Acute Care Flashcards
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
C) 20ml/kg normal saline
Anaphylaxis = IM epi
Penicillin allergy
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
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
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
Controversial between B. Hypertonic saline and C. Intubate and hyperventilate
I would go with C. Intubate and Ventilate
This is TBI with ICP
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
D. 9
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
A. PFT
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
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
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
C. 5
Uncuffed ETT = age/4 +4
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
C. Diazepam
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
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
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
B. Urgent plain films
Below what systolic blood pressure would a 3 y.o be considered hypotensive ?
A. 64
B. 70
C. 76
D. 84
C. 76
< 70 + (age in years x 2)
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
D. IN midazolam but only if no IV access otherwise it should be IV midazolam
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
A. RSI - GCS around 5
Exam tip: ETT in GCS <8
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
B. Insert IO and give bolus of saline
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
C. Normal saline bolus
Anaphylaxis = IM epi
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
B. Give NS bolus via intraosseous
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
A. Toddler’s fracture
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
C. Norepinephrine
WArm shock - NE
Cold shock - epi
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
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
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
A. Urinary ketones
This is ketorolac hypoglycaemia of childhood. Urine ketones are positive and it’s due to dehydration, vomiting etc.
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
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
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
A. Single dose of Oral steroid
This is croup give dexamethasone 0.6 mg/kg/dose PO
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
B. Bedside glucose stat
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
C. IM epi
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
C. Intubate, GCS of 5
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
B. Chest ultrasound to see if drainable pleura effusion
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
A. 1200 cc/kg ORT over 4h
Likely would say this is moderately dehydrated which would require 100cc/kg over 4h of ORT
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
C. Neuroleptic malignant syndrome
Serotonin syndrome - get myoclonus
NMS - lead pipe rigidity
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
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%
Criteria for brain death ?
A. EEG
B. Two examiners 24h apart
C. No response to hypercapnia test
C. No response to hypercapnia test
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
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
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
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
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
D. Intranasal midazolam
Teenager with hypertension, hyperthermia, tachycardia. Parents suspect drugs. Which drug would explain his presentation ?
A. Cocaine
B. LSD
C. Marijuana
A. Cocaine - sympathomimetics
But also isn’t LSD ??
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
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
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
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
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
D. 9:30pm
Obtain 4h post-ingestion acetominophen. If unsure of timing go ahead and order it
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
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…
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
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
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 B. 6
E-1: V-2, M-3 = 6
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
A. 1:1000 epinephrine IM
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
C. Amitriptyline - anticholinergic - she is dry so not sympathomimetic
The difference between TCA (anticholinergic) and sympathomimetics ingestion is the presence or
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
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
Name the phases of iron toxicity
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
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
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.
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
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
14 year old male with vesicular, very pruritic rash and work of breathing, tachypnea. Most likely cause:
A. Myocarditis
B. Pneumothorax
C. Varicella pneumonia
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
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
A. Reassure - likely a coin not a button battery
Can observe small foreign bodies and repeat X-ray in 4 weeks
An early sign of shock in a child is:
A. Delayed cap refill
B. Increased HR
C. Low BP
B. Increased heart rate
Tachycardia is the first sign of compensated shock, followed then by increased SVR and decreased perfusion, cold temperature
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
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
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
B. IM
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
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
Kid seizing for 30 min, no IV, glucose 3.6.
A. Intranasal midazolam
B. Insert IO
C. Rectal VPA
A. Intranasal midazolam
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
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.
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
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
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
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
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
C. Whole bowel irrigation.
Charcoal and ipecac are not used in iron overdose
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…..
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
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
A. 6 mo- 12 yr moderate dehydration
A child was found with anti- cholinergic symptoms cause?
A. Benadryl
B. Cocaine
C. PCP
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
A teen was agitated, hypertensive, dry, flushed, mydriasis. Cause?
A. Cocaine
B. PCP
C. LSD
D. Marijuana
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
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
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)
What is the o2 % in a boy from a fire
A. Overestimated
B. Underestimated
A. Overestimated
Standard pulse oximetry (sp02) Cannot screen for CO exposure as it does not differentiate carboxyhemoglobin form oxyhemoglobin
How do we treat neuropathic pain ?
A. Gabapentin
B. Morphine
A. Gabapentin
Neuropathic pain - TCAs, gabapentin, pregabalinwith adjuvant topical therapy ie: lidocaine
Opioids are second line
Kid from burning house, covered in soot; sat 89%; is it ?
A. Accurate
B. Overestimated
C. Underestimated
B. Overestimated
Kid took a bottle of camphor. What do you see on CXR ?
