Hospital Pediatrics and Acute Care

Question 1

What is the role for the following IV fluids:

• 0.9 % NaCl
• 0.9 % NaCl + D5W/D10W
• 0.45 % NaCl + D5W
• Ringer’s Lactate
• 3 % Saline

Answer 1

• 0.9 % NaCl
  
  • Intravascular repletion bolus
  • Catch-up hydration in Hyperglycemia (DKA, Burns)
• 0.9 % NaCl + D5W/D10W
  
  • Maintenance Fluid (D5W for pediatrics, D10W for neonates)
• 0.45 % NaCl + D5W
  
  • Maintenance ONLY for hypernatremia (NOT hyperCl)
• Ringer’s Lactate
  
  • NOT for bolusing
  • Maintenance in the OR or ED resusciation room
• Hypertonic (3 %) Saline
  
  • Acute management of cerebral edema for ICP

Question 2

When using a cuffed endotracheal tube - how do you decide the internal diameter size?

Answer 2

0 - 1 y. o. = 3 mm

1 - 2 y.o. = 3.5 mm

2+ y.o. = 3.5 mm + age/4

The ET tube cuff’s pressure should be between 20 - 30 cmH₂O to faciliate a good seal without compression complications. This is measured with a manometer.

Question 3

What are the infant contraindications to breastfeeding ?

Answer 3

Infant Contraindications

• Galactosemia
• PKU if phenylalanine levels are NOT as target. Requires close monitoring with metabolics but is not an absolute contraindication.

Question 4

EPI BULLETS

Answer 4

• ITP’s annual incidence is about 5 / 100,000
• Ages for ITP typically range from 2 - 5 y.o.
• Resolution of ITP typically within 6m.o. for 75 - 80 % cases
• Only 3 % have serious bleeds (0.17 % intracranial hemmorhage)

Question 5

Which of the following does the CPS want us to use to describe clinical wheeze in a child ?

• “Happy wheezer”
• Reactive airways disease
• Wheezy Bronchitis
• Bronchospasm

Answer 5

NONE

• “Happy wheezer” - is silly and minimizes parental concerns
• Reactive airways disease - avoids asthma diagnosis
• Wheezy Bronchitis - how many packs is this kid smoking to have bronchitis?
• Bronchospasm - physiologic description that avoids the diagnosis of asthma

​Don’t use these terms during your OSCE stations or in the MCQs as a diagnosis. RAD and bronchospasm are terms for discussion and explanation - but NOT a diagnosis.

Question 6

What are some of the CPS’ concerns with use of HFNC therapy ?

Answer 6

• High flows can worsen breath stacking
• Increases RV afterload, decreases RV pre-load
• Third spacing of air (pneumothorax/mediastinum)
• Post-wean decompensation

Question 7

EPI BULLETS

Answer 7

• Children get about 1-2 episodes of gastroenterities per year
• Gastroenterities is 20 % of annual emerge/clinic visits
• Ondansetron is a 5-HT3 inhibitor (not epi but you should know that)

Question 8

What are the 3 Stages of a complicated pneumonia ?

Answer 8

Stage 0 : Small parapneumonic effusion

Oral anti-biotics are sufficient

Stage 1 : Moderate-Large parapneumonic effusion

IV anti-biotics and possible drainage are needed

Stage 2: Loculated parapneumonic effusion

IV anti-biotics and drainage +/- thoracoscopy or TPA

Stage 3: Fibrinous peel about a parapneumonic effusion

IV anti-biotics, likely thoracoscopy +/- TPA

Question 9

What’s management for ITP with frequent bleeding ?

(Moderate accounts for 20 % cases)

Answer 9

Moderate ITP Management

1. Make sure diagnostic CBC included a smear
2. Assess for Red Flags*
3. Discuss benefits of hospital vs. outpatient therapy
4. Oral steroids vs. IVIG monotherapy
5. Repeat CBC in 1 week
6. If no response (1/3 patients), consider dual therapy
7. Educate NO NSAIDs and screen herbal remedies with MD

*Bone pain, B-symtpoms, Reccurence, refractory to treatment, LAD, hepatosplenomegaly, clinically unwell, signs of chronic disease

Question 10

What are the admission criteria for Bronchiolitis?

Answer 10

Admit if any of the following are present

• Not maintaining hydration status
• Observed or History suspicious for apnea
• Respiratory Distress refractory to OTC management
• Saturations at room air < 90 %
• Anticipated deterioration (Peak of disease at 72 h)
• Family not coping

Question 11

What are the signs of respiratory distress in an infant, and what physiologic parameter do they represent/try to fix ?

Answer 11

1. Grunting - [PEEP]
2. Nasal Flaring - [Laminar Air Flow]
3. Accesory Muscle Use - [PIP]
4. Tachypnea - [V/Q Mismatch and Hypercarbia]

Change in level of conciousness (hypoxia) is a represenation of the above becoming ineffective and decompensating

Question 12

What are the three separate diagnostic criteriae for Anaphylaxis ?

