Acute care/NICU

Question 1

Risk factors for preterm delivery

Answer 1

1. 40
2. Low SES
3. Low BMI
4. Pyelonephritis
5. Uterine/Cx abN
6. Multiple abortions
7. Preterm delivery
8. > 10 cig/day
9. heavy work
10. multiple pregnancies

Question 2

Effects of surfactant therapy

Answer 2

1. Mortality
2. PTX
3. PIE
4. Vent support
5. LOS
6. Hospital Cost
   (NO EFFECT ON IVH, BPD, NEC, ROP)

Question 3

Basic investigations for toxiology work up

Answer 3

1. Glucose
2. Acetamin/ASA
3. ECG
4. Preg
5. AXR
6. Temp

Question 4

Red flags for jaundice

Answer 4

1. Onset before 24 hours
2. Hemolysis
3. Pallor, unwell
4. HSM
5. Pale stools
6. Conjugated

Question 5

Maternal SLE fetal effects

Answer 5

1. IUD
2. Heart block
3. Neonatal lupus
4. Anemia
5. Thrombocytopenia

Question 6

ABC Equipment

Answer 6

Airway

1. O2, FM/NP
2. Oral airway, NG tubes, sxn devices and catheters
3. Forceps, tape, shoulder rolls
4. Bag-valve respirator, appropriate masks
5. LMAs, ETTs, capnograph
6. Stethoscope
7. Minimum BLS for HCWs

Breathing

1. IV needles for pneumothoraces
2. SpO2 monitors

Circulation

1. IVs, IV tubing, syringes, butterfly needles, armboards
2. Fluids (D10W/D25W, NS, RL, D5NS)
3. BP cuffs, sphygnomonometer

Question 7

Cholinergic toxidrome

Answer 7

1. Diaphoresis
2. Urination
3. Miosis
4. Bronchorrhea/Brady
5. Emesis
6. Lacrimination
7. Lethargy
8. Sallivation

Question 8

Anticholinergic toxidrome

Answer 8

1. Blind as a bat (mydriasis)
2. Mad as hatter
3. Dry as a bone
4. Red as a beet
5. Hot as a desert
6. Shaking
7. Tachycardia
8. Absent bowel sounds

Question 9

Sympathomimetic toxidrome

Answer 9

1. Mydriasis
2. Diaphoresis
3. Hypertension
4. Tachycardia
5. Seiures
6. Hyperthermia
7. Psychosis
8. Severe agitation

Question 10

Drugs that hypoglycemia

Answer 10

1. Glyburide
2. Beta blockers
3. Ethanol
4. Salicyclates

Question 11

Good prognostic indicators drowning

Answer 11

1. IMMEDIATE CPR
2. ROSC 5 min
3. PEARL at scene
4. NSR at scene

Question 12

Drugs activated charcoal doesn’t work

Answer 12

1. Potassium
2. Hydrocarbons
3. Alcohols
4. Irons
5. Lithium
6. Solvents

Question 13

One tablet toxins

Answer 13

1. Propanolol
2. Camphor
3. Clonidine
4. Glyburide
5. Theophylline
6. TCA
7. CCB

Question 14

Prem discharge checklist

Answer 14

1. Body temp
2. Apnea free (5-7days)
3. O2S> 90-95% in RA
4. Sustained weight gain
5. Success feeding
6. Provincial hearing screening
7. RSV PPx assessment
8. HUS if needed
9. ROP screening
10. Hearing screening
11. Car seat test
12. PE
13. CPR teaching
14. Sleep teaching
    FU appointment

Question 15

Safe sleep

Answer 15

1. Supine sleeping
2. No smoking
3. No soft bedding
4. Education of other caregivers
5. No co-sleeping
6. Encourage pacifiers (>1 month to 1 yr)
7. No home monitors
8. No sleep wedges
9. Encourage room sharing

Question 16

16 year old took 20 tablets of 500mg Tylenol 1 hour ago, told her mother who called ambulance. (HISTORY OR RESUS)

