin turgor, delayed cap refill but normal vital signs. Vomiting and diarrhea for 3 days. pH 7.33, pCO2 27, Bicarb 14, BE-9.7. Next step:
a. IV bolus NS 20cc/kg
b. IV bolus Ringer’s 10cc/kg
c. ORS 300cc/hr for 4 hours
d. ORS 5cc/hr over 24 hours
- ------------
81. 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
ORS 100mL/kg in 4H
13kg x 100mL/kg = 1300mL over 4H = 325mL/hr
15kg x100mL/kg = 1500mL over 4H = 375mL/hr
39
97. What is the best early indicator of mild dehydration?
a. Tachycardia
b. Capillary refill of 4-5 seconds
c. Hypotension
Tachycardia
40
122. Little kid with 3 days of diarrhea. Today, urine output less. In ER, tachycardic, poor skin turgor, BP OK. How to manage:
a. oral rehydration
b. IV hydration
c. Antibiotics
d. Kayopectate
------------
A toddler presents with diarrhea and moderate dehydration (tachycardia, normal BP, low skin turger, etc.). What management is appropriate?
a. give IV fluids now
b. rehydrate with oral rehydration solution
Oral rehydration
41
6. A kid has been seizing for 30 minutes, HR 220, breathing difficult to assess but SPO2 93%, glucose 4.2.
a. RSI
b. insert IO
c. insert IV
d. intranasal midazolam
-----------
9.Seizure of 30 min arrives in ER. What first?
intubate
IN midaz
IV access
IO access
----------
29. Kid seizing for 30 minutes, No IV, glucose 3.6.
a) intranasal midazolam
b) insert IO
c) Rectal VPA
----------
75. Child comes in status epilepticus. HR is 130, RR – difficult to determine, BP 110/70. You put oxygen on the child and the nurses cannot get an IV. Your next step is:
a. Insert an IO
b. Give rectal valproic acid
c. Give intranasal midazolam
d. IM dilantin
---------------
62. Seizing child, decreased LOC. Best treatment?
a. intranasal midaz
b. iv valproic acid
c. iv phenytoin
d. Intubate
Intranasal midazolam
Midazolam
- 0.2mg/kg IN/IM (1st line w/o IV access)
- 0.5mg/kg buccal
Lorazepam (1st line w IV access)
0.1mg/kg IV, IO, buccal PR
Fosphenytoin 20mg/kg IV/IM
Phenytoin 20mg/kg IV
Phenobarbital 20mg/kg
42
45. Describes 14y girl presents after a 15min seizure and is no longer seizing now. Her BP 190/100; edematous, but Cr ok. Neurologic exam is normal now. WBC 3.0 with 2% lymphocytes, Hgb 88, plts 130. Urine has large proteinuria. What to give immediately?
a. Methylpred
b. SL nifedipine
c. IVIG
d. Phenytoin IV
SL nifedipine
SLE: CNS involvement, cytopenias, lupus nephritis (characterized by proteinuria) in teenage girl. Technically needs one more criteria
43
64. Febrile 3 yo, seizing for 30 minutes. HR 180, RR 60, BP stable. Failed IV access. Next?
a. intubate
b. intranasal midazolam
c. IO
d. Rectal valproic acid
----------------
Seizing child with HR 200, BP 150/80, RR 40, afebrile. Unable to get IV access. What do you do?
a. Intranasal midazolam
b. Intubate
----------------
98. 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:
a. Sodium nitroprusside
b. Rectal benzodiazepine
c. Intubate
d. IM dilantin
Intranasal midazolam
44
107. 9 month-old baby with symptoms of gastroenteritis x 3 days, comes to ER and has a seizure. HR 180, BP 70/55. Labs listed – only abnormal value was Na 115. Choose your initial fluid.
a. 3% normal saline to increase Na by 2 mmol/L q2h
b. Normal saline
c. D5W 0.45 NS
d. D10W
--------------------
10 m with hyponatremic seizure
a. 3% NS to raise 2mmol/h
b. D51/2 NS at 20cc/kg/hr
c. NS bolus
d. Phenobarb 15 mg/kg
--------------------
126. 8 month old child presents with seizures. He is dehydrated and his sodium is 121. What do use for treatment?
