Acute Care Flashcards
(135 cards)
1
Q
15 year old with hypertensive emergency. List two medications that you can use to lower BP acutely.
For each medication, list one side-effect (not including hypotension).
A
IV medications
- labetolol: bradycardia, bronchospasm in asthmatics
- nicardipine: tachycardia, hypokalemia
- sodium nitroprusside: dizziness, cyanide toxicity (if malnourished or hepatic impairment)
2
Q
A 15 year old child is being transferred to your centre after an MVC in which he sustained a closed
head injury. Which of the following is likely to occur on transport and will cause significant sequelae?
A
Hypotension
3
Q
- Which of the following is least associated with increased intracranial pressure?
A
TCA overdose
4
Q
- What is the appropriate ETT tube size for a 2 year old? (1)
A
Uncuffed= (2/4) + 4= 4.5
age in years/4+4
5
Q
A 4-year-old with CP is involved in an MVA. He has been in the ICU for 1 week with a GCS of 4.
There is no improvement despite aggressive management and mechanical ventilation.
Parents approach you regarding the withdrawal of treatment.
A
Discuss the options again with the parents, and if they remain certain about the
decision then proceed with withdrawal
Notes: 3 components (2 examinations at separate times of 12-24h) o Irreversible coma with known cause o Absence of brainstem reflexes o Apnea
6
Q
- Regarding consent for organ donation, which is true:
A
b) can consent to donation of organs despite the absence of full brain death criteria
7
Q
- 4 “medical reasons” why brain dead patient may not be able to be an organ donor.
A
Contraindications:
- active CMV, Hep B or Hep C infection
- active extracranial malignancy
- severe, untreated systemic sepsis
- AIDS
- viral encephalitis
- risk of rare viral or prion protein illness like Creutzfeld-Jakob
- active West Nile virus or rabies
- active disseminated TB
8
Q
- A boy is struck by lightning in a field. Most likely consequence?
A
c. cardiovascular collapse
9
Q
- EKG kid in vfib/ maybe early torsades?. Patient has CPR being performed already intubated. Has IV.
Give the interventions and drugs that will be administered for his cardiac care in the first 5 minutes of
resuscitation.
A
CPR Shock CPR Shock CPR Epi CPR Shock Amiodarone or Lidocaine \+/- Mag Sulf if TDP (from long QT)
10
Q
- Child with pulseless wide-complex tach, got defibrillated x 1 and is receiving CPR. IV is in situ. What
do you do next?
a. shock
A
c. epinephrine 1:10000, 0.1 cc/kg
11
Q
Reversible causes of cardiac arrest?
A
- H’s: hypovolemia
- hypoxia
- hydrogen (acidosis)
- hyper/hypokalemia
- hypoglycemia
- hypothermia
- T’s: tension pneumo
- tamponande
- toxins
- thrombosis (pulmonary or coronary)
- unrecognized trauma
12
Q
Asystole A. epi
Bradycardia B high dose epi
SVT C Atropine
V. tach with pulse D adenosine
V tach without pulse E. amiodarone
Pulseless electrical activity F. Lidocaine
A
Asystole: epi bradycardia: epi or atropine (if increased vagal tone) SVT: adenosine V tach with pulse: amiodarone/adenosine Pulsesless V tach: defib, then epic PEA: epi
13
Q
- Child with 15% blood loss after MVA. ETA to ER is at least 1 hour. Which of the vital signs most
represents the patient upon arrival to ER.
A
a. pulse 120, RR 30, BP 90/60
- Can lose up to 30% of blood before BP decreases
- 15% is between very mild to mild hemorrhage
14
Q
- A teenager is seen in the ER with shortness of breath. He has distended neck veins, hepatomegaly
and an S3 and an S4. What are two abnormalities on this CXR? What are two possible diagnoses?
A
- Cardiomegaly and Left pleural effusion ?perivascular markings
Causes heart failure in adolescent - Myocarditis
- Acute hypertension (glomerulonephritis)
- Genetic or metabolic cardiomyopathy
- Thyrotoxicosis
15
Q
- Babe in shock with Na 131, K 5.9. What is the BEST thing to do right now?
A
b. NS bolus
16
Q
- 3 yo with trauma, skull and femur fracture and has already received 3 boluses of 20 cc/kg. HR 160,
low BP – unchanged Next step:
A
c) inotropes and packed RBC
Notes: - to improve cardiac output
- medication therapy for hemorrhagic hypovolemic shock: vasoactive agents not
routinely indicated but patients with persistent hypotension may require short
course of something like epinephrine to restore cardiac contractility and vascular
tone until adequate fluid resuscitation is provided
17
Q
- Description of toxic shock syndrome with erythema, fever, low BP. Already received 2x20cc/kg.
Slightly decreased LOC. Next?
A
a) bolus and inotropes. (norepi best as distributive shock)
18
Q
- Infant with temp 40C, BP 70/30, HR 160. Diffuse skin erythema. Refractory to 20 cc/kg bolus normal
saline X 3. Slightly decreased LOC. Next step?
A
b. Inotropes and re-bolus
19
Q
- Newborn term, Appropriate GA baby, cried at birth, Apgars 9 and 9. Few hours later found to be in
respiratory distress. RR 80, HR high. Cap refill 4-5 seconds, BP 48/32. Hyperinflated chest with minimal
indrawing. Cannot hear breath sounds on left, cannot hear heart sounds. Baby is turning cyanotic. What
investigation do you do (1)? What is your possible diagnosis (1) Baby’s heart rate is now 80 and is more
cyanotic. What one investigation do you want to do (1)
A
Transillumination. 2 nd choice: CXR
● False (+): ELBW, subcutaneous air or edema, PIE
● CXR would confirm but is clinical diagnosis
Tension Pneumothorax, DDX: Congenital Diaphragmatic Hernia.
