Ch 12. Pediatrics Flashcards
1
Q
Potential complications of AOM (6)
A
- Mastoiditis
- Perforation TM
- Meningitis
- Venous sinus thrombosis
- CN VI or VII palsy (temporal bone inflammation)
- Labyrinthitis
- Hearing loss
2
Q
Treatment of AOM? (4)
A
- > 6months and healthy
- MEE + bulging tympanic membrane
- Temp >39 or >48h symptoms
Then treat with - Amoxil 90mg/kg/day div BID x10days. Clavulin 7:1 if just failed Amoxil.
3
Q
Elbow ossification centres (6)
A
Come Rub My Tree of Love. They always appears in this order. 1-3-5-7-9-11 years. 1. Capitellum 2. Radial head 3. Medial epicondyle 4. Trochlea 5. Olecranon 6. Lateral epicondyle They are not useful if they are all present. They are only useful if one appears OUT OF ORDER. Then you know it is a fracture and not an ossification centre.
4
Q
Most common elbow fracture in peds? Radiological signs of this elbow fracture being present?
A
Supracondylar fracture (>60%)
- Anterior sail sign
- Posterior fat pad sign (pathognomic for #)
- Anterior humeral line does not intersect middle 1/3 of the capitellum
5
Q
Wheeze DDx (10)
A
- Asthma
- Foreign body aspiration
- Epiglottitis
- Pneumonia
- Tumor/mass with obstruction
- Bronchiolitis
- GERD
- TEF
- Laryngomalacia
- Tracheomalacia
- CHF (cong heart disease)
- CF
6
Q
Asthma PRAM score (5)
A
- Suprasternal retractions (0-2)
- Scalene retractions (0-2)
- Air entry (0-3)
- Wheeze (0-3)
- O2 saturation (0-2 with <92, 92-94, >94)
7
Q
Status asthmaticus treatment (8)
A
- Salbutamol 1mg/kg/hr continuous
- Ipratropium
- Corticosteroids (solumedrol or Dex)
- IV magnesium 50mg/kg (max 2g) over 20 minutes
- Heliox
- BiPAP
- IV ketamine 1mg/kg/hr for sedation
8. ETI with inhaled anaesthetics and permissive hypercapnia
8
Q
Stridor DDx (10)
A
<6mo 1. Laryngotracheomalacia 2. Vocal cord paralysis 3. Subglottic stenosis 4. Airway hemangioma 5. Vascular ring 6. Tumor/mass with obstruction, >6mo 7. Croup 8. Epiglottitis 9. Foreign body aspiration 10. Diptheria 11. Bacterial tracheitis 12. Peritonsillar abscess 13. Ludwig’s angina 14. Retropharyngeal abscess 15. Oropharyngeal trauma
9
Q
Risk factors for severe disease in bronchiolitis (5)
A
- Prematurity (<37 weeks)
- Age <12 weeks
- Previous apnea
- Immunocomprimised
- History of cardiac or respiratory disease
- Chronic lung disease
7. Presenting on day 1 (Disease is worst on day 2-3) - Previous hospitalization/intubation
10
Q
Which bronchiolitis needs admission (5)
A
- Signs of respiratory distress (indrawing, grunting, RR>70)
- O2 sats <90%
- Dehydration
- Cyanosis or apnea
5. High risk features (<37weeks, IC’d, cardiopulm disease)
11
Q
Treatment of bronchiolitis (3)
A
- Oxygen
- Hydration (PO preferable)
- +/- Epi neb
- +/- Nasal suctioning
12
Q
Steps to evaluate and treat neonatal central cyanosis (6)
A
Vitals. O2 sats. Glucose.
