volume 1

Question 1

Which of the following regarding automatic external defibrillators is false?
a) AEDs with paediatric systems should be used for children

Answer 1

d) IV and cardioresp monitor are not on the list because basic life paramedics don’t have training in them
the main change to what pre-hospital providers should have is the addition of AED
children with sudden witnessed collapse - at risk of pulseless ventricular tachycardia or ventricular fibrillation ->need AED
other equipment:
- see the list, includes airway equipment, defibrillation, immobilization, infection control, ob/neonatal supplies, other miscellaneous
- statements are for basic life support trained paramedics, so no IV or Cardioresp monitor is included on the list, since they are not trained in this, don’t have intubation equipment on the list either but do have oral airway, O2 and bag mask, nasopharyngeal airway, suction (special paramedics are but this statement doesn’t cover them) this is to basic minimum equipment needed to transport neonates and children , C spine as well
should have appropriate training and checking of equipment

Question 2

Which of the following is the most common side effect of ondansetron when used for gastroenteritis?

a) diarrhea
b) drowsiness
c) hallucinations
d) extra-pyrimidal side effects

Answer 2

a) diarrhea is the most common side effect when used for gastro, usually mild and self limiting
no drowsiness with ondansetron (hence the appeal)

selective serotonin receptor antagonist , peak within 1-2 hours rapidly absorbed
safe and effective in cancer patients as well as post-op
low risk of SEs in this population

Question 3

Which of the following is not true of gastroenteritis?

a) most commonly caused by rotavirus or norovirus
b) most common cause of ER by young children
c) incidence of acute gastroenteritis in children

Answer 3

c)false - 1-2 episodes per year in the industrialized world

20% of all outpatient hospital visits by younger children, 200000 hospitalizations per year

meds that are commonly prescribed, promethazine, metoclopramide, dimenhydrinate and domperidone rare (but scary) side effects include drowsiness, extra-pyrimidal symptoms, hallucinations, convulsions, neuroleptic malignant syndrome

3 main studies looking at ondansetron and gastroenteritis (over past 20 years)

Question 4

Which of the following is not one of the things that ondansetron has been shown to do in RCTs?

a) reduce need for IV fluids in children age 6 months-12 years with gastroenteritis causing mild-moderate dehydration or who have failed ORT
b) reduce frequency of vomiting children age 6 months-12 years with gastroenteritis causing mild-moderate dehydration or who have failed ORT
c) reduce symptoms in patients age 6 months-12 years with gastroenteritis presenting with severe diarrhea
d) may be helpful to reduce hospital admissions of children with gastroenteritis

Answer 4

c) is the answer - the only side effect was diarrhea, generally resolved within 48 hours
therefore, shouldn’t use for patients with gastro where moderate-severe diarrhea is the main presenting symptom

single dose
in hospital setting - need more studies to assess its role out of hospital

studies
#1: Freedman - reduced IV fluids, reduced vomiting, no difference in hospital admission
#2: Roslund - less likely to receive iv fluids or get admitted to hospital
#3: Ramsuck - vomited less, less IV fluids, less likely admitted to hospital
meta-analysis by Decamp of these studies and 3 others: decreased risk for further emesis in the ED, IV fluid administration and hospital admission

Question 5

Which of the following is an appropriate one time dose of oral ondansetron for a 30kg child?

a) 2 mg
b) 4 mg
c) 6 mg
d) 8 mg

Answer 5

b) 4 mg
one time dose
8-15 kg - 2 mg
15-30kg - 4 mg
>30 kg 6-8 mg
(dose 0.15 mg/kg is what we usually order, these are estimates)
oral rehydration should be given 15-30 minutes after oral ondansetron

Question 6

Which of the following is the most common identified trigger for anaphylaxis?

a) food
b) hymenoptera stings
c) medications
d) infection

Answer 6

a) food is the most common identified trigger, then hymenoptera stings (wasps/bees) and medications
a trigger is only identified in 1/3 of cases
cause of anaphylaxis - release of mediators from mast cells and basophils often in response to an allergen
incidence 1-4/1000
when food identified, trigger, peanuts, tree nuts, fish, milk, eggs and shellfish (eg, shrimp, lobster, crab, scallops and oysters) most commonly implicated in fatal and near fatal reactions

Question 7

Which of the following is the most predominant symptom of anaphylaxis in children?

a) GI involvement
b) cardiovascular involvement
c) respiratory involvement
d) cutaneous manifestations

Answer 7

d) cutaneous symptoms are the most common in 80-90%
(urticaria, angioedema, prutitus and flushing)
respiratory involvement 60-70% includes upper and lower airway symptoms including obstruction and bronchospasm
CV 10-30% include dizziness, hypotension, syncope

Question 8

Which of the following patients does not meet the criteria for anaphylaxis?

a) child with urticaria and hypotension presenting acutely
b) child with hives and persistent vomiting after exposure to a likely allergen for that child (known allergy)
c) child with stridor and nausea/vomiting that occurs acutely after exposure to a likely allergen for that child (known allergy)
d) reduced BP by 20% after exposure to a known allergen

Answer 8

d) needs to be reduction in 30% of the BP or low BP based on age norms
the 3 criteria for anaphylaxis:
FOR NEW PATIENT
1. acute onset of illness (minutes to several hours) with involvement of skin/mucosal tissue and at least one of either resp compromise or hypotension
FOR KNOWN PATIENT
2. 2 or more of the following occurring rapidly after exposure to likely allergen:
- urticaria
- resp sx
- GI sx
- reduced BP or end organ dysfunction
3. reduced BP after exposure to KNOWN allergen for that patient

Question 9

Which is the recommended body weight for the epipen Jr?

Answer 9

c) epipen Jr 10-25 kg
doses of epipen Jr: 0.15 mg and epipen 0.3 mg
does for 10-25kg and >25 kg person
risk of epipen vs drawing up dose for smaller person, is risk of delay and wrong dose; need to balance these
physicians should air on the side of caution, inject epinephrine early
for greater than 25 kg, use epipen 0.3 mg dose

Question 10

Which of the following should be the first step in the acute management of anaphylaxis in the hospital?

a) IV access
b) IM epinephrine
c) cardioresp monitor
d) NS 20 cc/kg bolus
e) intubation

Answer 10

b) IM epi is first and most important
dose is 1:1000 epi dose of 001 mg/kg into the lateral thigh
and initiate ABCs at the same time, O2, monitor, IV access (don’t delay epi to get IV)
if severe airway signs, then prepare for intubation **early preparation for airway management is crucial cause it may be a difficult airway
if cardiovascular compromise then give 20 cc/kg NS bolus to replenish volume; up to 35% of blood volume can be lost in first 10 minutes because of increased vascular permeability

Question 11

Which of the following is false?

a) only anaphylactic patients presenting with hypotension need an IV
b) an IO should be placed if you can’t get an IV and the patient is hypotensive and poorly perfused
c) ideally patients with anaphylaxis should be placed supine or in the Trendelenburg position
d) cetirizine is one of the second line medications for the treatment of anaphylaxis

