Acute Care Flashcards

Question 1

Q

Young girl with suspected sepsis. She is started on ceftriaxone and gets better. Culture grows S.pneumo sensitive time Ampicillin. She is switched to ampicillin and shortly after taking it develops urticaria. Her BP is low, HR 180 and RR 50. What is your next best step ?
A) IV diphenhydramine
B) Restart Ceftriaxone
C) 20ml/kg normal saline
D) Epi IV

Answer

A

C) 20ml/kg normal saline

Anaphylaxis = IM epi
Penicillin allergy

Question 2

Q

Heavy pot user is incarcerated. Withdrawal symptoms?

Or

Teenage girl, previously with heavy use of marijuana. Now incarcerated. What symptom is most likely?
A) none
B) Distorted thinking 
C) palpitations
D) Abdominal pain

Answer

A

D) abdominal pain

Cannabis use disorder: problematic pattern of cannabis use leading to clinically significant impairment of function or distress within a 1 year period. Usually have following functional impairments:

Reduced academic performance
Truancy
Reduced participation and interest in extracurricular activities
Withdrawal from their usual peer groups and conflict with family

Cannabis withdrawal syndrome
Sx usually 24-72h and duration 1-2 weeks

2/5 psych sx

1) Irritability
2) Anxiety
3) Depressed mood
4) Sleep disturbances
5) Appetite changes

1/6 physical sx

1) fever
2) Chills
3) shaking
4) Diaphoresis
5) H/A
6) abdominal pain

Question 3

Q

Boy comes in from MVA. GCS 10, pupils unequal. Becomes hypertensive 180/100, HR 40. Next steps?

A. Mannitol
B. Hypertonic saline
C. Intubate and hyperventilate
D. Labetalol

Answer

A

Controversial between B. Hypertonic saline and C. Intubate and hyperventilate

I would go with C. Intubate and Ventilate

This is TBI with ICP

Question 4

Q

MVA 10 y.o female reduced LOC, eye open to pain, withdrawal to pain and inappropriate words. GCS ?

A. 6
B. 7
C. 8
D. 9

Question 5

Q

Teen with acute SOB and wheeze, three times in the last few weeks, growing well, looks well, comes to ED - most likely test to give diagnosis ?

A. PFT
B. CXR
C. CT chest

Question 6

Q

A child ingested his grandmother’s bottle of iron pills, developed nausea and hematemesis and was brought to the hospital. In the ER he was fluid resuscitated, deferoxamine was started and his abdominal radiograph demonstrates many iron pills still in his stomach. What is your next step in management ?

A. Activated charcoal
B. Whole bowel irrigation
C. Endoscopic removal
D. Ipecac

Answer

A

B. Whole bowel irrigation

Management
- No role for charcoal or gastric lab age

Fluid resuscitation
WBI if tablets seen on AXR or of <6h post ingestion
IV deferoxamine

Question 7

Q

A four year old comes into the emergency department and needs intubation. What size of endotracheal tube do you choose for him ?

A. 3
B. 4
C. 5
D. 6

Answer

A

C. 5

Uncuffed ETT = age/4 +4

Question 8

Q

Teen at a music festival. Hypertensive, combative, agitated. No nystagmus. How do you manage? Mydriasis, flushed

A. Physical restraints
B. Olanzapine
C. Diazepam
D. Flumazenil

Answer

A

C. Diazepam

Question 9

Q

Patient with DKA. Given initial set of labs: ph 7.06, bicarbonate 7, lytes given Na 120s, Cl 100s anion gap 20 ( you must calculate AG yourself). Started in normal saline and 0.1 U/kg/h of insulin. Several hours later patient looks better. Given second set of labs: pH 7.03, bicarbonate still 7, but AG 8, Na 140s, Cl 130s. What is the cause of the acidosis ?

