EMERGENCY MEDICINE Flashcards
A 27-day-old with fever 103 °F for 1 day, feeding well, no cough, no vomiting, no diarrhea. Physical examination is normal. What is the next best step?
Full sepsis evaluation (blood, urine and CSF testing) and empiric IV antibiotics
An 8-week-old with fever 103 °F for 2 days, feeding well, no cough, no vomiting, no diarrhea. Physical examination is normal. What is the next
best step?
Complete blood count (CBC), urinalysis and urine culture (infants < 90 days of age with a temperature > 38 °C should be promptly evaluated)
A 15-month-old with fever 103 °F for 2 days, feeding well, fussy when fever is high, playful for brief periods after receiving antipyretics, no cough,
no vomiting, no diarrhea. Physical examination is normal. What is the next best step?
Reassurance (most likely viral syndrome, advise close follow-up)
Non-toxic, fully vaccinated toddler with nasal congestion has a barky cough, inspiratory stridor when agitated, but no resting stridor. What is the next best step?
Oral dexamethasone (viral croup)
A well-appearing, 12-month-old with upper respiratory infection (URI) symptoms and fever presents with diffuse wheezing on lung auscultation. What is the next best step?
Clearance of nasal secretions and reassurance (acute viral bronchiolitis)
Child with asthma, presenting with chest pain, chest tightness and diffuse bilateral expiratory wheezing in the setting of URI symptoms. What is the next best step?
Albuterol and ipratropium nebulizer treatments with oral steroids
Distressed, vaccinated toddler, with sudden onset of cough and inspiratory stridor while eating peanuts. What is the next best step?
Attention to ABCs (airway, breathing,
circulation) and emergent subspecialty
evaluation for a suspected foreign body in airway
An unvaccinated child with inspiratory stridor at rest, toxic appearing, leaning forward and drooling. Next best step?
Attention to ABCs (airway, breathing,
circulation) and emergent subspecialty
evaluation for suspected epiglottitis
Child with peanut allergy presents with diffuse hives and flushed skin after ingestion of peanuts, noted to have hypotension on initial vital signs.
What is the definitive treatment for the underlying diagnosis?
IM epinephrine for anaphylaxis
Child presents to the emergency department (ED) with a dog bite. What is the next best step?
Wound cleaning with adequate pressure
irrigation
After cleaning the wound of dog or cat bite, what is the most appropriate prophylactic antibiotic?
Amoxicillin/clavulanate, cover both aerobes and anaerobes, especially Pasteurella
Dog or cat bite and allergy to penicillin
Clindamycin plus
trimethoprim-sulfamethoxazole
Teenage patient punches another student in the teeth during an altercation at school and sustains
puncture lacerations to knuckles; what is the most appropriate prophylactic antibiotic?
Amoxicillin/clavulanate, cover both aerobes and anaerobes, especially Eikenella
A fully vaccinated child with a bite from a stray dog that was not captured. The child was admitted on NPO status due to multiple puncture lacerations requiring surgical repair. What is the next best treatment?
Rabies prophylaxis (rabies vaccine and rabies immunoglobulin) and intravenous ampicillin-sulbactam
Adolescent with pain, redness, and tenderness in the foot after stepping on a rusty nail that punctured the foot. There is no fever and the rest of
the exam is normal. Last tetanus vaccine was 7 years ago. What is the best treatment?
Tdap vaccine and oral ciprofloxacin
Pseudomonas aeruginosa infection
Child with a sudden stinging sensation in the right foot after playing in the basement, within a few hours develops severe pain and enlarging erythema
in the right foot, which 2 days later becomes a hemorrhagic blister surrounded by an erythematous halo and dark eschar. What is the most likely cause?
Brown recluse spider bite (local pain, necrosis, and less systemic manifestations)
Child presents with sudden pinching sensation in the foot after playing in the basement, within 8 h develops muscle cramping in the right leg, which progresses to the back and abdomen. O/E: elevated blood pressure, tachycardia, tender abdomen, target-like appearance redness in the foot. What is the most likely cause?
Black widow spider bite (initial pinch or
pinprick sensation, or unnoticed bite followed by significant systemic manifestations, muscle cramping, tachycardia, and hypertension)
Child stung on the left arm by a wasp, having pain, itching, erythema, and mild swelling in the left arm without any signs of systemic illness. What is the
best treatment?
Removal of the stinger, application of cool compresses or ice packs, and mild oral analgesics and oral antihistamines to help alleviate pruritus
A 1-year-old falls < 3 ft height, no loss of
consciousness, no headache, no vomiting. Physical examination is normal except mild swelling in the
forehead. What is the next best step?
