Pediatrics Flashcards
(108 cards)
1
Q
Sick neonate evaluation
A
“<img></img>”
2
Q
Congenital heart dis, what are the indications for intubation?
A
Profound dyspnea<br></br>Lethargy<br></br>Safety in transport<br></br>Anticipated apnea with prostaglandin infusion<br></br>
3
Q
<p>What are three ductal-dependent cyanotic congenital heart lesions?</p>
A
<ol> <li>Tetralogy of Fallot,</li> <li>Tricuspid atresia,</li> <li>Pulmonic atresia or stenosis</li> </ol>
4
Q
<ul> <li>Name three metabolic complications that patients are at risk for following drowning and/or accidental hypothermia:</li> </ul>
A
<ul> <li>Rhabdomyolysis,</li> <li>hyperkalemia,</li> <li>hypokalemia,</li> <li>hypoglycaemia,</li> <li>acidosis,</li> <li>DIC</li> </ul>
5
Q
<ul> <li>Name three indications for ECMO in a patient with accidental hypothermia:</li> </ul>
A
<ol> <li>Prehospital cardiac instability (arrest),</li> <li>systolic BP <90mmHg,</li> <li>ventricular arrhythmias,</li> <li>core temperature < 28 degrees</li> </ol>
6
Q
ED preparation for imminent labor:
A
<ul> <li>Move patient to resuscitation room,</li> <li>get ED delivery bundle (towels, kelly clamps, scissors, ring forceps, umbilical cord clamp, etc),</li> <li>prepare infant warmer,</li> <li>call for help</li> </ul>
7
Q
Important questions to ask in NRP
A
Term or not<br></br>How many babies<br></br>Any complication during pregnancy<br></br>No of previous pregnancies<br></br>PMH
8
Q
<ul> <li>You successfully deliver the baby after reducing a tight nuchal cord. Babe does not make any spontaneous cries and in fact seems a bit blue. What are the first 4 actions you would take in management?</li> </ul>
A
<ul> <li>Dry, stimulate, clear and position the airway, place in the warmer</li> </ul>
9
Q
<ul> <li>Baby’s HR is 90bpm: what 3 interventions would you perform next?</li> </ul>
A
<ul> <li>PPV with BVM at 30-60 breaths/min,</li> <li>apply O2 sat probe,</li> <li>apply ECG monitors for accurate HR monitoring</li> </ul>
10
Q
<ul> <li>At what point would chest compressions be started and at what rate?</li> </ul>
A
<ul> <li>HR < 60bpm, 3:1 with respirations;</li> <li>advanced airway strongly recommended</li> </ul>
11
Q
NRP
A
“<img></img>”
12
Q
<ul> <li>What is the compression rate in children?</li> </ul>
A
<ul> <li>100-120/minute (same as adults)</li> </ul>
13
Q
What is the recommended depth for compressions?
A
1/3 AP chest diameter (4cm infants, 5cm children)
14
Q
What is the compression:ventilation ratio if no advanced airway is in place?
A
30:2 single rescuer, 15:2 two rescuer<br></br>If advanced airway: one breath every 2-3 seconds with continuous compressions <br></br>(NEW in 2020)
15
Q
Peds assessment
A
“<img></img>”
16
Q
Name three features of the paediatric airway that differ from the adult <br></br>airway
A
smaller diameter, <br></br>smaller mandible, <br></br>large occiput, <br></br>large tongue, <br></br>anterior larynx, <br></br>long epiglottis, <br></br>angular vocal cords, <br></br>highly compliant trachea, <br></br>short trachea
17
Q
What is the formula for estimating ET tube size?
A
<i>age/4+4 (uncuffed traditionally)</i><br></br>• AAP/PALS now recommends cuffed ET tubes to decrease the need <br></br>for tube changes
18
Q
Name five non-infectious causes of stridor:
A
anaphylaxis, <br></br>foreign body, <br></br>subglottic hemangioma, <br></br>laryngomalacia, <br></br>tracheomalacia, <br></br>tumor
19
Q
Croup, indicationd for admission
A
Ongoing increased WOB, <br></br>respiratory distress, or stridor 4hrs after steroid administration or repeated doses of <br></br>epinephrine
20
Q
Epiglotis enlargement, name 2 non-infectious causes:
A
Steam inhalation<br></br>Caustic ingestion
21
Q
Epiglotitis, common bacteria?
A
Strep pneumoniae<br></br>Strep pyogenes<br></br>Staph aureus<br></br>(Used to be H.influenzae type B)
22
Q
What are indications on history of potentially severe <br></br>asthma exacerbation? Name five:
A
<p>Previous life threatening exacerbations, <br></br>previous ICU admission, <br></br>previous intubation, <br></br>deterioration while on steroids, <br></br>use of 2 or more salbutamol canisters in a month, <br></br>cardiopulmonary or psychiatric comorbidities</p>
23
Q
What are the components of the PRAM score?