A. Penumatocele
B. Hyperinflation
C. Cardiomegaly
D. Tracheal- bronchial narrowing
A. Penumatocele
Asthmatic presents with history of increased cough and is in severe respiratory distress. Ventolin, iptateopium bromide and steroids have all been attempted with no improvement. What do you do next ?
A. Give MgS04
B. Intubate and ventilate
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
Tylenol overdose at 8h. What do should see on lab work ?
A. PH 7.21
B. PH 7.58
C. PH 7.38, pO2 60
D. PH 7.38, pO2 90
Extra: what are the stages of Tylenol overdose?
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
Describes a 14 y.o girl presents after a 15 min seizure and is no longer seizing now. Her BP is 190/100; edematous but Cr ok. Neurological exam is normal now. WBC 3.0 with 2%lymphocytes, hg 88, plays 130. Urine has large proteinuria. What to give immediately ?
A. Methylpred
B. SL nifedipine
C. IVIG
D. Phenytoin IV
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
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 step in management ?
A. Increase PIP
B. Decrease PIP
C. Increase peep
D. Decrease peep
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
14 y.o boy has a witnessed collapse on the basketball court. He is pulseless. What is the next step in management ?
A. Defibrillate
B. Start CPR
C. Administer an epi pen IM
D. Start artificial ventilation
B. Start CPR
4 y.o boy presents after 5 days of URTI symptoms with fever, dysphasia and refusal to move his neck laterally. Flexion of the neck is fine. Which test is most likely to reveal the diagnosis ?
A. Lateral neck X-ray
B. CT neck with contrast
C. Neck u/s
A. Lateral x ray (if vitals stable and there is time for investigations)
6 year old girl with recurrent non bilious projectile vomiting with abdominal pain and pallor. She has headaches. Has had to get IV dehydration on several occasions. She is normal between episodes. What is your diagnosis ?
A. Cyclic vomiting
B. Intermittent intussuception
C. Intermittent volvulus
D. Brain tumor
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
Case scenario of a child who presents with decreased LOC. She has flexion posturing, moans to painful stimuli and will not open her eyes to painful stimuli. What is her GCS
A. 6
B. 7
C. 8
D. 9
A. 6
6 year old child post MVA in shock. You determine that airway is well protected saturation of 100% on oxygen. HR 170, BP hypotensive. You have 2 large bore IV and give 1 bolus of 400cc of NS and patient is still hypotensive. What do you do next ?
A. Start dopamine infusion
B. Bolus 400cc of NS
C. Bolus 400cc of albumin 5%
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
Baby in respiratory distress. rR12 and severe indrawing. Lots of wheeze on auscultation. What to do next ?
A. Bag and mask
B. Salbutamol inhalation
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
Trauma head injury question GCS 7, what is most likely to cause secondary injury on transport ?
A. Hypoxia
B. Hypotension
C. Hypercapnia
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
Extra: in mild head trauma what are the absolute indications for a head CT and what are the relative indications ?
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
Symptoms of ASA overdose
A. Hyperpyrexiq
B. Renal failure
C. Metabolic alkalosis
D. Elevated K
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)
Extra: What is the acid base status in ASA and what are lab abnormalities ?
Mixed metabolic acidosis and respiratory alkalosis
Increased temp + hypokalemia + hypoglycaemia + elevated LFTs + coagulopathy + thrombocytopenia + elevated CK
10 month old had private swimming lesson x45 min. 1h after lesson is found lethargic and brought to ER. Has GTC seizure. 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
D. Water intoxication
Concerns about swallowing a button battery
A. None
B. Perforation
C. Airway obstruction
B. Perforation
Causes pressure necrosis and liquefaction necrosis
16 year old Jehovah’s Witness, unstable with Hb in 40s, refusing therapy
A. Give blood anyway
B. Get directions from next of kin
C. Accept refusal
D. Assess capacity
D. Assess capacity
Treatment of methanol overdose ?
A. Fomepizol
A. Fomepizol
For 2 person resuscitation of a 5y.o boy, what is the appropriate compression:ventilation ratio ?
A. 10:2
B. 5:2
C. 30:2
D. 15:2
D. 15:2
Solo - 30:2
2 people - 15:2
What rate do you do CPR on a 5 year old boy ?
A. 15:2
B: 15:1
A. 15:2
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 the police the result
B. Call CMPA
C. Wait for the patient to wake up and ask him
D. Refuse unless the police produce a warrant/court order
D. Refuse unless the police produces a warrant/ court order
Oral rehydration in kid with moderate dehydration
A. 100cc/kg over 4h
B. 50cc/kg over 4h
C. NS bolus 20cc/kg
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
13 kg child with gastroenteritis, with k 2.5, Na 138. Physical findings…..management ?
