Acute Care Flashcards
1. Which of the following is not acceptable for long-term sedation? A. Intermittent lorazepam B. Midazolam infusion C. Propofol infusion D. Fentanyl infusion E. Morphine infusion
Propofol infusion
- Short onset <1min + duration 3-10min
- Activates central GABA receptors
- rapidly metabolized by liver, active metabolites renally excreted
- SE: low BP, burning at IV site
uncommon: bradycardia, arrhythmia, sz, myoclonus-like activity, infxn from contaminated vials
Propofol Infusion Syndrome
- high doses >4mg/kg/h + prolonged use >48H
1) Acute refractory bradycardia
2) Cardiac failure
3) Renal failure
4) Hepatomegaly
5) Hyperlipidemia
6) Rhabdomyolysis
7) Severe metabolic acidosis - Stop propofol + supportive care
3 yo girl with history of URTI presents with stridor. Vitals normal and stridor present when crying. What is the best management?
a. Single dose of oral steroid
b. Racemic epinephrine
c. Nebulized steroids
d. Humidified oxygen
Single dose of oral steroid
Improvement in 2-3H, persists for 24-48H
For croup
a) Mild (w/o stridor or substantial indrawing): PO dex 0.6mg/kg
b) Mod (stridor or indrawing at rest w/o agitation): PO dex 0.6mg/kg, observe for 4H
c) Severe (stridor and sternal indrawing, assoc’d with agitation or lethargy): blow-by O2, neb epi, PO dex 0.6mg/kg, can repeat once
Admit to hospital if:
- rec’d steroids 4H ago and has
1) cont’d resp distress (w/o agitation or lethargy)
2) stridor at rest
3) chest wall indrawing
If recurrent severe episodes of agitation or lethargy, contact PICU
4. Child presents in respiratory distress a few days after URTI with cough, tachypnea and fever. White out lung on CXR. What is your next test? A. Lateral decubitus x-ray B. Chest ultrasound C. Chest CT D. Diagnostic thoracentesis
Chest ultrasound
- 14yo M with vesicular, very pruritic rash and work of breathing, tachypnea. Most likely cause:
A. Myocarditis
B. Pneumothorax
C. Varicella pneumonia
Varicella pneumonia
Usually 1-6d after onset of rash
CXR: multiple nodules (5-10mm)
Tx: 7d of acyclovir
- 3 week old baby admitted with RSV proven bronchiolitis. Two days into his hospitalization he develops a fever to 39C. There is no change in his physical exam. He has been requiring 0.5L O2 since admission and remains tachypneic. A CXR is done after the fever and shows a small RML infiltrate. What is your management?
a) supportive care
b) amp gent
c) Ceftriaxone
d) Racemic Epi
Supportive care
More likely to be atelectasis. Less likely to be pneumonia if no change in O2 needs or exam.
- Kid with stridor a few times this week and now drooling, fever, stridor. What to do
a) Lateral XR
b) Call ENT
c) Neb of epinephrine
Call ENT
If stable -> lateral neck
If unwell/unstable airway -> call ENT/plan for intubation
CPS: ENT for a/w evaluation if persistently severe despite Tx
Airway visualization with the intention of intubation should be promptly performed if the underlying cause of stridor in an acutely ill child is thought to be epiglottitis or bacterial tracheitis or highly likely foreign body → should be done by experienced clinicians
- Asthmatic presents with history of increased cough and is in severe respiratory distress. Ventolin, ipratropium bromide and steroids have all been attempted with no improvement. What do you do next?
a. Give MgSO4
b. Intubate & ventilate
Give MgSO4
- Baby in respiratory distress. RR12 and severe indrawing. Lots of wheeze on auscultation. What to do next
a. Bag and mask ventilation
b. Salbutamol inhalation
BMV
That RR is worrisome
- Teen with tension pneumothorax, where do you put the needle?
a. needle over 3rd rib, in the second intercostal space at the midclavicular line
b. needle over 5th rib, in the fourth intercostal space midclavicular line
c. needle in 2nd IC space, anterior axillary line
- ———— - Site for needle decompression of suspected pneumothorax
a. 3rd ICS AAL
b. 3rd ICS MCL
c. 5th IC AAL
d. 5th ICS MCL
Needle in 2nd ICS, midclavicular line
OR
5th intercostal space, anterior axilliary line
Above the rib
- Baby with severe bronchiolitis, wheezing, severe retractions, lethargy. HR 160, RR 12, Sats 82% what is the next step.
a. Give racemic epi
b. Give salbutamol
c. Give steroids
d. Bag-mask ventilation
BMV b/c of impeding respiratory failure
Needs O2!
