Acute Care Flashcards

Question

A 5 year old boy is hurt in a MVA. At the scene, EMS note that he does not open his eyes, moans incomprehensively, 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

Answer 1

C. Intubate, GCS of 5

Answer 2

B. Chest ultrasound to see if drainable pleura effusion

Answer 3

A. 1200 cc/kg ORT over 4h Likely would say this is moderately dehydrated which would require 100cc/kg over 4h of ORT

Answer 4

C. Neuroleptic malignant syndrome Serotonin syndrome - get myoclonus NMS - lead pipe rigidity

Answer 5

B. Fracture of L1-L2 This is seatbelt syndrome with classic triad of “abdomen bruising + internal abdominal injury + spinal fractures “ - underdeveloped iliac crests of child’s pelvis does not properly support the anchoring points of a lap belt. Injury occurs when seatbelt testing improperly high across abdominal wall. - most common fracture from seatbealt is = Chance fracture - it describes a compression fracture to the anterior vertebral body + transverse fracture through posterior elements of vertebra - presence of neurological deficit or spinal canal compromise warrants immediate surgical intervention - significantly displaced fractures or ligament outs injuries generally require fusion - isolated bone injuries are treated with hyper extension brace or cast - overall good outcomes with very few persistent neurological deficits. Abdominal wall ecchymoses = 84% intra- abdominal wall injury MC hollow coach’s injury, also a/w vertebral fractures/ chance fractures in up to 50 % and spinal cord injury in up to 11%

Answer 6

C. No response to hypercapnia test

Answer 7

D. Correct Na to 118-120 in 24h 1. Even though central pontine myelinolysis is rare in pediatrics patients it is advisable to AVOID correcting the serum Na concentration by > 12mEq/L/24h or > 18 mEq/L/48h 2. A patient with severe symptoms (seizures), no matter the etiology, should be given a bolus of hypertonic saline 3% NaCl to produce a small, rapid increase in serum sodium. 3. If hypertonic saline treatment is undertaken, the serum Na should be raised only high enough to cause an improvement in mental status, and NO faster than 0.5 mEq/L/h

Answer 8

A. Return to play once they are back to school full time and no symptoms for several days Full return to academics must precede return to sports A concussed athlete should not return to sports u till all concussion signs and symptoms have resolved and she can be medically cleared. There should be no same day RTP. Once symptoms have resolved and the individual has been symptoms free for several days ie 7-10days they can progress through a medically supervised stepwise exertion protocol

Answer 9

D. Intranasal midazolam

Answer 10

A. Cocaine - sympathomimetics But also isn’t LSD ??

Answer 11

A. Oral ondansetron Single dose should be considered for children 6 months to 12 years of age 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 S/e - diarrhea

Answer 12

D. Defibrillate 2J/kg Ventricular fibrillation - shockable rhythm. 1st shock is 2J/kg next shock is 4 J/kg and subsequent above 4 J with max of 10 J/kg

Answer 13

D. 9:30pm Obtain 4h post-ingestion acetominophen. If unsure of timing go ahead and order it

Answer 14

Controversial B. 100% 02 vs C. Change the tracheostomy Ronish says C. Change tracheostomy. In an emergency if the tracheostomy is blocked - you must remove it. I think C - if tracheostomy is blocked or displaced remove trach tube and attempt oxygenation and ventilation via the the mouth then stoma...

Answer 15

A. Peaked t waves on eCG from hyperkalemia I concentration is higher in super start of pRBCs, especially those at the end of their shelf life. Transfusion large volume 1. Hyperkalemia 2. Hypothermic 3. Dilutional coagulopathy 4. Hypocalcemia 5. Acidosis

Answer 16

Answer B. 6 E-1: V-2, M-3 = 6

Answer 17

A. 1:1000 epinephrine IM

Answer 18

C. Amitriptyline - anticholinergic - she is dry so not sympathomimetic The difference between TCA (anticholinergic) and sympathomimetics ingestion is the presence or

Answer 19

D. Admit for observation of late stages of iron toxicity He has normal iron levels and AXR is normal so need for deferoxamine right now