A. 300ml/h ORS over 4 hours
B. Give D5 1/2 NS
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
2 week old child pale, limp, lethargic. HR 210, RR 70. After obtaining IV, you
A. Intubate
B. Broad spectrum antibiotics
or
2 week old with sepsis like picture. Hypotensive, RR 70, on 50% oxygen, sats 95%. What is your next step in management ?
A. IV abx
B. Bag mask
C. Intubate
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.
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. Cardio resp arrest at scene
A. Increased length of submersion
3 year old with miosis and seizure. Which toxin did he ingest ?
A. Insecticide
B. Cocaine
C. Beta blocker
D. Nicotine
A. Insecticide
Cholinergic - miosis, coma, seizures
Cocaine sympathomimetic - mydriasis
5 year old child accidentally took some of dad’s imipramine, unknown amount. QRS 130ms. What do you do ?
A. Activated charcoal
B. Sodium bicarbonate
B. Sodium bicarbonate
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 V- fib. Nurses get an IV. Along with rewarding what else you do for the child ?
A. Amiodarone
B. No specific treatment
C. Lidocaine
D. Defibrillate
B. No specific treatment
V- fib max 3 attempts while temp 30.
If child is 30C
- warm
- CPR
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
C. intubate - GCS < 8
Infant being treated for a. 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
Or Child with a diffuse erythematous rash, sick in ICU with strep penurmonia sepsis. He got his first dose of pen G, then developed rash and hypotension. Also HR 220, decreased LOC. What does this scenario describe ? A. Uncompensated hypovolemic shock B. Compensated cardiogenic shock C. Uncompensated distributive shock D. Uncompensated obstructive shock
Uncompensated distributive shock
Anaphylaxis - distributive shock
Low BP - uncompensated
Kid with fatigue, 13 kg, decreased skin turbot, delayed cap refill but normal vital signs. Vomiting and diarrhea x 3 days. Ph 7.33, pCO2 27, bicarbonate 14, BE -9.7. Next step?
A. IV bolus NS 20ml/kg
B. IV bolus ringer’s lactate 10cc/kg
C. ORS 300cc/h for 4h
D. ORS 5cc/h over 24h
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
15 kg child with tachycardia, dry mucous membranes and a history of vomiting and diarrhea. What is the most appropriate rehydration regimen ?
A. 400ml of ORS per hour for 4 hours
B. 100 ml of ORS per hour for 4 hours
C. Rehydrate with apple juice
D. Start IV fluids
A. 400 ml of ORS per hour for 4h
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 50 ml/kg
C. NS bolus 20ml/kg
A. ORF 100ml/kg
Kid with suspected overdose of amytriptilline. Treatment ?
A. Sodium bicarbonate
B. Phenobarbital
C. IV bolus
D. Observe
A. Sodium bicarbonate
Teenager overdosed on imipramine. Presents with decreased LOC. What do you do ?
A. Give phenytoin
B. Sodium bicarbonate
C. Activated charcoal
B. Sodium bicarbonate
Never give phenytoin to TCA overdose
Decreased LOC so no activated charcoal
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
Teenager in a MVA a day before and was observed in ER. Now presents with orange urine and his creatinine has tripled. What is the diagnosis ?
A. Renal vein thrombosis
B. Rhabdomyolysis
C. Glomerulonephritis
B. Rhabdomyolysis
Child with fever, rash, hypotension. Cap refill is 5s. What is the best immediate management ? A. Bolus D5W 1/2NS at 20cc/kg B. Bolus NS 20cc/kg via central line C .bolus 5% albumin D. Bolus NS 20cc/kg via peripheral line
D. Bolus 20cc/kg via peripherAl line
What is a criteria for neurologic determination of death ? A. Absence of hyperthermia B. Apnea despite hypercapnia C. Spinal reflexes are absent D. Characteristic EEG
B. Apnea despite hypercapnea
Teen with tension pneumothorax, where do you put the needle ?
A. Needle over the 3rd rib, in the second intercostal space at the midclavicular line
B. Needle over the 5th rob, in the 4th intercostal space modclavicular line
C. Needle in the 2nd IC space, anterior axillary line
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
Child 20 &g. Uncompensated shock. Airway secure. Next step
A. 800cc NS
B. 400cc 5% albumin
C. Dopamine infusion
D. Epi infusion
14 y.o F with sepsis but good sats. Most appropriate intervention
A. 40cc/kg IVF NS
B. Epi
C. Dopamine
D. 20cc/kg of albumin 5%
A and A
Cristalloid better for septic shock. Second question weird that starting at 40
Best indicator of compensated shock ?