Reassurance (very low risk of clinically
significant traumatic brain injury [height of fall in < 2 years of age > 3 ft is a high risk])
A 3-year-old falls < 5 ft height, no loss of
consciousness, no headache, no vomiting. Physical examination is normal except mild swelling in the
forehead. What is the next best step?
Reassurance (very low risk of clinically
significant traumatic brain injury [height of fall in > 2 years of age > 5 ft is a high risk])
A 6-year-old boy fell and hit his head while running, loss of consciousness for 30 s, one-time vomiting, headache that has slightly improved in the last 30 min. Physical examination is normal except mild swelling in the forehead. What is the next best step?
Observation period 4–6 h in ED
Child brought to the ED after severe head trauma, continues to have persistent vomiting and altered level of consciousness. What is the next best step?
Attention to ABCs (airway, breathing, and circulation)—the child needs CT head but first requires stabilization
A 6-year-old boy fell and hit his head, loss of consciousness for 2 min, progressive headache, persistent vomiting. Physical examination is
normal except mild swelling in the forehead. What is the next best diagnostic test?
Head CT scan without contrast
A 6-year-old boy fell and hit his head, loss of consciousness, headache, vomiting, improvement for few hours (lucid interval) followed by deterioration of symptoms and loss of consciousness. CT head shows hyperdense enticular-shaped mass situated between the brain and the skull. Most likely diagnosis?
Epidural hematoma—convex toward the brain and restricted by suture lines in CT scan
Head trauma, severe headache, and drowsiness. Head CT scan showed hyperdense (white), crescent-shaped mass between the inner table of the skull and the surface of the cerebral hemisphere. Most likely diagnosis?
Subdural hematoma—concave toward the brain and unlimited by suture lines in CT scan
Head trauma, bleeding from the ear, hearing loss, and facial paralysis. Most likely injury?
Temporal bone fracture
Head trauma, ecchymosis behind the ear (battle sign), periorbital ecchymosis (raccoon eyes), abducens nerve paralysis. Most likely injury?
Basilar skull fracture
Glasgow Coma Scale (GCS) of a child after head trauma who opens eyes only to sound, makes a few unintelligible sounds but does not say words, and
localizes to pain
GCS = 10 (3 E/2 V/5 M)
Effect of clonidine, cholinergic, opiates,
organophosphates, phencyclidine, phenothiazine, pilocarpine, and barbiturates (sedatives) on the pupil
Miosis
Effect of atropine, antihistamines, antidepressants, amphetamine, and cocaine on the pupil
Mydriasis
Ingestion of which agents can cause seizures, hyperthermia, agitation, decreased urine output, anhidrosis, flushing, and mydriasis?
Anticholinergic agents (e.g., amitriptyline, diphenhydramine, jimson weed, or deadly nightshade)
Ingestion of which agent can cause pinpoint pupils, unresponsiveness, and respiratory depression?
Opiate intoxication
What is the treatment of choice for opiate poisoning?
Naloxone
Child presents with neck spasms, oculogyric crisis, and tongue thrusting after accidental ingestion of promethazine (anti-nausea medication). What is the drug of choice to treat these symptoms?
Diphenhydramine; the patient has an acute dystonic reaction
Child ingests a large amount of a grandparent’s medicine, presents with hyperventilation, metabolic acidosis, high-anion gap, tinnitus, and confusion. Likely ingestion?
Aspirin
Healthy child ingests caretaker’s medicine, presents with altered mental status, seizure, drowsiness, lethargy, sinus tachycardia, widened QRS, prolonged QT interval. Likely ingestion?
Tricyclic antidepressants (TCA) toxicity
Adolescent currently on SSRI treatment for depression presents with confusion, sweating, and myoclonus admits to trying ecstasy at a party. Likely cause of symptoms?
Serotonin syndrome—hallmark is myoclonus
Occurs with: monoamine oxidase inhibitor (MAOI) and linezolid
Child is brought to the ED after ingesting numerous pills of metformin. Possible laboratory finding?
Lactic acidosis
Child presents with nausea, vomiting, abdominal pain 6 h after accidental ingestion of pills, felt better for a short period, then 24 h later presents with metabolic acidosis, shock, hepatic failure, and 6 weeks later develops pyloric and gastrointestinal scarring. What is the most likely ingested substance?
Iron
Child reaches the toxic level of acetaminophen 4 h after accidental ingestion. What is the antidote?
N-acetylcysteine (NAC)
Toddler ingests a small amount of windshield wiper fluid about 30 min before the presentation, is asymptomatic. Caretaker calls primary care office for advice. What is the next best step?