Answer 11

a) false - because you can lose your up to 35% of blood volume can be lost in first 10 minutes because of increased vascular permeability, ALL patients with anaphylaxis should get 2 large bore IVs

the rest are true

b) if no IV and poor perfusion/hypotension, then IO
c) helps to increased blood return to the heart/prevents pooling of blood in the extremities
d) true - second line includes H1 and H2 blockers, salbutamol, corticosteroids

Question 12

Please match up the effect of epi and the mechanism of action

a) alpha adrenergic
b) beta-1-adrenergic effects
c) beta 2 adrenergic effects
d) concentration used for anaphylaxis

1. bronchodilation and reduction of inflammatory mediator release
2. 1:1000
3. increased vascular resistance
4. chronotropic and inotropic cardiac effects
5. 1:10000

Answer 12

a) 3: alpha adrenergic - increases vascular resistance and decreases vasodilation, while decreasing angioedema and urticaria (i.e. alpha tightens it all up) - alpha is arteries
b) 4 beta -1 adrenergic : chronotropic and inotropic cardiac effects (beta one is number 1 and speeds it all up) - you have one heart
c) 1 beta 2 adrenergic: bronchodilation and reduction of inflammatiory mediator release from mast cells and basophils (i.e. like for asthma) - you have 2 lungs
d) 2 1:000 epi dose is 0.01mg/kg (max total dose is 0.5 mg) can repeat every 5-15 minutes

Question 13

Which of the following is correct

a) cetirazine is a non drowsy H2 blocker
b) H2 blockers such as ranitidine are given primarily when there are GI manifestations of anaphylaxis
c) IM epi works better when given in the deltoid in the arm
d) steroids have shown a proven benefit in the treatment of anaphylaxis in RCTs
e) inhaled salbutamol should only be used for patients with known asthma presenting with anaphylaxis

Answer 13

e)true - (not the greatest question I have made here), salbutamol for known asthma and wheezing , can considered inhaled epi for stridor but certainly not proven

c) false, better to give it in the anterolateral thigh - results in higher peak plasma concentrations and peak concentrations achieved sooner than when given in the arm
can repeat ever 5-15 minutes depending on condition

a) false - it is a H1 blocker, it is non drowsy, therefore if the patient isn’t vomiting, it should be your first line choice of H1 blockers
b) false - not according to statement, giving both H1 and H2 blockers together reduces the cutaneous manifestations of anaphylaxis compared to using H1 blockers alone
no RCTs for H1/H2 blockers or steroids
d) false - no RCTs have shown proven benefit, most experts will recommend it steroids onset of action is slow (4 h to 6 h), and that there will likely be little benefit in the acute phase of management (thought to prevent rebound from what I know). oral steroids, if severe, then IV
e) use for patients with bronchospasm/wheezing, known asthma, upper airway obstruction (i.e. stridor)(even though no proof for this indication)

Question 14

A patient has refractory hypotension after repeated doses of IM epi and fluid boluses, what should you do?

a) give IV glucagon
b) continue giving multiple fluid boluses
c) continue giving IM epi as hypotension will likely improve
d) start IV epi infusion

Answer 14

d) start IV epi infusion
- no evidence that repeated IM epi helps with hypotension
- IV infusions of epi have more sustained effect, whereas boluses have more immediate effect
IV boluses of epinephrine may have an immediate effect that is often short lived, accompanied by coexisting concerns for induced cardiac arrhythmias when administered too rapidly
- also co-existing concerns that epi can cause arrythmias with lots of doses
- IV glucagon - for patients who are on a beta blocker, since these patients can have anaphylaxis with persistent hypotension, glucagon activates adenylate cyclase independent of the beta receptor, bolus dose then infusion

Question 15

How long is the minimum you should you observe patients after anaphylaxis?

a) until symptoms resolve
b) 2 hours
c) 4-6 hours
d) 12 hours

Answer 15

c) reasonable amount of time to observe is 4-6 hours, most biphasic reactions will occur within this time
can happen up until 72 hours so may be reasonable in more rural situations to observe longer (12 hours) or to admit to hospital overnight
patients who are more likely to have biphasic reaction : have delayed epi admin, more severe initial reaction, or who needed more than one dose of epi
5-20% of patients can have biphasic reaction, 3% of children have a severe reaction
more severe reaction esp with hypotension or resp symptoms or biphasic reaction should be admitted to hospital, patients with high risk features - asthma, peanut allergy, use of beta blockers, should consider for overnight observation or admission
IV epi/glucagon or major airway symptoms should go to the ICU

Question 16

Which of the following is not part of the discharge instructions for anaphylaxis?

a) leave the ER with epi auto injector if possible
b) only administer epi after being sure that it is anaphylaxis
c) child should always carry epi with them
d) consider 3 day course of oral H1 and H2 blockers and oral steroids at discharge
e) referral to allergist/immunologist

Answer 16

b)false should err on the side of caution and administer whenever symptoms occur after exposure to individuals known trigger

the rest are true
a) should give them a prescription for epi pen, if possible give them an auto injector since they could have a reaction on the way to the pharmacy (biphasic)
c) home and school, ideally two doses at each place (i guess in case the first dose is given wrong)
d) most experts suggest this even though limited data since unlikely to cause harm and may help with faster resolution of symptoms
trict instructions to avoid the allergen
also give them online resources as well as discuss the importance of medic alert bracelet
allergist can provide additional testing
counsel detailed about symptoms of anaphylaxis

Question 17

Which of the following patients with minor allergic reaction does not need to be prescribed epinephrine?

a) generalized urticaria after bee sting
b) child with mild reaction to cats living in an urban area
c) allergic reaction to peanuts
d) on propanolol
e) asthma

Answer 17

b) should consider for people in remote areas

specific food triggers that are knob to be high risk - seafood, peanuts, etc.
generalized urticaria after insect venom
non selective beta blockers
repeat exposures likely
initial history unclear, possible anaphylaxis

Question 18

Which of the following is the most common trigger for asthma in children?

a) allergens
b) suboptimal control at baseline
c) pets
d) viral infection

Answer 18

d) viral infection is the most common trigger, other common ones are allergens, suboptimal baseline control.

asthma - most common reason for hospitalization in children
lifetime prevalence in Canada 11-16%
exacerbation - acute or subacute deterioration of control
9% of children with asthma ER visit, asthma is 3-7% of Er visits

Question 19

Which age group is the most likely to present to the hospital with asthma exacerbation?

a) <5 year old
b) 5–9 year old
c) 9-12 year old
d) 13-17 year old

Answer 19

a) more than 50% who present to ED with asthma exacerbate are preschool age < 5 year old.