A. N BP, cool extremities, decreases LOC, delayed cap refill
B. Brady, HTN, apnea
C. N Brady, N LOC, increased CO2, decreased PO2, N urine output
D. N BP, tachy, unresponsive, normal pulses
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
A 4 y.0 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
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
8 year old with 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
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.
What is the best early indicator of mild dehydration ?
A. Tachycardia
B. Cap refill of 4-5s
C. Hypotension
A. Tachycardia
M
A 3 year old child arrives in the ED with a history of seizing for 30min. HR is 220, respirations are difficult to asses, BP is 150/80. You are unable to get an IV. What do you do ?
A. Sodium nitro prissier
B. Rectal benzodiazepine
C. Intubate
D. IM Dilantin
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
Site for needle decompression of suspected pneumothorax?
A. 3rd ICS AAL
B. 3rd ICS MCL
C. 5th ICS AAL
D. 5th ICS MCL
B. 3rd ICS
13 year old male taken to ED 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
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
Boy found at house fire, stable, singed nasal hairs and burns around mouth, mild stridor, darting fine on O2
A. Early intubation
B. Admit observation
A. Early intubation
3y.o in 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 sequels be nil ?
A. 6h
B. 12h
C. 24h
D. 48h
D. 48h
9 month old baby with symptoms of gastroenteritis x 3 days, comes to ED 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 q2
B. Normal saline
C. D5w 0.45 NS
D. D10W
Or 10 month old with hyponatremia seizure A. 3% NS to raise 2mmol/h B. D5W 1/2 NS C. NS bolus D. Phenobarb 15mg/kg
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
10 year old boy with URTI x 10 days, presents to ER looking unwell. On exam, petechial rash, Grade 2/6 murmur with gallop. What is most likely diagnosis ?
A. Viral myocarditis
B. Acute rheumatic fever
C. SLE
D. SBE
A. Viral myocarditis is
7 year old with URTI 2 weeks ago. Now presents on CHF and a maculopapular rash. What is most likely diagnosis ?
A. Viral myocarditis
B. Acute rheumatic fever
C. Subacute bacterial endocarditis
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
11 month old infant with ECG showing some electrical activity but no pulse on exam. What do you give ?
A. Epi 1 ml of 1:1000
B. Epi 1 ml of 1:10000
C. Atropine
oR
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 1mg
B. Atropine 0.1mg
C. Epinephrine 1/1000 1ml
D. Epinephrine 1/10000 1ml
Epinephrine 1 ml of 1:10000
0.1ml/kg or 0.01mg/kg
Baby with severe bronchiolitis, wheezing, severe retractions, lethargy. HR 160, RR12, sats 82%, what is the next step ?
A. Give racemic epi
B. Give salbutamol
C. Give steroids
D. Bag- mask ventilation
D. Bag mask ventilation
Poor resp rate and poor saturation’s - requiring ultimately intubation
Child with near drowning with chest compressions started at scene by EMS. Child is given one shock with AED and arrives in ED. 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 0.1 ml/kg epi IV
C. Cardiovert with 2J/kg
D. Give amiodarone
A. Defibrillate with 4J/kg
Child with PEA in an outside hospital, now with wide complex QRS, tachycardia, shocked x1 in ER, still wide complex tachycardia. cPR ongoing. Next step :
A. Defibrillate 2J/kg
B. Defibrillate 4J/kg
C. Epi 0.1 ml/kg
D. Amiodarone
OR
Child with pulseless wide complex tachycardia, got defibrillated x 1 and is receiving CPR. IV is in situ. What do you do next ?
A. Shock 2J/kg
B. Shock 4J/kg
C. Epinephrine 1:10000, 0.1ml/kg
D. Lidocaine
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
Teenage boy previously well presents to your ED 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
Or
teen with dilated pupils, altered LOC, N HR , N BP, flushed face. Ingested what ?
A. Jimson weed
B. TCA
C. Ethanol
D. Marijuana
Or
A 13 year old boy presents with his parents in an o tundra state. His GCS is 9, he is rousable to stimulation but flails his arms and acts very inappropriately. He 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
D, A, B Jimson weed = anticholinergic
Could be imipramine as well but seems more likely to be smoking weed
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 intercostal one affected side
D. Chest tube of symptomatic
Or
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 of the pneumothorax is greater than 10%
C. Insert a needle into the 2nd intercostal space midclavicular line
D. Transfer without intervention
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.