Answer 12

1. Acute skin/mucosal changes with Respiratory symptoms OR Cardiovascular changes with neurologic changes
2. After likely allergen exposure, system changes in 2+ of :
   
   1. Skin / mucosa
   2. Respiratory (upper or lower) tract
   3. Cardiovascular (Vital sign or secondary CNS changes)
   4. Gastrointestinal (persistent, not 1 -2 episodes diarrhea/vomit)
3. ​Cardiovascular changes after known allergen exposure

Question 13

How does one manage ITP without active bleeding (mild) ?

(​This is 77 % of cases)

Answer 13

Mild ITP Management

• Make sure diagnostic CBC included a smear
• Assess for Red Flags*
• Discuss benefits of treatment vs. watchful waiting
• Address feasibility of return to care for bleed in this child (consider comorbidities, medications, socioeconomic status, geography)
• Consider oral steroids with above
• Consider admission for IVIG with above

*Bone pain, B-symtpoms, Reccurence, refractory to treatment, LAD, hepatosplenomegaly, clinically unwell, signs of chronic disease

Question 14

Define status epilepticus

Answer 14

> 30 minutes of continuous seizures

OR

> 30 minutes of multiple seizures without return to baseline in between episodes

Imprending status epileptics is sometimes used to describe >5 minutes of seizing activity without return to baseline.

Question 15

What’s the management for ITP with active bleeding?

(Considerable or severe bleeding accounts for 3 % of cases and involves GI, epistaxis, cutaneous or suspected intracranial)

Answer 15

Severe ITP Management

1. Make sure diagnostic CBC included a smear
2. Assess for Red Flags*
3. Admit to hospital
4. IV Steroids
5. Prepare for IVIG
6. Consider transexamic acid for severe as adjunct therapy
7. Platelet transfusions ONLY for lifethreatening bleed or impending surgery.

*Bone pain, B-symtpoms, Reccurence, refractory to treatment, LAD, hepatosplenomegaly, clinically unwell, signs of chronic disease

Question 16

Describe your step-wise management for a patient in anaphylactic shock?

Answer 16

The CPS has an algorithm (attached) but is as follows

1. Confirm diagnosis of anaphylaxis with rapid H & P
2. Epinephrine 0.01 mg/kg (1:1000 form) IM* Q5-15 min PRN
3. Airway
   
   1. If any occlusion suspected, Intubate
   2. Inhaled epinephrine for pre-intubation edema
4. Breathing
   
   1. O₂ if saturations are low
   2. Consider bronchodilators if wheeze/Hx asthma
5. Circulation (up to 35 % of intravascular vol. can be lost within 10 min)
   
   1. ​Place 2 large bore IVs immediately
   2. Have 20 mL/kg saline bolus ready
   3. Have epinephrine infusion ready (0.1 - 1 ug/kg/min)
6. Adjunct therapies
   
   1. Corticosteroids IV (no evidence outside of shock)
   2. H1/H2 antagonists (not evidence based)
7. Admit to PICU/PCCU/Step-Down/Floor

*Epinephrine boluses should only be given IM to prevent arrythmia. IV epinephrine is reserve for vasopressor infusion or PALS/ACLS protocols.

Question 17

What is the therapeutic mechanism, dosing and evidence based outcomes for Heated, Humidifed High Flow Oxygen ?

Answer 17

Dose is 1 - 2 L/kg/min

Mechanism

• Guarantees FiO₂ without ambient air dilution
• Flushes dead space with oxygen (preventing dilution and decreasing dyspnea)
• Provides some nasopharyngeal PEEP at 2 L/kg/min

Outcomes

• Decreased intubation rates for bronchiolitis
• Does NOT improve hospitalization time (maybe PICU stay)

Question 18

What are the doses of epinephrine suggested for anaphylaxis ?

What are the doses in Epipen vs. Epipen Jr ?

Answer 18

​0.01 mg / kg 1:1000 Epinephrine IM

Epipen contains 0.3 mg (assumed 30 kg weight)

Epipen JR contains 0.15 mg (assumed 15 kg weight)

Question 19

Often admission brings forward the notion of long-term management options such as port placement, PICCs, G-tubes etc.

What 3 aspects of a Family’s reluctance must be addressed when discussing these therapies?

Answer 19

1. Context; what is unique about this family’s dynamic and the patient’s condition that will determine your approach to a difficult conversation
2. Values; what does the Family value about the current state prior to the intervention, and what will be lost after the procedure (e.g. joy of eating by mouth for G-tubes)
3. Process of Care; ensure that the pre/peri/post-clinical context of the procedure are explained to the family in a way they understand, and explore reluctance they may have.

Question 20

What is the dosing for pediatric/neonatal defibrillation ?

Answer 20

2 - 4 J/kg

In the community, an automatic defibrillator is OK but if you can manually do it - do so.

