Emergency Medicine

Question 1

What is Cushing’s triad?

Answer 1

Answer
Hypertension, bradycardia, and irregular respirations
Explanation
Findings of hypertension, bradycardia, and irregular respirations constitute Cushing’s triad. Cushing’s triad is seen in the setting of increased intracranial pressure.

Question 2

A 5-year-old has a supracondylar elbow fracture that is displaced significantly.

Should orthopedics be consulted?

Answer 2

Answer
Yes
Explanation
Displaced supracondylar fractures have a high risk of neurovascular complications, including compartment syndrome of the forearm, which can lead to Volkmann contractures in the wrist and hand. Always evaluate for damage to the brachial artery, median nerve, and radial nerve. Displaced supracondylar fractures require emergent orthopedic consultation and precise reduction by an orthopedic surgeon. Refer all susp

Question 3

Why should infants with abusive head trauma (AHT; formerly shaken baby syndrome) be evaluated by an ophthalmologist?

Answer 3

To evaluate for retinal hemorrhages
Explanation
Always look for retinal hemorrhages in a child with suspected physical abuse and possible abusive head trauma. Most infants with severe abusive head injuries (62–100%) have bilateral retinal hemorrhages. Retinal hemorrhages from birth can be seen in nonshaken newborns, but these typically resolve by 2–6 weeks, depending on location. Infants with accidental head injuries can rarely have retinal hemorrhages. While you may be able to see these using a standard ophthalmoscope, a dilated eye exam should be performed by an ophthalmologist.

Question 4

A 9-year-old boy includes genitals in a drawing of his family.

What should you consider as a possibility?

Answer 4

Sexual abuse
Explanation
It is unusual for older, grade school-aged children to draw genitals on figures; this requires further inquiry. Sexual abuse must be strongly considered and thoroughly investigated when an older child includes genitals in a drawing.

Question 5

A 6-month-old infant presents with a large, unexplained swelling over the parietal area.

What should you do?

Answer 5

CT scan
Explanation
Infants < 2 years of age with nonfrontal scalp hematomas are at risk for intracranial injuries. While some physicians would choose observation rather than CT for traumatic scalp hematomas in a well-appearing child, the injury in this infant is unexplained. You should explore the possibility of abuse

Question 6

How does coingestion of ethanol affect signs and symptoms of methanol/ethylene glycol poisoning?

Answer 6

Answer
Delays onset
Explanation
Ethanol competes with the toxic alcohols for alcohol dehydrogenase, potentially delaying and masking signs of methanol/ethylene glycol toxicity. The toxic alcohols need the enzyme to convert to their toxic metabolites. Be sure to get an ethanol level in addition to the toxic alcohol level.

Question 7

Visual complaints
Abdominal pain
High anion gap metabolic acidosis
Ingesting what substance produces these signs and symptoms?

Answer 7

Methanol
Explanation
Methanol is found in windshield washer fluid and deicer and is used as a fuel additive. Methanol ingestion produces visual disturbances (blurry vision and photophobia—described as a “snowstorm”), abdominal discomfort, and a high anion gap metabolic acidosis. Early on, there is an osmolal gap, giving way to the anion gap acidosis as the methanol metabolizes. Differentiate this from ethylene glycol, which results in renal failure instead of visual problems.

Question 8

A 3-year-old child is seen after ingesting some of her grandmother’s “blood pressure pills.” She is somnolent, bradycardic, and hypotensive. Her blood sugar is 55 mg/dL.

What do you suspect?

Answer 8

β-blocker ingestion
Explanation
β-blocker poisoning may cause CNS depression, bradycardia, hypotension, arrhythmias, and hypoglycemia. Calcium channel blocker poisoning is similar but without the CNS depression and hypoglycemia. Treatment involves an assortment of supportive care measures, including vasopressors, glucagon, fluids, lipid emulsion, insulin/glucose, and pacing.

Question 9

A child presents with:

Spasms of the neck
Tongue thrusting
Oculogyric crisis
What did the child likely ingest?

Answer 9

Phenothiazine or another antipsychotic drug
Explanation
Drug-induced dystonic reactions—characterized by torticollis, tongue thrusting, oculogyric crisis, and involuntary or sustained muscle contractions—are often caused by phenothiazines or other antipsychotic drugs. This reaction is dose independent. The dystonia is treated with diphenhydramine or benztropine (IV or IM).

