KC Peds

Question 1

*Infantile colic question stem.
Definition of colic (3 things).

Answer 1

Crying >3 hours per day
>3 days per week
Longer than 3 weeks

Question 2

*What are 3 clinical features of colic than can help you differentiate from normal crying?

Answer 2

Paroxysmal
Occurs in the evening
Unprovoked
Maximally at 6 weeks

Question 3

*What is the proposed pathophysiology of colic? (3 possibilities)

Answer 3

Alterations in fecal microflora
Intolerance to cow’s milk protein or lactose
Gastrointestinal immaturity or inflammation
Increased serotonin secretion
Poor feeding technique
Maternal smoking or nicotine replacement therapy

(Think 4 options for baby and 2 for mom)

Question 4

*What age does colic resolve?

Answer 4

3-6 months

Question 5

*What are four things a caregiver can do at home to soothe an infant with colic?

Answer 5

Breastfed babies: moms switch to low allergen diet, try probiotics
Bottle: change to hydrolyzed formula
Sucrose solution (whaaaaa?)
Vented bottle

Question 6

*Ddx (6) toxic appearing neonate

Answer 6

THE MISFITS

T: Trauma, tumor, thermal
H: Heart disease, hypovolemia, hypoxia
E: Endocrine (CAH, DM, thyroid)
M: Metabolic disturbances (electrolyte imbalance), DiGeorge (hypercalcemia)
I: Inborn errors of metabolism - ammonia, urea cycle defect
S: Seizures or CNS abnormalities
F: Formula dilution or over-concentration leading to hypo/hypernatremia
I: Intestinal catastrophe (intussusception, volvulus, NEC)
T: Toxins (including home remedies such as baking soda for burping)
S: Sepsis

Question 7

At what age does a child 1) roll over 2) sit 3) stands 4) walks

Answer 7

1) 4 mo 2) 6 mo 3) 9 mo 4) 1 year

Question 8

At what age does a child 1) follow sounds 2) recognizes parents 3) babbles 4) says ‘mama’ or ‘dada’ 5) uses >2 words

Answer 8

1) 1 mo 2) 2 mo 3) 6 mo 4) 9 mo 5) 1 year

Question 9

What are the three components to the pediatric assessment triangle? What are 4 specific subcategories of each?

Answer 9

Appearance, work of breathing, circulation to the skin

Question 10

List 4 features on history concerning for child abuse

Answer 10

Box 160.3
History lacking in details, inconsistent story, inconsistent with child’s developmental status, inconsistent between mechanisms and injury

Question 11

List 5 features on physical exam concerning for child abuse

Answer 11

Box 160.4
bruises in precruising infants, patterned marks, bruises to the ears/trunk/inner thigh/or groin, posterior oropharynx lacerations, posterior rib fractures, bucket handle fractures, fractures in a non ambulatory child, fractures in different stages of healing

Question 12

What is the max RR and HR in a 5 year old?

Answer 12

See photo

Question 13

What is the best way to align the pediatric airway

Answer 13

<6 mo: shoulder roll
small child <5 years: no modification needed
>5 years: consider elevating the head

Question 14

What is the narrowest part of the pediatric airway

Answer 14

Subglottic region

Question 15

List 10 anatomic difference in the pediatric airway

Answer 15

Large occiput and head: need shoulder roll
Large tongue: needs jaw thrust and oral airway, easily obstructed
Obligate nose breathers
Superior larynx and anterior cords
Large, floppy epiglottis
Large adenoids and tonsils
Small cricoid cartilage
Subglottic space is narrowest airway
Floppy and dynamic trachea prone to obstruction
Smaller trachea length
Larger stomach with higher lungs
Higher metabolic rate, more prone to desaturation: needs preoxygenation

Question 16

What size endotracheal tube should be used in a child

Answer 16

Age/4 +4 (-0.5 if cuffed)

Question 17

What distance should an endotracheal tube be advanced

Answer 17

3* uncuffed tube size

Question 18

Describe the process for transtracheal jet ventilation

Answer 18

Used in children <6 in whom the cricothyroid membrane is not yet well developed. This is used as a bridge to a surgical airway.
1. Attach a 10cc syringe to a short angiocath
2. Palpate the cricothyroid membrane and prep the skin
3. Insert the angiocath down through the cricothyroid membrane 30-45 degrees caudally while aspirating back
4. Slide the plastic IV cannula into the trachea until the hub reaches the skin
5. Remove the needle and syringe
6. Connect the angiocath to a 3ml syringe with the plunger out and a 7.5ETT connector
7. Ventilate and bag through the needle

Question 19

List the pediatric doses for RSI for etomidate, ketamine, propofol, rocuronium, and succinylcholine

Answer 19

Etomidate 0.3 mg/kg
Ketamine 1-2 mg/kg
Propofol 3 mg/kg
Rocuronium 1-1.2 mg/kg
Succinylcholine 2 mg/kg if under 11 then 1.5
Midaz - 0.3mg/kg
Suggamdex 16mg/kg
Lidocaine 1.5 per rosens box 1 per ACLS
Atropine 0.02mg to dose of 0.5

Question 20

List 5 techniques to decrease the pain of local anesthetics

Answer 20

Box 162.1
Use a topical agent prior to injection
Use the smallest possible needle
use a warmed solution
Inject slowly
Inject into the subcutaneous space, not the dermis
Minimize the number of punctures
Inject through open wounds, not through intact skin
Buffer the anesthetic with bicarb

Question 21

List 3 categories of topical anesthetics

Answer 21

EMLA (lidocaine, prilocaine)
LET (lidocaine, epinephrine, tetracaine)
Vapo-coolant

Question 22

What is the maximum dose of lidocaine, lidocaine with epi, and bupivacaine

Answer 22

Lidocaine: 4-4.5/kg
Lidocaine with epi: 7 mg/kg
Bupivacaine: 3mg/kg

Question 23

How long should patients be fasting in the ED prior to sedation

Answer 23

ACEP: “procedural sedation not be delayed in adults or children receiving care in the emergency department based upon fasting time”

Question 24

List the pediatric dose for morphine, hydromorphone, and fentanyl

Answer 24

Morphine 0.1mg/kg IV
Hydromorphone 0.015 mg/kg IV
Fentanyl 2 mcg/kg IV

Question 25

*Define ALTE/BRUE

Answer 25

The term BRUE is defi ned as an event occurring in an infant younger than 1 year when the observer reports a sudden, brief, and now resolved episode of ≥1 of the following: (TRACtor) (1) Tone - marked change in tone (hyper- or hypotonia) (2) Respirations - absent, decreased, or irregular breathing; (3) Altered level of responsiveness (4) Cyanosis or pallor;

Question 26

*List 2 evidence based criteria for admission of ALTE/BRUE

Answer 26

If patient is not low risk. Low risk criteria include: Prematurity: gestational age ≥32 weeks and postconceptional age ≥45 weeks • First BRUE (no previous BRUE ever and not occurring in clusters) • Duration of event <1 minute • No CPR required by trained medical provider • No concerning historical features • No concerning physical examination findings

Question 27

*List 8 risk factors for SIDS

Answer 27

Age <1 year (maximum at 2-4mo) Smoking Not sharing a room Co-sleeping Bundling Soft objects in crib Belly sleeping Soft sleep surface Crib bumpers Parental alcohol/drug use and bed sharing Low SES

Question 28

*Ddx ALTE/BRUE (7)

Answer 28

Anemia Infection Dehydration Hypoglycemia Metabolic disorder Brain mass Brain hemorrhage Seizure Non-accidental trauma Arrythmia Congenital heart defect ## Footnote Good babies rarely seize or NAP (T)

Question 29

What is the compression ratio in infants, children, and adults

Answer 29

15:2, 15:2, 30:2 (if no advanced airway; if advanced airway continuous compressions with breath every 3-6 seconds)

Question 30

What shock should be used for defibrillation

Answer 30

first shock 2J/kg, second shock 4J/kg, up to a max 10J/kg or adult dose

Question 31

What is the dose for epinephrine, amiodarone, and lidocaine in pediatric ACLS

Answer 31

Epi 0.01 mg/kg (1:10,000) Amiodarone 5mg/kg Lidocaine 1 mg/kg

Question 32

List the 5 Hs and Ts of ACLS

Answer 32

Hypovolemia, hypoxia, hydrogen ion (acidosis), hypoglycemia, hypo/hyperkalemia, hypothermia Tension pneumo, tamponade, toxins, thrombosis (pulmonary), thrombosis (coronary)

Question 33

List 5 ways to improve CPR quality

Answer 33

Push hard (>1/3 anterior chest) and fast (100-120 mins) and allow for complete chest recoil Minimize interruptions in chest compressions Avoid excessive ventilation Rotate compressors every 2 mins or sooner if fatigued Ventilate at 15:2 if no advanced airway

Question 34

What dose of electricity is used in cardioversion

Answer 34

1-2J/kg

Question 35

In the context of pediatric bradycardia, when should CPR be started

Answer 35

HR <60

Question 36

What is the pediatric dose of atropine

Answer 36

0.02 mg/kg to a max of 0.5,g

Question 37

What is SIDS

Answer 37

Unexpected death of an infant <1 year for which no pathologic cause can be determined

Question 38

List 5 differentials for BRUE

Answer 38

Gerd, URTI with apnea, coughing, choking, periodic breathing, oral dysphagia, breath holding, seizures, infections, congenital heart disease, non accidental injuries, hypoglycemia, tox

Question 39

Calculate: Pediatric ETT size ETT depth of insertion Chest tube size OG size NG size

Answer 39

Age/4 + 4 (uncuffed) or Age/4 + 3.5 (cuffed) 3 x ETT size 4 x ETT size 2 x ETT size 3 x ETT size

Question 40

List 3 qualities of skull fractures that make them more significant

Answer 40

Depression, over a vascular channel (middle meningeal artery), diastatic fracture (through a suture) as a cyst may develop at this site

Question 41

Describe 3 types of scalp hematomas seen in peds

Answer 41

Caput succedaneum: hematoma in the connective tissue layer, freely mobile, crosses suture lines Subgaleal hematoma: within the loose areolar tissue above the periosteum Cephalohematoma: collection of blood under the periosteum, does not cross suture lines

Question 42

List signs of increased ICP in infants and children

Answer 42

ALL: altered LOC, persistent emesis, papilledema, posturing Infants: full fontanel, split sutures, irritability, sun setting eyes (bilateral downward gaze within an inability to elevate superiorly) Children: headache, stiff neck, photophobia

Question 43

Describe how to clear a pediatric C spine

Answer 43

Canadian C spine rule can be used in children >8  As per Trauma association of Canada C spines can be cleared clinically using NEXUS + pain free ROM assessment  Plain radiographs are the initial imaging of choice If getting a CT head consider doing C spine up to C3 to minimize damage to the thyroid"

Question 44

How do you distinguish between true and pseudo subluxation at C2/C3

Answer 44

Spinolaminar line of C1-3, If the line crosses C2’s anterior cortical margin by less than 2 mm, (and no cervical soft tissue swelling and no fracture is seen) the image demonstrates pseudosubluxation

Question 45

List the doses of resuscitation fluids

Answer 45

Crystalloid 20 ml/kg, pRBC 10 ml/kg, platelet 10 ml/kg, FFP 10 ml/kg

Question 46

List 3 sites for a pediatric IO

Answer 46

Proximal tibia, proximal humerus, distal femur

Question 47

List injuries associated with lap belt and bike injury with handlebars.

Answer 47

Lap belt (hollow viscus, diaphragmatic hernia, Chance fractures) Bike injury with handlebars: duodenal hematoma, pancreatic (delayed 24h)

Question 48

Indications for laparotomy in pediatric trauma.

Answer 48

HD Unstable despite resus + appropriate ED procedures (eg decompression of HTX/PTX) HD Unstable despite resus + positive FAST  Radiographic evidence of Pneumoperitoneum/ Bladder rupture / Grade V renovascular injury  GSW to the abdomen Evisceration of abdominal contents Peritonitis

Question 49

*3 inclusion criteria for PECARN CT head rule

Answer 49

Children < 18 years Head trauma Within 24h

Question 50

*4 exclusion criteria for PECARN CT head rule

Answer 50

Trivial injury Penetrating trauma Brain tumours Pre-existing neuro disorders Neuroimaging at outside hospital before transfer

Question 51

Outline low risk and high risk features for PECARN rule for <2 years and >2 years of age. What is reccomended for each stage?

Answer 51

Acting normally No LOC (or less than 5s) Frontal hematoma No vomiting No headache Minor mechanism

Question 52

*What is an impact seizure

Answer 52

A brief seizure that occurs immediately after an insult (with rapid return to normal level of consciousness) is commonly called an impact seizure.

Question 53

*Does an impact seizure change management?