Question 21

List the top three pathogens for a complicated pneumonia ?

Answer 21

Streptococcus pneumoniae

Staphylococcus aureus

Streptococcus pyogenes (GAS)

• All gram positive cocci, strep are chains staph are clusters.*
• S. pneumo’s virulence is classic for pleural effusions*
• Staph. pneumonia typically happens after influenza BUT - post-influenza pneumonia is still more likely to be S. pneumo, but the odds of it being Staph are higher.*

Question 22

What are history and physical red flags for suspected ITP ?

Answer 22

History

• Bone pain
• B-symptoms (Fatigue/malaise, night sweats, fever nyd, weight loss nyd)
• Recurrent thrombocytopenia
• Poor response to treatment

Physical

• Hepatomegaly or Splenomegaly
• Lymphadenopathy
• Child is unwell or toxic
• Signs of chronic disease (Growth, skin changes, iron defeciency)

Question 23

What are the historical red flags that merit close observation or immediate admission in asthma exacerbation?

Answer 23

• Previous intubation for asthma
• Previous PICU admission for asthma
• Previous deterioration while on systemic steroids
• Previous life-threatening hemodynamic event

Question 24

What are the discharge criteria for Bronchiolitis ?

Answer 24

• Saturations > 90 % on room air or candidate for home O₂
• Improving respiratory distress
• Good oral intake or baseline NG/GT tolerance
• Family comfortable with follow-up/return to care plan

Question 25

What issues with ABCD do you anticipate in Status epilepticus ?

Answer 25

• Airway (jaw clenching, secretions)
  
  • Do NOT force jaws open
  • Suction and lateral decubitus
  • Intubate if concerns after seizure abortion
• Breathing (aspiration pneumonitis, atelectasis)
  
  • 100 % oxygen on rebreather
  • 2+ doses of benzodiazepines give resp. depression
  • Phenobarbital is notorious for resp. depression.
• Circulation (Collapse from hypoxia or seizure aetiology typically)
  
  • Look for Cushing’s Triad (HypTN, bradycardia irr. breathing)
  • Have 2 large bore IVs placed
• Disability (neurologic stuff)
  
  • Look for focal neurologic signs or cortical signs
  • Have 3 % Saline at bedside if concerned for ICP
  • Seizure abortion algorithm

Question 26

How does one calculate a PRAM score ?

Answer 26

The PRAM score is used to determine the severity of an asthma exacerbation and the response to therapy

It is calculated be examining the Air entry (0-2), Wheeze (0-3). Oxygen saturation (0-2), Suprasternal (0-2) and Scalene (0-2) accesory muscle use.

Attached in a table describing the proper determination of PRAM scoring.

Question 27

PALS Update Bullets

Answer 27

• Etomidate is your rapid seq. intubation med (except for sepsis)
• Use ACTUAL weight not ideal weight in obese resusciation
• Don’t use cricoid pressure

Question 28

What must be considered when designing a Rapid Response System in their center?

Answer 28

1. Vital sign monitoring standards (anticipate events)
2. Calling/Early warning systems (respond to events)
3. Planned response team/arm of hospital (people for events)
4. Quality control of implementation
5. Education for all caregivers on implementation

Question 29

Describe the perfect chest compression

Answer 29

• Compresses 1/3 of thorax depth
• Allow full recoil
• Change people every 2 mins
• < 5 second pause between person change
• < 10 sec pulse checks

Question 30

What signs determine if a patient has mild, moderate or severe croup ?

Answer 30

• Barking / Stridor
  
  • Intermittent (Mild)
  • At rest (Moderate)
  • Constant (Mod-Severe)
• Respiratory Distress
  
  • None (mild)
  • Intermittent (mild-mod)
  • At rest (Moderate)
  • Constant (Moderate-severe)
• Decompensation
  
  • CNS changes (severe)
  • Persistent respiratory distress (severe)
  • Cyanosis (impending respiratory failure)

Question 31

EPI BULLETS

Answer 31

• 10-30% of admissions for Bronchiolitis have several viral coinfections
• ~30 % of children will get bronchiolitis between 0-2 y.o.
• < 3 % of bronchiolitis present with apnea*

***Exceptions include ex-prematures, personal history of apnea, and previous cardiorespiratory pathologies

Question 32

What are the 10 steps the WHO wants healthcare systems to apply to support Breast Feeding ?

Answer 32

Step 1: Have a written BF policy

Step 2: Enable all providers to implement the BF policy.

Step 3: Inform mothers and families about breastfeeding.

Step 4: Immediate post-natal skin-to-skin (1 h min)

Step 5: Assist mothers to breastfeed and maintain lactation.

Step 6: Support mothers to exclusively breastfeed for the first six months, unless supplements are medically indicated.

Step 7: Facilitate 24-hour rooming-in for all mother-infant

Step 8: Encourage baby-led or cue-based breastfeeding.

