Crit Care Flashcards
16-year-old boy with a bout of emesis at a party, presenting with chest pain, dysphagia and dyspnea. His vital signs are HR 120, RR 20, BP 120/65, sats 96% on RA. He had decreased air entry on one side with subcutaneous emphysema. The CXR shows a small pneumothorax and small pneumomediastinum. What is the next step?
Oxygen
Needle decompression
Chest tube
Upper endoscopy
Oxygen
If oxygen wasn’t an answer, would pick consult GI for scope, or if clinically stable may pick oxygen.
Boerhaave Syndrome: life threatening–needs prompt endoscopic or surgical intervention
5-year-old male with cerebral palsy nonverbal and severe motor impairment. Over the last couple of days, he has become more lethargic. Now presenting with lethargy. HR 60, RR 20, BP 130/90, SpO2 92%. One pupil is not reactive to light and dilated. He is somnolent. What is the next step?
CT head
Rapid sequence intubation
5ml/kg 3% saline
NS bolus
RSI
5-year-old child with cerebral palsy. Underwent G-tube placement 2 weeks ago and has been fussy since. Restarted on regular home feed regimen of 1000mL of 2kcal/mL formula with 500 mL of water post-op. Presenting with retching and lethargy. Blood work shows: Na 127, serum Osm 264, urine Na 146, urine Osm 1016, creatinine 55. What is the diagnosis? (no indication of hydration status)
Cerebral salt wasting
Primary polydipsia (other = excessive water intake)
Inadequate salt intake
SIADH
Cerebral salt wasting: usually dry (perhaps why this patient is obtunded, urine Na is very high)
what should you do in your management of low risk BRUE?
shared decision making with parents, resources for CPR, education
things you could consider but need not do in low risk BRUE
viral resp testing, head imaging, urinalysis, glucose, bicarb, lactate, admission to hospital solely for cardioresp monitoring
Which management actions may you consider in low risk BRUE?
EKG, pertussis testing, brief monitoring with continuous pulse ox, serial checks
+/- rapid viral test however can be falsely positive from previous viral infection
In low risk BRUE what should you not do?
labs, LP, EEG, echo, testing for GERD, antacid, AED, home cardioresp monitoring
Low risk BRUE as per Nelson’s where you don’t need to admit for observation (7 features)
1) age >60 days
2) gestational age >=32 weeks and post conceptional age >=45 weeks
3) occurrence of only 1 BRUE (no prior BRUE ever and not occurring in a cluster)
4) duration of event <1 min
5) No CPR by trained medical professional
6) No concerning historical features
7) No concerning physical exam findings
Other features:
no social concerns
family history of sudden cardiac death
8-week-old ex-35-week infant who coughs with a feed and becomes hypotonic for 15 seconds. No cyanosis noted by parents. He had a normal exam and bloodwork. What do you do?
Reassure and send home
Admit and observe for 24-48 hours with cardiorespiratory monitor
Echo as an outpatient
EEG as an outpatient
Admit and observe as CGA is 43 weeks
There is an infant on your ward with a tracheostomy. He is ready to be discharged. You are called for an acute change. The nurse has already tried suctioning him but there is no improvement. He has increased work of breathing with severe intercostal indrawing and cyanosis. What is your management?
CXR
Deep suction with saline
Change tracheostomy
Endotracheal intubation
change trach
There is an 18 month girl who was crying and wanted mom to pick her up. When mom picked up she noticed that she was limp and had turned blue. After a few seconds she started crying again. She had a similar episode last week. What investigation do you do?
EEG
Glucose
ECG
Ferritin
Ferritin
Toddler with episodes where she doesn’t get her way, cries/throws tantrum, then loses consciousness and sometimes turns blue. These episodes are increasing in frequency. What do you recommend?
Ignore the behaviour and put her in timeout after the episode
Refer for behavioural therapy
Put her in time-out before behaviour has a chance to escalate
Give in to what she wants
Time out before behaviour escalates
A child presents in SVT. You give 0.2mg/kg of adenosine. Based on the following ECG, what is the most accurate statement to tell the cardiologist?
(SVT to a flutter)
The adenosine worked and the arrhythmia is ongoing
The adenosine worked and the arrhythmia is terminated
The adenosine did not work and the arrhythmia is ongoing
The adenosine did not work and the arrhythmia is terminated
Adenosine worked and arrhythmia is ongoing
What should you do if swallow a magnet?
If >= 2 magnets, need admission for attempted retrieval by endoscopy or clearance by WBI. Weak refrigerator magnets may not need intervention.
Mom calls to tell you that her child swallowed a CR2032 button battery. What do you advise?
Urgent XR to assess location
Reassure her that children swallow things all the time
Reassess in 2 days if not in the stool
Immediate endoscopy
XR
Once past lower esophageal sphincter can allow it to pass however if lodges in airway or esophagus then it is considered a true emergency and requires immediate referral. Contact for even 2 hrs can cause necrosis.
How do you calculate GCS?
