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Royal College: Emergency Medicine > Pediatrics > Flashcards

Pediatrics Flashcards

This deck covers Chapters 160-177 in Rosens, compromising all of pediatrics.

1
Q

What medication should be given to babies (~2-3 weeks) presenting with cyanotic CHD? Dose? Side effects?

A

PGE1 0.05-0.1 ug/kg/min IV infusion

Side effects:

  • Fever
  • Seizure
  • Apnea
  • Hypotension
  • Bradycardia
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2
Q

List 7 anatomical differences in children and the relevance.

A
  1. Large surface to weight ratio = More heat loss
  2. Large head, floppy neck = Higher rate of head injury
  3. Narrow airway = More easily obstructed
  4. CV Compromise/Hypotension is late = Well until crashing
  5. Pliable bones = More force to vital organs
  6. Physeal plates are weakest = Growth plate injuries
  7. Nose breathers = Secretions cause significant WOB
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3
Q

List 5 causes of decreased stroke volume in children

A
  1. Dehydration
  2. Pericarditis w/ tamponade
  3. Myocarditis
  4. CHF
  5. HOCM
  6. Dilated cardiomyopathy
  7. Tachydysrhythmias
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4
Q

List 6 treatment options for a child having a “tet spell”

A
  1. Oxygen
  2. Knee-to-chest
  3. Calm the child
  4. Morphine 0.1 mg/kg IV/IM
    * Fentanyl 1 ug/kg IV/IM
  5. Ketamine 1 mg/kg IV
  6. Phenylephrine 20 ug/kg IV
  7. Propranolol 0.01 - 0.02 mg/kg IV
    * Esmolol 500 ug/kg bolus IV
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5
Q

What are the historical features (4) concerning for child abuse?

A
  • Lacking details
  • Inconsistent on repeat questioning
  • Inconsistent with developmental status
  • Inconsistent mechanism with injury
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6
Q

Draw a diagram outlining fetal circulation.

A

From mom, through umbilical vein (1)

Bypass liver via ductus venosus

Enter heart at IVC

Bypass lungs via patent foramen ovale to aorta

Bypass RV via patent ductus arteriosus to aorta

Blood then leaves placenta via umbilical arteries (2)

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7
Q

List 5 infectious and 3 non-infectious causes of HUS

Why are antibiotics contraindicated?

A

Infectious

  • E. coli O157:H7
  • Shigella
  • S. pneumoniae
  • Aeromonas
  • HIV

Non-Infectious

  • Drugs
  • Hereditary
  • Familial
  • Idiopathic

ABx enhances release of bacterial verotoxin

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8
Q

What is the peak age for SCFE?

Name 6 associations with SCFE

A

Peak age = 12 y/o, older in boys

  1. Male
  2. Obesity
  3. Black
  4. Endocrine disorders
  5. Radiation therapy
  6. Renal osteodystrophy
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9
Q

List 6 causes of childhood ataxia

A
  1. Acute cerebellar ataxia
  2. Post-infectious demyelinating encephalomyelitis
  3. Brainstem encephalitis
  4. Drug ingestion
  5. Inborn errors of metabolism
  6. Migraine
  7. MS
  8. Brain mass
  9. Seizures
  10. Stroke
  11. Vertebral artery dissection
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10
Q

List 4 CHDs that are duct dependent for Left to Right

  • Duct required to get blood into pulmonary circulation

List 3 CHDs that are duct dependent for Right to Left

  • Duct required to get blood into the arterial circulation
A

Left to Right

  1. Pulmonary atresia
  2. Tricuspid atresia
  3. Tetralogy of Fallot
  4. Hypoplastic right heart
  5. TGA

Right to Left

  1. Hypoplastic left heart
  2. Pre-ductal coarctation
  3. Severe aortic stenosis
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11
Q

List 8 episodic disorders that may mimic seizures in children

A
  1. BRUE
  2. Breath-holding spell
  3. Rigors
  4. GERD
  5. Migraine
  6. BPPV
  7. Syncope
  8. Stroke
  9. Sleep disorders
  10. Movement disorders
  11. Psychogenic seizure
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12
Q

Provide a DDx for a systolic murmur in the following locations:

  • LUSB
  • LLSB
  • RUSB
  • Apex
A

LUSB

  • Pulmonary stenosis
  • PDA
  • Flow murmur
  • ASD

LLSB

  • Tricuspid regurgitation
  • Still’s murmur
  • VSD
  • Tetralogy
  • HOCM

RUSB

  • Aortic stenosis
  • Coarctation

Apex

  • Mitral regurgitation
  • Still’s murmur
  • HOCM
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13
Q

Provide 2 congenital and 2 acquired causes of stridor in each of supraglottic, glottic, and infraglottic areas.

A

_Congenital_

  • Supraglottic
  • Micrognathia
  • Pierre Robin syndrome
  • Treacher Collins
  • Thyroglossal duct cyst
  • Lingual thyroid
  • Choanal atresia
  • Down syndrome
  • Macroglossia
  • Storage diseases
  • Glottic
  • Laryngomalacia
  • Vocal cord paralysis
  • Laryngeal web
  • Laryngocele
  • Infraglottic
  • Subglottic stenosis
  • Tracheomalacia
  • Tracheal stenosis
  • Vascular ring
  • Hemangioma cyst

_Acquired_

  • Supraglottic
  • Foreign body
  • Pharyngeal abscess
  • Epiglottitis
  • Tonsillar hypertrophy
  • Adenopathy
  • Glottic
  • Foreign body
  • Papillomas
  • Infraglottic
  • Foreign body
  • Croup
  • Bacterial tracheitis
  • Subglottic stenosis
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14
Q

List the most common organism for each of croup, epiglottitis, and bacterial tracheitis.