Step 9: Avoid False nipples (Contradicts other CPS statements)

Step 10: Provide seamless transition from hospital to community health services and peer support programs.

Question 33

What are the side effects of Ondansetron to consider ?

Answer 33

• QT Prolongation (no ECG needed if no risk factors*)
• Pseudotumour cerebri (no screening needed)
• Pro-kinetic diarrhea (last 2 days, no additional management needed)

*Risk factors to screen for include family history of sudden cardiac death, known Long QT syndrome, chronic medications with QT prolongation or active acute medications with QT prolongation.

Question 34

What is the initial therapy for a mild, moderate and severe asthma exacerbation ?

(The CPS’ management will be shown assuming each step does NOT work)

Answer 34

• Mild (PRAM 0-4)
  
  • Salbutamol (0.3 puff/kg) Q20 min x3
  • Increase inhaled steroid, consider systemic
  • Re-assessment after 1 h
• Moderate (PRAM 5-8 or no change from prev. assessment)
  
  • Salbutamol (0.3 puff/kg) Q20 min x3
  • Ipratroium Bromide with initial Q20 salbutamol**
  • Salbutamol (0.3 puff/kg) Q 30min as needed
  • Systemic corticosteroids (PO if tolerated)
  • Re-assessment after each salbutamol
• Severe (PRAM 8+)
  
  • Move to obervation area of ED, notify PICU if impending respiratory failure or concerned
  • Salbutamol (0.3 puff/kg) Q20 min x3
  • Ipratroium Bromide with initial Q20 salbutamol**
  • Consider continuoues Salbutamol (5 mg in 2mL)
  • Systemic corticosteroids (PO if tolerated but likely IV)
  • Consider High Flow Nasal Cannula
  • Obtain Chest X-ray
  • Obtain baseline electrolyte, blood gas (if RF suspected)
  • Prepare saline bolus (20 ml/kg)
  • Prepare Magnesium Sulfate (25-50 mg over 20 min)
  • Re-assessment after each salbutamol

Question 35

What is your management plan for a patient with a suspected community acquired pneumonia ?

I will put the step-wise approach from the CPS

Answer 35

1. Oral anti-biotics (typically Amoxicillin is sufficient x7-10 days)
2. Return if worsening symptoms or no change in 48 h
3. CXR or Ultrasound if physical suggests pleural effusion. (In otherwise healthy kids, CPS specifcallly discourages CT scans)
4. If the effusion is:
   
   1. Small: IV anti-biotics until off oxygen and clinical condition improves
   2. Moderate: Drain chest and IV anti-biotics until improvement
   3. Large or Complex: rain chest, IV anti-biotics, consider thoracoscopic intervention or TPA*
5. Send Chest Fluid for culture** and S. pneumo PCR.
6. Once vitals normalise and clinically improving, can switch to PO anti-biotics for 3-4 weeks.
7. Follow-up CXR in 3-4 Months is acceptable by the CPS

*TPA dose is 2 mg in 30-50 mL saline in the tube BID or 4 mg in 30-50 mL of saline in the tube daily x 3 days. **Odds of growing something are low as patient is already on Abx.

Question 36

What signs warrant a head CT in status epilepticus ?

Answer 36

• Cushing’s triad (Hypertension, bradycardia, abnormal breathing)
• Papilledema
• Focal neurologic findings
• History of head trauma

​CT scans should be reserved for when the patient is hemodynamically stable enough for the scan

Question 37

Defined Immune Thrombocytopenic Purpura (ITP)

Answer 37

Immune modulated destruction of otherwise normal platelets

• < 100 x10⁹ platelets/L
• No red flags* for other hematologic pathologies

*Bone pain, B-symptoms, recurrent thrombocytopenia, poor treatment response

Question 38

What are the diagnostic criteria for asthma in a preschool child?

(By pre-school they essentially mean one that cannot perform spirometry correctly and may not have been admitted for an exacerbation)

Answer 38

• Audible wheeze on exam*
• with any of the following*
• Objective reversal of obstruction with bronchodilators*
• Patient or Family History of atopy
• Previous emergency room/admission of asthma exacerbation (essentially the same as documented reversal)
• No other diagnosis to explain the wheeze (Cystic fibrosis, bronchiolitis, foreign body, auto-immunity, aspiration pneumonitis)

​*A family’s consistent, and appropriate description of these symptoms can be an acceptable surrogate for your own objectification.

Question 39

What acute investigations are needed for status epilepticus ?

Answer 39

• Bloodwork
  
  • CBC + differential (if febrile)
  • Gucose
  • Complete electrolytes (Na, K, Cl, Mg, Ca, PO₄)
  • Renal profile (BUN, Creatinine, NH₄)
  • Blood Cx (if febrile)
  • Urine tox screen
  • Anti-epileptic levels (Valproate, Lamotrigine)
  • Blood Gas (if respiratory or ingestion concerns)
• Imaging
  
  • CT head (If suspected ICP or Head trauma)
  • Chest X-ray (if persistent respiratory issues)

Question 40

If a patient is in need of resusciation, but is taking a B-blocker, what medication must be given to accomodate this ?