Answer 20

Phase 1: GI phase: 30 min 6h Phase 2: latent or relative stability phase - 6-24h Phase 3: shock and metabolic acidosis - 6 - 72h Phase 4: hepatotoxicity/hepatic necrosis - 12 - 96h Phase 5: bowel obstructin/strictures - 2- 8 weeks Vomiting most sensitive indicator of serious infections. Phase 1 risk of death from hypovolemic shock. Most pts with mild to moderate toxicity do not progress beyond this phase and sx may resolve in 4-6h. If no GI symptoms develop within 6h or iron ingestion it is unlikely that iron toxicity will occur. Except with enteric coated iron tablets - exception to 6h rule

Answer 21

B. Confusional migraine Controversial some said poisoning Stroke, and seizure would not have normal exam and likely poisening as well Dysphasic auras - least common type of typical aura and have been described as an inability or difficulty to respond verbally. The patient afterwards will describe an ability to understand what is being asked but cannot answer back. This may be the basis of what in the past has been referred to as confusional migraine. Most of the time these episodes are described as motor aphasia and they are often a/w sensory or motor symptoms. Confusional migraine - patients with confusional migraine have a headache that is typical of migraine a/w symptoms of agitation, disorientation, and aphasia that last longer than the headache. Confusional episodes tend to recur but are eventually replaced by typical migraine. Age range 6-15, males predominated, duration of confusion 2-24h. Hx of head trauma, agitation, past headache and migraine on maternal side of family.

Answer 22

A. Defibrillate 4J/kg This is a shockable rhythm - ventricular tachycardia without a pulse, therefore you attempt defibrillation up to 3 times. The second round of defibrillation should include an increase in joules per kg 4J/kg then > 4 J/kg with subsequent shocks. Epi is given after the 2nd shock

Answer 23

C. Varicella pneumonia Most increase morbidity and mortality in adults with varicella - onset 1-6 days after onset of rash - cough, dyspnea, cyanosis, pleuritic chest pain, hemoptysis - CXR - diffuse b/l infiltrates, early stages nodular component may be present, which can become calcified - Tx - IV acyclovir (perhaps steroids may be beneficial but not enough evidence yet) Risk factors for developing varicella pneumonia 1. Smoking 2. Pregnancy 3. Immunosuppression 4. Male sex

Answer 24

A. Reassure - likely a coin not a button battery Can observe small foreign bodies and repeat X-ray in 4 weeks

Answer 25

B. Increased heart rate Tachycardia is the first sign of compensated shock, followed then by increased SVR and decreased perfusion, cold temperature

Answer 26

D. Electrochemical dissociation = PEA A- 30 temp should be closer to 32-34 D- not an indication C- refractory v-fib - this can happen at lower temperature - need to warm up None of these are right :(. Reasons to stop CPR: no response to AcLs after 20 min of efficient resuscitation in absence of ROSC, a shockable rhythm or reversible causes

Answer 27

A. Duration of submersion Good quality CPR - they are talking about quality no immediate bystander CPR GCS has limited predictive value for recovery Good prognostic factors 1. Immediate bystander CPR is the most important factor influencing survival 2. Return of spontaneous circulation in < 10 min 3. Submersion < 5 min 4. Pupils equal and reactive at scene 5. Normal sinus rhythm at scene Bad prognostic factors 1. Delayed CPR 2. ROSC > 25 min 3 submersion > 10 min Bad from up to date 1. Duration of submersion > 5 min ( most critical) 2. Time to effective life support > 10 min 3. Resuscitation duration > 25 min 4. Age > 14 5. GCS < 5 6. Persistent apnea and requiring cardiopulmonary resuscitation in the emergency department 7. Arterial blood ph < 7.1 upon presentation

Answer 28

A. Intranasal midazolam

Answer 29

B. Ampicillin/ gentamycin Some might argue for supportive care due to RSV proven bronchiolitis, but given this is a 3 week old baby with fever, I would say that he should be treated as rule out sepsis and have a FSWU with amp/gent and the literature seems to agree with this. Labs and imaging for select patients - laboratory testing are not routinely indicated in the evaluation of infants and young children with bronchiolitis. However, laboratory and/or radio graphic evaluation may be necessary to evaluate the possibility of - Conor is or secondary bacterial infection in < 28 days of age with fever. Infants < 28 days old with fever > 38C and symptoms and signs of bronchiolitis have the same risk for serious bacterial infection as young febrile infants without bronchiolitis and should be assessed accordingly. In older infants those 29-60 days of age, RSV infected patients continue to have a clinically important rate of UTIs. Therefore do urine testing in these infants.