EKG
1. Pre and post-ductal O2 sats. BP in all four limbs. VBG
2. Hyperoxia test (100% O2 for 5-10 mins.
Cyanotic heart disease cannot raise sat >20% or PaO2 to 100mm Hg
3. CXR
4. Vascular access
5. CPAP
6. Presumed congenital heart disease? Prostaglandin E1 0.05mcg/kg/min
13
Q
Formula for hypotension (BP) in children? (1)
A
70+(2xAge)
14
Q
Formula for endotracheal tube size? (1)
A
(Age/4)+4 = uncuffed +3.5 is cuffed
15
Q
Anatomic considerations of the pediatric airway (6)
A
- Large head and occiput
- Large tongue
- Anterior vocal cords
4. Cricoid narrowing (cricoid ring narrowest part)
5. Large adenoids and tonsils - Small cricoid cartilage
16
Q
Succinylcholine contraindications (6)
A
- Hyperkalemia
- Burns >5days old
- Spinal cord injury
- Renal failure
5. Neuromuscular junction disease (myasthenia gravis, GBS)
6. Increased intra-ocular pressure - Pseudocholinesterase deficiency
- Malignant hyperthermia
- Muscular dystrophy
17
Q
Causes of failure to pass meconium in first 48 hours (3)
A
- Imperforate anus
2. Hirshsprung disease
3. CF
18
Q
Causes of uncontrollable crying or colic (10)
A
- ICH
- Meningitis
- Increased ICP
- Corneal abrasion
5. AOM
6. Nasal congetion (URTI) - Pneumonia
- CHF
- Intussception
- GERD
11. Anal fissure
12. Testicular torsion - Genital hair tourniquette
19
Q
Fever in the neonate (<1month): bugs and treatment? (2)
A
- LEG: Listeria, E.coli, GBS
2. Amp + Gent +/- Acyclovir
20
Q
Fever in the neonate 1-3 months: bugs and treatment? (2)
A
- Strep pneumo, H flu, Neisseria meningitides
2. Rx Amp + Cefotax +/- acyclovir
21
Q
For every 1 degree fever above 38 celcius HR and RR will (2)
A
- Heart rate will increase 10
2. Resp rate will increase 5
22
Q
Babe 1-3 months for a partial septic workup: what are the AAP criteria for low risk infants?
A
- No obvious source of infection
- No complex past medical history
- WBC count between 5–15,000
- Normal urinalysis (<10 WBCs/hpf)
5. Normal stool WBC count if they have diarrhea - Normal CXR if resp Sx
If these are met, do a partial septic workup. Their risk of SBI is 1.5%. Do a urinalysis, C+S, blood cultures, and CXR. FU in 24 hours!
23
Q
Define infantile colic:(3)
A
- Crying for >3hours per day
2. >3 days per week - > 3 week period
Dx of exclusion
24
Q
Cause of blood in the diaper in the first week (5)
A
- Swallowed maternal blood (most common in first 2-3 days) – Kleihauer-Betke test
- Coagulopathy
- NEC
4. Infectious colitis - Cows milk protein allergy/intolerance
25
Causes of neonatal jaundice (10)
1. Hemolysis (ABO-Rh incompatibility)
2. Congenital infection (TORCH)
3. Hematoma (cephalohematoma)
4. Neonatal sepsis (UTI, pneumonia, bacteremia, syphilis, CMV, toxoplasmosis)
5. Congenital disease (Gilbert syndrome, G6PD)
6. Biliary atresia
7. Hepatitis
8. Sickle cell anemia
9. Hemolysis (drugs)
10. Hypothyroid
11. Physiologic jaundice
12. Breastmilk jaundice
13. Beastfeeding jaundice
26
Definition of SUID? (1)
Sudden unexpected infant death. Death of a baby <1 year old in which no obvious case before investigation.
Sudden unexpected infant death (SUID) is a term used to describe the sudden and unexpected death of a baby less than 1 year old in which the cause was not obvious before investigation.
27
Criteria for a BRUE? (5)
Brief Resolved Unexplained Episode, child <1 year of age, with no discernable underlying cause after H+P
1. Brief – <1 minute
2. Resolved – it completely goes away
3. Apnea (stopped breathing, or abnormal breathing pattern)
4. Cyanosis/pallor
5. Tone
6. Altered LOC
28
DDx BRUE (8)
1. Sepis / SBI
2. Breath holding spell
3. GERD
4. Apnea of prematurity
5. Seizure
6. Bronchiolitis
7. Child abuse / poisoning
8. Pertussis
29
DDx: peds fever without a source >5days (6)
1. Kawasaki disease
2. UTI
3. IBD
4. Osteomyelitis
5. Lymphoma/leukemia
6. JIA
30
Causes of serious bacterial infection (10)
1. Meningitis
2. Encephalitis
3. Pneumonia
4. Myocarditis
5. Bacteremia
6. Cellulitis
7. UTI/pyelonephritis
8. Osteomyelitis
9. Septic arthritis
10. Mastoiditis
11. Disseminated gonococcus
31
```
Name the bug (4)
1. Hand foot mouth disease
2. Ophthalmia neonatorum
3. AOM
4. Infectious mononucleosis
5. Shingles
```
1. Hand foot mouth disease
Coxsackie virus
2. Ophthalmia neonatorum
Gonococcus, chlamydia, Staph, viral (all bad in neonates!)