A child comes in after an MVC. He has extensor movements of his arms and legs with pain, no eye opening to pain, and incomprehensible moaning. His pupils are 4 mm and reactive. What is your next step?
Mannitol
Rapid sequence intubation
Urgent CT head
Normal saline bolus 20cc/kg
RSI (GSC 5)
An 11 month infant presents to the ED 1 hour after going for a 45 minute swimming lesson. He has a 2 minute general tonic clonic seizure in the ED. His temperature is 35.6C. No evidence of any head trauma, and no lateralizing neurological findings. He is lethargic and post-ictal. What is the most likely etiology?
Head trauma
Chlorine poisoning
Water intoxication
Hypothermia
Water intoxication
A 12 year old female presents to the ED with dizziness. She is otherwise well and is awake and talking to you. Her ECG shows the following rhythm. What is your next best step?
(Torsades de pointes)
Magnesium sulfate
IV Adenosine
Debrillate 2J/kg
Cardioversion 1J/kg
Mag sulf
If mag self does work, treatment is defibrillation
Difference between croup and acute epiglottitis in terms of voice/symptoms, x-ray findings, and treatment
Croup: hoarse voice, barking cough, steeple sign, steroid, nebulized epi
Acute epiglottitis: muffled voice, drooling, preference of sitting in “sniffing position”, absence of barky cough, dysphagia, thumb print sign on lateral neck X-ray, treatment with IV ceftriaxone/cefotacime +/- Vanco/clinda
how to tell apart bacterial tracheitis from croup?
both have barky cough. Bacterial tracheitis have high fever and appear more toxic. May have poor response to epinephrine.
13 months male. History of URTI symptoms and treated dexamethasone. Fully immunized. Stridor, looked anxious, no drooling. Febrile at 40. Not responsive to epi neb in ER. (No mention of neck tenderness, restricted ROM or palate deviation.)
Bacterial tracheitis
Retropharyngeal abscess
Epiglottis
Croup
Bacterial tracheitis
A child presents in septic shock with hypotension. He weighs 20 kg (44 lbs). What is the best next step?
IV albumin 5% 400mL
IV dopamine 10 mcg/kg/minute
IV 0.9% saline 800mL
IV epinephrine 0.1mcg/kg/minute
Saline bolus
Child was playing at the park. Parents brought to ED with lip hematoma and 0.5cm laceration inside the mouth. How do you manage the laceration?
PO Tylenol
Topical analgesia
Wound irrigation
Suture to avoid poor cosmetic outcome
PO Tylenol
A mother brings her child in after he was found playing in the garden shed at home. He wet his pants, wheezing, drooling, and his HR is 65. What is the next treatment?
Atropine
Physostigmine
Pradlidoxime
Flumazenil
Atropine (cholingergic toxidrome due to pesticides–atropine is best treatment)
4 year old male who ingested a handful of TCA pills at home. Presents to ED, widening of QRS on ECG (no numbers or ECG given). What do you give immediately?
Sodium bicarbonate
Calcium gluconate
0.9% NS 20ml/kg bolus
0.01mg/kg of Epinephrine
Sodium bicarb
Fully immunized 2 year old child cut themselves at a playground. After cleaning the wound, what do you do?
Tetanus vaccine
Tetanus immunoglobulin and vaccine
Nothing
Antibiotics
Nothing (receive full series by 18 months, booster at 4-6 yrs, and 10 years later age 14-16)
for clean minor wounds, vaccine if uncertain or <3 doses or >=10 yrs since last tetanus toxoid containing dose
for all other wounds, TIG if uncertain or <3 doses, vaccine only if >= 5 yrs since last tetanus toxoid containing dose
other wounds = containing dirt, saliva, faces, puncture wounds, avulsions, missiles, crush wound, burns, frostbite
What should an average size 7 year old male sitting in the middle seat in the back of a car without a headrest use?
five point harness
Booster seat
Forward facing seat with headrest
Regular seat belt
Forward facing with head rest
5 point harness forward facing–at least 2 y/o
booster seat: at least 18kg (40lb) and at least 4 y/o
regular seat belt: >=145cm/4 ft 9
front seat once age 13
When you’re giving a bolus of magnesium sulfate to an asthmatic, what should you have ready in anticipation of possible adverse effect?
NS bolus
Epinephrine
Dextrose
Calcium gluconate
NS bolus
A teen male has a 3 week history of worsening headache. He has a BP of 180/105. He has a history of renal scarring and asthma. On examination his neck was supple and his reflexes were brisk. What do you use to treat him?
IV nitroprusside
IV labetalol
SL nifedipine
PO amlodipine
SL nifedipine:
IV nitro–instantaneous onset of action, can be titrated as continuouss infusion
Nifedipine: onset of action is 30 min, contraindicated in intracerebral hemorrhage
Nelson’s: patients with acute severe symptoms and life-threatening symptoms IV drug infusion is better because decreases in BP can be carefully monitored and titrated
Less severe symptoms ex. headaches, nausea/vomitting: can use oral meds
Dr. Alsalehi:
Hypertensive urgency, not emergency. Use PO meds:
A 15 year old presents with sepsis. You have given them 60 cc/kg of NS boluses, but they remain hypotensive. They have bounding pulses and CRT < 2 seconds. What is your next step in management?