Immediate referral to the ED for further
laboratory testing (toxic alcohol ingestion→ methanol)
Adolescent presents with slurred speech, tachypnea, cyanosis, pulmonary edema, renal failure, calcium oxalate crystals in the urine, high-anion gap metabolic acidosis. Likely ingestion?
Ethylene glycol
Adolescent presents with visual disturbance, abdominal pain, and high-anion gap metabolic acidosis. Likely ingestion?
Methanol
Child accidentally ingests window cleaner, presents with sore throat, dysphagia, and drooling. Next best step?
Caustic ingestion, immediate subspecialty consultation for endoscopy
Child complains of a headache, weakness, fatigue, and nausea for 2–3 weeks since the start of winter, caretaker reports self and 2 other siblings are feeling the same. Most likely exposure?
Carbon monoxide poisoning (measurement of carboxyhemoglobin on blood gas)
Child at a party ate some cookies then starts vomiting, swelling of the lips, and trouble breathing, should be treated with which medication
IM epinephrine at 0.01 mg/kg
Toddler presents with right arm pain and decreased arm mobility after being lifted up by the right arm during play. No falls or trauma reported. Most likely diagnosis?
Nursemaid’s elbow (annular ligament
displacement)
Child tripped and fell on an outstretched hand presents with tenderness to distal humerus. No obvious fracture on elbow radiograph, although there is a posterior fat pad sign on the lateral view. Most likely diagnosis?
Occult supracondylar fracture
Term neonate delivered vaginally had difficulty with vacuum extraction presents with “bump” over left clavicle 2 weeks after birth. Most likely diagnosis?
Clavicular fracture with healing callus from a traumatic birth
Chest radiograph performed on a healthy infant for evaluation of chronic cough reveals many callus formations to the posterior ribs bilaterally. Most likely diagnosis?
Non-accidental trauma/child abuse
Toddler presents with left leg pain and limps after going down a slide and getting the left foot stuck and twisted on the edge of the slide. Radiograph of
lower leg reveals a non-displaced spiral fracture of the lower third of the tibia. Most likely diagnosis?
Toddler’s fracture
Which type of burn is associated with mild pain, swelling, and redness that blanches with pressure?
Superficial burn (formerly 1st-degree burn)
Which type of burn is associated with severe pain, blebs, and blisters?
Partial thickness burn (formerly 2nd-degree burn)
Which type of burn is painless with a dry and leathery appearance?
Full-thickness burn (formerly 3rd-degree burn)
Child has electrical burns to the mouth after chewing on an electrical cord. Next best step?
Refer to burn surgeon—concern for labial artery bleeding
Child who weighs 20 kg has burns on 5% of the body surface area. What IV fluids should be given and how much?
Parkland formula: 4 ml/kg/% of the burn area of lactated Ringer’s
Total: 400 mL with 200 mL (50% of total) given in the first 8 h and 200 mL over the next 16 h
A toddler who presents with scald burns over legs in a stocking distribution (clearly demarcated) needs what further evaluation
Evaluation for intentional injury/abuse
Toddler presents with sudden onset vomiting and lethargy, bedside point-of-care glucose and venous blood gas are normal with a non-focal neurologic
exam, soft abdomen, and no concern for ingestion. Next best test?
Ileocolic US to rule out intussusception
Toddler presents with intermittent screaming episodes followed by periods of normalcy; caretaker reports a pink “jelly”-like stool. Most likely location of the intussusception?
Ileocolic
Adolescent female with acute onset of severe left lower pelvic pain, nausea, and vomiting; exam reveals severe tenderness and guarding in the left
lower quadrant. Next best test?
Pelvic US to rule out acute ovarian torsion
Adolescent male with acute onset of severe right testicular pain with nausea and vomiting; exam reveals high riding testicle with absent cremasteric reflex. Next best test?
Testicular US to rule out acute testicular torsion
Child with 1 day of nonbilious emesis and diarrhea, fever, periumbilical abdominal pain, and tenderness that is radiating to the right lower quadrant. Most likely diagnosis?
Acute appendicitis
What is the initial imaging study of choice in cases of suspected acute appendicitis?
Abdominal US
A 4-week-old with 10 days of worsening projectile vomiting and 1 day of intermittent apneic spells, found on ultrasound to have hypertrophic pyloric
stenosis. Most likely laboratory finding?
Hypokalemic, hypochloremic metabolic
alkalosis
A healthy infant with 1 day of intermittent bilious emesis. Stable vital signs on arrival. Next best test?
Upper GI series to rule out malrotation