3. AOM
Strep pneumo, H. flu, M. catarrhalis, viruses are >50%
4. Infectious mononucleosis =
Ebstein Barr Virus (heterophile antibodies! Beware Amoxil and a maculopapular rash)
5. Shingles = Varicella zoster
32
Centor criteria for likelihood of GAS pharyngitis (5)
1. Tonsillar exudates
2. Anterior lymphadenopathy
3. Absence of cough
4. Fever
5. Age 15-45 +1 point
0-1 = analgesia,
2-4 = test for GAS
33
Complications of GAS pharyngitis (why do we treat?) (3)
1. Shorten duration of illness 16 hours / prevent transmission (maybe!?)
2. Prevent local complications – sinusitis, peritonsillar abscess
3. Prevent rheumatic heart disease
- You can treat up to 9 days after symptom onset to prevent rheum heart disease!
34
Name the teeth (6)
Central incisors
Lateral incisors
Canines
First molar
, Second molar, Third molars
35
Name the Ellis classification of dental fractures (4)
1. Ellis 1 = Enamel
2. Ellis 2 = Enamal and dentin
3. Ellis 3 = Enamel, dentin, and pulp
4. Ellis 4 = Enamel, dentin, pulp, cementum
36
Name the treatment (3)
1. Avulsed primary tooth
2. Avulsed permanent tooth
3. Ellis 3-4 fracture
1. Avulsed primary tooth
- Leave it
2. Avulsed permanent tooth
- Replant immediately
3. Ellis 3-4 fracture
- Penicillin. Dentistry.
37
Pediatric neck mass DDx (10)
```
Lymphadenopathy
Mononucleosis
Retropharyngeal abscess
Bacterial lymphadenitis
Thyroglossal duct cyst
Branchial cleft cyst
Dermoid cyst
Cystic hygroma (lymphangioma)
Mumps
Granuloma (TB)
Toxoplasmosis
Sialoadenitis
Lymphoma
Thyroid cancer
```
38
The 5 T’s of pediatric cyanotic heart lesions (5)
1. Tetralogy of Fallot
2. Tricuspid atresia
3. TAPVR
4. Transposition of the great arteries
5. Truncus arteriosus
6. Three more: Ebstein anomaly, pulmonary atresia, hypoplastic left heart
39
Approach to the crashing neonate (4)
1. ABC, OIL (umbilical until d7-10, or IO), Glc, EKG, VBG
2. IVNS 10mL/kg
3. Abs: Cefotax and Gentamycin
4. Sepsis workup
5. DDx: Sepsis, cardiac, resp, abdominal (NEC, volvulus, intussception), metabolic (TSH, adrenal insufficiency, inborn error metabolism), structural (head injury, trauma)
*Differentiate congenital heart Dz with four limb BP, pre and post-ductal sat, hyperoxia test
*If congenital heart disease, likely requires prostaglandin infusion 0.05mcg/kg/min
40
Tetralogy of Fallot (4)
1.
Overriding aorta
2. Pulmonary artery stenosis
3. RVH
4.
VSD
41
Treatment of a Tet-spell (3)
1. Calm the baby
2. Apply oxygen
3. Knee-chest position
4. Morphine
42
How to treat neonatal SVT (rate >220!) (2)
1. Vagal maneuver (ice pack to forehead)
2. Adenosine
3. Shock, if you need to
*Refer to cardiology – they need an echo to rule out structural problems
43
How do infants with CHF present? (3weeks-6months) (5)
1. Tachycardia
2. Tachypnea
3. Low sat
4. Prolonged feeds/poor feeds/sweaty
5. Hepatosplenomegaly
6. Cardiomegaly
7. Poor weight gain
44
Cyanosis: how do you differentiate cardiac from respiratory cause? (2)
1. Cardiac has silent tachypnea, less WOB, no stridor/wheeze,
2. Cardiac has a positive hyperoxia test (sats do not improve with O2, max sat ~90%)
45
How do you do pre-ductal and post-ductal sats (1)?
1. Cardiac may have a differential oxygen saturation pre and post-ductal - >5% = coarctation
Use the right arm and the leg.