- You have a child with asthma and a pneumothorax that you are about to transport. What is appropriate management prior to transport?
a. Chest tube only if >10% pneumothorax
b. Chest tube in affected side
c. Needle thoracotomy in 2nd interspace on affected side
d. Chest tube if symptomatic
————–
You are called about an asthmatic with a unilateral pneumothorax. In arranging medical air transport to your intensive care unit, you suggest:
a. insert a chest tube on the affected side
b. insert a chest tube if the pneumothorax is greater than 10%
c. insert a needle into the 2nd intercostals space, midclavicular line
d. transfer without intervention
Chest tub in affected side
During transport, increased altitude, atmospheric pressure decreases, so gases expand
Need to decompress PTX with needle decompression or chest tube and NG placed for ileus
- 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
Intubate
- A child presents to the emergency room with shortness of breath and wheezing. This occurred suddenly after playing with older sibling. What should be the next management step after a CXR?
a. Broncoscopy
b. Ventolin via nebulizer
c. Racemic epinephrine
Bronchoscopy for FB
15. Kid with a tracheostomy desaturates and is cyanotic. The nurse has tried to suction without improvement. What do you do next? A. Intubate B. Provide 100% oxygen C. Change tracheostomy D. Try suction the tracheostomy yourself ------------- 84. Child with tracheostomy becoming blue and in respiratory distress. Nurse suctions with no improvement. You do: a. change trach b. attempt intubation
Change trach
3. A boy put his finger in an electrical socket and has the rhythm below. He’s in Emerg receiving CPR and sats are 100%. What’s the next step? (looks like VF a) Intubate b) IV/IO epinephrine c) Synch 1J/kg d) Defibrilate 2J/kg
Defibrillate 2J/kg for VF
- 14y boy has a witnessed collapse on the basketball court. He is pulseless. What is the next immediate step in management? [cps]
a. Defibrillate
b. Start CPR
c. Administer an EpiPen IM
d. Start artificial ventilation
Start CPR
Child with PEA in an outside hospital, now with wide complex QRS, tachycardia, shocked x 1 in ER, still wide complex tachycardia. CPR ongoing. Next step: a. defib 2J/kg b. defib 4J/kg c. Epi 0.1 ml/kg d. Amiodarone --------------- Child with pulseless wide-complex tach, got defibrillated x 1 and is receiving CPR. IV is in situ. What do you do next? a. shock 2 J/kg b. shock 4 J/kg c. epinephrine 1:10000, 0.1 cc/kg d. lidocaine
Defib 4J/kg
Second shock for Vtach
- 10 y.o boy with URTI x 10 days, presents to ER looking unwell. On exam, petechial rash, Gr 2/6 murmur with gallop. What is the most likely diagnosis.
a. viral myocarditis?
b. acute rheumatic fever (rash is erythema marginatum)
c. SLE (malar or discoid rash, photosensitivity skin changes)
d. SBE (Osler’s nodes)
————–
7 y with viral URTI 2 weeks ago. Now presents in CHF and a maculopapular rash. What is the most likely diagnosis?
a. Viral myocarditis?
b. Acute rheumatic fever
c. Subacute bacterial endocarditis
Viral myocarditis
Murmur with gallop suggests CHF
CHF is unlikely for ARF
Rash
- ARF = erythema marginatum
- SLE = malar + discoid rashes
- SBE = Osler node, Janeway lesions, splinter hemorrhages
Most common pathogens for viral myocarditis:
- enteroviruses e.g. coxsackie
- influenza
- adeno
- EBV/CMV
- parvo
Presentation
- fever, tachycardia, hypotension, gallop rhythm, murmur, resp distress
- acute or chronic heart failure or chest pain
- if decompensated heart failure, then hepatomegaly, peripheral edema, wheeze + rales
Diagnosis
- Cardiac MRI is standard for Dx!