Question 20

A 5 year old girl presents with an asthma exacerbation, her O2 saturations are 91% on R/A, she has intercostal and subcostal retractions, and has decreased feeding. She is speaking in phrases. What is the severity of her asthma exacerbation?

a) mild
b) moderate
c) severe
d) impending respiratory failure

Answer 20

B) moderate
classification based on the presence of several parameters, can overlap

look at clinical features, mental status, activity, speech, WOB, chest auscultation, SpO2 on R/A, peak flow vs personal best

mild exacerbation: sats>94%, mild WOB, moderate wheeze, peak flow >80% personal best
moderate: sats 91-94%, moderate WOB (intercostal and subcostal retractions), may be agitated, talks in phrases, biphasic wheeze, decreased feeding
severe: severe WOB - paradoxical breathing, nasal flaring, all accessory muscles used (may have nasal flaring and abdo movement), agitated, speaks in words , stop feeding, wheeze without stethoscope
impending respiratory failure: silent chest, drowsy, sats

Question 21

What is the peak flow result vs personal best in a severe asthma exacerbation?

a) >80%
b) 60-80%
c) <60%
d) none of the above

Answer 21

c) <60% is the flow in a severe exacerbation

in impending resp failure, unable to do

Question 22

Which of the following is not associated with sats<92% on presentation?

a) more morbidity
b) greater risk of hospitalization
c) improved outcome

Answer 22

c) not associated

sats <92% before treatment is associated with more morbidity and more hospitalization

Question 23

Which of the following is not a risk factor for ICU admission and death?

a) previous ICU admissions
b) previous life threatening events
c) previous need for oxygen
d) deterioration while already on systemic steroids

Answer 23

c) not one of the risk factors, but previous intubation is a risk factor

death - Alberta - 10% resulted in hospital, 1 death/25000 ER visits
also should ask about any previous meds

Question 24

Which of the following provides can provide the best objective measurement of disease severity in an asthma exacerbation in an 11 year old?

a) chest X ray
b) blood gas
c) peak flow meter
d) spirometry

Answer 24

d) spirometry
when children able to perform, it is an objective measure of airway obstruction: HOWEVER, difficult to do in t usually recommend other tests
CXR: only if suspect other processes such aspneumothorax, pneumonia (bacterial, foreign body, or lack of improvement with treatment
blood gases - only if not improving with maximal therapy

Question 25

Which of the following is a sign of impending respiratory failure? a) sats 91% b) speaking in single words c) normal CO2 on blood gas with ongoing resp distress d) agitation

Answer 25

c) normal CO2 with ongoing resp distress is a sign of resp failure scores that are used (based on previous criteria that categorize severity) include PRAM score and Clinical assessment score (CAS)

Question 26

Which of the following is the suggested treatment for moderate asthma exacerbation? a) back to back salbutamol/ipratropium, IV steroids b) back to back salbutamol/ipratropium, PO steroids c) back to back salbutamol, inhaled steroids d) back to back salbutamol, PO steroids, consider ipratropium x3 in 1 hour

Answer 26

d) is the answer for mild exacerbation - salbutamol q20 minutes x 1-3 doses, consider PO steroids moderate: back to back salbutamol x 3 q20, PO steroids, consider ipratropium x 3 in one hour severe: back to back salbutamol/ipratropium, give oral steroids, consider IV steroids, consider MgSO4

Question 27

Which of the following is not part of the management of a severe asthma exacerbation? a) must give IV steroids b) back to back salbutamol/ipratropium x 3 c) consider continuous ventolin neb d) consider MgSO4 e) NPO

Answer 27

a) false - give oral steroids, CONSIDER IV steroids the rest are part of the management sats should be >94% for all asthma exacerbation (non rebreather with 100% O2)

Question 28

Which of the following is not part of the management options for asthma exacerbation with impending resp failure? a) NPO b) back to back salbutamol and ipratropium c) get IV access d) 100% O2 e) IV steroids f) consider SC epi

Answer 28

``` b) should give continuous neb of salbutamol and 3 doses of ipratropium consider: aminophylline, MgSO4, IV salbutamol do blood gas and lytes consider SC epi if deteriorating consider RSI call PICU ``` sat target: no great evidence to suggest a particular sat target; in general>94% with resp distress makes sense hypoxemia is considered

Question 29

Which of the following is false of B agonist? a) should not be used as MDI when there is impending respiratory failure b) MDI is more likely to to provoke hypoxemia and tachycardia than a nebulizer c) MDI with spacer is the best way to delivery B agonist d) when there is hypoxia, should give O2 by nebulizer

Answer 29

b) opposite, when there is no initial O2 need, then MDI is less likely to provoke hypoxemia and tachycardia than a nebulizer MDI always better to deliver bronchodilator, except when impending respiratory failure even with hypoxia can give MDI with spacer and nasal prongs at the same time in children without O2 need, then MDI and spacer less likely to provoke tachycardia and hypoxemia severe act, might be better to give constant beta-agonist

Question 30

Which of the following is not a common side effect of beta agonist use in children? a) tachycardia b) hypokalemia c) hyperglycemia d) arrythmias

Answer 30

d) arrythmia - no evidence of this being an issues in children the other 3 are side effects of beta agonist use, generally well tolerated doses of meds are listed in the statement salbutamol 20 kg 10 puffs every 20 min in first hour pred or dex are listed as steroids - one single dose in the AM will reduce risk of adrenal suppression ipratropium 20 kg 6 puffs **use with caution in soy allergy

Question 31

Which of the following drugs should be used with caution in children with soy allergy? a) flovent b) salbutamol c) ipratropium bromide d) MgSO4

Answer 31

c) ipratropium - use with caution in children with soy allergy MgSO4 can cause hypotension

Question 32

Which of the following evidence is not correct? a) ipratropium - reduced hospital admission, improved lung function, useful when used beyond first hour b) steroids should be used for moderate -severe exacerbation and reduces the risk of hospitalization and risk of relapse c) IV MgSO4 may improve lung function and decrease hospitalization in children with severe asthma d) IV salbutamol in severe attacks has been shown to improve pulmonary function and gas exchange e) mechanical ventilation in the context of severe asthma is associated with increased risk of death

Answer 32

a) false - no evidence that useful when used beyond first hour, the other 2 are benefits that have been shown when used with beta agonist in the first hour severe exacerbation- should get IV steroids; methylpred or hydrocortisone there rest are true, MgSO4 should monitor for hypotension and bradycardia, consultation with ICU or respirologist recommended In general, inhaled drugs may have a limited effect in patients with nearly complete airway obstruction and have practical limitations in ventilated patients. IV salbutamol- cardiac effects include tachycardia and arrhythmia, so should have continuous cardiac monitoring intubation for asthma - increased risk of bad outcomes from pneumothorax and/or from increased intrathoracic pressure leading to cardiovascular collapse 26% of children intubated for asthma have these severe side effects, so should talk to ICU for these other for severe ICU who don't respond to anything: aminophylline, heliox

Question 33

Which of the following is false of inhaled corticosteroids for asthma? a) impairs final adult height b) should be prescribed for patients with moderate -severe exacerbation c) should not be given intermittently d) potential risk of adrenal suppression when used for prolonged periods

Answer 33

a) false - does not impair growth or final adult height the rest are true adrenal suppression - less likely when proper monitoring and with the new inhaled corticosteroids ICS reduces exacerbations and chronic morbidity doses of steroids are in a chart remember doses are based on severity and not on weight **statement has discharge criteria (includes sats>94%) course of oral steroids 3-5 days depending on severity continue using inhaled CS q4 hour until resolve then as needed

Question 34

What is the minimum age that budesonide (pulmoicort) nebulizer is used for? a) 3months b) 6 months c) 12 months d) 6 years

Answer 34

a) 3 months the others: flovent (fluticasone) 12 months by MDI if doing high dose should do with resp budesonide (pulmicort ) by dry powder - 6 years ciclesonide (alvesco) 6 years (*remember it's a pro-drug, so less systemic effects I believe - double check)

Question 35

Which of the following is false of acute hyponatremia? a) decrease in Na over 48 hours b) causes acute cerebral edema c) negative outcomes from acute hyponatremia more likely with

Answer 35

d) false, has 154 mmol/L NaCl, because this is more than body, it has raised the theoretical risk of hypernatremia and water overload, but mostly seems to be theoretical unless the child has renal concentrating defect, significant water loss, or prolonged fluid restriction. hyperchloremic metabolic acidosis - has been reported preoperatively, not as much when used for maintenance headache, lethargy and seizures, and potentially even respiratory and cardiac arrest secondary to brain stem herniation ->because of higher brain/intracranial ratio children more likely to have this consequence hospitalized children - release more ADH, impaired ability to excrete free water, and also get more free water in hypotonic fluids

Question 36

What of the following is false? a) isotonic fluids (vs. hypotonic fluids) were shown to be safer to present post operative hyponatremia b) only IV fluids need to be accounted for when assessing the Na content of IV maintenance fluids c) children undergoing surgery are at particular risk of hyponatremia d) children with respiratory or neurological infections (such as bronchiolitis, meningitis) are at particular risk of hyponatremia

Answer 36

b)false, oral fluids have low Na, need to account for oral and IV fluids when looking at IV intake (TFI) one study showed the type of fluid but not the rate affected the degree of Na fall young kids, low glycogen stores so should have dextrose in fluid

Question 37

A patient's serum Na is 150 mmol/L, what type of fluid should be used? a) D5NS at maintenance b) D50.45NS at maintenance c) D50.2 NS at maintenance d) D5 Ringers at maintenance

Answer 37

b) D50.45 NS at maintenance and very closely monitor the sodium in general, always do D5NS(for kids with normal Na can consider 0.45 according to statement but prefer D5NS) when normal at baseline but when high risk of ADH then should use D5NS for sure never use s not great because no sugar and have presence of lactate (so not great in young kids) preoperative should always use isotonic fluids

Question 38

Which of the following is not required monitoring for IV fluids? a) electrolytes prior to starting b) bid electrolytes for kids with impaired renal excretion c) monitor urine output d) daily monitoring of weight

Answer 38

b) only daily electrolytes is fine in these kids statement says do lytes before starting in hospitalized kids , should check lutes daily (more often if risk of renal problems/excretion) need daily monitoring of urine output and input should be aware of symptoms of hyponatremia headache, nausea and vomiting, irritability, decrease in level of consciousness, seizures and apnea.

Question 39

How much Na is in 2/3 1/3 IV fluid? a) 33 mmol/L b) 45 mmol/L c) 66 mmol/L d) 77 mmol/L

Answer 39