46
Diagnostic criteria for Kawasaki disease (5)
1. Fever for 5 days and 4 or more of:
2. Conjunctivitis (bulbar conjunctivitis, spares the limbus)
3. Rash: polymorphous rash, diffuse and non-specific
4. Adenopathy (cervical adenopathy)
5. Strawberry tongue/red and fissured cracked lips
6. Hands – palmar erythema, feet edema
*The bad complication of Kawasaki disease: coronary artery aneurysm and myocarditis
47
Classic triad of intusseception (only 20% of kids!) (3)
1. Abdominal pain
2. Vomiting
3. Red currant jelly stools
48
Vomiting in a neonate or toddler DDx (10)
1. Pyloric stenosis
2. Intusseception
3. Malrotation with volvulus
4. GERD
5. Gastro
6. Hernia (incarcerated)
7. Infection (UTI, AOM, sepsis)
8. Increased ICP
9. GERD
10. Hirschsprung, esophageal atresia, intestinal atresia, imperforate anus
11. Appendicitis
49
Who gets pyloric stenosis, how does it present, and classic lab finding (3)
1. Infants 6weeks – 6 months (5:1 male to female)
2. With progressive non-bilious emesis and appetite intact
3. Hypochloremic hypokalemia metabolic alkalosis (rare)
-
* Diagnosed with US (SN 98% SP 100%), length >15mm x 3mm thick
50
Who gets intussusception, how does it present, first-line Ix, what is the usual leadpoint, and treatment? (5)
1. 3 months – 3 years (peak 5-6 months).
2. Intermittent abdominal pain (minutes), then pain-free for 15-20 minutes, vomiting, and redcurrant jelly stools
- May progress to peritonitis, perforation, dehydration and shock
3. Ix: US (98%SN, 99% SP) – target sign, pseudokidney sign
4. Usual leadpoint is the terminal ileum
5. Treatment: air enema reduction
- Recurrence is 5-15%! Give good FU instructions
51
What is malrotation and volvulus? Which population does it present? How does it present? First investigation? Treatment? (5)
1. Abnormal rotation of the duodenum about the superior mesenteric artery, volvulus is when the midgut rotates and impedes blood flow, leading to bowel infarction
2. 0-5 years (90% in the first year of life, but can be any age – even adult!)
3. Bilious vomiting in a neonate is a surgical emergency until proven otherwise.
Infants have: bilious vomiting, irritable, worsening abdominal pain/distension, and hematochezia
4. Abdominal Xray: double bubble sign, lack of gas distal to duodenum OR upper GI series with small bowel follow through
5. Treatment: immediate surgery consult. Check glucose. NG tube. Pip Tazo.
52
What is necrotizing enterocolitis? Who gets it? Classic triad of NEC? Treatment? (4)
1. NEC is inflammation, ischemia, and infection of the bowel mucosa
2. Premature infants (although can be in full term – first 10 days of life)
3. Classic triad: abdominal distension, GI bleeding, pneumatosis intestinalis
4. Treatment: resus (IV fluids), NPO, full septic WU, Ampicillin + Cefotaxime + Flagyl, Gen Surg / NICU consult
53
What is Hirschsprung disease? How does it present? Investigation? Treatment? (4)
1. HD = aganglionic megacolon. No parasympathetic fibres in the distal gut.
2. Presents during the neonatal period, failure to pass meconium in first 24hours. Also bilious emesis, explosive diarrhea, poor feeding, fever.
3. Investigate: abdo Xray = dilated small bowel and empty rectum. Confirm with a contrast enema and rectal biopsy.
4. Treatment: surgical consult, IV fluids, IV flagyl
54
PECARN rule for pediatric head trauma (6)
1. Altered mental status
2. Not acting normally/persistent irritability infant according to the parent *Most concerning
3. Loss of consciousness for at least five seconds
4. Severe mechanism of injury
(MVC with rollover, ejection, death of another passenger, fall more 3 feet, head struck by high impact object, bicycle or passenger vs car)
5. Palpable skull fracture
6. Non-frontal scalp hematoma >2cm
*
The risk of clinically important head injuries is 0 to 0.02% if they have none of these factors
**
If they have 1-2 criteria, consider observation versus immediate CT scanning
55
CATCH rule for pediatric head trauma (4 high risk, 3 medium risk)?
Head CT is required for:
High risk (100% sensitive for neuro intervention):
1. GCS <15 2 hours post impact
2. Skull penetration or depressed skull fracture
3. Worsening headache on history
4. Irritable on exam
Medium risk (98% sensitive for any lesion on CT scan):
1. Basilar skull fracture
2. Large boggy scalp hematoma
3. Dangerous mechanism (3ft 5 stairs, MVC, fall from bike sans helmet)
56
What are the signs of basilar skull fracture (4)?
1. Hemotympanum
2. Periorbital ecchymosis (raccoon eyes)
3. Mastoid bone ecchymosis (battle sign)
4. CSF leak from nose or ears
57
Signs of an elevating ICP (7)?
