Pediatrics

Question 1

Pressors

Answer 1

Dopamine if poor perfusion

Cold shock (hypotensive and vasocontricted) = epinephrine

Warm shock (hypotensive and vasodilator) = norepinephrine (levophed)

If catecholamine resistant = hydrocortisone

Question 2

Intubation

Answer 2

Avoid etomidate in sepsis (adrenal insufficiency)

Have atropine available for bradycardia and secretions
PALS recommends everyone under 1 year gets atropine

Question 3

PALS

Answer 3

Reversible causes of asystole/PEA

2-4 J/K in VT/VF

Question 4

Jaundice

Answer 4

Physiologic (2-3 days)
Breastfeeding (relative dehydration)
Breast Milk (inhibitor of bili conjugation)
Infection
Hemolysis

Bad = first 24h or conjugated biliribuin

Bilirubin nomogram

Tx = phototherapy, exchange transfusion

Question 5

Crying Infant

Answer 5

Hair Tourniquettes
Infection
Corneal abrasion
Testicular torsion
Nonaccidental Trauma (Frenulum)

Question 6

Crashing neonate

Answer 6

Sepsis
Cardiac 
Metabolic (check ammonia)
GI catastrophe (NEC, bilious vomiting)
NAT

Question 7

Hypoglycemia

Answer 7

Rule of 50

D10W 5cc/kg neontes
D25W 2cc/kg young kids
D50W 1cc/kg older

Question 8

Fever abx for neonates

Answer 8

Ampicillin/Cefotaxime (or Gent)
>1 month rocephin
Acyclovir
Vancomycin for UTI or sepsis

Question 9

Pneumonia

Answer 9

Neonates: GBS, Listeria, Chalmydia, G- enterics
ABX: Tx for sepsis!

Infants/Toddlers: Viral, Strep pneumo, Haemophalus, Staph, atypicals, pertussis
ABX: Amoxicillin (high doses)

> 4-5 yrs: Mycoplasma
ABX: Macrolides

Afebile staccato cough = chlamydia, zithromax

Question 10

Otitis Media

Answer 10

Treat if bilateral or >48h
High dose Amoxicillin

Augmentin if recent infection or associated bilateral conjunctivitis (H-flu)

Question 11

Congenital Heart Disease

Answer 11

Bimodal, neonate (ductal dependent) and 2-6 months (CHF)

Ductal dependent
1. pulmonary blood flow = cyanosis/hypoxic
2. systemic blood flow = shock/acidotic
Tx = PGE 1 (intubate, MC side effect = apnea)
TRANSFER!!!

CHF = respiratory symptoms, looks like asthma, difficulty feeding, hepatomegaly

Question 12

Arrythmias

Answer 12

SVT (>220 infant, >180 child)

Vagals (ice to face)

Question 13

Acquired heart disease

Answer 13

Myocarditis 
Pericarditis
Endocarditis
Kawasaki
Cardiomyopathy

Question 14

Peds EKG

Answer 14

R heart dominant at birth
HR faster
Intervals shorter

Normal to have TWI in V1-3

Question 15

Croup

Answer 15

Middle of night barky cough and respiratory distress

Steroids, single dose dexamethasone

If severe, epi neb (watch x2h)

DDx = bacterial tracheitis if sick appearing and no improvement with tax’s

Question 16

Bronchiolitis

Answer 16

Suctioning, O2, PPV if needed

Maybe albuterol, hypertonic saline nebs, epi nebs

No role for steroids or abx

Question 17

Status Epilepticus

Answer 17

FSBS? Check frequently - can become hypoglycemic

Benzo’s (0.1 mg/kg)

Dilantin/Cerebyx, Phenobarbitol, Keppra
(all 20 mg/kg)
Dilantin if >2 yo (20 mg/kg)

Secure airway if refractory
Versed, propofol, ketamine, pentobarbitol

Causes?
Hypoglycemia
Hyponatremia
Hypocalcemia (DiGeorge)
INH toxicity (Pyridoxine)

Question 18

Febrile Seizures

Answer 18

Simple:
6 months - 6 years
15 min, focal, or recur in 24h

Question 19

AMS

Answer 19

FSBS
Low threshold to tx infection
Tox?
NAT
Intussusception

Question 20

Stroke in kids

Answer 20

50% hemorrhagic

Risk factors:
Infection
Arteriopathies
Cardiac disease
Hematologic disease (sickle cell - exchange transfusion)
Drugs
Chemo/rads

Management: controversial, officially don’t use TPA in kids

Question 21

Peds DKA

Answer 21

Less fluid resuscitation!
Cerebral edema

10mg/kg bolus over 1 hour
2nd bolus over hour 2 if circulation compromised
1.5-2x maintenance fluids