A
  • Croup = Parainfluenza virus
  • Epiglottitis = H. flu
  • Bacterial tracheitis = S. aureus
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15
Q

List 10 causes of vomiting in children

A
  • Meningitis
  • Brain mass
  • Overdose
  • DKA
  • CAH
  • UTI
  • CHF
  • Pneumonia
  • AOM
  • Sepsis
  • Any GI issue…
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16
Q

List the normal vital signs by age (HR, RR, BP)

A

Heart Rate

  • <1 year = 100 - 160
  • 1-2 years = 90 - 150
  • 2-5 years = 80 - 140
  • 5-12 years = 70 - 120
  • 12+ years = 60 - 100

Respiratory Rate

  • <1 year = 30 - 60
  • 1-2 years = 24 - 40
  • 2-5 years = 22 - 34
  • 5-12 years = 18 - 30
  • 12+ years = 12 - 16

Blood Pressure

  • <1 month = 60 mmHg
  • 1-12 months = 70 mmHg
  • 1-10 years = 70 + (Age x 2)
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17
Q

How do you manage bronchiolitis in the ED?

Name 2 treatments that have evidence for, 2 against, and 2 equivocal.

A

Treatment = Supportive

Evidence for:

  1. Oxygen
  2. Hydration

Equivocal:

  1. Nebulized epinephrine + Dexamethasone
  2. Nasal suction

Against:

  1. Ventolin/Atrovent
  2. Steroids
  3. Antibiotics
  4. Hypertonic Saline
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18
Q

List 8 things on a DDx for bacterial meningitis

A
  1. Stroke
  2. Brain bleed
  3. CNS vasculitis
  4. SAH
  5. AOM
  6. Sepsis
  7. Meningitis
  8. Encephalitis
  9. Brain abscess
  10. Brain mass
  11. Sympathomimetics
  12. ASA
  13. Anticholinergics
  14. Thyrotoxicosis
  15. NMS
  16. SS
  17. MH
  18. Heat stroke
  19. Viral URTI
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19
Q

What is the CPS statement on steroids in meningitis?

A

Dexamethasone 0.6 mg/kg IV div q6h

  • Give within 4h of ABx (earlier is likely better)
  • Mortality benefit with S. pneumoniae
  • Hearing loss benefit with H. influenzae
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20
Q

What investigations would you order as a “critical sample”?

A

Usual

  • Electrolytes
  • LFTs
  • Glucose
  • Lactate

Nutrients

  • Ketones
  • Free Fatty Acids
  • Amino Acids

Hormones

  • Growth Hormone
  • Cortisol
  • Insulin
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21
Q

What are the diagnostic criteria for Kawasaki disease?

A

CREAM

Fever >5 days plus 4 of the following:

  • Conjunctivitis (bilateral, non-suppurative)
  • Rash (generalized maculopapular rash)
  • Extremity changes (swelling/red, sloughing on hands/feet)
  • Adenopathy (>1.5 cm)
  • Mucosal involvement (Strawberry tongue, red lips/throat)
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22
Q

What is the treatment of phimosis?

A
  • Topical steroids (Betamethasone x6 weeks)
  • Dilation
  • Dorsal slit/Circumcision
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23
Q

How is the desired amount of ORT estimated and given?

A
  • Estimate degree of dehydration
  • Mild 30 mL/kg, Mod 60 mL/kg, Sev 90 mL/kg
  • Calculate the desired volume
  • Multiply weight by severity
  • Replace ongoing losses
  • 10 mL/kg per stool
  • 2 mL/kg per vomit
  • Administer 25%/hr x4 hr
  • Re-evaluate at 4 hours
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24
Q

What is the etiology and treatment for septic arthritis by age?