```
1. Worsening headache
2. Visual or neurologic complaints
3. Persistent vomiting
4. Abnormal pupils (one pupil dilated)
5. Decreasing LOC
6. Focal neurological signs
7. Cushing’s triad (Hypertension, bradycardia, abnormal respirations)
```
58
Management of elevated ICP? (4)
1. Elevated HOB to 30 degrees
2. Hyperventilation – target pCO2 30-35
3. Mannitol 1g/kg IV with a matched NS bolus
4. Hypertonic saline (3%) BOLUS 3mL/kg then 0.3mL/kg/hr – shown to be more effective than mannitol!
59
What are the Ottawa knee rules? (5)
```
Do a knee Xray if:
1. Age >55
2. Pain to fibular head
3. Isolated patella pain
4. Inability to flex to 90
5. Inability to walk 4 weight bearing steps immediately and in the ED
*Good for kids 2 years and older!
```
60
Fractures associated with ACL tear (2)?
1. Segond fracture
|
2. Tibial spine fracture
61
DDx of pediatric limp (6)
1. Fracture (acute fracture, stress fracture, NAT)
2. Septic arthritis
3. Transient synovitis
4. LCPD (4-10)
5. SCFE
6. Osteomyelitis
7. Neurological (spinal cord pathology)
8. Limb length discrepancy
9. Malignancy (leukemia, lymphoma, sarcoma)
62
Salter-Harris pediatric fracture classification? (5)
1. Straight through the physis (growth plate)
2. Above the physis
3. Below the physis into epiphysis
4. Through the metaphysis, physis, and epiphysis
5. Crushed
63
What is a Tillaux fracture? A buckle fracture? (2)
1. Tillaux = Intraarticular SH III with avulsion of the anterolateral tibial epiphysis in a partially fused growth plate (ages 11-15). Rx surgical.
2. Buckle fracture is an incomplete fracture with a bulge in the cortex. Treat with a removable splint.
64
Most common neuro and vascular injuries with elbow fracture (supracondylar fracture)? (2)
1. Brachial artery (radial and ulnar artery)
|
2. Anterior interosseous (AOK sign)
65
Classic lab triad of hemolytic uremic syndrome (3)?
HUS is a bacterial enteritis most commonly caused by the Shiga toxin produced by E. Coli 0157:H7. Sx include bloody stool, abdo pain, lethargy, edema, tea colored urine
1. Microangiopathic hemolytic anemia
2. Thrombocytopenia
3. Renal insufficiency.
66
What are the indications for stool culture in diarrhea (7)?
1. Travel to an endemic country
2. > 10 diarrhea stools in 24 hours
3. >5 days duration
4. Bloody stool
5. Unremitting fever
6. Immunocomprimised host (ex HIV)
7. Recent antibiotics (C Diff)
67
Causes of invasive or bloody diarrhea (7)
1. Salmonella
2. Shigella
3. EHEC
4. Yerssenia
5. Vibrio
6. Campylobacter
7. C Diff
68
Which antibiotic classes are associated with C Diff infections (3)?
1. Clindamycin
2. Cephalosporins
3. Penicillins
69
Formula for maintenance fluids in peds? (1)
4:2:1 (4mL/kg first 10kg, 2ml/kg next 10kg, then 1mL/kg after that)
70
Causes of abdominal pain 0-3months (6), 3months-3years (6), 3years-adolescence (10)
0-3months (6)
```
0-3months (6)
1. NEC
2. Volvulus
3. Incarcerated hernia
4. Testicular torsion
5. Hirschsprung disease
6. NAT
7. Gastro/constipation/colic
```
```
3months-3years (6)
1. Intusseception
2. Volvulus
3. Torsion
4. Appendicitis
5. UTI
6. Constipation
7. Henoch-Schonlein purpura
8. Gastro
```
```
3years-adolescence (10)
1. Appendicitis
2. Ectopic
3. Ovarian torsion
4. Testicular torsion
5. Cholecystitis
6. Pancreatitis
7. UTI
8. Pneumonia
9. IBD
10. HSP
11. Constipation/gastro/ovarian cyst/nephrolithiasis
```
71
Triad of Henoch-Schonlein purpura (3)
1. Palpable purpuric rash
2. Acute abdominal pain
3. Arthritis
-- Renal involvement
72
Oral antibiotics that cover MRSA (5)
1. Septra
2. Doxycycline
3. Cipro (not great coverage)
4. Clindamycin
5. Linezolid
73
Animal bites: what are the pathognomonic bugs for dog, cat, and human bites? (3)
1. Dog bites - Capnocytophaga canimorsus
2. Cat bites –Pasturella multicida
3. Human bites – Ichanella
Treat all cat bites. Treat human and dog bites on the hands/face/feet
Rx. Clavulin PO or Ceftriax + Flagyl IV
74
Difference between a Galeazzi and Monteggia fracture? (2)