``` b) 45 mmol/LNa dextrose is 33 gram/L the others: 0.45NS is 77 mmol/L 0.2NS is 33 mmol/L NS 154 mmol/L RL 130mmol/L only ringers and NS are considered isotonic Ringers has less chloride (110 vs 154 for NS) so less risk of hyperchloremic metabolic acidosis ```

Question 40

Which of the following is not a reason that children more likely to sustain intracranial injury from head trauma than adults? a) more myelinated tissue b) larger heads c) thinner cranial bone

Answer 40

a) opposite, less myelinated tissue

Question 41

Which of the following is relatively uncommon in children compared to adults? a) diffuse axonal injury b) cerebral edema c) hematoma needing evacuation

Answer 41

c) hematomas and other lesions that need evacuation comparatively less common in children than adults, more common to get DAI then cerebral edema secondary to it

Question 42

Which of the following frequently leads to intracranial injury? a) fall from less than twice the height of the individual b) fall from 80 cm c) MVC d) low velocity projectile

Answer 42

c) MVC common causes of head injury include: - falls, MVC, sports, being hit on the head or running into obstacle, bicycles, being hit by a car - for falls, increased frequency of intracranial injury if >3 feet (91cm or >2 x height/length of the individual) - high velocity projectile commonly leads to intracranial injury

Question 43

Which of the following signs is not particularly associated with intracranial injury? a) prolonged LOC b) disorientation, confusion, amnesia c) worsening headache d) vomiting after the impact

Answer 43

d) in fact repeated or persistent vomiting is associated with intracranial injury, lots of people might vomit once at the impact the others are listed as symptoms of head injury

Question 44

Which degree of head trauma does the following person have based on their glasgow coma scale? eye opening to verbal stimuli, speaking but using inappropriate words, flexion to pain a) minor b) moderate c) severe

Answer 44

b) severe GCS is 8 (3/3/2) severe is GCS

Question 45

Which degree of head trauma does the following person have based on their glasgow coma scale? eye opening spontaneously, speaking but confused, following commands a) minor b) moderate c) severe

Answer 45

a) minor GCS 14 (3/5/6) severe is GCS

Question 46

Which degree of head trauma does the following person have based on their glasgow coma scale? withdraws from pain, incomprehensible sounds, opens eyes to pain a) minor b) moderate c) severe

Answer 46

c) severe GCS 8 eye - 2/4 verbal - 2/5 withdraws from pain - 4/6 all severe injury needs a CT scan as well as all the other management (see question below)

Question 47

What is the GCS of the following 1 year old child? withdraws to touch, irritable/crying, eye opening to speech a) 11 b) 12 c) 13 d) 14

Answer 47

b) 12 - pediatric GCS for pre-verbal children eye opening 3/4 (spontaneous/to speech/to pain) verbal 4/5 (coos babbles/irritable and cries/cries to pain/moans to pain motor 5/6(normal, withdraws to touch, withdraws to pain, abnormal flexion/abnormal extension) **remember table has GCS of 3 see chart for all details

Question 48

Which of the following is not part of the routine management of suspected head injury in children? a) immobilization of the cervical spine using sandbags/IV bags/towel rolls in younger children b) immobilization of the cervical spine using a age appropriate cervical collar in older children c) consider rapid sequence intubation if unable to maintain airway after reposition and suctioning d) treat hypovolemia which is most likely caused by intracranial blood loss

Answer 48

d) should treat hypovolemia, however intracranial blood loss unlikely to lead to hemodynamicaly significant blood loss (exception is scalp or IC bleeding in a young infant unlikely to results history should include mechanism, LOC/seizures, presenting symptoms (include LOC, worsening headache or vomiting), medical history of head injury, medications, bleeding, neurological disorders always consider abusive head trauma

Question 49

Which of the following is not a contraindication to the placement of a NG tube? a) parietal skull fracture b) racoon eyes c) ecchymosis over mastoid bone (battle sign) d) leakage of CSF from nose/ears e) hemotympanum