A. Lactic acidosis
B. Hyperchloremia
C. Inadequate insulin
D. Hypoventilation

Answer

A

B. Hyperchloremia

Hypoventilation - this causes a respiratory acidosis PH <7.4, PCO2 > 40mmhg but should have elevated HCO3 not lower

This is metabolic acidosis with a low PH < 7.4 and low HCO3 < 24.
Check anion gap = Na - (Cl + HCO3). Normal anion gap is 8-12

For high anion gap
CAT MUDPILES

For normal anion gap

diarrhea
glue sniffing
RTA
hyperchloremia

Question 10

Q

You are working in a community practice and mom calls you about her kid who ingested a button battery. Kid less than 5 y.o, size of battery not given

A. XRs after 10 days
B. Urgent plain films
C. Referral for emergent endoscopy
D. Reassure because kids often swallow things

Answer

A

B. Urgent plain films

Question 11

Q

Below what systolic blood pressure would a 3 y.o be considered hypotensive ?

A. 64
B. 70
C. 76
D. 84

Answer

A

C. 76

< 70 + (age in years x 2)

Question 12

Q

Seizures kid on clobazam at home. Got one inhaled midazolam what is next step ?

A. IV fosphenytoin
B. IV phenytoin
C. IV midazolam
D. IN midazolam

Answer

A

D. IN midazolam but only if no IV access otherwise it should be IV midazolam

Question 13

Q

A 6 year old boy is brought into the ER by ambulance after a high speed MVA. He is moaning and not responsive, extends his arms and legs to pain. His respiratory rate is 18, BP is 120/60, HR is 130. His pupils are 4mm bilaterally and reactive. What is your next step in management ?

A. RSI
B. Mannitol
C. CT head
D. NS bolus

Answer

A

A. RSI - GCS around 5

Exam tip: ETT in GCS <8

Question 14

Q

6 month old child presents to the emergency department with significant facial swelling and bruising (r/o NAI). Given vital signs, tachycardia and hypotension with BP 60/40s. SpO2 99%. Respiratory rate is normal, pupils are equal and reactive. Most appropriate next step ?

A. CT head
B. Insert IO and give bolus of normal saline
C. Give mannitol
D. Intubate

Answer

A

B. Insert IO and give bolus of saline

Question 15

Q

Child is admitted with strep pneumonia bacteremia and started on ampiciilin. Shortly after receiving antibiotics has decreased LOC and urticaria. Tachycardic and hypotensive. What would you do?

A. IV epinephrine
B. IV Benadryl
C. Normal saline bolus
D. Oral cetirizine

Answer

A

C. Normal saline bolus

Anaphylaxis = IM epi

Question 16

Q

A child presents to ER with bruising on face and her response to pain is withdrawal on one side only. Vitals revealed hypotension. What is your next management step:

A. CT head
B. Give NS bolus via IO
C. Hydrocortisone IV

Answer

A

B. Give NS bolus via intraosseous

Question 17

Q

2 year old infant presents with refusal to weight bear and is found on imaging to have a spiral fracture. What is the most likely explanation ?

A. Toddler’s fracture
B. Non accidental injury
C. Metabolic bone disease
D. Osteogenesis imperfects

Answer

A

A. Toddler’s fracture

Question 18

Q

16 year girl presenting with fever and disseminating rash. She has a fever of 39.5C, and blood pressure of 85/40, HR 130, RR 30 and saturations of 92%. She has bounding pulses and cap refill of 2s. She has already received 60 cc/kg of normal saline. What is the most appropriate choice for treatment ?