Question 10

Describe in detail the types of growth plate (physeal) fractures seen in children.

Answer 10

Answer
The SALT(e)R mnemonic can help you remember (epiphysis site):
Type 1: Straight across
Type 2: Above
Type 3: Lower
Type 4: Two or Through
Type 5: Rammed together
Explanation
Growth plate injuries (15% of all childhood fractures) are unique to childhood and involve the physis (growth plate) with variable involvement of the surrounding bone. The Salter-Harris classification is both a mnemonic and a clinical descriptor of the area involved. Remember SALT(e)R:Type 1: Straight across (through the physis only); Type 2: Above (through the physis and metaphysis); Type 3: Lower (through the epiphysis extending to the growth plate); Type 4: Two or Through (extends from the articular surface through the epiphysis, physis, and metaphysis); Type 5: Rammed together (crush injury to the epiphysis).

Question 11

A 3-year-old child is playing outside with older siblings and runs inside to her mother, complaining of hurting her arm. She arrives at the emergency department with her arm held limply at her side but doesn’t seem to be in much pain.

What is the most likely diagnosis?

Answer 11

Answer
Subluxation of the radial head (a.k.a. “nursemaid’s elbow”)
Explanation
Subluxation of the radial head is most common in children 6 months to 5 years of age. It is caused by axial traction on an extended and pronated arm, causing the annular ligament to slide over the radial head. It can also be caused by falls. X-rays are not necessary in classic cases. To reduce it, hyperpronate the extended forearm or supinate the forearm and flex the elbow.

Question 12

Name 6 sexually transmitted infections that can be congenitally acquired.

Answer 12

Answer
HPV, HSV, HIV, syphilis, gonorrhea, and Chlamydia
Explanation
Be careful to consider perinatal maternal transmission of these infections in infants/young children up to 3 years of age. If seen in older children who were previously asymptomatic, it is likely due to abuse.

Question 13

Appears intoxicated with slurred speech and drowsiness
Renal failure with calcium oxalate crystals in the urine
High anion gap metabolic acidosis
Ingesting what substance produces these signs and symptoms?

Answer 13

Ethylene glycol
Explanation
Ethylene glycol is in antifreeze. Ingesting it results in an osmolal gap and a high anion gap metabolic acidosis, with the development of calcium oxalate crystals in the urine and eventual renal failure if not treated. Remember to differentiate ethylene glycol ingestion (renal failure) from methanol ingestion (visual disturbances).

Question 14

What test should be performed in well-appearing, < 2-year-old siblings of physically abused children?

Answer 14

Skeletal survey
Explanation
A significant number of siblings of abused children have fractures that are not suspected clinically. Twins are at especially increased risk.

Question 15

What eye finding do atropine, antihistamines, amphetamine, and cocaine cause?

Answer 15

Answer
Mydriasis
Explanation
Causes of mydriasis include (AAS):
Anticholinergics (atropine)
Antihistamines
Sympathomimetics (amphetamine, cocaine, lysergic acid diethylamide [LSD])

Question 16

A 16-year-old presents with a displaced tibial fracture. The pain appears to be out of proportion to the fracture, and he has pain remote to the fracture.

What is the suspected complication?

Answer 16

Answer
Compartment syndrome
Explanation
Compartment syndrome is most common with tibial and supracondylar fractures. The fracture causes hemorrhaging or swelling in an enclosed fascial compartment. The biggest clue is pain out of proportion to the fracture, especially pain that is remote to the fracture site. Pulses may still be palpable. Refer for an immediate consultation with an orthopedist.

Question 17

What eye finding do opiates, clonidine, phencyclidine, and barbiturates cause?

Answer 17

Miosis
Explanation
For the common causes of miosis, remember the mnemonic COPS:
Cholinergics, clonidine
Opiates, organophosphates
Phencyclidine, phenothiazine, pilocarpine
Sedatives (barbiturates)

Question 18

An 11-year-old male presents to the emergency department with a left ankle injury after he fell at a school basketball game a few hours ago. Physical examination reveals a moderately swollen left ankle with point tenderness of the distal lateral malleolus. Range of motion is limited in all directions. The child is unable to bear any weight onto the left ankle due to the severe pain.