Answer 30

B. Cystinosis - although this doesn’t totally fit with RTA type 2 (they usually have a normal urine PH because the distal acidification is still normal) but with these other choices this is the only one that fits - CAH - hyponatremia, hyperkalemia, metabolic acidosis - Pyloric stenosis - hypochloremic metabolic alkalosis, hypokalemia - cystic fibrosis - hypochloremia, hypokalemia, hyponatremia and metabolic alkalosis - cystinosis - RTA type II picture = usually have metabolic acidosis, normal acidified urine with PH < 5.5, hyperchloremia and hypokalemia

Answer 31

B. Booster with back High back belt positioning booster- this booster provides head and neck support for children seated in vehicles without head restraints and must be used with a lap and shoulder seat belt assembly

Answer 32

C. Whole bowel irrigation. Charcoal and ipecac are not used in iron overdose

Answer 33

B. Distributive and hypovolemic This is a case of a child with possible gastrointestinal perforation versus sepsis postoperatively following a gastroenterostomy tube insertion. Lactic acidosis suggests that he is hypoperfused and has hypovolemic shock; if he is septic this is distributive shock. There is nothing on history to suggest cardiac disease I believe that hypovolemic shock here makes the most sense; G-tune causes gastric outlet obstruction - bikinis emesis - hypovolemia - acidosis and high lactate Otherwise with the firm and distended abdomen either it’s a result of the obstruction or a perforation (although you would have seen this on plain film) but a perforation could explain sepsis and distributive shock. Or is he in distributive shock and third spacing into his abdomen ? Either way not enough info to say he is in cardiogenic shock Gastric outlet obstruction - Gastrostomy tubes can migrate forward into the duodenum and cause gastric outlet obstruction. This occurs if the external bolster on the gtube is allowed to migrate away from the abdominal wall, allowing it to move forward. Can occur with balloon gtube - balloon obstructs pylorus

Answer 34

A. 6 mo- 12 yr moderate dehydration

Answer 35

A. Benadryl - although PCP can also cause anticholinergic symptoms but I would say in a child they were probably able to get their hands on Benadryl rather than PCP

Answer 36

B. PCP causes mydriasis Cocaine and LSD are sympathomimetics and cause mydriasis but with diaphoresis ``` PCP anticholinergic symptoms RED DANES Rage Erythema Dilated pupils ``` ``` Delusions/ dry skin Amnesia Nystagmus Excitability Skin dry ```

Answer 37

A. Lateral X-ray ( if vitals stable and there is time for investigations ) Vs B. Call ENT Exam tip : - bacterial tracheitis no drooling - epiglottitis - drooling A lateral neck X-ray would help you differentiate between epiglottitis, croup, or a mass ie hemangioma This child may have epiglottitis. Needs ENT as may need intubation. Lennox says IF only says mild distress then it would be unlikely to be epiglottis so would choose A in that case (apparently there is another version of this question where it says mild)

Answer 38

A. Overestimated Standard pulse oximetry (sp02) Cannot screen for CO exposure as it does not differentiate carboxyhemoglobin form oxyhemoglobin

Answer 39

A. Gabapentin Neuropathic pain - TCAs, gabapentin, pregabalinwith adjuvant topical therapy ie: lidocaine Opioids are second line

Answer 40

B. Overestimated

Answer 41

A. Penumatocele

Answer 42

A. Give MgSO4 Generally it goes = 3 back to back ( ipratropium bromide and ventolin), IV methylprednisone, then MgSO4, then IV salbutamol, then intubate and ventilate

Answer 43

D. PH 7.38, pO2 90 Gas is normal. Labs normal in first 24h hours except possibly the acetominophen level; by the time you get to stage 3 can have metabolic acidosis Stages Stage 1 =up to 24h = GI sx - asymptomatic but less commonly n/v and in patients with very large doses, lethargy and malaise Stage 2= 24-72h = resolution of GI symptoms but now coagulopathy, elevated liver enzymes, RUQ pain. Severe cases evidence of Nephro toxicity elevated bun, Cr, oliguria and/ or pancreatitis (elevated amylase/lipase) Stage 3= 72-96h = evidence of liver failure and in severe cases, renal failure and multi- organ failure. Death most common in this stage Stage 4 = 4-14 days = recovery