Norepinephrine
Epinephrine
Dopamine
Dobutamine
Norepi
A child was found unresponsive facedown in a puddle, and has a GCS of 4 on presentation. It has been a week and in spite of maximum support he has not improved. The parents would like to withdraw care. What is your next step?
Arrange for follow-up with the family, and consult ethics or a colleague for a second opinion
Request neurology assessment to evaluate for brain death
Use cerebral angiography to confirm diagnosis of brain death
2 EEGs 24 hours apart
arrange for follow-up with the family and consult ethics or a colleague for a second opinion
Teen goes to a party and arrives to ED hypertensive, diaphoretic mildly agitated. How do you manage?
Physical restraint
Diazepam
Charcoal
**
Diazepam
Difference between cerebral salt wasting and SIADH
Cerebral salt wasting: hypovolemia, high urine Na, excessive urine output, normal or high uric acid, elevated atrial naturetic peptide, supressed vasopressin
SIADH: euvolemia, modestly elevated urine Na, elevated vasopressin
Examples, toxidrome, and antidote of anticholinergic
ex. atropine, antihistamines, TCAs, antispasmodics
Sx: Hyperthermia (hot as a hair), tachycardia, hypertensive, tachypnea, agitated, hallucinating (mad as a hatter), mydriasis (blind as a bat), dry flushed skin (dry as a bone, red as a beet), urinary retention
Antidote: Physostigmine
Examples, toxidrome to hallucinogen
ex. PCP, LSD, mescaline
Sx: hyperthermia, tachycardia, hypertension, hallucinations, agitation, mydriasis, nystagmus
Examples, toxidrome, antidote of cholinergic
ex. organophosphates, pesticides, nerve agent, physostigmine
Sx: Bradycardia, tachycardia, hypertension, confused, coma, miosis, SLUDGE (salivation, lacrimation, diarrhea, GI upset, emesis)
Antidote: Cholinergics: Atropine, Organophosphates: Pralidoxine
Examples, toxidrome, and antidote to opioids
ex: heroin, morphine, methadone, dilaudid
Sx: hypothermia, bradycardia, hypotension, bradypnea, CNS depression, coma, miosis, hyporeflexina, pulmonary oedema
Antidote: Naloxone 0.1mg/kg IV/IM/ETT
Examples, toxidrome, antidote of sedative hypnotic
ex.: benzos, barbiturates, alcohols
Sx: hypothermia, bradycardia, hypotension, bradypnea, CNS depression, confusion, coma, miosis, hyporeflexia
antidote: benzos: Flumazenil
examples, toxidrome of serotonin syndrome
ex: MAOIs, SSRIs, meperidine, dextromethorphan
Toxidrome: Hyperthermia, tachycardia, hypertension, tachypnea, confused, agitated, coma, mydriasis, tremor, myoclonus, diaphoresis, hyperreflexia, trisumus, rigidity
examples, toxidrome of sympathomimetic
ex: cocaine, amphetamines, pseudoephedrine
Sx: hyperthermia, tachycardia, tachypnea, agitated, hyper alert, paranoid, mydriasis, diaphoresis, tremors, hyperreflexia, seizures
what is the timeframe that you have to use gastric lavage within for a toxic ingestion?
1-2 hours of ingestion
activated charcoal is indicated for all ingestions EXCEPT (list 6)
1) alcohols,
2)iron,
3) lithium,
4) hydrocarbons,
5) electrolyte solutions,
6) strong acids and bases
antidote to anticholinergics
physostigmine
antidote to benzodizepines
flumazenil
antidote to beta blockers
glucagon
antidote to cholinergics
atropine
Antidote to ethylene glycol/methanol
Fomepizole
antidote to iron intoxication
deferoxamine
antidote to organophosphates
pralidoxine
antidote to TCAs
sodium bicarb
antidote to sulfonylureas
octreotide infusion
7 yo post MVC where he was a back seat passenger wearing a seatbelt. He had bruising along his abdomen. He is unable to urinate. What is the cause?
Renal rupture
Pelvic Fracture
L1-L2 Fracture
L1-L2 fracture
pelvic fracture could cause bladder rupture and gross hematuria not urinary retention
Patient with rhabdomylolysis after car crash. Despite max hydration is now presenting with peaked T waves on ECG. What is your next step in management?
Ca gluconate
Hemodialysis
Lasix
Ca gluconate
What is the parkland formula
4mL ringers lactate/kg/%BSA burned
1/2 fluid is given in first 8 hr since time of burn injury, other 1/2 given over the next 16 hr
only partial thickness and full thickness burns are included in calculation
pulse, BP should return to normal, with adequate urine output.
