Resuscitation
A 4-month-old unresponsive infant is rushed to the ED by EMS. The infant is cyanotic and has no pulse. However the CR monitor reveals a narrow complex rhythm at a rate of 80–100 beats per minute. What is the most common cause of pulseless electrical activity (PEA) in children?
1. Hypoxia
2. Toxic ingestions
3. Tension pneumothorax
4. Cardiac tamponade
5. Hypovolemia
Hypovolemia
Profound hypovolemia is the most common etiology of PEA in pediatrics. Therefore, in addition to CPR and epinephrine, one should always consider a rapid fluid bolus in any child with PEA. The key to successfully resuscitating a child from PEA is to rapidly identify and treat the underlying reversible causes of PEA.
When confronted with a child in PEA, use the asystole treatment algorithm and “head down the right PATH in the algorithm”:
P = Pneumothoarx
A = Acidosis
T = Tamponade
T = Toxins
H = Hypovolemia
H = Hypoxemia
H = Hyper/Hypokalemia
H = Hypothermia
A 2-year-old boy is transferred from another hospital after he swallowed a coin earlier in the day. New radiographs demonstrate that the coin has not moved from the thoracic inlet where it was seen by the transferring physician. Which treatment option do you recommend?
1. Activated Charcoal
2. Discharge home with repeat X-ray in 1 week
3. GI consultation
4. Surgical/ENT consultation
Surgical/ENT consultation
Coins are the most frequently swallowed objects. Other common items include coins, jewelry, toys, batteries, and inedible food products such as small bones.
Several areas in the esophagus may trap foreign bodies. The most common site of obstruction is at the level of the thoracic inlet. Approximately 10% to 15% of foreign bodies lodge in the midesophagus, where the carina and aortic arch overlap.
A 6-month-old girl with a history of truncus arteriosus repair is brought in by her mother for a history of tactile fever, fussiness, and an episode of emesis. Which of the following statements involving her emergency department assessment is TRUE?
1. Arrhythmias are common and may present with symptoms of palpitations, decreased appetite, emesis, and decreased exercise tolerance
2. Arrhythmias are not seen out of the immediate post-operative period
3. The most common arrhythmia is heart block
4. Endocarditis is only a consideration with a documented fever without a source
5. Antibiotic prophylaxis should be given to patients after simple laceration repair
Arrhythmias are common and may present with symptoms of palpitations, decreased appetite, emesis, and decreased exercise tolerance
Arrhythmias are the most common post-heart surgery problem and may present with symptoms of palpitations, decreased appetite, emesis, and decreased exercise tolerance. The most common arrhythmia seen is SVT.
Endocarditis should always be considered in corrected or uncorrected congenital heart disease, especially without a known source.
Antibiotic prophylaxis guidelines do not include simple laceration repair.
A 2-week-old presents to the emergency department and the parents state that their child has been vomiting a lot. While in the ED during a feeding trial, bilious emesis is noted. Which disposition is safest for the neonate?
1. Call the pediatricians office for a visit the next morning
2. Check blood work and if normal discharge
3. Have an immediate surgical evaluation
4. Make a surgical appointment within 2–3 days for the child
5. Perform an UGI series
Have an immediate surgical evaluation
Bilious emesis is an ominous sign and should warrant further investigation - especially a surgical consult. The things we worry about with bilious emesis is malrotation with volvulus. Usually present with bilious emesis, abdominal distention and lethargy.
Most times we will obtain an abdominal X-ray but Ultrasound and UGI series is more definitive for diagnosis.
A 4-year-old girl is brought to the ED by her grandmother. As per the grandmother, the child was less playful and had a decreased appetite. The grandmother believes the child has another urinary tract infection. The child appears well hydrated and nontoxic. You suspect a viral illness. Which of the following statements is true?
1. E coli urinary tract infection can improve without medical interventions
2. Lack of septic appearance in the ED rules out a bacterial infection
3. Activity level and feeding behavior are important observations.
4. Respiratory pathogen panels that are negative warrant further workup if viral process is suspected
Activity level and feeding behavior are important observations.
Family members tend to know patients best. If patient has previous history of urinary tract infection, especially with a similar prior presentation, I would consider work up with urinalysis rather than just suspecting it is a viral illness.
Young children have a hard time describing urinary symptoms. Most common presentation is nausea, vomiting, decreased appetite, fevers, decreased urination and abdominal pain.