● CC: sudden deterioration with O2 desat/increased O2 need
● Tachycardia, fall in BP
● Circulatory compromise due to mediastinal shift (pressure on RA= lower preload and CO) =
bradycardic due to hypoxemic
Treatment: Needle Decompression
● Butterfly needle (23 gauge if > 32 GA or > 1500g) + 3 way stop cock and syringe
● Insert into 2 nd intercostal space mid-clavicle line (just above 3 rd rib)
● Advance while aspirating until pull air back; and shoot out through different port; repeat
20
Q
- 2 diagnostic criteria for ARDS.
A
- within 1 week of known clinical insult or new or worsening resp symptoms
- bilateral opacity on CXR not explained by effusion, collapse or nodules
- resp failure not explained by cardiac failure or fluid overload
- Oxygenation issues (PaO2/FiO2 less than 300 with PEEP 5 or more)
21
Q
- What are two life-threatening acute presentations of a teenage boy with an anterior mediastinal
mass? State the acute presentation, and describe why it is life-threatening
A
Risks (compression)
o Airway compromise (airway obstruction/ respiratory failure)
o Cardiac tamponade (obstructive shock)
o Vascular Obstruction (SVC syndrome) (obstructive shock)
22
Q
What are 5 causes of mediastinal mass?
A
Etiology (5Ts- thymoma, terrible lymphoma, teratoma, ectopic thyroid, dilated thoracic aorta)
23
Q
- Child in status asthmaticus who has been given inhaled beta agonists, ipratroprium bromide and iv
steroids. Heʼs still in trouble. What are FOUR other medications that can be tried?
A
IV Ventolin/epinephrine
Magnesium Sulfate
Heliox
Theophylline
24
Q
- Toxic child with high fever, respiratory distress. White-out on 1 side of the lung on CXR. What to do?
A
b. chest ultrasound
Notes: Whiteout Hemithorax DDx: large pleural effusion, empyema, hemothorax, complete lung collapse,
community acquired pneumonia, pleural masses
25
1. Name 4 clinical signs or symptoms of a tension pneumothorax. Where would you insert a needle and
what size needle would you use. In one line describe the purpose of a Heimlich or flutter valve.
Clinical signs of a tension pneumothorax:
- respiratory distress with tachypnea and increased work of breathing
- tracheal deviation toward contralateral side
- hyperresonance of affected side
- hyperexpansion of affected side
- diminished breath sounds on affected side
- pulsus paradoxus (decrease in SBP by >10mmHg during inspiration)
Mgmt: 18-20 gauge needle and catheter over the top of the third rib (second intercostal space) in
the midclavicular line
```
Heimlich: - one way valve mechanism within a thoracostomy tube or tube drainage system that allows air and fluid to exit the pleural space, but prevents air or fluid from entering the pleural cavity from
the outside (now we use water seal instead)
```
26
3. 16 yo female on surgical ward in traction for femoral fracture and splenic rupture. She develops
sudden onset CP, cough and O2 sats 84%. Give 3 of the most likely causes of the sudden distress. Give
3 investigations to do to confirm diagnosis.
Pulmonary venous thromboembolism
Pulmonary fat embolism
Pneumothorax
- U/S of legs with doppler flow to look for DVT
- d-dimer (good sensitivity, poor specificity)
- Spiral CT with IV contrast
27
30. The following scenarios can be seen in a child with meningitis. For which one of the following children
would you order a head CT?
c) a 5 year old with generalized tonic-clonic seizures on presentation
28
106. Febrile 3 yo, seizing for 30 minutes. HR 180, RR 60, BP stable. Failed IV access. Next?
b) intranasal midazolam
29
111. Child with flexion response to pain, incomprehensible moaning, eyes don’t open. GCS?
c. 6
30
45. A 6 year old boy present to your ED with acute onset of headache. In the waiting room he suddenly
loses consciousness and is brought into your resuscitation room. He begins to have decorticate then
decerebrate posturing on the right side. You assess his ABCs and they are stable. What is the next step
in your management:
f. Mannitol
Note: clinical signs of impending herniation, including alterations in the respiratory pattern (e.g.,
hyperventilation; Cheyne-Stokes respirations, ataxic respirations, respiratory arrest), abnormalities of
pupil size and reactivity, loss of brainstem reflexes, and decorticate or decerebrate posturing.
31
9. 3 indications for intubation in a trauma patient.
General reasons to intubate:
- unable to maintain effective airway
- unable to oxygenate
- unable to ventilate
Decreased level of consciousness such that patient cannot protect airway
Soft tissue injury/swelling raising concern for maintained airway patency
Injury to chest wall/lungs/heart leading to inability to maintain oxygenation or ventilation
Cardiorespiratory arrest
Secure airway for transportation
Need for diagnostic or interventional procedures that require patient cooperation
32
41. Which fractures most specific to trauma X?
a) posterior rib fractures
33
16. Dog bite 2 hours ago on the dorsum of the hand. Both the child’s and dog’s vaccinations are
up-to-date. On exam, full ROM of hand with mild edema. Appropriate management:
d) irrigate with saline and treat with clavulin prophylactically
34
50. Child gets a tooth knocked out while playing. What are two things to do in your
management?
