The Toxic Track
A 2 year old boy presents with 4 days of URI symptoms. Mom has been giving him 240 mg (13 kg) of tylenol Q4H as well as cold medicine that contains acetaminophen. Exam and vitals are normal except for rhinorrhea. Serum tylenol level is 20 mg/L, AST 15, ALT 10. What's the next best step?
A. Activated charcoal
B. Consult poison control
C. Discharge home with tylenol dosing education
D. Plot serum acetaminophen concentration on nomogram
Consult poison control
A 5-year-old boy is brought in with difficulty breathing and lethargy. His mother reports that he has had a fever and cold symptoms for the past few days but today developed rapid breathing and appeared very tired. On examination, he is pale and has cool extremities with delayed capillary refill. His vital signs are HR 160/min, BP 70/40, RR 36/min, SpO2 92% on RA. A bedside echo shows poor left ventricular function and dilation of the left ventricle. Which of the following is the most appropriate next step in the management of this patient?
A. Administer a 20 mL/kg bolus of normal saline
B. Start an infusion of epinephrine
C. Administer intravenous furosemide
D. Initiate high-dose intravenous steroid
Start an infusion of epinephrine
A 6-year-old boy is brought after falling from a height of 10 feet while climbing a tree. He briefly lost consciousness but is now awake and oriented, though he complains of a severe headache and nausea. His initial vital signs are HR 100/min, BP 110/70, RR 20/min, and SpO2 98% on RA. He has a large bruise on his forehead but no signs of external bleeding. His pupils are equal and reactive, and he has full range of motion in all extremities. What is the most appropriate next step in managing this patient?
A. Discharge home with strict return precautions and follow-up instructions
B. Obtain a head CT scan without contrast
C. Perform continuous neurological monitoring in the emergency department for 4 hours
D. Administer intravenous mannitol
Obtain a head CT scan without contrast
A 7-year-old boy with a history of asthma presents with severe respiratory distress. He has been receiving albuterol treatments at home without improvement. On arrival, he is using accessory muscles to breathe, has an SpO2 of 88% on room air, and is audibly wheezing. His vital signs are HR 140/min, RR 36/min, BP 100/60. Which of the following is the next best step in managing this patient?
A. Administer intravenous epinephrine
B. Start continuous nebulized albuterol and administer intravenous methylprednisolone
C. Administer intravenous magnesium sulfate
D. Intubate the patient immediately
Start continuous nebulized albuterol and administer intravenous methylprednisolone
A 2-month-old infant is brought to the emergency department by ambulance after being found unresponsive in her crib. Upon arrival, the infant is pulseless and apneic, and CPR is in progress. Her initial rhythm on the monitor shows asystole. Which of the following is the most appropriate next step in the resuscitation of this patient?
A. Defibrillate at 2 J/kg
B. Administer 0.01 mg/kg of epinephrine intravenously
C. Intubate the patient immediately and administer 100% oxygen
D. Administer 0.1 mg/kg of atropine intravenously
Administer 0.01 mg/kg of epinephrine intravenously
A 4-year-old boy is brought in after being found with an open bottle of clonidine tablets at home. His parents are unsure of the exact number of tablets ingested. On arrival, the child is drowsy and has the following vital signs: HR 50/min, BP 85/45, RR 12/min, SpO2 95% on room air. Which of the following is the most appropriate initial treatment for this patient?
A. Administer intravenous naloxone
B. Begin an intravenous infusion of atropine
C. Start a continuous intravenous infusion of dopamine
D. Initiate activated charcoal administration via nasogastric tube
Administer intravenous naloxone
A 13-year-old boy is seen in the clinic for evaluation of hypertension. His blood pressure has consistently measured above the 95th percentile for age, gender, and height at multiple visits. He denies headaches, vision changes, chest pain, or palpitations. His family history is significant for early-onset hypertension in his father. Physical examination reveals a blood pressure of 145/92 mmHg in both arms and a systolic murmur best heard over the back. Which of the following is the most likely cause of this patient’s hypertension?
A. Primary (essential) hypertension
B. Coarctation of the aorta
C. Pheochromocytoma
D. Renal artery stenosis
Coarctation of the aorta
A 10 year old boy falls out of a tree from a height of 10 feet and lands on his abdomen. He is evaluated and reports abdominal pain, nausea, and feeling light-headed when standing. Vital signs: HR 150/min, RR 25/min, BP 80/40 mm Hg. Exam is notable for pallor and diffuse abdominal tenderness. Which of the following is the most immediate priority?
A. CT abdomen
B. IV access and fluid resuscitation
C. FAST exam
D. Surgical consultation
IV access and fluid resuscitation
A 2-year-old girl is brought in by her parents, who report a sudden onset of coughing and difficulty breathing while she was eating peanuts. Since then, she has had intermittent episodes of coughing and wheezing. On examination, she appears in mild respiratory distress with decreased breath sounds over the right lung and scattered wheezes. Her vital signs are HR 120/min, RR 30/min, SpO2 94% on RA. What is the most appropriate next step in the management of this patient?