Answer 44

B. SL nifedipine This is a hypertensive emergency defined as a severe symptomatic elevation in BP WITH evidence of acute target organ dAmage Mc organs involved - Brain = sz, ICP - kidneys = renal insufficiency - eyes = papilledema, retinal hemorrhages, exudates - heart = heart failure She also has hypertensive encephalopathy. Hypertensive emergencies in children usually manifest as hypertensive encephalopathy: sever BP elevation with cerebral edema and neurological symptoms of lethargy, coma, and/or seizures Up to date tx = IV labetalol or nicardipine, also hydralazine Or could be PRES = headache, confusion, visual symptoms and seizures. Most often occurs in hypertensive crisis, preeclampsia, or with cytotoxic immunosuppressive therapy

Answer 45

B. Decrease PIP vs D. decrease peep Cheo chose B, Mac chose D Likely obstructive cause to shock secondary to overventilation = pneumothorax Patients on mechanical ventilation are at risk of barotrauma. The normal resp cycle relies upon negative pressure. In contrast, invasive mechanical ventilation involves the delivery of positive pressure. PPV causes barotrauma by increasing transalveolar pressure ( alveolar pressure minus the pressure in the adjacent interstitial space), which results in alveolar rupture. Alveolar rupture allows air from the the alveolus you enter the pulmonary interstitium. The interstitial air can then dissect along the perivascular sheathes towards the pleural space, mediastinum, peritoneum, and/or skin, leading to pneumothorax, pneumomediastinum, penumoperitoneum, and/or subcutaneous emphysema respectively Elevated peak pressure (peak PIP) - there is no absolute threshold for the peak pressure High levels of Peep - several studies have reported that open lung ventilation strategies using high levels of peep or recruitment maneuvers, have not been shown to increase the risk of barotrauma. This is probably because most open lung approaches also concomittantly use lung protection strategies ( ie; low tidal volume with a target plateau pressure < 30cmh2o) and perhaps because the application of peep appropriately recruited involved atelectic lung thereby improving lung compliance

Answer 46

B. Start CPR

Answer 47

A. Lateral x ray (if vitals stable and there is time for investigations)

Answer 48

A. Cyclic vomiting Diagnostic criteria all must be met 1. At least 5 attacks in any interval, or a minimum of 3 episodes during a 6 month period 2. Recurrent episodes of intense vomiting and nausea lasting 1h to 10 days and occurring at least 1week apart 3. Stereotypical pattern and symptoms in the individual patient 4. Vomiting during episodes occurs >\= 4 times/hr for >\= 1h 5. Return to baseline health between episodes 6. Not attributed to another disorder

Answer 49

B. Bolus 400 cc of NS then consider blood Fluid - fluid -blood -blood - 20nl/kg saline x2 then 10ml/kg blood (cal for blood with second fluid bolus - massive transfusion protocol 1:1:1 ratio of blood products

Answer 50

A. Bag and mask ventilation Baby has bradypnea and impending respiratory failure/apnea. BMV and stabilize airway then consider definitive treatment of asthma/bronchiolitis Likely bronchiolitis in a baby therefore second answer would not make sense

Answer 51

B. Hypotension All of these can cause secondary injury; hypotension is the most important (per last years lecture) and is also the main cause of secondary injury mentioned in Nelson’s

Answer 52

Absolute indications 1. Focal neurological deficit 2. Clinically suspected open or depressed skull fracture or a widened or diastatic skull fracture observed on X-ray Relative indications 1. Abnormal mental status: GCS < 14 at any point from time of initial assessment onwards 2. Clinical deterioration over 4-6h period of observing a symptomatic patient in ED, including worsening headache or repeated vomiting 3. Signs suggestive of basilar skull fracture 4. Large boggy scalp hematoma in child >/= 2 y.0; in younger children consider performing a skull X-ray first 5. Mechanism of trauma raising suspicion for serious injury ie: falling from a height, MVA, impact with a projectile 6. Persistent irritability in a child < 2 7. Seizures at the time of event or later 8. Known coagulation disorder

Answer 53

A. Hyperpyrexiq C. Metabolic alkalosis - aspirin causes metabolic acidosis and respiratory alkalosis D. Elevated K ( patients usually hypokalemia - resp alkalosis leads to urinary loss of bicarbonate which pulls k out with it)

Answer 54

Mixed metabolic acidosis and respiratory alkalosis Increased temp + hypokalemia + hypoglycaemia + elevated LFTs + coagulopathy + thrombocytopenia + elevated CK