1. MUGR – Monteggia is fracture ulna, dislocation at the elbow.
2. Galeazzi is fracture at the radius, with a dislocation at the distal radioulnar joint
75
Kanavel’s cardinal signs for flexor tenosynovitis (4)
1. Finger is held in slight flexion
2. Swelling over the tendon
3. Pain over the tendon
4. Pain on passive extension of the finger
76
DDx for newborn in shock (5)
1. Sepsis – meningitis, bacteremia, pneumonia, pylelo, abdominal
2. Cardiac – terrible T’s and hypoplastic left heart
3. Metabolic – congenital adrenal hypoplasia, hypothyroid, hypoglycemia, hypocalcemia
4. Abdominal – malrotation with volvulus, intussception, bowel obstruction, pyloric stenosis, NEC
5. Toxins
6. Trauma, NAT
77
Antibiotic choice in neonatal sepsis (1)
1. Amp + Gent if <7days or Amp + Cefotaxime
78
How do you do a pre and post-ductal sat (1)? How to do a hyperoxia test (1)?
1. Right hand and right lower limb
| 2. Hyperoxia test: 100% FiO2 – if it doesn’t improve the O2 sat think cardiac shunt
79
Pediatric trauma: formula for ETT size, Foley/NG size, chest tube size (3)
1. ETT size – Age/4 +4 (+3.5 for cuffed)
2. Foley/NG – 2xETT size
3. Chest tube – largest is 4X ETT size
80
Anatomic differences of the pediatric airway (6)
1. Larger occiput
2. Airway is more anterior
3. Larger tongue, larger adenoids
4. Big, floppy epiglottis
5. More vagal response to laryngoscopy (bring atropine)
6. Cricoid ring is the narrowest part of the airway
7. They desaturate more quickly
8. Shorter trachea – don’t intubate right mainstem
81
How do you make an epi push-dose pressor? (1)
1. 10mL syringe with 9mL NS. Add 1mL of the cardiac amp epi (which is 100mcg/mL).
Now you have 10mcg/mL
Push 10mcg (1mL) at a time in an adult patient.
82
Which fractures are concerning for abuse? (5)
1. Any fracture in non-ambulatory infant/toddler “gotta cruise to bruise”
2. Femur # <18 months
3. Humerus # <18months
4. Multiple fractures at diff stages of healing
5. Skull fractures
6. Metaphyseal bucket handle fracture (shaken)
7. Posterior rib fracture
83
Priapism: difference between low-flow and high-flow priapism (2), treatment of priapism (2)
1. Low flow – decreased venous drainage (ischemic). Sickle cell, thalassemia, cauda equine, medication SE.
2. High flow – arterial injury, or AVM (non-ischemic). Trauma, straddle injury.
*Do a corpus cavernosum ABG. Call urology!
1. Treatment of priapism: pain control (dorsal nerve block). Intercavernosal aspiration. Irrigation with phenylephrine. Consider RBC transfusion if sickle cell Dz.
84
Difference between phimosis and paraphimosis (2)
1. Phimosis: constriction of the foreskin. Not usually emergency unless glans is obstructed, or infection.
2. Paraphimosis: can lead to ischemia. Dorsal nerve block. Manual compression to reduce. Consult urology. Emergency dorsal slit if all else fails.
85
```
Which of these febrile patients gets a urinalysis?
1. < 28 days old + fever =
2. 1-3 months old =
3. 3 to 6 months =
4. >6 months Male (circumcised) =
5. 6-12 months Male (uncircumcised) =
6. >12 months Male (uncircumcised) =
7. Female (not toilet trained) =
8. Female (toilet trained) =
```
1. < 28 days old + fever = Full septic workup
2. 1-3 months old = Partial septic workup including urine collection
3. 3 to 6 months = 48 hours of fever without a source
4. >6 months Male (circumcised) = 5 days of fever without source
5. 6-12 months Male (uncircumcised) = 48 hours of fever without a source
6. >12 months Male (uncircumcised) = 5 days of fever without a source
7. Female (not toilet trained) = 48 hours of fever without source
8. Female (toilet trained) = 48 hours of fever without source
* Peds UTI? Rx Cefixime or clavulin (Or Ceftriaxone IV)
86
Which UTI patients get a renal bladder US (RBUS)? (1)
1. After 2nd or 3rd UTI (often ordered by GP)
87
Sensitivity and specificity of leukocyte esterase (1) and nitrites (1)
1. Leukocyte esterase = 80% Sn and 80% Sp
| 2. Nitrites = 50% Sn and 99% Sp
88
Treatment of O157:H7 diarrhea?
