CR - Pediatric Emergencies

Question 1

What is the best screening test for the diagnosis of Reyes syndrome?

Answer 1

Serum ammonia level

Question 2

Clinical presentation: a young boy (5 years of age) presents with a limp. There is no history of trauma. There is remote history of URI symptoms roughly 1 week ago. On examination, the hip is noted to be slightly flexed, externally rotted, and adducted.

What is the most likely diagnosis?
What diagnosis must be excluded?
What other diagnosis must be considered if symptoms persist?

Answer 2

Transient synovitis is the most common cause of a non traumatic acute hip pain with a limp. Typically occurs between 3-8 years of age. Children will normally be well appearing.

You must exclude septic arthritis

If the condition is chronic, you should exclude Legg-Calve-Perthes disease (avascular necrosis of the femoral head)

Question 3

What are the most common pathogens (organisms) causing pneumonia in children after the newborn period?

Answer 3

Viruses (age <5)
Mycoplasma pneumonia (ages 5-13 years)
Adolescence: assume same infectious risks of healthy adults
Recent history of influenza - concern for s. aureus

Question 4

What is the most common cause of bacterial pneumonia in children after the newborn period?

Answer 4

streptococcus pneumonia
(>5yrs, atypical begin to become more common i.e. mycoplasma pneumoniae)

Question 5

Slipped capital femoral epiphysis occurs most frequently in which group of children?

Answer 5

Obese males, ages 14-16 or slender, rapidly growing adolescents (usually male)

Females present earlier, 11-13. Rare in females after the start of menarche.

Note: the slipped epiphysis is best seen on the AP frog leg x-ray of the pelvis. However, the use of a frog leg view is controversial given the potential for further epiphyseal displacement. Current recommendations include bilateral hip radiograph with AP and lateral (Lowenstein view)

Question 6

What is the second most common primary dysrhythmia in pediatrics after sinus tachycardia?

Answer 6

Paroxysmal supra ventricular tachycardia (PSVT)

Wolff-parkinson-white syndrome is the most common form of ventricular preexcitation in children.

Question 7

What is the most common pre-arrest rhythm disturbance seen in the setting of pediatric arrest?

Answer 7

Bradyarrhythmias, especially sinus bradycardia, are the most common pre-arrest rhythm. Systole is the most common arrest rhythm. Hypoxia is the most common cause of symptomatic bradycardia.

Note: epinephrine is the drug of choice (after oxygenation and ventilation) for treating bradycardia in the pediatric population. Initiate CPR in children with HR < 60 and signs of poor perfusion.

Question 8

In which age group are radial head subluxations most commonly seen?

Answer 8

Children < 6 years of age, peaks between 1-4 years

Usually occurs as the results of a pulling mechanism on an outstretched arm.

Question 9

Which fractures are most commonly seen in children who fall on an outstretched arm?

Answer 9

Distal radial fractures
(epiphyseal fractures and/or torus fractures)

Question 10

Clinical presentation: A 1-year old presents with intermittent abdominal discomfort and a palpable sausage-shaped mass in the right mid-abdomen.

What is the most appropriate therapeutic course of action?

Answer 10

Air insufflation or barium enema (BE)

These studies are useful both diagnostically and therapeutically since 90% of intussusception cases may be corrected if it is performed within the first 12-24 hours.

Note: ultrasound should be the first diagnostic tool if the diagnosis is ambiguous

Question 11

What are the most common signs/symptoms of hypothermia in infants

Answer 11

Lethargy
Decreased feeding

Remember, very young infants do not have the ability to shiver. They rely on non-shivering thermogenesis

Question 12

In addition to the rash, what are the characteristic physical findings of rubella (German measles)?

Answer 12

Lymphadenopathy involving the post auricular, posterior cervical, and sub occipital nodes.
Conjunctivitis (mild nonexudative) and an exanthema on the soft palate may be observed in some cases.
Forchheimer spots are pinpoint petechiae involving the soft palate that coalesce.

Question 13

Clinical presentation: a child known to have a ventricular septal defect develops sudden onset of agitation and cyanosis.

What is the most likely explanation?