a. Ativan
b. 3% Saline
3% NS to treat acute hyponatremic Sz
Then start isotonic fluids for gradual normalizations of Na + ongoing GI losses
45
118. Child presents with seizure x 30 minutes, HR 200’s, BP high, O2 given by face mask and airway patent, respirations “difficult to assess”, what is the next appropriate management?
a. Phenytoin intraosseous
b. Rectal benzodiazepine
c. Intubate
Rectal benzodiazepine
46
10. Teenager with hypertension, hyperthermia, tachycardia. Parents suspect drugs. Which drug would explain his presentation.
a) cocaine.
b) LSD
c) marijuana
Cocaine
Hyperthermia:
- Sympathomimetics
- Anticholinergics
LSD has sympathomimetic effects that are generally more mild
47
37. A teen was agitated, hypertensive, dry, flushed, mydriasis. Cause?
a) Cocaine
b) PCP
c) LSD
d) Marijuana
PCP - NYSTAGMUS
```
Mad as a hare
Dry as a bat
Red as a beet
Blind as a bat
= Anticholinergic
```
```
Cocaine + LSD = sympathomimetic
- Mydriasis
- Agitation
- Tachycardia
- Hypertension, hyperthermia
- Sweating, sz
Would be wet rather than dry
```
48
12. Kid 4 yo comes in with torticollis and rigidity. Mom says she has been giving enema for illness for past several days but doesn’t know what it is. Which medication will you give immediately?
a) Diphenhydramine
b) Diazepam
Fleet enema, contains phosphate, leading to hypocalcemia
Should give calcium
Metoclopramide PR can lead to acute dystonic reaction (trismus, torticollis, facial spasms), treat with anticholinergic like benztropine or diphenhydramine
49
```
14. An adolescent girl takes 7g. of Acetaminophen (Tylenol) at 5:30pm and gets to the Emergency Department at 6pm. At what time should acetaminophen levels be drawn?
A. Immediately
B. 7:30pm
C. 8:30pm
D. 9:30pm
```
4h after = 9:30PM
50
19. A 16 year old girl arrives in the ER unconscious, she is dry and hyperthermic, her pupils are large. Which of the following could be the cause of her presentation?
a) Cocaine
b) Ecstasy
c) Amitriptyline
```
Dry as a bone
Hot as a hare
Blind as a bat
Most likely anticholinergic
= amitryptyline
```
51
20. A 2 year old boy ingested 10-20 of his mother’s iron pills. At home, he had nausea + vomiting, but now he is asymptomatic. At 6 hours post ingestion, his serum iron level is normal and his liver enzymes are normal. AXR is “normal”. What is the appropriate management at this point?
a) Gastric lavage
b) Deferoxamine
c) Whole bowel irrigation
d) Admit for observation of late stages of iron toxicity
Admit for observation of late stage of iron toxicity
If no significant Sx of iron toxicity at 6h, unlikely to have severe toxicity. However, he had nausea + vomiting, so should be monitored
52
33. Iron overdose, on dexoferoxime already. Is now at 1hr post ingestion...what is the next step?
a) Endoscopy
b) Charcoal
c) WBI (whole bowel irrigation)
d) Ipecac
Whole bowel irrigation (if there are radiopaque pills on stomach)
53
21. A 12 year old girl has not been responding to her mother for the last few hours. In the ER she is non-responsive; in response to painful stimuli, she rolls over and continues “sleeping”. Her muscle tone, vital signs, and pupils are all normal. Which of the following is most likely?