A. Dopamine
B. Epinephrine
C. Norepinephrine
D. Dobutamine

Answer

A

C. Norepinephrine

WArm shock - NE
Cold shock - epi

Question 19

Q

2 year old swallows a 8mm 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 48h, follow serially with xrays
C. Wait for 10 days, follow serially with xrays
D. Reassess if it does not appear in the stool

Answer

A

Controversial
A vs B vs C

Choosing C. Wait for 10 days, follow serially with x rays

Naspghan

Urgent endoscopy within 48h = asymptomatic, < 5 y.o , BB > 20mm
Repeat xrays at 48h = asymptomatic, > 5 y.o, BB 20mm
Repwar xrays at 10-14 days = asymptomatic, all ages, BB <20mm

Nelson’s
A button battery in the stomach should be removed within 48h as it can cause gastritis

Question 20

Q

A young child who comes to the ER with hypoglycaemia. Improves very quickly and completely with IV dextrose. What would be in keeping with this diagnosis ?

A. Urinary ketones
B. Inappropriately high insulin level
C. Failed ACTH stim test

Answer

A

A. Urinary ketones

This is ketorolac hypoglycaemia of childhood. Urine ketones are positive and it’s due to dehydration, vomiting etc.

Question 21

Q

Which of the following are not acceptable for long- term sedation ?

A. Intermittent lorazepam
B. Midazolam infusion
C. Propofol infusion
D. Fentanyl infusion
E. Morphine infusion

Answer

A

C. Propofol infusion

Propofol infusions are rarely prescribed for longer than 4h in critically ill children requiring sedation due to a concern for the development of propofol infusion syndrome characterized by:

Cardiac failure
Metabolic acidosis
Rhabdomyolysis
Renal failure
Death

The most commonly used agents for long term sedation in the PICU are:

Benzodiazepines
Opioids
Alpha agonists

Question 22

Q

3 y.o girl with history of URTI presents with strider. Vitals normal and stridor presents when crying. What is the best management ?

A. Single dose of oral steroid
B. Racemic epinephrine
C. Nebulized steroids
D. Humidified 02

Answer

A

A. Single dose of Oral steroid

This is croup give dexamethasone 0.6 mg/kg/dose PO

Question 23

Q

In ED - 4 year old girl with newly dx diabetes. Glucose 18.7, initial gas 7.14, bicarbonate 11. Insulin infusion is started, 2 hours later the girl has decreased LOC. What would be your immediate next step ?

A. IV mannitol
B. Bedside glucose stat
C. Stat calcium, Mg, P04
D. Stat head CT

Answer

A

B. Bedside glucose stat

Question 24

Q

No with wheezing and respiratory distress and urticaria after lunch. What should you treat with ?

A. Oral dexamethasone
B. Inhaled ventolin
C. IM epi
D. IV diphenhydramine

Answer

A

C. IM epi

Question 25

Q

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

A

C. Intubate, GCS of 5

Question 26

Q

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

Answer

A

B. Chest ultrasound to see if drainable pleura effusion

Question 27

Q

Toddler with dehydration. Weight 12kg. Irritable, no tears. What is your management ?

A. 1200 cc/kg ORT over 4h
B. 600 cc/kg ORT over 4h
C. IV fluids

Answer

A

A. 1200 cc/kg ORT over 4h

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

Question 28

Q

A 15 y.o boy with depression and conduct disorder presents to emergency with confusion and agitation. His vitals are T38.9C, HR 110, BP 145/95. He has lead pipe rigidity and tremor. Glucose, electrolytes, Ca, Mg, PO4 are normal. CK is elevated (8900). What is the most likely cause ?

A. Serotonin syndrome
B. Alcohol ingestion
C. Neuroleptic malignant syndrome
D. Amphetamine overdose

Answer

A

C. Neuroleptic malignant syndrome

Serotonin syndrome - get myoclonus
NMS - lead pipe rigidity

Question 29

Q

A child is involved in a 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
D. Pelvic fracture

Answer

A

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%

Question 30

Q

Criteria for brain death ?

A. EEG
B. Two examiners 24h apart
C. No response to hypercapnia test

Answer

A

C. No response to hypercapnia test

Question 31

Q

A child has been sick with vomiting and diarrhea. Mom has been feeding sugar water. Comes in with sodium 108, urea 13, Cr 95. How do you manage ?