Answer 13

Reversal of the left-to-right shunt; eisinmenger syndrome is seen in many unrepaired congenital cardiac anomalies. Reversal leads to shunting of deoxygenated blood entering the systemic circulation and causing symptoms of hypoxia.

Congenital heart lesions causing shunts are best corrected before reversal occurs, since pulmonary hypertension may not be reversible after surgery.

Question 14

What additional infection is common in infants who present with osteomyelitis?

Answer 14

Septic arthritis

Because of the unique nature of the blood supply to the skeletal system, osteomyelitis and septic arthritis often occur together in infants.

This phenomenon is the result of two mechanisms. Capillaries from the metaphysic perforate the epiphyseal growth plate, which causes the infection to spread to the epiphysis and joint surface. Second, the joint capsule often extends beyond the epiphyseal plate allowing infection of the periosteum to invade the joint space

Question 15

What is the initial fluid therapy for children in shock

Answer 15

Rapid infusion or boluses of crystalloids, 20 ml/kg over 5-10 minutes repeated up to 2-3 times. Then consider blood in trauma patients and pressors in sepsis patients

Question 16

What is an important disease to include in the differential diagnosis for unimmunized children less than four years old that present with persistent cough/URI for several weeks

Answer 16

Pertussis (whooping cough)

Question 17

What is the most common complication of pertussis (whooping cough) in infants?

Answer 17

Secondary bacterial pneumonia

Secondary bacterial pneumonia occurs in up to 25% of infants with pertussis, it is the most common cause of most pertussis-related deaths across age groups.

Pneumonia occurs in 5.2% of cases, and 11.8% of infants. Other complications include seizures and encephalopathy in infants <6 months of age.

Question 18

Under what circumstances is the discovery of an inguinal hernia in an infant a surgical emergency?

Answer 18

If there are signs of strangulation such as severe pain, bilious emesis, bloody stool, overlying edema or erythema, or the hernia is not reducible. Otherwise these hernias should be repaired on an elective basis.

Question 19

A child without a spleen is particularly susceptible to which illness?

Answer 19

Meningitis and bacteremia or sepsis from gram-positive encapsulated organisms.

Streptococcus pneumoniae (pneumococcus), haemophilus influenza type B (Hib), and Neisseria meningitides are the most common organisms

Question 20

Which respiratory tract infection is most commonly confused with asthma?

Answer 20

Bronchiolitis

Is a viral disease which often presents with wheezing, cough, and increased respiratory effort. It can progress to hypoxia and respiratory failure. 70% of cases are caused by the respiratory syncytial virus (RSV). Less commonly implicated viruses are parainfluenza, adenovirus, and influenza. Occurs in children < 2 years of age. Treatment is largely supportive and includes nasal suctioning and supplemental oxygen for hypoxia.

Question 21

What sequelae can result from failure of treatment with acute otitis media?

Answer 21

Meningitis
Mastoiditis
Epidural / subdural / brain abscess
Hearing loss
Sinus thrombosis
Labyrinthitis, facial or abducens nerve palsy

Question 22

What diagnosis should be considered in children between the ages of 3 and 12 months who present with severe, intermittent abdominal pain?

Answer 22

Intussusception

Most often 3-12 months, but can occur at any age. The classic triad is colicky abdominal pain, vomiting, and currant jelly stools. Diagnosis is commonly made with ultrasound/enema. Typically treated with air enema.

Question 23

Why is the fundoscopic examination important in the suspected child abuse victim?

Answer 23

To check for retinal hemorrhage. A fundoscopic exam should be done within the first 24-72 hours in order to ensure transient retinal changes are not missed; this is often best done by ophthalmology. Have a high index of suspicion for shaken baby syndrome with retinal hemorrhages. A fundoscopic exam is non-invasive and should always be performed when suspecting child abuse, particularly in those too young to speak to you about what happened.

Question 24

In the early stage of this illness, symptoms are indistinguishable from a nonspecific upper respiratory infection with rhinorrhea, low grade fever, cough, conjunctivitis, and anorexia.

As the disease progresses, the characteristic cough is often the dominant clinical feature.