A
suprasternal indrawing, <br></br>scalene retractions, <br></br>wheeze, <br></br>air entry, <br></br>oxygen saturation
24
Q
What medications are evidence based treatment for <br></br>severe asthma exacerbations? Name 3:
A
continuous nebulized salbutamol, three doses <br></br>nebulized atrovent, <br></br>IV steroids (methylprednisolone 1mg/kg or hydrocortisone 8mg/kg), <br></br>(IV fluid bolus), <br></br>IV MgSO4 (40-50mg/kg over 20min, beware BP)
25
What other medications might you consider if nothing is
helping?
helping?
IM epinephrine (anaphylaxis dosing), BiPAP/HFNC,
IV salbutamol,
subdissociative dose ketamine,
heliox
IV salbutamol,
subdissociative dose ketamine,
heliox
26
What are the admission criteria for asthma
exacerbation?
exacerbation?
• ongoing need for supplemental O2
• persistently increased WOB
• beta agonist needed more frequently than q4h after 4-8hrs of treatment
• deterioration on systemic steroids
• persistently increased WOB
• beta agonist needed more frequently than q4h after 4-8hrs of treatment
• deterioration on systemic steroids
27
What are the discharge criteria for asthma
exacerbation?
exacerbation?
• O2 sat > 94% on RA
• minimal or no respiratory distress
• improved air entry
• beta agonist use > q4h after 4-8 hours of treatment
• minimal or no respiratory distress
• improved air entry
• beta agonist use > q4h after 4-8 hours of treatment
28
Severe resp distress, Name 5 specific pieces of information you wish to obtain on history
Term delivery? NICU stay? Known cardiopulmonary issues? Recent
hospitalizations? Vaccination status? History of recent fever?
Feeding? Making urine?
hospitalizations? Vaccination status? History of recent fever?
Feeding? Making urine?
29
When would you consider a CXR in this patient?
Unclear diagnosis,
focal lung findings,
response to treatment is not as expected,
‘toxic’ appearance,
severe respiratory distress
focal lung findings,
response to treatment is not as expected,
‘toxic’ appearance,
severe respiratory distress
30
Bronchiolitis, What initial treatments would you offer in the emergency department?
Nasal suctioning, observation, oxygen therapy if needed
31
What treatments would you NOT use for bronchiolitis? Name 4:
Salbutamol,
ipratropium bromide (atrovent),
inhaled corticosteroids,
systemic corticosteroids,
antibiotics
ipratropium bromide (atrovent),
inhaled corticosteroids,
systemic corticosteroids,
antibiotics
32
What are 3 risk factors for severe bronchiolitis?
Age <2mo,
history of prematurity,
underlying cardio-respiratory disease or immunodeficiency
history of prematurity,
underlying cardio-respiratory disease or immunodeficiency
33
What are admission criteria for bronchiolitis? Name 4:
Ongoing moderate to severe respiratory distress,
need for supplemental O2 to maintain sats >90%,
cyanosis or history of apnea,
dehydration/poor fluid intake,
infant at high risk for severe disease,
family unable to cope
need for supplemental O2 to maintain sats >90%,
cyanosis or history of apnea,
dehydration/poor fluid intake,
infant at high risk for severe disease,
family unable to cope
34
What elements on history and physical examination are
highly suggestive of true seizure activity? Name 3:
highly suggestive of true seizure activity? Name 3:
Lateralized tongue biting,
flickering eyelids,
dilated pupils,
blank stare,
lip smacking,
increased HR and BP during event,
post-ictal phase
flickering eyelids,
dilated pupils,
blank stare,
lip smacking,
increased HR and BP during event,
post-ictal phase
35
Simple febrile seizure:
Age 6mo-5yrs,
associated with elevated temperature greater than 38,
single seizure in 24hrs,
generalized, lasts <15 min,
post-ictal with return to baseline (usually within 1 hour), and normal neurological exam
associated with elevated temperature greater than 38,
single seizure in 24hrs,
generalized, lasts <15 min,
post-ictal with return to baseline (usually within 1 hour), and normal neurological exam
36
What are 3 features of a complex febrile seizure?
Focal seizure,
seizure lasting greater than 15 minutes, multiple seizures in 24 hours
seizure lasting greater than 15 minutes, multiple seizures in 24 hours
37
Status epilepticus:
seizure lasting >5min (and/or ongoing seizure on arrival to
ED) OR 2 or more consecutive seizures without a return to baseline in between
ED) OR 2 or more consecutive seizures without a return to baseline in between
38
Status Epilepticus
• What are your first steps in management? Name 5
• What are your first steps in management? Name 5
Supplemental oxygen,
airway assessment,
IV access,
cardiac monitors,
administration of benzodiazepines,
check the glucose and treat hypoglycemia
airway assessment,
IV access,
cardiac monitors,
administration of benzodiazepines,
check the glucose and treat hypoglycemia
39
You are not able to obtain IV access. Name two different drugs and
three different routes of administration you could use:
three different routes of administration you could use:
• IM midazolam 0.2 mg/kg (max 10mg)
• intranasal midazolam 0.2mg/kg (max 5mg/nare)
• rectal diazepam 0.5mg/kg (max 20mg)
• intranasal midazolam 0.2mg/kg (max 5mg/nare)
• rectal diazepam 0.5mg/kg (max 20mg)
40
The seizure continues after you administer IM midazolam
and IV midazolam. Name two medications other than
benzodiazepines you could administer next:
and IV midazolam. Name two medications other than
benzodiazepines you could administer next:
fosphenytoin 20mg/kg IV (1st);
levetiracetam 60mg/kg/dose (1st);
phenytoin 20mg/kg (2nd);
phenobarbital 20mg/kg IV (2nd)
levetiracetam 60mg/kg/dose (1st);
phenytoin 20mg/kg (2nd);
phenobarbital 20mg/kg IV (2nd)
41
What is the risk of epilepsy for this child?