Management (permanent teeth)
1. Find tooth
2. Rinse tooth (don’t scrub or touch the root)
3. Insert tooth into socket or in cold cows milk/isotonic solution
4. Go directly to dentist
5. (evaluate for other head/facial trauma)
35
51. Child stepped on a nail that punctured the sole of his shoe and his foot. What is the most likely
organism?
o Pseudomonas
36
52. Description of a child holding their arm flexed and pronated. He refuses to move
the arm. There is no history of trauma. What is the diagnosis?(1 line) What do you
do?(2 lines)
Pulled elbow
o Rotation of forearm into supination while applying pressure to radial head OR hyperpronation
37
101. Bite in daycare Q. What to do:
a. Reasure mom of low risk of hiv infection
38
13. Blunt abdominal trauma. One reason to take patient to OR for laparotomy.
perforation from a hollow viscous injury as demonstrated by pneumoperitoneum (i.e. bowel
perforation)
39
96. Child with blunt abdominal trauma, gross hematuria, positive Diagnostic Peritoneal Lavage. What's
next:
1. Abdo CT (most helpful!)
40
12. An 8 year sustained a severe head injury from which he has completely recovered.
The most likely long-term sequela is:
b. specific learning disability
41
42. 12 yr old male in MVA. Closed head injury. In peripheral hospital, no ct no neuro surgery. Pt is
intubated and has IV in situ. Give three immediate interventions .
- Continuous monitoring of vital signs (if possible EtCO2)
- Ventilation to maintain normal oxygen and CO2
- Maintain normothermia
- Provide sedation/analgesic
- Fluids to maintain normovolemia and avoid hypotension
- elevate head of bed
42
50. Child presents to the emergency room with a traumatic brain injury. What are 4 factors that can
cause secondary brain injury?
Hypoxia, Hypo/hypercarbia, Hyperthermia, Hypotension,
| Hypoglycemia
43
49. List 3 reasons to image a child with headaches.
- abnormal neuro exam (focal, raised ICP, altered LOC)
- seizures
- recent onset of severe, change in type, or neurological dysfunction
44
68. 3 yo trauma patient with depressed skull fracture is unstable with desaturation and hypotension.
What is your next management step?
b) intubate
45
136. Infant with skull fracture, suspect SCAN. What is the most likely bleed?
a. subdural
46
8 year old boy plays soccer competitively. He crashed into another player was confused and amnesic
afterwards. Now asymptomatic. He has practices every day for two weeks and then the playoffs start.
What do you tell him regarding his play (2)?
● no activity is step 1
● each step min. 24h and progression only if symptom free
● if symptoms recur then rest until resolve (24-48h) before trying again at last step where
asymptomatic
● only after symptom free 7-10 day and fully returned to school can begin medically supervised
return to play
47
A child playing a sports game has a head injury with transient loss of consciousness. What to do:
1. Have him do mental tasks. If he succeeds, have him return to game
2. Sit out for 1 week
3. Sit out for 15 minutes
2. Sit out for 1 week
“only after symptom free 7-10 day and fully returned to school can begin medically
supervised return to play”
48
Scenario of child head trauma. GCS 6 intubated and ventilated. To CT scan (CT of epidural
hematoma). Posturing and pupil blown in CT scan. What is the diagnosis? What next 3 things are in your
immediate management.
```
Epidural hematoma with raised ICP
Mgmt:
1. Head of bed to 30 degrees
2. hyperventilate with 100% O2
3. 3% hypertonic saline IV bolus (5ml/kg)
4. Call neurosurgery
```
49
```
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. it has sympathomimetic properties
Notes: - ketamine dissociates the connections between the cortex and limbic system
- in lower doses releases catecholamines (sympathomimetic action) which maintain BP and
cardiac function BUT per Nelson’s can also be associated with increased ICP
50
A child is in the ICU with a severe head injury. The social worker thinks that the father inflicted the injuries. What to do.
a) despite accusation of abuse, decision to withdraw care must be made in communication with the parents
b) courts are to decide on withdrawal of care (unless parent’s rights taken away)
c) police must be notified before withdrawal
d) MD can make decision about withdrawal of care
a) despite accusation of abuse, decision to withdraw care must be made in communication with the parents
51
All are true of shaken baby syndrome except:
1. homicide is the most common cause of death due to injury in kids <4y.o.
2. external physical findings of shaken baby syndrome are not always present
3. shaken baby syndrome does not occur after 3 years of age (AAP article says age 5)
4. retinal hemorrhages are not always present
1. homicide is the most common cause of death due to injury in kids <4y.o.
52
Teenager in a motor vehicle accident a day before and was observed in ER. Now presents with orange urine and his creatinine has tripled. What is the diagnosis?
a. renal vein thrombosis
b. rhabdomyolysis
c. glomerulonephritis
b. rhabdomyolysis
53
Child in MVA 24h ago discharged home after brief observation. Returning today with decreased U/O
of orange urine. Cr is rising and is unresponsive to fluids. Why?
a. Renal contusion
b. Renal artery thrombosis
c. Rhabdomyolysis
c. Rhabdomyolysis
54
List 3 treatments for hyperuricemia.
Allopurinol (decrease production of uric acid)
Alkalinize urine
Hydration
Diuresis
Rasburicase (enzyme that degrades uric acid)
55
10 year old 30 kg girl presents in DKA. pH<7.25, glucose 4(0?), 10% dehydrated. Current Na is 120.
A) What type of initial fluid would you give her? B) What would be the rate? C) What initial insulin
dose/type would you start her on?
A) Normal saline
B) Rate = 4cc/kg/h for kids over 20kg
C) once starting insulin (after running fluids for 1-2 hours) run novolin (short acting) at 0.1U/kg/h
56
Young child presents to the emergency room looking unwell with a sodium of 132 and potassium of
6.2. What is the diagnosis?
Hyponatremia + Hyperkalemia = primary adrenal insufficiency (insufficient cortisol)
Also have pigmented skin, metabolic acidosis, weakness, fatigue, weight loss, myalgia, arthralgia, nausea, vomiting, abdo pain, diarrhea, salt craving
*treat with hydrocortisone
57
Child presents with an ammonia level in the 400-range. What 3 things would you do in your management?
