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RC Study Cards > Pharm and Critical Appraisal > Flashcards

Pharm and Critical Appraisal Flashcards

1
Q

What are the 3 Ps to pain management?

A
  • Pharmacological
  • Physical
  • Psychological
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2
Q

In what 3 circumstances is LET contraindicated?

List 3 topical anesthetics. Which works fastest? Which works for longest?

List 2 non-pharmacological managements to managing fracture pain.

A
  1. < 3 mo
  2. Mucosal surfaces
  3. Large, deep or contaminated wounds

Topical anesthetics

  1. Maxilene (liposomal lidocaine 4%; amide anesthetic)
  2. Ametop (amethocaine 4%/tetracaine; ester anesthetic)
  3. Emla (lidocaine-prilocaine 5%; amide anesthetic)
  4. Pain ease (vapocoolant spray; pentafluoropropane tetrafluoroethane)

Onset: Pain ease → Ametop/Maxilene (30min) → Emla (60min)

Duration: Pain ease (1 min) → Emla (1-2h) → Maxilene → Ametop (4h)

Fracture pain: Immobilize, icing

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3
Q

Provide 3 examples of physical pain management

Provide 3 examples of psychological pain management

How can you minimize injection pain? List 3

A

Physical

  • Skin-to-skin (kangaroo) care
  • Pacifier
  • Swaddling
  • Tucking
  • Sitting upright

Psychological

  • Parental presence
  • Age-appropriate preparation
  • Distraction
  • Deep breathing
  • Hypnosis
  • Music

Injection pain

  • Topical anesthetic
  • Buffered lidocaine: add bicarbonate to lidocaine in 1:10 ratio
  • Inject slowly
  • Use solution warmed to body temperature
  • Small gauge needle (27G-30G)
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4
Q

What are the 4 recommendations from the CPS for pharmacare in Canada

A
  • All governments should:
    • Develop/implement pharmacare plans that mandate universal, comprehensive, portable prescription drug coverage for children/youth
    • Develop a comprehensive, evidence-informed national list of paediatric drugs for inclusion to the pharmacare program
    • Modernize processes for drug approvals to expand access and ensure appropriate paediatric labelling for all medications marketed in Canada
    • Support drug trials, cost-effectiveness research and the development of commercial paediatric drug formulations
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5
Q

What percentage of medications are currently administered “off label” in Canada?

A

80%

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6
Q

Why are children more affected by climate related changes? List 2.

Which children are at greatest risk?

A
  1. Metabolize more water/air/food per kg than adults
  2. Rapid growth/development, physiologically dynamic systems and risk exposure over a longer life course

Greatest risk

  1. Low socioeconomic status
  2. Indigenous
  3. Living with a chronic disease
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7
Q

List 5 specific climate related risks children may face and one example of each.

A
  1. Depletion of ozone → ↑skin cancer
  2. ↑air pollution → ↑respiratory disorders/asthma + cardiovascular illnesses, ↑risk for cancer
  3. ↑natural disaster events →
    • Displacement of home/living in overcrowded shelters
    • Inability to access chronic disease management
    • Loss of possessions/routines
    • Loss of loved ones
  4. Heat/cold injuries → burns/frostbite (due to immature temperature regulation systems)
  5. Contaminated water sources d/t heavy rain/flooding overwhelming sewage treatment facilities → water-borne infections (Salmonella typhi, E coli, Cryptosporidium, amebiasis)
  6. Inset, tick and roden related infections → Lyme disease, Equine encephalitis, RMSF
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8
Q

List 4 risk factors for lead toxicity

A
  1. Live in home built before 1960 for ≥6mo (esp if water supplied by lead pipes, original paint is chipping, under renovation)
  2. Sibling/housemate/playmate with lead poisoning
  3. Pica, lick/mouth painted surfaces or eat paint chips
  4. Emigrated or international adoption from country with higher lead levels
  5. Infant born to mother with lead exposure or mineral deficiency (zinc, calcium, iron, magnesium)
  6. Any above risk factors + known or suspected neurodevelopmental disorder
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9
Q

List 2 low-lead symptoms and 4 toxicity symptoms

A

Low-lead:

  1. Neurodevelopmental signs
    • Inattention
    • Hyperactivity
    • Hearing impairment
    • Poor balance
    • Speech delay
  2. Cognitive delay

Lead toxicity:

  • CNS: headache, clumsiness, somnolence, seizure
  • GI: abdominal pain, constipation, vomiting
  • Heme: anemia (microcytic)
  • GU: renal failure
  • possible death
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10
Q

What are 4 long-term consequences of lead poisoning?

A
  1. Hypertension
  2. Vascular disease
  3. Renal impairment
  4. Aberrant behaviour/cognitive delay
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11
Q

You want to order a screen for suspected lead exposure.