2% after simple febrile seizure and 5% after complex febrile seizure (compared to 1% in the general population)
42
Seizure DDx:
Breath holding spell,
BRUE,
hyponatremia,
sepsis,
meningitis,
hypoglycaemia,
metabolic disorders,
trauma (accidental or non accidental),
bleeding disorder,
mass lesion
BRUE,
hyponatremia,
sepsis,
meningitis,
hypoglycaemia,
metabolic disorders,
trauma (accidental or non accidental),
bleeding disorder,
mass lesion
43
What are high risk factors on history and physical that should prompt consideration of
imaging? Name 3:
imaging? Name 3:
• Focal seizure or persistent seizure activity
• Focal neurologic deficit
• VP shunt
• Neurocutaneous disorder
• Signs of elevated ICP
• History of trauma
• Immunocompromise
• Hypercoagulable state or bleeding disorder
• Focal neurologic deficit
• VP shunt
• Neurocutaneous disorder
• Signs of elevated ICP
• History of trauma
• Immunocompromise
• Hypercoagulable state or bleeding disorder
44
Name two surgical causes of abdominal pain in each age group:
• Neonates (0-30d):
• Malrotation, NEC, Hirschsprung
• Infant and toddler (1mo - 2yrs):
• Pyloric Stenosis, Intussusception
• Young child - older (2 yrs and up):
• Appendicitis, Obstruction
• Malrotation, NEC, Hirschsprung
• Infant and toddler (1mo - 2yrs):
• Pyloric Stenosis, Intussusception
• Young child - older (2 yrs and up):
• Appendicitis, Obstruction
45
Name 4 non-abdominal causes of paediatric abdominal pain:
Pneumonia,
AOM,
pharyngitis,
DKA,
HSP,
testicular torsion
AOM,
pharyngitis,
DKA,
HSP,
testicular torsion
46
Name 4 non-abdominal causes of vomiting:
Intracranial mass,
meningitis,
strep throat,
pneumonia,
myocarditis,
DKA
meningitis,
strep throat,
pneumonia,
myocarditis,
DKA
47
Best measures to predict 5% dehydration:
prolonged capillary refill,
abnormal skin turgor, and
tachypnea
abnormal skin turgor, and
tachypnea
48
Oral rehydration indicated for children with “mild” or
“some” dehydration
“some” dehydration
Rehydrate with pedialyte or dilute juice: 1mL/kg q 5min; goal for 30mL/kg in first hour and 50-100mL/kg within 2-4hrs
• Give single dose zofran and start rehydration after 15min
• Give single dose zofran and start rehydration after 15min
49
Noah is in his mother’s arms looking very
limp and his skin is pale with mottled extremities.
Name five non-infectious causes of this presentation:
limp and his skin is pale with mottled extremities.
Name five non-infectious causes of this presentation:
Trauma,
heart disease,
hypovolemia,
endocrine emergency,
electrolyte abnormality,
inborn error of metabolism,
seizure,
toxin
heart disease,
hypovolemia,
endocrine emergency,
electrolyte abnormality,
inborn error of metabolism,
seizure,
toxin
50
What three management steps do you want to take first?
(Call for help, get the Broselow out), Monitors, IV access
(or IO), supplemental O2, check a sugar, get ECG
(or IO), supplemental O2, check a sugar, get ECG
51
What are the recommendations for glucose administration in
children?
children?
• 0.5-1g/kg IV or IO: use D25W (2-4mL/kg age >1year) or
D10W (5-10mL/kg in infants)
• Follow bolus with an infusion of D10W at maintenance
D10W (5-10mL/kg in infants)
• Follow bolus with an infusion of D10W at maintenance
52
What are some common signs of neonatal sepsis? Name 4:
Jaundice,
hepatomegaly,
poor feeding,
irritability,
hypoglycaemia,
respiratory distress,
vomiting
hepatomegaly,
poor feeding,
irritability,
hypoglycaemia,
respiratory distress,
vomiting
53
What are the 3 most common bacteria implicated in neonatal
sepsis?
sepsis?
Group B strep,
E.coli,
Listeria
E.coli,
Listeria
54
What are 3 risk factors for neonatal sepsis?