Answer 16

o Ingestion
□ What? Number of pills in home, number taken, strength/dose per pill □ Co-ingestion
□ When?
□ All at once, over what period
□ Where? did they get it from, where did they take it
□ Why? Suicidal ideation, etc
□ Any signs/symptoms:
Nausea, vomiting, abdo pain Diaphoresis
Pallor, lethargy, malaisa Many asymptomatic
o HEADS assessment
□ Mood disorder screen
□ Suicide RFs:
Sex [Assign one point only if male]
Age [Assign one point only if 45 years old] Depression, bullying, homosexuality
Previous attempts
Ethanol abuse [alcohol or substance abuse]
Rational thinking loss
Social supports lacking [lack of family, friends, etc]
Organized plan [lethal, affairs in order, note]
No spouse [divorced, widowed, separated, single, no children]
Sickness [chronic, debilitating and severe]
□ Consider Form 1 INVESTIGATIONS
o 4h postingestion acetaminophen level, plot on Rumack-matthew normogram o Baseline lytes, glucose, urea, Cr, liver transaminases, INR
o Repeat acetaminophen level, liver transaminases, INR after NAC treatment o Blood gas, lactate, serum osmolality, Tox screen (urine ± blood)
o Calculate AG, osmolal gap

MANAGEMENT: qMedical
o Administer Activated Charcoal within 4h
o NAC Indications:
□ 4h level above the hepatotoxic line when plotted on the Rumack-Matthew normogram (see below)
□ History of ingestion of >200mg/kg and no level available within 8-10h of ingestion
□ Presentation > 24 h postingestion with detectable acetaminophen level and evidence of hepatotoxicity o Administration:
□ Various IV/oral protocols, contact local Poison Control Centre
o Outcome excellent if NAC started within 8-10h of ingestion, treatment initiated >8h postingestion beneficial but effectiveness
diminishes with time

Question 17

21 month old with fever and cough x 5 days, mid-December. RR 50, SpO2 90%, temp 40, HR 120. (ABCs or HISTORY)

Answer 17

HISTORY:
o When did cough start? Paroxysmal?
o Associated with respiratory distress? Wheezing? Rhinorrhea? o Getting worse or better?
o Temperature measured? Fever pattern?
o Hydration status? Voiding well? Feeding well?
o Ear pain? Throat pain? Neck stiffness? Headache?
o Activity level? Energy? Any signs of lethargy?
o Sick contacts? Travel history? Daycare?
o ROS (think DDx)
□ Kawasaki signs and symptoms □ Vomiting/diarrhea
□ Myalgias
□ Skinchanges
o Past Medical History (term delivery, lung disease, recurrent infections, hospitalizations, surgeries)
o Meds, Allergies, Immunizations (Influenza, H1N1), family contacts with vaccines o Social history (e.g., housing, smoking in home, financial difficulties, hygiene, how is family
coping at home)
o Family History (any siblings)
PHYSICAL:
o WASH HANDS
o General appearance (well, unwell, critical)
o Height, weight, HC
o Vital signs (list exactly what you would want)
o Resp exam (inspection, palpation, percussion, auscultation)
o Cardiovascular (heart sounds, murmur, peripheral pulses, cap refill)
o Hydration status (eye, mucous membranes, tearing, skin turgour, level of consciousness)
o Head and neck (eyes, conjunctivitis, ears, throat, neck, adenopathy, neck stiffness
(Brundzinski, Kernig)
o Abdomen
o Neurologic exam (brief: LOC, moving all 4 limbs, alert, responsive to examiner, stimuli)
Vitals provided: Temp 40
qINVESTIGATIONS (List 4)
o CBC with diff
o Blood culture
o CXR
o NP swab
CXR showed: Left lower lobe infiltrate with pleural effusion. NP swab positive for Influenza A.

Question 18

General approach to ingestion

Answer 18

• Immediately: get weight and age, ABC and sugar
• Serious poisons before child can ambulate
• Before arrival, have parent collect the bottles
• Contact poison control in advance
History – key
- timing, amount known
- at scene, odour, things seen
- ANY substances in home:
o Prescribed o OTC
o Pet meds
o Substances in garage
- Meds the child is taking, meds family members taking
- Sx and timing of progression:
o pupils
o sz
o vomiting o pain
- developmental level of child
- detailed description of event and who witnessed
- risk factors for neglect or inadequate supervision: prev problems, substance use in home, parental status / divorce /
financial issues
- also, suicide note
- illnesses in home
- mental health dx in home
Physical:
o weight
o vitals and frequent checks for rapid progression – monitors o nurse at bedside
In all ingestions:
• Tylenol and ASA level
• Fe level!
• Urinalysis
• Blood sugar
• ECG
• Lytes, renal, liver
• Gas, lactate, and AG
• OSM
• w/ iron, radiopaque, so AXR and see how much and where
Considerations:
- ABC
- Decontamination
- Increased elimination
- Antidote – look those up and get poison information
o Desfurosidine
o NAC if Tylenol - dialysis

Question 19

Ingestion counselling

Answer 19

Gen counseling:
• Educate that ingestions are common and can cause significant morbidity and mortality
• Disposal of meds – asap, don’t keep meds don’t need
• Storage of meds – high up , locks, childproof bottles – same for caustics
• Supervised play
• Appropriate places for play
• Caring for kids website on safety measures in home
• Poison control number next to phone at daycare
• Out of sight, out of reach
• Re-engage child resistant packaging immediately after use

Question 20

4 year old with 20 minute seizure treated requiring Ativan and PB. Fever 39.4 with viral URI started two days ago. GTC seizure, recovered with short post-ictal phase, back to baseline and looks well. Acute management and physical.