What is the disease and what is important to note regarding immunization status?

Answer 24

Pertussis

The first consideration of immunization is that the CDC recommends vaccination beginning at 2 months with Dtap and requires 4 boosters by age 6. This can lead to under immunization, particularly in those under the age of 12 months. Furthermore, it is important to take a thorough history including immunization status to evaluate if the patient was initially immunized against pertussis. Also of note, the vaccine can wane in adults. Adults can get the disease and pass it on to infants at a much higher risk of morbidity and mortality.

Question 25

What are the Ottawa knee rules for ordering knee x-rays in children and at what age are they applicable

Answer 25

The ottawa knee rules have been validated for children with traumatic knee injuries over the age of 5 and support obtaining a knee radiograph if any of these findings are present on physical exam:
Isolated patellar tenderness
Tenderness at the head of the fibula
Inability to flex knee 90
Inability to bear weight and walk 4 steps (immediately after injury and in the ED)

Question 26

Do children with post-traumatic seizures following blunt head trauma require admission?

Answer 26

Yes.

Children with post traumatic seizure, are categorized as moderate to high risk of occult intracranial injury and require neurosurgical consultation and admission. Incidence of seizures post TBI has been reported in 10-20%

Question 27

What is the current drug of choice for the treatment of GABHS tonsillopharyngitis in children?

Answer 27

Penicillin remains the drug of choice for GABHS infection (amoxicillin is equally efficacious. It is more palatable). If treatment failure or penicillin allergy, consider a cephalosporin or macrolide. Clindamycin or amoxicillin/clavulanic acid should be considered for recurrent treatment failures.

Question 28

What fracture occurs at the distal metaphysis due to failure of the cortex on the compression side of the bone?

Answer 28

Torus (buckle) fracture.

This injury is caused by buckling of the cortex due to trabecular compression from an axial loading force. The periosteum and cortex remain intact on the side of the bone opposite the fracture. Torus fractures are stable, and treatment is aimed at pain relief, comfort, and protection of the bone from any further injury using a short arm cast or a splint.

Question 29

A 7 year old Caucasian male presents to the emergency department for altered mental status. He is obtunded and intubated for airway protection. His mother states he had a cold two days prior and took some pills to help with his symptoms but that he was perfectly fine when he woke up this morning. The patient’s lab work reveals elevated BUN, elevated AST and ALT and a prolonged PT time. What medication is the likely cause of the patient’s condition?

Answer 29

Aspirin

This child presented with Reye’s syndrome which is a result of aspirin intake in a child during a viral illness. This results in hepatocyte mitochondrial damage with secondary dysfunction and neurological sequelae. This is thought to be secondary to an occult inborn error of metabolism. Management includes: ICU admission, supportive care, and discontinuation of aspirin.

Question 30

What is the appropriate outpatient treatment for well appearing children who are afebrile and diagnosed with periorbital cellulitis?

Answer 30

Amoxicillin clavulanic acid (20 mg/kg PO twice a day)

Should cover most common organisms (s pneumo, h influenzae, s aureus, strep sp & anaerobes)

Clindamycin 30 mg/kg/day q8h (MRSA and anaerobic coverage)

Or combination therapy with below if unable to tolerate clindamycin

Amoxicillin clavulanic acid 45 mg/kg/d or cefpodoxime (10mg/kg/d) or cefdinir (14 mg/kg/d)

Question 31

What is the most common complication of pneumonia in children?

Answer 31

Acute dehydration

Less common complications include: necrotizing pneumonia, parapneumonic effusion, empyema, and/or lung abscess

Question 32

What is the best way to diagnose arrhythmogenic right ventricular cardiomyopathy?

Answer 32

Cardiac MRI
(Fibro-fatty infiltration of right ventricle +/- wall motion abnormalities)

Bonus: suggestive EKG findings include: Epsilon wave, T wave inversions V1-V3, and/or prolonged upstroke of S wave

Question 33

A 3 week old male presents with bilious vomiting, abdominal distension and occasional blood-streaked stool. Mother reports he is inconsolable. Abdominal x-ray shows bowel distension and loops of bowel overriding the liver. What is the most likely diagnosis?