Have mannitol at bedside

Risk factors for cerebral edema:
Age
First time episode
Degree of acidosis

Question 22

Congenital Adrenal Hyperplasia

Answer 22

Hyperkalemic, Hyponatremic, Hypoglycemic

N/V/D
Arrythmias (due to elevated K)
Hypoglycemia can cause seizures

IVF, glucose, hydrocortisone

Question 23

Inborn Errors of Metabolism

Answer 23

Enzyme deficiency leads to toxic metabolite

Metabolic Acidosis
Hypoglycemia
**Hyperammonemia

Supportive, make NPO
Replete glucose
Control seizures
Correct electrolyte abnormalities

Tx for sepsis, these are higher risk

Question 24

Bilious Vomiting

Answer 24

Surgical emergency

Malrotation with midgut volvulus until proven otherwise

Call surgery, if stable may get upper GI as well.

Question 25

Hirschsprung's Disease

Answer 25

No meconium in neonates Lesser form: Infants/children with chronic constipation

Question 26

Pyloric Stenosis

Answer 26

Hypertrophy of gastric outlet, hungry but vomiting US diagnostic Olive mass at epigastrium Correct dehydration or metabolic deficiency

Question 27

Intussusception

Answer 27

Abdominal pain Palpable sausage mass Red currant jelly stool Lethargy, N/V, paroxysms of pain 3 months - 2 years Surgical emergency Diagnosed with US or air/barium enema (dx and therapeutic, but perf risk) 10% recurrence, usually early

Question 28

Meckel's Diverticulum

Answer 28

Painless rectal bleeding Can be nidus for volvulus or intussusception

Question 29

Hemolytic Uremic Syndrome

Answer 29

``` Follows diarrhea (Ecoli, bloody) Abx with bloody diarrhea increase risk of HUS ``` Acute Renal Failure Thrombocytopenia MAHA (schistocytes) If neuro findings as well consider TTP Tx = supportive, dialysis

Question 30

Leukemia

Answer 30

``` Presents like viral syndrome Fever Petechiae Bone pain, limp HSM Lymphadenopathy ```

Question 31

Lymphoma

Answer 31

``` Night sweats Fever Pruritis Respiratory distress (if mediastinal mass) Lymphadenopathy ```

Question 32

Limping Kids

Answer 32

Fracture Discitis Abdominal pain Transient Synovitis Septic Joint (fever, elevated CRP/ESR/WBC, effusion on XR/US, decreased ROM) AVN (Legg-Calve-Perthes) - NWB SCFE - frog leg view, chubby 13 year old, Klein's line - NWB Malignancy Arthritis (ANA >> RF) Apophysitis (overuse injuries)

Question 33

Nonaccidental Trauma

Answer 33

``` Posterior rib fractures Multiple injuries Skull fractures Serious injuries Recurrent visits Metaphyseal lesions (bucket fractures) Frenulum tears ```

Question 34

5th's disease

Answer 34

Parvovirus B19, slapped cheek | Worry in pregnancy (hydrops) and sickle cell (aplastic crisis)

Question 35

Varicella

Answer 35

Vesicles in different stages = varicella Acyclovir, VZIG Can happen in vaccinated kids

Question 36

Scarlet Fever

Answer 36

Scarlet Fever - pastia's line, sandpaper, strawberry tongue, desquamation (toxin mediated)

Question 37

Staph Scaled Skin

Answer 37

Desquamination More well defined than TEN ABx Nikolsky positive

Question 38

Henoch Schonlein Purpura

Answer 38

Palpable Purpura (dependent, symmetric, edema) Arthritis/Arthralgias (>50%) Abdominal pain (can lead to intussusception) Renal disease If normal urine dip can f/u outpatient with kids, all adults should have Cr checked as well Supportive tx with NSAIDs

Question 39

Erythema Multiforme

Answer 39

Minor = no mucosal involvement Major = mucosal involvement Negative Nikolsky sign 90% a/w infection (HSV usually) Symptomatic tx

Question 40

Stevens Jonhsons Syndrome

Answer 40

Postive Nikolsky On TEN spectrum Prior abx usually Mucous membrane involvement IVF, supportive care

Question 41

Kawasaki

Answer 41

5 days of fever PLUS 4/5 criteria ``` Mucosal changes Conjunctivitis Extremity changes Cervical LAD Polymorphous rash ``` ASA, IVIG Concern for coronary artery aneurysm

Question 42

Neonatal Resuscitation

Answer 42

PPV if HR under 100 Compressions if HR under 60 120 bpm if intubated Otherwise 3:1 with thumb compressions With hold support if under 23wks or 400g DC if after 10 min with no HR