Boy comes in with 20% of his BSA second and 3rd degree burns. He weighs 20 kg. Using the Parkland formula, what’s his initial replacement fluid order?
50cc/hr
100cc/hr
200 cc/hr
400 cc/hr
100cc/hr
A 2 year old girl is brought to the Emergency Department after she was found with fragments of her brother’s imipramine pills in her mouth. He was prescribed imipramine for bed wetting. What symptoms are you mostly likely to observe in her?
a. Constricted pupils
b. drooling
c. agitation
d. Wide QRS
TCA- anticholinergic
Wide QRS–for QRS >100, treat with sodium bicarb
Can also use activated charcoal and norepinephrine if hypotensive
A teen was hypertensive, tachycardic, dry, flushed, mydriasis. Cause?
A- Cocaine
B- PCP
C- Diphenhydramine
D-
Diphenhydramine
New DKA presenting with GCS 10. Acidotic, high glucose. What is your next step?
NS bolus
Insulin
Mannitol
NS bolus
Patient with refeeding (an eating disorder that was admitted and started on high enteral feeds) with low GCS and difficulty breathing what’s causing it?
A- HypoK
B- HypoPO4
C- HypoBG
D- HypoCa
hypophos–can cause confusion, lethargy, coma, impaired diaphragm contracticitly leading to rest failure
HypoK causes weakness and paralysis
symptoms of metformin overdose
metformin associated lactic acidosis (MALA)
large overdose interferes with liver’s ability to clear lactic acid. Can result in hemodynamic instability. Treatment is hemodialysis.
Little kid found with empty bottle grandparent glyburide glucose 3.9
Reassure and d/c
NS +D10W
Admit and monitor for 12 hours
admit and monitor for 12 hrs
Glyburide is a sulfonylurea (antidote octreotide infusion). As per nelson’s should admit for serial glucose monitoring for at least 12 hours including an overnight fast. D10W infusion not recommended because stimulates more insulin release leading to prolonged hypoglycaemia. If persistent hypoglycaemia after >= 2 doses of IV dextrose, next step is octreotide. IV or SC. Sulfonylureas work by enhancing endogenous insulin secretion. Hypoglycemia can last up to 24 hours.
1)Up to what age/weight should you use pediatric dose attenuator on AED?
2)Kid comes after collapsing, wide complex tachycardia. EMS gave AED appropriately. Remains in wide complex.
Defib at 4J/kg
Epi IV
Defib 2J/kg
Continue CPR x 5 min
defibrillate at 4J/kg
AED can be used in infant and children. Manual defibrillator preferred in infants. Can use pediatric dose attenuator with AEDs up to 25kg or 8 yrs of age. Can also use standard adult defibrillator if pediatric dose attenuator not available. Can use initial shock dose of 2J/kg to 4J/kg.
3 month old term baby has one episode of limpness, colour change. The episode lasts for 30 seconds, no precipitating factors. No previous episodes. Exam is normal afterwards. What is the BEST management?
a. Reassure and no further investigations
b. Admit for polysomnography study
c. EEG
d. Head ultrasound
Reassure
A 9-week old baby is lying on his back in a stroller. Mother hears the baby cough, after which becomes stiff and red, followed by limp and pale. The episode lasts less than 30 seconds, after which baby returns to normal. What is the MOST likely diagnosis:
1. Seizure
2. GERD
3. Breath-holding spell
4. Bronchiolitis
GERD
A 16 year old girls who has been incarcerated. She is a heavy marijuana smoker. What will be the most likely withdrawal symptom for her to suffer?
1. Abdominal pain
2. Hallucinations
3. No withdrawal symptoms
4. Tachycardia
Abdominal pain
definition of cannabis use disorder
cannabis use causing significant impairment in function or distress within a 12 month period
3% prevalence in North American adolescents, males>females, and older youth
functional impairments due to cannabis use disorder in adolescents
reduced academic performance, truancy (skipping school), reduced participation and interest in extracurriculars, withdrawal from peer groups, conflict with family
5 psychological symptoms and 6 physical symptoms of cannabis withdrawal syndrome. How many do you need of each to meet diagnosis?
2/5 psychological:
irritability, anxiety, depressed mood, sleep disturbance, appetite changes
AND
1/6 physical:
abdo pain, shaking, fever, chills, headache, diaphoresis
sx commonly occur 24-72 hours after last use, persist 1-2 weeks, sleep disturbance reported for up to 1 month
Young girl with suspected sepsis. She is started on Ceftriaxone and gets better. Culture grows S. pneumo sensitive to Ampicillin. She is switched to ampicillin and shortly after taking it develops urticaria. Her blood pressure is low, HR 180 and RR 50. What is your next best step:
IV diphenhydramine
Restart Ceftriaxone
20 ml/kg normal saline
Epi IV
normal saline bolus
Boy comes in from MVA. GCS 10, pupils unequal. Becomes hypertensive 180/100, HR 40. Next steps?