Prematurity,
low birth weight,
maternal GBS positive,
prolonged ruptured membranes
low birth weight,
maternal GBS positive,
prolonged ruptured membranes
55
Neonatal Sepsis, What antibiotics will you order
• IV ampicillin
• IV gentamicin
• +/- IV cefotaxime (if suspected meningitis)
• Consider IV acyclovir
• IV gentamicin
• +/- IV cefotaxime (if suspected meningitis)
• Consider IV acyclovir
56
Fever 29-60 days old, if stable, well appearing, and no evident source of infection
UA and microscopy
urine culture (catheter or clean catch sample)
blood cultures
CBC
CRP
procalcitonin
urine culture (catheter or clean catch sample)
blood cultures
CBC
CRP
procalcitonin
57
What are the low risk criteria that baby must satisfy ALL of prior to discharge? Name 5
• Greater than 37 weeks gestation
• No prior hospitalization
• No prolonged newborn nursery care
• WBC 5-15x109/L
• Bands less than 1.5x109/L
• Urine WBC < 5/HPF
• Urine negative for nitrites or leukocyte esterase
• CRP <20mg/L (if available)
• Procalcitonin < 0.5mcg/L (if available)
• No chronic illness
• No prior antibiotics
• No unexplained jaundice
• No prior hospitalization
• No prolonged newborn nursery care
• WBC 5-15x109/L
• Bands less than 1.5x109/L
• Urine WBC < 5/HPF
• Urine negative for nitrites or leukocyte esterase
• CRP <20mg/L (if available)
• Procalcitonin < 0.5mcg/L (if available)
• No chronic illness
• No prior antibiotics
• No unexplained jaundice
58
If Discharging
• What 3 actions would you take if Noah met ALL low risk
criteria and you planned outpatient management?
• What 3 actions would you take if Noah met ALL low risk
criteria and you planned outpatient management?
• Give caregivers clear direction regarding monitoring
treatment, and when to return
• Arrange followup within 24 hours
• Follow up all relevant culture results
treatment, and when to return
• Arrange followup within 24 hours
• Follow up all relevant culture results
59
What is the dosing of antipyretic agents in children?
Acetaminophen 15mg/kg or ibuprofen 10mg/kg
60
Name 3 commonly diagnosed conditions presenting with fever (and other symptoms) that do not routinely need immediate antibiotics:
Otitis media (children over age 2),
uncomplicated pharyngitis,
URTI
uncomplicated pharyngitis,
URTI
61
Fever > 3 Months, What are 3 occult bacterial infections to consider in your differential diagnosis?
UTI, pneumonia, soft tissue infection, septic arthritis, osteomyelitis, appendicitis, meningitis
62
What are 3 non-infectious causes of acute fever?
Heat-related illness,
thyrotoxicosis,
toxin ingestion,
intracranial hemorrhage,
neuroleptic malignant syndrome
thyrotoxicosis,
toxin ingestion,
intracranial hemorrhage,
neuroleptic malignant syndrome
63
Factors associated with increased risk of occult bacteremia in children aged 3-36 months are:
fever >38.9 degrees and
WBC 15 or greater
WBC 15 or greater
64
What are signs of severe sepsis in children > 28 days? Name 5
Fever > 38 or hypothermia <36,
tachycardia,
prolonged capillary refill,
cold extremities,
decreased urine output,
SpO2 < 94%,
mottled skin,
mental status changes (lethargy, confusion, inconsolability)
tachycardia,
prolonged capillary refill,
cold extremities,
decreased urine output,
SpO2 < 94%,
mottled skin,
mental status changes (lethargy, confusion, inconsolability)
65
How much IV fluid would you order for a child with suspected sepsis?
Bolus: 10-20mL/kg initial (IV PUSH) then 10-20mL/kg repeat boluses: aim for
approx 60mL/kg total in first hour (*if PICU level care is available)
approx 60mL/kg total in first hour (*if PICU level care is available)
66
What antibiotics would you administer as quickly as possible to a child > 28 days
with suspected sepsis?
with suspected sepsis?
• IV Ceftriaxone 100mg/kg/dose
• IV Vancomycin if suspected meningitis 15mg/kg/dose
• IV Vancomycin if suspected meningitis 15mg/kg/dose
67
What are risk factors for UTI in infants <24 months? Name 4:
• History of prior UTI
• Temperature 40 degrees or more
• Fever > 24 hours
• Suprapubic tenderness
• Jaundice
• Uncircumcised male
• Temperature 40 degrees or more
• Fever > 24 hours
• Suprapubic tenderness
• Jaundice
• Uncircumcised male
68
Check the urine in:
• Febrile, less 2 months: EVERYBODY (needs UA and Cx)
• Febrile, 2-24 months: Suggest use of UTI Calc to assist in determining risk of UTI and likelihood of UTI based on UA findings
• Febrile, >24 months: presence of urinary symptoms can be used as a criterion to determine need for UA and Cx
• In kids <2months: catheter or clean catch specimen
• In kids >2months: bag ok for screen, catheter or clean catch specimen for culture if leuk est or nitrite +, or leuks/bacteria on microscopic analysis
• Febrile, 2-24 months: Suggest use of UTI Calc to assist in determining risk of UTI and likelihood of UTI based on UA findings
• Febrile, >24 months: presence of urinary symptoms can be used as a criterion to determine need for UA and Cx
• In kids <2months: catheter or clean catch specimen
• In kids >2months: bag ok for screen, catheter or clean catch specimen for culture if leuk est or nitrite +, or leuks/bacteria on microscopic analysis