(1)
1. Supportive. Avoid antibiotics (can make HUS worse)
89
Which toddler with fever and cough needs a CXR?
1. Temp >39.5 (consider)
2. Hypoxia <95%
3. Increased WOB
4. Tachycardia when fever resolves
5. Tachypnea when fever resolves
6. Focal findings
7. PMHx: immunocompromised, cardioresp history, unvaccinated
90
Normal breastfeeding? Normal bottle-feeding? (2)
1. Breast q1-3 hours
| 2. Bottle q2-4 hours, 2-4Oz (6-9feeds per 24hours)
91
When should babies get back to their birth weight? (1)
1. 10 days
92
DDx of hyper-bilirubinemia (10)
*Always bad
1. Sepsis (gram negative)
2. Congenital infection (TORCH)
3. Hematoma (cephalohematoma)
4. Neonatal sepsis (UTI, pneumonia, bacteremia, syphilis, CMV, toxoplasmosis)
5. Congenital disease (Gilbert syndrome, G6PD)
6. Biliary atresia
7. Hepatitis
8. Sickle cell anemia
9. Hemolysis (drugs)
10. Hypothyroid
11. Physiologic jaundice 2-3days
12. Breastmilk jaundice
13. Beastfeeding jaundice
93
Neonatal jaundice workup (7)
1. Direct and indirect bilirubin
* You can stop after here if no other risk factors and normal level
2. CBC
3. Blood type
4. DAT
5. Peripheral smear
6. Reticulocyte count
7. Liver function tests
8. TSH, G6PD test
9. +/- sepsis WU if indicated
* Plot on the bilirubin nomogram: phototherapy or exchange transfusion?
94
Neonatal metabolic emergencies (3)
1. Hypoglycemia. 5mL/kg D10W, then 1.5X maintenance
2. Hyper-ammonemia
3. Congenital adrenal hypoplasia
95
SIDS risk factors (6)
1. Peak incidence 2-4 months
2. Prone sleeping position
3. Co-sleeping
4. Premature
5. Cardiorespiratory disease history
6. Previous infant with SIDS
7. Low SES
8. Smoking in household
9. ++ Blankets used
96
Measles symptoms (3)
1. Cough
2. Coryza
3. Conjunctivitis
4. Rash spreads from head down
* Look for Koplik spots in the mouth.
97
Scarlet fever symptoms (3)
1. Palate red and petechiae
2. Strawberry tongue
3. Sandpaper rash (feels like goose flesh)
* Group A Strep. Rx penicillin
98
Staph scalded skin syndrome (2)
1. Red rash everywhere
2. + Nikolsky sign (sloughing skin)
3. Sick appearing kiddo
Rx. Treat Staph
99
Difference between erythema multiforme minor and erythema multiforme major (2)
1. Erythema multiforme minor = no mucosal involvement,
2. Erythema multiforme major = + mucosal involvement,
*90% is associated with infection. More benign.
If Nikolsky sign + that is Steven Johnson Syndrome (90% involve medications!). SICK
100
NEXUS or Canadian C-spine in pediatrics? (1). What is the rule? (5)
```
*Use NEXUS in peds. Can be used >1year. Caution >65years because the sensitivity is much lower. Reliable kid >5years? Use NEXUS. Low threshold for distracting injury.
For toddlers and infants get an AP and lateral Xray. If Xrays look fine – collar off. If child moves neck – clear! If guarding or torticollis: CT neck.
"NEXUS: I Am a Frickin MD"
1. Altered LOC = Xray
2. Intoxication = Xray
3. Distracting injury = Xray
4. Midline Cspine pain = Xray
5. Focal neuro deficit = Xray
```
101
What is pseudosubluxation? (1) How do you correct for it? (1)
1. Pseudosubluxation – C2 on C3 or C3 on C4
| 2. Use Swischuk line (anterior spinous process line C1 to C3 should be within 2mm of C2)
102
Signs and symptoms of idiopathic intracranial HTN (“pseudotumor cerebri”) (4)
*Same as signs of increased ICP. The obese adolescent female on OCP is classic.
