ED

Question 1

Management of foreign body aspiration

Answer 1

Patient alert and able to maintain airway: supplemental O2 and leave patient in position of comfort
Patient with complete airway obstruction:
Infant ( < 1 year old) - perform five back blows followed by 5 chest thrusts
Child (>=1 yo)- perform abdominal thursts
If BLS manuevers fail, begin bag mask ventilation
If no chest rise with bag mask ventilation perform laryngoscopy and remove FB with pediatric Magill forceps

Question 2

If foreign body aspiration what is the next step?

Answer 2

complete obstruction: back blows (infants), Heimlich maneuver (children); CPR for any age if the child becomes unresponsive
§ manual extraction of object if able to visualize it; do not attempt blind finger sweep

partial obstruction: anteroposterior-view x-ray of chest, neck, and/or abdomen
bronchoscopy, depending on type and location of object

Question 3

What does radiodense mean?

Answer 3

radiodense=radiopaque
inhibits passage of electromagnetic radiation
WHITE
EJ.BONE

Question 4

What does radiolucent mean?

Answer 4

radiolucent
passage of electromagnetic radiation

black or gray - skin and muscles

Question 5

How are coins seen in Rx

Answer 5

Radiopaque- white

Coin in trachea: visualized in sagital plane on AP Rx
Coin in esophagus: coronal on frontal chest Rx

Question 6

Chest Xray sensitivity and specificity in FB aspiration

Answer 6

sensitivity and specificity of 67% to detect abnormalities consistent with a FB aspiration

Question 7

For pathophysiological variables that help determine nature of any lesion affecting the brain, functional level involvement and rate of progression

Answer 7

Pattern of respiration
Size and reactivity of pupils
Spontaneous and induced eye movements
Motor response

Question 8

Location of respiratory centers

Answer 8

medulla oblongata and pons- two in the medulla and one in the pons.

medulla : dorsal and ventral respiratory groups.

In the pons, the pontine respiratory group two areas: pneumotaxic centre and the apneustic centre.

Question 9

Types of respiratory patterns to consider in brain lesions

Answer 9

Postventilation apnea ( forebrain injury)
Cheyne Stokes (Metabolic encephalopathy)
Central neurogenic hyperventilation (Midbrain dysfunction )
Apneustic breathing(Pontine infarction, anoxic encephalopathy, severe meningitis)

Question 10

Characteristics of post ventilation apnea and where is the lesion?

Answer 10

brief periods of apnea lasting 10-30 seconds, followed by voluntary deep breathing.
Forebrain injury

Question 11

Cheyne stokes respirations characteristics and what does it indicate

Answer 11

Hyperpnea episodes alternating with apnea. depth of breathing waves.

lesion affecting deep brain structures or diencephalon

Question 12

Central neurogenic hyperventilation characteristics and what does it indicate

Answer 12

sustained regular and rapid respirations despite normal PaO2 and low PaCO2.

Midbrain dysfunction

Question 13

Apneustic breathing characteristics and what does it indicate

Answer 13

brief inspiratory pauses that last 2-3 seconds, often alternating with end expiratory pauses.

Pontine infarction, anoxic encephalopathy, severe meningitis

Question 14

Pupils in transtentorial herniation

Answer 14

initially small–> but as herniation occurs asymetric pupils and then fixed and dilated.

Question 15

Two specific eye manuevers to assess comatose child

Answer 15

Oculocephalic or doll’s reflex

Oculovestibular reflex evaluated with caloric testing.

Question 16

Normal or positive Oculocephalic or doll’s reflex

Answer 16

conjugate deviation of the eyes opposite of the direction in which the head is turned.

Question 17

Normal Oculovestibular reflex

Answer 17

Normal - COWS-Cold opposite Warm

Question 18

With cerebral lesions, the eyes look to __ the lesion

Answer 18

towards the lesion

Question 19

With brainstem lesions, the eyes look to __ the lesion

Answer 19

away of the lesion

Question 20

What is setting sun sign and it is associated with

Answer 20

downward deviation of the eyes

upper midline lesions and hydrocephalus

Question 21

Decerebrate posturing- where is the lesion

Answer 21

brainstem, pons.