a) Ischemic stroke
b) Confusional migraine
c) Poisoning
d) seizure
Poisoning
Likely sedative hypnotic
No description of sz. Post-ictal period:
- usually manifests as confusion + suppressed alertness
- can have focal neuro deficits that reflect type + location of sz (e.g. Todd paresis = postictal paresis: aphasia, hemanopsia, numbness)
- lasts from sec to hours
- most recover responsiveness + alertness within 10-20 min of generalized sz. Gradual + consistent improvement with time
Ischemic stroke
- would expect changes in tone + pupils
Confusional migraine
- H/A typical of migraine
- PLUS agitation, disorientation, aphasia that last longer than H/A
- Duration of confusion 2-24H
54
36. A child was found with Anti-cholinergic symptoms cause?
a) Benadryl
b) Cocaine
c) PCP
Benadryl (antihistamine)
55
42. Kid took bottle of camphor. What do you see on CXR?
a. Pneumatocele
b. Hyperinflation
c. Cardiomegaly
d. Tracheal-bronchial narrowing
Pneumatocele
Camphor = hydrocarbon
Vicks inhaler, tiger balm
- early onset of Sx (5-15min post ingestion)
- oxidized + conjugated by the liver, renally excreted
- Sx typically resolve within 24H
- aspiration leading to pneumonitits are most dangerous consequence of acute hydrocarbon ingestion
- oropharyngeal irritation, N/V, abdo pain, sz
- transient mild CNS depression
IVx
- Can detect camphor in blood + urine, but not useful
- leukocytosis, proteinuria, transient transaminitis
- ECG
- CXR: lung changes within 2-8H, peak in 48-72h. Pneumatoceles + pleural effusions can occur 2-3wks after
Tx
- No gastric emptying (risk of aspiration worse than risk of systemic toxicity)
- No activated charcoal (hydrocarbon absorbed too quickly for it to be effective)
- ASx or mild oropharyngeal irritation/GI irritation observe minimum 4H
- If Sz (highest risk in first 2H0, give benzo
56
44. Tylenol overdose at 8h. What do you see on lab work?
a. pH – 7.21
b. pH – 7.58
c. pH – 7.38, PO2 60
d. pH – 7.38, PO2 90
7.38, PO2 90
Metabolic acidosis
Normal O2
57
57. Symptoms of ASA overdose.
a. Hyperpyrexia
b. Renal failure
c. Metabolic alkalosis
d. Elevated K+
```
Hyperpyrexia
Diaphoresis
Increased RR*
Tinnitus*
Sz
```
Resp alkalosis (from hyperventilation)
AG Metabolic acidosis (d/t accumulation of lactic acid + ketoacid)
Hypokalemia
Hyperglycemia (early on) then hypoglycemia (later on)
Renal failure is rare, but indication for dialysis
Activated charcoal
NaHCo3 to alkalinize urine
Give dextrose
IVF
Check for acetaminophen co-ingestion!
58
61. Treatment of methanol overdose
| a. fomepizole
Fomepizole
Methanol
- 2 step metabolism into formic acid (toxic metabolite)
- lethal dose 1g/kg
- AG met acidosis with OG>10
- OCULAR TOXICITY
- Afferent pupillary defect = ominous sedation
Tx
- ABCs
- Fomepizole: inhibits hepatic oxidation, so elimination shifts to pulmonary + renal routes
- NaHCO3
- Folic acid co-factor
- Hemodialysis if acidemia or visual changes (methanol) or renal failure (ethylene glycol)
Note: ethylene glycol issue is renal failure
Note: isopropyl alcohol hallmark is ketosis without acidosis, no osmolar gap
59
71. 3yr old with miosis and seizure. Which toxin did he ingest?
a. insecticide
b. Cocaine
c. beta blocker
----------------
Child presents with generalized tonic seizure x 10 minutes, and miosis. Which toxic ingestion is most likely?
a. beta blocker
b. cocaine
c. nicotine
d. Insecticide
```
Insecticide
Cholinergic
D - diarrhea
U - urination
M - miosis
B - bronchorrhea, bronchospasm
B - bradycardia
E - emesis
L - lacrimation
L - lethargy
S - salivation
```
Nicotine is also cholinergic, but unlikely to be that much
Cocaine is restricted pupils
60
73. 5 yo child accidentally took some of dad’s imipramine, unknown amount. QRS 130ms. What do you do?
a. activated charcoal
b. sodium bicarbonate
-----------
82. Kid with a suspected overdose of amytriptiline. Treatment?
a. sodium bicarb IV
b. ?phenobarb
c. ?IV bolus
d. ?observe
---------------
Teenager overdosed on imipramine. Presents with decreased LOC. What do you do?
a. give phenytoin
b. sodium bicarbonate
c. activated charcoal
--------------
93. 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
-----------------
A child ingested his grandmother’s amitryptilline pills. He is alert and otherwise stable.