Answer 53

CPS: Patients with impact seizures or an isolated post-traumatic seizure shortly after the event, but whose neurological examination and imaging are normal, are at low risk of further complications and may be discharged.

Question 54

*3 Reasons why pediatric patients are more at risk for intra-abdominal injuries

Answer 54

Children have proportionally larger solid organs, less subcutaneous fat, and less protective abdominal musculature than adults. Therefore they have relatively more solid-organ injury. Children have relatively larger kidneys with fetal lobulations that predispose them to renal injury. Children also have a fairly flexible cartilaginous rib cage that allows for significant excursion of the lower chest wall, permitting compression of the internal organs.

Question 55

*List the high risk criteria for CATCH (4)

Answer 55

W – Worsening Headache I – Irritability G – GCS <15 2 hours after the injury S – Suspected open/depressed skull # medium risk: S – Skull # D – Dangerous mechanism (MVC, fall >3ft or 5 stairs, bike accident without helmet) H – Hematoma (boggy)

Question 56

*Mechanism of chance fracture in pediatrics?

Answer 56

Lap belt

Question 57

*2 injuries associated with chance fractures?

Answer 57

Diaphragmatic hernia Small bowel injury

Question 58

*Name 5 differences between the pediatric and adult cspine

Answer 58

Higher anatomic fulcrum (c2-c3) More lax ligaments of the cervical column. This leads to an increased risk of SCIWORA. Flatter facet joints with a more horizontal orientation. Relatively larger head size, resulting in greater flexion and extension injuries. Incomplete ossification/fusion Relatively large occiput in children younger than 2 years old leads to flexion of cervical spine if they are laid flat on standard backboard without support under their scapula and pelvis. Smaller neck muscle mass with ligamentous injuries more common than fractures.

Question 59

Describe how to calculate APGARS

Answer 59

see photo

Question 60

List the equipment to assemble in a neonatal resuscitation

Answer 60

Radiant warmer, blankets, towels, plastic wrap  (use if baby <32 weeks) - Suction, bulb syringes (10-12Fr) - Oxygen (heated) - Cardiac and O2 monitors (paediatric sized)  - BMV with pressure gage  - Masks, laryngoscopes (Miller 0 and 1), ET tubes (2.5-3.5), CO2 detector, LMA (size 1) - Meconium aspirators - IV infusion equipment, including umbilical catheters

Question 61

Describe the appropriate endotracheal tube size to use in a neonate

Answer 61

see photo Roughly age in weeks/10

Question 62

What is the targeted preduct SpO2 after birth at 1 min, 3 min, and 10 mins

Answer 62

60-65%, 70-75%, 85-95% (goes up by 5% every 5 mins up to 5 mins)

Question 63

What side does the preductal sat go on

Answer 63

R arm

Question 64

List 5 corrective maneuvers to improve ventilation in a neonate

Answer 64

MR. SOPA: Mask adjust, reposition airway, suction, open mouth, pressure increase, alternatives (LMA/ETT)

Question 65

When delivering a baby, when can the infant go directly to the mother

Answer 65

Term, good tone, breathing or crying

Question 66

When is suctioning recommended?

Answer 66

Routine suctioning of meconium is not recommended Suction if: meconium + poor tone, poor respiratory effort, bradycardia <100bpm after 1 min PPV Avoid routine suctioning as this can cause vagal stimulation and bradycardia Suction the mouth before the nose (prevents aspiration)

Question 67

When should babies be put directly in a plastic bag

Answer 67

<32 weeks

Question 68

What are initial respiratory settings for PPV - for NRP

Answer 68

RA (21% O2), PIP 20-25, PEEP 5 If preterm start at 21-30%; up to 100% if compressions started

Question 69

When should compressions be started as per NRP

Answer 69

HR <60 after 15 seconds of PPV that moves the chest, and after a secure airway

Question 70

What is the limit of fetal viability

Answer 70

22 weeks or 400g

Question 71

Describe the process for obtaining umbilical vein access

Answer 71

1. Flush a 3.5-5F umbilical catheter with NS and attach to a stopcock  2. Clean the cord base (~1-2cm above the skin line). There will be 2 arteries and 1 vein  3. Advance the catheter until there is flashback (at the level of the liver. Measure from diploid to umbilical and add 1-2cm or measure total body length/6+1-2cm 4. Then pull back until you are 4cm deep (you do not want to deliver any epinephrine to the liver). Tip can be confirmed with X ray 5. Place a constricting loop of umbilical tape at the cord base (do not compromise skin)

Question 72

*26 day old with rhinorrhea and fever; otherwise well. Temperature 38.3ºC. What 5 laboratory tests are indicated?

Answer 72

Blood culture Urine culture/analysis LP CBC/CRP NPS

Question 73

*What treatment would you give (febrile neonate)? Be specific with dose, frequency, and duration

Answer 73

- Ampicillin (300 mg/kg/24 hours, divided every 6 hours) - Gentamicin (4-5 mg/kg/24 hours q24h)

Question 74

*If all testing comes back negative, now what?

Answer 74

Admission pending cultures

Question 75

*Risk of SBI in child less than 1 month old

Answer 75

about 10%

Question 76

*5 organisms that cause SBI in neonates? (3 most common?)

Answer 76

1. Group B strep 2. E. Coli 3. Listeria 4. Gonorrhea 5. Chlamydia | LEGS - listeria, E coli, GBS, sexual (G/C)

Question 77

*5 maternal historical factors increasing suspicion for SBI?

Answer 77

1. Lack of antenatal care 2. Positive GBS swab during T3 3. Maternal antepartum fever 4. Prolonged rupture of membranes (PROM) 5. Instrumentation during delivery Three things that have to do with mum and then 2 ways you actually give it to the baby

Question 78

*5 causes of head and torso petechiae in febrile neonate

Answer 78

1. Meningococcal septicemia 2. Straining / coughing / vomiting 3. Non-accidental trauma (shaking, choking, etc) 4. ITP 5. Trauma from birth 6. RhD alloimmunization 7. RMSF 8. pneumococcal bacteremia 8. Streptococcus pyogenes infection 9. Leukemia 10. DIC

Question 79

*Antibiotic treatment for febrile 22 day old

Answer 79

- Ampicillin (300 mg/kg/24 hours, divided every 6 hours) - Gentamicin (4-5 mg/kg/24 hours q24h)

Question 80

*What are 5 criteria of simple febrile seizure

Answer 80

< 15 min in duration Single seizure in 24 hrs Nonfocal, generalized tonic-clonic seizure Occurs in neurologically and developmentally normal child Between 6 months and 6 years of age

Question 81

*What are 3 criteria of complex febrile seizure.

Answer 81

- More than one seizure in 24-hour period - Seizures lasting longer than 15 minutes - Seizures have focal component

Question 82

*What percentage of patients will have recurrence of febrile seizure

Answer 82

30%

Question 83

*2 other drugs and route (not dose) to give for seizure in peds

Answer 83

- Diazepam PR/IV - Midazolam IM/IN/buccal/IV - Lorazepam IV

Question 84

*3 other meds aside from benzos that you can give IV for seizure (you can assume airway is managed)

Answer 84

- Fosphenytoin - Levetiracetam (e.g. Keppra) - Phenobarbital - Propofol

Question 85

*Most common cause of serious bacterial infection in infants

Answer 85

UTI

Question 86

*Organisms that cause SBI in 1-3month olds

Answer 86

o - Haemophilus influenzae o - Streptococcus pneumonia o - Neisseria meningitidis o - Escherichia coli ## Footnote Add in the meningitis bugs HENS

Question 87

*What are 6 features in 29-90 day old infants that make them low risk

Answer 87

o Previously healthy infant o Nontoxic clinically o No focal source of infection o Normal WBC (between 5000 and 15,000 WBCs/mm3) o Fewer than 1500 bands/mm3 o Normal urinalysis o Normal CSF, if obtained

Question 88

*Disposition for low risk infant with fever

Answer 88

Home with reassessment in 24h

Question 89

*What are 5 risk factors for UTI in children

Answer 89

febrile girls <24 months old uncircumcised boys <12 months old circumcised boys <6 months old) vesicoureteral reflux hypospadias

Question 90

*What treatment regimen would you use for suspected HSV encephalitis in neonate?

Answer 90

- Ampicillin (300 mg/kg/24 hours, divided every 6 hours) - Gentamicin (4-5 mg/kg/24 hours q24h) - Cefotaxime (200mg/kg/day divided q6h) - Acyclovir (60 mg/kg/24 hours divided every 8 hours)

Question 91

*Five maternal/obstetrical risk factors for vertical HSV transmission?

Answer 91

- Active genital lesions at or near time of delivery - Prodromal symptoms at or near time of delivery - Primary maternal HSV infection - Premature delivery - Invasive fetal monitoring

Question 92

*List 6 clinical findings that make you suspect HSV in a neonate?

Answer 92

- Maternal history of HSV - Cutaneous vesicles on physical examination - CNS disease: seizure, lethargy, irritability, tremors, poor feeding - Ill-appearing or sepsis syndrome (i.e. disseminated disease) - Transaminitis - Coagulopathy (i.e. thrombocytopenia) - CSF pleocytosis (i.e. high lymphocytes)

Question 93

*What are 5 non infectious causes of fever in peds

Answer 93

Bundling, environmental, leukemia, lymphoma, neuroblastoma, juvenile rheumatoid arthritis, thyroid storm, tox

Question 94

What is the least sensitive modality for measuring a fever (i.e. which method should have the lowest threshold)

Answer 94

Axillary -> oral -> tympanic -> rectal

Question 95

14 day infant comes in with a fever. What workup is appropriate

Answer 95

Full septic w/u: blood cultures, urinalysis, LP, CXR - even in the presence of an identified source

Question 96

14 day infant comes in with a fever. What is the drug therapy of choice?

Answer 96

Ampicillin 50mg/kg with cefotaxime 50mg/kg or gentamicin +/-acyclovir 20mg/kg if HSV.

Question 97

2 mo infant comes in with a fever. What organisms commonly cause SBI

Answer 97

Haemophilus, Ecoli, Strep pneumo, Neisseria meningitidis Think Gen H

Question 98

Briefly describe the Rochester criteria

Answer 98

Sn 81. Derived for 0-2mo population. If well infant, >37 weeks gestation, previously healthy, no evidence of AOM/SSTI/bone/joint infection, normal labs (WBC <15000, Urine, stool) can be d/c with reliable parents for f/u in 24 hours This is the one most commonly used in Eds as Boston and Philadelphia require LPs and step by step requires procalcitonin

Question 99

4mo infant comes in with a fever. What investigations are necessary?

Answer 99

None; investigate source only as directed, most fevers represents a self limited virus

Question 100

According to the step by step algorithm, which children should get a full septic workup

Answer 100

looks unwell, ≤ 21do, leukocyturia, elevated ANC >10,000/CRP >20/procalcitonin

Question 101

List 5 clinical clues that suggest the presence of HSV infections in infants

Answer 101

maternal hx of genital HSV lesions, vesicles, mucous membrane ulcers, seizures, hypothermias, leukopenia, thrombocytopenia, elevated liver enzymes

Question 102

Briefly describe the Philadelphia criteria

Answer 102

Sns 98% Sp 42%. Infants 29-60 days old; all well looking. All got BW + urine + CSF. If low risk home w/o antibiotics

Question 103

Briefly describe the Boston criteria

Answer 103

Sn and Sp not available. Infants 28-89 days old; all well looking. All got BW + urine + CSF. If low risk home with antibiotics

Question 104

*What is the most common pathogen that causes croup? What are 4 others?

Answer 104

- Parainfluenza virus - RSV - Influenza A - Influenza B - Rhinovirus - Adenovirus - Measles - Enterovirus

Question 105

*What are 4 emergency department management priorities for a child with croup?

Answer 105

- Glucocorticoids (dexamethasone 0.15- 0.6 mg/kg) - Aerosolized epinephrine (indicated if stridor at rest) - Limit anxiety - Fever reduction - Encourage oral intake - Monitor for improvement/decompensation

Question 106

*3 year old, febrile, drooling, stridor, no cough. Dx and causative organism.

Answer 106

Epiglottitis, H flu (even still)

Question 107

*3 year old, febrile, drooling, stridor, no cough. Appears toxic and doesn't improve with inhaled/oral Tx. Dx and causative organism.

Answer 107

Bacterial tracheitis, Staph aureus/polymicrobial

Question 108

*This child does not have croup. List 4 other potential causes of stridor

Answer 108

Supraglottic diseases - Acquired: RPA, PTA, Ludwig’s angina, epiglottitis, foreign body, anaphylaxis, upper airway trauma, upper airway burn - Congenital: macroglossia (Down syndrome), micrognathia (Pierre Robin, Treacher-Collins), choanal atresia, thyroglossal cyst Glottic diseases - Acquired: laryngeal papilloma - Congenital: laryngomalacia, laryngeal web, vocal cord paralysis Subglottic diseases - Acquired: airway foreign body, croup, bacterial tracheitis - Congenital: subglottic stenosis, subglottic hemangioma, tracheomalacia, tracheal stenosis, vascular ring

Question 109

*3 year old with stiff neck. Non toxic. Injected pharynx. Most likely Dx?

