EM pharmac and preventive

Question 1

Typical absence seizures begin between 3 and 10 years of age in otherwise normal children and are characterized by brief, 5 to 20 second lapses in consciousness, speech, or motor activity, sometimes associated with flickering of the eyelids.

Answer 1

Absence seizures are never accompanied by an aura or postictal drowsiness, but lip smacking or eye blinking automatisms may be observed during the seizure. Numerous seizures can occur every day.

Question 2

The EEG shows classic ictal generalized 3-Hz spike and wave discharges. Typical childhood absence seizures can be triggered by hyperventilation in 80% of children as well as photic stimulation in those with absence epilepsy.

Answer 2

Good response is seen with use of valproic acid, ethosuximide, or lamotrigine. Seizures usually remit by adolescence or early adulthood.

Question 3

Valproic acid has shown good response for absence epilepsy, second-line therapy for infantile spasms, and variable affect for Lennox-Gestaut syndrome. Of other antiepileptic drugs (AED) for absence seizures, it is least likely to affect behavior adversely. The risk of is of ____ most concern causing it to be contraindicated in ____ disease.

Answer 3

hepatotoxicity, The risk of fatal hepatotoxicity is highest in children younger than 2 years of age who are developmentally delayed or neurologically impaired and receiving other antiepileptic drugs. It can increase levels of other antiepileptic drugs, especially phenytoin and phenobarbital, however, it does not affect oral contraceptives.

Question 4

The primary adverse effects seen with lamotrigine, one of the newer AED, for the treatment of absence and Lennox-Gestaut syndrome are

Answer 4

severe skin rash, ataxia, and insomnia.

Question 5

Ethosuximide, the AED of choice for absence seizures, may rarely cause

Answer 5

drowsiness, nausea, and blood dyscrasias.

Question 6

Carbamazepine has been used to treat partial seizures. Potential side effect are…

Answer 6

Hepatic or blood dyscrasias, associated with aplastic anemia and neutropenia. Other possible side effects include ataxia, diplopia, and rash. Carbamazepine also induces hepatic metabolism thus lowering concentrations of other antiepileptic drugs such as phenytoin, valproic acid, lamotrigine, and topiramate in addition to oral contraceptives, steroids, and warfarin.

Question 7

Tiagabine is used to treat complex partial seizures. It is another newer AED, and is most likely to cause fatigue in addition to

Answer 7

dizziness, nausea, nervousness, tremor, abdominal pain, confusion, and difficulty in concentrating.

Question 8

____ is an anesthetic that blocks association pathways and also produces sedation at moderate doses. It may induce dreamlike states of mind and hallucinations before producing a sensory blockade. Hallucinations are common as the medication starts to wear off, and can cause emergent hallucinations; hallucinations are more common in adolescents and adults.

Answer 8

Ketamine. It is especially useful for short painful procedures in younger children. High doses may induce general anesthesia. Midazolam given in conjunction with ketamine helps to minimize the severity of these hallucinations.

Question 9

____ is a commonly used as an opioid analgesic in hospitalized patients and has a long period of duration. Patients must be carefully monitored for respiratory depression.

Answer 9

Morphine

Question 10

____ is a potent sedative, anxiolytic, and amnestic with no analgesic effect and a short half-life. It can be given orally, IV, intranasally, or rectally. High doses may cause respiratory depression.

Answer 10

Midazolam

Question 11

commonly used sedative, ____ , has a longer half-life but less predictable duration; therefore, it requires longer monitoring of patients for respiratory depression. It is useful for lengthy, non-painful, and distressing procedures.

Answer 11

chloral hydrate

Question 12

___ is used for painful procedures. It is a potent opioid analgesic that may be combined with midazolam to reduce anxiety. High doses are associated with chest wall stiffness and rigidity, especially with rapid titration.