- ECG + ECHO: non-specific
Supportive care
- Inotropes (esp milrinone), use but with caution
- Diuretics
- IVIG + steroids are controversial
- 11 month-old infant with ECG showing some electrical activity but no pulses on exam. What do you give?
a. Epi 1 mL of 1:1000
b. Epi 1 mL of 1:10000
c. Atropine
————-
A 10kg child is brought into the ER unconscious. There is a rhythm on the monitor but no pulse. Which medication should you administer?
a. Atropine 1 mg
b. Atropine 0.1 mg
c. Epinephrine 1/1000 1ml
d. Epinephrine 1/10 000 1ml
————– - 11 month old with PEA, how do you treat? (No weight given, you have to estimate on your own)
a. Atropine
b. Epinephrine IV 1 mL 1:10,000
c. Epinephrine IV 1 mL 1:1000
d. Epinephrine ETT 1mL 1:10,000
—————
1 year old is in septic shock, he weighs 9 kg. You assess him and find that he is hypotensive and extremities are shut down and not responsive. Cardiac monitor shows sinus rhythm but when you assess his pulses, you cannot feel them. What do you give him?
a. Atropine
b. Epinephrine 1/1000 , 1ml
c. Epinephrine 1/10,000, 1 ml
Epi 1 mL in 10,000 IV
Epi 0.01mg/kg (0.1mL/kg of 0.1mg/mL (previously 1:10,000)) Q3-5min
3. A 5 y.o boy is hurt in a MVA. At the scene, EMS note that he does not open his eyes, moans incomprehensibly, and extends his arms to painful stimuli. Vitals: HR 110 RR 14 BP 120/85. He has a c-spine collar in place. What should be your next step? A. Give mannitol B. Hyperventilate C. Intubate D. Urgent CT head ------------------- 83. Kid in an MVC. On scene no verbal response, extensor posturing to deep pain, moaning incomprehensibly to pain. On arrival in ED HR 95, bp 130/75, RR 14. Pupils are 4 bilaterally and reactive. Best initial management: a. Arrange for urgent CT b. BMV c. IV Mannitol d. Rapid sequence intubation ------------------ 29. 3 yo trauma patient with depressed skull fracture is unstable with desaturation and hypotension. What is your next management step? a. urgent CT b. intubate c. give mannitol
Intubate
E1, V2, M2 = 5
No signs of increased ICP
- A child is involved in an MVC. He was sitting in the back seat with a seat belt on at the time. He now presents with ecchymosis around the area of the lap belt. He has not voided since the accident and can’t move his legs. What is the most likely diagnosis?
a. Kidney rupture
b. Fracture of L1-L2
c. Bleeding into his spine
c. Pelvic fracture
—————– - Child in MVC. No booster seat, wearing lap belt. No urine output, not moving lower limbs. Cause?
a. Chance # L1-L2
b. intraspinal hemorrhage
c. urethral injury
—————-
A 5 year old boy is the back seat during a serious MVC. He is wearing a lap belt and shoulder belt. On arrival he has no urine output and cannot move his lower limbs. Which of the following is the likely cause?
a. Intraspinal bleed
b. Chance fracture at L1-L2
c. Bladder rupture
d. Pelvis fracture
Fracture of L1-L2
Seat belt syndrome
Classic triad
1) abdo wall bruising
2) internal abdo injury - high risk for duodenal perf, mesenteric disruption, pancreatic, bladder injuries for compression
3) spinal # - compression # of L1L2 is most common (Chance #)
16. A 4 year old girl is seen in the emergency department after a motor vehicle collision. She is diagnosed with splenic rupture, and receives a large volume transfusion of packed red blood cells. Which is the most likely to occur as a result? A) Peaked T waves on ECG B) Decreased urine output C) Hypotension D) Seizure
Peak T waves on ECG
Massive transfusion defined as
- transfusion of >50% of total blood volume w/in 3H
- > 100% of total blood volume in 24H
- transfusion to replace ongoing blood loss of >10% of total blood volume per min
SE
- Dilutional coagulopathy if only getting pRBCs
- Hyperkalemia
- Hypocalcemia +/ hypoglycemia due to infused citrate in preservative
- Hypothermia
17. 4yr old boy victim of MVC. At the scene, wouldn’t open eyes, moans incomprehensibly, flexes legs with painful stimuli. What is his GCS? 5 6 7 8
E1V2M3 = 6
DeCORticate
- damage to corticospinal tract
Decerebrate
- damage to upper brain stem (midbrain or pons)
- Alcohol-related MVC. Police wants a blood EtOH level. you
a. give it
b. ask for warrant
c. call CMPA
d. wait for patient to wake up for consent
———————
Teenager driving and hit a pedestrian. You are treating the teen driver who smells like alcohol. Police ask you for the blood alcohol level result on your patient. What do you do?