Answer 109

Retropharyngeal abscess

Question 110

*2 imaging tests for RPA

Answer 110

o Soft tissue neck X-ray, lateral and AP o Soft tissue neck CT scan

Question 111

*2 causes of RPA

Answer 111

o An abscess may result from direct trauma (e.g. toothbrush), o contiguous spread of infection, or o hematogenous seeding

Question 112

*Four bacteria most likely in RPA

Answer 112

o Group A streptococcus o Staphylococcus aureus (including MRSA) o Haemophilus influenzae o Fusobacteria

Question 113

*For each of the following clinical scenarios, name the most likely diagnosis and causative organism. a. Child with barky cough and stridor, improved on way to ED b. Child with dysphagia and stridor, not responding to epinephrine c. Child with bilateral cervical adenitis and exudate on tonsils d. Child with torticollis, fever, and URTI sx. e. Tripod position and drooling.

Answer 113

a. Croup b. Bacterial tracheitis c. Strep pharyngitis d. RPA e. Epiglottitis/FB

Question 114

*What are immediate management steps in someone with epiglottis

Answer 114

DO NOT DISTURB THIS CHILD - airway risk; requires immediate ENT consultation - Provide oxygen and epi neb if tolerated, contact experts for consideration of intubation or tracheotomy - try to AVOID intubation in the ED, instrumentation may cause laryngospasm - Ceftriaxone +/- vancomycin +/- steroids - Adults tend to be more stable as their airways are larger  Intubation - Maintain the patient upright in a position of comfort - Awake intubation with light sedation (1mg midazolam) - Consider glycopyrrolate 0.2mg intravenously - Flexible laryngoscopy is preferred as it provides the most minimally invasive view of the airway - Backup adjuncts for surgical airway

Question 115

What age range is associated with retropharyngeal abscess

Answer 115

Children <6

Question 116

What is the normal prevertebral soft tissue space in children

Answer 116

C2 <6mm C6 <14 mm (22 in adults)

Question 117

What are the recommended antibiotics in retropharyngeal abscess

Answer 117

Clinda + ceftriaxone

Question 118

What is the most common x ray finding in epiglottitis? The most specific?

Answer 118

Most common: normal (70%) Most specific: epiglottic width >8mm or aryepiglottic folds >7mm

Question 119

What is the most common cause of stridor in infants

Answer 119

Laryngomalacia

Question 120

What is the narrowest part of the pediatric airway

Answer 120

Subglottic region

Question 121

What are indications for admission in croup

Answer 121

Question 122

Name two conditions associated with primary tracheomalacia

Answer 122

Down syndrome, DiGeorge syndrome

Question 123

How can you differentiate between tracheomalacia and tracheal stenosis

Answer 123

Tracheal stenosis should worsen with age as the tracheal diameter is fixed Tracheomalacia should improve with age as the cartilage strengthens

Question 124

List 3 secondary causes of tracheomalacia

Answer 124

Vascular ring, cyst, lymphoma, lymphadenopathy

Question 125

What is the clinical presentation of bacterial tracheitis

Answer 125

Croup-like symptoms that worsen; fever, stridor, cough, toxic appearance Needs bronchoscopy for diagnosis and therapy (tracheal debridement)

Question 126

What organisms cause croup

Answer 126

Parainfluenza virus accounts for 50% to 75% of cases; respiratory syncytial virus, influenza A and B viruses, and rhinovirus cause the remainder

Question 127

*4 things on PRAM score

Answer 127

- Oxygen saturation - Suprasternal retractions - Scalene contractions - Air entry - Wheezing

Question 128

*PRAM of 7 represents what degree of asthma exacerbation?

Answer 128

Moderate

Question 129

*2 MOST important treatments and route (Tx moderate asthma exacerbation)

Answer 129

- Salbutamol (via MDI or nebulizer) - Dexamethasone (PO)

Question 130

*10 causes of wheeze in children

Answer 130

- Asthma - Viral bronchiolitis - Bacterial tracheitis - Acute laryngotracheobronchitis - Epiglottitis - Acute bronchitis - Pneumonia (e.g. viral, bacterial, TB) - Foreign body aspiration - Heart failure - Aspiration/reflux - Anaphylaxis

Question 131

*3 initial management steps with drug doses and details for moderate asthma

Answer 131

- Ventolin 8 puffs via MDI - Ipratropium 8 puffs via MDI - Dexamethasone 0.3 mg/kg PO (rest given as second dose at home)

Question 132

*3 things on an outpatient prescription for child with recurrent asthma attacks

Answer 132

Salbutamol 2 puffs q4h PRN Fluticasone 100ug ihn BID x3 months Dexamethasone 0.3 mg/kg PO

Question 133

What should the PCO2 be in an asthmatic

Answer 133

Decreased; normal PCO2 is an ominous finding; indicates respiratory fatigue. PCO2 should be decreased with hyperventilation

Question 134

What are three physiologic reasons children are more at risk for severe asthma exacerbations?

Answer 134

Compliant chest walls -> less able to increased tidal volume. Increased RR may quickly lead to fatigue. Higher oxygen consumption needs and faster desaturations

Question 135

What is the dosing for ventolin in pediatrics

Answer 135

Question 136

What is the dose of magnesium in asthma exacerbations

Answer 136

50mg/kg max 2 g

Question 137

Describe the components of the PRAM score

Answer 137

see photo

Question 138

What PRAM scores correspond to a mild, moderate, and severe exacerbation

Answer 138

Mild 0-3, moderate 4-7, severe 8+

Question 139

What is the dose of IV ventolin

Answer 139

<10kg 25mg salbutamol in 50ml syringe >10kg 50mg salbutamol in 50ml syringe Continuous infusion 1-10 mcg/kg/min

Question 140

List 4 populations at risk of severe bronchiolitis

Answer 140

Premature infants, <3 mo age, comorbid disease ex. Congenital cardiac, immunocompromised

Question 141

Describe the management of bronchiolitis

Answer 141

Hydration, supplemental O2 as necessary - Equivocal: mild suctioning, 3% saline, epi nebs + dex, epi nebs - Not recommended: Ventolin, antibiotics, steroids, antivirals, normal saline nebs

Question 142

*Recognize pneumonia on lateral peds CXR. Most likely organism?

Answer 142

Strep pneumonia

Question 143

*What is the name of the antibiotic, the dose, the route, and for how long would you treat peds pneumonia?

Answer 143

Amox 90mg/kg divided TIDD for 10 days

Question 144

*PNA on peds CXR, if patient has SCD, what should you consider?

Answer 144

Acute chest syndrome

Question 145

*What is the treatment of acute chest syndrome (peds)?

Answer 145

Oxygen for sat >95 Antibiotics Fluids PRN Analgesia Transfusion if anemic +/- exchange transfusion ?consult heme

Question 146

What is the most common cause of CHD in infants

Answer 146

Acyanotic: VSD. Cyanotic: ToF

Question 147

What cardiac abnormalities will have increased pulmonary blood flow on CXR

Answer 147

Increase in blood flow suggest s L to R shunt Acyanotic: ASD, VSD, Eisenmenger's syndrome, PDA, endocardial cushion defects Cyanotic: transposition of great arteries, total anomalous pulmonary venous return, hypoplastic left heart syndrome, truncus arteriosus

Question 148

What cardiac abnormalities will have decreased pulmonary blood flow on CXR

Answer 148

Acyanotic: pulmonic stenosis, aortic stenosis, coarction of the aorta Cyanotic: ToF, severe pulmonic stenosis, Ebstein's anomaly, tricuspid atresia, pulmonary atresia, hypoplastic right heart

Question 149

*Kawasaki criteria

Answer 149

Fever for 5 days plus: ● 4 of: ○ CREAM ■ Conjunctivitis ■ Rash ■ Extremity changes (edema/palmar rash) ■ Adenopathy (cervical) ■ Mucous membrane changes

Question 150

*The least common finding of Kawasaki disease criteria

Answer 150

Cervical Adenopathy

Question 151

*Typical age group for incomplete Kawasaki

Answer 151

<6months

Question 152

*2 treatments for Kawasaki

Answer 152

IVIG and ASA

Question 153

*Percentage of patients with Kawasaki that get coronary aneurysm

Answer 153

1) treated; 2% 2) untreated 20%

Question 154

*3 bedside tests you can do to determine CHD and which CHD lesion

Answer 154

- Hyperoxia challenge: Differentiating pulmonary disorders from cardiac disorders - Pulse delay or absence: Decreased femoral pulses may suggest coarctation of the aorta - Blood pressure differential: Difference between preductal (i.e. right arm) blood pressure and lower extremity blood pressure > 10 mmHg, think of an obstructive process

Question 155

*3 causes of ductal cyanotic lesions

Answer 155

• Any infant < 1 month of age with cyanosis or shock should be considered to have a ductal-dependent critical congenital heart disease until proven otherwise. • As the ductal arteriosus closes, cardiac defects with obstructive lesions of the pulmonary or systemic circulations will be unmasked: - Tetralogy of Fallot (CXR: Boot-shaped heart) - Tricuspid atresia - Pulmonary atresia - Total anomalous pulmonary venous return (snowman) - Transposition of the great vessels (CXR: Egg on a string)

Question 156

*2 causes of ductal shock (cyanotic and shocky in first weeks of life)

Answer 156

- Severe coarctation of aorta - Severe aortic stenosis

Question 157

*3 side effects of prostaglandins

Answer 157

- Apnea - Hypotension - Bradycardia - Flushing - Fever

Question 158

*1 week old presents with cyanosis: 6 cyanotic heart lesions

Answer 158

Transposition of the great arteries Total anomalous pulmonary venous return Tricuspid atresia Ebstein's anomaly of the tricuspid valve Truncus arteriosus Pulmonary atresia Hypoplastic right heart syndrome Hypoplastic left heart syndrome Tetralogy of Fallot

Question 159

*Why do patients present with cyanosis in a delayed fashion?

Answer 159

Gradual closure of the ductus arteriosus connection between the pulmonary artery and aortic arch (fully closed at 3 weeks)

Question 160

*What is the one treatment to give to a newborn presenting with cyanotic heart lesion?

Answer 160

Prostaglandin IV 0.1 mcg/kg/min

Question 161

*Differential of enlarged mediastinum on CXR in 1 year old with chronic cough

Answer 161

- TB - Teratoma - Thymoma - Lymphoma - Congenital heart disease - Thyroid goiter

Question 162

*How to perform the hypoxia test

Answer 162

ABG is performed after several minutes on high-flow oxygen (100% oxygen), with a PaO2 of more than 250 mmHg excluding hypoxia due to congenital heart disease PaO2 less than 100 mmHg in a child without obvious pulmonary disease is consistent with a right-to-left shunt

Question 163

*3 abnormal lab values in Kawasaki

Answer 163

Elevated CRP/ESR Albumin ≤3 g/dL Anemia for age Platelet count of ≥450,000/mm 3 White blood cell (WBC) count ≥15,000 mm 3 Elevation of alanine aminotransferase Sterile pyuria of ≥10 WBCs per high-power field ## Footnote PAWAPA

Question 164

*What are the abnormalities in TOF?

Answer 164

(1) right ventricular outflow tract obstruction (2) large, unrestrictive, misaligned VSD (3) over-riding aorta that receives blood flow from both ventricles (4) right ventricular hypertrophy secondary to the high pressure load placed on the right ventricle by the right ventricular outflow tract obstruction

Question 165

*3 general principles in management of a Tet spell?

Answer 165

- Increase the SVR - Abolish the hyperpnea - Correct metabolic acidosis

Question 166

*4 drugs would you use in management of a Tet spell?

Answer 166

Oxygen Fentanyl or Midazolam Ketamine Sodium Bicarb then propranolol or phenylephrine

Question 167

*What are two non medication interventions you would employ to treat this patient as she is moved into an examining room?

Answer 167

Knees to chest, calm infant in mothers arms

Question 168

*Explain the pathophysiology of a tet spell

Answer 168

Any event that suddenly lowers the SVR, such as crying or defecation, and hypovolemia or tachycardia will produce a large right-to-left shunt across the VSD. This drops the O2, increases the CO2 and drops pH. This causes an increase in RR which drops intrathoracic pressure, increasing venous return and further shunts deoxygenated blood across the VSD.