What are the indications for x-ray according to the Ottawa ankle rules?

Answer 18

Answer
Inability to bear weight for 4 steps immediately after injury and in the emergency department
Tenderness to palpation of the distal posterior 6 cm of either malleolus
Explanation
Sprains are less common in prepubescent children because the ligament is stronger than the growth plate; thus, be concerned about fractures in children presenting with ankle pain.

The Ottawa ankle rules have been found to be nearly 100% sensitive in detecting clinically significant fractures and are useful in determining which children require x-rays. Children with acute ankle injury who cannot bear weight for 4 steps or who have tenderness over the distal posterior 6 cm of either malleolus should get x-rays of the ankle. Children with mid foot pain who cannot bear weight for 4 steps and have bony tenderness at the base of the 5th metatarsal or the navicular should have x-rays of the foot.

Question 19

Tachycardia
Hypotension
Widened QRS
Drowsiness
Lethargy
Seizures
Coma
What drug, if ingested, results in these findings?

Answer 19

Answer
Tricyclic antidepressant (TCA)
Explanation
TCAs have anticholinergic activity and can inhibit cardiac fast sodium channels, resulting in widened QRS (> 100 ms). Tachycardia and hypotension is classic, but hypertension can occur early. Other arrhythmias can also occur. Give sodium bicarbonate to alkalinize the serum pH to 7.50–7.55, and look for decreasing QRS intervals to see if the treatment worked. Avoid phenytoin due to the risk of arrhythmia. Also avoid physostigmine and flumazenil, because these may cause seizures.

Question 20

Nausea, vomiting
Respiratory alkalosis
Anion gap metabolic acidosis
Tinnitus
Fever
Agitation, confusion, or coma
Ingestion of what agent results in these findings?

Answer 20

Answer
Salicylate
Explanation
Salicylate ingestion (e.g., aspirin, oil of wintergreen, and certain antidiarrheal agents) results in GI, respiratory (respiratory alkalosis), and metabolic (anion gap + nongap metabolic acidosis) effects. Tinnitus is the most specific finding. Treatment includes giving sodium bicarbonate to raise the urine pH to > 8.5 with a serum pH no higher than 7.55. Hemodialysis may be needed for severe cases.

Question 21

How should you treat an infected puncture wound to the foot?

Answer 21

Answer
Cleanse, update tetanus, consider x-ray and antibiotics
Explanation
Treatment includes standard wound cleansing, tetanus prophylaxis, and consideration of x-ray for foreign bodies or possible bony involvement. If an infection develops after puncture through the sole of a shoe (especially sneakers), treat for Pseudomonas aeruginosa, as well as Staphylococcus and Streptococcus.

Question 22

A toddler presents after ingesting lamp oil. She has no coughing or difficulty breathing, and initial O2 saturation is normal.

What should you do?

Answer 22

Observe on pulse oximetry; CXR at ~ 6 hours
Explanation
The patient is at risk of pneumonitis and respiratory compromise from hydrocarbon aspiration. If there are no symptoms after 6 hours and pulse oximetry and CXR are normal, it is not likely she will develop significant pneumonitis. Charcoal and induction of vomiting are inappropriate.

Question 23

Classic metaphyseal lesions (“bucket handle fractures”) and posterior rib fractures are highly suspicious of what diagnosis?

Answer 23

Answer
Physical abuse
Explanation
Bucket handle fractures, corner fractures, and rib fractures (particularly those posterior and near the spine) are almost always due to abuse. Chest compressions from CPR rarely cause rib fractures in young children. Spiral fractures, fractures in bones that are difficult to break (e.g., scapula, sternum), and multiple fractures in various stages of healing are also concerning for child abuse.

Question 24

A child presents to the Emergency Department pulseless and is found to have ventricular tachycardia on the cardiac monitor. CPR has been started.

What is the next step in management?