Boy post MVA with multiple injuries, initially very hypotensive (50/20) but recovered with multiple blouses 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
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 ?
Boy with rhabdomyolysis, now with orange urine and increasing creatinine, not responding to multiple blouses of NS. What to do next ?
A. Mannitol perfusion
B. NE perfusion
C. Epinephrine perfusion
D. 3% NS perfusion
Or
14 year old boy presents after an MVA and major trauma. He is stabilized and admitted. The following day he develops very dark urine and his creatinine roses from 50 to 300. After hyper- hydrating him, what medication would you use ?
A. Epinephrine
B. Mannitol
C. Norepinephrine
Mannitol
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 1:10000 C. Epinephrine IV 1ml 1:1000 D. Epinephrine ETT 1ml 1:10000
Or
1 year old is in septic shock, he weighs 9kg. You assess him and find that he is hypotensive and extremities are shut down and not responsive. Cardiac monitors shows sinus rhythm but when you assess his pulses, you cannot feel then. What do you give him ?
A. Atropine
B. Epi 1/1000 1 ml
C. Epi 1/10000 1ml
B, C - Epi 1/10000 1 ml. From these questions it is safe to say that a 1 y.o weighs approximately 10kg
Child presents with seizure x 30 min, HR 200s, BP high, O2 given by face mask and airway patent, respirations “difficult to assess”, what is the next appropriate management ?
A. Phenytoin IO
B. Rectal Benzo
C. Intubate
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
Child presents to ED with decreased level
Of consciousness, starts posture fever rate but then quickly progresses to decorticating posturing. What should you do ?
A. Mannitol
B. CT scan
C. Phenytoin
OR
6y.o with severe headache collapses and has progressive posturing. After intubation, what would you do ?
A. Mannitol
B. Urgent CT scan
A. Mannitol
Which of the following would do the least in a child with severe head injury ( might also have been seizing) ?
A. Control fever
B. Hyperventilate
C. Sedate and analgesia
D. Mannitol
Or kid with excruciating h/a this morning. Collapsed in ED. CT shows big goober in L hemisphere with midline shift. Which of the following would be least helpful in management ?
A. Analgesia and sedation
B. Hyperventilation
C. Mannitol
B. Hyperventilate
What is the best way to assess initial adequacy of ventilation ?
A. Chest movement, 02 saturation, capnography
B. Chest movement, venous gas, capnography
C. 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. CXR, capnography, end- tidal CO2
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
A 4Y.o with CP is involved in an MVA. He has been in the ICU for 1 week with a GCS of 4. There is no improvement despite aggressive management and mechanical ventilation. Parents approach you regarding withdrawal of treatment.
A. If two EEGs done 24h apart show isoelwctroc background, then withdraw
B. So cerebral angiography to document no blood flow to confirm brain death
C. Obtain neurological consult to substantiate brain death
D. Discuss the options again with the parents, and if they remain certain about the decision then proceed with withdrawal
D. Discuss and withdraw
Little kid with 3 days of diarrhea. Today urine output is less. In ER, tachycardic, poor skin turgor, BP ok. How to manage ?
A. Oral rehydration
B. IV hydration
C. Antibiotics
D. Kayopectate
Or
A toddler presents with doarrhea and moderate dehydration ( tachycardia, normal BP, low skin turgor). What management is appropriate ?
A. Give IV fluids now
B. Rehydrate with oral rehydration solution
Oral rehydration solution
2 month old baby comes with meningitis and focal seizure. Symptoms of shock described. GCS 6. What is first step in management ?
A. Culture and antiobiotica
B. Intubation
C. CT
D. LP
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)
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
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.
A child invests 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
C. Observe and treat supportively
A child presents with progressive coma, but normal pupils. What is the most likely diagnosis ?
A. Poisening
B. Hemorrhagic stroke
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
A child presents to the emergency department with SOB and wheezing. This occurred suddenly after playing with older sibling. What should be the next management step after CXR?
A. Brinchoscopy
B. Ventolin via nebulizer
C. Racemic epinephrine
A. Bronchoscopy
Likely foreign body aspiration
3 y.o trauma patient with depressed skull fracture is unstable with desaturation and hypotension. What is your next management step ?
A. Urgent CT
B. Intubate
C. Given mannitol
B. Intubate
aBCs first. Mannitol takes too long and too unstable for CT
A 6 year old child swallowed a coin. It is visible in the stomach on AXR. What should be done ?