His ECG shows a QRS of 130ms. Which of the following is the most important step?
a. Charcoal
b. Physostigmine
c. Sodium bicarbonate
d. Dilantin
TCA - NaCO3 b/c QRS >100
Wouldn't give activated charcoal to the decreased LOC or drowsy kids
61
100. 13 year old male taken to ER by paramedics with increased HR, normal BP and flailing arms and legs non-sensibly, pupils dilated. What intervention would you give?
a. Symptomatic management
b. Naloxone
c. Atropine
d. Flumazenil
- -----------------
101. 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
Symptomatic management
Dilated pupils
Sympathomimetics
Anticholinergics
Increased HR in both
Flailing arms + legs suggests NM excitation, which is more likely sympathomimetic
- Naloxone for opioids: Expect miosis (constricted pupils), sedation, decreased HR
- Atropine for cholinergics: Expect DUMBBELLS. Bradycardia. Constricted pupils.
- Flumazenil for BZDP = sedative hypnotics: normal/decreased HR, constricted pupils, sedation
62
113. Teenage boy previously well presents to your ER with GCS 11, responds to voice with flailing of arms and inappropriate speech. Dilated pupils, flushed skin, HR 148, BP 108/64. Which of the following substances is most likely culprit?
a. Opiates
b. Imipramine
c. Ethanol
d. Jimson Weed
----------------
Teen with dilated pupils, altered LOC, N HR, N BP, flushed face. Ingested what?
a. Jimsen weed
b. TCA
c. Ethanol
d. Marijuana
----------------
A 13-year old boy presents with his parents in an obtunded state. His GCS is 9, he is rousable to stimulation but flails his arms and acts very inappropriately. His is flushed, tachycardic and his pupils are very dilated. What toxin was he most likely to have ingested?
a. imipramine
b. jimson weed
c. alcohol
d. Morphine
Jimson weed = anticholinergic
Dilated pupils + tachycardia
- sympathomimetics
- anticholinergic
Opiates: expect constricted pupils, sedation, resp depression, bradycardia
Imipramine = TCA = anticholinergic. TCA would expect hypotension (fluid refractory)
Ethanol = sedative hypnotic = constricted pupils, normal HR, sedation
63
125. A child ingests some paint thinner which is a hydrocarbon. What should you do in the emergency department?
a. Gastric lavage
b. Activated charcoal
c. Observe and treat supportively
d. Discharge home
Observe + treat supportively
Gastric lavage + activated charcoal is not helpful b/c hydrocarbons are quickly absorbed in the gut
Watch for later effects
64
23. 6 year old child collapses in the periphery. CPR is initiated and one shock is given with an AED for a wide complex rhythm with no pulse. CPR is continued. The child arrives in your ER with an IV, intubated, without a pulse, rhythm now showing VT. What is your next step?
a) Defibrillate 4J/kg
b) Give Epinephrine 1:10,000 0.1 ml/kg IV
c) Defibrillate 2J/kg
d) Continue CPR
Defibrillate 4J/kg
1. CPR, give O2, attach monitor/defibrillator
2. If rhythm shockable, first shock defibrillate 2J/kg
3. CPR 2min. Get IV/IO access
4. If still shockable, second shock defibrillate 4J/kg
5. CPR 2min. Epi 0.01mg/kg (0.1mL/kg of 0.1mg/mL concentration) IV/IO Q3-5min. Consider advanced airway
6. If still shockable, then defibrillate >=4 J/kg to max 10J/kg
7. CPR 2min.
8. For shock-refractory VF or pVT: lidocaine IO/IV 1mg/kg loading dose, then 20-50 mcg/kg/min (repeat bolus dose if infusion initiated >15min after initial bolus therapy) OR amiodarone IO/IV 5mg/kg may repeat up to 2 times
9. Treat H&Ts
65
26. An early sign of shock in a child is:
a) Delayed cap refill
b) Increased HR
c) Low BP
Increased HR
66
62. A 14 year old boy was found unresponsive in a park the morning after the overnight temperature dropped to -3°C. He has been receiving resuscitation in the ER for 30 minutes. Which of the following would be an indication to stop the resuscitation?