If patient is in diapers, we advise GRAM STAIN :)
A 7-year-old boy with myocarditis who was transferred to your ED suddenly becomes unresponsive. The CR monitor reveals ventricular fibrillation. What would be the appropriate initial defibrillation dose for this average size 7 year old?
1. 25 J
2. 30 J
3. 50 J
4. 75 J
5. 100 J
50 J
The initial defibrillation dose for pediatric patients is 2 J/kg. Based on the average weight of a 7-year old which is approximately 25 kg, the correct initial defibrillation dose would be 50 J. The second defibrillation dose should be at 4 joules/kg, which would be equal to 100 joules in a 25 kg 7 year old.
A 6-month-old infant is brought to the emergency department for evaluation of increased work of breathing. The parents report that the infant has been less active and refusing her bottle. Which of the following signs is most consistent with impending respiratory failure in infants?
1. Tachypnea
2. Tachycardia
3. Grunting
4. Hypoxemia
5. Hypertension
Grunting
Grunting is a form of end expiratory pressure generated by infants in marked respiratory distress. It is usually in response to varying degrees of -alveolar collapse or hypoventilation.
A 6-month old is brought by his parents for rapid breathing. The mother reports that since this morning the infant has had increased irritability and poor feeding. Upon arrival to the ED, the infants appears ill, tacypneic, and lethargic. The monitor shows PSVT. Which of the following is the most appropriate intervention for this infant?
1. Verapamil, 0.1 mg/kg slow IV push
2. Digitalis, 30 µg/kg IV slow IV for acute digitalization
3. Synchronized cardioversion, 0.5 J/kg, increasing to 2 J/kg as needed
4. Adenosine, 0.1 mg/kg IV push followed by 0.3 mg/kg, if needed
5. Vagal maneuvers, such as placing a bag of ice water over the nose and forehead
Synchronized Cardioversion
Unstable SVT is treated with cardioversion. Vagal maneuvers may be used to convert stable patients. Adenosine is effective but immediate recurrence rates approach 50%. Digitalis is best used in the well-known stable patient with AV nodal reentry. Verapamil can cause hypotension, cardiovascular collapse, and death in infants and its use is not recommended for infants under 2 to 3 years of age.
A mother brings her 5-week-old son in for evaluation of forceful vomiting after every feed. He was diagnosed with reflux by his pediatrician last week but has lost 8oz since that time. You observe a feed. He takes the bottle eagerly but then has a large volume episode of nonbilious emesis 1 minute after the feeding. Your next step is to:
1. Try another feed, encouraging the mother to feed him more slowly this time.
2. Obtain a blood culture and a CBC.
3. Change his formula to gentlease and send him home with close follow-up with his pediatrician.
4. Obtain a urine culture.
5. Place an IV, give IVF, check electrolytes, and order an abdominal ultrasound.
Place an IV, give IVF, check electrolytes, and order an abdominal ultrasound.
This 5-week-old has projectile vomiting after every feed, weight loss, and dehydration. His age and symptoms strongly suggest pyloric stenosis. These infants frequently develop hypochloremic hypokalemic metabolic alkalosis due to persistent vomiting. The most important step in management is to provide IV hydration, check electrolytes, and order an abdominal ultrasound, which is the definitive test to document hypertrophy of the pylorus muscle.
A 4-year-old male presents with a rash to his buttocks and legs; he also complains of joint pain. On examination, you note the characteristic rash of HSP. There is no history of diarrhea or bloody stools. Which test should you recommend?
1. Inflammatory markers
2. Radiographs of the affected joints
3. Complete blood count
4. Coagulation panel
5. Urinalysis
Urinalysis
A late sequela of HSP is nephritis, which may present with hematuria or proteinuria at the onset of HSP. Patients with significant findings on urinalysis should be followed closely for development of complications and might require steroids and renal biopsy.
Coags and platelet count are normal!