69
Name 3 indications for a CXR in a febrile child:
• Fever >5 days
• Cough >10 days
• Persistently high temperature (>40) with no other explanation
• WBC 20 or greater
• Or if respiratory symptoms …
• Cough >10 days
• Persistently high temperature (>40) with no other explanation
• WBC 20 or greater
• Or if respiratory symptoms …
70
Fever of Unknown Origin, Name 3 possible infectious causes:
Malaria,
TB,
Tularemia,
Toxoplasmosis,
Cat Scratch Disease
TB,
Tularemia,
Toxoplasmosis,
Cat Scratch Disease
71
Fever of Unknown Origin, Name 5 possible non-infectious causes:
Leukemia,
lymphoma,
Kawasaki disease,
juvenile idiopathic arthritis,
drug fever,
diabetes insipidus,
inflammatory bowel disease,
periodic fever disorders
lymphoma,
Kawasaki disease,
juvenile idiopathic arthritis,
drug fever,
diabetes insipidus,
inflammatory bowel disease,
periodic fever disorders
72
Fever and Rash
• What epidemiological factors would you consider on history? Name 3:
• What epidemiological factors would you consider on history? Name 3:
Season,
Travel history,
Geographic location,
Exposures (insects, plants, animals, sick contacts),
Medications,
Immunization status,
Immunologic status
Travel history,
Geographic location,
Exposures (insects, plants, animals, sick contacts),
Medications,
Immunization status,
Immunologic status
73
What features of the rash would you consider on history? Name 3:
• Lesion characteristics
• Distribution and progression of rash
• Timing of rash onset in relationship to fever
• Changes in morphology (ie papules to vesicles)
• Symptoms associated with the rash (pruritus, pain)
• Distribution and progression of rash
• Timing of rash onset in relationship to fever
• Changes in morphology (ie papules to vesicles)
• Symptoms associated with the rash (pruritus, pain)
74
Kawasaki
• Vasculitis of unknown cause
• Fever for 5 days plus four of:
• Bilateral conjunctivitis
• Oral mucous membrane changes
• Peripheral extremity changes (erythema, edema, or desquamation)
• Polymorphous rash
• Cervical adenopathy
• Treatment: IVIG, ASA
• Complications: coronary artery aneurysm, heart failure, MI, arrythmias
• Fever for 5 days plus four of:
• Bilateral conjunctivitis
• Oral mucous membrane changes
• Peripheral extremity changes (erythema, edema, or desquamation)
• Polymorphous rash
• Cervical adenopathy
• Treatment: IVIG, ASA
• Complications: coronary artery aneurysm, heart failure, MI, arrythmias
75
Neonatal Jaundice
• What are risk factors for development of severe hyperbilirubinemia? Name five:
• What are risk factors for development of severe hyperbilirubinemia? Name five:
Predischarge bilirubin in high risk zone,
jaundice in first 24 hours,
ABO incompatibility,
hemolytic disease,
Prematurity
previous sibling received phototherapy,
cephalohematoma or significant bruising,
exclusive breastfeeding,
East Asian race
jaundice in first 24 hours,
ABO incompatibility,
hemolytic disease,
Prematurity
previous sibling received phototherapy,
cephalohematoma or significant bruising,
exclusive breastfeeding,
East Asian race
76
What are causes of conjugated hyperbilirubinemia?
Biliary atresia,
hepatitis,
biliary cholestasis,
alpha-1-antitrypsin deficiency
hepatitis,
biliary cholestasis,
alpha-1-antitrypsin deficiency
77
What are causes of unconjugated hyperbilirubinemia?
Sepsis,
ABO incompatibility,
hereditary spherocytosis,
Gilbert’s syndrome,
G6P deficiency,
breastfeeding
ABO incompatibility,
hereditary spherocytosis,
Gilbert’s syndrome,
G6P deficiency,
breastfeeding
78
Name 4 risk factors for paediatric physical abuse:
• Caregiver: criminal history, mental health history, substance abuse, young/single parent, former victim of abuse/neglect
• Child: young age, behavioural problems, chronic illness, disability, non-biologic, premature, low birth weight
• Family/environment: High unemployment, IPV, poverty, social isolation, lack of support
• Child: young age, behavioural problems, chronic illness, disability, non-biologic, premature, low birth weight
• Family/environment: High unemployment, IPV, poverty, social isolation, lack of support
79
Name 6 examination findings that may be associated with non-accidental trauma:
• Bruises: in pre-mobile infant, in unusual or protected area (torso, ears, neck), bruises in patterns, significant number of bruises
• Breaks: any fracture in a non-ambulatory child, femur fracture in an infant, humerus fracture in an infant, multiple fractures, healing fractures, skull fractures, metaphysical fractures (bucket handle), posterior rib fractures
• Bonks: head trauma - especially if skull fractures that are depressed, bilateral, complex, or open
• Burns : immersion scald, contact burns, patterns
• Bites: stereotypical pattern to human bites
• Breaks: any fracture in a non-ambulatory child, femur fracture in an infant, humerus fracture in an infant, multiple fractures, healing fractures, skull fractures, metaphysical fractures (bucket handle), posterior rib fractures
• Bonks: head trauma - especially if skull fractures that are depressed, bilateral, complex, or open