Answer 20

Age, weight, time of onset, history of seizures, meds
Monitors, full set of vitals: HR, RR, BP, TEMP, SpO2
AIRWAY o Specifics: do not put anything into mouth (risk of teeth clenching àloss of fingers)
BREATHING
CIRCULATION
o Obtain IV access quickly (for meds) o Tachycardia, hypertension common; be weary of the opposite
DISABILITY
o Assess: Seizure manifestations: eyes, face, limbs, incontinence
□ Level of consciousness, GCS, moving limbs, tone
□ PERLA
□ Signs of ICP
o Do: Accucheck o Send bloodwork: CBC/Diff, lytes + Ca, Mg, PO4, glucose, cap/art gas ± AED levels □ Not routine (PRN): Blood C&S, Tox screen, urea/Cr, liver enzymes, NH4
□ LP (if indicated) deferred until VSS, seizure aborted, no ICP
• DO NOT delay antibiotics if sepsis/meningitis suspected!
o SEIZURE MANAGEMENT
□ Lorazepam 0.1mg/kg / Diazepam 0.3 mg/kg IV at 5 min, q5 min x 3
□ Fosphenytoin or Phenytoin 20mg/kg IV over
□ Alternate with Phenobarbital 20mg/kg IV over 20 min
□ ICU for Midazolam infusion, other
REFER TO CPS STATEMENT

qPHYSICAL EXAM: o General:
□ Washhands
□ Weight, height, HC (plot)
□ Vitals
□ Generalappearance
o HEENT: Dysmorphic features, head shape, eye movements
□ Oral lesions (herpes), nuchal rigidity
o CVS, RESP, ABDO exams complete
o DERM: Neurocutaneous findings (CAL macules, ashleaf spots, shagreen patch, adenoma sebaceum, portwine stain)
o Neuro exam
□ Menigismus: Kernig’s and Brudzinski’s if appropriate
□ CN exam (don’t forget fundoscopy and comment on papilledema) □ Motor, sensory, cerebellar, gait

Question 21

Seizure history

Answer 21

HISTORY: o Events leading to seizure
□ Aura prior to onset
□ Fever
□ Focalorgeneralized
o Have parents describe in own words
□ Features of a seizure: • Ability to stop activity with holding
• Loss of consciousness
• Urinary / fecal incontinence
• Cyanosis
• Eyes open or closed, eye deviation • Staring, day-dreaming
• Lip smacking
CPS
□ Duration of event (anticipate overestimate)
□ Post-ictal disposition (lethargy, Todd’s paralysis, FNDs)
□ Recurrent events: describe, frequency, duration o Collateral History
□ Recent behavior changes, school performance
□ History of head trauma
□ Feeding history, level of consciousness
□ Infectioushistory,fever
□ Sickcontacts
□ Headache, vomiting, focal neurological changes
□ Substance use, medications accessible in home o Past Medical History
□ Obstetrical: Age and preg hx, serologies, meds, smoking/Etoh/drugs, illness/perinatal infection,
DM, HTN, genetic testing, U/S. Previous pregnancies.
□ L&D: Mode of delivery, GA, BW, APGAR, any complications/asphyxia
o Family History
□ Delay or regression
□ Neonatal events (jaundice, sepsis, seizures) o Medications, toxin exposure o Immunizations (recent) o Social History
□ Impactonfamily
□ Impact on child’s level of functioning
□ Knowledge about seizures, level of education of parents
□ Consanguinity
□ Seizures, dev delay, metabolic disorder, neurocutaneous disorder, genetic syndromes o Development

Question 22

14 year old injures her right ankle playing tennis and presents with 9/10 ankle pain. History and Physical