  • 0-2 months
  • 2 months - 5 years
  • 5 - 12 years
  • >12 years
A

0-2 months

  • GBS
  • S. aureus
  • N. gonorrhea

2 months - 5 years

  • S. aureus
  • Streptococcus
  • Kingella
  • H. influenzae

5 - 12 years

  • S. aureus
  • Streptococcus pyogenes

>12 years

  • S. aureus
  • N. gonorrhea

Treatment

  • Cefotaxime/Ceftriaxone + Vancomycin
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25
How do you manage an upper airway obstruction in an infant (\<1 year) vs. a child (\>1 year)?
**Infant (\<1 yr)** * 5x back blows then 5x chest compressions **Child (\>1 yr)** * Heimlich If unconscious, start CPR. No blind finger sweeps. Needle cric if necessary * 14-18G needle on a 3 mL syringe without the plunger * Connect to BVM using 3-0 ETT connector
26
Review the developmental milestones in children \<2 years old
27
List 10 drugs that may cause seizures
**OTIS CAMPBELL** * **O**ral hypoglycemic * **T**heophylline, **T**CA * **I**nsulin, **I**soniazid * **S**ulphonylureas, **S**ympathomimetics * **C**amphor, **C**ocaine, **C**O * **A**SA, **A**nticholinergics * **M**ethanol * **P**CP, pesticides * **B**otanicals, **B**ZD/**B**arbituate w/d * **E**thylene glycol, **E**thanol w/d * **L**idocaine * **L**ithium
28
Outline the Boston Criteria
* Age 28-89 days * Fever \>38.0 degrees * Well looking * Labs * WBCs \< 20 * UA \< 10 WBCs/hpf * CSF \<10 WBCs/hpf * CXR normal (if obtained) * NPV 94.6% * All children received a dose of IM ceftriaxone
29
List 3 conditions that cause a double-bubble sign on AXR
1. Pyloric stenosis (non-bilious - 4 weeks progressive) 2. Duodenal atresia (bilious - immediate) 3. Midgut volvulus (bilious - 4 weeks sudden)
30
List 4 indications for LP in suspected acute bacterial meningitis
1. Fever \<60 days 2. Neonatal sepsis 3. Altered mental status/Neck stiffness 4. Suspected sepsis in abnormal host 5. Consider in: * Fever + Seizure * Fever + Petechiae * Fever + Contact
31
Name 6 risk factors for meningitis in children
1. Neonate 2. Native 3. Black 4. Malnourished 5. Low SES 6. Daycare 7. Sickle Cell Immune Compromise 1. AIDS 2. Asplenia 3. Renal Disease 4. Hepatic Disease 5. DM 6. Dysgammaglobulinemia 7. Immunosuppressive medication
32
What is the peak age for Legg-Calve Perthes disease? Name 8 associations with the disease.
Peak age = 7 y/o 1. Male 2. Breech 3. Low birth weight 4. Later birth order 5. Older parents 6. Short 7. Asian 8. Low SES 9. HIV 10. Renal disease
33
Describe the Salter-Harris classification system
1. **S**traight 2. **A**bove 3. be**L**ow 4. **T**hrough 5. c**R**ush
34
Give a DDx for conjugated and unconjugated jaundice in an infant.
**Conjugated** 1. Obstructive * Biliary atresia * Bile duct stricture * Choledochal cyst 2. Infectious * Sepsis * TORCH infection 3. Metabolic/Genetic * Cystic fibrosis * Galactosemia * Alpha-1 antitrypsin deficiency **Unconjugated** 1. Hemolysis * G6PD * Spherocytosis * Sickle Cell * ABO incompatibility * Cephalohematoma 2. Infectious * Sepsis * TORCH infection 3. Obstructive * Duodenal atresia * Pyloric stenosis 4. Metabolic/Genetic * Galactosemia * Crigler-Nejar syndrome * Gilbert syndrome
35
What is the treatment for paraphimosis?
* Analgesia (nerve block) * Reduce edema (ice) * Reduce foreskin (two thumbs, pull shaft)
36
List 6 cardiovascular causes of sudden death in an athlete.
1. HOCM 2. Brugada 3. WPW 4. ARVD 5. Commotio cordis 6. Long QT 7. Mitral valve prolapse 8. Coronary disease from Kawasaki 9. Aortic rupture from Marfans 10. Dilated cardiomyopathy 11. Myocarditis 12. Aortic stenosis 13. Congenital coronary anomaly
37
What is the inpatient and outpatient antibiotic regimen for pneumonia treatment in children \>3 months?
**Outpatient** * Amoxicillin 90 mg/kg/day TID x10 days * PCN Allergic: Clarithromycin 7.5 mg/kg BID x10 days **Inpatient** * Ceftriaxone 50-100 mg/kg q24h and * Azithromycin 10 mg/kg on day 1, 5 mg/kg on days 2-5
38
What are the 4 radiographic classification stages of Legg-Calve-Perthes disease?
1. Initial - femoral head smaller than opposite 2. Fragmentation - epiphysis fragments 3. Re-ossification - bone density restores 4. Healed - residual deficits remain
39
List 3 ways to estimate ETT size for children \>1 y/o?
1. Breslow tape 2. Diameter of little finger 3. Cuffed = 3.5 + (age/4)
40
How do you counsel a parent regarding febrile seizures?
* Risk of epilepsy from 1% to 2% * 30% of kids will have another * Younger they are, higher the risk * During seizure * Protect from injury, nothing in mouth * If seizure \<5 min * Check airway, recovery position, seek MD advice * If seizure \>5 min * Call 911
41
List 7 factors associated with priapism
1. Sickle cell 2. Leukemia 3. Anticoagulation 4. Immunosuppression 5. Trauma 6. Spinal cord injury 7. Drugs - SSRI, sedatives OAC, abuse
42
List 4 organism that cause a 'whooping cough'