Question 169

*Name the 2 congenital long QT and the ion channel affected

Answer 169

Romano-Ward (Na+/K+) Jervell–Lange-Nielsen (K+)

Question 170

*4 ECG characteristics that help distinguish SVT from sinus tachycardia

Answer 170

SVT Presence of retrograde P-waves Constant R=R >220 in age < 1yr ; >180 for older children Paroxysmal attenuation Sinus Tach Physiologic variability Beat to beat variability Presence of P-waves. <220 for infants; <180 for children

Question 171

*What would be the next most appropriate management step in the ED for a stable 3w baby with SVT? Then, the intervention does not work and on reassessment the child looks unwell, grey and has a BP of 55/35. What is your next step?

Answer 171

Vagal (ice to face) Then cardiovert 0.5 to 1 J/kg

Question 172

*What pharmacologic intervention can be used for SVT? What are 2 essential aspects of the administration of this medication?

Answer 172

Adenosine (0.1mg/kg), large bore proximal IV with rapid flush.

Question 173

*3 investigations for coarctation of the aorta

Answer 173

4 limb BP, CXR, echo

Question 174

*EKG showing long QT. What 2 antibiotics can cause this?

Answer 174

Macrolides: Erythromycin, clarithromycin Fluoroquinolones: Levofloxacin, moxifloxacin

Question 175

Describe newborn circulation

Answer 175

Umbilical vein -> ductus venosus (shunts liver where deoxygenated fetal blood is returning) -> R atrium -> foramen ovale -> left atrium -> aorta OR R atrium -> right ventricle -> pulmonary arteries -> ductus arteriosus -> aorta Lungs have higher pressure in utero so blood is shunted across the heart

Question 176

Describe changes to circulation at birth

Answer 176

L sided pressure > R side and pulmonary blood flow is restored  - Increased global oxygenation causes a physiologic closure of the umbilical arteries, umbilical veins, ductus venous, doctor arteriosus - Closing foramen oval (complete at 3mo of age) - Ductus arteriosus closes (15 hrs - 2/3 weeks of life) with a decrease in prostaglandins

Question 177

Explain the utility of a 4 limb BP

Answer 177

Blood pressures should normally be higher in the lower extremities SBP > 15-20 mmHg higher in R arm than legs indicative of coarctation or R-to-L shunt across PDA

Question 178

Explain the utility and pre and post ductal sats

Answer 178

Pre ductal (R hand) vs. post ductal (either foot) Pre > post = R-to-L shunt. When post ductal saturations are lower there is a mixing of blood through a shunt Post > pre = TGA with additional anomaly (rare) abN: > 3% difference b/t UE/LE, < 94% LE, < 90% UE/LE

Question 179

Explain the hyperoxia test

Answer 179

After several minutes of 100% O2 a PaO2 >250 demonstrates a “pass,” 100-250 represent mixing, and <100 represent a “fail” due to a right to left shunt Respiratory issues should improve with oxygen and crying

Question 180

List 5 signs that this cyanotic infant has a congenital cardiac abnormality

Answer 180

A "comfortably" blue baby with no respiratory distress Cyanosis that gets worsen with crying or feeding Murmur PaO2 does not rise with hyperoxia test Chest radiograph shoes boot shaped, egg on a string, or snowman shaped heart Upper limb BP > lower limb BP Preductal sat > post ductal sat

Question 181

When do infants with duct dependent lesions present in distress

Answer 181

2-3 weeks

Question 182

Describe the pathophysiology of a tet spell

Answer 182

R sided outflow tract obstruction or lower systemic vascular resistance (ex. crying) leading to R to L shunting through a VSD -> Hypoxia + hyperventilation + acidosis -> increased intrathoracic pressure increases blood flow to the heart, worsening the shunt

Question 183

List 5 management steps for a tet spell. What does propranolol do?

Answer 183

Goal is to increase pulmonary blood flow by increasing after load and causing L->R shunting Flex children’s knees to chest, calm the child, administer oxygen   IV and sodium bicarb to reverse the acidosis Consider intranasal fentanyl or midazolam or ketamine for relaxation Consider phenylephrine to increase SVR Consider propranolol 0.1-0.25 mg/kg IV to reduce infundibular spasm

Question 184

List 5 acyanotic congenital cardiac defects

Answer 184

Increased pulmonary blood flow: L-> R shunt: ASD, VSD, PDA, AVSD, AV malformation Normal pulmonary blood flow: obstruction (this decreases the blood flow to the lung): Coarctation of the aorta, aortic stenosis, pulmonary stenosis, mitral stenosis  

Question 185

List 5 duct dependent lesions

Answer 185

Acyanotic: duct is needed to get the blood to the body because of an obstruction in the left side of the heart of aortic arch ex. AS/AAA, coarct, hypoplastic left heart Cyanotic: duct is needed because there is a structural abnormality on the right side that wont allow them to oxygenate blood ex. TOF, TGA, TA, PS/PA, hypoplastic right heart

Question 186

Describe the physiology, murmur, ecg, chest x ray, and clinical presentation of: tetralogy of fallot

Answer 186

Cyanotic VSD + RV outflow obstruction (pulmonic stenosis) + overriding aorta + RVH Pulmonary stenosis with loud S2 R axis deviation and RVH Boot shaped heart Cyanotic with tet spells

Question 187

Describe the physiology, murmur, ecg, chest x ray, and clinical presentation of: transposition of the great vessels

Answer 187

Cyanotic Separate systemic and pulmonary circulation that worsens as the ductus arteriosus closes: Aorta arises from RV and pulmonary trunk through LV, needs PFO, ASD, VSD, DA for mixing Murmur only if VSD ECG shows R axis deviation and RVH CXR shows egg shaped heart (narrow mediastinum) Cyanotic with CHF if VSD

Question 188

Describe the physiology, murmur, ecg, chest x ray, and clinical presentation of: total anomalous venous return

Answer 188

Cyanotic All pulmonary veins drain into R sided circulation, no pulmonary venous return to L atrium. Leads to RA/RV dilation Murmur fixed S2 (ASD) ECG shows R axis deviation and RVH CXR shows snowman sign Cyanotic with CHF

Question 189

Describe the physiology, murmur, ecg, chest x ray, and clinical presentation of: truncus arteriosus

Answer 189

Cyanotic Single great vessel for the aorta, pulmonary, and coronary arteries Single loud S2 with VSD ECG shows biventricular hypertrophy CXR shows cardiomegaly, increased pulmonary vascular markings Cyanotic

Question 190

Describe the physiology, murmur, ecg, chest x ray, and clinical presentation of: tricuspid atresia

Answer 190

Cyanotic No tricuspid valve, decreasing pulmonary blood flow, R atrium needs an ASD or VSD to empty Murmur is a single S2  ECG shows R and L ventricular hypertrophy CXR shows decreased pulmonary vascular markings Cyanotic

Question 191

Describe the physiology, murmur, ecg, chest x ray, and clinical presentation of: hypoplastic left heart

Answer 191

Cyanotic LV hypoplastic may include atretic or stenotic mitral valve. In utero the R ventricle provides the systemic circulation through the PDA. Essential no aorta; dependent on the duct for systemic circulation  Murmur is an ASD ECG shows R atrial enlargement CXR shows cardiomegaly, CHF Cyanotic

Question 192

Describe the physiology, murmur, ecg, chest x ray, and clinical presentation of: coarction of the aorta

Answer 192

Acyanotic Narrowing of the aorta at the level of the ductus.  Murmur is similar to AS: crescendo-decrescendo ECG shows RBBB, RVH CXR rib notching on chest xray, cardiomegaly, and pulmonary edema Associated with bicuspid aortic valves and Turners. BP difference between the upper and lower extremities, brachiofemoral delay. CHF

Question 193

Describe the physiology, murmur, ecg, chest x ray, and clinical presentation of: VSD

Answer 193

ACyanotic Membranes do not close. Murmur is holosystolic ECG shows LAH, LVH CXR may be normal or may show increased vascular markings Does not present as a newborn due to high R sided pressures

Question 194

What is Eisenmenger's syndrome

Answer 194

A worsening, uncorrected L to R shunt increased pulmonary hypertension and eventually leads to a R to L shunt (cyanotic)

Question 195

Describe the physiology, murmur, ecg, chest x ray, and clinical presentation of: ASD

Answer 195

ACyanotic Membranes do not close. Murmur is pulmonic systolic murmur with a split S2 ECG shows RAD, RVH, RBBB CXR may be normal or may show cardiomegaly with increased vascular markings Often asymptomatic, may lead to severe CHF if severe

Question 196

List 5 post of complications of repaired congenital heart defects

Answer 196

Thrombosis, decreased shunt flow, increased shunt flow, CHF, dysrhythmias, myocardial ischemia, endocarditis, pericarditis

Question 197

Describe 2 innocent murmurs

Answer 197

Pulmonic flow murmur: systolic due to think walls of the pulmonary arteries at birth, should disappear within 3-6 months of age. Tend to be low pitched, soft, systolic Stills murmur: age 2-6, vibratory musical murmur that is different from the harsh murmur of the VSD. Should increase in the supine position, with fever, excitement, exercise, or anemia

Question 198

Describe 2 worrisome murmurs

Answer 198

Diastolic, systolic murmurs that are: louder than 3/6, continuous, or associated with a thrill; murmurs that are associated with abnormal heart sounds ex. Clicks, presence of cyanosis or respiratory distress, bounding or weak pulses, abnormal ECG, abnormal cardiac silhouette

Question 199

List 7 causes of sudden cardiac death in children

Answer 199

Potential causes - Hypertrophic cardiomyopathy - Congenital coronary artery anomalies ex. anomalous left coronary artery, congenital coronary artery hypoplasia - Prolonged QT - Preexcitation syndromes ex. WPW - Aortic rupture secondary to Marfan's syndrome - Dilated cardiomyopathy - Myocarditis - CAD secondary to Kawasaki - Aortic stenosis - Mitral valve prolapse - Blunt trauma

Question 200

Explain the pathophysiology of hypertrophic cardiomyopathy

Answer 200

Obstructive cardiomyopathy involves a thickened muscular intraventricular septum that bulges into the left ventricle and impedes forward flow, causing SOB, syncope

Question 201

What is the ECG criteria for hyperopic cardiomyopathy

Answer 201

LVH via voltage criteria: 11, 25, 35, 45 - R wave in aVL >11, R wave in I and S wave in III >25, R wave in V5, V6, S wave in V1 >35, Largest R wave in precordial limbs >45 L sided changes - L atrial enlargement  - L axis deviation - ST depression and T wave inversions in L sided leads Prominent Q waves in lateral and inferior leads

Question 202

What medications are used to manage hypertopic cardiomyopathy

Answer 202

Beta blockers

Question 203

What is ALCAPA syndrome

Answer 203

ALCAPA Anomalous left coronary artery from the pulmonary artery. Left coronary artier from the PA (deoxygenated blood) 

Question 204

What is the diagnostic criteria for Kawasaki

Answer 204

Vasculitis with risk of coronary aneurysm, can lead to acquired heart disease - Fever >5 days (high fever, may not respond to antipyretics) + MyHEART - Mucosal involvement (fissured lips, strawberry tongue, injected pharynx - Hand and extremity edema of hands and feet (or peeling) - Eyes - Bilateral non exudative conjunctivitis - Adenopathy >1.5cm - Rash (polymorphous) - Rash is NOT pruritic and NOT vesicular - Typically begins on the trunk and spreads to the face and extremities  - Temperature

Question 205

List 3 lab findings that may occur in Kawasaki

Answer 205

high CRP, anemia, elevated ALT, high platelets >450, high WBC >15, pyuria >10 WBC/hpf, low albumin <3.0 | PAWAPA

Question 206

What is the treatment of Kawasaki

Answer 206

IVIG 2g/kg as a single infusion and ASA (80-100mg/kg/day divided in 4 doses), ideally within 10days

Question 207

What is the diagnostic criteria for rheumatic fever

Answer 207

JONES criteria + hx of prior group A strep infection - Major: JONES criteria: joint arthralgias, O carditis (murmur, CHF, pericarditis), nodules, erythema marginatum, Sydenham chorea  - Joint pain is typically migratory in the large joint, with pain out of proportion to the swelling - Erythema marginatum: non-pruritic, ring-shaped, painless - Minor: arthralgia, fever, elevated CRP, long PR FAPER is rheumatic fever, fever, arthalgia, PR long + CRP or ESr

Question 208

*5 causes of neonatal jaundice (unconjugated) other than physiologic/breast milk

Answer 208

Increased hemolysis of RBCs: - ABO incompatibility - Physiologic breakdown of birth trauma hematoma (cephalohematoma) - Intracranial/intraventricular hemorrhage - Spherocytosis, elliptocytosis - Sickle cell anemia - Thalassemia - G6PD deficiency - Pyruvate kinase deficiency Decreased conjugation: - Gilbert syndrome Crigler-Najjar Infectious: - TORCHS infection - Urinary tract infection - Sepsis Obstructive (increased enterohepatic circulation): - Meconium ileus - Hirschsprung's disease - Duodenal atresia - Pyloric stenosis Metabolic or genetic: - Congenital hypothyroidism

Question 209

*5 causes of direct (conjugated) hyperbilirubinemia

Answer 209

Infectious: * TORCHS infection * Urinary tract infection * Gram-negative sepsis * Listeriosis * Tuberculosis * Hepatitis B * Varicella * Coxsackievirus infection * Echovirus infection * HIV infection Obstructive (increased enterohepatic circulation): * Biliary atresia * Choledochal cyst * Bile duct strictures * Inspissated bile syndrome * Neonatal hepatitis * Alagille syndrome * Byler's disease * Congenital hepatic fibrosis Metabolic or genetic: * Galactosemia * Tyrosinemia * Glycogen storage disease type IV * Niemann-Pick disease * Wolman's disease * Gaucher's disease * Cholesterol ester storage disease * α 1 -Antitrypsin deficiency * Cystic fibrosis * Dubin-Johnson syndrome * Neonatal hypopituitarism * Zellweger's syndrome * Donohue syndrome (leprechaunism) * Rotor syndrome

Question 210

*What is kernicterus?