Answer 24

Answer
Defibrillation with 2 J/kg
Explanation
Once cardiac arrest is recognized, begin CPR while preparing to assess the rhythm. Pulseless ventricular tachycardia and ventricular fibrillation require defibrillation. Begin with 2 J/kg, and then resume CPR for 2 minutes before checking pulse/rhythm. Give epinephrine every 3–5 minutes. Since 2020, there is a new emphasis to start epinephrine within 5 minutes of starting chest compressions. The 2nd shock is 4 J/kg; 3rd and subsequent shocks are 4 J/kg. The sequence is CPR → shock→ CPR → drug → shock (repeat). Give high-quality compressions and minimize breaks in CPR.

Question 25

A 6-month-old presents with a spiral fracture of the femur.

What should you suspect as the etiology of the injury?

Answer 25

Physical abuse
Explanation
Any fracture in a child who is not walking yet is highly concerning for physical abuse. Additionally, a spiral fracture is concerning for physical abuse if the history does not seem consistent with the injury. An exception is an oblique or spiral fracture of the lower tibia in a young ambulatory child (“toddler’s fracture”) as this is a common accidental injury, often with a very minor mechanism.

Question 26

What are the 5 overlapping phases of iron toxicity?

Answer 26

1) GI phase
2) Relative stability phase
3) Systemic toxicity phase
4) Hepatic toxicity/failure
5) GI/Pyloric scarring
Explanation
The GI stage (30 minutes–6 hours) includes nausea, vomiting, diarrhea, and abdominal pain. Hematemesis and bloody diarrhea may develop in severe cases. Relative stability occurs 6–24 hours after ingestion. Systemic toxicity (6–72 hours) includes shock, severe metabolic acidosis, hepatic failure, and coma. GI/Pyloric scarring occurs 2–6 weeks after ingestion.

Question 27

A 6-year-old is seen after an ankle injury. He is tender over the distal fibula. X-rays do not show a fracture.

What injury is most likely?

Answer 27

Salter-Harris Type 1 fracture
Explanation
Children with open physes (growth plates) may have Salter-Harris Type 1 fractures with normal x-rays. If a young child is tender over the distal fibular physis, a Salter-Harris Type 1 fracture is likely, even if the x-ray is normal.

Question 28

It is wintertime and an entire family, including children, presents with:

Headache
Nausea
Lethargy, malaise
Flu-like symptoms
Pulse oximetry is normal.
What is the likely diagnosis?

Answer 28

Carbon monoxide poisoning
Explanation
Carbon monoxide is colorless and odorless; poisoning from it presents with nonspecific symptoms. Be very suspicious if you see a family in the wintertime (or during periods of prolonged power outages [e.g., hurricanes] when using gas generators) with similar complaints, especially if afebrile. Remember, PaO2 on ABG and oxygen saturation by pulse oximetry typically appear “normal.” Diagnose by checking carboxyhemoglobin levels on a CO-oximeter.

Question 29

A 4-year-old boy presents with the following:

History of swallowing a quarter
Some choking
Retrosternal pain
Plain films suggest the quarter is in the midesophagus.
He is in no respiratory distress and can swallow his own secretions.
What is the best management?

Answer 29

Answer
Endoscopic removal within 24 hours
Explanation
If the child is asymptomatic, coins in the esophagus can be observed for up to 24 hours after ingestion and should be removed before then endoscopically. In 20–30% of these cases, the coin will pass into the stomach during the observation period. If the patient is symptomatic, or if the coin remains in the esophagus after 24 hours, removal with endoscopy is required. Coins can be observed if in the stomach or beyond

Question 30

What is the most common physical examination finding of the genital/anal area in sexually abused children?

Answer 30

Answer
Normal examination
Explanation
Few sexually abused children have abnormal genital or anal findings. History is usually more important in determining if there has been abuse. Additionally, many normal variants and nonabuse conditions can be mistaken for abuse.

Question 31

Coma
Respiratory depression
Pinpoint pupils
What ingestion does this triad describe?

Answer 31

Answer
Opiates
Explanation
Other expected findings include altered mood, nausea, vomiting, and abdominal pain. Clonidine and imidazole eye drops may cause a similar picture. Some opioids do not cause the classic pupillary findings (e.g., meperidine).

Question 32

Decreased sweating
Urinary retention
Flushing
Mydriasis
Agitation
Seizures
Hyperthermia
Ingestion of what type of agent causes these symptoms?