• Burns : immersion scald, contact burns, patterns
• Bites: stereotypical pattern to human bites
80
Syncope in a teenage DDx:
Cardiac dysrhythmia,
ectopic pregnancy,
vasovagal,
seizure,
hypoglycemia,
anemia,
hypokalemia,
orthostatic,
substance use
ectopic pregnancy,
vasovagal,
seizure,
hypoglycemia,
anemia,
hypokalemia,
orthostatic,
substance use
81
Name five ‘red flags’ in paediatric syncope:
Exertional,
family history of sudden cardiac death, chest pain/dyspnea,
no prodrome,
history of structural cardiac disease,
abnormal cardiovascular exam,
focal neurologic signs,
fever
family history of sudden cardiac death, chest pain/dyspnea,
no prodrome,
history of structural cardiac disease,
abnormal cardiovascular exam,
focal neurologic signs,
fever
82
Name three investigations you can perform quickly to help you narrow
your differential diagnosis:
your differential diagnosis:
ECG, accu check, POCUS for ectopic
83
The ECG In Syncope
• What ECG findings would you look for? Name 4:
• What ECG findings would you look for? Name 4:
• Short PR: WPW
• Long PR: AV conduction block
• Narrow, deep QRS: HCM
• Wide QRS and epsilon waves: arrhythmogenic RV hypertrophy
• Wide QRS: Vtach, WPW
• QT interval: long or short
• Also look for Brugada, ACS, myocarditis
• Long PR: AV conduction block
• Narrow, deep QRS: HCM
• Wide QRS and epsilon waves: arrhythmogenic RV hypertrophy
• Wide QRS: Vtach, WPW
• QT interval: long or short
• Also look for Brugada, ACS, myocarditis
84
"Interpret this ECG
![]()
"
Arrhythmogenic RVH
1. TWI in R precordial leads
2. Epsilon waves (low amplitude notches after QRS and before T waves) in R precordial leads
1. TWI in R precordial leads
2. Epsilon waves (low amplitude notches after QRS and before T waves) in R precordial leads
85
"A 4 month old female is brought to your department by her parents. They say that when they removed her from the crib she was floppy and blue and looked as though she wasn’t breathing. The child started crying after they rubbed and patted her back. She is now lying quietly in her mother’s arms.
What other historical factors are of specific value in this case? (5 marks)
"
What other historical factors are of specific value in this case? (5 marks)
"
-Sleeping position
-Antecedent events such as seizure activity, feeding, recent URTI
-Duration of episode
-Resuscitative efforts provided by the parents (eg. mouth to mouth, stimulation)
-Any previous similar episodes?
-Pregnancy history (incl. maternal substance abuse)
-Gestational age at birth / prematurity
-Family history of SIDS
-Antecedent events such as seizure activity, feeding, recent URTI
-Duration of episode
-Resuscitative efforts provided by the parents (eg. mouth to mouth, stimulation)
-Any previous similar episodes?
-Pregnancy history (incl. maternal substance abuse)
-Gestational age at birth / prematurity
-Family history of SIDS
86
"When you examine the child you note the presence of retinal hemorrhage. What other physical exam findings in an infant or older child would make you suspicious of physical abuse? "
-Bruises in non-mobile children
-Multiple bruises in various stages of healing
-Concerning bruise location (away from bony prominences)
-Patterned bruising
-Ligature marks
-Bites with an intercanine diameter >3cm (adult bite)
-Lacerations of frenulum / oral mucosa
-Burn patterns suggestive of immersion
-Cigarette burns
-Contact or caustic burns
-Multiple bruises in various stages of healing
-Concerning bruise location (away from bony prominences)
-Patterned bruising
-Ligature marks
-Bites with an intercanine diameter >3cm (adult bite)
-Lacerations of frenulum / oral mucosa
-Burn patterns suggestive of immersion
-Cigarette burns
-Contact or caustic burns
87
"Other than abuse, list 7 conditions that may present with similar features as in the initial question stem: "
-Sepsis
-Congenital airway anomalies
-Seizures
-CNS lesions
-Hypoglycaemia
-Inborn errors of metabolism
-Congenital heart disease
-Dysrhythmias
-GERD
-Sepsis
-Meningoencephalitis
-Pneumonia
-UTI
-RSV/ Croup/ Pertussis
-Infantile botulism
-Accidental poisoning/ drug ingestion
-Congenital airway anomalies
-Seizures
-CNS lesions
-Hypoglycaemia
-Inborn errors of metabolism
-Congenital heart disease
-Dysrhythmias
-GERD
-Sepsis
-Meningoencephalitis
-Pneumonia
-UTI
-RSV/ Croup/ Pertussis
-Infantile botulism
-Accidental poisoning/ drug ingestion
88
ER Rx of peds seizure
Lorazepam 0.05-0.1 mg/kg IV
-or Midazolam 0.2-0.5 mg/kg intranasal
-or midazolam 0.05-0.2 mg/kg IM
-or Diazepam 0.2-0.5 mg/kg IV/PR
Dilantin 20mg/kg IV (rate 1mg/kg per minute)
-or fosphenytoin 20 mg/kg IV (rate 1-3mg/kg per minute)
If refractory:
-Secure the airway
-Phenobarbital 20 mg/kg IV
-or Midazolam 0.2-0.5 mg/kg intranasal
-or midazolam 0.05-0.2 mg/kg IM
-or Diazepam 0.2-0.5 mg/kg IV/PR
Dilantin 20mg/kg IV (rate 1mg/kg per minute)
-or fosphenytoin 20 mg/kg IV (rate 1-3mg/kg per minute)
If refractory:
-Secure the airway
-Phenobarbital 20 mg/kg IV
89
"List 5 diagnoses on your differential for a child with stridor."