Answer 210

Kernicterus refers to the chronic, long-term neurologic sequelae of BIND (bilirubin-induced neurologic dysfunction) from toxic levels of bilirubin and is characterized by yellow staining of basal ganglia.

Question 211

*What are 3 risk factors for kernicterus ?

Answer 211

Severely elevated bili levels Failure of phototherapy BIND Or Risk factors for the development of severe hyperbilirubinemia: Prematurity (<37 wks GA) Isoimmune-mediated hemolysis ABO incompatibility) Sepsis Cephalohematomas, Dehydration, Genetically inherited abnormalities hereditary spherocytosis glucose-6-phosphate dehydrogenase (G6PD) deficiency.

Question 212

*Kid swallows coin, it is in his esophagus, 3 places where it can get stuck

Answer 212

- Upper esophageal sphincter (cricopharyngeus muscle)* - Aortic arch - Left mainstem bronchus - Lower esophageal sphincter (diaphragmatic hiatus)

Question 213

*3 mechanical ways to get FB out of the esophagus

Answer 213

- If in upper esophagus, Kelly clamps or Mcgill forceps under direct visualization - Pass Foley catheter beyond foreign body, inflate balloon - Esophageal dilator to push foreign body into stomach - Endoscopy

Question 214

*FOUR mechanisms of injury for button battery in esophagus

Answer 214

- Pressure necrosis - Leakage of alkaline electrolyte - Generation of electrical current - May leak mercury ? toxicity

Question 215

*5 indications for further workup of neonatal jaundice

Answer 215

- Jaundice within first 24 hours of life - Elevated direct (conjugated) bilirubin level - Rapidly rising total serum bilirubin unexplained by history of physical examination - Total serum bilirubin approaching exchange level or not responding to phototherapy - Jaundice persisting beyond 3 weeks of age - Sick-appearing infant

Question 216

*10 day old with: Total bilirubin 170 Conjugated bilirubin 50 c. What is the most likely diagnosis? d. What is the next step in management?

Answer 216

Breast milk jaundice. Keep feeding.

Question 217

*Single most important lab test in 4week old jaundiced

Answer 217

Total bili

Question 218

*3 causes of obstructive jaundice

Answer 218

Obstructive (increased enterohepatic circulation): - Meconium ileus - Hirschsprung's disease - Duodenal atresia - Pyloric stenosis Direct: * Biliary atresia * Choledochal cyst * Bile duct strictures * Inspissated bile syndrome * Neonatal hepatitis * Alagille syndrome * Byler's disease * Congenital hepatic fibrosis"

Question 219

*Single best imaging test for obstructive causes

Answer 219

US

Question 220

*3 hematologic causes of jaundice in newborn

Answer 220

ABO incompatibility Physiologic breakdown of birth trauma hematoma (cephalhematoma) Intracranial/intraventricular hemorrhage Spherocytosis, elliptocytosis Sickle cell anemia Thalassemia Glucose-6-phosphate dehydrogenase deficiency Pyruvate kinase deficiency

Question 221

*2 most common causes of jaundice in newborn

Answer 221

Physiologic jaundice Breastfeeding jaundice

Question 222

*Abnormal time frames for jaundice

Answer 222

(a) Anything in the first 24 hrs of life (b) Beyond the first 3 weeks of life

Question 223

*XR findings of intussusception

Answer 223

- Dilated loops of small bowel - Paucity of gas in colon - Target sign - Meniscus sign (i.e. air compressed like meniscus from invaginating bowel) - Free air - Soft tissue density - Obscured liver edge Note: Ultrasound is the diagnostic imaging modality of choice, features of intussusception:

Question 224

*4 other causes of bowel obstruction in children

Answer 224

- Severe constipation - Adhesions from prior surgery - Volvulus - Hirschsprung's - Meckel's diverticulum - Incarcerated hernia - Cancer/mass - FB - Hernia

Question 225

*Causes of LGIB in infancy

Answer 225

Necrotizing enterocolitis Intussusception Gastroenteritis Milk allergy Vascular malformation Meckel's

Question 226

*5 potential causes of intussusception in older child

Answer 226

HSP vasculitis Meckel's diverticulum Lymphoma, polyps Postsurgical scars Celiac disease Cystic fibrosis

Question 227

*Contraindications of air enema

Answer 227

Peritonitis or sign perforation

Question 228

*3 week old with bilious vomiting and double bubble sign on AXR Dx and 3 other causes of obstruction in 3mo old

Answer 228

Duodenal atresia Malrotation with midgut volvulus Meckel's diverticulum Intussusception Bowel obstruction Incarcerated hernia

Question 229

*4 indications for removal of gastric FB

Answer 229

Obstruction Perforation >2 cm wide >5 cm long Containing toxins Inability to pass – not passed stomach x 3-4 weeks, same intestinal location x 1 week or absolutely no change in position in 24hrs Sharp or pointed (toothbrush, bone, pick) High powered multiple magnets

Question 230

*4 lab tests for jaundice in well appearing newborn

Answer 230

Bilirubin total and indirect CBC with smear Coombs

Question 231

*Conjugated hyperbilirubinemia, list 2 tests you would order next in its evaluation

Answer 231

Abdo U/S Blood cultures

Question 232

*Table for causes of LGIB by age (6 months, 2 years, 10 years)

Answer 232

INFANCY Necrotizing enterocolitis Intussusception Gastroenteritis Milk allergy Vascular malformation CHILDHOOD Gastroenteritis Intussusception Meckel's diverticulum Inflammatory bowel disease Vascular malformation Henoch-Schönlein purpura Hemolytic-uremic syndrome Colitis ADOLESCENCE Gastroenteritis Intussusception Meckel's diverticulum Inflammatory bowel disease Vascular malformation Henoch-Schönlein purpura Hemolytic-uremic syndrome Polyps Colitis

Question 233

List 4 side effects of phototherapy

Answer 233

Risks: bronze-baby syndrome, temperature instability, diarrhea, eye protection for the retina, interference with maternal bonding - No risk of UV radiation or dehydration

Question 234

Infants has rising bilirubin despite phototherapy. List 3 next steps

Answer 234

Exchange transfusion (separate nomogram), triple phototherapy, IVIG 

Question 235

What is Gilbert syndrome

Answer 235

Gilbert syndrome: autosomal recessive disorder of UDP glucuronosyl transferase, 5% affected. Normal conjugated, higher unconjugated hyperbilirubinemia. Crigler Najjer syndrome is a more severe type of Gilbert

Question 236

List indications for Emergency Removal of Gastrointestinal Foreign Bodies

Answer 236

[Box 171.3] Signs of respiratory distress Evidence of esophageal obstruction (inability to swallow secretions) Button battery in esophagus Sharp or long >5cm object in the esophagus or stomach High powered magnets Signs of intestinal inflammation, obstruction, or perforation Esophageal foreign bodies impacted for >24 hours or an unknown amount of time

Question 237

What x ray finding is associated with NEC

Answer 237

Pneumatosis

Question 238

What is the clinical presentation of pyloric stenosis

Answer 238

Projectile non bilious vomiting in infants immediately after feeding; seen in 3-5 weeks of ago

Question 239

What is the diagnostic criteria for pyloric stenosis on US

Answer 239

Thickness >3mm and length >14mm PIE-lyric stenosis 3.14 is 3mm thick and 14mm long

Question 240

What lab abnormality is associated with pyloric stenosis

Answer 240

hypochloremia hypokalemic metabolic alkalosis Lose acid so metabolic acidosis and low chloride. Loss K because its turns on RASS and H/K pump at kidney

Question 241

List 4 supportive management strategies for an infant with GERD

Answer 241

avoid cigarettes smoke, anti reflux positioning, smaller and more frequent feeds, thickened bottle feeds, hypoallergenic trial.

Question 242

What is the diagnostic modality of choice for malrotation with volvulus

Answer 242

upper GI contrast series

Question 243

List 3 pediatric conditions associated with bowel obstruction? (3 different locations in GI tract)

Answer 243

duodenal w Down Syndrome, jejunal-ilea w Cystic Fibrosis, Colonic w Hirschsprung disease 

Question 244

What x ray finding is associated with intestinal atresia

Answer 244

double bubble sign (duodenal atresia)

Question 245

List 5 potential lead points for intussusception

Answer 245

lymphoma, Peyer's patches enlarged post viral infection, meckel’s, appendix, post surgical scars, celiac disease

Question 246

What clinical triad is associated with intussusception

Answer 246

pain, palpable abdominal mass, blood in stool

Question 247

What is the treatment for intussusception

Answer 247

air contrast enema

Question 248

List 5 differentials for abdominal pain in each of the following age groups: 1) infancy 2) childhood 3) adolescence

Answer 248

see photo

Question 249

Besides primary functional, list 5 other etiologies for constipation

Answer 249

Neurogenic: Hirschsprung disease, CP, spinal cord injury, infantile botulism Endocrine: CF, electrolyte abnormalities (hypercalcemia), hypothyroid, SM Other: celiac, cows milk allergy

Question 250

What is the definition of colic

Answer 250

Crying >3x/day >3 days/week >3 weeks

Question 251

What clinical tetrad is associated with HSP

Answer 251

Palpable purpura (generally in lower extremities), arthritis/arthralgias (lower extremities, bilateral), abdominal pain, renal disease (hematuria) RAAPP Renal disease (hematuria) Abdo pain Athralgia Palpable Purpura

Question 252

List 5 complications of HSP

Answer 252

GI: intussusception -> which leads to GI bleeding PLUS pancreatitis Renal: nephritis -> Which leads to hypertension

Question 253

List causes of pancreatitis more commonly seen in pediatric patients

Answer 253

Trauma: ex. Bicycle crash, handlebar injuries Infection: EBV, CMV Systemic: autoimmune (Sjogren, IBD, primary biliary cholangitis), cystic fibrosis, sickle cell Drugs: metronidazole, valproate

Question 254

List 10 causes of biliary tract disease in children

Answer 254

Hemolytic disease: sickle cell, spherocytosis (pigment stones from hemolytic anemia are more common than cholesterol stones) Cystic fibrosis Drugs: TPN, ceftriaxone in the newborn Infectious causes: sepsis, RMSF, salmonella, recent URTI, Kawasaki, strep pharyngitis

Question 255

List 5 GI and 5 non GI causes of vomiting in children

Answer 255

GI: obstruction, gasto, peritonitis, hepatitis, appendicitis, pyloric stenosis, midgut volvulus, intussusception, inborn errors of metabolism Non GI CNS: space occupying lesion Tox: ingestion, drug effect Endocrine: Addisonian, diabetic ketoacidosis, CAH Renal: UTI, pyelonephritis, renal failure Cardiac: CHF Infection: pneumonia, OM, sinusitis, sepsis

Question 256

List 5 GI and 5 non GI causes of diarrhea in children

Answer 256

GI: Malabsorption (ex. Milk intolerance), IBD, IBS, short gut, infectious gasto, intussusception, appenditis, HUS, colitis Non GI Drug: ingestion, overdose Endocrine: thyrotoxicosis, addisonian crisis, diabetic enteropathy, CAH Renal: UTI, pyelo Infection: pneumonia, AOM, sinusitis, sepsis

Question 257

Which organisms responsible for infectious gastro should get routine treatment with Abx

Answer 257

Campylobacter, Cdiff, Giardia, Entamoeba Samonella, campylobacter, cryptosporidium are maybes

Question 258

List 5 causes of gastroenteritis in pediatrics

Answer 258

Similar to adults - Viral 70-80%: rotavirus (vaccine available), norovirus, adenovirus - Bacterial 10-20%: salmonella, shigella, campylobacter, yersinia, Ecoli, clostridium, staphylococcus, vibrio - Protozoa <10%: cryptosporidium, giardia

Question 259

List 6 indications for medical evaluation of diarrhea in children

Answer 259

Young age <6 mo or <8kg, history of premature birth, fever, visible blood in the stool, high output, persistent vomiting, signs of dehydration, change in mental status, failure of oral rehydration

Question 260

List 5 signs and symptoms of dehydration

Answer 260

Dry mucous membranes, delayed cap refill, tears, educed skin turgor, depressed fontanel, lethargic mental status, sunken eyeballs, hypotension, tachycardia, reduced urine output

Question 261

What volume of oral rehydration solution is recommended in pediatrics

Answer 261

Remember there are two types of dehydration that get oral rehydration solution - MILD and MODERATE Mild 30-50ml/kg Moderate 60-80 ml/kg 25% in the first 4 hours, replace ongoing losses 10 per BM and 2 per kg for vomit?