a. Rectal temperature of 30°C
b. Barbiturates found on toxicology screen
c. Refractory ventricular fibrillation
d. Electromechanical dissociation
---------------
Teenager found in the park. Outside temperature -3 degrees. CPR is provided. What would suggest to you that you can discontinue resuscitation?
a. benzo found in urine
b. electromechanical dissociation
c. refractory ventricular fibrillation
d. Rectal temp <30oC
---------------
50. Kid with hypothermia. When would you stop resuscitation?
a. Electromechanical dissociation
Electromechanical dissociation
- Electromechanical dissociation = PEA can be seen commonly in hypothermia, though more commonly see VF and asystole
- Benzos in urine: often hypothermia is preceded by other disorders (e.g. drug overdose, alcohol use, or trauma). Should look for and treat these underlying conditions simultaneously with hypothermia Tx
- Rewarm to T32-34. Rectal temp can often lag behind central temperature measurements. If pt fails to rewarm, use more aggressive rewarming techniques. Treat reversible factors
- Arrhythmias can resolve once rewarmed. Assuming that pt has core T>32C and still has refractory VF, would consider discontinuining resuscitation. Whereas, if warm and PEA, then still need to go through other Hs&Ts and potentially epi may be more effective once warm
67
34. Picture of normal CXR. Down’s kid had g-tube inserted and is now acidotic, high lactate, bilious emesis. No double bubble sign, not full abdomen on plain film seen but you are told his abdo is firm and distended. Type of shock
a) Cardiogenic and hypovolemic
b) Distributive and hypovolemic
c) Cardiogenic and distributive
d) Cardiogenic and…
Distributive + hypovolemic
Distributive: 3rd spacing of intravascular fluids into extravascular component
Risks of G-tube placement
- peritonitis
- bleeding
- infection
- perforation
- anesthesia-related
- rarely periop death
68
53. 6yr (20 kg) child post MVA in shock. You determine that airway is well protected saturation 100 % on oxygen. HR 170, BP hypotensive. You have 2 large bore IV and give 1 bolus of 400 cc of NS and patient is still hypotensive. What do you do next:
a. start dopamine infusion
b. bolus 400cc of NS
c. give 400cc of albumin 5%
Give bolus of 400mL of NS
Need to reassess response after each bolus.
Signs of improvement: decrease HR, improved u/o, decreased RR, improved LOC
Once give 60mL/kg, consider adding inotrope
Consider pRBC 10mL/kg for refractory hemorrhagic hypovolemic shock
69
```
60. 16 year old Jehovah’s Witness, unstable with Hgb in 40’s, refusing therapy
A. give blood anyway
b. get directions from next of kin
c. accept refusal
d. assess capacity
```
Assess capacity
70
63. For 2-person resuscitation of a 5 y.o. boy, what is the appropriate compression:ventilation ratio?
a. 10:2
b. 5:2
c. 30:2
d. 15:2
--------------
What rate do you do CPR on a 5 year old boy?
a. 15:2
b. 15:1
---------------
109. Child brought to ER, VSA – according to the new AHA guidelines, what compression to ventilation ratio should be used (two rescuers)
a. 3:1
b. 5:1
c. 15:2
d. 30:2
-------------------
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?
a. 30:2
b. 5:1
c. 15:2
d. 5:2
15:2 for two rescuers of child up to puberty
Otherwise 30:2 for everyone else
71
95. 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?
a. Synchronous 15:2
b. Synchronous 30:2
c. Asynchronous 100:10
d. Asynchronous 15:2
Asynchronous 100:10
100 bpm continuous compressions
10 breaths per min
72
68. 2 week old child pale, limp, lethargic. HR 210 RR 70. After obtaining IV, you
a. intubate
b. broad spectrum antibiotics
Intubate
73
2 week old with sepsis like picture. Hypotensive, RR 70, on 50% oxygen sats 95%. What is your next step after fluid bolus?