1. B. pertussis 2. C. pneumoniae 3. M. pneumoniae 4. Adenovirus
43
What risk factors (8) are referred to in the phototherapy guidelines for risk of bilirubin related encephalopathy?
**S**ome **A**iling **B**abies **H**ave to **G**et **L**ower **P**hototherapy **T**hresholds * **S**epsis * **A**lbumin \<30 * **B**lue (Asphyxia) * **H**emolysis * **G**6PD * **L**ethargy * **p**H (Acidemia) * **T**emperature instability
44
List 10 complications of status epilepticus
1. Brain ischemia 2. Tachycardia 3. Hypertension 4. Hyperpyrexia 5. Rhabdomyolysis 6. Hyperglycemia 7. Lactic acidosis 8. Aspiration 9. Takotsubo cardiomyopathy 10. CHF 11. Apnea 12. Neurogenic pulmonary edema
45
What is first-line treatment for pneumonia in 0-3 months?
**0-30 days** * Ampicillin 50 mg/kg q8h + Cefotaxime 50 mg/kg q8h **30 - 90 days** * Ceftriaxone 100 mg/kg IV q24h
46
What does the CPS recommend in regards to the management of status epilepticus?
* Lorazepam 0.1 mg/kg IV, then * Fosphenytoin/Phenytoin 20 mg/kg, then * Phenobarbital 20 mg/kg, then * RSI + Midaz infusion
47
When (10) would you work-up a child with acute diarrhea?
1. \<6 months 2. Premature 3. Chronic medical conditions 4. Fever 5. Bloody stool 6. High output 7. Persistent vomiting 8. Dehydration 9. Altered 10. Poor ORT in ED
48
List 10 causes of diarrhea in children
1. Overdose 2. CAH 3. Addisonian crisis 4. Thyrotoxicosis 5. UTI 6. Pyelonephritis 7. Pneumonia 8. AOM 9. Sepsis 10. Malabsorption 11. CF 12. Intussusception 13. IBD 14. Gastroenteritis 15. IBS 16. Short gut syndrome
49
List 10 causes of HTN in children
1. Essential HTN 2. Conn's 3. Pheo 4. Renal artery stenosis 5. Coarctation 6. Nephritic syndrome 7. ICP 8. Brain mass 9. HSP 10. PCKD 11. SLE 12. Diabetic nephropathy 13. Cushing's 14. CAH 15. Chronic steroids 16. OCP 17. Sympathomimetics
50
What are the risk factors (6) for febrile seizure recurrence?
1. Age on onset \<18 months 2. Fever \<39 degrees 3. 1st-degree relative FHx 4. Fever \<1h before the seizure 5. Multiple seizures in the same illness 6. Daycare
51
What do you do if a child has a fever for 6 days and only 2 criteria for Kawasaki?
**Incomplete Kawasaki Workup** 1. ESR \>40 + CRP \>30 * If not, stop * If so, get: HgB, WBC, Plt, Alb, ALT, Urine * HgB AbN * WBC \>15 * Plt \>450 * Alb \<30 * ALT AbN * Sterile pyuria (\>10 WBCs/hpf) * If 3+ AbN, get an echo and treat * If 0-2 AbN, get an echo * If echo AbN treat * If echo normal, stop
52
Name the top 3 **bacterial** causes of pneumonia by age: * 0-3 weeks * 3 weeks - 3 months * 3 months - Adolescent
**0-3 weeks** * E. coli * GBS * L. monocytogenes **3 weeks - 3 months** * C. trachomatis * S. pneumoniae * H. influenzae **3 months - Adolescent** * C. pneumoniae * M. pneumoniae * S. pneumoniae
53
What pediatric patients are at higher risk of UTI?
* Female \< 2 years * Male \< 1 year uncircumsized * Male \< 6 months circumsized \*Send UCx even if dip negative
54
Name 13 infectious causes of diarrhea
1. Campylobacter jejuni 2. Clostridium difficile 3. E. coli - STEC 4. E. coli - ETEC 5. Salmonella, non-typhoid 6. Salmonella typhi 7. Shigella 8. Vibrio cholera 9. Vibrio parahemolyticus 10. Yersinia enterocolitica 11. Cryptosporidium 12. Entamoeba histolytica 13. Giardia
55
List the 5 components of the Westley Croup Score. What defines mild/moderate/severe?
**CARLS** * **C**yanosis (0/4/5) * **A**/E (0/1/2) * **R**etractions (0/1/2/3) * **L**evel of Consciousness (0/5) * **S**tridor (0/1/2) Mild = 0 - 2 (Dex 0.15-0.6 mg/kg then home) Moderate = 3 - 5 (Dex 0.15-0.6 mg/kg then observe) Severe = 6 - 11 (Dex 0.15-0.6 mg/kg + Epi 5 mL neb)
56
What is a Tillaux fracture? How is it managed?
SH3 fracture of the distal tibia epiphysis caused by an avulsion of the AITFL Ortho to see in ED
57
List 5 fracture patterns that are worrisome for child abuse
1. Non-linear skull fractures 2. Long bone in a non-ambulatory child 3. Posterior rib 4. CML 5. Vertebral body 6. Fractures at different stages of healing 7. Multiple fractures 8. Any fracture \<1-year-old
58
Compare and contrast extension vs flexion-type supracondylar fractures: * How common? * Mechanism? * Physiology? What nerves are injured? * Presentation?
**How common?** * Extension = 95% * Flexion = 5% **Mechanism?** * Extension = Hyperextension with FOOSH * Flexion = Direct blow to flexed elbow **Physiology?** * Extension = Ant. cortex breaks with post. displacement * Flexion = Post. cortex breaks with ant. displacement **Presentation?** * Extension = Holds in extension, arm in "S" * Flexion = Holds in flexion, olecranon missing **Nerves Injured?** * #1 anterior interosseous nerve (AIN) (branch of median n.) * #2 radial nerve palsy * ulnar nerve palsy (seen with flexion-type)
59
What is a triplane fracture? How is it managed?
