Emergency Medicine & Maltreatment Syndromes

Question 1

Ingestion of what agent results in these findings:

• Nausea, vomiting
• Respiratory alkalosis
• Anion gap metabolic acidosis
• Tinnitus
• Fever
• Agitation, confusion, or coma

Answer 1

Salicylate Ingestion

Salicylate ingestion (includes aspirin, oil of wintergreen, and antidiarrheal agents) results in GI, respiratory (respiratory alkalosis), and metabolic effects (anion gap metabolic acidosis). Tinnitus is the most specific finding. Treatment includes giving bicarbonate to raise the urine pH to > 7.5. Hemodialysis may be needed for severe cases.

Question 2

Name 5 sexually transmitted infections that can be congenitally acquired.

Answer 2

HPV, HSV, HIV, Syphilis, and Chlamydia

Be careful to consider vertical 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 3

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

Answer 3

Mydriasis

Causes of mydriasis include (AAAS):

• Anticholinergics (atropine)
• Antihistamines
• Antidepressants (tricyclics)
• Sympathomimetics (amphetamine, cocaine, LSD)

Question 4

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

Answer 4

Normal Examination

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

Question 5

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 and bruised left ankle with point tenderness posterior to the 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 is the likely complication associated with this sports-related injury?

Answer 5

Ankle Sprain Grade III, Likely Fracture

Sprains are rare in prepubescent children because the ligament is stronger than the growth plate; thus, younger children more often get fractures than sprains. Ankle sprains are graded from I–III, with I being a partial ligament tear, II an incomplete tear with moderate functional impairment, and III a complete tear. The Ottawa ankle rules have been found to be nearly 100% sensitive in detecting clinically significant fractures. 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. Although the majority of children with ankle injuries get x-rays, those who can bear weight and who do not have bony tenderness are very unlikely to have a significant fracture.

Question 6

Ingestion with what type of agent is responsible for the following symptom complex?

• Decreased sweating
• Decreased urine output
• Flushing
• Mydriasis
• Agitation
• Seizures
• Hyperthermia

Answer 6

Anticholinergic Ingestion

Anticholinergic agents include diphenhydramine, amitriptyline, atropine, over-the-counter sleep medications, 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.”

Question 7

A patient presents with a head injury and has the following symptoms:

• Hypertension
• Bradycardia and irregular respirations
• Tachycardia
• Frontal hematoma
• Glasgow Coma Scale (GCS) = 15

Which of the these findings are signs of a potentially serious head injury?

Answer 7

Hypertension, Bradycardia, and Irregular Respirations

Findings of hypertension, bradycardia, and irregular respirations constitute Cushing’s triad, which alerts you to the possibility of increased intracranial pressure (ICP).

Question 8

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

• Headache
• Nausea
• Lethargy, malaise
• “Flu-like” symptoms
• Pulse oximetry is normal

What is the likely diagnosis?

Answer 8

Carbon Monoxide Poisoning

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 are typically normal. Both are wrong. Diagnose by checking carboxyhemoglobin levels on a CO-oximeter.

Question 9

A child presents pulseless and is found to have ventricular tachycardia on ECG. CPR has been started.

What is the next step in management?

Answer 9

Defibrilation with 2 J/kg

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. 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 10

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

Answer 10

Miosis

Remember the mnemonic (COPS):

• Cholinergics, clonidine
• Opiates, organophosphate
• Phencyclidine, phenothiazine, pilocarpine
• Sedatives (barbiturates)

Question 11

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

What should you suspect as the etiology?

Answer 11

Child Abuse

Any fracture in a child who is not walking yet should make you strongly suspicious of child abuse. Additionally, a spiral fracture is concerning in any child, except those of the lower tibia in a young ambulatory child (“toddler fracture”), which is a common accidental injury.

Question 12

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

Answer 12

Skeletal Survey

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

Question 13

What physical finding should you look for in a child with shaken baby syndrome?