a. IV abx
b. Bag Mask
c. Intubate
IV antibiotics
74
86. Child with fever, rash, hypotension. Cap refill is 5 seconds. What is the best immediate management?
a. bolus D51/2NS at 20 cc/kg
b. bolus NS 20 cc/kg via central line
c. bolus 5% albumin
d. bolus NS 20 cc/kg via peripheral line
Bolus NS 20mL/kg via peripheral line
For rapid delivery of isotonic fluids in pts with shock, prefer large bore, shorter peripheral catheters to central catheters
22-24 G in newborns/infants
18-20G in older children
Use central line if no other options
75
91. Child 20 kg. Uncompensated shock. Airway secure. Next step?
a. 800 cc NS
b. 400 cc 5% albumin
c. dopamine infusion
d. epi infusion
-----------------
14 y.o. F with sepsis but good sats. Most appropriate intervention
a. 40 cc/kg IVF NS
b. Epi
c. Dopamine
d. 20 cc/kg of albumin 5%
800mL NS or 40mL/kg NS
76
92. Best indicator of compensated shock.
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, N LOC, N urine output, increased CO2, decreased O2
Compensated shock
- Normal BP, but impaired delivery of O2 + nutrients to vital organs
- Tachycardia
- Prolonged CRT
- Cool, pale, mottled, diaphroetic
- weak pulses
- narrowed pulse pressure (increased DBP)
- Oliguria
- Vomiting, ileus
77
120. What is the best way to assess initial adequacy of ventilation?
a. Chest movement, oxygen saturation, capnography
b. Chest movement, venous gas, capnography
c. Capnogpraphy, venous gas, O2 sat
d. Auscultation, O2 sat, venous gas
-------------
What is the best initial way to assess ventilation?
a. Chest wall movement, venous blood gas, auscultation
b. Chest wall movement, auscultation, end-tidal CO2
c. Chest wall movement, capnography, end-tidal CO2
d. Chest x-ray, capnography, end-tidal CO2
Chest movement, capnography, EtCO2
VBG: reliable estimate of arterial pH and PCO2 values, provided tissue perfusion is reasonably adequate. Poor correlation with PaO2
CBG: good estimate of PaCO2 and arterial pH, but less so for PaO2
78
123. 2 mo baby comes in with meningitis and focal seizure. Symptoms of shock described. GCS 6. What is the FIRST step in management?
a. Culture and antibiotics
b. Intubation
c. CT
d. LP
GCS <8, intubate
79
28. A child was rescued after drowning. What is the most important in determining prognosis?
a. Duration of submersion
b. Good quality CPR at scene
c. A GCS of 7 on arrival to the ED
d. A lack of pulse and respirations at the scene
--------------
69. 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
------------
In a drowning accident, which one of these gives you BEST prognosis of survival without sequelae?
a. duration of immersion
b. GCS < 7 at arrival to ED
c. Quality cardiac resuscitation at drowning site
d. Cardiac and respiratory arrest on field
Duration of submersion
80
58. 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.
a. Chlorine intoxication
b. Closed head injury
c. Near drowning
d. Water intoxication
- -----------------
105. 8m old infant parents found him lethargic after a 45 minutes private swimming lesson. In the ER his rectal tem 35.5, blood pressure 120/80 and he had a generalized tonic clonic seizure
a. closed head injury
b. water intoxication
c. near drowning episode
d. chlorine poisoning
- ---------------
106. 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.
a. Chlorine intoxication
b. Closed head injury
c. Near drowning
d. Water intoxication
Water intoxication
CPS: swimming lessons for infants/toddlers
Hazards:
1. Drowning
2. Water intoxication with hyponatremia + sz
3. Hypothermia
3. Infections (e.g. otitis externa)
Recommendations
- <4yo cannot developmentally swim independently, swimming programs in this age is not an effective drowning prevention strategy
- Residential pools should be fenced on all 4 sides (not including house), include self-closing, self-latching gate
- PFDs for all young children and those who cannot swim. NOT a substitute for supervision
- All parents + pool owners should have first aid + CPR training and maintain emergency action plan
81
46. Child with drowning injury is in PICU on conventional mechanical ventilation, requiring PIP 30 and PEEP 10. He suddenly has an increase in his HR and a drop in his BP to hypotensive levels. What is your next best management?