1. HA, N+V, blurry vision
2. Papilledema
3. Transient change in vision
4. CN VI palsy (no lateral eye movement). No other neuro Sx.
5. CT head normal
6. Lateral decubitus ICP >250
Rx. Weight loss. Acetazolamide
103
When do you need to use jet ventilation instead of cricothyroidotomy (1)
1. <8-10 years = use jet ventilation (14guage IV, 3mL syringe, ETT adapter, then BVM)
104
Injuries concerning for child abuse (5)
1. Fracture (femur, ribs, humerus, scapula, multiple #) – any fracture in a non-ambulatory child
2. Burns (accidently shows splash – stocking/glove/buttocks is bad)
3. Bruises to cheeks, ears, chest, inner thighs – especially a non-ambulatory child
4. Frenulum tears (forced feeding)
5. Injury does not match the mechanism
6. Delayed presentation with no explanation
105
Approach to fever in the 29-60 day infant (3)
1. Step-by-Step (partial septic WU – urine, blood, CXR)
2. Temp >38, no clear source, appears well, age >28days, no urine leuks, CRP <20, Neut’s <10,000
3. Consider any serious risk factors (premature, underlying medical problem, appears ill, poor follow-up)
106
Intranasal analgesia for pediatric patients (1)
1. IN fentanyl 2mcg/kg, repeat q20min PRN
| 2. If only sedation? IN Midaz 0.2mg/kg/dose max 10mg
107
Treatment of diaper dermatitis (2)
1. If severe hydrocortisone 1-2.5% ointment for 1-2 days
2. Zinc oxide paste 40% with every diaper change
3. Increase diaper-less time
* Ointments don’t hurt, but creams do
108
Differentiate scarlet fever, staph scalded skin syndrome, toxic shock syndrome (3)
1. Scarlet fever – red sandpaper rash, strawberry tongue, swab the throat!
2. Staph scalded skin – red, sloughing skin. +Nikolski sign (superficial). Sick.
3. Toxic shock syndrome – SICK, red rash, + Nikolski (deep)
109
Risk factors for neonatal sepsis (6)
1. GBS
2. Maternal fever
3. Prolonged ROM
4. Prematurity
5. Maternal GBS – especially if no antibiotics given
6. Out of hospital delivery
7. No preterm care
110
Big differences between kids and adults sepsis (3)
1. Kids get lethargic, altered
2. Kids get febrile and tachy and COLD shock – they shut down with poor CRT. Adults get warm shock
3. Kids get hypoglycemia
4. Kids don’t get hypotensive until very late
111
(2) infectious causes of purpura
1. Meningiococcemia
| 2. RMSF
112
Rheumatic fever diagnostic criteria (5)
JONES: 2 major + 1 minor or 2 minor + 1 major
1. Joints (arthralgia)
2. Carditis (O=heart)
3. Nodules
4. Erythema marginatum rash
5. Sydenham chorea (involuntary jerking movements)
MINOR=arthralgia, fevers, elevated PR, elevated ESR/CRP.
*Most common valve involved is mitral – MR
113
List (5) suppurative and (5) non-suppurative complications of GAS pharyngitis?
1. Tonsillopharyngeal cellulitis
2. Para-tonsillar abscess
3. Sinusitis
4. Meningitis
5. Bacteremia/sepsis
6. Deep space neck infection
7. Lemierre’s syndrome (septic thrombophlebitis jugular vein)
1. Toxic shock
2. Reactive arthritis
3. PANDAS/OCD TICS
4. Post-Strep GN
5. Scarlet fever (rash + strawberry tongue)
6. Rheumatic fever
114
UTI risk factors (5)
1. Female <24 months
2. Uncircumcised male
3. Circumcised male <6months
4. Prev UTI
5. IC’d
115
Characteristics of pathologic lymph node enlargement (4)
1. Unilateral, >2cm, firm, fixed, rubbery, enlargening. Hot and tender are signs infection.
*Unilateral lymphadenitis: GAS, staph aureus, anaerobes, TB
*Bilateral majority are viral (rhino,adeno, EBV/CMV)
Not toxic? No imaging, just Keflex 100mg/kg/d QID 7 days.
116
What is cat scratch fever? (1)
1. Bartonella from scratches or bites. Lymphadenopathy near the site of scratch. Typically resolves but 15% get disseminated infection.
117
Treatment of diaper dermatitis (1)
1. Air time
| 2. Barrier cream (any). Vaseline - apply after a change. DO NOT wipe off. When you change just pad it dry and add more.