What tests do you order?

A
  • Serum lead level (venous)
  • CBC
  • Ferritin
  • Calcium, protein, albumin
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12
Q

What are the 3 ranges for management of serum lead levels?

When do you need to repeat testing?

What intervention is recommended?

A
  1. 5-14 mcg/dL
    • Repeat in 1-3 months, if stable - 3 months
    • Nutrition counselling (fruit with every meal, encourage iron containing foods)
    • Supplement if iron deficient
    • Contact public health for guidance
    • Full neurodevelopmental assessment and follow-up
    • PEHH for sources of exposure
  2. 15-44 mcg/dL
    • ABOVE, except repeat in 1-4 weeks
    • AXR to r/o foreign body
    • If asymptomatic, no chelation
  3. >44 mcg/dL
    • ABOVE, except repeat in 48h
    • Admit to hospital
    • Chelation therapy with Poison control centre
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13
Q

The mechanism of morphine for pain relief 1. works at only 1 type of receptor 2. reduces sensation of pain and emotional perception of pain 3. IM route preferred over IV 4. analgesic effect on subjective perception of pain and decreased emotional response

A
  1. analgesic effect on subjective perception of pain and decreased emotional response
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14
Q

Mechanism of Topical benzyl peroxide: a. Decrease resistance of P. acne b. Decrease androgen sensitivity at sebum gland c. Decrease sebum production

A

c. Decrease sebum production The mode of action of benzoyl peroxide in acne is three-fold, i.e. sebostatic, comedolytic and inhibitory to P. acnes

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15
Q

What are the main differences between a neonate and an adolescent with respect to drug dosing? Neonate has… a. Increased distribution of liquid b. Increased distribution of lipid c. More rapid renal clearance d. More rapid liver metabolism

A

a. Increased distribution of liquid - infants have more total body water and extracellular water than adolescents - adolescents have similar or slightly higher body fat - renal and liver metabolism increase with age

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16
Q

Mom on INH. Can she breastfeed?

A

Yes ToxNet (NIH): BF should not be discouraged in women taking isoniazid ● Low levels of isoniazid in breast milk; safe for infants; unlikely AE

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17
Q

Which cardiac meds taking during pregnancy will increase risk of hypothyroidism in baby? a. Esmolol b. Digoxin c. Amiodarone d. Procainamide

A

c. Amiodarone

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18
Q

In utero exposure to cocaine results in which of the following in the newborn: a) hearing deficits b) microcephaly c) hypotension d) spinal dysraphism

A

b) microcephaly

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19
Q

What condition is contraindicated for the use of succinyl choline? a. Muscular dystrophy b. TOF c. T21 d. asthma

A

a. Muscular dystrophy

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20
Q

4 absolute contraindications to ketamine

A
  • hypersensitivity to ketamine or any component in the formulation - conditions in which an increase in BP would be hazardous (e.g. severe HTN) - infants <3 months of age - known or suspected schizophrenia, even if currently controlled well with medication
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21
Q

Description of a girl with a renal transplant in hospital being treated for an infection with clarithromycin. Her initial cyclosporine level is normal (80 ish) and the repeat one several days later is 350 ish. What is the reason for this? a. Her compliance with cyclosporine is better in hospital than at home b. The clarithromycin causes decreased metabolism of the cyclosporine c. The clarithromycin decreases renal excretion of the cyclosporine d. Resolution of acidosis

A

b. The clarithromycin causes decreased metabolism of the cyclosporine - macrolide antibiotics inhibit CYP3A4 pathway (cyclosporine is metabolized by this pathway)

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22
Q

Side effect of marijuana in adolescents a. gynecomastia b. decreased testicular volume c. tachycardia

A

c. tachycardia

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23
Q

Side effects of marijuana include all of the following except: 1. bronchospasm 2. conjunctival injection 3. large testicles 4. tachycardia

A
  1. large testicles
24
Q

Child on risperdol for Tourette syndrome has frequent syncopal episodes with exertion. What is the cause? a) hypoglycemia b) Prolonged QT

A

b) Prolonged QT

25
Q

List 3 serious side effects of Risperdol in addition to weight gain

A
  • long QT - neuroleptic malignant syndrome - agranulocytosis
26
Q

What antiepileptic drug has the adverse effect of pancreatitis, hepatitis and thrombocytopenia? a) carbemezapine b) valproic acid c) Topiramate d) Phenytoin

A

b) valproic acid

27
Q

Girl with Rett’s syndrome, on Valproic acid. Hx of vomiting and lethargy. Give 2 possible reasons for the vomiting and lethargy