A 3-day-old male born at home to a mother who received no prenatal care is brought to the emergency department with poor feeding, sweating and sleepiness since this morning with episodes of pallor. The child is pale, blue, and dusky with oxygen saturation in triage of 78% despite blow by oxygen applied by the nurse. The femoral pulses are weak and perfusion is poor and the infant has increased work of breathing with a rate of 68/min with significant retractions. A loud murmur is noted and an enlarged liver is present on abdominal exam. The child likely has:
1. Hypovolemic shock from dehydration
2. Septic shock from Group B streptococcus
3. Cardiogenic shock from complex congenital heart disease
4. Pneumothorax
5. Cardiogenic shock from acquired heart disease
Cardiogenic shock from complex congenital heart disease
Complex congenital heart disease is often detected with prenatal ultrasound during pregnancy. This child has heart failure based on the enlarged liver and murmur on exam. Unlike adult heart failure, pediatric heart failure will manifest as subtle history findings such as poor feeding, poor weight gain, diaphoresis with feedings, or difficulty breathing with feedings. Cyanosis with congenital heart disease indicates the presence of the following: tetralogy of Fallot, total anomalous pulmonary venous return, transposition of the great vessels, truncus arteriosus, tricuspid atresia, aortic arch anomalies, and hypoplastic left heart syndrome. The delayed presentation of cardiogenic shock is likely due to the fact that the patent ductus arteriosus is beginning to close, compromising systemic perfusion and increasing pulmonary flow creating pulmonary edema, V/Q mismatch, and increasing work of the heart. Acquired heart disease would be very unlikely in a 3-day old.
There is a 9-year-old male in the ED with status asthmaticus. He is in severe respiratory distress despite maximal conventional medical therapy. The ED physician could next consider:
1. High flow
2. Nonrebreather mask oxygen3. IV fluids
4. CPAP
5. BiPAP
BiPAP
BiPAP has been used to treat status asthmaticus in pediatric patients in the ED who were refractory to conventional medical therapies.
BiPAP is often favored over CPAP in managing status asthmaticus because it offers more tailored respiratory support. While both provide positive airway pressure, BiPAP's unique ability to deliver two distinct pressure levels – a higher inspiratory positive airway pressure (IPAP) and a lower expiratory positive airway pressure (EPAP).
A 17-year-old boy presents with syncope while playing football. He has no medical history and was in good health. He has no current complaints. His mother tells you that her brother was a victim of sudden death for unexplained reasons 20 years ago. His ECG is normal except for a QTc of 0.55 seconds. What is the prognosis?
1. The findings are a sign of delayed repolarization and unlikely to cause any significant problem.
2. This patient has congenital long QT syndrome (LQTS) and may experience recurrent syncope but is not at risk of significantly increased mortality
3. β-Blockers are contraindicated
4. Mortality of untreated congenital LQTS approaches 10%
5. QTc prolongation of more than 0.5 s is highly associated with sudden death
QTc prolongation of more than 0.5 s is highly associated with sudden death
QTc prolongation of more than 0.5 seconds is highly associated with sudden death.
Calculation: Bazett's formula: QT/SquareRoot(RR)
LQTS can cause major arrhythmic events or death, and it represents a leading cause of sudden death in populations under 20 years of age. Mortality of untreated congenital LQTS approaches 50%.
Treatment: β-Blockers decrease the incidence of syncope and reduce mortality.
After months of abdominal pain, a 7-year-old female gets relief after being given an enema. Her mother is not satisfied with your diagnosis of constipation because her daughter has been having diarrhea. How do you explain this symptom?
1. Concurrent UTI
2. Acute gastroenteritis
3. Chronic laxative use
4. Encopresis
5. Lactose intolerance
Encopresis
The child’s symptoms stem from leakage of liquid stool around an impacted stool. This symptom can often be a barrier to the parent’s acceptance of constipation as the true source of a child’s abdominal pain.
Follow our ED Constipation discharge order set!
You are the assistant coach for your son’s eighth grade soccer team. The team’s best striker has just hit his head on the goalpost. He was not knocked out, but was quite dazed for a few minutes and vomited once. It is the deciding game for the playoffs and there are 25 minutes of playing time left. He insists that he is now fine and ready to play. The coach, player, and parents are all agitating to have the striker return to play now. This is his first concussion. You decide that this is a first-time grade I concussion and that he can return to play when he has been asymptomatic for 15–20 minutes. In this scenario, the RTP guidelines are used to:
1. Ensure that players have enough rest during a game.
2. Reduce the risk of long-term cognitive dysfunction.
3. Protect yourself from litigation.
4. Reduce the risk of second-impact syndrome (SIS).
5. Make players and parents aware of the risks of multiple concussions.
Reduce the risk of second-impact syndrome (SIS) or second phenomenon
As a wife of a sports medicine physician, this is usually the first thing he recommends!
Second impact syndrome has recently gained increased attention as many athletes sustaining a concussion and returning to the sport early as being particularly at risk. Though it is a relatively rare condition, patients should be educated who have experienced or are at risk of experiencing a head injury, as the syndrome is often deadly.