A. Fluid restrict
B. Correct Na to 135-140 in 24h
C. Correct over 4-6h by giving 3% NaCl
D. Correct Na to 118-120 in 24h

Answer

A

D. Correct Na to 118-120 in 24h

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
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.
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

Question 32

Q

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

Answer

A

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

Question 33

Q

A kid has been seizing for 30 min, Hr 220, breathing difficult to assess but spo2 93%, glucose 4.2.

A. RSI
b. Insert IO
C. Insert IV
D. Intranasal midazolam

Answer

A

D. Intranasal midazolam

Question 34

Q

Teenager with hypertension, hyperthermia, tachycardia. Parents suspect drugs. Which drug would explain his presentation ?

A. Cocaine
B. LSD
C. Marijuana

Answer

A

A. Cocaine - sympathomimetics

But also isn’t LSD ??

Question 35

Q

4 year old girl presents to emergency with 48h 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 is the best course of action ?

A. Oral ondansetron
B. D5NS with 20KCL at maintenance
C. IV metoclopramide
D. PO gravel

Answer

A

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

Question 36

Q

A boy puts his finger in an electrical socket and has the rhythm below. He’s in emergency receiving CPR and sats are 100%. What is the next step ? ECG shows v- fib

A. Intubate
B. IV/IO epinephrine
C. Synchronised 1J/kg
D. Defibrillate 2J/kg

Answer

A

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

Question 37

Q

An adolescent girl takes 7g of Acetominophen at 5:30pm and gets to the emergency department at 6pm. At what time should acetominophen levels be drawn ?

A. Immediately
B. 7:30pm
C. 8:30pm
D. 9:30 pm

Answer

A

D. 9:30pm

Obtain 4h post-ingestion acetominophen. If unsure of timing go ahead and order it

Question 38

Q

Kid with a tracheostomy desaturates and is cyanotic. The nurse has tried to suction without improvement. What to do next ?

A. Intubate
B. Provide 100% oxygen
C. Change tracheostomy
D. Try suction the tracheostomy yourself

Answer

A

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…

Question 39

Q

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. What is most likely to occur as a result ?

A. Peaked T waves on ECG
B. Decreased urine output
C. Hypotension
D. Seizure

Answer

A

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

Hyperkalemia
Hypothermic
Dilutional coagulopathy
Hypocalcemia
Acidosis

Question 40

Q

4 year old boy victim of MVC. At the scene, wouldn’t open eyes, moans incomprehensibly, flexes legs with painful stimuli. What is his GCS

A. 5
B. 6
C. 7
D. 8

Answer

A

Answer B. 6

E-1: V-2, M-3 = 6

Question 41

Q

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

Answer

A

A. 1:1000 epinephrine IM

Question 42

Q

A 16 year old girl arrives in the ER unconscious, she is dry and hyperthermia, her pupils are large. Which of the following could be the cause of her presentation ?

A. Cocaine
B. Ecstasy
C. Amitriptyline

Answer

A

C. Amitriptyline - anticholinergic - she is dry so not sympathomimetic

The difference between TCA (anticholinergic) and sympathomimetics ingestion is the presence or

Question 43

Q

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 6h 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

Answer

A

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

Question 44

Q

Name the phases of iron toxicity

Answer

A

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

Question 45

Q

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, vita signs, and pupils are all normal. Which of the following is most likely ?

A. Ischemic stroke
B. Confusional migraine
C. Poisoning
D. Seizure

Answer

A

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.

Question 46

Q

6 year old 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 ED with an IV, intimated, without a pulse, rhythm now showing VT. What is your next step ?