A
  • Hyperammonemia causing encephalopathy - Pancreatitis - Liver failure
28
Q

Patient on phenytoin. Started on septra for UTI. Develop clinical sign indicative of phenytoin toxicity. Which is most likely explanation a. By displacing phenytoin from binding to albumin b. By decreasing liver metabolism

A

b. By decreasing liver metabolism - inhibits hepatic metabolism via CYP2C8 pathway Phenytoin Toxicity: nystagmus, ataxia, altered mental status, lethargy, poor feeding, hypotonia

29
Q

Most common side effect of cephalosporin a. rash b. diarrhea c. anaphylaxis

A

b. diarrhea

30
Q

12 year old girl with a history of hypopigmented flat scars following mild trauma, as well as spontaneous vesicular lesions when exposed to sun. Which medication would this most likely be a side effect of: a) Prednisone b) Naproxen c) Lisinopril d) Methotrexate

A

b) Naproxen - pseudoporphyria: small hypopigmented depressed scars occurring in areas of minor skin trauma (e.g. fingernail scratches) - CC: vesicles (typically dorsum of hands, forearm, face, leg, feet) + easy bruising and fragility after minor trauma *D/C NSAID as scarring can be permanent

31
Q

What complication is associated with erythromycin use in infants? (1)

A

pyloric stenosis

32
Q

Neonate with PDA treated with indocid. List four side effects of indocid

A
  • decreased platelet function (GI bleed, IVH) - NEC - transient renal insufficiency - spontaneous GI perforation
33
Q

Neonate with BPD being treated with furosemide. List 4 side effects.

A
  • hyponatremia - hypochloremia - hypokalemia - nephrocalcinosis
34
Q

You are a rural doc seeing a child who had just completed chemotherapy. What are the side effects of anthracyclines -what do you need to monitor for? a. hearing test b. cardiac echo c. thyroid function d. renal function

A

b. cardiac echo Anthracyclines - Doxorubicin, daunorubicin, idarubicin, epirubicin, and the anthraquinone mitoxantrone - dilated cardiomyopathy is long-term effect

35
Q

What is a long term effect of doxyrubicin a. Dilated cardiomyopathy b. Hypertrophic cardiomyopathy c. Pericarditis d. Restrictive cardiomyopathy

A

a. Dilated cardiomyopathy

36
Q

Who should not get succinylcholine a. DMD b. adrenoleukodystrophy

A

a. DMD

37
Q

Kid with DM type I on clavulin (amox to clav ratio 4:1) for OM. On day 3 he develops vomiting and diarrhea. Most likely cause of vx/dx? a. Viral gastro b. Wrong clavulin dose c. Allergy to clavulin

A

b. Wrong clavulin dose To minimize diarrhea caused by clavulanic acid, oral formulations with the ratio of amoxicillin to clavulanic acid of at least 7 to 1 are preferred

38
Q

A child has bacterial meningitis. Soon after starting his vancomycin infusion, he breaks out in a red rash. Blood pressure is normal. What is your immediate management? What are two things that can be done so this doesn’t happen the next time?

A
  1. Stop infusion, can treat with diphenhydramine and ranitidine 2. Pretreatment with diphenhydramine (antihistamine) - infuse at a slower rate
39
Q

The estrogen part of the OCP causes what? a. Moodiness b. salt and water retention c. acne

A

b. salt and water retention (cyclical) - progesterone causes moodiness

40
Q

Kid with signs of increased ICP, teased at school because of obesity and acne. PE reveals papilledema, MRI head normal. No sexual activity. What is the most likely cause? a. oral contraceptive b. minocycline c. benzoyl peroxide d. topical tretinoin

A

b. minocycline

41
Q

Child with head injury. Which of the following is a reason for why ketamine should not be used in this child? a. it has sympathomimetic properties b. it has negative inotropic properties c. it causes respiratory suppression

A

a. it has sympathomimetic properties - which increase HR, BP, theoretical increase in ICP - now controversial

42
Q

A 6 year old boy has been on moderate dose inhaled corticosteroids continuously for his asthma. His mother is concerned about his final adult height. What do you tell her about the current literature in the area: a. He will be slightly shorter than his expected adult height b. There will be no effect on his adult height c. He will have fast growth in this upcoming year

A

a. He will be slightly shorter than his expected adult height - adult height reduced by 1.2cm with moderate ICS use

43
Q

What can prolong the QT a. Hypokalemia b. Clarithromycin c. Hypercalcemia d. Digitalis

A

a. Hypokalemia *clarithromycin can also cause long QT (rare), and is contraindicated in people with long QT

44
Q

Teenage female presents deterioration in her school performance. She is teased at school because of her acne. She has headache. On exam, has bilateral papilledema. CT normal. What is the most likely cause? a. Oral tetracycline b. OCP c. Topical retinoid d. Clindamycin