Answer 49

a) parietal skull fracture not a contraindication | the other signs are signs of a basal skull fracture which means that no tubes should be placed through the nose

Question 50

A 3 year old presents with fall from coffee table landing on head. He had a brief loss of consciousness, but is now conscious. They are opening eyes spontaneously , irritable and crying, and moving limbs spontaneously. Mom says that he is complaining of a headache. What is your management? a) discharge home with instructions for mom b) immediate CT head c) close clinical observation in ER for 4-6 hours with consideration of CT scan if symptoms persist/worsen d) none of the above

Answer 50

d) for mild injury, with persistent symptoms of headache and/or vomiting, observe for 4-6 hours, if symptoms worsen then should do a CT. If there is LOC then need to observe also. if symptoms improve and GCS 15, can d/c home with instructions to return if worse (LOC, vomiting, headache). If don't improve, admit, vitals and LOC q2-4 hour, CT if symptoms after 18-24 hours if not already done. algorithm in the statement applies to >2 year old, with GCS 14 or 15 only here, GCS is 14. although CATCH rules doesn't seem to say an age group (although they do say later that greater caution should be used in

Question 51

A 1 year old baby falls from his high chair. On exam, he has a large boggy mass on the side of his skull. GCS is 15 and he appears well. What is your next step in management? a) CT head b) skull X ray c) observation in ER only d) discharge home with instructions

Answer 51

b) skull X ray - should be performed in the presence of a large boggy hematoma in a child t need to do skull X ray for all patients skull X ray also indicated when abuse is suspected

Question 52

Based on the CATCH rules, which of the following is not an absolute indication for CT head? a) focal neurological findings b) clinically suspected open or depressed skull fracture c) widened or diastatic skull fracture on X ray d) known coagulation disorder

Answer 52

d) known coagulation disorder is on the list of relative indication for CT head the other 3 are the absolute indications for CT head CATCH rules - low probably of finding something on CT, high radiation and need for sedation in some cases - reasons why work has been done to determine who needs a CT head. CATCH rules - focus more on things that the Absence of which will stop need for CT - may actually lead to more CT scans being performed 98% sensitive

Question 53

Which of the following is not a relative indication for immediate head CT scan based on the CATCH rules? a) clinical deterioration in ER including worsening headache or persistent vomiting b) large boggy hematoma in child >2 years c) abnormal mental status which is defined as GCS

Answer 53

c) abnormal mental status is an indication, but is defined as Abnormal mental status: GCS

Question 54

Which of the following is commonly associated with widened or diastatic skull fracture >4 mm in infants? a) leptomeningeal cyst b) epidural hematoma c) subdural hematoma d) meningitis

Answer 54

a) leptomeningeal cyst associated, should arrange follow up need to observe regularly/closely and for longer in babies

Question 55

What is the cause of increased ICP in epidural hematoma? a) mass effect from bleeding b) vasogenic edema c) infection d) none of the above

Answer 55

a) mass effect from bleeding in epidural and subdural hematoma in diffuse axonal injury, vasogenic edema is the cause of increased ICP

Question 56

Which of the following is not part of the routine management of a severe head injury? a) normal ICP and cerebral perfusion pressure b) maintain cool (35-36 C) core body temperature c) maintain normal oxygenation and ventilation with mechanical ventilation d) maintain normovolemia and avoid hypotension

Answer 56

b) FALSE - should maintain a NORMAL core body temperature the other measures are true other things to do include: continuous monitoring of vitals and end-tidal CO2 provide sedation and analgesia should refer to trauma centre need continuous monitoring on the transport

Question 57

A 4 year old patient falls from the monkey bars and hits his head. He is noted to have a seizure immediately after his fall. He is now back to baseline with a normal neurological exam and has a normal CT head. What is your management? a) transfer to a tertiary care centre b) admit for 24 hours c) discharge home with instructions for family d) MRI head

Answer 57

c)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.IMPACT seizure - seizure that occurs immediately after impact,

Question 58

Which of the following is not a risk factor for post-traumatic seizures? a) open/depressed skull fractures b) cerebral edema c) severe head trauma d) older age

Answer 58

d) younger age is a risk factor the other 3 are risk factors for post traumatic seizures most occur within 24 hours, and rarely beyond 7 days incidence 5-6.5% but may be as high as 30-35% in severe head injuries post traumatic seizures (other than impact seizures) can contribute to secondary head injury administering phenytoin to prevent seizures post head injury doesn't have a lot of evidence proving it, but is still commonly used post severe injury ``` young child previous seizure GCS <8 bleed - SDH cerebral edema ```

Question 59

Which of the following factors is not associated with poor prognosis post head injury? a) high SES b) GCS< or equal to 5 c) raised ICP d) previous ADHD

Answer 59

a) lower SES is associated ``` severe injury (especially GCStheses are predictors of poor prognosis may have longstanding problems with attention and concentration long after the injury ```

Question 60

What is the estimated mortality from convulsive status epileptics? a) <2% b) 2-8% c) 10% d) 15%

Answer 60

b) mortality estimated to be 2-8% with estimated morbidity (mainly newly diagnosed neurological disorders) of 10-20%

Question 61

Which of the following is not part of the the definition of convulsive status epileptics? a) generalized tonic clonic seizure b) loss of consciousness >30 minutes in duration c) focal partial seizure d) 2 or more discrete seizures without return to baseline

Answer 61

c)status refers to generalized seizure with LOC (see below) convulsive status epileptics: continuous generalized tonic-clonic seizure activity with loss of consciousness for longer than 30 min, or two or more discrete seizures without a return to baseline mental status recently "early" status epilepticus - continuous or intermittent or 2 seizures without recovery of mental status to baseline lasting >5 minute **early status epileptics should be treated since early treatment more likely to prevent progression of seizures; animal models, get neuronal death/injury after 30 minutes

Question 62

Which age group is most likely to have convulsive status epileptics? a) 10-15 year old b) 6-10 year old c) 2-6 year old d) <2 year old

Answer 62

d) 1 month of age

Question 63

Which of the following metabolic abnormalities is not commonly associated with causing status epileptics? a) hypercalcemia b) hyperglycemia c) hypoglycemia d) hyponatremia

Answer 63

a) hypercalcemia is not listed - hypocalcemia is more commonly associated with seizures there others are listed

Question 64

Which of the following is the most common cause of prolonged convulsive status epileptics? a) CNS infection b) drug overdose c) prolonged febrile convulsion d) brain tumours

Answer 64

d) 23-30% - prolonged febrile convulsion most common cause of convulsive status epileptics is prolonged febrile seizure other common acute causes (17-52%) include infection, drug overdose/withdrawal/underdose, metabolic abnormalities, structural causes (more remote 16-29%) idiopathic 5-19%

Question 65

Which of the following is not part of the acute management of a child with status epileptics who is desating? a) place on side b) pry open teeth c) suction visible secretions d) place on back and do jaw thrust or chin lift after suctioning e) 100% O2 and cardioresp monitoring