Answer 55

D. Water intoxication

Answer 56

B. Perforation Causes pressure necrosis and liquefaction necrosis

Answer 57

D. Assess capacity

Answer 58

A. Fomepizol

Answer 59

D. 15:2 Solo - 30:2 2 people - 15:2

Answer 60

D. Refuse unless the police produces a warrant/ court order

Answer 61

A. 100 cc/kg over 4 Mild - 50cc/kg over 4 hours Moderate - 100 cc/kg over 4h Severe- 20-40cck/kg NS IV bolus over 1 hour

Answer 62

A) 300 ml/hr ORS over 4h Assuming kid is not severely dehydrated you would give 50-100 ml/kg ORS over 4h - 50-100ml/kg x 13kg = 650-1300 ml over 4h = 162-325ml/h ORS - you wouldn’t give 1/2 NS in a patient who’s Na is 138 - I am not sure what they are getting at with the low K - I guess just that he’s had a lot of diarrhea

Answer 63

IV antibiotics I would think ABCs would be first line but apparently from lecture IV abx is the best answer. Maybe this is because he is protecting his airway enough to maintain 95% sats ? AAP: priorities in resuscitation of a child who has septic shock mirror those of other types of shock - initial attention should focus on the presence of an adequate airway and breathing. All children should receive supplemental oxygen. The child in respiratory distress should be intubated If mechanical ventilation is required then cardiovascular instability during intubation is less likely after appropriate cardiovascular resuscitation. Due to low FRC, young infants and neonates with severe sepsis may require early intubation; however, during intubation and mechanical ventilation, increased intrathoracic pressure can reduce venous return and lead to worsening shock of the patient is not volume loaded. In those who desaturate despite administration of face mask oxygen, high flow nasal cannula oxygen or nasopharyngeal CPAP can be used to increase FRC and reduce the WOB, allowing for establishment for IV/IO access for fluid resuscitation and peripheral inotrope delivery.

Answer 64

A. Increased length of submersion

Answer 65

A. Insecticide Cholinergic - miosis, coma, seizures Cocaine sympathomimetic - mydriasis

Answer 66

B. Sodium bicarbonate

Answer 67

B. No specific treatment V- fib max 3 attempts while temp 30. If child is 30C - warm - CPR

Answer 68

C. intubate - GCS < 8

Answer 69

Uncompensated distributive shock Anaphylaxis - distributive shock Low BP - uncompensated

Answer 70

C. ORS 300cc/h for 4 h Decreased skin turgid and delayed cap refill but normal vitals = moderate dehydration - 100cc/kg = 1,300mls in 4h = 300mls/h x 4h

Answer 71

A. 400 ml of ORS per hour for 4h

Answer 72

A. ORF 100ml/kg

Answer 73

A. Sodium bicarbonate

Answer 74

B. Sodium bicarbonate Never give phenytoin to TCA overdose Decreased LOC so no activated charcoal

Answer 75

A. Change trach

Answer 76

B. Rhabdomyolysis

Answer 77

D. Bolus 20cc/kg via peripherAl line

Answer 78

B. Apnea despite hypercapnea

Answer 79

A. Second intercostal space, midclavicular line Tension pneumothorax management - needle thorancentesis followed by thoracostomy tube insertion - Chest tube is placed in 4th to 5th intercostal space mid-axillary line

Answer 80

A and A Cristalloid better for septic shock. Second question weird that starting at 40

Answer 81

C. N BP, N LOC, increased CO2, decreased PO2, N urine output A- out because of decreased LOC B - Cushing triad of increased ICP D- out because of unresponsive As the body’s ability to compensate reaches its limit, hypotension develops, along with additional signs of hypoperfusion and end- organ damage. At this stage, the clinical findings include weak central pulses, poor urine output, mental status changes and metabolic acidosis

Answer 82

C. Asynchronous 100:10 Limit interruptions of Chest compressions < 10s - for 1 rescuer 2 ventilations/30 compressions - for 2 rescuers 2 ventilations/ 15 compressions - once intubated ventilation and compression can be performed independently - ventilations are given at a rate of 8 to 10 per minute - compressions are delivered at a rate of 100-120 per minute without pauses

Answer 83

Controversial Not completely clear signs of ICP - has HTN but HR 80 which is not bradycardia If it was clear ICP then then hyperventilate as temporizing measure until you give 3% saline. I feel we don’t use mannitol a lot anymore cause it’s so darn hard to order and get. If no clear signs of ICP and he is stable then head CT. Hyperventilation is one of fastest ways to lower ICP in a child with impending hernia toon. However prophylactic hyperventilation without signs of impending herniation should be avoided. Hyperventilation decreases ICP by causing vasoconstriction which decreases CBF in a hyperaemic brain. However recent studies have shown that hyperaemia is uncommon and that children may actually have decreased CBF after TBI. Hyperventilation thereforore dramatically decrease CBF which may cause further cerebral ischemia.