-Croup
-Anaphylaxis
-Angioedema
-Foreign body (airway or esophagus)
-Retropharyngeal abscess
-Bacterial tracheitis
-Epiglottitis
-Peritonsillar abscess
-Anaphylaxis
-Angioedema
-Foreign body (airway or esophagus)
-Retropharyngeal abscess
-Bacterial tracheitis
-Epiglottitis
-Peritonsillar abscess
90
"List 5 exam findings on your initial examination that would be worrisome for severe croup"
-Fever
Features of impending respiratory failure:
-Tachycardia
-Tachypnea
-Hypoxia
-Significant distress or agitation
-Stridor at rest
-Marked retractions or intercostal/subcostal indrawing
-Tracheal tugging
-Decreased breath sounds
-Cyanosis or pallor
-Lethargy
Features of impending respiratory failure:
-Tachycardia
-Tachypnea
-Hypoxia
-Significant distress or agitation
-Stridor at rest
-Marked retractions or intercostal/subcostal indrawing
-Tracheal tugging
-Decreased breath sounds
-Cyanosis or pallor
-Lethargy
91
"List 3 features on history and exam that would make epiglottitis a more likely diagnosis."
-Unvaccinated status
-Tripoding/ sniffing position
-Drooling
-High fever
-Dysphagia
-Dysphonia
-Sore throat
-Tripoding/ sniffing position
-Drooling
-High fever
-Dysphagia
-Dysphonia
-Sore throat
92
"On the basis of your history and exam, you diagnose Liam with moderate croup. What investigation, if any, should you order?"
"-No investigations are required: clinical diagnosis"
93
"Croup, What are 2 actions you could initiate?"
Single dose of dexamethasone (0.6 mg/kg to max of 10 mg) PO plus one of the following:
-Observation in ER for improvement
-Parental education with discharge
-Observation in ER for improvement
-Parental education with discharge
94
"What are 5 factors which increase the likelihood of need for hospital admission after the initial treatment of croup?"
-Age less than 6 months
-History of previous severe croup
-Known structural airway anomaly
-Significant degree of respiratory distress
-Poor response to initial therapy
-Inadequate fluid intake/ clinical dehydration
-Parental anxiety
-Living far from the hospital/ difficult access to return to hospital
-Uncertain diagnosis
-History of previous severe croup
-Known structural airway anomaly
-Significant degree of respiratory distress
-Poor response to initial therapy
-Inadequate fluid intake/ clinical dehydration
-Parental anxiety
-Living far from the hospital/ difficult access to return to hospital
-Uncertain diagnosis
95
"Liam’s condition does not improve. What are 3 additional actions you could take? Be specific with any medication doses."
-Nebulized epinephrine [L-epinepherine 1:1000 (5mls)]
-Repeat steroid dose (dexamethasone 0.6mg/kg PO or budesonide 2mg neb)
-Intubation
-Admission to hospital
-Pediatric consultation
-Repeat steroid dose (dexamethasone 0.6mg/kg PO or budesonide 2mg neb)
-Intubation
-Admission to hospital
-Pediatric consultation
96
"Name two features that might suggest HSV encephalitis. What is the dose of acyclovir for this patient?"
-Altered mental status
-Focal neurologic deficits
-Seizures
-Sacral radiculopathy (includes urinary retention, constipation, paresthesia, and motor weakness)
-Acyclovir 10mg/kg IV q8hr
-Focal neurologic deficits
-Seizures
-Sacral radiculopathy (includes urinary retention, constipation, paresthesia, and motor weakness)
-Acyclovir 10mg/kg IV q8hr
97
"Your nursing staff were exposed to this patient without any exposure precautions in place. What will you prescribe them for contact prophylaxis? Include drug name, dose, route and duration. "
Any ONE of:
-Rifampin 600mg PO BID x2 days
-Ciprofloxacin 500mg PO x1 dose
-Ceftriaxone 250mg IM x1 dose
-Rifampin 600mg PO BID x2 days
-Ciprofloxacin 500mg PO x1 dose
-Ceftriaxone 250mg IM x1 dose
98
Other than infection, what are the causes of fever in children?