Answer 65

b)do not pry open the teeth the other steps are reasonable risk factors for airway and ventilation being at risk include a clenched jaw, poorly coordinated respirations, and production of secretions and vomitus, hypoxia frequently present consider assisted ventilation if respiratory depression or low sats despite 100% O2

Question 66

Which of the following is the not a particularly ominous sign in a child with convulsive status epileptics a) hypotension b) bradycardia c) tachycardia d) poor perfusion

Answer 66

c) tachycardia and hypertension and common with seizures hypotenion, bradycardia and poor perfusion are ominous signs which signify severe hypoxia->need immediate airway management (bag/mask or intubation), IV access and glucose

Question 67

A 2 year old child has been having GTC seizure for 10 minutes, 2 doses of ativan have been given. Still seizing. What should you do next? a) more ativan b) try diazepam c) give phenobarbital load d) give phenytoin load e) midazolam infusion

Answer 67

d)phenytoin load phenobarb is used for neonates and for people who are already on phenytoin need IV/IO to give second line ask about seizure disorder, other symptoms (eg, fever), medication usage and allergies to medications. common mistakes in treatment giving more than two doses of benzo and delaying second line treatment, delay in intubation and midazolam infusion

Question 68

A patient arrives seizing for 10 minutes, bedside glucose is 2.5 mmol/L. ABCs are stable. has received 2 doses of SL benzo. What is the next step? a) give more benzo SL b) give 2-4 ml of D25W or 5 ml of D10W (0.5g/kg) IV and recheck glucose in 3-5 minutes c) load with fosphenytoin immediately d) intubate

Answer 68

b) need to correct the sugar before doing other things if persistently hypoglycaemic may need another bolus hypoglycemia is

Question 69

Which of the following is false of benzodiazepines? a) work equally IV and sublingual b) administering within 20 minutes can stop 70-85% of seizures c) buccal and intranasal midazolam have been shown to be the most effective non IV benzo medications to stop seizures d) intranasal midazolam has been shown to be as effective as IV lorazepam to treat prolonged febrile convulsions in one study

Answer 69

a) false works better IV, so should get IV access ASAP the rest are true b) true , very effective at stopping seizure if given early studies: buccal midazolam better than rectal diazepam intranasal midazolam as effective as IV lorazepam some would say that if available, buccal midazolam or intranasal midazolam should be first line for children without IV access

Question 70

All but which of the following is an advantage of IV lorazepam ? a) less respiratory depression than IV diazepam b) repeat doses continue to be very effective c) longer acting anti-convulsant than IV diazepam d) more effective at stopping seizures than phenytoin and IV diazepam

Answer 70

b) repeat doses are less effective (17% vs 85% for first dose) treatment with more than 3 doses of IV medication is associated with respiratory depression if pre-hospital benzos given, reasonable to give one does of IV benzo in hospital. if don't have access, very important to give the two doses of benzo through whichever route is needed

Question 71

Which of the following is false of phenytoin and fosphenytoin? a) less likely to cause respiratory depression than phenobarb b) less likely to cause altered LOC than phenobarb c) should be given in glucose containing fluid d) phenytoin can cause "purple glove syndrome" e) side effects of both include bradycardia, arrythmias and hypotension

Answer 71

c) opposite - don't give in a glucose containing solution, it will precipitate purple glove syndrome - severe SC irritation characterized by edema, discolouration and pain distal to the site of injection doesn't happen with fosphenytoin, which is the water soluble prodrug of phenytoin fosphenytoin can be given more rapidly and also IM, but more expensive and not as easily available need continuous BP and ECG monitoring during infusion or either drug

Question 72

Which of the following is false? a) phenobarbital generally causes more respiratory depression than phenytoin and is less effective b) dose is 20 mg/kg in NS, should be given over 20 minutes c) rectal route is the recommended route for paraldehyde, although it is used very uncommonly d) fosphenytoin is the best treatment choice for neonatal seizures

Answer 72

d)false - phenobarb is used for neonatal seizures and also for kids already on phenytoin maintenance if patient already on phenytoin or phenobarb - can give 5/kg but then should wait for levels to give more overall not great studies more resp depression especially when given with benzo sedation, respiratory depression and hypotension, paraldehyde - bad side effects with IV (include cyanosis, pulmonary edema, cough, hypotension) therefore should only consider rectal route with dilution with oil; many people don't recommend it, only say to use it if no IV other potential options: interest in valproic acid as a second line treatment studies - some show similar efficacy to phenytoin to less side effects (esp no resp or CV compromise)

Question 73

Which of the following patients might one consider a trial of pyridoxine (B6)? a) 10 month old b) 20 month old c) 24 month old d) 36 month old

Answer 73

a) consider for children <18 months who may have an undiagnosed metabolic condition such as pyridoxine dependant epilepsy

Question 74

A 14 year old arrives in status epileptics, which has resolved after 2 doses of benzodiazepines. He has a temperature of 39 C and looks unwell. What is the most important step in management? a) lumbar punture b) broad spectrum antibiotics c) CBC d) blood culture e) head CT

Answer 74

b)if suspect sepsis, most important to give antibiotics (should definitely do as much as possible to get cultures first, but don't delay antibiotics for the LP) investigations: CBC, glucose, culture (if suspect sepsis), lytes if on anticonvulsants, should measure levels in certain cases, do calcium/magnesium/LFTs, lactate and ammonia urine and blood tox can be assessed always consider intoxication LP after patient is stable and no signs of increased ICP and convulsion stopped, if suspect sepsis should give antibiotics asap if have focal signs, history of trauma, increased ICP or suspect herniation, do CT after stabilizing ABCs

Question 75

When should one consider starting midazolam infusion? a) after 2 hours of seizure b) after 1.5 hours of seizure c) after 1 hour of seizure d) after 20-30 minutes of seizure

Answer 75

d)after refractor status (see definition below), unlikely to respond to other meds, so should consider midazolam infusion within 20-30 minutes refractory status - if no improvement after 2 different anti-epileptics , some places have a time specification also (longer than 30 or 60 minutes) 1st line for refractory status - most common is midaz, low BP is most common side effect thiopental another option others should be used with expert if a child doesn't recover LOC as expected after seizure or if paralytics are being used, then should do EEG to rule out non-convulsive status, if no EEG available then do empiric treatment

Question 76

Which of the following should be the initial step when responding to a cardiac arrest? a) re-position airway and suction b) give O2 c) start an IV d) start chest compressions