Answer 84

A. Tachycardia | M

Answer 85

B. Rectal benzo Depending on how they word his airway and breathing status - might need intubation as per algorithm. But actually in agorythm intubation is wayyy down the line

Answer 86

B. 3rd ICS

Answer 87

A- symptomatic management Anticholinergic toxidrome Me- could be sympathomimetics toxidrome B- naloxone is for opioids = miosis C. Atropine is for cholinergics = miosis D. Flumazenil is for benzo = sedative = miosis

Answer 88

A. Early intubation

Answer 89

A. 3% saline Usually initial goal is correction of intravascular volume depletion with isotonic fluid (NS or RL) - don’t want to correct by > 12 mEq/L in the first 24h as a/w central pontine myelinolysis But in patients with seizures need acute infusion of hypertonic saline to increase serum sodium concentration rapidly in order to quickly reduce cerebral edema ( goal is to increase extra cellular osmolality so that water moves down its osmolar gradient from the intracellar to the extra cellular space. Each ml/kg of 3% sodium chloride increases serum Na by 1mEq/L: a child with active symptoms improves after 4-6ml/kg of 3% NS - sz a/w hyponatremia generally are poor responders to anticonvulsant

Answer 90

A. Viral myocarditis is

Answer 91

A. Viral myocarditis All can present with fever + rash + new murmur B- ARF - less likely to present with CHF C- subacute bacterial endocarditis - less likely because it’s acute form that usually causes CHF, subacute is prolonged low grade fevers and non-specific complaints

Answer 92

Epinephrine 1 ml of 1:10000 0.1ml/kg or 0.01mg/kg

Answer 93

D. Bag mask ventilation Poor resp rate and poor saturation’s - requiring ultimately intubation

Answer 94

A. Defibrillate with 4J/kg

Answer 95

Defibrillate 4J/ kg Be careful in 1st question originally has PEA then converts to pVT Wide- complex QRS/tachycardia = pVT Shock 2J/kg - shock 4J/kg - epi

Answer 96

D, A, B Jimson weed = anticholinergic Could be imipramine as well but seems more likely to be smoking weed

Answer 97

B , A chest tube in affected side Prior to transport a pneumothorax should be decompressed and a nasogastric tube inserted for ileus - a small < 5% or even moderate- sized pneumothorax in an otherwise normal child may resolve without specific treatment, usually within 1 week - a small pneumothorax complicating asthma may also resolve spontaneously - administrating 100% 02 may hasten resolution - if the pneumothorax is recurrent, secondary or under tension or there is > 5% collapse, chest tube drainage is necessary A current pneumothorax is a contraindication to commercial air travel. Patients who have a thoracostomy tube in place with a unidirectional valve for decompression may be able to tolerate air travel when medically necessary.

Answer 98

D. High output acute renal failure Kinda sounds like ATN caused by initial severe pre renal failure Other answers don’t make sense A- fat embolus - hypoxemia, neurological abnormalities and petechial rash B. Renal vein thrombosis - would need to be bilateral for renal failure C- diabetes insipidus - why would there be blood ?

Answer 99

B, C - Epi 1/10000 1 ml. From these questions it is safe to say that a 1 y.o weighs approximately 10kg

Answer 100

B. Rectal benzo Your priority is stopping the seizure so if you can support their breathing without intubation you should do that and prioritize benzos. The CPS algorithm doesn’t mention intubation until before doing a midazolam infusion

Answer 101

A. Mannitol

Answer 102

B. Hyperventilate

Answer 103

A. Chest wall movement, oxygen saturation, capnography And B. Chest wall movement, auscultatio , end- tidal CO2 Weird question but can eliminate all the ones with venous gas or CXR

Answer 104

D. Discuss and withdraw

Answer 105

Oral rehydration solution

Answer 106

B. Intubation Controversial question- as cheo picked intubation and mac chose IV and abx Going with intubation ABCs first. Otherwise antibiotics. Should not delay abx to do LP. With GCS of 6 airway likely not protected ( GCS < 8)

Answer 107

Controversial. Previous years chose heliox as it’s the last ditch effort prior to intubation. Others chose intubation as no matter the cause, any child in impending respiratory failure should be prepared for endotracheal intubation and reap support.