Answer 22

History
- Mechanism of injury – LOC, assoc injuries, ‘pop’, laceration, bleeding
- Immediate management
C haracter L ocation O nset R adiation I ntensity D uration - E xacerbating / relieving factors
- Review of systems: - Fever
Rash
- Activity tolerance - Joint pain (other)
- Associated injury, LOC
- Past medical history: previous sprains, breaks, injuries - Previous hospitalizations / surgeries
- Sports: teams, level of competition, training regimen
- Medications, Allergies, and Immunizations (tetanus)
- Family history: hypermobile/lax joints, connective tissue disease
Physical Examination
- Vital signs
- Neurovascular: perfusion, sensation
- Observation:
- S welling E rythema A trophy - D iscolouration/dislocation - S cars - Gait/weight-bearing - Palpation: - Tenderness: joint lines, length of fibula, malleoli, 5th metatarsal
- Ottawa ankle rules: - Range of motion:
- pain in malleolar zone + pain at posterior/tip lateral or medial malleolus - pain in midfoot zone + pain at navicular or base of 5th metatarsal
- Active: dorsiflexion, plantar flexion, inversion, eversion - Passive
- Special tests:
- Inversion stress test (for instability of talofibular and calcaneofibular ligaments) - Syndesmotic squeeze (for interosseous membrane and syndesmotic injury)
- Anterior drawer (for anterior talus and talofibular stability) Remember: joint above and below!
Investigations
- Ankle series: anteroposterior, lateral, and mortise views (if meet criteria)
- Foot series: anteroposterior, lateral, and oblique views (if meet criteria)

Question 23

MSK injury counselling and ottawa ankle/foot rules

Answer 23

Counselling and Treatment
The general principles of PRICE – Protection, Rest, Ice, Compression, Elevation – should be followed.
- Ankle sprain (Grade 1-3, describes immobility):
- RICE: rest, ice, compression, elevation (crutches, elastic wrap) x48-72 hrs
- Early weight bearing
Rehab: start early (day of injury=isometrics)
- Ankle brace (to prevent reinjury) - If unstable, refer to Ortho
– Schedule follow-up

• Ankle series: anteroposterior, lateral, and mortise views (if meet criteria)
• Foot series: anteroposterior, lateral, and oblique views (if meet criteria)

An ankle x-ray series is only necessary if there is pain in the malleolar zone and any of the following:

Bone tenderness at the posterior edge or tip of the lateral malleolus, or
Bone tenderness at the posterior edge or tip of the medical malleolus, or
Inability to weight bear both immediately and in the emergency department

A foot x-ray series is only necessary if there is pain in the midfoot zone and any of the following:

Bone tenderness at base of fifth metatarsal, or
Bone tenderness at the navicular bone, or
Inability to bear weight both immediately and in the emergency department

Question 24

Concussion 15 year old brought to Emergency room after taking a hit to the head during a football game, lost consciousness for “few minutes” and now awake and alert. History and physical exam

Answer 24

History
-Mechanism of injury (e.g. what hit head, type of ground, height of fall, wearing helmet, etc) -Immediate management
-Review of systems:
o Headache
o Nausea/vomiting
o Dizziness, poor balance/coordination
o Visual changes
o Tinnitus
o Confusion, amnesia
o Lethargy/sleepiness, LOC
o Bleeding
o Seizure activity, incontinence
o Slurred/confused speech
o Personality changes, inappropriate emotions
Past medical history
o Previous hospitalizations / surgeries, previous head injuries
o Bleeding diathesis
o Medications (anticoagulation) Academic and developmental Hx
Family history: hereditary bleeding diathesis
Physical Examination Vital signs, GCS
CPS
CNS: C-spine exam, CN exam, tone, power, sensation, DTRs, gait, cerebellar
HEENT: pupils, fundi, Battle’s sign, hemotympanum, raccoon eyes, CSF leak (otorrhea, rhinorrhea), bruising, laceration, scalp bogginess, teeth
CVS: hypertension, bradycardia
RESP: rule out pneumothorax (depending on trauma)
ABDO: rule out visceral injuries
MSK: rule out skull and other fractures **Standardized scales (e.g. SAC, WPTAS) can be used to test orientation, memory and concentration (basically like a truncated MMSE: who, what, where, when, etc)

Question 25

Concussion investigations?
When to order head imaging?
Management?
Concussion definition

Answer 25

Investigations
Assessment tool: The Sport Concussion Assessment Tool 3 (SCAT3) is recommended for use in patients ≥13 years of age. The Child-SCAT3 has been developed for use in children five to 12 years of age and includes a parent symptom report as well as more age-appropriate cognitive tests
Simple: none (unless red flags – see below)
Complex: neuroimaging, neuropsychiatric testing, referral to neurologist
**Neuroimaging indications: continued emesis, prolonged headache, persistent antegrade amnesia (poor short-term memory), seizures, Glasgow Coma Scale score

Question 26

3 year old, 2 weeks post VSD repair arrives because woke up from nap less than an hour ago extremely lethargic, cold hands and feet. Has had what seemed to be a cold for past 3 days. HR 180, BP 60/30.
DDx
Acute management