Answer 40

Glucagon load followed by infusion

This is particularly important for patients with anaphylaxis

Question 41

How do you manage hypoglycemia in the neonate versus a child in status epilepticus?

Answer 41

1. Neonate
   
   1. 2 mL/kg D10W bolus
   2. Increase GIR through most optimal modality
   3. Recheck in 5 minutes
2. Status epilepticus
   
   1. 5 mL/kg D10W bolus
   2. Have IVF with D5W running
   3. Recheck in 5 minutes

Question 42

Give 3 indications for gastrostomy feeding tube placement

Answer 42

• Oromotor dysfunction WITH aspiration risk
• Progressive decline in neuromuscular function
• Insufficient nutritional intake
• Insufficient tolerance of oral medications/therapies
• Anticipated need for > 6 months of assisted enteral feeding

Whenever the above is suspected or expected, approach the idea of G-tubes as early as possible as per CPS

Question 43

What are the 4 key factors for Rapid Response Team Training?

(As per the CPS)

Answer 43

• Leadership; (organise, direct, synthesize, delegate..)
• Situation Awareness; (Anticipate progression, note response to therapy)
• Resource Allocation; (Best person for best job)
• Communication; (One leader, closed loop, respectful yet direct)

Question 44

What are maternal contraindications to breastfeeding ?

Answer 44

Maternal Contraindications

• HIV Positive (in 1st world countries)
• Active infection with Tuberculosis, Ebola, T-cell lymphotrophic viruses, brucellosis
• Active Herpetic lesion on the breast (can use other)
• Cannot breastfeed but CAN give EBM if acutely ill with influenza, varicella (- 5 days to +2 days of birth)
• Cytotoxic chemotherapy and Isotope radiotherapy

(Start Wean immediately to prevent stress on baby)

Question 45

EPI BULLETS

Answer 45

• 9 - 24 % of hospitalised childiren on IVF have hyponatremia
• Admitted Paediatric patients secrete more ADH, particularly:
  
  • Respiratory Diseases (bronchiolitis, asthma, croup …)
  • Cardiac Disease (Heart failure, post-arrest, shock)
  • Neurologic Diseases (any CNS disease, head trauma)
  • Peri-surgical patients (any surgery, ortho paricularly)

Question 46

What is your post-cardiac arrest resuscitation care ?

Assuming the resus was successful

Answer 46

1. O_{<strong>2</strong>} sat goals of 94-99 % (100 % increase reperfusion injury risks)
2. Closely monitor IN/OUT (low cardiac eff., resus ichemia = 3rd spacing)
3. Assess organ function (Renal/Liver profile, CBC, Blood Gas)
4. 2 days of therapeutic hypothermia (32ºC - 34ºC)
5. EEG within 7 days
6. NO seizure prophylaxis
7. Call for Spiritual Care/Family Support

• ​All post-acute care should go through the A, B, C, D(isabilities) and F(amily)*
• Circulation includes C1: Volume, C2: Perfusion and C3: Rhythm*

Question 47

EPI BULLETS

Answer 47

• Croup is primarily seen in 6 months to 3 years of age
• < 1 % of Croup develops severe/refractory symptoms
• 3-5 % of emergency department visits are croup!
• 60 % of barking coughs resolve in 48 h after onset
• Aetiologies include:
  
  • Parainfluenza viruses 1, 2 and 3
  • Influenza A /B
  • RSV
  • Adenovirus

Question 48

What is the management of Croup ?

Answer 48

1. Assess for Mild, Moderate, Severe or Impending Failure
2. Consider possibility of differential diagnoses*
3. Steroids for everyone (Dexamethasone 0.6 mg /kg PO x1 has evidence)
4. Inhaled epinephrine for mild/severe
5. If tolerating PO, no or improving respiratory distress and otherwise well - discharge home with return intructions.

*Differential includes epiglotitis (no cough? vaccines?), tracheitis (toxic/febrile no inh. epi response), retropharyngeal abscess, foreign body (biphasic stridor, otherwise well, acute development), anaphylaxis)

Question 49

List the discharge criteria for an asthma exacerbation

Answer 49

• No red flags on asthmatic history unaccounted for
• Hemodynamically stable with salbutamol Q4+h
• > 94 % O₂ saturations on room air (or baseline O₂ needs)
• Minimal to no respiratory distress
• Good or improved air entry bilaterally
• Family is comfortable with appropriate aerochamber/inhaler technique
• Follow-up with asthma clinic or Family doc is arrange

Question 50

Which of the following bronchiolitis treatment modalities are validated, equivocal or not-validated by evidence ?

