EM respiratory

Question 1

diagnosing RSV

Answer 1

immunofluorescence of nasal secretion can lead to rapid viral identification.

Question 2

A 3-month-old infant develops rapid breathing and staccato cough, but otherwise appears well and is afebrile. Physical examination detects fine rales over the lungs as well as red and thickened tympanic membrane. A chest X-ray shows bilateral patchy infiltrates. Laboratory studies indicate eosinophilia and elevated serum immunoglobulin concentrations. What is the likely causative organism?

Answer 2

Up to one-third of pneumonia cases in infants 2-6 months of age are caused by Chlamydia trachomatis. Particularly, chlamydia trachomatis is the most common cause of pneumonia among infants between 2 weeks and 3 months of age. The clinical picture of this case is highly suggestive of chlamydia trachomatis pneumonia (staccato cough, afebrile infant, and eosinophilia). Staining a smear of nasopharyngeal specimen with fluorescein-conjugated monoclonal antibody can establish the diagnosis. The specimen for this commercially available test has to be evaluated within 30 minutes. The early onset of this form of pneumonia suggests infection through direct contact during the birth process. The treatment of choice is erythromycin.

Question 3

Peak incidence is in late fall and winter and the majority of affected children are between 6 months and 3 years of age. There is usually a history of upper respiratory infection (URI) for 2 to 3 days before the onset of inspiratory stridor. Temperatures up to 39.0°C to 40.0°C may be present. Lungs are clear to auscultation and there is no increased respiratory effort. A barking cough is present with stridor at the end of the cough.

Answer 3

Acute laryngotracheitis or viral croup is a common viral respiratory infection in infants and children.

Question 4

Which of the following risk factors is most likely responsible for the increased incidence of sudden infant death syndrome (SIDS) seen among African-American infants?

Answer 4

Prone sleeping position.

Question 5

symptomatology is characteristic Erythema multiforme major, or Stevens-Johnson syndrome. The frequent causes include various drugs (phenytoin, penicillin, NSAID, etc.) but also

Answer 5

M. pneumoniae infection. The prime age for M. pneumoniae infection is between 5 and 15 years. This form of pneumonia is often referred to as an atypical or walking pneumonia. Food, bites, or stings can lead to urticaria but urticarial wheels resolve within hours. Tetracycline is implicated in erythema nodosum but not considered a frequent cause of Stevens-Johnson syndrome.

Question 6

The incidence is equal among boys and girls. Prematurity does not seem to put infants at an increased risk, though ______ has been found to be a significant risk factor in several studies. Unlike sudden infant death syndrome, a prone sleeping position is not associated with ALTE

Answer 6

maternal smoking. ALTEs are characterized by some combination of apnea, color change, a usually limp muscle tone, and choking or gagging that is witnessed by a frightened caregiver. The average age for reported ALTE event is 8 weeks. ALTE represents 0.6% to 0.8% of all emergency visits for children less than 1 year of age and the incidence is 0.6 to 2.45 per 1,000 live births.

Question 7

Although boys are 3 times more likely to die from drowning than girls. Though the patient is male, his need for 5 minutes of CPR is a much better indicator of what the outcome of his case will be. Brain death occurs approximately

Answer 7

4-6 min after cardiac arrest if no CPR is provided. If it is provided, the time between the onset of cardiac arrest and start of CPR is vital to the patient’s ability to survive and his/her level of permanent brain damage.

Question 8

Many of the factors that increase morbidity and mortality in drownings are

Answer 8

the length of time the patient was underwater and unresponsive (especially if greater than 5 minutes), rural location of drowning, and the administration of epinephrine in the field or ED.

Question 9

The constellation of severe respiratory distress, absent breath sounds with shifted heart sounds, and a scaphoid abdomen suggests strongly the presence of a

Answer 9

diaphragmatic hernia. This herniation of abdominal contents into the thorax occurs in 1 in 5,000 births. Next step is Et tube intubation.

Question 10

The absent breath sounds and a shift of heart sounds could be indicative of a tension pneumothorax, but needle aspiration of the chest should await

Answer 10

radiological confirmation. Performing this procedure in the setting of a diaphragmatic hernia could lead to intestinal perforation.

Question 11

No apparent cause for the event is ever found in 50% of all cases diagnosed as ALTE and in the other 50%, a comorbid condition is eventually identified. The 3 most common of these include

Answer 11

gastroesophageal reflux, seizures, and lower respiratory infection.