A. Administer nebulized albuterol and observe for response
B. Order a chest X-ray with inspiratory and expiratory views
C. Arrange for rigid bronchoscopy under general anesthesia
D. Discharge home with supportive care and follow-up in 24 hours
Arrange for rigid bronchoscopy under general anesthesia
A 12-year-old girl with T1DM presents with abdominal pain, vomiting, and fatigue. She appears ill, with tachypnea and a fruity odor to her breath. Vital signs reveal HR 130/min, RR 32/min, BP 100/65 mmHg, and temp 37.0°C. Initial laboratory values are glucose 450 mg/dL, bicarb 10 mEq/L, K 5.8 mEq/L, pH 7.15. Which of the following is the next best step in managing this patient?
A. Administer a bolus of IV insulin
B. Start an IV insulin infusion at 0.1 units/kg/hr
C. Give an IV bolus of potassium chloride
D. Administer an isotonic saline bolus
Administer an isotonic saline bolus
2 year old girl brought in with decreased responsiveness. She has had URI symptoms for 2-3 days. She was with her grandma today, who takes several medications. Since the afternoon, she has been sleepier and difficult to arouse. On exam, temp 37.5C, HR 72/min, RR 16./min with a shallow effort, BP 84/42, and SpO2 95% on room air. She's lethargic with equal and constricted pupils. Glucose is 75. Which of the following is the next best step?
A. Administer D10 bolus
B. Administer IV Naloxone
C. Perform a LP
D. Perform a urine tox screen
Administer IV Naloxone
10 year old male presents with 2-3 days of increased WOB, mild abdominal pain, and nausea with emesis. He has recently been unable to exercise due to dyspnea and has developed mild, diffuse chest pain. 2 weeks ago, he had a cold. No exposures, fevers, or similar symptoms in family.
On exam, he is tired, vital signs are significant for HR 110/min, RR 20/min, and BP 100/60. Exam shows crackles at the lung bases, tachycardia with a soft systolic murmur, and liver palpable 3 cm below the costal margin. Cap refill is 3 seconds. Which is the most likely diagnosis
A. Acute PE
B. Atypical pneumonia
C. Infectious viral hepatitis
D. Myocarditis
Myocarditis
A 5-year-old boy is brought in after accidentally spilling a pot of boiling water on himself. He has partial-thickness burns covering approximately 15% of his total body surface area, primarily on his chest and left arm. On examination, he is alert and in moderate pain. Vital signs are HR 120/min, BP 100/60 mm Hg, RR 22/min, Temp 37 C. What is the most appropriate initial management step for this patient?
A. Apply silver sulfadiazine cream to the burns and discharge with outpatient follow-up
B. Initiate fluid resuscitation with lactated Ringer's solution
C. Administer intravenous antibiotics to prevent infection
D. Cover the burns with sterile dressings and apply cool compresses
Initiate fluid resuscitation with lactated Ringer's solution
Parkland formula:
Total fluid required in 24 hours= 4 x (BW in kg) x (%TBSA)
1/2 the volume in 1st 8 hours, rest over 16 hours
A 4-year-old girl with a history of asthma presents with severe respiratory distress. Her mother reports that she has been wheezing and coughing for the past 2 days, despite using her albuterol inhaler every 4 hours. On exam, she is visibly fatigued, with nasal flaring and intercostal retractions. Her vital signs are HR 140/min, RR 40/min, SpO2 88% on RA. On auscultation, there is diminished air movement with faint wheezing bilaterally. She appears drowsy and has difficulty speaking in full sentences. Which of the following is the most appropriate next step in managing this patient?
A. Administer a high-dose albuterol nebulizer and observe closely for improvement
B. Initiate noninvasive positive pressure ventilation with supplemental oxygen
C. Administer intravenous methylprednisolone and beta-agonists and prepare for possible intubation
D. Start a magnesium sulfate infusion and discharge home with close follow-up
Administer intravenous methylprednisolone and beta-agonists and prepare for possible intubation
A 6-year-old girl with a history of epilepsy is brought to the ED by EMS after experiencing a GTCS at home that has lasted over 15 minutes. EMS administered an initial dose of intramuscular midazolam en route, but the seizure continues upon arrival. Her vital signs are HR 145/min, BP 100/60 mm Hg, RR 24/min, SpO2 92% on supplemental O2. Which of the following is the next best step in the management of this patient?
A. Administer an additional dose of midazolam intravenously
B. Begin a continuous intravenous infusion of midazolam
C. Administer an intravenous bolus of lorazepam
D. Administer an intravenous bolus of fosphenytoin
Administer an intravenous bolus of lorazepam
14 year old female presents with agitation and bizarre behavior. She admits to taking pills in a suicide attempt but will not say what she took. She has large, slowly responsive pupils, dry mucus membranes, and dry, flushed skin. Temp is 38.8C, HR 130/min, and RR 16/min. Which of the following ingestions is most likely in this patient?