Question 262

List 6 differentials for volume depletion

Answer 262

Renal: diuretics, renal tubular acidosis, renal failure, urinary obstruction, diabetes insipidus, diabetes mellitus, hypothyroidism, adrenal insufficiency, renal trauma, salt wasting nephritis Extrarenal: third spacing (pancreatitis, sepsis), skin losses (burns), CHF, liver failure, hemorrhage

Question 263

What is the calculation for pediatric maintenance fluid

Answer 263

4 mls/kg for first 10, 2 mls/kg for second 10, 1 ml/kg each additional kg

Question 264

What volume of IV fluids should be given for severe dehydration

Answer 264

20 ml/kg

Question 265

List 5 bacteria (causing GI illness) that produce toxins

Answer 265

Vibrio cholerae, salmonella, shigella, e coli, c diff

Question 266

*What are 3 physiologic reasons children are more susceptible to the complications of an acute diarrheal illness?

Answer 266

Larger ECF compartment so more susceptible to dehydration by GI losses Higher metabolic rate with high turnover of fluids Limited metabolic substrate reserves (glucose, fat…) Limited access to water Kidney are less capable of retaining water

Question 267

*What are 3 bugs that routinely require Abx treatment?

Answer 267

Salmonella TYPHI Campylobacter jejuni C. diff Could also include the protozoa: Entamoeba histolytica Giardia intestinalis

Question 268

*What are 5 components of the Gorelick scale?

Answer 268

General appearance Cap refill Tears Mucous membranes Eyes Breathing Quality of pulses Skin elasticity Heart rate Urine output

Question 269

*Rehydration of moderate dehydration: Type of fluid, route of fluid administration, volume of fluid, and over how long

Answer 269

Oral rehydration: Pedialyte, or whatever the kind the kid will drink 80 mL/kg for moderate (6% to 9%) volume depletion Replace 25% of above per hour x4h and then reassess Replace losses 10ml/kg stool and 2ml/kg emesis as well Give zofran if puking.

Question 270

*Stem: 4yoM bloody diarrhea 10d ago, now very dehydrated and HSM on exam. Most likely Dx and etiologic agent:

Answer 270

HUS and e. coli o157:H7

Question 271

*3yo with 24h vomit and diarrhea. Normal vitals. How to rehydrate?

Answer 271

Oral rehydration

Question 272

*3 complications of HSP

Answer 272

- Acute renal failure - Nephritic syndrome - Nephrotic syndrome - Hypertension - Scrotal edema - Intussusception - Gastrointestinal bleeding

Question 273

*Most common indicated treatment in HSP

Answer 273

NSAIDs Steroids can be used for severe pain

Question 274

*3 lab findings in HUS

Answer 274

Elevated leukocyte count Elevated CRP Schistocytes Teardrop cells Helmet cells Microspherocytes Burr cells Thrombocytopenia Anemia Elevated creatinine

Question 275

*5 complications of HUS

Answer 275

Metabolic acidosis Hyperkalemia Thrombocytopenia Hypertension Seizures Acute renal insufficiency Stroke Pancreatic insufficiency Toxic megacolon Ischemic colitis Intussusception Perforation

Question 276

*9 y/o boy with 4hrs of testicular pain (previous shorter episodes – self resolved). On exam he has a tender and swollen right sided hemiscrotum. a) 2 emergent diagnoses that require immediate intervention b) 3 alternative dx which do not require immediate intervention c) 2 tests that you would perform in the emergency department d) If this was a 67 y/o man instead, which 2 other dx would you consider

Answer 276

a) testicular torsion, incarcerated hernia b) epididymitis, hydrocele, appendix testes torsion c) US and urinalysis/culture d) STI, lymphoma

Question 277

*3 management steps and 3 lab tests for PSGN

Answer 277

Management: consult nephro, diuretics, monitor BP Tests: ASO titre, urinalysis, urea and lytes, complement

Question 278

*Treatment for balanoposthitis and 2 complications

Answer 278

sitz baths, topical antifungals, hydrocortisone, keflex complications include cellulitis and constrictive phimosis

Question 279

*4 causes of painless scrotal swelling

Answer 279

Hydrocele, varicocele, reducible hernia, germ cell tumour CHF/cirrhosis, epididymal cyst, idiopathic scrotal edema

Question 280

*4 causes of painful scrotal swelling

Answer 280

Torsion Hernia Appendix testes torsion Epididymitis Orchitis Trauma

Question 281

*1 investigation for scrotal swelling

Answer 281

US

Question 282

*Immediate management for possible torted teste

Answer 282

Call urology

Question 283

*7 etiologies for dysuria in children

Answer 283

Chemical irritation (bubble bath) Abuse Appendicitis UTI FB Candida Balanoposthitis Balanitis Paraphimosis Pinworms Straddle injury Self-stimulation

Question 284

*List top 2 pathogens causing UTI

Answer 284

e. coli and klebsiella

Question 285

What is a Bell Clapper deformity

Answer 285

Tunica attaches higher on the spermatic cord and testicular fixation does not occur

Question 286

What is testicular appendix torsion

Answer 286

Torsion of the testicular appendix (remnant of the paramesonephric duct). May be seen as a blue dot (only in 25% of cases). If there is no testicular torsion appendix torsion is treated conservatively; NSAIDs, ice etc

Question 287

List 3 physical findings of testicular torsion

Answer 287

Swollen, high riding testes, abnormal lie, lack of cremastic reflex

Question 288

List 3 reasons for normal ultrasound with torsion

Answer 288

early in disease course, intermittent torsion, partial obstruction (venous obstruction without arterial obstruction)

Question 289

Describe 1 physical maneuver that can be used in a patient with torsion

Answer 289

manual de-torsion; like 'opening a book' twisting the testes from midline to lateral. Successful if immediate relief, can try twisting past 360 degrees.

Question 290

List 5 infectious and 2 non infectious causes of epididymitis

Answer 290

Viral: coxsackie, varicella, mumps Bacterial: STIs (chlamydia, gonorrhea), Ecoli, Klebsiella, Pseudomonas, Staph, Strep Rare infectious causes: tuberculosis, syphilis, fungal Non infectious: Drug related: amiodarone, Immune: Bechet's

Question 291

Which types of hydrocele needs referral for surgical repair

Answer 291

Communicating

Question 292

What is a varicocele

Answer 292

Dilated veins of the pampiniform plexus due to incomplete drainage. "Bag of worms" texture

Question 293

List 3 types of testicular tumors. Which type is the most common in young men?

Answer 293

Teratomas, embryonal carcinomas, yolk sac tumors, choriocarcinomas, Leydig cell tumors, Sertoli cell tumors, lymphoma. Germ cells are the most common

Question 294

What is the difference between phimosis and paraphimosis

Answer 294

Phimosis: stenosis of the foreskin, preventing retraction over the glans Paraphimosis: foreskin is retracted and becomes trapped in that position; unable to retract the skin distally see photo

Question 295

List 5 strategies for reducing a paraphimosis

Answer 295

Sugar soaked gauze or LET gel Compression of the glans with a wrap to reduce edema Ice Pain control Manual reduction: pressure on the glans with traction on the foreskin Dorsal slit

Question 296

Where should anesthesia be injected for a dorsal slit procedure

Answer 296

10 o'clock and 2 o'clock for dorsal anesthesia 6 o'clock if anesthesia is needed for the whole penis

Question 297

Describe the procedure for a dorsal slit

Answer 297

Dorsal penile nerve block: inject lidocaine (without epi) at 10 and 2 o'clock positions. Should feel a pop as the needle passes through the fascia. Aspirate before injection. Dorsal slit: clamp the foreskin between two hemostats for 2 mins. Cut with a scalpel. Edges need to be sutured. Needs to be referred to urology for circumcision

Question 298

List 2 main types of priapism and for each describe 1) blood flow 2) etiology 3) clinical presentation 4) blood sample

Answer 298

Ischemic: low flow due to venous outflow obstruction. Causes: leukemia, sickle cell. Clinical presentation: rigid, painful. Blood sample: Hypoxic Pa O2 <30, hypercapnic PaCO2 >60, acidotic <7.25 Nonischemic: high flow to due increased arterial flow. Causes: trauma, fistulas. Clinical presentation: not rigid or painful. Blood sample: similar to normal arterial blood; PaO2 >90, PaCO2 <40, pH 7.40

Question 299

What is stuttering priapism

Answer 299

Intermittent ischemic priapism, often due to sickle cell

Question 300

List 3 management strategies for priapism

Answer 300

Conservative management: ice, physical activity, warm bath PO pseudoephridine Aspiration 20-30cc at a time Irrigation with NS or dilute phenylephrine (100-500 mcg of phenylephrine/ml)

Question 301

List 2 management strategies for priapism unique to sickle cell

Answer 301

Administer oxygen to keep sats >95% Exchange transfusion to reduce HbS <30%

Question 302

What is balanoposthitis? Balanitis?

Answer 302

Balanoposthitis is cellulitis of the glans, foreskin Balanitis is cellulitis of the glans only

Question 303

List 5 causes of balanoposthitis/balanitis

Answer 303

Poor hygiene, contact dermatitis, local trauma STIs Bacterial infection: staph, Ecoli, strep (esp. if still in diapers) Candida, tinea

Question 304

List 3 causes of circumcision

Answer 304

Bleeding, urethral meatal stenosis, phimosis

Question 305

List 5 causes of renal masses in children

Answer 305

Cystic lesions, severe hydronephrosis Solid masses: Wilm's tumor, neuroblastoma, renal cell carcinoma, mesoblastic nephromas, cystic nephromas

Question 306

List 5 risk factors for the development of pediatric UTI

Answer 306

female gender, uncircumcised male, age (females <2 years, males <6mo), white race, fever >2 days, fever >39 degrees,  hx of UTI, sexual activity, anatomic abnormalities, poor hygiene, voluntary urinary retention, abnormal bladder emptying due to constipation

Question 307

List 5 organisms that commonly cause UTI in pediatric patients

Answer 307

KEEPS - Klebsiella, Ecoli (most common), Enterobacter, Proteus, Staphylococcus

Question 308

List 3 causes of culture -ve dysuria

Answer 308

viral urethritis/cystitis, urethritis (contact irritation, self stimulation, poor hygiene, foreign body, trauma, sexual or physical abuse), STIs, renal disease (glomerulonephritis, kidney stones)

Question 309

What is the laboratory definition of UTI

Answer 309

UTI if >50,000 cfu/ml on urinalysis

Question 310

List the antibiotic that you would use to treat a UTI in a 1) <1 mo old 2) <2 year old 3) >2 year old

Answer 310

<1mo: IV Abx x7 days (Cefotaxime, Ampicillin) then oral Abx (amoxicillin, Septra, Cephalexin) >1mo <2yr: Admit if toxic, treat with CTX then oral Abx >2 yr: oral Abx for 7 days  - Cefixime 8mg/kg/day, Amoxicillin 50mg/kg/day (divided in 3 doses), Cephalexin 500mg/kg/day (divided in 4 doses)

Question 311

List 2 antibiotics that should NOT be used to treat UTIs in children

Answer 311

Macrobid, Fluoroquinolones

Question 312

An 18 months F is dx with a UTI and sent home with Abx. What follow up is needed?

Answer 312

Child <2 yrs of age: Should be investigated after the first UTI with a renal/bladder ultrasound to identify any significant abnormalities. May need follow up with a voiding cystourethrogram if there are signs of a vesicoureteral reflux (hydronephrosis, scarring) or obstructive uropathy

Question 313

List 10 causes of hematuria in children

Answer 313

[Box 173.2] Extrarenal: trauma, meatal stenosis, exercise, menstrual cycle, rectal bleeding, foreign bodies, cystitis, epididymitis Intrarenal: pyelonephritis, kidney stones, glomerulonephritis, acute interstitial nephritis, acute tubular necrosis, glomerular disease, renal vein or artery thrombosis, polycystic kidney disease Systemic: HSP, lupus, HUS, sickle cell, bacterial endocarditis, bleeding disorders, medications (amitriptyline, ibuprofen, dyes)

Question 314

What is the laboratory definition of hematuria

Answer 314

Microscopic >5RBCs/huff Macroscopic gross hematuria visible to the naked eye

Question 315

What is post strep glomerulonephritis? What are typical lab findings?