An angled fracture of the distal tibia in 3 planes Age 10-17 Ortho in ED
60
What are the different lines on the phototherapy guideline?
1. Term (\>38) and well 2. Term + risk factors OR 35-37+6 wk and well 3. 35-37+6 wk + risk factors
61
List 8 complications from HSP
1. Intussusception 2. Renal failure 3. Gallbladder hydrops 4. Pancreatitis 5. GI bleed 6. Bowel ischemia 7. Coronary artery vasculitis 8. Headache 9. Orchitis
62
List 8 causes of headache in children
1. Stroke 2. SAH 3. AVM 4. HTN 5. Meningitis 6. Encephalitis 7. Brain abscess 8. Brain mass 9. Hydrocephalus 10. AOM 11. Cocaine 12. Congenital malformation 13. Abuse 14. Dehydration 15. Migraine 16. UTI 17. Pyelonephritis 18. Pneumonia 19. Medication S/E
63
List 10 causes of dysuria in a child
1. UTI 2. Pyelonephritis 3. Renal colic 4. Balanitis 5. STI 6. Vaginitis 7. Pinworms 8. Vaginal FB 9. Chemical irritant (soap, bubble bath, etc.) 10. Sexual abuse 11. Masturbation 12. Straddle injury
64
What are the most common causes of fever in the following age groups? Name 3 bacterial and 3 viral. * 0-28 days * 1-3 months * 3-36 months * 3 years - Adult
65
List the three components of the Pediatric Assessment Triage
1. Appearance 2. Circulation to Skin 3. Work of Breathing
66
Provide a DDx (3) for **cyanotic** heart disease with **decreased** and **increased** vascular markings on CXR.
**Increased vascular markings** 1. Transposition 2. Truncus arteriosus 3. TAPVR 4. Hypoplastic left heart **Decreased vascular markings** 1. Tricuspid atresia 2. Pulmonary atresia 3. Tetralogy of Fallot
67
List 5 mimics of child abuse
1. Metaphyseal cupping & spurring 2. Osteogenesis imperfecta 3. Rickets 4. Scurvy 5. Hypervitaminosis A 6. Congenital syphilis 7. Congenital rubella 8. Periosteal new bone formation
68
What are the indications for IE prophylaxis for patients undergoing procedures? What procedures? What medication?
**Indications** * History of IE * Hardware * CHD * Transplant **Procedures** * Dental with mucosal involvement * Resp incision * Infected Skin **Prophylaxis** * Amoxicillin 50 mg/kg PO (max 2g) * PCN Allergic: Clindamycin 20 mg/kg (max 600 mg) * Give 30-60 minutes before procedure
69
Outline the Rochester Criteria
* Age \< 60 days * Fever \>38.0 degrees * Well looking * Labs * WBCs 5 - 15 * Bands \< 1500 * UA \< 10 WBCs/hpf * Stool \<5 WBCs/hpf * Sens 92% * NPV 98.9%
70
What are 4 conditions associated with severe RSV infection?
1. Chronic lung disease 2. Pulmonary hypertension 3. Chronic heart disease 4. Prematurity 5. Immunodeficiency
71
List the pediatric doses for the following asthma medications: * Ventolin MDI * Ventolin Neb * Atrovent MDI * Atrovent Neb * Dexamethasone * Prednisone * Methylprednisolone * Epinephrine * Magnesium sulfate
* Ventolin MDI * \<20 kg = 4 puffs * \>20 kg = 8 puffs * Ventolin Neb * \<20 kg = 2.5 mg * \>20 kg = 5 mg * Atrovent MDI * \<20 kg = 4 puffs * \>20 kg = 8 puffs * Atrovent Neb * \<20 kg = 250 ug * \>20 kg = 500 ug * Dexamethasone 0.6 mg/kg IV * Prednisone 2 mg/kg (max 60 mg) * Methylprednisolone 1-2 mg/kg (max 125 mg) * Epinephrine 0.01 mg/kg IM * Magnesium sulfate 50 mg/kg
72
What is the dose of: * Cardioversion * Defibrillation * Epinephrine * Atropine * Adenosine * Amiodarone * Procainamide * Lidocaine * Magnesium
* Cardioversion = 1 J/kg * Defibrillation = 2-4 J/kg * Epinephrine = 0.01 mg/kg * Atropine = 0.02 mg/kg * Adenosine = 0.1 mg/kg * Amiodarone = 5 mg/kg * Procainamide = 15 mg/kg * Lidocaine = 1 mg/kg * Magnesium = 50 mg/kg
73
What are physical exam and radiographic findings (7) are concerning for child abuse?
1. Bruising in young infant 2. Patterned bruises/burns 3. Bruises on ears/neck/trunk/inner thigh/groin 4. Posterior rib fractures 5. Classic metaphyseal fracture 6. Any fracture in a non-ambulatory child 7. Fractures of different stages of healing
74
List 8 conditions at high risk for developing arrhythmia
* Kawasaki * Myocarditis * CHD * Congenital heart block * WPW * Long QT * Rheumatic heart disease * Commotio cordis * Hypoxia * Electrolytes * Hypothermia
75
Name and describe 3 physical exam techniques to diagnose development dysplasia of the hip
1. **O**rtolani (**O**kay - reduces hip) * Stabilize pelvis, abduct hip, pull up on thigh 2. **B**arlow (**B**ad - dislocates hip) * Stabilize pelvis, adduct hip, push down 3. Galeazzi Sign 1. Femur length discrepancy by bending knees
76
What are 6 signs/symptoms of acute bilirubin encephalopathy?
1. Arching 2. Fever 3. High-pitched cry 4. Hypertonia 5. Opisthotonos 6. Retrocollis
77
What is the DDx for a child with altered mental status?
**AEIOU TIPS** * **A**lcohol * **E**lectrolytes * **I**nfection * **O**xygen, **O**verdose * **U**remia * **T**rauma, **T**umour * **I**nsulin, **I**ntussusception * **P**sychiatric * **S**eizure
78
Name 8 non-infectious causes of pneumonia-like presentation.