Question 12

There are 3 sleep stages in newborns that have been defined by electroencephalogram (EEG) patterns, movements of the eyes, and muscular tone:

Answer 12

(a) active stage (“REM-like;” 50% of sleep); (b) quiet stage (“non REM-like”); (c) ‘indeterminate’ sleep state (a transitional sleep stage).

Question 13

approximately 25% to 50% of 6- to 12-month-olds and 30% of 1-year-olds have

Answer 13

problematic night waking

Question 14

____ are undesirable physical or experiential events that accompany sleep. These disorders consist of abnormal sleep-related movements, behaviors, emotions, perceptions, dreaming, and autonomic nervous system functioning. They are disorders of arousal and sleep stage transition.

Answer 14

Parasomnias. Many of the parasomnias are manifestations of CNS activation and autonomic nervous system changes with skeletal muscle activity. The parasomnias often occur in conjunction with other sleep disorders, such as obstructive sleep apnea syndrome or narcolepsy, and it is common for several parasomnias to occur in the same patient.

Question 15

____ are characterized by an arousal from slow-wave sleep that is accompanied by autonomic (tachycardia) and behavioral manifestations of fear and amnesia for the episode.

Answer 15

Night terrors

Question 16

presence of ______ correlates with increased severity and a poor outcome in congenital diaphragmatic hernia (CDH). It is suggestive of a large defect.

Answer 16

right-sided hernia and an intrathoracic liver

Question 17

The most common cause of mortality in infants with congenital diaphragmatic hernia (CDH) is associated

Answer 17

pulmonary hypoplasia.

Question 18

Bronchiolitis or acute inflammation of the bronchioles is usually caused by a viral infection and is the most common lower respiratory tract infection in infants and children under 2 years of age. The resulting edema, mucus production, and eventual necrosis and regeneration of the small airway epithelial lining cells clinically manifests as cough, tachypnea, retractions, hypoxia, and variable wheezing and crackles.

Answer 18

Prior to these, most clinical interventions seem to have had no significant impact on length of hospital stay, severity of clinical course, or subsequent recurrent wheezing or diagnosis of asthma. Emphasis is now directed to supportive care, primarily with assessment of hydration status and oxygenation being of utmost importance. Intravenous fluid rehydration and subsequent nutrition support with nasogastric feedings may also be required.

Question 19

Infants with a history of prematurity, chronic lung disease and hemodynamically significant congenital heart disease should be given the monoclonal IgG antibody palivizumab, mainly to help prevent RSV-associated hospitalization though no significant decrease in mortality has been demonstrated. The duration of prophylaxis for premature infants is determined by the degree of prematurity. If born less than 28 weeks gestation, then palivizumab should be given

Answer 19

for the full first postnatal year; if born between 29 to 32 weeks, then palivizumab should be given for the first 6 postnatal months; and for infants born at 32 to 35 weeks, consider prophylaxis if now younger than 6 months and 2 of the following risk factors are present: child care attendance, school-age siblings, exposure to environmental air pollutants, congenital airway abnormalities, or severe neuromuscular disease.

Question 20

what tests to order for a baby with meconium ileum?

Answer 20

Rectal manometry, rectal biopsy, sweat chloride. Meconium ileus is associated with both Hirschsprung’s disease (colonic aganglionosis) and cystic fibrosis. Rectal manometry and biopsy will provide the most information regarding the former, and sweat chloride analysis is the standard for the initial diagnosis of cystic fibrosis.

Question 21

____ is the most common congenital anomaly of the larynx. The infant commonly presents with inspiratory stridor, which is aggravated when the infant is crying, feeding, or is placed in supine position. It typically starts at 4 - 6 weeks of age. The infant is otherwise usually happy and thriving. Stridor is due to partial collapse of a flaccid supraglottic airway. Condition is self-limiting and resolves by 18 months of age.

Answer 21

Laryngomalacia

Question 22

___ occurs as a complication of bacterial infection of the upper respiratory tract and commonly occurs in children between 3 and 4 years of age. It occurs due to spread of infection from the upper respiratory tract to the retropharyngeal lymph nodes, which suppurate and form an abscess. It may present with fever, reduced mobility of the neck, stridor, dysphagia, and drooling. Child may have respiratory distress or obstructive sleep apnea.

Answer 22

Retropharyngeal abscess. Physical examination can reveal bulging of the posterior pharyngeal wall. Cervical lymphadenopathy may also be present. Lateral neck radiograph shows a soft tissue bulge in the posterior pharyngeal wall.