Answer 315

PSGN is a sequelae of streptococcal pharyngitis believed to result from the deposition of circulating immune complexes in the kidney, occurs ~2 weeks after primary infection Dx with hematuria (often with RBC casts) and hx of strep infection (+ASOS titre) Managed with restriction of fluid and salt intake, thiazide diuretics

Question 316

List 5 causes of proteinuria. What are false positives and false negatives?

Answer 316

Pathologic: nephrotic syndrome, lupus, glomerulonephritis, post transplantation, heavy metal poisoning, UTI False positive: urine with blood, vaginal secretions, semens,  False negative: dilute urine 

Question 317

What is a significant amount of protein on a urine dip

Answer 317

3+ protein

Question 318

What is the treatment for primary nephrotic syndrome

Answer 318

Corticosteroids; prednisone 2mg/kg/day divided TID

Question 319

List the indications for hospitalization in nephrotic syndrome

Answer 319

fever (relatively immunocompromised), hypertension, marked impairment in renal function

Question 320

List 10 causes of AKI

Answer 320

Prerenal: decreased volume (burns, third spacing, sepsis), cardiac shock, decreased renal artery blood flow Intrarenal - Glomerular: PSGN, pyelonephritis  - Systemic: HUS, HSP, lupus, sepsis - Toxins: heavy metal poisoning, myoglobin, antibiotics, anticonvulsants, dyes Post renal: kidney stones, tumors, infection renal vein thrombosis

Question 321

List the diseases associated with each of the following: - Red casts - White casts - Granular casts - Hyaline casts (devoid of contents) - Fatty casts - Eosinophils casts

Answer 321

Red casts = glomerular nephritis or vasculitis  White casts = renal parenchymal inflammation, AIN Granular casts = debris, cellular remnants, ATN  Hyaline casts (devoid of contents)= prerenal azotemia or obstruction ex. dehydration, exercise  Fatty casts: nephrotic syndrome  Eosinophils casts = allergic interstitial nephritis 

Question 322

List 10 causes of hypertension in pediatrics

Answer 322

see photo

Question 323

What 1 test is most important in HSP

Answer 323

Urine for hematuria and proteinuria; if normal no need for further renal function test

Question 324

What is the most common cause of HUS

Answer 324

Shiga producing Ecoli STEC

Question 325

What clinical symptoms are associated with HUS

Answer 325

Renal failure, microangiopathic hemolytic anemia, thrombocytopenia

Question 326

Describe the step by step algorithm

Answer 326

See photo

Question 327

List 5 contraindications to LP

Answer 327

Overlying infection/cellulitis Coagulopathy Signs of high ICP Focal neurologic deficits HD instability Plt <50

Question 328

List 10 causes of altered mental status in peds

Answer 328

see photo

Question 329

List empiric antibiotics for meningitis in each of the following age groups: 0-28 days, 28 days to 3 mo, >3 mo

Answer 329

0-28: amp + gentamicin or cefotaxime 28-3mo: ampicillin or vanco + cefotaxime or ceftriaxone >3mo: cefotaxime or ceftriaxone + vancomycin

Question 330

What are the two main types of seizures

Answer 330

Partial: consciousness maintained Generalized: consciousness is lost

Question 331

*5 criteria of simple febrile seizure

Answer 331

- Seizure in presence of fever - No CNS infection/other identifiable cause - Generalized seizure - Lasts less than 15 minutes - No recurrence during 24-hour period - Occurs in neurologically and developmentally normal child between 6 months and 6 years of age

Question 332

*3 criteria of complex febrile seizure

Answer 332

- More than one seizure in 24-hour period - Seizures lasting longer than 15 minutes - Seizures have focal component

Question 333

*What percentage of patients will have recurrence of febrile seizure

Answer 333

30%

Question 334

*3 other meds aside from benzos that you can give IV for seizure (you can assume airway is managed)

Answer 334

- Fosphenytoin - Levetiracetam (e.g. Keppra) - Phenobarbital - Propofol - Valproic acid

Question 335

*Child has recurrence of seizure in ED without IV or IO access. 2 drug options (give dose, route)

Answer 335

- Lorazepam 0.1 mg IO - Midazolam 0.1-0.2 mg/kg IM - Midazolam 0.2 mg/kg buccal - Midazolam 0.2 mg/kg IN - Diazepam 0.5 mg/kg PR

Question 336

*Contraindications to LP

Answer 336

signs of elevated ICP, focal neurologic deficits on examination, and underlying coagulopathy

Question 337

*3 most common pathogens in neonatal meningitis

Answer 337

- Group B streptococcus - Escherichia coli - Listeria

Question 338

*5 symptoms of shunt obstruction

Answer 338

Headache Vomiting Diplopia Blurred vision Confusion Irritability Lethargy

Question 339

*5 signs of shunt obstruction

Answer 339

CN6 lateral gaze palsy Papilledema Sunset eyes Ataxic Gait Differentially size pupils Altered Mental Status Cranial suture diastasis

Question 340

*2 causes of communicating and 2 causes non-communicating hydrocephalus

Answer 340

1) IVH, meningitis, NPH, choroidal plexus tumour 2) Obstructive tumour, SAH with obstructive clot

Question 341

*Ddx for gait ataxia in childhood

Answer 341

Acute cerebellar ataxia (MCC) Acute postinfectious demyelinating encephalomyelitis Brainstem encephalitis Drug ingestion Guillain-Barré syndrome Metabolic disorders Aminoacidopathies Mitochondrial disorders Organic acidopathies Urea cycle disorders Migraine headaches Multiple sclerosis Neoplasm Opsoclonus-myoclonus syndrome Recurrent and chronic genetic ataxias Seizures Stroke Vertebral artery dissection

Question 342

*2 week old baby had fever for 4 hours and brief unilateral seizure activity. Bulging fontanelle. Ddx:

Answer 342

Meningitis Encephalitis Abscess Non-accidental trauma Spontaneous ICH Complex febrile seizure

Question 343

3 medications for 2 week old baby had fever for 4 hours and brief unilateral seizure activity. Bulging fontanelle

Answer 343

Ampicillin, gentamycin, acyclovir

Question 344

List 5 causes of seizure, and 5 causes of seizure unique to pediatrics

Answer 344

Fever: meningitis, encephalitis, brain abscess Trauma: cerebral contusion, intracranial hemorrhage, impact seizure Tox: drug intoxication or withdrawal Metabolic: hypoglycemia, hyponatremia Vascular: AV malformations, CVST, stroke VP shunt malfunction Unique to peds: inborn errors of metabolism, neurocutaneous disorders (neurofibromatosis, tuberous sclerosis, Sturge-Weber syndrome), cerebral palsy, simple febrile seizures, non accidental injury

Question 345

Which traumatic seizures are less worrisome

Answer 345

Impact seizures that occur within 1 hour of head trauma Early post traumatic seizures in the first week may be associated with cerebral edema or intracranial hemorrhage

Question 346

What symptoms are associated with baby botulism

Answer 346

Constipation, poor feeding, weak cry, hypotonia

Question 347

What is the treatment for baby botulism

Answer 347

Botulism immunoglobulin 50mg/kg

Question 348

What is the definition of status epilepticus

Answer 348

Seizure lasting longer than 5 minor recurrent seizure >5 min without a return to baseline

Question 349

What is the definition of epilepsy

Answer 349

More than 1 unprovoked seizure

Question 350

List 4 types of generalized seizures

Answer 350

Absence, tonic/clonic, myoclonic, atonic, infantile spasms

Question 351

What percentage of children experience a febrile seizure

Answer 351

5%

Question 352

What is the risk of recurrence with febrile seizure

Answer 352

33%

Question 353

What is the risk of epilepsy following febrile seizure

Answer 353

1-2% vs. 0.5-1% in the baseline population

Question 354

What workup is required for simple febrile seizures List 5 reasons to consider an LP in febrile seizure?

Answer 354

No specific workup is required; only the workup you would have done in the source Red flags to consider doing an LP for meningitis: post ictal symptoms lasting >1 hr, any physical signs of meningitis(neck stiffness, petechial rash, photophobia), irritability or lethargy, already on antibiotics, incomplete immunizations, complex febrile seizures

Question 355

list indications for neuroimaging in the context of a febrile seizure

Answer 355

suspicion of non-accidental injury, signs of increased ICP, persistent abnormal neurologic status, underlying CNS disorders (ex. VP shunt)

Question 356

List 5 differentials for seizure disorder in children (sounds like seizure but not a seizure)

Answer 356

breath holding, syncope, GERD (Sandifer’s syndrome), chorea (acute rheumatic fever), myoclonic jerks, rigors, night terrors, tic d/o, migraines, drug exposure/tox

Question 357

Describe the treatment algorithm for status epilepticus

Answer 357

0-5 mins: benzos (0.1mg/kg lorazepam, 0.2 mg/kg midazolam, 0.5 mg/kg diazepam PR) 5-10 mins: benzo again 15 mins: 2nd line agent (20 mg/kg phenytoin, 20 mg/kg phenobarbital, 20PE/kg fosphenytoin, 20mg/kg Keppra, 20 mg/kg Valproic acid) After 3rd seizure medication prepare for intubation

Question 358

List the pediatric dosing of hypertonic saline, dextrose, and calcium gluconate

Answer 358

3% NaCL 3ml/kg 10% dextrose 2-5 ml/kg 10% calcium gluconate 100mg/kg (1 ml/kg)

Question 359

What neurologic disease is associated with 1) café au lait spots 2) ash leaf spots

Answer 359

Neurofibromatosis, tuberosclerosis

Question 360

List indications for CT head in a headache

Answer 360

[Box 174.3]: abnormal neurological exam findings, signs and symptoms of elevated ICP, meningeal signs + altered mental status or focal neurologic findings, significant head trauma, severe nocturnal headaches that awaken the patient from sleep, severe "worst headache of my life" presence of a VP shunt, chronic progressive headache Consider if: headache or vomiting on awakening, unvarying location of headache esp. occipital, persistent headache with no family history of migraines, neurocutaneous syndrome, age <3

Question 361

What is acute cerebellar ataxia

Answer 361

Disease caused by an autoimmune response post infection that leads to cerebellar demyelination. Causes 40% of pediatric ataxia. Sx are maximal at onset. Mental status is normal

Question 362

List 10 risk factors for stroke in the pediatric patient

Answer 362

Cardiac: congenital cardiac disease, R to L shunts, endocarditis, arrhythmias, cardiac tumors, cardiac surgery Heme: sickle cell disease, HUS, TTP, polycythemia, DIC, leukemia, cancer Vasculitis: lupus, moyamoya, Takayasu Infection, metabolic, vascular, trauma, substances

Question 363

What is benign paroxysmal vertigo of childhood

Answer 363

Repeated vertiginous episodes with occasional vomiting Remits spontaneously within months to years Most frequent cause is migraine headache, with vertigo as an aura BPPV is rare in children, earliest report at 11 years old

Question 364

What constellation of symptoms are associated with the Miller Fischer variant of GBS

Answer 364

Ataxia, loss of DTR, ophthalmoplegia of vertical gaze ## Footnote Ben saying "AOA"

Question 365

*Describe the treatment of pediatric supracondylar fractures as per the Gartland classification system

Answer 365

I Nondisplaced fracture - splint or case x3w II Displaced fracture with intact posterior cortex - cast vs. pinning. Many NV status re-checks in firs 24-48h III Displaced fracture with no cortical contact - pinning. Many NV status re-checks in firs 24-48h

Question 366

*What are 4 complications of supracondylar fractures? What is deformity called?

Answer 366

• Malunion • Ischemic contracture (Volkmann contracture), due to damage/occlusion of the brachial artery • Damage to ulnar, median or radial nerve (most common: anterior interosseous nerve, a branch of median nerve) • Compartment syndrome • Cubitus varus deformity ("gunstock" deformity)

Question 367

*Most common complication of supracondylar #

Answer 367

anterior interosseous nerve (AIN) neurapraxia (brachial artery is second)

Question 368

*How can you test for AIN neuropraxia?

Answer 368

Motor: Distal phalanx flexion (thumb and first finger) Make the OK sign Purely motor - no sensory

Question 369

*8 year old child with fall on elbow from trampoline; normal neurovascular status. Obvious swelling at elbow. Brought in by dad. What are three interventions you can do at this point?