A. Arrange for urgent removal of coin from stomach
B. No intervention necessary, follow up only
C give syrup of ipecac
B. No intervention necessary, follow up only
Young child is in PICU with a brain tumor; terminal. Which is true regarding organ donation ?
A. Organ donation does not need consent for all the organs
B. Patient need not be brain dead for consent to be obtained for organ donation
C. There are no absolute contraindications for organ donation
D. Do not need consent for tissue donation
E. It is possible to consent only to donation of specific organs
E. It is possible to consent only to donation of specific organs
15 y.o post trauma observed for 24h and d/c home. Presents a day later with orange urine and oliguria and high CR, no improvement with fluids.
A. Rhabdomyolysis B. Renal vein thrombosis C. Renal artery thrombosis D. Renal contusion E. Pre renal failure
A. Rhabdomyolysis
Crush injuries in the pelvic area can lead to rhabdomyolysis
Pre renal failure improves with fluids whereas rhabdomyoma more resistant
3 year old with trauma, skull and femur fracture and has already received 3 boluses of 20cc/kg. HR 160, low BP - unchanged. Next step:
A. Mannitol/lasix
B. Intubate and give another bolus
C. Inotropes and packed RBCs
D. Intubate and blood
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 !?!
Q1- Description of toxic shock syndrome with erythema, fever, low BP. Already received 2 x 20cc/kg. Slightly decreased LoC. Next ?
A. Bolus and inotropes
B. Intubate and bolus
C. Epi
D. Blood
Q2- infant with temp 40C, BP 70/30, HR 160. Diffuse skin erythema. Refractory to 20cc/kg bolus normal saline x 3. Slightly decreased LOC. Next step ?
A. Intubate and re- bolus
B. Inotropes and re- bolus
C. Ceftriaxone and transfuse pRBCs
D. Something else and pRBCs
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.
16 y.o M had been agitated and aggressive earlier in the evening. Brought in unconscious, but rouses intermittently showing rigidity and hyper reflex is. What has he ingested ?
A. Cocaine
B. PCP
C. Heroin
B. PCP
You are asked to assess a 5 year old kid who had surgery and has been receiving 20mg/kg acetominophen q4h for 5 days. He now has decreasing LoC. Which is true ?
A. Acetominophen is not a good drug for post- op pain management
B. He needs to be worked up for hepatic toxicity
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
Which is used to treat overdose of windshield wiper fluid (containing methanol)
A. Fomepizole B. Physistigmine C. Flumazenil D. Naloxone E. Pralidoxime
A. Fomepizole
Child with blunt abdominal trauma, gross hematuria, positive DPL ( diagnostic peritoneal lavage). What is next ?
A. Abdo CT
B. AXR
C. Transfuse pRBCs
E. Insert foley
Controversial
Cheo chose A - abdo CT
Mac chose d- transfuse pRBCs
Parents decide to withdraw life support from a brain injured child who has been comatose for 6 months. All are true except:
A. May rapidly increase morphine
B- if in resp distress or hypoxemic may start morphine
C. Removing feeding tube constitutes terminating care
D. If he develops pneumonia you are allowed not to treat
E. You may consult ethics if there is a difference in opinion
C. Removing feeding tube constitutes terminating care
What is the indication to use HCO3 in a TCA overdose ?
A. On presentation
B. To maintain a normal Ph
C. To prevent cardiac dysrhythmia
C. To prevent cardiac dysrhythmia
After faking off of a bike a couple of hours a 6 y.0 boy presents with flank pain and hematuria. What test is diagnostic ?
A. CT abdo
B. Retrograde pyelogram
C. Surgical exploration
D. Peritoneal lavage
A. CT abdo
A boy is brought in to the ER from a musica concert. He is agitated, tachycardic, hypertensive. What do you do ?
A. Given diazepam
B. Put him in restraints
C. Give haldol
D. Give Benadryl
A. Give diazepam
You are transporting a child with a pneumothorax. What is mos likely to make her deteriorate ?
A. Increased pCO2
B. Decreased p02
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
What are common side effects of hypernatremic dehydration ?
A. High serum glucose, high serum calcium
B. High serum glucose, low serum caclcium
C. Low serum glucose, low serum calcium
D. Low serum glucose, high serum caclicum
B. High serum glucose, low serum calcium
Hypernatremia is a/w hyperglycaemia and mild hypocalcemia; the mechanisms are unknown
If you are hit by lightning, the most likely sequela:
A. Renal failure
B. Liver failure
C. Persistent psychosis
D. Cardiovascular collapse
D. Cardiovascular collapse
Child in playing garden shed, comes out drooling. Appropriate management:
A. Pyridostigmine
B. Atropine
B- atropine
Likely insecticide ingestion - organophosphate - cholinergic
Pyridostigmine is also an organophosphate and you use it to treat anticholinergic intoxication
Toddler with GE presents with lethargy, pallor and significant dehydration . hr 120, BP 70/40, rapid respirations, given 20cc/kg NS bolus. Nurse informs you that the child has stopped breathing, next step in management?