a. Increase pip
b. Decrease pip
c. Increase peep
d. Decrease peep
Decreases PIP
Could be too high of pressures impeding venous return
But the sudden change suggests obstructive shock from PTX
Positive pressure causes barotrauma
(vs volutrauma = injury due to overdistension of lung during mechanical ventilation)
High PEEP has not been shown to increase risk of barotrauma
82
74. Child is found submerged underwater. Paramedics resuscitate at the scene with chest compressions and 3 shocks with the AED. Child arrives in ER with temp of 26C and in Ventricular fibrillation. Nurses get an IV. Along with rewarming what else would you do for the child:
a. amiodarone
b. no specific treatment
c. lidocaine
d. defibrillate
---------------
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
Rewarm!
Continue CPR
No specific treatment/do nothing
83
94. Child is victim of drowning. She is intubated by the paramedics and has received three shocks with the AED. She arrives to the emergency department with a core temperature of 26 degrees. The nurses quickly get an IV. In addition to rapid internal warming what would be your next step?
a. Start lidocaine
b. Cardiovert with 4J/kg
c. Start amiodarone
d. Do nothing?
---------------
Girl submerged in icy water. AED used at scene. In hospital, temp 26 C and VFib
a. Do nothing
b. Lidocaine
c. Amiodarone
d. Defibrillate
Rewarm!
Continue CPR
Do nothing
84
76. Child with near drowning with chest compressions started at scene by EMS. Child is given one shock with AED and arrives in ER. ECG tracing shows pulseless Ventricular tachycardia. IV is established. Patient is intubated. The next step is:
a. Defibrillate with 4J/kg
b. Give 1/10000 0.1cc/kg epinephrine IV
c. Cardiovert with 2J/kg
d. Give amiodarone
Defibrillate with 4J/kg
85
103. 3 y.o. in a coma in the ICU following near-drowning in a backyard swimming pool. GCS of 6, with no spontaneous respirations. If there is no improvement in neurological status, after what interval of time will the likelihood of recovery with no major sequelae be almost nil:
a. 6 hours
b. 12 hours
c. 24 hours
d. 48 hours
- -------------
104. 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
48H
Neurologic exam & progression during first 24-72H are best prognosticators of long-term CNS outcome
- If regain consciousness within 48-72H (even with prolonged resusc), usually unlikely to have serious neuro sequelae
- Poor recovery in child with abnormal brainstem function or absence of purposeful movements at 24H
86
39. Was the O2 % in a boy from a fire?
a) Overestimated
b) Underestimated
- --------------------------------------
41. Kid from burning house, covered in soot; sat 89%; is it?
a. Accurate
b. Overestimated
c. Underestimated
Overestimated
b/c CO poisoning. O2 sat reads normal, but O2 on Hbg replaced with CO.
SSx
H/A, N/V, alt LOC, irritability, unconciousness, coma
IVx
COHb
Mgmt
1. Give 100% O2
2. Hyperbaric O2 therapy for COHb >25%, altered LOC, significant ischemia
3. Check cyanide level
4. Monitor end organ ischemia (met acidosis, MI, rhabdo)
87
102. Boy found at house fire, stable, singed nasal hairs and burns around mouth, mild stridor, satting fine on O2
a. early intubate
b. admit observation?
- ------------------
130. 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. IV antibiotics
Early intubation
88
18. Which formulation of epinephrine and by which route should be given in anaphylaxis?
a) 1:1000 epinephrine IM
b) 1:10000 epinephrine IV
c) 1:1000 epinephrine SC
d) 1:10000 epinephrine IM
1: 1000 epinephrine IM
| 0. 01mg/kg IM Q5-15min
89
27. A child presents to the emergency room in anaphylaxis. What is the best route to administer epinephrine?
a. IV
b. IM
c. Inhaled
d. SC
- ----------------------
51. In anaphylaxis, how is epinephrine 0.01mg/kg delivered? [cps]
a. IM
b. SC
c. IV
IM
90
78. Infant being treated for S. Pneumococcus meningitis and sepsis. After the first dose of IV Penicillin G he develops the following erythematous, raised rash (pic given – looks like hives). He is also now hypotensive and tachycardic. He is in which type of shock:
a. Hypovolemic
b. Cardiogenic
c. Obstructive
d. Distributive
---------------
Baby with urticaria and low BP and tachycardia after penicillin. What type of shock:
a. decompensated distributive
---------------
Child with a diffuse erythematous rash, sick in the ICU with strep pneumoniae sepsis. Got his first dose of Pen G, then developed rash and hypotension. Also HR 220, decreased LOC. What does the scenario describe?