-mannitol
-hypertonic saline
-intubate and hyperventilate
-labetalol
intubate and hyperventilate
what classifies as critical hyperbilirubinemia?
a TSB concentration greater than 425 during the first 28 days of life
What classifies as severe hyperbilirubinemia
TSB>340 any time during the first 28 days of life
Baby first noted to have jaundice at 4 days of life. Now 1 week old, with total bilirubin 380, conjugated 150, presented with poor feeding, vomited once, and has temp 35. No vital signs mentioned. Most likely diagnosis?
Sepsis
Galactosemia
Biliary atresia
Neonatal hepatitis
sepsis–as per Nelson’s, Jaundice appearing after the 3rd day and within the 1st week suggests bacterial sepsis or urinary tract infection
MVA 10yo F reduced LOC, eye open to pain, withdrawal to pain and inappropriate words. GCS?
6
7
8
9
9
2 year old fully-immunized girl fell on playground and has a deep arm laceration. After laceration has been cleaned and sutured, what further management?
1. Tetanus toxoid (exact wording on exam - did not say tetanus toxoid vaccine)
2. Tetanus toxoid and immune globulin
3. Antibiotics
4. Nothing
nothing
A child ingested his grandmother’s bottle of iron pills, developed nausea and hematemesis and was brought to the hospital. In the ER he was fluid resuscitated, deferoxamine was started and an abdominal radiograph demonstrates many iron pills still in his stomach. What is your next step in management?
a) Activated charcoal
b) Whole bowel irrigation
c) Endoscopic removal
d) Ipecac
whole bowel irrigation (as per Nelson’s)
Deferoxamine is a specific chelator of iron and is the antidote for moderate to severe iron intoxication
how to determine ETT sizes in kids
uncuffed: age/4 +4
cuffed: uncuffed - 0.5
A four year old comes into the emergency department and needs intubation. What size of endotracheal tube do you choose for him?
3
4
5
6
5
3yo with gradually increasing oxygen requirement over the last 3 hours. He had a chest tube inserted for empyema, which drained 500mL, and continues to drain well. He is tachycardic, tachypneic, chest exam with decreased air entry on the side with the empyema. He is afebrile and well perfused. X-ray that shows a marked reduction in the size of the empyema. He has been given ceftriaxone, acetaminophen and ibuprofen. What is your next step in management?
Clamp chest tube
Add vancomycin
Bolus 20ml/kg
Give morphine
clamp the tube
Teen at a music festival. Hypertensive, combative, agitated. No nystagmus. How do you manage, mydriasis, flushed?
Physical restraints
Olanzapine
Diazepam (not lorazepam, no route suggested)
Flumazenil
Diazepam
You are working in a community practice and mom calls you about her kid who ingested a button battery. Kid <5yo, size of battery not given (although CR _ _ _ _ code given….)
XRs after 10 days
Urgent plain films
Referral for emergent endoscopy
Reassure because kids often swallow things
urgent plain films
Below what systolic blood pressure would a 3yo be considered hypotensive?
64
70
76
84
76 (70+ age x 2)
A 10 year old child twists his ankle playing soccer. He presents to the ER, where he is able to bear some weight but with ++ pain. What findings on physical exam would prompt you to order an x-ray?
a) If he has pain on palpation anterior to the medial malleolus
b) If he was unable to walk immediately after the injury
c) If he has pain on palpation posterior to medial malleolus
d) If there is swelling
Pain on palpation posterior to medial malleolus
X-ray only if there is pain in the malleolar region AND:
Bone tenderness and posterior edge of lateral malleolus OR pain at the posterior edge of medial malleolus or inability to weight bear at the time of the injury AND in the emergency department
OR
X-ray if there is pain in the mid-foot region AND:
bone tenderness at base of fifth metatarsal OR navicular bone OR inability to weight bear at the time of the injury and in the emergency department
A child presents a few days after tonsillectomy with dysphagia and worsening pain, on standing Tylenol. He is afebrile. You admit and start him on IV fluids. What is your next step in management - there is a picture of an eschar (below).
a) Start Nystatin
b) Start amoxicillin
c) Start Codeine
d) Optimize dosing of acetaminophen
optimize acetaminophen
A 6 month old presents to ER with bruising on face and her response to pain is withdrawal on one side only. Vitals revealed hypotension, tachycardia, sat 99%, normal RR, PERL. What is your next management step:
CT head
GIve NS bolus bolus via intraosseous
Hydrocortisone IV
NS bolus
Fracture patterns suggesting child abuse
transverse fractures in long bones (most prevalent), corner fractures in metaphysis (most classic), femur fractures in non-ambulatory child (<18 months), distal femoral methaphyseal corner fractures, posterior rib fractures, scapular spinous process fractures, proximal humeral fractures
2 year old infant presents with refusal to weight bear and is found on imaging to have a spiral fracture. What is the most likely explanation?