Answer 26

DDx of shock:
Cardiogenic: arrhythmia, myocarditis, post-op cardiac tamponade, cor pulmonale: increased PVR, PPHN secondary to pulmonary vascular reactivity exacerbated by hypoxia from URTI?
Septic: c a little late post-op, but could be late wound infection gone septic
(Unlikely hypovolemia, neurogenic or anaphylactic, given clinical scenario)

• Call for appropriate help (MD, RT, nurses) and delegate roles for team members
• Ensure proper equipment present
• Oxygen mask, laryngoscope with proper size blade and various size tubes (age/4 + 4), oral airway, nasal airway, CO2
detector, suction tubes (5F-14F), Yankauer suction, bag-valve mask
• Large bore IV, Normal saline, intraosseus needle o Medications
• Broselow tape
• Ask for vitals including temperature, apply monitor and O2
§ Airway
o Listen for stridor, talking
o Head-tilt chin lift
o Consider intubation if obstruction, or signs of impending obstruction § Breathing
o Look for chest rise, listen for bilateral air entry, look at colour o Assess respirations, O2 sat, work of breathing
o Apply O2 if needed
o Consider intubation if irregular respirations
§ Circulation
o o o
Assess HR, BP, look at colour, cap refill, mucous membranes, skin turgor, cyanosis/pallor Start IV, bolus 20cc/kg (even if cardiac – better to treat shock and worry about lungs later)
Consider CPR, epinephrine, cardioversion, adenosine depending on scenario
§ Disability
o AVPU (alert, verbal, pain, unresponsive)
o Pupils, motor activity bilaterally, lateralizing signs, seizures, posturing
o Assess for increased ICP (pupils if not given atropine, heart rate, BP, LOC, resp, posturing)
o if increased consider mannitol 1g/kg over 15 minutes, 3cc/kg of 3% NS, slight hyperventilation, raise HOB up
Exposure/Secondary survey
□ AMPLE history – allergy, meds, PMH, last meal, events associated
□ Insert NG
□ Insert foley unless signs of urethral injury (blood at meatus)
□ Initial blood work: CBC, cross and match, gas, lactate, lytes, liver enzymes, BUN, creat, INR/PTT, blood culture □ CXR, ECG, ECHO
□ Tx: volume, inotropes, anti-arrhythmics, antibiotics
Speak to family about patient’s condition

Question 27

3 month old arrives to small, northern community hospital with bronchiolitis. You have the help of one nurse. [Later: sats 80s despite ‘100% O2’ by face mask]

Answer 27

MEDICATIONS Intubation:
Atropine 0.02 mg/kg
Personal protective equipment (wash hands, mask, gown, glove)
Ensure proper resuscitation equipment present
S uction → flexible 5F-14F (2 x ETT size); Yankauer O 2 mask → simple mask, bag-valve mask
A irway → oral airway, nasal airway (nasal trumpet) → laryngoscope (3-5 kg infant = 0-1 straight blade)
→ ETT (age/4 + 4) → term infant = 3.0-3.5 uncuffed → ETT stylet
→ End-tidal CO2 detector
→ tape
P harmacology (including reversal agents)
M onitoring E quipment
IV, IO needles
Normal saline o Broselow tape
Weight (estimate ~4 kg)
Term or preterm baby?
General appearance (well, unwell, toxic) Vital signs (HR, BP, RR, O2 sat, Temp) Cardiorespiratory monitors
Airway
o Assess for sounds, stridor, secretions o Head tilt, chin lift (or jaw-thrust if C-spine precautions) o Suction o Oral airway (if obtunded) or nasal airway (if stridorous) o Intubation if obstruction or signs of impending obstruction (e.g., burns)
Breathing o Look for chest rise, listen for bilateral air entry, look at colour o Assess respirations, work of breathing o O2 sats and apply O2 if needed
→ Bag-mask ventilation (may need to show nurse how to use)
o Intubation if irregular respirations o Call for CXR o Consider Ventolin NEB (0.5 mL if

Question 28

Anaphylaxis acute management

Answer 28

o IV, IO needles o Normal saline o Broselow tape Weight (estimate ~10 kg for 3 year old child)
q General appearance (well, unwell, toxic)
q Vital signs (HR, BP, RR, O2 sat, Temp)
q Cardiorespiratory monitors
q Call for Epinephrine at first suspicion of anaphylaxis
Airway
o Assess for sounds, stridor, secretions o Head tilt, chin lift (or jaw-thrust if C-spine precautions) o Suction
o Intubation if obstruction or signs of impending obstruction (e.g., burns)
Breathing o Look for chest rise, listen for bilateral air entry, look at colour o Assess respirations, work of breathing Ventolin NEB