1. Asthma 2. FB 3. Pneumothorax 4. Congenital anomalies (TE fistula, bronchopulm. dysplasia) 5. Pericarditis 6. CHF 7. Anaphylaxis 8. Aspiration 9. Cystic Fibrosis 10. PE
79
When would you (in ED) reduce a supracondylar fracture?
**Indications** * Pale, pulseless, cool hand by ED * Pulseless but perfusing should be done by ortho! **Reduction** * In-line traction * Correct lateral/medial displacement * Hold elbow and flex elbow to 40 degrees * Splint in place
80
What are the most common causes of jaundice in a newborn?
**Breastfeeding jaundice** * Increased RBC mass * Decreased hepatic uptake of bilirubin * Increased hepatoenteric circulation of bilirubin * Bilirubin normal at birth, peaks at day 3, normal by 1 week **Breast milk jaundice** * Mechanism unknown * Bilirubin continues to rise, peaking at day 10-21 * Responds to withdrawal of breast milk for 48h
81
What is Baumann's (outer) angle? What is it used for?
For subtle supracondylar fractures * Line from growth plate of capitellum * Line parallel to humeral shaft Normal = 75 degrees or \<5 degrees between sides
82
In SCFE, how is slip severity described?
As a percentage of displacement * Mild = * Moderate = ⅓ - ½ * Severe = \>½
83
List the 7 acyanotic heart diseases
1. ASD 2. VSD 3. Endocardial cushion defect 4. PDA 5. Aortic stenosis 6. Pulmonic stenosis 7. Coarctation
84
Describe the physiology of a "tet spell"
Crying causes a decrease in SVR This causes a R-to-L shunt across the VSD Hypoxia ensues
85
Describe how to perform the hyperoxia test
100% O2 for 10 minutes, get ABG before/after PaO2 \> 250 = lung PaO2 \< 100 = heart
86
List 5 causes of neonatal seizures
1. HIE 2. CNS infection 3. Intracranial bleed 4. Ischemic stroke 5. Chromosomal abnormality 6. Metabolic disturbance * Hypoglycemia * Hypocalcemia * Hypomagnesemia * Pyridoxine deficiency * Inborn error of metabolism 7. Drug withdrawal
87
Explain the Gartland classification system
For extension-type supracondylar fractures: * I = non-displaced fracture * II = anterior cortex displaced * III = anterior + posterior cortex displaced
88
What are the three phases of pertussis? How is it diagnosed? Treatment?
**Phases** 1. Catarrhal phase - URTI 2. Paroxysmal phase - cough, post-tussive emesis 3. Convalescent phase - chronic cough **Diagnosis** * NP Swab for PCR or Cx **Treatment** * Azithromycin 10 mg/kg day 1, then 5 mg/kg on days 2-5 * Vaccine * Public health * Isolate
89
List 10 causes of acute renal failure in children
1. Dehydration 2. DKA 3. Cardiogenic shock 4. AIN 5. RTA 6. ATN 7. Glomerulonephritis 8. HUS 9. TTP 10. Pyelonephritis 11. Posturethral valves 12. Renal vein thrombosis 13. Nephrolithiasis 14. RCC
90
What nerve is at risk in flexion-type supracondylar fractures? Extension-type?
* Flexion = Ulnar * Extension = AIN (Median)
91
List 5 x-ray findings consistent with epiglottitis.
1. Thumbprint sign 2. Thickened epiglottitis 3. Thickened aryepiglottic folds 4. Dilated hypopharynx 5. Lack of air in the vallecula
92
List 8 differences between the adult and pediatric airway.
1. Prominent occiput 2. Large tongue 3. Large tonsils 4. Dynamic airway collapse w/ res 5. Large, floppy epiglottis 6. Anterior/Cephalad larynx 7. Cricoid is narrowest 8. Small airways
93
List 3 clinical clues that can help differentiate cardiac vs respiratory central cyanosis
1. Response to hyperoxia test 2. Response to crying 3. Work of breathing
94
What is the ED management of SCFE? List 2 complications.
**Treatment** * NWB (crutches or wheelchair) **Complications** 1. AVN 2. Chondrolysis 3. Non-union 4. Growth arrest 5. Arthritis
95
How do you differentiate SVT and sinus tachycardia in a baby?
**SVT** * No precipitating event (fever, pain, etc.) * No variability * No response to fluids * No p waves on ECG * Rate \>220
96
What is the risk of serious bacterial infection in a neonate (0-28 days)? What about 29-60 days?
* Neonate (0-28 days) - 10-20% * Infant (29-60 days) - 10%
97
List 7 causes of phimosis in a child
1. Physiologic 2. Trauma 3. Infection 4. Chemical irritation 5. Poor hygiene 6. Congenital 7. Circumcision
98
List 5 complications of supracondylar fracture.
1. Vascular injury 2. Nerve injury 3. Compartment syndrome 4. Volkmann's contracture 5. Gunstock deformity
99
Name 5 risk factors/Px findings that are associated with severe bronchiolitis.
1. Underlying heart disease 2. Underlying lung disease 3. Prematurity 4. RR \>70 5. SpO2 \<95% 6. Ill appearance 7. Atelectasis on CXR
100
What makes a heart murmur more likely to be pathologic?
1. Diastolic 2. Any thrill 3. Murmur with click/rub/gallop 4. Weak pulse 5. Cyanosis 6. Respiratory distress 7. ECG abnormality 8. CXR w/ cardiomegaly
101
Outline an approach to a febrile neonate (0-28 days)