The athlete will rapidly develop altered mental status and a loss of consciousness within seconds to minutes of the second hit, resulting in catastrophic neurological injury. The devastating injury results from the dysfunctional cerebral blood flow auto-regulation, leading to an increase in intracranial pressure. Ultimately leading to brain herniation!
A 10-month-old infant presents with respiratory distress and hypoxia (room air oxygen saturation 89%). A self-inflating bag with a mask is placed in front of the patient’s mouth and nose. The tubing is attached to an oxygen outlet at 15 L/minute. The patient’s oxygen saturation remains at 89% despite this. Which of the following best explains is the most likely explanation?
1. The patient has methemoglobinemia
2. The oxygen flow meter is attached to a room air line.
3. No oxygen passes through the mask of a self-inflating bag unless the bag is compressed.
4. The pulse oximeter is inaccurate in hypoxic states.
5. The patient is in respiratory failure and needs to be intubated.
No oxygen passes through the mask of a self-inflating bag unless the bag is compressed.
Self-inflating bags are designed to be squeezed to deliver a breath. The compression forces air (and oxygen, if connected) into the patient's lungs.
While some bags may have an oxygen reservoir, it is designed to enrich the delivered breath during compression, not to provide a continuous flow of oxygen without squeezing the bag.
A 2 year old presents to the emergency department with difficulty breathing. The parents report a low-grade fever, mild respiratory symptoms, and difficulty with PO intake. Which of the following signs and symptoms is concerning for a diagnosis of myocarditis?
1. History of respiratory illness exposure
2. Tachypnea and retractions with clear lung sounds.
3. Severe cough and multiple episodes of emesis
4. Green nasal discharge and swollen nasal mucosa.
Tachypnea and retractions with clear lung sounds
Red flag signs and symptoms that may be helpful for diagnosis: tachypnea and retractions in the setting of clear breath sounds suggests respiratory compensation for underlying pathology. A lot of times, respiratory distress without lung pathology is concerning for a metabolic acidosis.
In contrast, patients with bronchiolitis, reactive airways disease exacerbation, or pneumonia frequently have abnormal lung examinations. Another concerning scenario occurs during the treatment of wheezing.
Many children who have had recent viral illness and present with TACHYCARDIA, chest pain and shortness of breath should make you PROMPTLY think of myocarditis.
A 16-year-old girl presents to the emergency department with polymigratory arthritis, an erythema marginatum rash, and subcutaneous nodules. She recalls having a sore throat 2 to 3 weeks ago but did not seek medical treatment. The diagnosis of acute rheumatic fever is considered. Which of the following is a mainstay of initial treatment?
1. High dose aspirin
2. Intravenous immunoglobulin
3. High-dose ibuprofen
4. Plasmapheresis
5. Arthrocentesis
High Dose Aspirin
High-dose aspirin is a mainstay treatment in acute rheumatic fever. The use of high-dose aspirin results in a rapid improvement in symptoms and attenuates the inflammatory response seen in this condition.
IVIG and aspirin often used in Kawasaki and MIS-C
A 1-week-old infant is referred to the ED by the primary care physician for follow-up of a bilirubin level obtained in the office the prior day. The mother states she thinks the nurse said it was 22. The infant appears normal except for significant jaundice including scleral icterus. Birth History is significant for gestational age of 35 weeks and poor feeding for the first two days. The infant was discharged on day of life #3 and mother reports intermittent poor feeding. The next best step is
1. Repeat level in 2 days
2. Send CBC and reticulocyte count
3. Establishment of IV for hydration
4. Begin phototherapy
Begin phototherapy
The initiation of phototherapy is imperative in this patient to reduce the risk of neurotoxicity given the high number. USE BILITOOL
In addition, the infant has several other risks factors including prematurity and poor feeding.
Risk factors for jaundice: Exclusive breastfeeding, G6PD deficiency, ABO incompatibility and premature birth
A 21-day-old infant presents to the ED in critical condition. He is mottled and lethargic. Vital Signs are temperature 96.8˚F rectal, HR 220, RR 50, capillary refill 4 seconds, pulse ox 90%. The first steps in management are:
1. Establish IV and start cefotaxime and ampicillin
2. Immediately start assisted ventilation with 100% oxygen
3. Immediately perform an LP, blood culture, and urine culture and start IV antibiotics
4. Put under a warmer, start IV, and begin maintenance fluids
5. Place under warmer, start oxygen by mask, obtain IV access and dextrostick and give 20 cc/ kg NS push.
Place under warmer, start oxygen by mask, obtain IV access and dextrostick and give 20 cc/ kg NS push.