Answer 33

Malrotation of the intestine

Usually presents in the first month of life with life-threatening volvulus. Patients may also present in shock, and emergent surgical consultation is warranted. Consider this diagnosis in any child <1 month of age with bilious emesis

Question 34

What is the first line intervention for pediatric patients with stable SVT?

Answer 34

Vagal maneuvers to increase parasympathetic tone. This can be accomplished by placing bags of ice or cold water over the patients forehead for 15-30 seconds, or stimulating the rectum with a thermometer to encourage the patient to bear down. Have older children blow through a straw or syringe while bearing down for 10-15 seconds

Question 35

What diagnosis should be considered in an infant <1 month of age who presents with tachypnea, cyanosis, and shock? What is the first line treatment?

Answer 35

Ductal-dependent congenital heart defect

Most important intervention is IV prostaglandin E1 (initial dose of 0.1 mcg/kg/min, then titrated to lowest effective dose)

Question 36

How can we objectively evaluate the need for head CT in a pediatric patient?

Answer 36

We can use the PECARN pediatric head injury algorithm which considers patients age, evidence of injury (altered mental status, decreased GCS, signs of basilar skull fracture), and mechanism associated with trauma (loss of consciousness, vomiting, severe headache, or severe mechanism).

Question 37

What differentiates a simple febrile seizure from a complex febrile seizure?

Answer 37

Simple febrile seizure is characterized by:
-Presence of fever in child 6 mo-5 years
-single seizure in 24 hours
- seizure lasts less than 15 minutes
- child has no neurologic deficits
- seizure is generalized

In a patient who does not have an intracranial infection, metabolic abnormality, or history of afebrile seizures.

Question 38

A 10 day old neonate with good pre and postnatal care presents with bilateral purulent conjunctivitis. What is the most likely causative agent and what is the appropriate treatment?

Answer 38

Chlamydial conjunctivitis typically presents around day 5-14 with unilateral or bilateral eye discharge. Treatment is a 14 day course of oral erythromycin as up to 30% can develop secondary pneumonia.

Neonatal conjunctivitis causes are typically distinguished by timing (chemical <24 hrs, gonococcal 2-7 days, chlamydial 5-14 days, HSV 1-2 weeks)

Question 39

What are some of the differentiating factors of transient synovitis vs septic arthritis

Answer 39

Septic arthritis more likely to have fever
Septic arthritis more likely to be painful during all motion and not just weight-bearing

Can use Kocher criteria to base probability of septic joint (non-weight bearing on affected side; ESR >40; fever >38.5; WBC >12,00)

Question 40

3-year-old male presents to the ER with expiratory stridor, respiratory distress and copious secretions. He was seen in the ED 2 days prior and diagnosed with croup and is post racemic epinephrine and steroids. What diagnosis should be considered?

Answer 40

Bacterial tracheitis: an infection of the epithelium of the trachea

Most likely starts out as viral prodrome followed by acutely severe worsening

Most often need intubation as well as bronchoscopy; need ICU admission

Abx: ceftriaxone plus vancomycin or clindamycin

Question 41

What is the clinical triad of hemolytic uremic syndrome?

Answer 41

1. Acute renal failure
2. Thrombocytopenia
3. Microangiopathic hemolytic anemia (MAHA)

Question 42

What are the most common etiologies of acute otitis media?

Answer 42

Viral (70% of cases)

Bacterial:
1. S. pneumo (50%)
2. Nontypable H. influenzae (30%)
3. Moraxella (30%)

Question 43

What is the initial treatment for bacterial acute otitis media?

Answer 43

Initial treatment: high dose amoxicillin (80-90 mg/kg/day BID for 7-10 days)

If patient has been treated with abx in prior month:
Augmentin with 80-90mg of amoxicillin
Cefdinir (14 mg/kg/day BID x7-10 days)
Cefpodoxime (10 mg/kg PO daily x7-10 days)
Cefuroxime (15 mg/kg PO BID x 7-10 days)
or Cefproxil 15 (mg/kg PO BID x7-10 days)

If clinical suspicion for H. flu: augmentin with 80-90 mg amox

Treatment failure: augmentin or ceftriaxone 50 mg/kg IM once

Question 44

What are the clinical features of Hand foot and Mouth disease?