• Low flow Oxygen
• High flow Oxygen
• Hydration Support
• Nebulized epinephrine (racemic)
• Corticosteroids
• Nebulized 3 % Saline
• Anti-viral therapy
• Empirical antibiotics
• Chest physiotherapy

Answer 50

• Low flow Oxygen - Recommended, strong evidence
• High flow Oxygen - Recommended, growing evidence
• Hydration Support - Recommended, strong evidence
• Nebulized epinephrine (racemic) - equivocal
• Corticosteroids - Dexamethasone with Epi. equivocal
• Nebulized 3 % Saline - NOT recommended
• Anti-viral therapy - NOT recommended
• Empirical antibiotics - NOT recommended***
• Chest physiotherapy - NOT recommended

**​Anti-biotics are only to be given is a suspicion for secondary infection or concomitant pneumonia. NG was found to be equivoval to IV rehydration therapy, for admission duration as an outcome.

Question 51

Explain the 3 ways gastrostomy tubes are placed

Answer 51

1. Endoscopic Guided percutaneous insertion
2. Laparoscopic surgical implantation
3. Interventional Radiological percutaneous insertion

The procedure can be done by Interventional Radiology, General Surgery or (rarely) Gastroenterology depending on your center

Question 52

EPI BULLETS

pew pew

Answer 52

• Asthma lifetime prevalence is 11 - 16 %
• ~ 50 % asthma exacerbations are in children < 5 y.o.
• About 10 % of children with asthma, report presenting to the emergency department in the last 2 years for their asthma.

Question 53

What’s the dosing of ondansetron for non-chemo nausea/vomit ?

Remember all ondansetron prescriptions should be accompanied with some form of Oral Rehydration Therapy/Plan

Answer 53

0.15 mg/kg PO

• x 1 (outpatient) or Q8H (inpatient)*
• Larger dosing tends to be in increments of 2 mg; CPS suggests 8 -15 kg get 2 mg, 15 - 30 get 4 mg and greater than 30 mg can titrate 6 - 8 mg.*

Question 54

EPI BULLETS

Answer 54

• Status epilepticus’ annual incidence is 1 - 156/100,000
• Status epi. has a 2-8 % mortality, and a 10-20% morbidity
• 5-19 % of status epi. cases are idiopathic
• Prolonged Febrile seizure account for 23-30 % cases
• Acute events are 17 - 52 % of cases, including :
  
  • CNS infection or reactivivity (meningitis, encephalitis)
  • Metabolic derangement (glucose, electrolytes,)
  • Anti-epileptic withdrawal/OD (consider non-compliance)
  • Pharmaceutical/Illicit drug overdose
• Remote aetiologies from young age are 16-39 %
  
  • Perinatal/Congenital disorder exacerbation (e.g. stroke)
  • Progressive neurodegenerative disease

Question 56

EPI BULLETS

bang bang !

Answer 56

• 1 - 4/1000 Emergency Dept. presentations are anaphylactic
• Only 1/3 of Anaphylactic presentation find a trigger
• Systemic symptoms for anaphylaxis include:
  
  • Skin / Mucosal Involvement (80 - 90 %)
  • Respiratory Distress (60 - 70 %)
  • Cardiovascular changes (10 - 30 %)
  • Gastrointestinal Changes
  • CNS alteration secondary to poor perfusion (CVS)

Question 57

Justify the following investigations for a patient with bronchiolitis:

• Chest X-ray
• Nasopharyngral aspirate/Swab for Virus Panel
• CBC and differential
• Blood Cultures
• Urine Culture

Answer 57

• Chest X-ray; i**f strong suspicion for concomitant/secondary pneumonia, atypical disease progression or severe disease
• Nasopharyngral aspirate/Swab for Virus Panel; only recommended for research/epidemiology cohorting
• CBC and differential; does not change management
• Blood Cultures; severe disease, not recommended routinely
• Urine Culture; n**ot recommended routinely

Question 58

What are your abortive therapies in status epilepticus?

(Assume ABCs are being managed, what your escalating seizure management)

Answer 58

1. Lorazepam 2 - 4 mg IV x 2 doses* (IN midazolam is also an option)
2. Phosphenytoin 20 mg/kg over ‘20 min IV’ or IM
3. Sodium Valproate (growing evidence for preference over phenobarbital)
   
   1. ​Loading dose 30 mg/kg over 5 minutes
   2. then 10 mg/kg Q8h IV maintenance
   3. 10 mg/kg IV PRN Q8h are allowed after first bolus
4. Phenobarbital 20 mg/kg over 20 min IV
5. Trial Pyridoxine 100 mg if refractory in child <3 y.o.

Question 59

What pathologies have shown to benefit from HFNC ?

(High Flow Nasal Cannular Oxygen therapy)

Answer 59

• Bronchiolitis
• Obstructive Sleep Apnea
• Asthma*
• Pneumonia / inhallation pneumonitis
• Heart Failure**

*Be wary that HFNC can worsen the symptoms of breath stacking, lower flows can be better for asthmatics. ** The intrathoracic pressure is increased acutely with HFNC, however pulmonary hypertension will improve with better oxygenation over time. Be aware of this with corpulmonale or RV-failure.