Answer 76

``` d) start chest compressions new guidelines (2010) emphasize that chest compressions should be the first step in the hospital, can do this concurrently while another rescuer takes care of airway and ventilation ```

Question 77

Which of the following is the appropriate ratio of chest compressions to ventilation in a code with 2 responders in an unintubated 2 year old girl? a) 3:1 b) 100 compressions per minute with 8-10 breathes / minute c) 15:2 d) 30:2

Answer 77

c) 15:2 is the ratio for two rescuer CPR 30: 2 for one rescuer CPR 3: 1 for neonates if patient is intubated, then do continuous compressions at 100 /minute with 8-10 breathe/minute, do not pause for CPR

Question 78

Which of the following statements is not true? a) Chest compressions should have a depth of 4 cm in children and infants b) Compressors should switch every 2minutes c) should not pause more than 5 seconds for compression switches and limit pulse checks to 10 sec d) most arrests in children are asphyxial in nature

Answer 78

a) 4 cm in infants, 5 cm in children, should be 1/3 of the AP diameter of the chest the rest are true because most arrests are asphyxial in nature, ventilation is very important, **with the new guidelines, the emphasis is on early chest compressions, which is better than no chest compressions at all.

Question 79

An asymptomatic six-year-old boy with a family history of sudden death is being evaluated in the cardiology clinic. While visiting the hospital cafeteria, he suddenly collapses, becomes unresponsive and has only gasping respirations. As a health care provider, what should be the next steps? a) look, listen and feel b) initiate CPR immediately c) may pulse check for no more than 10 seconds then start CPR d) none of the above

Answer 79

c) is the answer no longer have look, listen and feel in the algorithm for lay people, should check a) responsiveness b) breathing ; if not responsive and not breathing normally (including gasping) then should start CPR ASAP HCP can check for a pulse for no more than 10 seconds - if no pulse or unsure about pulse, start CPR

Question 80

Which of the following is not the best place to check for a pulse when about to start a rescucitation? a) brachial in an infant b) radial in an infant c) femoral in a child d) carotid in a child

Answer 80

b) radial in an infant not the recommended place to check the others are: for infant, brachial, for child, femoral or carotid

Question 81

Which of the following is the recommended method of defibrillation in infants? a) adult AED b) AED with paediatric dose attenuator for children

Answer 81

d) manual defibrillation is preferred for infants dose initial dose should be 2-4 J/kg, later doses should be between 4J/kg and not more than 10 J/kg AEDs CAN be used for infants and children but not the best choice if you need to use an AED, use a paediatric dose attenuator if

Question 82

Which of the following is sometimes recommended post cardiac arrest in children ? a) hyperoxemia b) maintaining O2 sats between 89-94% with O2 therapy c) therapeutic hypothermia d) none of the above

Answer 82

c) therapeutic hypothermia if the patient is comatose after resuscitation, should consider therapeutic hypothermia, temperature of 32-34 C rectal, need expert consult for this (don't get confused, it is okay for post cardiac arrest, remember enter boy, not post head injury) hyperoxaemia can increase the oxidative injury during repercussion O2 sat target should be 94-99% (as a saturation of 100% corresponds to a partial pressure of oxygen in arterial blood of between 80 mmHg and 500 mmHg...?)

Question 83

An obese 10 year old girl presents with a wide complex tachycardia with a rate of 180. The child is hemodynamically stable. Which of the following is false? a) can try adenosine treatment b) should calculate dose of medications based on ideal body weight c) WPW is a contraindication to adenosine treatment d) should only be used for regular, monomorphic rhythms

Answer 83

b) doses should be calculated based on actual body weight, up to adult maximums (if not known, use length based tapes because this is more accurate than age based or observer based methods) because this is a wide complex tachycardia (defined as QRS>0.09) which can be ventricular or supra ventricular in origin, can try adenosine to distinguish the 2 as long as the patient is stable use only if regular monomorphic rhythms, and avoid if patient with known WPW presents with wide complex tachycardia

Question 84

Which of the following is true? a) crystalloid has been shown to be more effective than colloid solution during resuscitation for septic shock b) etomidate should be used routinely for intubation in septic shock c) etomidate has been associated with increased mortality in children d) cricoid pressure is recommended during intubation to decrease aspiration

Answer 84

c)TRUE etomidate is a sedative, it has been associated with increased mortality should not be used routinely for intubation in children DOES have less hemodynamic impact But has been associated with adrenal suppression in adults and children as well as increased mortality therefore should not use routinely insufficient evidence to recommend cricoid pressure to decrease aspiration, might slow down intubation or make it harder

Question 85

Which of the following is the appropriate size of cuffed ET tube for a 4 year old child? a) 4 b) 4.5 c) 5.0 d) 5.5

Answer 85

b) 4.5 can use cuffed and uncured tube to intubate children for children >2 year old, formula of 3.5 + age/4 can be used therefore 4.5 is the appropriate size for uncuffed, add 0.5 (so would be 5.0 uncured) foruncuffed tube, children<1 use 3.0 tube, for children between 1-2 use 3.5 tube in certain settings, the use of cuffed endotracheal tubes may help to decrease the risk of aspiration and reduce the need for reintubation. three-quarters of all in-hospital paediatric cardiac arrest victims still die. Methods, such as team training with realistic patient simulators, debriefing with standardized scripts and video-based learning with a ‘practice while watching’ approach, may help to consolidate learning and, ultimately, lead to improved patient outcomes from cardiac arrest.

Question 86

What type of steroids should you give for mild asthma exacerbation?

Answer 86

inhaled corticosteroids

Question 87

How often do you watch for mild exacerbation? | for moderate?

Answer 87

mild watch for 2 hours | for moderate if needing more than <4 hours then admit

Question 88

How does steroids help with asthma? a) earlier discharge b) decreased hospitalization c) decrease chance of relapse d) all of the above

Answer 88

d) all of the above may reduce the risk of hospitalization and risk of relapse from treatment Mg: improves resp function, decreases admission

Question 89

What are complications of intubation in asthma? a) CV collapse b) decreased venous returne c) pneumothorax d) increased death risk e) all of the above

Answer 89

e) all of the above

Question 90

True or false - anaphylaxis can occur a few hours after exposure

Answer 90

true - usually within minutes but in rarer cases can happen a few hours after

Question 91

True or false - epinephrine can cause harm in healthy individual and should be given with great caution

Answer 91

false - in heathy individuals, should not cause harm if given unnecessarily epi is the first line med to treat, don't give antihistamines or asthma meds instead, if you give epi need to to go hospital (ideally bia ambulance) even if they are a lot better, need more epi for the transport no one in anaphylaxis can fully resuscitate themselves - may need help, especially kids

Question 92

True or false - individuals who are feeling faint or dizzy because of impending shock should lie down

Answer 92

true - they should lie down unless they are vomiting or having severe resp symptoms should raise the legs, help increase blood flow if vomiting, put them on their side if having trouble breathing, keep them sitting up.

Question 93

What are 3 recommendations you should give to a patients with anaphylaxis

Answer 93

1. carry auto injector at all times when age appropriate 2. wear medical identification - i.e. medic alert bracelet regular practice with an auto-injector for either the allergic person or others (i.e. school staff), if they are in the wilderness should pack a back-up injector 3. staff training of school staff who are in regular contact with the student at risk

Question 94