Toddler’s fracture
Non accidental injury
Metabolic bone disease
Osteogenesis imperfecta
Toddlers fracture
Child is admitted with strep pneumo bacteremia and started on ampicillin. Shortly after receiving antibiotics has decreased LOC and urticaria. Tachycardic and hypotensive. What would you do?
IV epinephrine
IV benadryl
Normal saline bolus
Oral cetirazine
NS bolus
16 year old girl presenting with fever and disseminating rash. She has a fever of 39.5, and blood pressure of 85/40, HR 130, RR 30 and saturations of 92%. She has bounding pulses and capillary refill 2 seconds. She has already received 60 cc/kg of normal saline. What is the most appropriate choice for treatment?
a. Dopamine
b. Epinephrine
c. Norepinephrine
d. Dobutamine
Norepi
1 month old with bronchiolitis admitted with poor feeding . On examination there is mild intercostal recession, tachypnea and bilateral wheeze. At what oxygen saturation do you apply oxygen:
a. < 88%
b. < 90%
c. <94%
d. <96%
<90%
A young child who comes to the ER with hypoglycemia. Improves very quickly and completely with IV dextrose. What would be in keeping with this diagnosis?
Urinary ketones
Inappropriately high insulin level
Failed ACTH stim test
urinary ketones
3 y/o with generalized tonic-clonic seizure for 30 min. HR 120, O2 93%, RR hard to assess. What is your next step?
Get IV access
Get IO access
Intubate
Intranasal midazolam
As per rohan: get IV access if in ED
Child present to ED with viral URTI symptoms, stridor, no significant respiratory distress, FiO2 approx 95%. What do you do?
One dose of dex
Neb epi and dex
one dose of dex
12kg girl with dry mucous membranes, no tears, otherwise well after D/V. What is the fluid management?
300mL/hr of ORS
600mL of ORS over 4 hours
IV NS
1200 ml of ORS over 4 hours( Moderate Dehydration)
1200ml ORT over 4 hours
what are the symptoms of moderate dehydration and was is the treatment?
moderate= 5-10% dehydrated
Sx= thirsty, tachycardia, pulses present (may be weak), orthostatic hyspotension, cutaneous perfusion normal, skin turgor slight reduced, fontanelle slightly depressed, MM dry, tears present or absent, respirations deep, may be rapid, oliguria
Tx=Rehydrate with ORS 100mL/kg over 4 hours, replace ongoing losses with ORS, age appropriate diet after rehydration
what are symptoms of mild dehydration and was is the treatment?
mild <5%
Tx=Rehydrate with ORS 50mL/kg over 4 hours, replaces ongoing losses with ORS, age appropriate diet
what are symptoms of severe dehydration and what is the treatment?
> 10%
Sx=decreased LOC, cold, sweaty, cyanotic extremities, wrinkled skin on fingers and toes, muscle cramps, reduced and mottled cutaneous perfusion, MM very dry, no tears, respirations deep and rapid, anuria and severe oliguria
Tx=IV bolus with normal saline or RL (20-40mL/kg for one hour)
Repeat as necessary, begin ORT when patient is stable
A kid had vomiting illness that mom was treating at home with oral glucose and water only. The kids is admitted and found to have Na of 108 on investigations. (Note: the kids was not seizing). What do you do?
Restrict free water intake
Correct to Na of 135-140 over 24 hours
Correct to Na of 118-120 over 24 hours
Correct Na rapidly with 3% NaCl
Correct to Na of 118-120 over 24 hours
Child with a vomiting illness described with signs of moderate dehydration. Had vomited up with first attempt at ORS. What do you do next?
Ondansetron
IV fluids
Ondansetron
Picture of ECG that looks like v.fib and a cardiac arrest scenario described. Management?
Cardioversion
Epinephrine
Defibrilate 2 J/kg
Defib
Transfusion threshold in pediatrics
70
how much blood should you order when transfusing pRBC and how long do you transfuse it over
10mL/kg, over 2 hours (not longer than 4 hours), will raise hgb by approx 10
how to treat severe iron deficiency anemia?
IV or PO Iron, no pRBC unless hemodynamically unstable
what electrolyte abnormality to you see with massive pRBC transfusion?
hyperkalemia (potassium content of pRBC increases with storage time and after irradiation)
Kid swallowed a 5-cent coin and you see it in the stomach on x-ray. What should you do?
Endoscopic remove
Observe
Do another x-ray in 24 hours
Observe
Repeat AXR if hasn’t passed in 2 weeks
Toddler with dehydration. 12 kg. Irritable, no tears. What is your management?
1200 cc/kg ORT over 4 hours mo
600 cc/kg ORT over 4 hours
IV fluids
1200cc/kg ORT over 4 hours
Criteria for brain death?