Answer 108

C. Observe and treat supportively

Answer 109

Difficult question. Usually in poisening you either have dilated or constricted pupils but I assume not all of them. Not sure about this one anymore ...maybe if it hadn’t quite progressed into increased ICP yet the pupils will be normal The predominant feature In children with intracerebral hemorrhage is coma - these will act like TBI. The second key feature after coma is progressibe increased ICP with impending herniation - new or worsening h/a - HTN, low HR, irreg resp - CN6 palsy - lateral rectus - CN3 palsy - foxed dilated pupils - ptosis - down and out positioning globe

Answer 110

A. Bronchoscopy Likely foreign body aspiration

Answer 111

B. Intubate aBCs first. Mannitol takes too long and too unstable for CT

Answer 112

B. No intervention necessary, follow up only

Answer 113

E. It is possible to consent only to donation of specific organs

Answer 114

A. Rhabdomyolysis Crush injuries in the pelvic area can lead to rhabdomyolysis Pre renal failure improves with fluids whereas rhabdomyoma more resistant

Answer 115

C. Inotropes and packed RBCs - no mention a out airway or breathing so don’t know about intubation. He is probably loosing lots of blood with femur fracture so definitely RBCs Controversial as some debate about c - intubate and blood = but stem says nothing about airway and breathing difficulty or GCS. Has a skull fracture but could be linear not depressed Already had 3x boluses so now move on to blood therefore B is wrong and no increased ICP so a is wrong. If patient remains in shock after boluses totalling 40-60 ml/kg of crystalloid, then 10-15 ml/kg of cross matched, packed RBCs should be transfused. Use 0 negative till cross match blood arrives. If shock persists despite these measures, surgery to stop internal hemorrhage is usually indicated. From up to date: Common reasons for ETT includes hemorrhagic shock and vasoactive pressor infusions are not appropriate for the treatment of hypovolemic shock but may be necessary to treat shock secondary to spinal cord injury. *** with this does that mean intubate and blood is right !?!

Answer 116

Question 1 = A. Bolus and inotropes Septic shock Question 2. Controversial CHeo chose B. Inotropes and re- bolus but Max chose ceftriaxone and transfuse pRBCs Thinking of going with B.

Answer 117

B. Hepatic tox 120mg/kg/day = BAD Repeated administration of acetominophen at supratherapeutic doses > 90 mg/kg/day for consecutive days can lead to hepatic injury or failure in some children, especially in the setting of fever, dehydration, poor nutrition, and other conditions that serve to reduce glutathione stores

Answer 118

A. Fomepizole

Answer 119

Controversial Cheo chose A - abdo CT Mac chose d- transfuse pRBCs

Answer 120

C. Removing feeding tube constitutes terminating care

Answer 121

C. To prevent cardiac dysrhythmia

Answer 122

A. CT abdo

Answer 123

A. Give diazepam

Answer 124

B. Decreased p02 Hypoxemia will cause the child to deteriorate further, as this would increase the intrapulmonary shunt Boyle’s law = volume of gas is inversely proportional to the pressure to which it is exposed. This as an aircraft ascends during flight, barometric pressure falls, and trapped air expands in non- communicating body cavities ie: pneumothorax was, lung blend, lung Bullard, lung cysts

Answer 125

B. High serum glucose, low serum calcium Hypernatremia is a/w hyperglycaemia and mild hypocalcemia; the mechanisms are unknown

Answer 126

D. Cardiovascular collapse

Answer 127

B- atropine Likely insecticide ingestion - organophosphate - cholinergic Pyridostigmine is also an organophosphate and you use it to treat anticholinergic intoxication

Answer 128

A. Ventilate with 100%o2, fluid bolus, epinephrine ABcs then follow shock algorithm so fluid resuscitation first then pressor

Answer 129

C. Increased bowel sounds

Answer 130

D - not a real word Rest are true

Answer 131

A. Attending physician can take the blood alcohol level

Answer 132

Lecturer’s answer is c - bolus - ceftriaxone - intubate Don’t like any of the answers. I would give abx bolus again twice and then inotrope if needed. It does say he is on 100% 02 but they don’t give you the sense that his resp status is imminently deteriorating so fluids and abx would be priority Sounds like staph scalded skin caused by impetigo = want to treat with penicillin or initially with cloxacillin if penicillin made producing staph is suspected