**Workup** * CBC * BCx * UA + UCx * LP * CXR * +/- Stool Cx **Treatment** * Ampicillin 50 mg/kg/dose * Cefotaxime 50 mg/kg/dose * +/- Acyclovir 20 mg/kg/dose if RF for HSV
102
What diagnosis must you consider in a boy with a left-sided varicocele? Right-sided?
* Left * RCC with left renal vein occlusion * Right * IVC thrombosis/compression
103
Provide a DDx of 8 things for a child with wheeze
**Infectious** 1. Croup 2. Bronchiolitis 3. Pneumonia 4. Tuberculosis 5. Bronchiolitis obliterans **Anatomy** 1. GERD 2. CF 3. CHF 4. Tracheoesophageal fistula 5. Mediastinal mass 6. Vascular ring **Acquired** 1. Foreign body 2. Anaphylaxis
104
Compare and contrast the various degrees of dehydration
**Mild (\<3%, 30 mL/kg)** * Alert * Normal vitals * Normal cap refill **Moderate (6%, 60 mL/kg)** * Irritable * Maybe normal vitals * Abnormal cap refill **Severe (9%, 90 mL/kg)** * Lethargic * Hypotensive/Tachycardic * No urine
105
List 5 central and 5 peripheral causes vertigo in children
**Central** 1. AVM 2. Meningitis 3. Encephalitis 4. CNS Abscess 5. CNS Mass 6. Migraine 7. Trauma **Peripheral** 1. BPPV 2. Benign Paroxysmal Vertigo of Childhood 3. Cholesteatoma 4. DM 5. Labyrithinitis 6. Lyme 7. AOM 8. Ototoxin 9. Trauma 10. Vestibular Neuritis
106
List and differentiate 4 types of diarrhea
**Secretory** * Enterotoxin induced cAMP causing Cl and HCO3 secretion to lumen **Osmotic** * Poorly absorbed solutes draw water into lumen **Altered Motility** * Neurologically increased transit time **Dysentery** * Enteroinvasive bowel ischemia causing poor absorption
107
What is the treatment for infectious diarrhea?
* Azithromycin for most * CTX for typhoid * Doxy for cholera * Vanco for C. diff * Flagyl for protozoa Fluoroquinolones are often 2nd line agents
108
List 5 low-risk criteria for bacterial meningitis
1. Negative gram stain 2. CSF protein \<80 mg/dL (\<0.5 g/L) 3. CSF ANC \<1000 cells/mL 4. WBC \<10 5. No seizures
109
When and how much steroid is given in meningitis?
As per CPS: Within 4h of ABx (earlier = better) Dexamethasone 0.15 mg/kg IV q6h
110
What does the IDSA recommend in regards to when to culture (6) stool in a traveler with diarrhea?
* Diarrhea 2+ weeks * Bloody * Mucoid * Fever * Severe abdominal pain * Sepsis
111
When do you work up a jaundiced baby (5)?
1. Jaundice at birth 2. Fever 3. Looks unwell 4. Conjugated hyperbilirubinemia 5. \>3 weeks 6. Not responding to phototherapy 7. Rapidly rising bilirubin not explained by hx/pe
112
Name 6 lead points that can cause intussusception
1. Lymphoma 2. Meckel diverticulum 3. IgA vasculitis (formerly called Henoch-Schönlein purpura or HSP) 4. Mesenteric lymphadenitis 5. Peyer's patches 6. Polyps 7. Celiac disease 8. CF
113
How does fetal circulation change at birth?
First gasp fills lungs with air, reducing hypoxic vasoconstriction RV resistance drops and blood prefers RV over LV With this shift, LA pressures increase and close the PFO Increased oxygen causes PDA and PDV to close
114
What is the treatment of meningitis by age? * 0-28 days * 1-3 months * 3+ months
**0 - 28 days** * Dexamethasone 0.15 mg/kg * Ampicillin 75 mg/kg * Cefotaxime 75 mg/kg * Gentamycin 3 mg/kg **1-3 months** * Dexamethasone 0.15 mg/kg * Ceftriaxone 100 mg/kg * Vancomycin 15 mg/kg **3+ months** * Dexamethasone 0.15 mg/kg * Ceftriaxone 100 mg/kg * Vancomycin 15 mg/kg
115
List 5 steps in the management of a child with a suspected inborn error of metabolism?
1. ABCs 2. NPO 3. Critical Sample 4. D5NS at 2x maintenance 5. NaHCO3 if no resolution of acidosis 6. Dialysis if necessary 7. Ammunol if encephalopathic
116
Which diarrhea-causing bugs (4) do **not** require antibiotics?
* E. coli STEC * Salmonella, non-typhoid * Vibrio parahemolyticus * Yersinia enterocolitica
117
List 5 indications for neuroimaging in children with headache
1. Trauma 2. Focal neuro deficits 3. VP Shunt 4. Morning headaches 5. Meningimus
118
Outline the Philadelphia Criteria
* Age 29-60 days * Temperature \>38.2 degrees * Well looking * Labs * WBC \< 15 * Bands:Neutrophil \< 0.2 * UA \< 10 WBCs/hpf * CSF \< 8 WBCs/hpf * CXR normal (if obtained) * Stool negative (if obtained) * Sens 98% * NPV 99.7%
119
What is the DDx for the sick neonate?
**THE MISFITS** * **T**rauma * **H**eart, **H**ypovolemia, **H**ypoxia * **E**ndocrine (CAH) * **M**etabolic * **I**nborn Error of Metabolism * **S**epsis * **F**ormula * **I**ntestinal Catastrophe * **T**oxin * **S**eizure
120
List 8 risk factors associated with death from asthma
1. Three ED visits in 12 months 2. Two admissions in 12 months 3. One ICU admission 4. One ED/hospitalization in last month 5. \>2 MDIs in the last month 6. Current use/withdrawal from systemic steroids 7. Difficulty perceiving symptoms 8. Low SES 9. Illicit drug use 10. Psychosocial problems 11. Chronic heart disease 12. Chronic lung disease 13. Chronic psychiatric illness