EEG
Two examiners 24 hours apart
No response to hypercapnea test
No response to hypercapnea test
Only need two examines 24 hours hours apart for infants <30 days and >36 weeks GA, otherwise need two physicians but doesn’t need to be 24 hrs apart. If significant resus (ex. CPR) then needs to be >24 hour
What are the minimum 5 criteria for brain death in children 1 yr and older
1) Deep unresponsive coma with established etiology
2) No confounding factors
3) Documentation of core temp
4) Absence of brainstem reflexes
5) Apnea test
need two examiners
Definition of complex febrile seizure
> 15 min or focal or recurs within 24 hours
6 minor risk factors for recurrence of febrile seizure
1) Family history of febrile seizures
2) Family history of epilepsy
3) Complex febrile seizure
4) Daycare
5) Male gender
6) Low serum sodium at time of presentation
risk for subsequent epilepsy after simple febrile seizure and after recurrent febrile seizures
1% and 4%
Greatest risk factor for subsequent epilepsy after a febrile seizure
Neurodevelopment abnormalities (33%)
then complex febrile seizure (focal) (29%)
then family history of epilepsy (18%)
3 major risk factors for recurrence of febrile seizure
age <1 yr, duration of fever <24 hr, fever of 38-39 Celsius (ie. occurring at a lower temp)
Definition of febrile status epilepticus
Febrile seizure lasting longer than 30 min
Definition of simple febrile seizure
generalized, usually tonic clonic, associated with fever, last max of 15 min, not recurring within 24 hour period
An 18 month-old female presents to the emergency department with a febrile seizure secondary to an acute otitis media. This is her third febrile seizure in three months. What is the next step in management?
a. EEG
b. CT head
c. Neurology consult
d. Reassure parents, and no further investigations
consensus doc reassure parents
SickKids: if in ED, consult neurologist, if in clinic order EEG
A 3 month old male infant presents to the emergency department with a 1 month history of “spit ups” and 2 day history of projectile vomiting. His last two vomits were bilious. On exam, he looks dehydrated and unwell. His abdomen is distended, non tender, with no palpable masses. What diagnostic test would MOST likely reveal the underlying abnormality?
a. Abdominal ultrasound
b. Barium enema
c. Upper GI series
d. Abdominal X ray (anterioposterior and lateral)
Upper GI series( to rule out volvulus ,malrotation)
A 10 year old boy presents with 12 hours of scrotal pain. He has focal tenderness at the upper pole of the testis with a focal blue discolouration, and there is some edema. What is the best next step?
a. Ultrasound
b. Analgesia and scrotal support
C. Urology consult
analgesia and scrotal support
torsion of appendix testis: bed rest x 24 hours, NSAIDs x 5 days, if diagnosis uncertain then scrotal exploration if recommended
tends to resolve in 3-5 days
13 year old girl presents to the ED with a generalized tonic clonic seizure. Her parents say she’s been drinking a lot of water recently. Her labs: Na 118, Cl 86, osm 262, Urine Na 20, serum urine osm 68. What’s the MOST likely diagnosis?
T1DM
Psychogenic polydipsia
SIADH
Adrenal insufficiency
psychogenic polydipsia
Child with concussion. When can she return to play?
Back at school full time with no symptoms and no accommodations
After symptom free for 7 days
Back at school full time with no symptoms and no accommodations (outdated question)
Baby with poor pulses and looks unwell. ? SVT
1. adenosine
2. asynchonized shock
3. vagal manouvers
4. ?
adenosine
Which formulation of epinephrine and by which route should be given in anaphylaxis?
a. 1:1000 epinephrine IM
b. 1:10000 epinephrine IV
c. 1:1000 epinephrine SC
d. 1:10000 epinephrine IM
1:1000 IM
2) A 16 year old girl arrives in the ER unconscious, she is dry and hyperthermic, her pupils are large. Which of the following could be the cause of her presentation?
a. Cocaine
b. Ecstasy
c. Amitryptiline
Amitryptiline
A 2 year old boy ingested 10-20 of his mother’s iron pills. At home, he had nausea + vomiting, but now he is asymptomatic. At 6 hours post ingestion, his serum iron level is normal and his liver enzymes are normal. AXR is “normal”. What is the appropriate management at this point?
a. Gastric lavage
b. Deferoxamine
c. Whole bowel irrigation
d. Admit for observation of late stages of iron toxicity
Admit for observation of late stages of iron toxicity
A 12 year old girl has not been responding to her mother for the last few hours. In the ER she is non-responsive; in response to painful stimuli, she rolls over and continues “sleeping”. Her muscle tone, vital signs, and pupils are all normal. Which of the following is most likely?
a. Ischemic stroke
b. Confusional migraine
c. Poisoning
d. Seizure
confusional migraine
Boy was in an MVC. His eyes do not open. He has a flexion response to pain. He moans incoherently. What is his GCS?
a. 5
b. 6
c. 7
d. 8
6
6 year old child collapses in the periphery. CPR is initiated and one shock is given with an AED for a wide complex rhythm with no pulse. CPR is continued. The child arrives in your ER with an IV, intubated, without a pulse, rhythm now showing VT. What is your next step?