Answer 13

Retinal Hemorrhages

Always look for retinal hemorrhages in a child with suspected physical abuse and possible abusive head trauma. Most infants with 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. While you may be able to see these using a standard ophthalmoscope, a dilated eye exam should be performed by an ophthalmologist.

Question 14

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

Answer 14

Type 1: Straight across; Type 2: Above; Type 3: Lower; Type 4: Two or Through; Type 5: Rammed together

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 15

A child presents after a head injury. What do you suspect if one of the following is present?

• Bleeding from the external auditory canal
• CSF otorrhea
• Hearing loss
• Facial paralysis

Answer 15

Temporal Bone Fracture

Question 16

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

What radiologic study should you perform?

Answer 16

Skeletal Survey

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 17

Which drug, if ingested, results in these findings?

• Tachycardia
• Hypertension or hypotension
• Widened QRS
• Prolonged QT
• Drowsiness
• Lethargy
• Seizures

Answer 17

Tricyclic Antidepressant Ingestion

TCAs have anticholinergic activity and can inhibit cardiac fast sodium channels, resulting in widened QRS (> 100 msec). Prolonged QTc and arrhythmias can also occur. Give bicarbonate to alkalinize the serum pH to 7.45–7.55, and look for decreasing QRS intervals to see if the treatment worked. Avoid phenytoin, physostigmine, and flumazenil because these may cause seizures.

Question 18

How does co-ingestion of ethanol affect signs and symptoms of methanol/ethylene glycol poisoning?

Answer 18

Delays Onset

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 19

Ingestion if what substance produces these signs and symptoms?

• Diarrhea
• Urination
• Miosis (pinpoint)
• Bronchorrhea/bronchospasm
• Emesis
• Lacrimation
• Salivation

Answer 19

Organophosphate or Carbamate

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 (large doses) and pralidoxime (2-PAM) are the antidotes.

Question 20

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

Answer 20

Child Abuse

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 (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 21

Name the 4 overlapping phases of iron toxicity.

Answer 21

1) GI

2) Stability

3) Systemic Toxicity

4) GI/Pyloric scarring

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 from 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 22

Ingestion of which substance produces these signs and symptoms?

• Appears intoxicated with slurred speech and drowsiness
• Tachypnea, cyanosis, pulmonary edema
• Renal failure with calcium oxalate crystals in the urine
• High anion gap metabolic acidosis

Answer 22

Ethylene Glycol Ingestion

Ethylene glycol is in antifreeze. Ingesting it results in 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 (renal failure) from methanol ingestion (visual disturbances).

Question 23

A 16-year-old presents with a 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 23

Compartment Syndrome

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. Get an emergent orthopedic consult!

Question 24

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

Answer 24

Epidural

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

Question 25

If abuse is confirmed in a child < 3 years of age, what radiologic study should be performed?

Answer 25

Skeletal survey

This should be done to look for subtle, occult, or old fractures. A bone scan can be helpful for acute rib fractures and other older fractures if indicated.

Question 26

What are “sentinel injuries,” and why are they important?

Answer 26

Minor Injuries that Raise a Red Flag for Abuse

Recognition and evaluation of these minor but suspicious injuries might prevent further abuse. A 2013 study found that > 25% of infants with severe physical abuse had previously been seen for more minor sentinel injuries. Common sentinel injuries include bruising, intraoral injuries, and minor burns.

Question 27

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

Answer 27

Cleanse, Update Tetanus, Consider X-Ray and Antibiotics

Treatment includes standard wound cleansing, tetanus prophylaxis, and consideration of x-ray for foreign bodies (FBs) or possible bony involvement. If an infection develops after puncture through the sole of a sneaker, treat for Pseudomonas aeruginosa, as well as standard wound pathogens.

Question 28

A 15-year-old has an elbow fracture that is displaced slightly.

Should orthopedics always be consulted?

Answer 28

Yes

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. Refer all suspected supracondylar fractures to an orthopedist for follow-up.