121
What is the DDx of a crying infant?
**IT CRIES** * **I**nfections * **T**rauma, **T**orsion * **C**ardiac * **R**eflux * **I**ntestinal Catastrophe * **E**ye * **S**trangulation
122
Describe the ossification centers around the elbow.
**CRITOE** * 1 - Capitellum * 3 - Radial head * 5 - Internal (medial) epicondyle * 7 - Trochlea * 9 - Olecranon * 11 - External (lateral) epicondyle
123
What are 4 x-ray findings in SCFE?
1. Blurring of the metaphyseal-growth plate junction 2. Blanch sign of steel 3. Klein's line doesn't intersect lateral femoral head 4. Enlarged angle of Southwick
124
What return instructions do you give for children with diarrhea?
1. V/D worsens 2. Vomiting \>24h 3. Bloody vomit/stool 4. Decreased U/O
125
A 4yo boy presents with seizure and a sodium of 110 mEq/L. Calculate how much 3% saline to get his sodium to 125 mEq/L
Amount Na = (0.6 x weight) x (desired Na - measure Na) Weight = 10 + (Age x 2) = 18 (0.6 x 18) x (125 - 110) 10.8 x 15 = 162 mEq Na 513 mEq/L of 3% saline (162 / 513) x 1000 cc = ~320 cc Give 2 cc/kg q10min until seizure stops
126
What is the treatment for Kawasaki disease?
* IVIG 2 g/kg IV over 2 hours * ASA 20-25 mg/kg q6h * Steroids in refractory cases
127
What are the Rule of 2's in a Meckel's?
* 2 cm wide * 2 cm long * 2 ft from the ileocecal valve * 2% of the population * 2% symptomatic * ½ present by age 2, most age 20
128
What are the 5 diagnostic criteria for a febrile seizure? What 4 things define simple vs. complex?
* Seizure + Fever with no other cause * Etiology = rapid rise in fever * **Dx:** 1. Age 6 mo - 6 yr 2. Fever \>38 degrees 3. No CNS infection 4. No acute metabolic abnormality 5. No previous afebrile seizures * **Simple:** 1. \<15 mins 2. 1 per 24 h 3. GTC 4. Neurologically normal
129
List 7 complications of circumcision
1. Bleeding 2. Infection 3. UTI 4. Urethral meatus stenosis 5. Phimosis 6. Skin bridges 7. Inclusion cysts
130
List 10 causes of hip pain in children
1. AVN 2. Reiters 3. Septic joint 4. Juvenile arthritis 5. Osteomyelitis 6. Fracture 7. Abuse 8. SCFE 9. Ewing's sarcoma 10. Sickle cell
131
What is the workup for a jaundiced baby?
* CBC w/ smear * Bili - direct and indirect * Haptoglobin * LDH * TSH * BCx * G6PD assay * Coomb's test * U/S abdomen
132
List 10 causes of hematuria in a child
1. Trauma 2. UTI 3. Pyelonephritis 4. Renal colic 5. RCC 6. Nephritic syndrome 7. AIN 8. ATN 9. PCKD 10. HSP 11. SLE 12. SS 13. Mono 14. Hemophilia 15. Munchausen's
133
Which diarrhea-causing bugs (9) require antibiotics?
* Campylobacter * Clostridium difficile * Cryptosporidium * E. coli ETEC * Entamoeba histolytica * Salmonella typhi * Shigella * Vibrio cholerae * Giardia
134
Provide two formulas to estimate the weight of an infant/child
1. **Neonate (0-12m):** Weight (kg) = 4 + (Months / 2) 2. **Child (1-12y):** Weight (kg) = 10 + (Age x 2)
135
Name four possible x-ray findings in intussusception
1. Target sign - air in intussusceptum 2. Meniscus sign - air compresses from invaginating bowel 3. Crescent sign - lucency in LUQ soft tissue mass 4. Free air
136
List 6 admission criteria for croup.
1. Hypoxemia 2. Significant work of breathing 3. Tachycardia/Tachypnea 4. Stridor at rest after treatment 5. Complex PMHx 6. Dehydration
137
What is a BRUE? List 4 diagnostic criteria.
Event occurring in an infant \<1 year with a sudden, brief, resolved episode with at least one of: 1. Change in colour 2. Change in breathing 3. Change in tone 4. Altered LOC
138
List 5 criteria to define a LOW RISK BRUE.
1. Age \> 2 months 2. Born \>32 weeks + Corrected age \>45 weeks 3. No CPR by a medical person 4. Lasted \<1 minute 5. First event
139
List 8 DDx for BRUE
1. Choking/Gagging 2. Periodic breathing 3. Breath-holding 4. Respiratory infection (pertussis, RSV) 5. Sepsis 6. Intestinal catastrophe 7. Inborn error of metabolism 8. Endocrine 9. Abuse 10. GERD 11. Arrhythmia 12. Cardiomyopathy 13. Seizure 14. Syncope THE MISFITS
140
What is the #1 cause of death in infants 1 mo - 1 yr old?
**SIDS** Unknown cause of death after thorough investigation/autopsy
141
List 10 risk factors for SIDS
**Baby** 1. **P**remature 2. **P**rone 3. **P**illows 4. **P**uny (Low birth weight) 5. **P**enis (Male) 6. Age 1 - 6 months **Maternal** 1. Late/no pre-natal care 2. Smoking during pregnancy 3. \<20 years old **Environment** 1. Second-hand smoke 2. Born fall/winter 3. Overheating 4. Bed-sharing
142
List 8 AAP recommendations to prevent SIDS
1. Sleep supine 2. Firm sleeping surface 3. No pillows 4. No co-sleeping 5. No smoking 6. No overheating 7. Pacifier at bedtime 8. Breastfeed 9. Sleep in crib in parents room to 6 months 10. Prone while awake to prevent plagiocephaly

Royal College: Emergency Medicine (25 decks)

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