Question 29

Anaphylaxis history & counselling

Answer 29

History
Present episode (recent foods, quantity of food, onset of symptoms, type of symptoms (rash, respiratory distress, GI symptoms such as nausea and vomiting, swelling of face, etc), duration of symptoms)
Previous reactions? When? Other foods and symptoms of concern in the past? Management to date (skin testing, RAST, elimination diet, MedicAlert, Epi-Pen)
PMHx (eczema, asthma, rhinitis) Medications
Allergies
Immunizations
FMHx (atopy, anaphylaxis, hereditary angioedema)
Social Hx (who lives at home, supervision of child, insurance to cover cost of Epi-Pen and MedicAlert bracelet, school environment, etc)
How does this illness/diagnosis impact the child and family
Explore DDx (infectious, reflux, lactose intolerance, celiac, etc)
Counsel
Educate regarding anaphylaxis (e.g., life-threatening reaction…)
Educate all potential caregivers, day care, school, etc
Discuss symptoms (e.g., urticarial rash, difficulty breathing, wheezing, hoarseness, chest pain,
tachycardia, nausea, vomiting, difficulty swallowing, dizziness, etc)
Do NOT give Benadryl at home (this may mask a reaction and lead to a more fatal reaction) Strict avoidance of the specific food(s) → Provide a list of foods to avoid (e.g., egg may be listed as ‘albumin’ or ‘lecithin’)
→ Be aware of potentially lethal substitutions (e.g., cheap peanuts for almonds)
→ Be aware that any bulk foods can be cross-contaminated
→ Children should not eat food from other children/adults other than their own caregivers
→ Life long allergy, so do not re-challenge
o MedicAlert bracelet
o Have injectable epinephrine available at all times (Ana-Kit or EpiPen)
→ day care, school, etc → watch for expiry date → ensure prescription with refills
o All children should have an Anaphylaxis Emergency Plan
o Consider referral to an Allergist
o Follow-up with primary care physician
qReview Epi-pen use
o Form a fist around the auto-injector with the black tip facing down
o Pull off the grey safety cap
o Place the black tip against the outside of the upper thigh; be sure the black tip is perpendicular ot the thigh (this can be done through clothing, even jeans)
o Push the pen firmly against the thigh → this will trigger the injection
o Hold the pen firmly in place and count to 10
o Call 911

Question 30

14 year old boy in MVC: riding in passenger seat with 15 year unlicensed friend driving, T-boned a truck. Friend
pronounced dead on arrival. Perform the primary survey

Answer 30

O2: 100% non-rebreather   Monitors  
IV: 2 large bore, send trauma labs  
Weight  
Talking to you=ABCs OK  
Airway:
q C-spine collar, spine board  
q look/listen/feel  
q jaw thrust  
q RSI (oral/nasal airways risk aspiration)   q inline stabilization  
q attn local trauma  
Breathing:
qO2 
q WOB, AE, sounds, sats, RR, trachea, chest markings   q needle thoracostomy, chest tube(s)  
q open PTX dressing  
q RSI: open PTX, massive flail chest  
Circulation:
q colour, cap refill, pulse(x4)   q abdo soft?  
q pelvis stable?  
q limbs deformed?  
q control bleeding  
q boluses(warmed) & prep blood(give after 60ml/kg NS)   q rapid infuser  
q if unstable despite ++fluid consider: 
Disability:
q AVPU, GCS   q Pupils  

Exposure
q core temp
q warm blankets q Adjuncts
AMPLE hx: include age or weight NG/OG, Foley XRs: C-spine, CXR, pelvic Transport

Question 31

Trauma- 14 Y
What size ETT would you need?
Drugs for intubation in concern situations?
What are the life-threatening injuries

Answer 31

PEP:
What size ETT would you need? 7-8
What induction drugs would you use for his RSI if:
-hypotensive: ketamine
-HI: etomidate or low-dose thiopental; consider lidocaine pre-med
What would be contraindications to succ in his case?
-inc ICP, penetrating globe injury, late presentation(risk hyperK)
What are life-threatening chest injuries he may have?
Tension PTX, open PTX, flail chest, hemothorax, airway disruption, tamponade, pulmonary contusion,
commotio cordis, aortic disruption