"-Drug fever/ toxic exposures
-Antibiotics: beta-lactams, sulfonamides, and nitrofurantoin
-Anticholinergic drugs/ antihistamines:
-Malignancy: leukemia, lymphoma
-Kawasaki's disease (½ mark for ‘vasculitis’)
-Systemic lupus erythematosus (SLE) (½ mark for ‘vasculitis’)
-Polyarteritis nodosa (½ mark for ‘vasculitis’)
-Juvenile idiopathic arthritis
-Inflammatory bowel disease: Crohn’s or Ulcerative Colitis
-Diabetes insipidus
-Familial Mediterranean fever
-Immunoglobulin deficiency (congenital or acquired)
-Non-accidental conditions/ Munchausens by proxy/ Factitious fever"
-Antibiotics: beta-lactams, sulfonamides, and nitrofurantoin
-Anticholinergic drugs/ antihistamines:
-Malignancy: leukemia, lymphoma
-Kawasaki's disease (½ mark for ‘vasculitis’)
-Systemic lupus erythematosus (SLE) (½ mark for ‘vasculitis’)
-Polyarteritis nodosa (½ mark for ‘vasculitis’)
-Juvenile idiopathic arthritis
-Inflammatory bowel disease: Crohn’s or Ulcerative Colitis
-Diabetes insipidus
-Familial Mediterranean fever
-Immunoglobulin deficiency (congenital or acquired)
-Non-accidental conditions/ Munchausens by proxy/ Factitious fever"
99
Atypical fever in children
"-Infective Endocarditis (viridans streptococci, enterococci, staphylococci)
-Brucellosis
-Bartonellosis
-Leptospirosis
-Salmonellosis
-Toxoplasmosis
-Tularemia
-Tuberculosis/Mycobacterium
(no marks for conditions with localized pain, resp or urinary symptoms, etc)"
-Brucellosis
-Bartonellosis
-Leptospirosis
-Salmonellosis
-Toxoplasmosis
-Tularemia
-Tuberculosis/Mycobacterium
(no marks for conditions with localized pain, resp or urinary symptoms, etc)"
100
"Measles, What complications of this condition must be considered? List 4, each from a different organ system"
Pneumonia/Bronchiolitis
Gastroenteritis/ Hepatitis
Encephalitis/ deafness
Myocarditis/ pericarditis
Keratitis/ corneal ulceration
Gastroenteritis/ Hepatitis
Encephalitis/ deafness
Myocarditis/ pericarditis
Keratitis/ corneal ulceration
101
Complications of Chicken pox
Cellulitis/impetigo/necrotizing fasciitis
Encephalitis/Reye’s syndrome
Pneumonia/Pharyngitis/Otitis media
Gastroenteritis/ Hepatitis
Septicemia/disseminated VZV
Myocarditis
Glomerulonephritis
Thrombocytopenia/ Purpura
Encephalitis/Reye’s syndrome
Pneumonia/Pharyngitis/Otitis media
Gastroenteritis/ Hepatitis
Septicemia/disseminated VZV
Myocarditis
Glomerulonephritis
Thrombocytopenia/ Purpura
102
Estimation of Wt, HR, BP, RR (in Peds)
WEIGHT
- (Age x2) + 10
- < 1 yr: (Age (mo)/2) + 4
BLOOD PRESSURE
- Normal= (Age x2) + 90
- Lowest tolerable (i.e. decrease BP)= (Age x2) + 70
103
Indications for work up in Jaundiced neonate
Jaundice in 1st 24 hrs
Elevated conjugated bilirubin
Rapidly rising TSB
TSB approaching exchange level
TSB not responding to phototherapy
Rising TSB > 3 wks
Sick-appearing neonate
Elevated conjugated bilirubin
Rapidly rising TSB
TSB approaching exchange level
TSB not responding to phototherapy
Rising TSB > 3 wks
Sick-appearing neonate
104
Brief Resolved Unexplained Events (BRUE) [formerly ALTE]
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"
105
Kawasaki disease
- mnemonic Warm C‐R‐E‐A‐M
- Warm ‐ Fever >39°C for 5 days, PLUS 4 of the 5 following signs (or less in ‘atypical’ form of the disease):
- C ‐ Conjunctivitis, bilateral non‐exudative
- R ‐ Rash, polymorphic (e.g. urticarial, maculopapular) and on the body (not vesicular nor bullous)
- E – Edema or erythema of the hands, eventually leading to desquamation
- A ‐ Adenopathy with at least one anterior cervical lymph node >1.5cm (not generalized over the whole body)
- M – Mucosal involvement: fissured red lips, strawberry tongue
106
High risk factors on history and physical that should prompt consideration of imaging after febrile seizure
· Focal seizure or persistent seizure activity
· Focal neurologic deficit
· VP shunt
· Neurocutaneous disorder
· Signs of elevated ICP
· History of trauma
· Immunocompromise
· Hypercoagulable state or bleeding disorder
107
Undifferentiated sick infant = THE MISFITS
· Trauma,
· Heart disease,
· Hypovolemia,
· Endocrine emergency,
· Metabolic,
· Inborn error of metabolism,
· Seizure,
· Formula problem,
· Intestinal disaster,
· Toxins,
· Sepsis
108
What are some common signs of neonatal sepsis?
Jaundice,
hepatomegaly,
poor feeding,
irritability,
hypoglycaemia,
respiratory distress,
vomiting
hepatomegaly,
poor feeding,
irritability,
hypoglycaemia,
respiratory distress,
vomiting