Name some risk factors for severe anaphylactic reaction

Answer 94

can't always predict who will have more severe reaction, however, those with asthma and who have had previous anaphylaxis are at increased risk avoid allergen only way to prevent can try to reduce exposure Factors that may increase the risk of a severe anaphylactic reaction: 1. anaphylaxis and asthma - children with both, more likely to have severe breathing problems when experiencing an anaphylactic reaction, in cases where an anaphylactic reaction is suspected but there is uncertainty whether or not the person is experiencing an asthma attack, epi should be used first epi can be used to treat life-threatening asthma attacks as well as anaphylactic retains should carry puffers with their epi 2. under-utilization and delay in the use of epi. 3. underlying cardiac diseases : some meds can interfere with epi Other factors: previous history , age

Question 95

You are discharging a patient with anaphylaxis from the ER. What are 3 important things to do

Answer 95

1. give them auto-injector prescription and make sure that it is immediately filled 2. teach them how to use the auto-infector 3. make sure they have follow up with their physician including referral to allergist 4. teach them signs of anaphylaxis 5. tell them to wear a medic-alert bracelet 6. have a written anaphylaxis emergency plan

Question 96

True or false - anaphylaxis can occur without hives

Answer 96

true , it can never ignore any of the signs most dangerous are airway or hypotension

Question 97

Most common triggers for anaphylaxis

Answer 97

foods insect stings another cause of life threatening - latex allergy, less common, is exercise

Question 98

What are the priority allergens as per Health Canada

Answer 98

Fish , shellfish, crustaceans, sulphites (a food additive)

Question 99

What are some common side effects of epi?

Answer 99

rapid heart rate, pallor, dizziness, weakness, tremors and headache mild, better in a few hours NO CONTRAINDICATIONS to using epi for life-threatening allergic reaction, in normal individuals, epi will no cause harm if given unnecessarily

Question 100

Name 2 medications that may interfere wight he action of epi and worsen the allergic reaction

Answer 100

cardiac disease/high BP meds 1. beta-blockers 2. ACE inhibitors

Question 101

How many children with anaphylaxis do not report a previous episode?

Answer 101

65% of children (and 25% of adults) don't report a previous episode although previous history of anaphylaxis is a strong predictor of future anaphylaxis

Question 102

What age group has the highest incidence of anaphylaxis?

Answer 102

0-19 year old highest food most common in children, adolescents and adults middle age and older - more likely from meds and insect venom

Question 103

Which patients might you want to observe for longer than 4-6 hours after anaphylaxis in the ER?

Answer 103

patients with asthma - most deaths happen in these individuals 4-6 hours in general, to watch for biphasic reaction also think about people that live far away in general, if people feel unwell, advise them not to go to the bathroom

Question 104

True or false - auto-injectors should be kept in locked cupboards or drawers

Answer 104

FALSE - should be kept in locations where they are easily accessible, but out of reach of young children should not be exposed to extreme cold (fridge/freezer) or heat (glove box in a vehicle) by age 6-7, kids should carry their own epinephrine (carry in a waist pack)

Question 105

A parent is worked that the odor of peanut butter can cause an anaphylactic reaction. what do you tell them

Answer 105

it is the protein in a food which causes an allergic reaction, inhalation of airborne peanut protein can cause reactions, though usually not anaphylaxis . the door has not been shown to cause an anaphylactic reaction as the smell does not contain the protein. in contrast, vapor/steam from cooking fish can trigger asthma or even anaphylaxis shouldn't share utensils in for allergic kids, try not to involve foods in rewards systems, clearly label foods , no eating during travel on school buses

Question 106

True or false - hand sanitizer can remove peanut butter residue as well as soap and water

Answer 106

false - hand sanitizer isn't as effective, children should wash their hands with soap and water before and after eating kids with allergies also shouldn't eat if they do not have an auto-injector with them, be cautious about foods prepared by others

Question 107

What are some interventions that individuals who are allergic to insect stings can do in the summer

Answer 107

stay away from areas where there are lots of insets, wear light colours, avoid loose flowing garments or hair that could entrap an insect, wear shoes instead of sandals, avoid scents, drink from cups rather than cans,

Question 108

Which type of allergies can we consider immunotherapy for

Answer 108

venom immunotherapy - a desensitization program which is highly effective for anaphylaxis to insect bites

Question 109

What are the important components of an anaphylaxis plan for a school?

Answer 109

needs to be written 1. should not imply a guarantee or that there is zero risk, school communities should strive to create an environment that is described as allergy-safe rather than allergen-free should prepare and address role and responsibilities communication strategy, so everyone including subs is trained and knows what to do

Question 110

A parent wants your advice on filling out a form that talks about the school's responsibility in the event that their child has an anaphylactic event at school. Which of the following is false? a) complete a write anaphylaxis emergency plan b) talk to school staff in advance of field trips c) should sign a waiver that absolves the school of responsibility if the epi is NOT injected d) provide consent that the school can give the kid epi if they consider it necessary in an allergic emergency

Answer 110

c) FALSE - should not waive this responsibility rather, should provide consent so that school staff use epi when they consider it necessary in an allergic emergency should also complete an anaphylaxis er plan with child's photograph and allergy, emergency contact numbers, emergency protocol, signature of a parent/guardian, and if needed signature of physician provide non-perishable foods and safe snacks for food-allergic children talk to school staff about field trips

Question 111

pneumonic for CATCH rules

Answer 111

high risk - Wigs - Dr. Nzau wearing a wig - likely to get neurological intervention - 1. Worsening headache 2. Irritability on exam for kid < 2 year old 3. GCS 3 feet or 5 stairs, MVA, bike accident without a helmet 2. Hematoma - large boggy hematoma 3. basal skull skull# skull # Dangerous Hematoma (SDH is the pneumonic)

Question 112

when does catch criteria apply

Answer 112

minor head injury: GCS 14-15, and 1 of the following: - witnessed disorientation, witnessed LOC, amnesia of the event, persistent vomiting, persistent irritability

Question 113

Absolute indication for CT head post head trauma

Answer 113

1. focal neuro deficits 2. GCS <13 (moderate-severe head trauma) 3. minor head trauma meeting catch 4. depressed skull fracture

Question 114

Relative indication for CT head post head trauma

Answer 114

1. seizure post event (may not do if immediate post impact) | 2. bleeding disorder

Question 115

CATCH criteria - what the injury needs to be to actually use the CATCH criteria (i.e. inclusion criteria)

Answer 115

GCS needs to be 14-15 and need to meet the following criteria to meet minor head injury: 1. definite amnesia 2. witnessed disorientation 3. witnessed LOC after trauma 4. persistent vomiting after the head injury 5. kid who is <2 years old with persistent irritability reported by parents

Question 116

What is the definition of high risk?

Answer 116

high risk - higher risk of needing neurosurgery: medium risk - found something on CT but didn't need to do anything about it high risk: 1. worsening headache 2. Medium risk:

Question 117

10 year old fell from bike, bad headache, vomit x 3, had LOC, GCS 15/15, what to do?

Answer 117

can apply CATCH but does not meet criteria for CT watch x 4-6 hours if still having persistent symptoms then admit to hospital, observe, after 18-24 hours then CT them then

Question 118

why fosphenytoin instead of phenytoin

Answer 118

less resp depression less purple glove can run over 5 minutes instead 20 minutes same line as dextrose