Question 29

A child presents after a head injury with:

• “Raccoon eyes”
• “Battle sign”
• Hemotympanum
• CSF otorrhea or rhinorrhea

If one of these findings is present, what do you suspect?

Answer 29

Basilar Skull Fracture

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 30

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

What is the appropriate antidote?

Answer 30

N-acetylcysteine (NAC)

NAC is the drug of choice for treating acute acetaminophen ingestion/toxicity. It is most effective when given within 8 hours.

Question 31

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

Answer 31

Pasteurella multocida

Pasteurella 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 32

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 32

Subluxation of the Radial Head

(“Nursemaid’s Elbow”)

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 fix it, hyperpronate the forearm or supinate the forearm and flex the elbow.

Question 33

A 16-year-old boy sustains a concussion playing football. He is anxious to get back in the game.

When should he be allowed to play?

Answer 33

When Asymptomatic and Has Passed through Concussion Rehabilitation Stages

No return to play the same day! He must have physical/cognitive rest (including school work, video games, etc.) until he is asymptomatic without medication. Then he may attempt gradual resumption of activities, stopping if symptoms return. Second impact syndrome is thought to occur when children sustain another injury while still symptomatic from the first.

Question 34

A 10-year-old boy presents after being hit in the eye with a baseball. He has blood in the anterior chamber of the eye. He complains of pain. Opthalmology is consulted. What is the most likely diagnosis?

Answer 34

Hyphema

It is the presence of blood in the anterior chamber of the eye. Usually it occurs after blunt or perforating injury. Opthalmologic consult is required.

Question 35

A patient presents with a head injury. If any of the following is present, what study should you order next?

• History of loss of consciousness > 1 minute
• Seizure after the event
• Persistent/progressive vomiting
• Depressed mental status
• Focal neurologic signs
• Signs of skull fracture
• Persistent irritability
• Bulging fontanelle
• Abuse is suspected as the etiology

Answer 35

CT Scan if the Head

Question 36

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 do you suspect?

Answer 36

Salter-Harris Type 1 Fracture

Young children are more likely to have a fracture than sprain. If tender over the distal fibular growth plate, it is likely to be a Salter-Harris Type 1 fracture, even if the x-ray is normal.

Question 37

A child presents with:

• Spasms of the neck
• Tongue thrusting
• Oculogyric crisis

What did the child likely ingest?

Answer 37

Phenothiazine or Other Antipsychotic Drug

Drug-induced dystonic reactions, characterized by torticollis, tongue thrusting, oculogyric crisis, and other manifestations, are often caused by phenothiazines or other antipsychotic drugs. This reaction is dose independent. The dystonia is treated with diphenhydramine (IV or IM).

Question 38

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

Answer 38

Child Abuse

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 (scapula, sternum), and multiple fractures in various stages of healing are also causes of concern for child abuse.

Question 39

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 39

Observe on Pulse Oximetry; CXR at ~ 6 hours

The patient is at risk of pneumonitis and respiratory compromise from hydrocarbon aspiration. If there are no symptoms after 6–8 hours and pulse oximetry and CXR are normal, it is not likely she will develop significant pneumonitis.

Question 40

Ingestion of which substance produces these signs and symptoms?

• Visual complaints
• Abdominal pain
• High anion gap metabolic acidosis

Answer 40

Methanol Ingestion

Methanol is found in windshield washer fluid and de-icer 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 41

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

What should you do?

Answer 41

CT Scan

Infants < 2 years of age with nonfrontal scalp hematomas are at risk for intracranial injuries (ICI). 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 42

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 42

Beta-Blocker Ingestion

Βeta-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, tailored to the severity of the symptoms (e.g., IV glucagon may be needed to help increase HR).

Question 43

What ingestion does this triad describe?

• Coma
• Respiratory depression
• Pinpoint pupils

Answer 43

Opiate Ingestion

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., miperidine).