Answer 44

Cause: coxsackie virus
-brief prodrome with low fever, anorexia, and sore mouth
-oral lesions 1-2 days later (vesicles on erythematous base with ulceration; painful; on buccal mucosa, tongue, soft palate, and gingiva)
-hand and sole of foot lesions (red papule that change to gray vesicles)

Resolves in 7-10 days

Treatment: supportive

Question 45

2-year old female comes in with mom holding her left arm flexed and pronated. Mom states that she was swinging her around in the backyard and then the child began crying and holding her arm. Upon exam, she refuses to use the arm and will not reach out for her favorite toy. Neurovascular status is intact. What is the next best step in management?

Answer 45

Reduction

2 reductions techniques - hyperpronation or supination
Hyperpronation has greater first attempt success

Hyperpronation - hold elbow at 90 degrees flexion in one hand while placing thumb over radial head; with the other hand hyperpronate the patients wrist

Supination - hold patient’s elbow at 90 degrees flexion and place thumb over radial head; with the other hand, supinate the patient’s wrist and then fully flex the elbow (may need some traction)

Question 46

What are the salter Harris fracture types

Answer 46

I - Slipped (through the physics / growth plate)

II - Above (physics with metaphysics fracture)

III - Lower (physics with epiphysis fracture)

IV - Through (physics, metaphysics, and epiphysis fracture)

V - Rammed (growth plate is crushed)

Pneumonic is SALTR

Question 47

1 year old male presents to the ED with excessive vomiting and irritability. Parents state it came on suddenly during the night while the child was sleeping. On physical exam, abdomen is benign but a genital exam shows a swollen, high riding left testicle with absent cremasteric reflex. What is the most important next step

Answer 47

Emergent Urologic Consultation

In children with testicular torsion, urologic consultation should not be delayed for work-up if there is a strong suspicion.
Can also get an ultrasound to look for unilateral absence of blood flow.

Manual detorsion is a temporizing measure and should be done with the “open the book” technique

Question 48

About how long after delivery can you use the umbilical vein for catheterization

Answer 48

Remains viable and patent until roughly 1 week following birth

Contraindications include omphalitis, peritonitis, and necrotizing enterocolitis

Question 49

What are the most reliable clinical signs in terms of diagnosing appendicitis

Answer 49

Local tenderness and positive McBurney’s point rigidity

Can use pediatric appendicitis score to further predict:
Nausea / vomiting (+1), anorexia (+1), migration of pain to RLQ (+1), cough/percussion/hopping tenderness (+2), RLQ tenderness (+2), leukocytosis WBC >10,000 (+1), neutrophilia ANC >7,500 (+1)

Low risk </= 2
Indeterminate risk 3-6
High risk >/= 7

Question 50

This is the most common vasculitis seen in childhood (2 years -11 years)

Answer 50

Henoch-schonlein purpura

Classical triad: non-thrombocytopenia palpable purport, abdominal pain, arthritis

IgA mediated and most commonly preceded by URI
May have glomerulonephritis/renal disease with hematuria +/- proteinuria
95% recovery completely after 3-4 weeks

Most feared complication is renal insufficiency (this is more severe in adults vs children)

Question 51

2 year old female presents to the ER with fevers of 40C (104F) for 7 days. Parents state she was initially diagnosed with viral infection but has now developed a rash that is maculopapular in etiology as well as dry/crecked lips, redness of both her eyes, and her fingertips have started to peel. What is a complication that needs to be screened for in this disease?

Answer 51

Coronary artery aneurysm

Patient has Kawasaki disease (ie mucocutaneous lymph node syndrome) which is the leading cause of acquired heart disease in children

Cardiac complications develop early on, and aneurysm development is most prevalent as the fever lessens (during 3rd-4th week of illness)

Myocardial infarction is leading cause of death

Management is with IVIG (2gm/kg over 12 hr) as well as aspirin 20mg/kg/dose q6h