A

a. Oral tetracycline

45
Q

You are about to put a child on stimulant medication for his ADHD. The mother asks you about the potential for increasing his potential risk for future drug addiction. What do you counsel her about her son’s future risk: a. Stimulants have no effect on risk of drug addiction b. Stimulants decrease future risk of drug addiction c. There is an increased risk of drug addiction, but less so with the dextroamphetamines

A

b. Stimulants decrease future risk of drug addiction - consistent treatment with medication and adjuvant therapies lowers risk of substance abuse

46
Q

Late side effect of ADHD stimulant treatment: j) Decreased appetite k) Sleep difficulties l) Tics m) Depression

A

m) Depression

47
Q

Greek 6 y/o girl with fever to 40 degrees. WBC 38. Pain in the right hypochondrium. Tender in right hypogastrium but no guarding or rebound. What is the diagnosis: 1. Pleurodynia 2. Bacterial pneumonia 3. First presentation of Familial Mediterranean Fever 4. Fitz-Hugh-Curtis 5. Cholecystitis

A
  1. Bacterial pneumonia *1. Pleurodynia (Bornholm disease=usually coxsackie or echovirus; illness with paroxysmal thoracic pain due to myositis involving chest and abdo wall)
48
Q

2 year old with torticollis, neck pain and refusal to move neck. 3 things on the differential

A
  • infection (retropharyngeal abscess, cervical lymphadenitis, meningitis) - trauma (muscular or c-spine injury) - cervical cord or posterior fossa tumour - drugs (acute dystonic reaction) - antipsychotics or antiemetics
49
Q

Management of postoperative pain in children aged 6-10 years: a) use BP and HR as a guide for when to give pain medications b) give regular doses of pain meds in the first 24 hours as they cannot reliably report pain c) they can assess pain meds as required using self report d) use facial expression as an indication of pain e) use a visual analog pain scale

A

e) use a visual analog pain scale

50
Q

Scenario of a child dying with metachromatic leukodystrophy who is palliative. You want to start opioids at home for pain control, What are four things/four principles you will have to consider when starting opioids?

A
  • Type of Pain - Frequency of Pain (basal) - Breakthrough pain (prns) - Titration to effect - Administer via simplest, most effective, least distressing route - Anticipate and treat side effects (constipation)
51
Q

A mother calls you and tells you that her 4 year old has taken 5 tablets of her paroxetine. a. What advice do you give her (1 line) b. Name 3 features of an overdose with this medication. c. What is the treatment for this overdose (1 line)?

A

a. Come to ED b. Tachycardia, sedation, sz, long QT. Rarely serotonin syndrome (altered LOC, autonomic instability, fever, neuromuscular like rigid/hyperreflexia/clonus) c. Supportive Care. Consider Cyproheptadine if severe.

52
Q

A child has been vomiting, mother giving suppositories unknown what kind, child comes into ER with recurrent tonic spasms but not unconscious, mouth open most of the time, what do you administer: a. diazepam b. benadryl c. naloxone

A

b. benadryl likely this is an acute dystonic reaction from an antiemetic (e.g. rectal metoclopramide/prochlorperazine)

53
Q

4 effects of excess vitamin D.

A
  • Excess= hypercalcemia (high D, high Ca, high PO, (appropriately) low PTH) 1. GI (emesis, anorexia, pancreatitis, constipation) 2. CVS (hypertension, arrhythmias, short QT) 3. CNS effects (lethargy, hypotonia, psychosis, coma) 4. Renal (hypercalcuria, polyuria, nephrolithiasis, ARF)
54
Q

Which has amnesia effects? a. midazolam b. chloral hydrate c. fentanyl d. morphine

A

ANSWER: a. midazolam (no analgesia; sedative + amnesia) b. chloral hydrate (no amnesia or analgesic; sedative) c. fentanyl (no amnesia; good analgesic + sedative) d. morphine (no amnesia; good analgesic + sedative)

55
Q

What medication should be used for sedating a 2-year old child for a CT scan? (a) oral midazolam (b) chloral hydrate (c) propofol (d) ketamine

A

(a) oral midazolam -chloral has long half life (10h) so not good for procedural sedation -propofol can cause resp depression - ketamine could be good too, especially if there’s pain

56
Q

What should be used for sedation while doing a CT scan in a patient with head injury? a) Midazolam b) Chloral hydrate c) Propofol

A

c) Propofol - decreases ICP so good option for stable head injury patients - midaz is probably also fine

57
Q

15 year old girl with fever for over 5 days but no tachycardia, normal blood pressure, and hepatomegaly present. Blood culture are positive for gram negative rods. What antibiotics would you treat with? a. Ciprofloxacin b. Gentamicin c. penicillin d. flagyl

A

Fever, relative bradycardia, GNB - likely salmonella typhi - cipro is treatment of choice

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