A. Defibrillate 4J/kg
B. Give epinephrine 1:10000 (0.1 ml/kg) IV
C. Defibrillate 2J/kg
D. Continue CPR

Answer

A

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

Question 47

Q

14 year old male with vesicular, very pruritic rash and work of breathing, tachypnea. Most likely cause:

A. Myocarditis
B. Pneumothorax
C. Varicella pneumonia

Answer

A

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

Smoking
Pregnancy
Immunosuppression
Male sex

Question 48

Q

A child comes to the ER with an URTI, you do an X-ray and find a perfectly circular and completely opaque mass in the stomach. What do you do ?

A. Reassure
B. Call GI for urgent removal

Answer

A

A. Reassure - likely a coin not a button battery

Can observe small foreign bodies and repeat X-ray in 4 weeks

Question 49

Q

An early sign of shock in a child is:

A. Delayed cap refill
B. Increased HR
C. Low BP

Answer

A

B. Increased heart rate

Tachycardia is the first sign of compensated shock, followed then by increased SVR and decreased perfusion, cold temperature

Question 50

Q

A 14 your old boy is found vital signs absent in a park in -3C weather. He has received CPR for 30 min. Which of the following would be reason to stop?

A. Rectal temperature of 30C
B. Barbiturates found on tox screen
C. Refractory v- fin to debrillation
D. Electromechanical dissociation

Answer

A

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

Question 51

Q

A child presents to the emergency room on anaphylaxis. What is the best route to administer epinephrine ?

A. IV
B. IM
C. Inhaled
D. SC

Question 52

Q

A child was rescued after drowning. What is the most important in determining prognosis ?

A. Duration of submersion
B. Good quality CPR at the scene
C. A GCS of 7 on arrival to the ED
D. A lack of pulse and respirations at the scene

Extra: name the 5 good prognostic factors and the 3 bad prognostic factors and 7 bad prognostic factors from up to date

Answer

A

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

Immediate bystander CPR is the most important factor influencing survival
Return of spontaneous circulation in < 10 min
Submersion < 5 min
Pupils equal and reactive at scene
Normal sinus rhythm at scene

Bad prognostic factors
1. Delayed CPR
2. ROSC > 25 min
3 submersion > 10 min

Bad from up to date

Duration of submersion > 5 min ( most critical)
Time to effective life support > 10 min
Resuscitation duration > 25 min
Age > 14
GCS < 5
Persistent apnea and requiring cardiopulmonary resuscitation in the emergency department
Arterial blood ph < 7.1 upon presentation

Question 53

Q

Kid seizing for 30 min, no IV, glucose 3.6.

A. Intranasal midazolam
B. Insert IO
C. Rectal VPA

Answer

A

A. Intranasal midazolam

Question 54

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 02 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. Ampicillin and Gentamycin
C. Ceftriaxone
D. Racemic epi

Answer

A

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.

Question 55

Q

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

Answer

A

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

Question 56

Q

Picture of car seats- choose best one for 7 y.o with no head rest

A. Booster no back
B. Booster with back
C. 5 point restraint forward facing

Answer

A

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

Question 57

Q

Iron overdose, on deferoxamine already. Is now 1h post ingestion…what is the next step ?

A. Endoscopy
B. Charcoal
C. Whole bowel irrigation
D. Ipecac

Answer

A

C. Whole bowel irrigation.

Charcoal and ipecac are not used in iron overdose

Question 58

Q

Picture of normal CXR. Downs kid had a gtube 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 abdomen is firm and distended. Type of shock ?

A. Cardiogenic and hypovolemic
B. Distributive and hypovolemic
C. Cardiogenic and distributive
D. Cardiogenic and…..

Answer

A

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

Question 59

Q

Ondansetron is proven effective in 
A. 6 mo- 12 yr moderate dehydration
B. 3 mo- 12 yr with moderate dehydration 
C. 3 mo - 12 yr with severe dehydration
D. 6 mo- 12yr with severe dehydration

Answer

A

A. 6 mo- 12 yr moderate dehydration

Question 60

Q

A child was found with anti- cholinergic symptoms cause?