1. Sodium benzoate to bind ammonia and allow excretion
2. give arginine (supplies the urea ammonia cycle)
3. provide adequate fluids, electrolytes and calories IV, but minimize protein
4. dialysis if the above does not work sufficiently
*high ammonia is toxic to CNS
58
```
6 month old with hx of dev delay is brought in to ER and needs resusc . Is now stable. What would you need to help make diagnosis:
A) CT scan
B) Lactate, carnitine, ammonia
C) Serum organic acids
D) Urine amino acids
```
B) Lactate, carnitine, ammonia
Acidopathies and organic acidurias present earlier than 6 months
Dx likely carnitine-acylcarnitine translocase deficiency - fatty acid oxidation defect (show up when kids start to have longer periods of fasting between feeds)
59
A patient with septo-optic dysplasia presents hemodynamically unstable. He is mottled and has a low
blood pressure. WBC is normal, Na 138, K 6.1. After fluid resuscitation, what is your next management
step?
a) give IV hydrocortisone
b) start antibiotics
c) give hypotonic saline
d) start Kayexalate
a) give IV hydrocortisone
Could have panhypopit causing secondary adrenal insufficiency (means not enough ACTH)
60
Child fatigued and tanned, K 5.2, Na 132, glucose 2.6, shocky, vomiting and has
diarrhea. What is used to treat the underlying condition?
a. D5 0.25NS
b. nothing - just observe
c. NS 20 cc.kg
d. iv hydrocortisone
d. iv hydrocortisone
61
3 week old with pyloric stenosis, severe metabolic alkalosis (bicarbonate 34). What to do:
1. Give hydrochloric acid IV
2. OR immediately
3. Give large amounts of chloride IV
4. Give 5mmol/kg of KCl IV bolus
5. Give ascorbic acid IV
3. Give large amounts of chloride IV
62
5 week baby with pyloric stenosis. Labs show a bicarb 34. What solution would you use for rehydration (1) and why (3)
1. D5NS + 20mEq/L KCl
2. correct alkalosis, will likely have hypokalemia, restore hydration
- chloride will correct alkalosis
- better to correct lytes and acid-base status pre-op for better post-op outcome
63
Child with vomiting and diarrhea who was fed a home concoction of enteral feed. Now is lethargic
and seizing. Na 115, creatinine elevated. Ur Na 12, Bicarb 18, glucose 3.5. Which is the best next step:
1. Administer 3% NaCl at a rate to increase Na by 2mEq/L/hr.
2. Give Lasix to increase urine output
3. Give bicarb
4. Give bolus of D5W0.45 20cc/kg
1. Administer 3% NaCl at a rate to increase Na by 2mEq/L/hr.
● If severe hyponatremia (<120) and CNS symptoms)
o 3% NaCL 3-5 cc/kg IV push with hyponatremia induced seizures
o Rate of increase should not exceed rise of > 2 mEq/L/hour to prevent central pontine
myelinolysis
64
Teenaged boy who has just had orthopedic surgery. Has been in the casts and on bedrest for 11
days. Suddenly develops anorexia, polydipsia and polyuria. Glucose is normal on admission, BMI 29.
What is the diagnosis? What one test can give you the diagnosis (1). What is the management?
1. immobilization hypercalcemia (from increased bone resorption)
2. ionized calcium
3. IV fluids at 1.5-2x maintenance; lasix to increase excretion of calcium
65
Toddler with gastroenteritis presents with lethargy, pallor and significant dehydration.
HR 120, BP 70/40, rapid respirations. Given 20 cc/kg normal saline bolus.
Nurse informs you that the child has stopped breathing. Next step in management:
a) ventilate with 100% 02, fluid bolus, epinephrine
b) ventilate with 100% 02, dopamine, fluid bolus
c) dopamine, ventilate with 100% 02, fluid bolus
d) fluid bolus, ventilate with 100% 02, bicarb
a) ventilate with 100% 02, fluid bolus, epinephrine
66
15 kg child with tachycardia, dry mucous membranes and a history of vomiting and diarrhea. What is the most appropriate rehydration regimen?
a. 400 mL of ORS per hour, for 4 hours
b. 100 mL of ORS per hour, for 4 hours
c. rehydrate with apple juice
d. start IV fluids
a. 400 mL of ORS per hour, for 4 hours (1600ml = ~100ml/kg)* this is the answer
(b. 100 mL of ORS per hour, for 4 hours (400ml = 26ml/kg = too little)
Can try ORT for anything but severe dehydration (mild = 50ml/kg over 4h, moderate = 100ml/kg over 4h)
67
List 6 clinical signs of early hypovolemic shock in a 3 year old who is dehydrated.
1. low urine output
2. orthostatic hypotension
3. delayed capillary refill
4. tachycardia
5. dry mucous membranes
6. decreased skin turgor
68
List 3 clinical signs of increased ICP in an 8 month old baby with vomiting for 5 days.