Question 32

NICU Approach to discharge planning

Answer 32

Brief Hx of issues for baby:
‐GA
‐BW and Discharge weight
‐Specific issues that the baby had been dealing with in NICU: ROP, IVH, Ventilated, GI
Mother’s info: ‐First baby? Mother’s age?
‐Social situation: who lives at home? Supports? Caregivers? ‐ smoking in the home?
­other children at home?
‐any concern at home with alcohol or drug use, violence or conflict?
BASIC CARE:
‐mother needs diapers, wipes, Vaseline, sleepers, basin for bathing, bottles, crib
‐does she know how to bathe the baby? Dress the baby?
FEEDS:
­breast feeding or bottle? EBM or formula?
‐amount baby is taking over how long, concerns
‐ Vit D and Fe if BF

SLEEP:  
  ‐needs to be place on back in a standard crib with crib mattress 
  ‐no quilts, bumper pads, pillows 
  ‐ONLY a thin blanket allowed 
  ‐may place crib in parent’s room 
‐never sleep on sofa or soft surface    

BREATHING:   ­cannot have apneas x 1 wk before DC 
  ‐should be off caffeine 
  ‐should be off O2   
CNS: 
  ‐results of previous HUS 
  ‐grades I and II‐ no f/u 
  ‐grade III or more: weekly HC   
HEARING SCREEN:  
  ‐was it done? any concerns   
VISION ROP 

IUTD:

RSV:
‐prophylaxis started?
‐will they require it?
‐explain about handwashing especially if other children at home
‐no contact with sick people because prone to infections
CAR SEAT:
‐90 minute test with O2 sat monitor
IMMEDIATE PLAN:
­Care by parent room for at least one night to work on BF and feel comfortable with baby not in a monitored environment

Question 33

A 3 year old boy was bitten by a dog in the face. The bite occurred 4 hours ago. The child was taking food away from a stray dog. Take a history and provide immediate management.

Answer 33

History
 History of Presenting Illness
o Circumstances of injury (who, what, where, when, how)
o Information about animal (domesticated vs wild, shots received) o T etanus status
 Past Medical History
 Medications, Allergies, Immunizations
Physical Examination
 General appearance
 Growth parameters (height, weight, HC)
 Vital signs (HR, BP, RR, O2 sats, temp)
 Airway, breathing, and circulation
 Wound
o Bite > 3 cm → suspect child abuse
o Swelling, tenderness, redness, purulent drainage o Lymphadenitis
 Neurovascular assessment Investigations
 Bloodwork
o CBC and diff
o +/- ESR, CRP (if signs of cellulitis, joint infection, osteomyelitis)
o +/- aerobic and anaerobic blood cultures (if signs of systemic infection)
 Wound culture (if bite is infected; wound culture is useless in clinically uninfected bites)
 Imaging
o AP and lateral radiographs (disruption of bone / joint; evidence of foreign body; sc gas) o Ultrasound (abscess formation)

Management
 Stabilization (direct pressure)
 Wound preparation
o Local anesthesia
o Iodine
o Irrigation with copious amounts of saline → pressure irrigation (20 cc syringe; 18-20 gauge needle)
 Closure
o Dog bites → primary closure if

Question 34

Fetal viability counselling

Answer 34

General
1) Introduce yourself as the pediatrician on call
2) Confirm the name of the patient
3) State the purpose of the meeting is to discuss whether or not the baby should be delivered at this time
4) Inquire / offer to contact partner and other supports
5) Medical History
a. Mother’s age
b. Confirm gestational age / EDC
c. GTPAL
d. Confirm singleton pregnancy
e. Prenatal care (e.g., dating U/S, integrated prenatal screening)
f. Congenital anomalies
g. Blood type
h. Antenatal steroids (can be given up to 34 weeks)
6) Past medical history
7) Education level
8) Inquire about religious affiliations
9) Ask about the family’s social situation
Counsel
10) (Re)state that the purpose of the meeting was to discuss whether or not the baby should be delivered at this time
11) Ask about understanding of the current situation and plan
a. Is she in active labour? Is birth imminent?

b. Has she been given steroids (in anticipation of a preterm delivery)
12) Ask the mother whether she had any understanding of the prognosis for the baby
13) Discuss the options:
a. 1) Deliver the baby, resuscitate and provide intensive care, and then re-evaluate the situation
b. 2) Deliver the baby and provide comfort care only
c. 3) If C-section required, this will pose risks to mother as well
d. 4) Another option would be that of non-intervention; expectation that the baby may die in utero
14) Use terms which are easily understood by a non-medical person
15) Explain the risk of mortality and disability if delivered
a.

Question 35

You’re seeing a patient on rounds in the newborn nursery who was born to a high­risk mother who you’re told used cocaine and alcohol throughout pregnancy. Manage/counsel.