Answer 369

Analgesia Immobilization Xray

Question 370

*Recognize Monteggia and explain findings

Answer 370

Injury defined as proximal 1/3 ulnar fracture with associated radial head dislocation

Question 371

*What are the ossification centres in the paediatric elbow? Write them in order.

Answer 371

Capitellum Radial head Internal epicondyle Trochlea Olecranon External epicondyle The approximate ages at which these sites ossify are 1, 3, 5, 7, 9, and 11 years, respectively

Question 372

*2 lines on pediatric elbow XR (eg. supracondylar fracture)

Answer 372

Anterior humeral line Radiocapitellar line

Question 373

*What are 4 XR findings of supracondylar fracture?

Answer 373

Anterior fat pad Posterior fat pad Capitella not in line with anterior humeral or radiocapitellar lines Baumann's angle greater or less than 75-80deg Cortex disruption

Question 374

*5 categories of diagnosis and specific causes for child with a limp

Answer 374

- Infection: septic arthritis, OM - Trauma: Fracture, overuse - Neoplastic: Leukemia, Ewing’s - inflammatory: JRA, TS, Rheumatic fever - Hematologic: SCD, Hemophilia - Misc: LCP, SCFE

Question 375

*4 investigations for child with limp

Answer 375

WBC ESR Synovial fluid for gram stain, culture and cell count xray

Question 376

*Causes of osteomyelitis in children

Answer 376

S. aureus (MCC) GBS Kingella H flu S. pyogenes N. gonorrhea

Question 377

*List ossification centres and when they ossify

Answer 377

C - Capitellum (1) R - Radial head (3) I - Internal (medial) epicondyle (5) T - Trochlea (7) O - Olecranon (9) E - External (lateral) epicondyle (11)

Question 378

*4 XR findings of SCFE

Answer 378

- Widening of physis - Posterior step-off at physeal plate - Klein's line does not come in contact with epiphysis (known as "Trethowan sign") - Crescent-shaped, increased density in proximal portion of femoral neck due to superimposition of posteriorly displaced epiphysis on femoral neck (known as "blanch of Steel" sign)

Question 379

*5 Risk factors for SCFE

Answer 379

- Gender, boys > girls - endocrinopathies, • hypothyroid, • , • hypogonadism, • exogenous growth hormone. - renal osteodystrophy, and - radiation therapy - Obesity

Question 380

*Complications of SCFE

Answer 380

- Further slippage - Avascular necrosis - Chondrolysis (i.e. acute cartilage necrosis) Longer term: - Non-union - Premature closure of epiphyseal plate - Degenerative changes

Question 381

Outline the technique for reduction of pulled elbows

Answer 381

Flexion-supination or hyper-pronation of the elbow (the other hand holding the elbow to feel for a click)

Question 382

*What would cause these strategies to fail (reduction of pulled elbow)?

Answer 382

- Annular ligament rupture - improper technique - edema - hematoma - spasm - fracture

Question 383

*2 XR findings in septic arthritis

Answer 383

- Normal X-ray - Periarticular soft tissue swelling - Widening of joint space - Obliteration or displacement of gluteal lines - Asymmetric fullness of iliopsoas and obturator soft tissue planes - Subchondral bone erosions* - Narrowing of joint space* *Late findings

Question 384

*2 XR findings in transient synovitis

Answer 384

- Normal X-ray - Medial joint space widening - Accentuated peri-capsular shadow - Waldenstrom's sign/ Lateral displacement of femoral epiphysis, with surface flattening secondary to effusion

Question 385

*4 tests that would help distinguish between septic arthritis and transient synovitis

Answer 385

Kocher criteria - Fever >38.5 - Inability to bear weight - ESR > 40 - WBC > 12

Question 386

*What specific treatment would be most appropriate (be specific) if suspected septic arthritis

Answer 386

ROSENS: Nafcillin, 50 mg/kg, and ceftriaxone, 50 mg/kg

Question 387

*Define torus (buckle) fracture

Answer 387

Buckling of bone without cortical disruption, tends to occur from compression failure at the metaphyseal-diaphyseal junction

Question 388

*Define greenstick fracture

Answer 388

Cortical disruption on one side of a long-bone, with the periosteum on the fracture's compression side remaining intact

Question 389

*Define plastic deformation

Answer 389

Bone is bowed, with no obvious cortical disruption

Question 390

*Illustrate the salter-harris classification

Answer 390

see photo

Question 391

*What is the most common organism causing septic arthritis?

Answer 391

Staph aureus

Question 392

*Bony cause of limping in a toddler

Answer 392

1) Toddler’s fracture 2) Osteochondroma 3) Septic joint 4) Osteomyelitis 5) Non accidental injury 6) DDH

Question 393

*Systemic cause of limping in a child

Answer 393

1) JRA 2) Rheumatic fever 3) HSP 4) Sickle Crisis 5) Congenital Limb length discrepancy 6) appendicitis/ torsion

Question 394

*Causes of limping in an adolescent

Answer 394

1) SCFE 2) Osgood Schlatter’s disease 3) Femoro patellar syndrome 4) Gonococcal arthritis 5) Ankylosing Spondylitis

Question 395

*4 life or limb-threatening causes of limping

Answer 395

1) Nec Fasc 2) Osteomyelitis 3) Popliteal aneurysm (all) 4) septic joint 5) compartment syndrome

Question 396

List 4 conditions that can mimic child abuse

Answer 396

Osteogenesis imperfecta, osteopenia of prematurity, scurvy, copper deficiency, Menkes disease, diffuse osteopenia

Question 397

List 4 differences between pediatric and adult bone

Answer 397

Active growth plates with risk of growth arrest in fracture Weaker, more porous bone that is more likely to fracture Thicker more active periosteum that promotes healing Remodeling allows for greater angulation and displacement

Question 398

Which Salter Harris fractures are intraarticular

Answer 398

III and above

Question 399

list 4 types of fractures unique to pediatrics

Answer 399

SALTER Harris Greenstick Bowing/plastic deformation Buckle/Torus Bucket handle fracture

Question 400

What is the most common joint for septic arthritis in a pediatric patient

Answer 400

Knee

Question 401

List 4 risk factors for septic arthritis

Answer 401

Preceding viral infection, trauma, immunodeficiency, hemoglobinopathy, diabetes, RA, previous surgery, intra articular injections or operations

Question 402

List 3 organisms that can cause septic arthritis

Answer 402

Staph aureus, Group B strep, Neisseria gonorrhea, Streptococcus pneumonia, Kingella kingae, hemophilia influenza 

Question 403

List 4 types of pediatric bone tumors

Answer 403

Osteoblastoma (bone forming), oestoma (non spreading, non cancerous) osteochondroma (cartilage forming), cystic tumors, giant cell tumor

Question 404

What type of vascular injury can occur with supracondylar fractures

Answer 404

Brachial artery injury; Volkmann ischemia

Question 405

What is Baumann's angle

Answer 405

Line through the midshaft of the humerus and the growth plate of the capitellum. Should be ~75%; but best to compare to the other side

Question 406

List 2 reduction techniques for a nursemaid's elbow

Answer 406

Hyperpronation or supination/flexion

Question 407

Describe the anatomic abnormality in a nursemaid's elbow

Answer 407

Radial head subluxes out of the annular ligament

Question 408

What is a Tillaux fracture

Answer 408

Salter Harris III fracture that extends through the distal tibial physis and exits intra articularly; the anterior ATFL pulls the lateral epiphysis from the medial malleolus

Question 409

What is a Triplanar fracture

Answer 409

Salter Harris IV fracture that occurs in the sagittal, coronal, and transverse planes; similar mechanism to a Tillaux

Question 410

List 3 types of apophysitis and their anatomical location

Answer 410

Osgood Schlatter - tibial tubercle Little league elbow - medial epicondyle Sever's disease - calcaneus

Question 411

What is SCFE

Answer 411

Displacement of the capital femoral epiphysis from the femoral neck through the physical plate

Question 412

What is Legg-Calve Perthes

Answer 412

Avascular necrosis of the femoral head with a subchondral stress fracture

Question 413

What age does Legg-Calve Perthes typically present

Answer 413

Between the ages of 4 and 10 years

Question 414

Describe the progression of x ray findings for Legg-Clave Perthes

Answer 414

Initial phase - smaller femoral head, widening of medial joint space, subchondral lucency, subchondral collapse, irregular physeal plate, blurry and radiolucent metaphysis Fragmentation - epiphysis begins to fragment and there are areas of radiolucency as the new bone forms; speckled calcification Reossification - normal bone density returns, radiodensities replace radiolucency Healed - residual deformities, early arthritis

Question 415

List 3 clinical findings of developmental dysplasia of the hip

Answer 415

leg length differences (Galeazzi's sign), asymmetric skin fold, decreased range of motion, positive Barlow and Ortolani

Question 416

Describe the Barlow and Ortolani tests

Answer 416

Barlow - provocative maneuver to sublux a hip: Stabilize the pelvis, place thumb on the inner aspect of the thigh near the lesser trochanter, abduct the hip while exerting downward pressure on the thigh Ortolani - reduction maneuver: Stabilize the hip, slightly abduct the infant's hip, pull up in the GT to gently reduce the hip

Question 417

List 3 difference in drug metabolism between adult and pediatric patients

Answer 417

Skin: increased surface area and hydration; net increased absorption of topical medications Distribution: higher total body water and volume of distributions affects drug concentrations GI: Higher gastric pH affects the bioavailability of acid labile drugs Drug metabolism is different in infants and neonates as their metabolizing enzymes are not yet mature. Children 1-6 may actually have higher metabolism and may require relatively higher doses Absorption via non oral route (ex. IM) is unpredictable

Question 418

List 3 drugs that should be avoided in the pediatric patient

Answer 418

ASA: Reye’s syndrome Doxycycline: tooth discolouration Cough and cold products Ceftriaxone, septa: increased bilirubin can lead to kernicterus 

Question 419

*10 historical features concerning for abuse

Answer 419

1. Injury pattern inconsistent with the injury mechanism 2. Mechanism inconsistent with developmental stage 3. Inconsistent history provided by different care providers (stories don’t match up) 4. Inconsistent history provided by same care provider at different times 5. Prior history of abuse 6. Injury sustained as a result of punishment to the child 7. History of similar or multiple injuries in the past 8. History of drug abuse 9. Unwanted pregnancy / child 10. History of domestic violence in the household

Question 420

*10 fractures or fracture patterns concerning for abuse

Answer 420

1. Any fracture < 1 yr 2. Fractures of different ages 3. Multiple # 4. Skull # (complex more suspicious than linear) 5. posterior Rib # 6. CMLs (classic metaphyseal lesion /bucket handle) 7. Vertebral # 8. Midshaft diaphyseal humeral/femur # (in non-weight bearing children) 9. Scapular # 10. Periosteal bone formation

Question 421

*Nurse brings in her child with multiple skin abscesses, grew e.coli last presentation. 2 tests:

Answer 421

Skeletal survey re-culture

Question 422

*Nurse brings in her child with multiple skin abscesses, grew e.coli last presentation. Dx and treatment

Answer 422

Munchausen by proxy Medical management then social services for child, psych for mother

Question 423

List 5 soft tissue injuries concerning for child abuse

Answer 423

Injuries/bruising to the oral mucosa, lip lacerations, tongue lacerations, frenulum tears, ear helix, neck Patterned marks ex. bites Burns ex. immersion burns, cigarettes, hair curler

Question 424

What are reporting obligations for suspected child abuse

Answer 424

Mandatory reporting to CAS (not police) up until age of 16 by you (the one who received the information)

Question 425

List 5 pediatric 'one pill can kill' ingestions

Answer 425

ABC GET MOM - Antimalarials - Beta blockers - Clonidine, calcium channel blockers - Glyburide (or another sulfonylurea) - Ethelene glycol (antifreeze) - Tricyclic antidepressants (amitriptyline) - Methanol (nail polish remover) - Opioids (hydromorphone) - Methyl salicylates (oil of wintergreen)

Question 426

What are causative organisms in cystic fibrosis

Answer 426

Staphylococcus aureus and Pseudomonas aeruginosa. But, Burkholderia cepacia, a significant pathogen in CF patients, has been associated with an accelerated decline in clinical status and increased mortality. In general, antimicrobial coverage is similar to that for Pseudomonas.

Question 427

Inconsolable crying in an infant

Answer 427

Intussception/ infection Trauma/ torsion Cardiac Reflux Eye (corneal abrasion) Strangulation (hair tourniquet)

Question 428

PECARN rule for abdominal CT in peds trauma

Answer 428

Question 429

How does voice change in GCS if patient is under 2 years old?

Answer 429

5 - coos 4 - irritable/ cry 3 - cries with pain 2 - moans 1 - nothing