1. decreased level of consciousness
2. bulging fontanelle
3. hypertension, bradycardia
69
A 10-year-old boy has a temp 39.3, RR 44 on 100% O2, HR 140, and BP 60/P. There is a diffuse
erythematous rash on his body and one lesion that looks like impetigo. He is given a 20 cc/kg bolus of
saline with no improvement. How do you proceed:
a) bolus again – intubate – penicillin
b) bolus again – inotrope – cloxacillin
c) bolus again – ceftriaxone – intubate
d) inotrope – intubate – cloxacillin
e) intubate – bolus again – penicillin
b) bolus again – inotrope – cloxacillin
Mgmt:
- fluids
- abx: antistaph (clox) and antitoxin (clinda)
70
2 week old with Hypotension, RR 70, HR 210, on 50% oxygen sats 95%. What is your next step after fluid bolus?
a. IV abx
b. Bag Mask
c. Intubate
a. IV abx
Late onset sepsis
71
3 year old with severe hypotension secondary to meningoccocemia. You have started an IV, given a
few boluses and the child still is hypotensive. What 3 things will you do for management (3) of his
hypotension?
1. push repeated boluses 20ml/kg NS
2. vasopressor support (epinephrine for hypotensive cold shock)
3. consider steroids if hypotension is fluid refractory (2mg/kg hydrocortisone)
4. Obviously start antibiotics but won't help the hypotension any time soon
72
```
5 year old fever 38.5 degrees, had a recent URTI. Hip was externally rotated and child not
weight-bearing. ESR was 40. Diagnosis?
a) transient synovitis
b) JIA
c) septic arthritis
```
c) septic arthritis
73
What are the Kocher criteria for septic arthritis?
```
T>38.5
WBC >12
ESR >40
CRP >23
inability to weight bear
```
74
List 3 symptoms of hypernatremia.
1. polyuria
2. increased thirst
3. irritability/lethargy
4. weakness
5. seizures/coma
6. nausea
7. fever
75
Kid with AKI and a potassium of 8. Not getting any K supplements. 4 ways to treat hyperkalemia
(doses not required).
1. calcium gluconate to stabilize myocardium
2. ventolin neb
3. insulin (with glucose)
4. kayexalate
5. bicarb
6. lasix
7. dialysis
76
```
Kid with vomiting and diarrhea. Mom feeding glucose water. Comes in with sodium 108. Not seizing.
How do you manage?
a. correct Na with 3% NaCl over 4-6 hrs
b. correct to 135-140 in 24 hrs
c. correct to 118 -120 in 24 hrs
```
c. correct to 118 -120 in 24 hrs
Not more than 0.5meq/h (12meq/day)
3% NS only for severe hyponatremia (<120 AND seizing)
77
Reason why we remove esophageal foreign bodies that have been sitting for >24 hours
a. esophagitis
b. risk of aspiration
c. risk of esophageal perforation
c. risk of esophageal perforation
78
What are 4 clinical signs that are suggestive of an inhalation injury in the setting of an acute burn?
1. facial burns
2. soot in the mouth or nose (carbonaceous sputum)
3. singed nasal hairs/eyebrows
4. edema/blistering of oropharynx
5. stridor/hoarse voice
79
A child was involved in a house fire. He is alert and oriented, with soot coating his nostrils and mouth.
He has mild stridor and indrawing. What is your management?
a) Observe since he is likely to improve
b) arrange for urgent intubation
c) racemic epinephrine
d) parenteral steroids
e) IV antibiotics
b) arrange for urgent intubation
80
What is the Parkland formula?
```
IV fluid requirement for the first 24 hours (*add maintenance to the rate you end up with)
body weight (kg) x percentage of TBSA burned x 4
- half volume is given in first 8 hours, next half given over next 16 hours
```
81
Scenario of a mom who brings her infant in after he/she was at the sitters (age?), and the kid has
burns of both hands, and a scald on his chest. She was told that he pulled the coffee pot down on
himself. What do you do? List 3 reasons why you would admit him.
1. call CPS - infant probably can't pull coffee pot down on self
2. estimate percentage of BSA involved and fluid resuscitate
3. indications for admission: burns affecting >10% BSA
- burns to face, hands, feet, genitals, major joints
- suspected child abuse or neglect
82
4 yo with drowning injury. GCS 6, no spontaneous breathing. How long of no improvement of GCS
signifies almost nil chance of survival without sequelae
A) 6 h
B) 12 h
C) 24 h
D) 48 h
D) 48 h
83
10 month had private swimming lessons x 45 min. 1 h after lesson is found lethargic and brought to
ER. Has GTC Sz. BP 120/80. RR normal. No external signs of head injury. Lungs are clear. What is
the most likely etiology.
E) Chlorine intoxication
F) Closed head injury
G) Near drowning
H) Water intoxication
F) Closed head injury
Water intoxication: rare complication, not clear this is a real thing
Near drowning: can wash out surfactant and cause delayed respiratory distress (4-8h after submersion)
84
What prognostic feature is associated with worst neurological outcome in drowning injury?
a. increased length of submersion
b. GCS < 7 on arrival to ER
c. poor quality CPR at scene
d. cardioresp arrest at scene
a. increased length of submersion
Submersion >5 minutes is most critical factor in prognosis
Other bad prognostic factors: >10 minutes to effective BLS
- resusc for more than 25minutes
- persistent apnea and CPR in ED
85
Patient in an ice-water drowning, received 3 shocks, CPR started. Temp 26 degrees. He is getting CPR, what to do now?
a. amiodarone
b. lido
c. do nothing
d. asynchronous cardioversion at 4 J/kg
d. asynchronous cardioversion at 4 J/kg
Assuming they have a shockable rhythm (usually have brady arrest or PEA, but sometimes have v fib in which case should be shocked)
- shock may not be effective until temp >30 but still do it
86
Child submerged in icy water for 6 minutes. On arrival, T28 degrees celsius. Vitals absent. CPR started early. Resusc goes on. Can they stop resus at 15 minutes? Why or why not and justify (4 lines given).