Answer 12

Fentanyl

Question 13

____ is a synthetic corticosteroid. It has 15 times greater anti-inflammatory activity than hydrocortisone but it is more than 125 times more active as a mineralocorticoid, hence it is used to treat aldosterone deficiency in patients with salt wasting disease. It is not indicated for use in prenatal management of congenital adrenal hyperplasia.

Answer 13

Fludrocortisone. The dose is 0.1-0.3mg daily in 2 divided doses, occasionally up to 0.4mg. In infants the mineralocorticoid requirement is very high in the first few months of life. Older infants and children are usually maintained on 0.05-0.1mg daily.

Question 14

_____ is the drug of choice and is recommended for pregnancies at risk, as it readily crosses the placenta and helps in prevention of virilization of the female fetus.

Answer 14

Dexamethasone. It is administered in the dose of 20µg/kg of pre pregnancy weight of the mother daily in 2-3 divided doses. This suppresses the secretion of steroids and adrenal androgens by the fetal adrenal gland. If started by 6 weeks of gestation it prevents virilization of the female fetus. No adverse effects have been noted in children exposed to this therapy. Maternal side effects of prenatal treatment include excessive weight gain, edema, hypertension, glucose intolerance, and cushingoid facies.

Question 15

_____ are not used in prenatal management of congenital adrenal hyperplasia.

Answer 15

Betamethasone and prednisolone

Question 16

_____ is generally used for long term replacement therapy for congenital adrenal hyperplasia. Dose is 10mg/M2/24 hr in 3 divided doses. It is not used in prenatal management of congenital adrenal hyperplasia.

Answer 16

Hydrocortisone

Question 17

Though there is a strong link between violent behavior and a history of personal victimization, most children are resilient and do not grow up to be victims, abusers, or violent criminals. Protective factors responsible for this resilience are poorly understood, but may include

Answer 17

innate personality characteristics, encompassing an easy temperament, positive disposition, active coping skills, positive self-esteem, good social skills, internal locus of control, and a balance between help-seeking and autonomy. Protective factors also include the availability of affectionate, stable, alternate adult caretakers; school success; and the presence of a supportive network of family, friends, and community members.

Question 18

There is a wide range of physical and emotional sequelae impacting children of spouse battering,

Answer 18

including PTSD, depression, anxiety disorders, nightmares, somatic complaints, and hypervigilance.

Question 19

children who witness violence are at risk for psychosocial and developmental sequelae just like children who are the direct victims of abuse, although the risk is not as severe.

Answer 19

Experiencing both forms of violence represents the most potent predictor of future aggression.

Question 20

Child neglect also predicts future criminality; however, there is a stronger link between violent behavior and a history of

Answer 20

personal victimization

Question 21

the child received a clean wound, has had 3 vaccinations, the last within 10 years; therefore, he needs

Answer 21

no further tetanus protection.

Question 22

DTaP (diphtheria and tetanus toxoids and acellular pertussis) is not indicated for children over the age of 7 years. Both DTap and DT, without the pertussis component, are products that can be used in children younger than age 7 years and usually have 3-5 times as much of the diphtheria component than the adult formulation.

Answer 22

Older children and adults should receive the formulation Tdap and/or Td. 2 relatively new pertussis containing vaccines, named Tdap products, were introduced in 2005 due to continued endemic outbreaks of pertussis seen in adolescents 11 through 18 years of age whose vaccine induced immunity seemed to be waning. The preferred age, however, for Tdap immunization is 11 to 12 years. Before this age, Td should still be used in those older than 7 years but younger than 11 years.

Question 23

Beyond the age of 5 years, _____ is not necessary unless the child has specific underlying conditions predisposing. Routine recommended schedule is 4 doses at age 2 months, 4 months, 6 months and between 12-15 months.

Answer 23

HIB (Haemophilus influenzae type B vaccine)

Question 24

The recommended routine schedule for IPV is at ages

Answer 24

2 months, 4 months, 6-18 months, and 4-6 years. Unvaccinated or undervaccinated older children should receive 2 doses of IPV separated by 4-8 weeks with a third dose 6-12 months after the second.