a. uncompensated hypovolemic shock
b. compensated cardiogenic shock
c. uncompensated distributed shock
d. uncompensated obstructive shock
Decompensated distributive shock
| Anaphylactic reaction
91
25. A child comes to the ER with a URTI, you do an X-ray and find a perfectly circular and completely opaque mass in the stomach (looked like a coin, not a battery). What do you do?
Reassure
Call GI for urgent removal
----------------
131. A 6 year child old swallowed coin. It is visible in the stomach on AXR. What should be done?
a. arrange for urgent removal of coin from the stomach
b. no intervention necessary, follow-up only
c. give syrup of ipecac
---------------
52. Kid w coin in stomach, what to do?
a. Observe
Observe/no intervention necessary/reassure/arrange F/U
92
59. Concerns about swallowing a button battery
a. None
b. Perforation
c. Airway obstruction
Perforation
93
31. 2 month old baby with FTT, constipation, and vomiting. Labs show pH 7.28, Na 128, K 2.7, Cl 107, urine pH 7.5. What is the underlying problem?
a) CAH
b) cystinosis
c) pyloric stenosis
d) cystic fibrosis
??????Cystinosis
Low Na, low K, high chloride
need to know bicarb, but presumably metabolic acidosis
Suggests RTA
urine pH 7.5
Not type IV = hyperkalemic
Proximal RTA = problem with reabsorbing HCO3. If normal kidneys, urine pH <5.5
Distal RTA = failure to acidify the urine. Urine pH >5.5
Pyloric stenosis: expect higher bicarb leading to metabolic alkalosis, low K, low Cl
CAH: expect low Na, high K
Not cystic fibrosis
94
40. How do we treat neuropathic pain
a) Gabapentin
b) Morphine
Gabapentin
95
48. 6 year old girl with recurrent non bilious projectile vomiting with abdominal pain and pallor. She has headaches. Has had to get iv rehydration on several occasions. She is normal between episodes. What is her diagnosis
a. Cyclic vomiting
b. Intermittent Intussuception
c. Intermittent volvulus
d. Brain tumor
Cyclic vomiting
```
Stereotypical pattern
Recurrent episodes of intense vomiting + nausea
Vomiting >=4X/hr or >=1 H
Last 1-10d, occur at least 1wk apart
Well in between episodes
Diagnosis of exclusion
```
```
Tx
A. Supportive
- hydration
- diphenhydramine (Benadryl)
- meperidine
- lorazepam
B. Abortive
- Ondansetron
- Ketorolac
- Granisetron
- Sumatriptan
```
96
70. 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
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Baby had gastroenteritis and mom has only been giving juice and water. Illness course 3 days. Na 118, Urea 13, Cr 95. Management:
a. give 3% NaCl to correct sodium over 4-6 hrs
b. correct Na to 128-130 over the next 24 hrs
c. correct Na to 138-140 over the next 24 hrs
d. fluid restriction
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Kid with Na 108. Mom feeding baby water. No sz. Mgt?
a. Water restrict
b. Increase Na to 118-120 over 24 hours
c. Increase Na to 120-134 over 24 hours
If Na 108: Correct to 118-120 in 24H
If Na 118: Correct to 128-130 over next 24H
Goal is to correct by max 10-12mmol/L over 24H
Chronic hyponatremia, so more likely to have risk of cerebral pontine demyelination with rapid correction
97
87. What is a criteria for Neurologic Determination of Death?
a. absence of hyperthermia
b. apnea despite hypercapnea
c. spinal reflexes are absent
d. characteristic EEG
Apnea despite hypercapnea
98
127. A child presents with progressive coma, but normal pupils. What is the most likely diagnosis?
a. Poisoning
b. Hemorhagic stroke
Poisoning
| Likely sedative hypnotics