No
- resuscitation should continue until patient's temp 34 degrees
- even if not hypothermic should run resusc for 25-30 minutes
- this patient has some positive prognostic factors (submerged <10 minutes, CPR started early)
87
```
Child found face down in pool. Resuscitation started at scene. At the hospital, his temp is 37.5, HR 100, RR 20, sat 95% in R/A. He is alert and oriented. What to do
immediately?
1. Admit for 24 hours
2. Observe for 4 hours
3. Call social work
4. CXR
5. IV antibiotics
```
4. CXR
Observe for 6-8 hours minimum
1/2 of kids who are looking great go on to develop some resp distress and pulmonary oedema after 4-8 hours after submersion
CXR not necessarily needed for asymptomatic children, but some advocate for CXR prior to D/C from ED
88
Organophosphate overdose antidote
atropine (muscarinic effects) pralidoxime (nicotinic effects)
89
Boy found in garden shed with cholinergic symptoms. Tx:
a. atropine
b. pralidoxime
c. physiostigmine
a. atropine
b. pralidoxime
Want to give both
90
Increased intracranial pressure occurs in all EXCEPT:
(a) TCA overdose
(b) Reye’s syndrome
(a) TCA overdose
In Reye syndrome get death secondary to raised ICP and herniation
91
A child ingests paint thinner (hydrocarbon). What to do:
1. Gastric lavage
2. Activated charcoal
3. Observe and treat symptomatically
4. Discharge home
3. Observe and treat symptomatically
Charcoal doesn't bind hydrocarbon, gastric lavage increases risk of aspiration, need to observe for pneumonitis
92
A teen comes to ER about 1 hour after taking a diazepam overdose. She is awake, but slightly drowsy. The best management option is:
a. charcoal and gastric lavage
b. gastric lavage only
c. ipecac
d. immediate dose of naloxone
e. intubate and then charcoal and gastric lavage
d. immediate dose of naloxone
Naloxone for coingestion (flumazenil is benzo antidote)
Never ipecac, rarely gastric lavage (aspiration risk), AC within first hour
93
Child brought to the emergency department by parents. They suspect he has taken an overdose, the child denies any ingestion. On examination: T 38.2 o C, heart rate 132, blood pressure 150/90. The most likely drug is:
a) LSD
b) Cocaine
c) Cannabis
d) Barbiturates
b) Cocaine
94
A 4 month old infant presents in shock with a temperature of 41.8 o C. In the ICU on
ventilator, spontaneous bleeding occurs and the pupils are sluggish. The most likely
diagnosis is:
a. E. coli meningitis
b. Hemorrhagic shock and encephalitis syndrome (HSES)
c. Reye syndrome
b. Hemorrhagic shock and encephalitis syndrome (HSES)
- occurs in 3-8 month olds in context of high fever
- encephalopathy, shock, severe DIC, renal and liver failure
95
Adolescent in the ER after an MVA. He is comatose. His breath smells of alcohol.
a) attending physician can take a blood alcohol level without patient’s consent
b) attending physician should talk to police about possible alcohol ingestion
c) parents can refuse alcohol level
d) police can look at medical files
a) attending physician can take a blood alcohol level without patient’s consent
96
A teenager is brought into the ER after taking 4 pills consisting of a white powder. He is comatose with hypertension, muscle rigidity, myoclonic jerks, and nystagmus.
a) Cocaine
b) Psilocybin (= mushrooms)
c) PCP
d) LSD
e) Amphetamines
c) PCP
dissociative, adrenergic
97
A teenager is brought into the ER. He is hypertensive, tachycardic, and agitated. Management:
a) physical restraints
b) activated charcoal
c) chlorpromazine
d) diazepam
d) diazepam
Likely ingestion is amphetamines
- benzo treats hypertension and possible arrhythmias
98
List 3 serotonergic symptoms/side effects from an SSRI.
- irritability/restlessness
- insomnia
- diaphoresis
- behavioural activation
99
List 4 signs/symptoms of serotonin syndrome
- myoclonus
- hyperreflexia
- delirium
- hyperthermia
- tachycardia
- agitation/confusion
- diaphoresis
100
A 3 year with 5 days low grade temperature, rhinorrhea, occasional cough. On exam he looks well, has green crusted nasal discharge. Mom has been giving acetaminophen 6 to 7 x/day. Next test:
a) Sinus x-rays and treat if fluid level present
b) treat with amoxil
c) consult with ENT
d) counsel on Tylenol dosing and risk of too much acetaminophen
d) counsel on Tylenol dosing and risk of too much acetaminophen
Toxic dose of acetaminophen: 150mg/kg
101
15 year old boy comes in agitated, flailing limbs and speaking incomprehensibly. Pupils are dilated,
skin is flushed. HR 115, BP 110/70, afebrile. How do you manage?
A) Supportive
B) Naloxone
C) Flumazenil
D) Atropine
A) Supportive
B) Naloxone (Opioids)
C) Flumazenil (Benzos)
D) Atropine (Organophosphates)
Mgmt of anticholinergic: patients with moderate toxicity can be treated with physostigmine IV (note can induce sz and worsen arrhythmia in patients with conduction issues); seizures and agitation can be treated with benzos
102
15 year old boy comes in with decrease LOC, GCS 11, flailing limbs and speaking incomprehensibly.