Question 22

Labs for ALOC with undetermined cause

Answer 22

CBC
Electrolytes
BUN
Creatinine
Bedside and serum glucose

Question 23

Labs for ALOC suspecting metabolic

Answer 23

liver function testing, ammonia, tox screen

in additiion to:
CBC
Electrolytes
BUN
Creatinine
Bedside and serum glucose

Question 24

Differential dx of ALOC

Answer 24

AEIOU TIPS

Abuse/Alcohol
Electrolytes/Endocrine ( SIADH, adrenal insuff) /Encephalopathy(Reye syndrome, lead
Infection ( meningitis, encephalitis)
Overdose ingestion 
Uremia ( HUS)

Trauma
Inborn errors of metabolism/Insulin and Hypoglycemia( consumption of family oral hypoglycemia agent, ketotic hypoglycemia)/Intussusseption
Psychogenic
Seizure, Shock, AVMs, Shunt

Question 25

Reye syndrome

Answer 25

rapidly progressive encephalopathy. .
cause of Reye syndrome is unknown.

It usually begins shortly after recovery from a viral infection, such as influenza or chickenpox. About 90% of cases in children are associated with aspirin (salicylate) use. Inborn errors of metabolism are also a risk factor.

Question 26

Hemolytic Uremic Syndrome

Answer 26

prodromal phase of GI or URI dollowed by acute onset of renal failure, microangiopathic hemolytic anemia and thrombocytopenia.

Question 27

CUSHING TRIAD

Answer 27

Bradycardia, hypertension, irregular respirations

Question 28

Etiology of bacterial meningitis in neonates

Answer 28

GBS strep
E.coli
Listeria

Question 29

Etiology of bacterial meningitis in infants

Answer 29

S.pneumoniae
N.meningitidis
GBS
Gram negative bacilli

Question 30

aseptic meningitis

Answer 30

viral meningitis and they look less ill

Question 31

When does neck stiffness is reliable for nuchal rigidity

Answer 31

18 months- previous to this age the neck musculature might not be adequately developed

Question 32

presentation of bacterial meningitis in neonates vs infants

Answer 32

neonates: irritability , temperature instability, lethargy , poor feeding, apnea, tremor.

children older than 18 months: nuchal rigidity, anorexia, headache, vomiting, focal neuro signs, seizures

Question 33

Brudzinski sign and Kernig sign

Answer 33

flexion of neck causes flexion at the hip, knee or ankle

Kernig: inability to extend the legs when hips flexed

Question 34

If petequiae is present in a meningitis, what is the cause?

Answer 34

N. meningitidis
S. pneumoniae
H. influenza

Question 35

CSF Labs viral vs. bacterial meningitis

Answer 35

Bacterial: 
 appearance clear 
  WBC :10-500 (PMN 0-30)
 Glucose 50-90
 protein 50-150
  Gram stain negative

Viral
appearance clear or cloudy
  WBC :100-20,000 (PMN >90)
 Glucose < 40
 protein >250-500
  Gram stain positive

Question 36

Labs when suspecting bacterial meningitis

Answer 36

CSF culture and PCR
Blood culture
Serum glucose measurement
Electrlytes

Question 37

Should we still order CSF in a pretreated with abcs bacterial meningitis?`

Answer 37

multicenter retrospective study showed WBCs count or absolute neutrophil count was not affected if antibiotics were given 24 hours before lumbar puncture.

But the flucose was higher and protein lower with pretreatment specially after 12 hours later.

Question 38

Differential dx of meningitis

Answer 38

Cervical or retropharyngeal adenitis
Retropharyngeal abscess
Sinusitis, mastoiditis, CNS tumor , abscess, encephalitis
pharyngitis
Torticollis
Cervical spine trauma