Question 60

EPI BULLETS

Answer 60

• Retention of PALS/NRP/ACLS is < 3-12 months if not used
• Hospital Rapid Response Teams decrease pediatric Cardiopulmonary arrest by 37.7 %, mortality by 21.4 %

Question 61

SSD-1

What are the 3 main Acute Complications of Sickle Cell Disease

Answer 61

Acute Complications of Sickle Cell Anemia/Disease

• Hemolytic Anemia
• Occlusive Syndromes (both occlusive and reperfusion crises)
• Results of End Organ Damage (renal, hepatic, skin, heart and lung)

Question 62

SSD-4

Give a detailed stepwise management for Acute Pain Syndrome in Sickle Cell Disease

Answer 62

Management of Acute Pain Syndrome (SCD)

1. Calming environment/private room (Child life) - WARM compresses only
2. Fentanyl IN 1-2 μg/kg/dose (50 μ/mL solution split between both nostrils)
3. Place IV at maintenance until PO is tolerated then titrate downwards
4. Oxygen Saturations > 95 %
5. Acetaminophen 15 mg/kg Q6h - HOLD IN LIVER INSUFFICIENCY
6. Ibuprofen 10 mg/kg Q8H - HOLD IN RENAL INSUFFICIENCY
7. Morphine 0.2-0.5 mg/kg PO Q 4-6h (with half dose PRN)
8. PEG 3350 as per formulation (non-urgent)
9. Consider Discharge if Family is comfortable, patient is maintaining PO fluids and pain management.
10. Daily Phone Follow-up with Clinic Follow-up that week

Question 63

SCD-5

Give a detailed stepwise management of Acute Chest Syndrome in Sickle Cell Disease

Answer 63

Management of Acute Chest Syndrome (SCD)

1. Calming environment/private room (Child life)
2. NPO & NG tube when possible
3. Oxygen Saturations > 95 %
4. Fentanyl IN 1-2 μg/kg/dose (50 μ/mL solution split between both nostrils)
5. Place IV at ½ maintenance D5W-NS + Lytes (Ideally TPN)
6. Draw bloods with CBC & diff., Blood Cx, Hemolytic Profile, Crossmatch
7. Beta-lactam AND macrolide anti-biotics
8. Morphine 0.2-0.5 mg/kg PO Q 4-6h (with half dose PRN)
9. NPA viral panel and M. pneumoniae PCR
10. Chest X-Ray and obtain previous CXR records
11. Consult PICU and Hematology
12. PEG 3350 NG as per formulation (non-urgent)

Question 64

SCD-6

Provide Reassuring Criteria for Fever in a Child with Sickle Cell Disease

Answer 64

Sick Febrile Patients with SCD should be managed aggressively.

These points from the CPS are here to reassure conservative management.

• First presentation for this episode
• Well appearing and ^*hemodynamically stable
• Pain controlled and tolerating PO fluids and medications
• Fever < 40 °C
• > 6 months old
• ^$Normal or elevated Cell Counts
• Normal ^#neurologic, *Respiratory, ^%MSK, ^$Abdominal Exams
• ^*Stable CXR - old consolidations/opacities can be present
• ^#No history of severe pneumococcal infection (meningitis or sepsis)
• Solid Discharge and return-to-care plan

*Checking for early Chest Syndrome ^#Checking for early meningitis ^$Considering aplastic crises and possible sequelae ^%Osteomyelitis, septic joints and cellulitis

Question 65

Pain

Which of the following opioids should be considered in emergency pediatric care?

Morphine

Oxycodone

Hydromorphone

Fentanyl

Codeine

Tramadol

Answer 65

Opioids in Paediatrics

• Morphine
  
  • Well understood and relatively safe to use
  • Large First Pass effect so beware in patients with hepatic insufficiency
  • PO for sustained pain control with IV boluses for short-term pain control
  • PO DOES NOT EQUAL IV for dosing
• Fentanyl
  
  • Bridge for pain control to facilitate IV placement (and Δ to morphine)
  • Requires vital monitoring - not a long-term solution for pain.
• Oxycodone - Don’t use due to risks associated with hyper-metabolizers
• Hydromorphone - Don’t use due to risks associated with hyper-metabolizers
• Codeine - Don’t use due to risks associated with hyper-metabolizers
• Tramadol - Codeine analogue so avoid due to metabolic concerns

Question 66

Explain Oxygenation Index (OI) used in the NICU/PICU

(What is the formula ? what is normal ?)

Answer 66

Oxygenation Index (OI)
Describes the presence of a V/Q mismatch; where a larger number represents a massive dependance on ventillatory support, or a very small result of arterial oxygenation

OI= (FiO2 x Mean Airway Pressure)/ PaO2

< 10 is our typical goal, but this should be measured dynamically with your clinical management

Question 67

Explain the Oxygen Saturation Index (OSI)

(What is the formula ? what is normal ?)