Pupils are dilated, skin is flushed. HR 115, BP 110/70, afebrile. Which of the following is most likely what
he ingested:
a. Imipramine
b. Jimson weed
c. Morphine
b. Jimson weed
Anticholinergic toxidrome
103
All of the following are therapeutic measures in TCA overdoses EXCEPT:
a) alkalinization of the urine
b) phenytoin for arrhythmias
c) repeated doses of activated charcoal
d) hemodialysis
e) norepinephrine for hypotension
d) hemodialysis
104
```
In an overdose with a tricyclic antidepressant, all of the following would be present EXCEPT:
a) tachycardia
b) urinary retention
c ) increased bowel sounds
d) mydriasis
e) seizures
```
c ) increased bowel sounds
105
3yr old with miosis and seizure. Which toxin did he ingest?
a. insecticide
b. cocaine
c. beta blocker
a. insecticide
(organophosphate toxicity)
SLUDGE (muscarinic) and nicotininc effects
b. cocaine (seizures, mydriasis, high HR, HTN)
c. beta blocker (low HR, hypoTN, hypoglycaemia, decreased GCS)
106
Side effect of marijuana in adolescents
a. gynecomastia
b. decreased testicular volume
c. tachycardia
c. tachycardia
Some evidence of decreased testosterone and spermatogenesis in chronic users
107
16 y M had been agitated and aggressive earlier in the evening. Brought in unconscious, but rouses
intermittently showing rigidity and hyper-reflexia. What has he ingested?
e. Cocaine
f. PCP
g. Heroine
f. PCP
Coma of PCP may be distinguished from that of opiates by the absence of respiratory
depression, presence of muscle rigidity and hyperreflexia and nystagmus, and lack of response
to naloxone
108
You are asked to assess a 5 year old kid who had surgery and has been receiving 20 mg/kg acetaminophen q4h for 5 days. He now has decreasing LOC. Which is true?
h) Acetaminophen is not a good drug for post-op pain management
i) he needs to be worked up for hepatic toxicity
i) he needs to be worked up for hepatic toxicity
109
Teenager overdosed on imipramine. Presents with decreased LOC. What do you do?
a. Give phenytoin
b. Sodium bicarbonate
c. Activated charcoal
c. Activated charcoal
Phenytoin for arrhythmias (and may be questionable)
NaHCO3 for QRS>110, ventric arrhythmia or hypotension
110
3 yo has ingested 6 tablets of older sibling's SSRI. Mom calls you for advise on what to do. What do
you advise? (1 line) Name 3 side effects of SSRI overdose. What is the treatment for SSR overdose (1
line).
1. take child to ED for assessment
2. decreased LOC, tachycardia, QT prolongation
3. supportive management, hydration, gastric decontamination, may be a role for benzos and
cyproheptadine depending on severity of ingestion
111
List 4 signs of recent marijuana use
- elation and euphoria
- decreased coordination
- tachycardia
- conjunctivitis
- increased appetite
112
Which is used to treat a methanol overdose
1. Fomepizole
1. Physostigmine
2. Flumazenil
3. Naloxone
4. Pralidoxime
Answer: Fomepizole (methanol usually from windshield washer fluid) - if not available or allergic, give ethanol; may need dialysis
1. Physostigmine (anticholinergic)
2. Flumazenil (benzos)
3. Naloxone (opioids)
4. Pralidoxime (cholinergic - specifically organophosphates and nerve gas)
113
What toxic ingestion is suggested by a rapid afferent pupillary defect?
methanol - 18-24h after ingestion have decreased vision and feeling of seeing through a snow storm
114
Ibuprofen ingestion – list 3 blood tests you would perform
Toxic dose: usually <200mg/kg is okay, >400mg/kg more likely to have toxic effects
BUN, Cr, gas, CBC (for platelets), screen for coingestion (acetaminophen, salicylate level)
115
Child with headache, nausea, father admitted with CO poisoning. First step in management?
100% oxygen at normal atmospheric pressure via non-rebreather facemask (enhances elimination of CO)
- if syncope, seizure, coma, MI consider hyperbaric oxygen to even further increase rate of CO elimination
116
14 year old girl was found in a field by her friends. She was agitated and disoriented. On examination she was found to have jimson weed on her, with a few the seeds from the plant. This is known to be an isomer of atropine. What are 4 signs that you might find on examination? What are two things you should do for management?
```
Anticholinergic toxidrome:
- tachycardia
- dry red skin
- mydriasis
- urinary retention
- hyperthermia
- hallucinations
- decreased bowel sounds
Mgmt: benzos for delirium, agitation or seizure
- charcoal if in tact LOC and protecting airway
- physostigmine if normal ECG
- screening tests: ECG, look for coingestion (acetaminophen, salicylate)
```
117
Teenager took overdose of Gravol and Tylenol. List six clinical signs of Gravol overdose.
Anticholinergic presentation
- tachycardia
- dry red skin
- mydriasis
- urinary retention
- hyperthermia
- hallucinations
- decreased bowel sounds
118
Mom wants to know where her 18 month old daughter acquired perineal warts. You tell her from:
a. perinatal acquisition
b. sexual abuse
c. day care
d. from bathing with her older sister
e. from dad changing diapers
a. perinatal acquisition
Vertical transmission reasonable until 3 years of age and most likely
- could also have come from dad or sister
119
13 y/o male with intermittent testicular pain. 3 things on your ddx.
- torsion (testicular or appendix testis)
- hernia
- epidydimitis
- trauma (ruptured testis)
- testicular vasculitis
- renal stone (referred)
120
9 year old boy comes into your ER with severe abdominal pain and bilious vomiting. He has presented in a similar manner on 3 previous occasions in the past 2 years. List the most likely underlying diagnosis [1 point] and one investigation you would do in about 1 week when he is feeling well [1 point].
Malrotation with intermittent Volvulus- UGI
121
Child had a URTI a week ago. He now presents with bloody diarrhea, abdo pain and a petechial
rash. What is his diagnosis?