A. Ventilate with 100% 02, fluid bolus, epinephrine
B. Ventilate with 100% O2, dopamine, fluid bolus
C. Dopamine, ventilate with 100% 02, fluid bolus
D. Fluid bolus, ventilate with 100%O2, bicarb
A. Ventilate with 100%o2, fluid bolus, epinephrine
ABcs then follow shock algorithm so fluid resuscitation first then pressor
In an overdose with a TCA all would be present except ?
A. Tachycardia B. Urinary retention C. Increased bowel sounds D. Mydriasis E. Seizures
C. Increased bowel sounds
All are features of a first degree burn except ?
A. Redness B. Pain C. Dry skin D. Pterychnia E. Blanches on palpation
D - not a real word
Rest are true
Adolescent in the ER after a MVA. He is comatose. His breath smells of alcohol
A. Attending physician can take a blood alcohol level without patient’s consent
B. Attending physician should talk to the police about possible alcohol ingestion
C. Parents can refuse alcohol level
D. Police can look at the medical file
A. Attending physician can take the blood alcohol level
A teenager is brought into the ER after taking 4 pills consisting of a white powder. He is comatose with hypertension, muscle rigidity, myoclonic jerks and nystagmus.
A. Cocaine B. Psilocybin C. PCP D. LSD E. Amphetamines
C. pCP
10 year old boy has a temp of 39.3, Rr 44 on 100% 02, HR 140 and BP 60/p. There is a diffuse erythematous rash on his body and one lesion that looks like impetigo. He is given a 20cc/kg bolus of saline with no improvement. How do you proceed ?
A. Bolus again- intubate - penicillin B. Bolus again - inotrope - cloxacillin C. Bolus again - ceftriaxone - intubate D. Inotrope - intubate - cloxcillin E. Intubate - bolus again - penicillin
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
7 year old child has been in MVA . He is unstable with a HR of 160. Hb 50. The parents are jehovah’s witnesses. How should you proceed:
A. Transfuse blood now without parental consent
B. Await for a court order before transfusing blood
C. Respect the parents decision to refuse transfusion
D. Transfuse with albumin instead of blood
E. Spend time with the parents in hopes of changing their decision about transfusion
A. Transfuse blood now without parental consent.
Toddler with gastroenteritis and moderate dehydration. What management is most appropriate?
A. Give Iv fluids now
B. Give IV fluids if vomiting
C. Give oral solution containing 20-65mmol of Na
D. Stop breastfeeding and give electrolyte solution
E. Hold refeeding for 72 h
D. Stop breast feeding and start e solution
Best oral rehydration solution in a child with gastroenteritis ?
A . Sodium 20mmol/L, potassium 20 mmol/L, glucose 10%
B. Sodium 60mmol/L, potassium 20 mmol/L, glucose 2%
C. Sodium 60mmol/L, potassium O mmol/L, glucose 8%
D. Ginger ale
E. Apple juice
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
Q1 child was involved in a house fire 1 hour prior to arrival in your ER. He is in respiratory distress with an O2 sat 78% on FIO2 1.0. His response to bag and mask is inadequate and a decision is made to intubate. Despite previous ventilation in the field, his saturation is still poor on FIO2 1.0. Initial way to assess adequate ventilation ?
A. Chest motion- capnography - sao2
B. Chest motion - auscultation - sao2
C. Chest motion - auscultation - capnography
D. Ausculatation - capnography - Sa02
E. Auscultation - venous gas - capnography
Q2 same scenario. What would be your initial ventilator settings ?
A. FI02 1.0 - Pip 20 - peep 5 - rate of 20
B. FIo2 1.0 - PIP 10 - PEEP 5 - rate of 20
C. FI02 1.O - PIP 10 - Peep 0 - rate of 40
D. FIO2 0.5 - PIP 30 - PEEP 5 - rate of 20
E. FIO2 0.5 - PIP 20 - PEEp 0 - rate of 20
Q1 c- Chest motion - auscultation - capnography
Q2 a- FIO2 1.0 - PIP 20 - peep 5 - rate 20
All of the following are therapeutic measures in TCA overdoses except:
A. Alkalinization of the urine B. Phenytoin for arrhythmias C. Repeated doses of activated charcoal D. Hemodialysis E. Norepinephrine for hypotension
B. Phenytoin for arrhythmias
Cardiovascular and CnS symptoms dominate
CCCA Coma Convulsions Cardiac dysrhythmia Acidosis
Child with 15% blood loss after MVA. ETA to ER is at least 1h. Which of the vital signs most represents the patient upon arrival to ER ?