Multiple things need to be done at the same time, as the patient is in shock, 20 cc per kilogram NS push is imperative. Antibiotics are secondary to cardiovascular stabilization. While the patient has a low pulse oximetry, he is breathing well but he does need oxygen but not assisted ventilation. The patient is too unstable to perform a sepsis workup. The child is in shock and needs aggressive fluid management.
An 8-year-old male involved in an ATV crash is brought by EMS to your emergency department with a suspected spinal cord injury. His heart rate is 48, BP is 82/46, and has both arms paralyzed and legs with poor rectal tone. Which of the following is most likely to be found in patients with neurogenic shock?
1. Fever
2. Euthermia
3. Hypothermia
4. Peripheral vasoconstriction
Hypothermia
Loss of sympathetic tone from a spinal cord injury results in bradycardia and hypotension. There is also concomitant dilation of vessels leading to increased heat loss and subsequent development of hypothermia if not monitored appropriately. Temperature regulation involves the hypothalamus and fever would not be expected with a spinal cord injury.
A 6-month-old ex-premie born at 32 weeks is brought to the emergency department from his daycare program by the program director. The caregiver notes that the infant has had post-tussive emesis and recurrent coughing episodes. The caregiver has received written authorization from the parents to seek medical attention for the infant. Which of the following is correct regarding infants with pertussis?
1. During the convalescent phase in infants, the symptoms (e.g. the cough and whoop) become worse
2. Infants always present with classic findings
3. Infants always have the typical three phase presentation
4. During the convalescent phase in infants, symptoms gradually improve
5. Pertussis in infants is usually mild
During the convalescent phase in infants, the symptoms (e.g. the cough and whoop) become worse
Patients, except infants, get better gradually during the convalescent phase. Infants are the only age group that can get worse ( increase in the cough and whoop) during the convalescent phase. Infants commonly have an atypical presentation without classic findings. Infants often lack the three-phase presentation. Infants have the greatest morbidity and mortality
A 14-year-old boy presents to the emergency department with the complaint of positional chest pain. It hurts most when he is lying on his back and feels best when he is leaning forward. His electrocardiogram shows diffuse ST segment elevations. The presence of which of the below increases his likelihood of having pericarditis?
1. History of juvenile rheumatoid arthritis.
2. History of Noonan’s syndrome
3. History of phenylketonuria
4. History of DiGeorge syndrome
5. History of Williams’ syndrome
History of juvenile rheumatoid arthritis.
The presence of inflammatory autoimmune diseases such as juvenile rheumatoid arthritis, systemic lupus erythematosus, and acute rheumatic fever increases the likelihood of pericarditis. In addition, infectious etiologies such as viral, bacterial, and fungal infections, uremia, hypersensitivity to drugs, and postpercardiotomy states are associated with pericarditis and pericardial effusion. Noonan’s syndrome, Williams’ syndrome, DiGeorge syndrome and phenylketonuria are not associated with pericarditis. They are associated with other congenital cardiac abnormalities.
A 3-year-old child is brought to emergency department for abnormally colored stools. Upon examination, the child is playful, appears well hydrated, and has normal vital signs. In taking a dietary history, which of the following foods would provide a possible explanation?
1. Blueberries
2. Carrots
3. Eggplant
4. Plums
5. Tomatoes
Blueberries
All that is red is not necessarily a GI bleed. Foods such as beets or blueberries can all color the vomitus and stool. Spinach can also turn stools very dark and be mistaken for melena.
A 3-year-old with history of anemia and is on iron supplements presents with a petechial rash that started one week ago in the buttocks, now on the upper chest, neck, around right eye and mouth. The patient was diagnosed with anemia and she also a cast on the right leg for presumed occult fracture with persistent leg pain. She had a persistent limp before the cast was placed. The most likely diagnosis for this patient’s limp is:
1. Septic arthritis
2. Henoch–Schönlein Purpura
3. New onset leukemia
4. Slipped capital femoral epiphysis
5. None of the above.
New onset leukemia
New onset leukemia presenting with prior history of a limp, anemia and now with a petechial rash.
Bone fractures can be one of the initial signs of leukemia, particularly in children with ALL.
If bone pain or fractures occur, particularly in conjunction with other leukemia symptoms like fatigue, fever, or easy bruising, it's crucial to consult with a doctor for prompt evaluation to rule out or diagnose leukemia.