Question 23

____ is more commonly caused by Staphylococcus aureus. It often follows a viral upper respiratory tract illness. Mean age is between 5 and 7 years. After a few days, the child develops a brassy cough, biphasic stridor, high fever, and toxicity; unlike epiglottitis, the child can lie flat, does not drool, and does not have dysphagia.

Answer 23

Bacterial tracheitis is a life-threatening emergency, as respiratory obstruction may develop due to mucosal edema and thick purulent secretions, which can be adherent and membranous. Bronchoscopy is both diagnostic and therapeutic because it shows the purulent secretion that can be mechanically debrided.

Question 24

_____ usually starts with rhinorrhea, cough, and low-grade fever. After 2-3 days, the child develops the characteristic “barking” cough, hoarseness of voice, and a biphasic stridor. In epiglottitis, the stridor is inspiratory. Temperature ranges from 102 degF to 104 degF.. Throat examination shows moderately inflamed pharynx, rhinitis, and mild tachypnea with subcostal and intercostal retractions.

Answer 24

Laryngotracheobronchitis (Croup).
Croup is most commonly caused by viruses (influenza A and B, adenovirus, and respiratory syncytial virus)

Epiglottitis has a more acute and rapid course than croup. X-ray chest shows the characteristic narrowing of the subglottic region and is known as the “steeple sign.”Cough is usually absent in epiglottitis, as seen in the above patient.

Question 25

As the child has presented with sudden high fever, sore throat, dysphagia, drooling, and dyspnea.

Answer 25

acute epiglottitis. Cough is usually absent in epiglottitis. The diagnosis is further supported by the presence of polymorphonuclear leukocytosis and lateral radiograph of the upper airway showing the “thumb sign,” which is due to swelling and inflammation of the epiglottis and other supraglottic structures, especially the aryepiglottic folds.

Question 26

Haemophilus influenzae type b is the most common cause of acute epiglottitis. Stridor is a late finding and suggests severe airway obstruction. Rapid airway management is essential and includes nasotracheal intubation and oxygenation. Examination of the throat with a tongue depressor should be avoided; it can precipitate a fatal laryngospasm.

Answer 26

Antibiotics commonly used for treatment are cefotaxime, ceftriaxone, or meropenem pending culture and sensitivity reports.

Question 27

Independent risk factors for SIDS that have been consistently identified across studies are

Answer 27

prone sleep position, sleeping on a soft surface, overheating, late or no prenatal care, young maternal age, preterm birth and/or low birth weight, male gender, and maternal smoking during pregnancy. Almost every epidemiologic study has shown maternal smoking during pregnancy to be a major risk factor. Smoking after birth has emerged as a separate risk factor, but separating this variable from maternal smoking before birth is difficult.

Question 28

most reliable predictors of drowning outcomes are the

Answer 28

presence or absence of coma, pupillary response, and blood glucose levels.

Question 29

Hypothermia, when the core body temperature drops below 34° C almost always predicts a bad outcome. There are, however, anecdotal cases of children surviving icy water submersions. In these instances, hypothermia occurs before hypoxic and ischemic injury and becomes protective.

Answer 29

All studies have shown that age has no role in outcome when submersion duration and other factors are controlled for. Lower case fatality rates of preschoolers may be explained by their greater likelihood to be rescued earlier.

Question 30

_____ is a common cause of persistent wheezing in early infancy, with male preponderance in the ratio of 2:1.

Answer 30

Tracheomalacia. In primary tracheomalacia, there is insufficient cartilage to maintain the patency of the airway throughout the respiratory cycle. It commonly occurs in premature infants. Secondary tracheomalacia occurs when trachea is compressed by structures like vascular rings or deficient cartilage due to tracheoesophageal fistula.

Question 31

_____ is the 3rd most common congenital anomaly of the larynx causing stridor, which is usually biphasic or primarily inspiratory. Recurrent or persistent croup occurs in these infants.

Answer 31

Congenital subglottic stenosis. The 1st symptom often occurs during an episode of respiratory infection, as edema and thick secretions cause narrowing of the already compromised airway.

Question 32

_____ is a metabolite of nicotine and has a half-life of up to 20 hours. It can remain detectable in urine for several days after exposure. It can be measured in serum, saliva, or urine, but the results are the most reliable for serum measurement.

Answer 32

Cotinine