a. Give police the result
b. Call CMPA
c. Wait for patient to wake up and ask him
d. Refuse unless police produces a warrant/court order
Ask for warrant
- Teenager in a motor vehicle accident a day before and was observed in ER. Now presents with orange urine and his creatinine has tripled. What is the diagnosis?
a. renal vein thrombosis
b. rhabdomyolysis
c. glomerulonephritis
rhabdomyolysis
Elevated CK
Proximal muscle pain
Myoglobinuria
- Boy post MVA with multiple injuries, initially very hypotensive (50/20) but recovered with multiple boluses of Ringer’s lactate. Now creatinine markedly increased, passed 5L of urine, and urine positive for blood. What is the cause?
a. Fat embolus
b. Renal vein thrombosis
c. Diabetes insipidus
d. High output acute renal failure
AKI - ATN
Fat embolus: - fat globules in pulm circulation - long bone orthopedia truma classic triad 1) hypoxemia, 2) neuro abN, 3) petechial rash
Renal vein thrombosis
- hematuria, proteinuria, anuria, hypovoemia, vomiting, thrombocytopenia
- nephrotic syndrome + renal transplant
DI
- polyuria, polydipsia, nocturia, high sodium
- Child with concussion. When can she return to play?
a) Back at school full time with no symptoms and no accommodations
b) After symptom free for 7 days
Back at school full time with no Sx and no accommodations
- Trauma head injury question GCS 7, what is most likely to cause secondary injury on transport?
a. Hypoxia
b. Hypotension
c. Hypercarbia
——————— - 7 year old with closed head injury to be transported. What is most likely to occur on transport that will affect long term prognosis
a. hypoxia
b. hypercarbia
c. hyperglycemia
d. hypotension
—————–
A 15 year old child is being transferred to your centre after an MVC in which he sustained a closed head injury. Which of the following is likely to occur on transport and will cause significant sequelae?
a. Hypoxia
b. Hypercarbia
c. Hypoglycemia
d. Hypotension
——————– - A 3 y.o. with a severe head injury is being prepared for transport to hospital. What would most likely occur during transport that would be most damaging to this child?
a. hypoxia
b. hypotension
c. hypoglycemia
———-
Closed head injury - which would likely occur during transport and cause the most brain damage?
a. hypoxia
b. hypercarbia
c. hypoglycemia
d. hypotension
Hypotension
- Child brought by EMS with severe head injury with HR 95, RR 14, BP 95/70 and is not responsive to name. Not opening eyes. He does have extensor posturing to pain. Pupils are 4mm and equally reactive. Next step is:
a. Hyperventilation
b. Mannitol
c. Intubate
d. CT head
Intubate
E1V<5M2 = 8 at the highest
No Cushing’s triad
- 8 year old with a significant closed head injury. You intubate the patient and give IV fluid. The patient has an O2 sat of 98% with oxygen applied. His blood pressure is 130/85 and a heart rate of 80. (No mention of pupils) What would be the next best step.
a. Hyperventilation
b. Mannitol
c. CT head
Hyperventilate
HTN, lower HR.
- Which of the following would do the LEAST in child with severe head injury (might have also been seizing)?
a. Control fever
b. Hyperventilate
c. Sedate and analgesia
d. Mannitol
————–
Kid with excruciating headache this morning. Collapsed in the ER. CT shows big goober in L hemisphere with midline shift. Which of the following would be least helpful in management:
a. analgesia & sedation
b. hyperventilation
c. Mannitol
Mannitol
- Child presents to ED with decreased level of consciousness, starts to posture decerebrate but then quickly progresses to decorticate posturing. What should you do?
a. Mannitol
b. CT scan
c. Phenytoin
————–
6 y o with severe headache collapses and has progressive posturing. After intubation, what would you do?
a. mannitol IV
b. urgent CT scan
Urgent CT scan
Decorticate to decerebrate posturing is often indicative of uncal (transtentorial) or tonsillar brain herniation
- Child presents to ED with decreased level of consciousness, starts to posture decerebrate but then quickly progresses to decorticate posturing. What should you do?
a. Mannitol
b. CT scan
c. Phenytoin
————–
6 y o with severe headache collapses and has progressive posturing. After intubation, what would you do?