a. Defibrillate 4J/kg
b. Give Epinephrine 1:10,000 0.1 ml/kg IV
c. Defibrillate 2J/kg
d. Continue CPR
Defibrillate 4J/kg
14yo M with vesicular, very pruritic rash and work of breathing, tachypnea. Most likely cause:
a. Myocarditis
b. Pneumothorax
c. Varicella pneumonia
varicella pneumonia
An early sign of shock in a child is:
a. Delayed cap refill
b. Increased HR
c. Low BP
Increased HR
A 14 year old boy is found VSA in a park in -3 degree weather. He has received CPR for 30 minutes. Which of the following would be a reason to stop?
a. Rectal temperature 30 degrees
b. Barbituates found on tox screen
c. Refractory V Fib to defibrillation
d. Electromechanical dissociation = PEA
Electromechanical dissociation = PEA
Reasons not to stop CPR:
young people with persistent VF until reversible factors have been fixed
Hypothermia
Asthma (need to correct dynamic hyperinflation)
toxicological arrest
thrombolytics given during CPR
pregnancy prior to resuscitative c-section
A child was rescued after drowning. What is the most important in determining prognosis?
a. Duration of submersion
b. Good quality CPR at scene
c. A GCS of 7 on arrival to the ED
d. A lack of pulse and respirations at the scene
Duration of submersion
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
amp gent
consensus doc –>febrile 3 week old–>rule out sepsis
2 month old baby with FTT, constipation, and vomiting. Labs show pH 7.28, Na 128, K 2.7, Cl 107, urine pH 7.5. What is the underlying problem?
a) CAH
b) cystinosis
c) pyloric stenosis
d) cystic fibrosis
cystinosis
CAH: hyponatremia and hyperkalemia
PS: hypokalemic, hypochloremic metabolic alkalosis
CF: hyponatremia, hypochloremia, hypokalemia, and metabolic alkalosis
Iron overdose, on dexoferoime already. Is now at 1hr post ingestion…what is the next step?
a) Endoscopy
b) Charcoal
c) WBI
d) Ipecac
WBI
Picture of normal CXR. Down’s kid had g-tube inserted and is now acidotic, high lactate, bilious emeisis. No double bubble sign, not full abdomen on plain film seen but you are told his abdo is firm and distended. Type of shock
a) Cardiogenic and hypovolemic
b) Distributive and hypovolemic
c) Cardiogenic and distributive
d) Cardiogenic and…
Distributive and hypovolemic
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-12yr moderate dehydration
Limited data for infants less than 6 months
A child was found with Anti-cholinergic symptoms cause?
a) Benadryl
b) Cocaine
c) PCP
Benadryl
A teen was agitated, hypertensive, dry, flushed, mydriasis. Cause?
a) Cocaine
b) PCP
c) LSD
d) Marijuana
PCP
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
Was the CO2 % in a boy from a fire?
a) Overestimated
b) Underestimated
How do we treat neuropathic pain
a) Gabapentin
b) Morphine
Gabapentin
Kid from burning house, covered in soot; sat 89%; is it?
a. Accurate
b. Overestimated
c. Underestimated
Overestimated
carbon monoxide binds
Kid took bottle of camphor. What do you see on CXR? ??
a. Pneumatocele
b. Hyperinflation
c. Cardiomegaly
d. Tracheal-bronchial narrowing
Pneumatocele–late effect
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
Tylenol overdose at 8h. What do you see on lab work?
a. pH – 7.21
b. pH – 7.58
c. pH – 7.38, PO2 60
d. pH – 7.38, PO2 90
pH – 7.38, PO2 90
Normal bloodwork from 0-24 hours
Describes 14y girl presents after a 15min seizure and is no longer seizing now. Her BP 190/100; edematous, but Cr ok. Neurologic exam is normal now. WBC 3.0 with 2% lymphocytes, Hgb 88, plts 130. Urine has large proteinuria. What to give immediately? Neuro Lupus
a. Methylpred
b. SL nifedipine
c. IVIG
d. Phenytoin IV
SL Nifedipine
Child with drowning injury is in PICU on conventional mechanical ventilation, requiring PIP 30 and PEEP 10. He suddenly has an increase in his HR and a drop in his BP to hypotensive levels. What is your next best management?
a. Increase pip
b. Decrease pip
c. Increase peep
d. Decrease peep (decrease MAP)
Decrease PEEP
Increased PEEP reduces pre-load, patient is tachycardic and hypotensive due to decreased preload
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
6 year old girl with recurrent non bilious projectile vomiting with abdominal pain and pallor. She has headaches. Has had to get iv rehydration on several occasions. She is normal between episodes. What is her diagnosis
a. Cyclic vomiting
b. Intermittent Intussuception
c. Intermittent volvulus
d. Brain tumor
Cyclic vomitting
Case scenario of a child who presents with decreased LOC. She has flexion posturing, moans to painful stimuli and will not open her eyes to painful stimuli. What is her GCS?
a. 6
b. 7
c. 8
d. 9