A. Pulse 120, RR 30, BP 90/60
B. Pulse 130, RR irregular, BP 100/70
C. Pulse 220, RR 36, BP 60/40
D. Pulse thready, RR 36, BP not obtainable
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
An 8 year old male with Down’s syndrome is admitted to the PICU with his 5th episode of pericarditis . Which is true:
A. It is time to discuss a DNR
B. When parents and physicians disagree on management, the ethics committee must be consulted
C. The choice is up to the patient
D. Once parents have decided to treat the child, they may change their minds at a later stage
D. Once parents have decided to treat the child they may change their minds at a later time
Which of the following statements regarding autonomy is true on pediatrics
A. The wishes of the parents supersedes the wishes of the child
B. If there is a psychiatric problem, the wishes of the parent and child are not valid
C. CAS authority can supersede the wishes of the parent and the child
D. The right to autonomy can be used to force the MD to take medical action that they feel is inappropriate
E. If conflict exists, the physician’s opinion takes precedence over that of the parent or the chikd
C. cAS authority can supersede the wishes of the parent and the child
Child is brought to the emergency department by parents. They suspect he has taken an overdose. The child denies any ingestion. On examination: T 38.2C, HR 132, BP 150/90. The most likely drug
A. LSD
B. Cocaine
c. Cannabis
D. Barbiturates
B. Cocaine
Sympathomimetics
LSD - hypertension and hyperpyrexiq but not tachycardia
Barb - hypotension
A 4 month old infant presents in shock with a temp of 41.8C. In the OcU on ventilator, spontaneous bleeding occurs and the pupils are sluggish. The most likely diagnosis is :
A. E. Coli meningitis
B. Hemorrhagic shock and encephalitis syndrome (HSES)
C. Reye syndrome
B. 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
A 15 year old male collapses while playing basketball. CPR is initiated, emergency responders intubate the patient. You see the following rhythm strip: ( they show strip with wide complex tachycardia, irregular rate)
A. What does the rhythm show?
B. What are two treatments you should initiate ?
C. What is your compression ratio per min ?
D. What is your ventilation ratio per min ?
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)
A boy is involved in a MVC. He was intubated by the ED doctor. He now develops bradycardia, hypotension and a dilated pupil. List 4 steps in your treatment
ICP management
- Head of bed to 30 degrees, midline head position
- 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
- Stat neurosurgery consultation - if possible prior to hyperosmolar therapy or hyperventilation
- Hyperosmolar therapy with 3% saline or mannitol
- Avoid hypotension - IVF, bolus, pressors = keep normovolemic
- Pain control and sedation = decreases ICP by reducing metabolic demand, ventilator asynchrony, venous congenstion and the sympathetic responses of hypertension and tachycardia +- neuromuscular paralysis
- Maintain normal temperature = aggressive treatment of fever with acetominophen and mechanical cooling
- CT head without contrast once stable
- Correct glucose + Na
A three year old boy is brought to th emergency department room after extrication from a house fire. He was found in a smoky room.
A. What three clinical features would make you think that he has upper airway inhalational injury?
B. What is your immediate intervention ?
- Burns to face
- Spot in mouth/nose/sputum
- Singed nose hairs
- Edema/erythema/ulceration or oro- nasopharyngeal mucosa
- Stridor, WOB, tachypnea
Intubation next step
Go back to table in acute care for epi, NE etc and fill out the blanks !!!
See table
Kid with methanol toxicity. Na 140, k 4.0, Cl 96, bicarbonate 11, BUN11, glucose 4, serum osmolarity 396
A. Calculate the anion gap
B. If anything what would you expect of the osmolar gap ?
C. What is the long term complication of methanol toxicity ?
D. What is one Med to treat methanol toxicity ?
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
2 patients arrive at the same time in the ED:
Patient 1 - 8 y.0 boy with asthma attack, resp distress and tracheal tug. RR 36, pCO2 28
Patient 2 - 8 y.o boy with asthma attack, resp distress and tracheal tug. RR 20, PCO2 38
A. Which patient do you see first ?
B. Explain your choice
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