Answer 32

Answer
Anticholinergic
Explanation
Anticholinergic agents include antihistamines (e.g., diphenhydramine), tricyclic antidepressants (e.g., amitriptyline), atropine, some mushrooms, jimson weed, and deadly nightshade. Remember this to help recognize the toxidrome: “dry as a bone, red as a beet, hot as a hare, blind as a bat, mad as a hatter, full as a flask.”

Question 33

What is the most common organism found in an infected cat bite wound?

Answer 33

Answer
Pasteurella multocida
Explanation
P. multocida is the most common organism in cat bite wounds, followed by Staphylococcus aureus. P. multocida infections can progress rapidly (within 24 hours). Treatment is with amoxicillin/clavulanic acid.

Question 34

What is the most common cause of serious head injury in infants < 1 year of age?

Answer 34

Child abuse
Explanation
Abusive head trauma (AHT) is the most common cause of serious head injury in infants < 1 year of age. Head injury is the most common cause of death due to physical abuse. Infants with AHT frequently have subdural and/or subarachnoid hemorrhages, and most patients with severe inflicted head injury (62–100%) have bilateral retinal hemorrhages as well. Retinal hemorrhages from birth can be seen in nonshaken newborns, but these typically resolve by 2–6 weeks, depending on location

Question 35

A child presents after a head injury with:

“Raccoon eyes”
“Battle sign”
Hemotympanum
CSF otorrhea or rhinorrhea
If any of these findings are present, what do you suspect?

Answer 35

Answer
Basilar skull fracture
Explanation
Get a CT of the brain and temporal bone, although it doesn’t always show the fracture. Children with basilar skull fractures (fractures at the base of the skull involving temporal bone, occipital bone, and/or ethmoid) have a small risk of subsequently developing meningitis, particularly if they have CSF leakage from the ear (otorrhea) or nose (rhinorrhea). They may also develop hearing loss or facial paralysis.

Question 36

A child presents with an acute acetaminophen ingestion and is found at 4 hours after ingestion to have a toxic level.

What is the appropriate antidote?

Answer 36

Answer
N-acetylcysteine (NAC)
Explanation
NAC is the drug of choice for treating acute acetaminophen ingestion/toxicity. It is most effective when given within 8 hours.

Question 37

Diarrhea
Urination
Miosis (pinpoint)
Bronchorrhea/Bronchospasm/Bradycardia
Emesis
Lacrimation
Salivation
Ingestion of what substance produces these signs and symptoms?

Answer 37

Answer
Organophosphate or carbamate
Explanation
This is cholinergic toxidrome (remember the DUMBELS mnemonic), which is essentially miosis with an outpouring of every body fluid from every orifice. Also look for CNS effects and nicotinic muscular effects, which are not included in the DUMBELS mnemonic. Atropine (for both organophosphates and carbamates) and pralidoxime (for organophosphates) are the antidotes.

Question 38

Assuming prompt treatment, which has a better prognosis—epidural or subdural hematoma?

Answer 38

Answer
Epidural
Explanation
In epidural hematoma, the underlying brain is generally uninjured. Subdural hematomas are associated with more severe brain injuries, and hence they have a worse prognosis.

Question 39

You are seeing an 18-month-old child with multiple bruises concerning for child abuse.

What radiologic study should you perform?

Answer 39

Skeletal survey
Explanation
Perform a skeletal survey on a child < 2 years of age if physical abuse is known or suspected. This includes quality views of the skull, chest/ribs, spine, pelvis, and extremities. A “babygram” is not detailed enough to see subtle fractures. A follow-up skeletal survey in ~ 2 weeks may detect additional injuries not seen on the initial survey.

Question 40

List 3 possible signs or symptoms of abusive head injury.

Answer 40

Vomiting, fussiness, lethargy, seizures, scalp hematomas, “not acting right,” coma, apnea, cardiac arrest
Explanation
Findings of abusive head trauma may include vomiting, fussiness, lethargy, seizures, scalp hematomas, “not acting right,” coma, apnea, and cardiac arrest. Patients may have associated spinal trauma. Complex skull fractures in infants without a significant mechanism (e.g., motor vehicle collision) are concerning for physical abuse.