A. Benadryl
B. Cocaine
C. PCP

Answer

A

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

Question 61

Q

A teen was agitated, hypertensive, dry, flushed, mydriasis. Cause?

A. Cocaine
B. PCP
C. LSD
D. Marijuana

Answer

A

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

Question 62

Q

Kid with striders few times this week and now drooling, fever, stridor. What to do ?

A. Lateral XR
B. Call ENT
C. Neb of epinephrine

Answer

A

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)

Question 63

Q

What is the o2 % in a boy from a fire

A. Overestimated
B. Underestimated

Answer

A

A. Overestimated

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

Question 64

Q

How do we treat neuropathic pain ?
A. Gabapentin
B. Morphine

Answer

A

A. Gabapentin

Neuropathic pain - TCAs, gabapentin, pregabalinwith adjuvant topical therapy ie: lidocaine

Opioids are second line

Answer 62

A

B. Overestimated

Answer 63

A

A. Penumatocele

Answer 64

A

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 65

A

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 66

A

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 67

A

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 68

A

B. Start CPR

Answer 69

A

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

Answer 70

A

A. Cyclic vomiting

Diagnostic criteria all must be met

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

Answer 71

A

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 72

A

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 73

A

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 74

A

Absolute indications

Focal neurological deficit
Clinically suspected open or depressed skull fracture or a widened or diastatic skull fracture observed on X-ray

Relative indications

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

Answer 75

A

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 76

A

Mixed metabolic acidosis and respiratory alkalosis

Increased temp + hypokalemia + hypoglycaemia + elevated LFTs + coagulopathy + thrombocytopenia + elevated CK

Answer 77

A

D. Water intoxication

Answer 78

A

B. Perforation

Causes pressure necrosis and liquefaction necrosis

Answer 79

A

D. Assess capacity

Answer 80

A

A. Fomepizol

Answer 81

A

D. 15:2

Solo - 30:2
2 people - 15:2

Answer 82

A

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

Answer 83

A

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 84

A

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 85

A

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 86

A

A. Increased length of submersion

Answer 87

A

A. Insecticide

Cholinergic - miosis, coma, seizures

Cocaine sympathomimetic - mydriasis

Answer 88

A

B. Sodium bicarbonate

Answer 89

A

B. No specific treatment

V- fib max 3 attempts while temp 30.

If child is 30C

warm
CPR

Answer 90

A

C. intubate - GCS < 8

Answer 91

A

Uncompensated distributive shock

Anaphylaxis - distributive shock
Low BP - uncompensated

Answer 92

A

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 93

A

A. 400 ml of ORS per hour for 4h

Answer 94

A

A. ORF 100ml/kg

Answer 95

A

A. Sodium bicarbonate

Answer 96

A

B. Sodium bicarbonate

Never give phenytoin to TCA overdose
Decreased LOC so no activated charcoal

Answer 97

A

A. Change trach

Answer 98

A

B. Rhabdomyolysis

Answer 99

A

D. Bolus 20cc/kg via peripherAl line

Answer 100

A

B. Apnea despite hypercapnea

Answer 101

A

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 102

A

A and A

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

Answer 103

A

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 104

A

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 105

A

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 106

A

A. Tachycardia

M

Answer 107

A

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 108

A

B. 3rd ICS

Answer 109

A

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 110

A

A. Early intubation

Answer 111

A

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 112

A

A. Viral myocarditis is

Answer 113

A

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 114

A

Epinephrine 1 ml of 1:10000

0.1ml/kg or 0.01mg/kg

Answer 115

A

D. Bag mask ventilation

Poor resp rate and poor saturation’s - requiring ultimately intubation

Answer 116

A

A. Defibrillate with 4J/kg

Answer 117

A

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 118

A

D, A, B Jimson weed = anticholinergic

Could be imipramine as well but seems more likely to be smoking weed

Answer 119

A

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 120

A

D. High output acute renal failure

Kinda sounds like ATN caused by initial severe pre renal failure

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