Answer 35

History
Explain your role as pediatrician, need to obtain medical history
Do not accuse or discuss what you’ve been told by others (often unfounded, biased!) Pregnancy
Maternal age, preg history (incl spont abortions), health, blood group, serologies (Syphilis, HBV, HIV, Rubella)
Smoking, Etoh, meds, OTC, herbal and recreational substances
− Timing of exposure (start, frequency, when most recent)
 Organogenesis affected most during 1st trimester, later = physiologic effects − Dose
− Route (if IV, where needles from)
− Any toxicity/overdose to mother during pregnancy (require hospitalization, treatment)
− Screen for other risky behaviours and stressors during pregnancy (use HEADS as template)
 Home (where, with whom)
 Education/work (level of education, employment)
 Eating (nutrition during pregnancy, folic acid)
 Activities, Abuse during pregnancy
 Drugs
 Sex
 Safety, trauma
 Suicide, depression
Genetic screening, ultrasounds Complications during pregnancy
− Eg: Infection, DM, PIH, placental abruption
L&D
Mode of delivery, ROM
GA, BW
APGAR, resuscitation
Dysmorphism, birth length and HC if known
Neonate
Breathing (tube, CPAP, O2) Jaundice, feeding (breast vs formula) Seizures, tremor, startle reflex, sleep Fever, sweating, sneezing
Vomiting, diarrhea
Medications
Requirement of morphine, phenobarbital, benzodiazepine
Extended family history
Parental age, ethnicity, health, occupation Consanguinity
Sibling age, health
Psychiatric illness (schizophrenia, anxiety, depression)
Social History
Who will be living at home, where will be living Supports – reliable family/friends involved Plans for substance use, quitting

o Alcohol in the home, access to cocaine and other drugs o Financial situation, other stressors
o Second hand smoking
o Plans for breastfeeding
o Previous CAS involvement, previous abuse o Previous criminal/legal involvement
Physical Examination
Full exam
Specific features of neonatal abstinence:
Vitals: Fever, tachypnea, tachycardia, hypertension Growth parameters: LBW, decreased length, microcephaly General
− Dysmorphic features
[FAS = short palpebral fissures, thin upper lip, smooth philtrum, maxillary hypoplasia]
− Irritability, hyperactivity − Sweating
− Yawning
HEENT
− Nasal congestion, sneezing (heroin, other opioid) − Excessive sucking
CVS
− Septal defects associated with FAS
MSK
− Subtle joint and limb defects Neurological exam
− High-pitched cry
− Hyper-alert, startles easily, jittery
− Hyperactive Moro
− Tremor
− Hypertonia
− Myoclonal jerks or generalized seizures Derm
− Mottling

Differential Diagnosis
 T eratogens
o Fetal Alcohol syndrome
o Fetal cocaine exposure
o Exposure of fetus to other substances o Teratogenic drugs
Other
o Birth asphyxia: HIE
o Neurologic: hemorrhage, malformation o Sepsis

Question 36

Investigation and counselling possible teratogen

Answer 36

Investigations
o Regular glucometer checks
o Blood gas
o CBC, extended electrolytes, glucose, urea, Cr o Maternal STI testing
o ECHO if concerned
o Blood culture (if concerned about sepsis)
o EEG and head imaging if seizures
o Drug testing
− Maternal if possible
− Newborn: urine has low sensitivity (requires recent exposure)
-Meconium and hair samples are more sensitive for in-utero exposure
-Results take time, not useful for immediate management
Counseling and Management

Counselling
What is mother’s understanding of risk of alcohol and cocaine exposure to fetus
Explain current findings (dysmorphic features, neurological findings, growth)
Explain what is associated with alcohol and cocaine exposure (see chart below) and it is difficult to tell right now if baby will develop these manifestations
If safe to do so, infants should remain with birth families
Referrals below
Management
Environment: quiet, reduce external stimuli (lights, interruptions), swaddling
Rx: seizures, diarrhea, or hyperirritability affecting sleep, feeding patterns, weight gain − Opioid withdrawal: Opioid + Phenobarbital, ± further sedation
− IV fluids
− NPO if risk of aspiration
Use Neonatal Abstinence Score to monitor signs/symptoms
Call:
− MotherRisk for advice regarding breastfeeding
 If substance abuse to continue, advise not to breastfeed − CAS always: to determine well-being of child
− Social Work to see mother
Referrals:
− MotherRisk for follow-up and further counseling
− Psychiatry for any psychiatric issues
− FAS multidisciplinary team
− Parenting courses
Keep in hospital until discharge can be done safely