Answer 133

A. Transfuse blood now without parental consent.

Answer 134

D. Stop breast feeding and start e solution

Answer 135

B. Sodium 60 mmol/L, potassium 20mmol/L, glucose 2% Remember that 2% glucose = 2g/100ml of solution therefore 20g/L Standard WHO recommended ORS contains - 90mmol/L of Na - 20 mmol/L of K - 80 mmol/L of Cl - 30 mmol/L of bicarbonate - 111 mmol/L of glucose Osmolarity of 311 mOsm/L

Answer 136

Q1 c- Chest motion - auscultation - capnography Q2 a- FIO2 1.0 - PIP 20 - peep 5 - rate 20

Answer 137

B. Phenytoin for arrhythmias Cardiovascular and CnS symptoms dominate ``` CCCA Coma Convulsions Cardiac dysrhythmia Acidosis ```

Answer 138

A pulse 120, RR 30, BP 90/60 15% blood loss - compensated by vasoconstriction and tachycardia. Blood pressure is maintained and resp rate is usually normal Class 1 hemorrhage- up to 15% = limited change in vitals Class II hemorrhage : 15-30% = tachycardia, tachypnea, fall in pulse pressure Class III hemorrhage: 30-40% = shock

Answer 139

D. Once parents have decided to treat the child they may change their minds at a later time

Answer 140

C. cAS authority can supersede the wishes of the parent and the child

Answer 141

B. Cocaine Sympathomimetics LSD - hypertension and hyperpyrexiq but not tachycardia Barb - hypotension

Answer 142

B. hSES ``` Shock Coagulopathy Encephalopathy Liver and kidney dysfunction Most cases infants - 3-8 months Very high temp and multi organ failure ``` Reye - encephalopathy and liver failure no temp increase

Answer 143

A. V. Fib B. Defibrillate 2J/kg x 2 shocks then epinephrine 1:10000 = 0.01mg/kg IV q3-5min C. Intubated so 100-120 min continuous D. 8-10 breaths/min (every 6-8 seconds)

Answer 144

ICP management 1. Head of bed to 30 degrees, midline head position 2. Intubation and hyperventilate to PaCO2 < 35mmHg with signs of herniation as temporization measure as other interventions get put in place. Then want to maintain normal ventilation and avoid hypoxia 3. Stat neurosurgery consultation - if possible prior to hyperosmolar therapy or hyperventilation 4. Hyperosmolar therapy with 3% saline or mannitol 5. Avoid hypotension - IVF, bolus, pressors = keep normovolemic 6. Pain control and sedation = decreases ICP by reducing metabolic demand, ventilator asynchrony, venous congenstion and the sympathetic responses of hypertension and tachycardia +\- neuromuscular paralysis 7. Maintain normal temperature = aggressive treatment of fever with acetominophen and mechanical cooling 8. CT head without contrast once stable 9. Correct glucose + Na

Answer 145

1. Burns to face 2. Spot in mouth/nose/sputum 3. Singed nose hairs 4. Edema/erythema/ulceration or oro- nasopharyngeal mucosa 5. Stridor, WOB, tachypnea Intubation next step

Answer 146

A. Anion gap AG = (Na + K ) - (Cl + HCO3) AG = (140+4) - (96+ 11) = 37 B. Expect osmolar gap to be elevated Calculated = 2xNa + glucose + urea Osmolar gap = measured - calculated Normal = < 10 ``` Causes of elevated osm gap 1. Methanol 2. Ethylene glycol 3. Mannitol, sorbitol 4. Polyethylene glycol ( IV lorazepam) 5. Propylene glycol ( is lorazepam, diazepam and phenytoin 6. Glycine 7 . Maltose ``` C. Long term complication of methanol toxicity - blindness D. Med to treat Fomepizole

Answer 147

Patient 2 - evidence of fatigue give. Decreased resp rate and normal CO2; in a child undergoing asthma exacerbation that is well compensated, child will be tachypneic with hypoventilation as evidenced by low CO2. But when they get tired they stop compensating and stop hyperventilating causing their CO2 to rise. Rising CO2 asthmatic = bad