Question 25

An accelerated schedule can be followed with

Answer 25

3 doses separated by at least 4 weeks from each other. Because of the successful eradication of wild-type polio in the United States, OPV (live oral polio vaccine) is no longer recommended for a primary vaccination series.

Question 26

2 doses of MMR are recommended for all children and adolescents and can be given no less than 4 weeks apart. If the recommended schedule is followed, the first vaccination is given at 12-15 months with the second dose at age 4-6 years. Older children and adolescents should receive the second dose at

Answer 26

the next available opportunity as long as at least 4 weeks have passed since the previous dose.

Question 27

What condition requires exclusion from day care due to the potential for outbreaks?

Answer 27

Varicella-Zoster

Question 28

Recent guidelines recommend starting cervical cancer screening with pap smears at the age of

Answer 28

21 regardless of the age of onset of sexual activity, and screening should occur every 3 years until the age of 65.

Question 29

HPV DNA testing is not usually recommended for

Answer 29

adolescents.

Question 30

A vaccine against human papillomavirus (HPV) became licensed in 2006 for use in girls and woman ages 9 through 23; it should be administered at

Answer 30

a 0, 2, and 6 month schedule. It is effective against HPV types 6, 11, 16, and 18.

Question 31

Hyperbilirubinemia at levels that require exchange transfusions, low Apgar scores, positive family history, in utero infections, respiratory distress, prolonged mechanical ventilation, and symptoms indicative of syndromic hearing loss are all important risk factors for

Answer 31

sensorineural hearing loss in the first 28 days after birth

Question 32

_____ is contraindicated in individuals allergic to eggs, chicken proteins, or gelatin, and in infants less than 6 months of age.

Answer 32

Yellow fever vaccine

Question 33

_____ is a contraindication for subsequent doses of DTaP.

Answer 33

If the infant develops signs of encephalopathy (coma or diminished level of consciousness, prolonged or multiple seizures not attributable to another identifiable cause, within 7 days of giving a dose of DTaP or DTP), it

Question 34

Seizure within 3 days of a dose of DTaP is

Answer 34

not a contraindication, but needs precaution and a consideration of the risks and the benefits. If the benefits outweigh the risk (e.g., during an outbreak or foreign travel), the vaccine should be given under observation.

Question 35

Iso-pentyl acetate, the honeybee alarm pheromone is emitted by individual bees when disturbed. High concentrations are deposited with the stinger at the sting site. This airborne pheromone signals other bees to pile on the victim in large numbers. Africanized honeybees produce more of the pheromone than European honeybees. A single sting equals roughly 1 mg of venom. It is estimated that 500 stings will kill an adult.
Africanized honeybees have venom that is no more potent than that of European honeybees

Answer 35

Bee and wasp venom contain complex mixtures of biogenic amines, polypeptide, and enzyme toxins. The acidity is not a factor in the venom toxicity. Toxic components include histamine, acetylcholine, phospholipase, bradykinin, melittin, dopamine, and serotonin. Neurotoxicity, hemorrhagic toxicity with increased capillary permeability, and hemolysis are the most common toxicities.

Venom from bee stings is released immediately, generally within the first minute.

Question 36

The American Academy of Pediatrics Task Force on SIDS identifies breast feeding as having a protective effect, approximately halving the risk of SIDS. This protective effect is even stronger when the

Answer 36

infant is breastfed exclusively, which is possibly due to decreased infectious diseases and overall immune benefits in addition to studies demonstrating that these infants are more easily aroused from sleep than formula fed babies.

Question 37

The risk of SIDS is highest between 2 and 4 months. Multiple studies have found that pacifier use is actually associated with a decreased risk of SIDS.

Answer 37

Though the exact mechanism is unknown, it is theorized that its use may alter arousal thresholds or autonomic responses during sleep. Its use may further modify the effect of other adverse risk factors and is encouraged by the AAP as a risk reduction strategy when introduced after 2 to 4 weeks of age.