Answer 67

Oxygen Saturation Index (OSI)
A postulated surrogate for OI when arterial lines aren’t possible. Describes the presence of a V/Q mismatch; where a larger number represents a massive dependance on ventillatory support, or a very small result of arterial oxygenation

OSI= (FiO2 x Mean Airway Pressure)/ SpO2

< 10 is our typical goal, but this should be measured dynamically with your clinical management

Question 68

What is the definition of neutropenia ?

Answer 68

Absolute Neutrophil Count (ANC) < 1.5 x 10^9 cells/L

Severe Neutropenia is < 0.5 x 10^9 cells/L

Question 69

What criteria must a febrile neutropenic patient meet, to not be given empirical antibiotics ?

Answer 69

Conservative Therapy for Febrile Neutropenic
- Normal physical exam, other than fever and associated mild tachycardia
- Isolated neutropenia (other cell lines are normal)
- No history of chronic disease
- No history of medical implants or foreign bodies
- Availability for close follow-up
- Well appearing
- Must not be severely neutropenic

Question 70

Give the indications for the following pain assessment tools :
(1) EVENDOL
(2) CHEOPS
(3) FLACC
(4) NIPS
(5) COMFORT

Answer 70

EVENDOL ; 0-7 y. o. for urgent care, clinic and ED visits
CHEOPS ; 2-22 months for post-operative pain
FLACC ; 2 months - 7 years for physical responses to pain
r-FLACC ; 4-19 y. o. with developmental deficits
NIPS ; Newborns and infants
COMFORT ; intubated patients of all ages

Question 71

How does the CPS define Mild, Moderate and Severe DKA?

Answer 71

CPS Definition of DKA
Mild : pH 7.2-7.29 with HCO3 between 10-18 mM
Mod : pH 7.1-7.19 with HCO3 between 5-9 mM
Severe : pH < 7.1 with HCO3 < 5 mM

To confirm DKA as the cause, you need to identify >3 mM of B-hydroxybutyrate (BHB) and hyperglycemia > 11 mM. The anion gap will be elevated from the BHB

Question 72

What are the separate goals, in order of importance and intervention, when managing DKA in a child ?

(The CPS came out with new guidelines that specifically highlight the differences between adult and child management )

Answer 72

Goals for Management of DKA
(1) Rehydration with isotonic fluids (NS + KPO4)
(2) Normalization of pH (occurs with rehydration and insulin NOT bicarbonate bolus)
(3) Cessation of ketosis (occurs with insulin infusion)
(4) Correct electrolyte imbalances (Na, K, PO4, Cl), Mg, Ca)
(5) Normalization of glucose
(6) Management of precipitating (or coexistent) factors
(7) Prevention of secondary electrolyte imbalances from therapies

The goal is to have frequent follow-ups with biochemistry, and slowly normalize the patient to avoid sequelae. Thus the best management involves the placement of a central line, arterial line and availability of a blood gas machine that can measure ketones, glucose and a full electrolyte panel confidently.

Question 73

What are the CPS’ Fluid resuscitation Guidelines for DKA

Answer 73

Fluid Resuscitation Options for DKA
The correct fluids include Normal Saline, Ringer’s Lactate and Plasmalyte. 1/2NS+D5W should be avoided early on, and absolutely with any neurologic changes.

• Initial dose: 10-20 mL/kg (maximum of 1000mL) over 30 minutes
• Hemodynamic bolus : 10 mL/kg bolus to a maximum of 40 mL/kg in consultation with PICU (and neuro vitals)
• Maintenance + deficit should be given over 36 h as per the following formula.

Question 74

What is the goal rate for decline in glucose during DKA Management ?

Answer 74

< 5 mM/h

(This should be slowed by adding dextrose to the infusion, NOT decreasing the insulin)

Question 75

What are the indications for starting insulin therapy during DKA ?

What dose would you start at ?

Answer 75

When to start Insulin during DKA
- _1 hour_ of fluid resuscitation has already passed
- Potassium is > 3 mM (can add to fluids prior to the 1 h mark)

*You can start at 0.05 units/kg/h to a max of 0.1 unit/kg/h titrating to the drop in glucose that you can. If the response is to strong as the patient improves, compensate with more IV dextrose *

Question 76

Besides calling a CODE BLUE, what is the initial management of the **DKA patient* with _suspected cerebral injury_ ?

Answer 76

Management of Acute Cerebral Injury during DKA Management
(1) Minimizing patient movement/agitation
(2) Raising the head of the bed to 30 degrees with the patients neck midline (helps with venous draining of the brain)
(3) Cessation of hypotonic fluids
(4) Cutting IV fluids by 25 % (assuming normal perfusion)
(5) 5 mL/kg of 3%NaCl over 15 minutes OR 0.5 g/kg Mannitol over 20 minutes
(6) CALL PICU