HSP - 1/2 of cases are preceded by viral URTI; can have bloody diarrhea (bowel hemorrhage or necrosis, though rare)
Also consider HUS, BUT does not typically follow viral illness. Do have bloody diarrhea and TCP though
122
What are four clinical signs that would be considered a contraindication for a lumbar puncture?
Signs of raised ICP:
- decreased LOC
- hypertension
- bradycardia
- focal neurologic defect or seizure
- petechiae (suggest TCP)
- overlying infection (cellulitis)
- spina bifida
123
A child who is known to be allergic to peanuts presents to emergency after having eaten some 30
minutes ago. He is very itchy and has hives all over his body. His vitals including BP are stable and
there is no wheezing. Which of the following is correct?
a) IV epinephrine would be the preferred medication
b) Benadryl can be given IV, IM or PO
c) ventolin and Pulmicort should be administered
d) hydrocortisone does not prevent the late onset effects
e) desensitization therapy should be undertaken
d) hydrocortisone does not prevent the late onset effects
B is also true (benadryl can be given PO, IV or IM)
124
```
A 10kg child is brought into the ER unconscious. There is a rhythm on the monitor but no pulse. Which medication should you administer?
A) Atropine 1 mg
B) Atropine 0.1 mg
C) Epinephrine 1/1000 1ml
D) Epinephrine 1/10 000 1ml
```
D) Epinephrine 1/10 000 1ml
Epi 0.1ml/kg for PEA
125
A child is brought into ER unresponsive without a pulse. According to the latest AHA guidelines, what
is the ratio of compression to breaths that should be provided?
E) 30:2
F) 5:1
G) 15:2
H) 5:2
G) 15:2
126
Which of the following is true about management of postoperative pain in children aged 6-10 years:
d. use BP and HR as a guide for when to give pain medications
e. give regular doses of pain meds in the first 24 hours as they cannot reliably report pain
f. they can assess pain meds as required using self report
g. use a visual analog pain scale
g. use a visual analog pain scale
Should also give routine analgesia post-op, but not because the child cannot reliably report pain, more because you anticipate they will have pain and want to stay on top of it
127
Description of child with serum sickness day 10 of abx for URTI, joint pain, anemia, rash, hematuria. Management:
a) Pulse pred
a) IVIG
b) high dose NSAIDS
c) plasmapheresis
b) high dose NSAIDS
Remove triggering drug
steroids can be used for severe symptoms
128
What are the cardinal features of serum sickness?
rash, fever, polyarthritis (thin serpiginous bands of erythema)
- presents in 1-2 weeks after starting triggering agent (contains animal serum - foreign serum protein)
129
Kid with kawasaki disease. Received IVIG and asa. Now has hemolysis. Massive hematuria. Low
haptoglobin. GN picture. High bili and LDH and liver enzymes
1) renal vein thrombosis from thrombocytosis
2) hemolysis from IVIG
3) ASA mediated platelet dysfunction
4) Kawasaki mediated GN
2) hemolysis from IVIG - occurs in 10% of people getting IVIG
- increased bill, LDH and low haptoglobin all in keeping with hemolysis
130
6 year old Greek girl with RR42, 38.8 degrees, RUQ pain, slight tenderness but no guarding. Abdo U/S normal.
a. First presentation of Familial Mediterranean Fever
b. Pleurodynia (Bornholm’s disease)
c. Bacterial pneumonia
d. Appendicitis
c. Bacterial pneumonia
131
year old in the ER with passage of bright red blood mixed in with his stool. Pale looking but otherwise okay. On rectal exam you find blood mixed with stool on your glove. Hemoglobin is 94. Most likely diagnosis:
A) anal fissure
B) bleed from a peptic ulcer
D) Meckel’s diverticulum
D) Meckel’s diverticulum
132
Parents are worried about their 9 year old daughter; she has been snoring a lot
and having episodes overnight where she stops breathing. Polysomnography was done and shows
episodes of significant, severe central apnea. What to do?
a) consult ENT
b) MRI brain
c) brainstem evoked auditory potentials ( hearing test)
d) CPAP overnight
b) MRI brain
133
2 yo found screaming in cottage bedroom under covers. Bat is flying around the room. On exam there are no marks on the child or saliva and PE is normal. What treatment do you offer if any
CDC has recommended that rabies PEP be considered after any physical contact with a bat OR when a bat is found in the same room as a person who cannot give a reliable history (e.g. young children), or is upset (suggestive of contact with bat)
Tx: tetanus prophylaxis if break in skin
- passive immunization with rabies Ig - 20IU/kg - inject around bite site and then into distant limb IM
- immunization with inactivated vaccine at 0, 3, 7, 14 days
134
Retropharyngeal abscess with very poor x/ray (soft tissues neck).
a.) List 2 X-ray findings compatible with retropharyngeal abscess.
b) What makes the xray adequate?
```
a.) List 2 X-ray findings compatible with retropharyngeal abscess.
Increased width of retropharyngeal space
Air fluid level in retropharyngeal space
b) What makes the xray adequate?
- neck extended
- film taken during inspiration
- good penetration
- not rotated
```
135
13 year old girl who was sexually assaulted by a stranger at a party that night. Now in your emerg. 5 things in your management
1. assess and treat for physical injuries
2. psychological assessment and support
3. pregnancy testing and offer emergency contraception (plan B)
4. offer STI testing (HIV, Hep B, Hep C, VDRL) and treatment (hep B vaccine), consider HIV PEP if high risk assaulter, ceftriaxone and azithro empirically for chlamydia and gonorrhoea
5. forensic evaluation (rape kit) - clothing, combed scalp and pubic hair, fingernail clipping, swabs