a. mannitol IV
b. urgent CT scan
Urgent CT scan
Decorticate to decerebrate posturing is often indicative of uncal (transtentorial) or tonsillar brain herniation
5. Toddler with dehydration. 12 kg. Irritable, no tears. What is your management? 1200 cc ORT over 4 hours 600 cc ORT over 4 hours IV fluids ---------------- 51. Dry mucous membrane, irritable, no tears, 12kg [CPS] a. 1200 cc over 4h b. 600 cc over 4h
1200cc ORT over 4H
For all dehydration
- replace ongoing losses with ORS
- age appropriate diet after rehydration
Mild dehydration (<5%): - ORS 50mL/kg over 4H
Moderate dehydration (5-10%) - ORS 100mL/kg over 4H
Severe dehydration (>10%)
- IV NS or RL 20-40mL/kg for 1H
- Reassess and repeat if necessary
- ORS once stable
Rehydration + replace ongoing losses + maintenance
- Ondansetron is proven effective in
a) 6mo-12yr moderate dehydration
b) 3mo-12yr old with moderate dehydration
c) 3m-12y with severe dehydration
d) 6m-12y with severe dehydration
6mo-12y with moderate dehydration
Ondasetron
- 5HT3 receptor antagonist
- PO peak 1-2H
- SE: diarrhea (mild + self-limiting)
- single dose PO ondans reduces freq of vomiting + IVF admin to 6mo-12yo who present to ED with mild-mod dehydratin who have failed trial of ORT
- GIve ORT 15-30min after ondans
- 4 year old girl presents to emerg with 48 hour history of vomiting and diarrhea. She can’t keep water down, and she just vomited her ORT. Her HR is 95 with BP 100/65. Normal cap refill, alert. Her tongue is dry. What’s the best course of action?
a) Oral ondansetron
b) D5 NS with 20KCL at maintenance
c) IV metoclopramide
d) PO Gravol
Oral ondansetron
- Child with gastroenteritis, develops thirst and poor skin turgor. He has normal vital signs. What type of rehydration in would you provide?
a. 300 cc/kg over 4h
b. NS bolus 20cc/kg
————- - Child with 24 hours of diarrhea and vomiting, moderately dehydrated. How to rehydrate
a. 100 cc/kg ORT over 4 hours
b. 60 cc q5 min x 24 hours
c. IV NS
d. IV D5/45 + K
———— - Oral rehydration in kid with mod dehydration
a. 100cc/kg over 4h
b. 50cc/kg over 4h
c. NS bolus 20cc/kg
————–
13 kg child with gastroenteritis, with K 2.5, Na 138. Physical findings… management?
a. 300 ml/hr ORS over 4 hrs
b. give D5 ½ NS
Moderate dehydration
100mL/kg over 4H
If 13kg = 1300mL over 4H = 325mL/hr
Child with gastroenteritis, decreased skin turgor, sunken eyes. K = 2.9, pH = 7.33, HCO3 = 13, BE -7. Vitals are normal. What do you give?
a. ORF 100ml/kg
b. ORF 5cc q5min
c. NS bolus 20cc/kg
- ————
112. 5 yo Kid with gastro now mod dehydration. VS normal. K+ 2.9, HCO3 12, pH 7.3. what next step?
a. ORS 300cc/h x 4 h
b. ORS 5 cc/hr x 24 h
c. IVF D5 ½ NS
d. IVF NS bolus
- ————
79. Kid with fatigue, 13 kg, decreased skin turgor, delayed cap refill but normal vital signs. Vomiting and diarrhea for 3 days. pH 7.33, pCO2 27, Bicarb 14, BE-9.7. Next step:
a. IV bolus NS 20cc/kg
b. IV bolus Ringer’s 10cc/kg
c. ORS 300cc/hr for 4 hours
d. ORS 5cc/hr over 24 hours
- ————
81. 15 kg child with tachycardia, dry mucous membranes and a history of vomiting and diarrhea. What is the most appropriate rehydration regimen?
a. 400 mL of ORS per hour, for 4 hours.
b. 100 mL of ORS per hour, for 4 hours
c. rehydrate with apple juice
d. start iv fluids
ORS 100mL/kg in 4H
13kg x 100mL/kg = 1300mL over 4H = 325mL/hr
15kg x100mL/kg = 1500mL over 4H = 375mL/hr
- What is the best early indicator of mild dehydration?
a. Tachycardia
b. Capillary refill of 4-5 seconds
c. Hypotension
Tachycardia