A. Clonidine
B. Diphenhydramine
C. Fentanyl
D. Lorazepam
Diphenhydramine
Anticholinergic overdose: blind as a bat, mad as a hatter, dry as a bone, red as a beet, and hot as a hare
A 2 month old with several days of irritability and slow feeding. Mom reports he looks pale today, but denies fever, cough, rhinorrhea, vomiting, diarrhea, or sick contacts. Temp 36.8C, HR 230/min and regular, RR 52/min. Exam shows a pale, quiet infant in no distress. Fontanelle is open and flat, clear lungs, liver palpable 2 cm below the RCM. Cap refill time is 3 seconds. Which of the following is the most appropriate step in the management?
A. CXR
B. Abdominal US
C. Perform vagal maneuvers
D. Refer to cardiology
Perform vagal maneuvers
A 10-year-old boy is brought in after being struck by a car while riding his bicycle. He was not wearing a helmet and has abrasions on his face, torso, and extremities. On initial examination, he is alert but in pain. His vital signs are HR 130/min, BP 80/50, RR 28/min, SpO2 94% in room air. FAST reveals free fluid in the abdomen. What is the next best step in managing this patient?
A. Perform an immediate CT scan of the abdomen and pelvis
B. Start an intravenous infusion of normal saline and observe closely
C. Perform immediate laparotomy
D. Administer intravenous pain medication and repeat the FAST examination in 30 minutes
Perform immediate laparotomy
A 10-year-old girl with a known peanut allergy is brought to the emergency department with sudden onset of difficulty breathing, swelling of her lips, and hives after accidentally ingesting peanut-containing food. Her parents report that she began to feel unwell within minutes of ingestion. On examination, she is anxious, with audible wheezing and stridor. Her vital signs are HR 140/min, BP 80/45, RR 30/min, and SpO2 89% on RA. What is the most appropriate first step in the management of this patient?
A. Administer an intravenous fluid bolus of 20 mL/kg normal saline
B. Give an intramuscular injection of epinephrine
C. Start an intravenous diphenhydramine infusion
D. Administer a nebulized albuterol treatment
Give an intramuscular injection of epinephrine
A 3-year-old boy is brought in with fever, lethargy, and decreased urine output over the past day. His parents report that he has been less responsive and hasn’t been eating well. On examination, he is pale, lethargic, and has cold extremities with a capillary refill time of 5 seconds. His vital signs are HR 160/min, BP 70/45, RR 35/min, SpO2 95% on RA. Which of the following is the most appropriate next step in the management of this patient?
A. Administer a 20 mL/kg bolus of normal saline
B. Start an epinephrine infusion
C. Begin broad-spectrum antibiotics immediately
D. Obtain blood and urine cultures and await results before starting treatment
Administer a 20 mL/kg bolus of normal saline
A 3-year-old boy is brought after ingesting an unknown quantity of his mother’s amitriptyline tablets approximately 1 hour ago. He is drowsy, and his initial assessment reveals the following vital signs: HR 160/min, BP 85/50 mmHg, RR 18/min, Temp 37.2C. Initial EKG shows a QRS interval of 130 msec. Which of the following is the most appropriate next step in managing this patient?
A. Administer intravenous sodium bicarbonate
B. Perform gastric lavage
C. Give intravenous calcium gluconate
D. Administer intravenous magnesium sulfate
Administer intravenous sodium bicarbonate
A 15-year-old boy with a history of chronic kidney disease presents to the emergency department with a severe headache, nausea, and blurred vision. His blood pressure is 210/130 mmHg. He denies any chest pain or shortness of breath. Physical examination reveals mild facial edema but is otherwise unremarkable. Laboratory tests show elevated serum creatinine and blood urea nitrogen. Which of the following is the most appropriate next step in managing this patient?
A. Administer oral amlodipine and recheck blood pressure in 2 hours
B. Begin an intravenous infusion of labetalol to gradually lower blood pressure
C. Administer an intravenous bolus of hydralazine to rapidly decrease blood pressure
D. Start oral hydrochlorothiazide and discharge with close outpatient follow-up
Begin an intravenous infusion of labetalol to gradually lower blood pressure
A 4-year-old boy is brought in after being found submerged in a pool for an unknown period. He was initially unresponsive but regained consciousness after CPR performed by bystanders. On arrival, he is lethargic but responsive to voice. His vital signs are HR 110/min, RR 28/min with mild intercostal retractions, SpO2 92% on room air, temp 35.5 C. Physical examination reveals crackles in both lung fields and mild cyanosis around his lips. Which of the following is the most appropriate next step in managing this patient?
A. Discharge home with close outpatient follow-up in 24 hours
B. Initiate supplemental oxygen and observe closely in the emergency department for 4–6 hours
C. Administer intravenous antibiotics to prevent aspiration pneumonia
D. Admit to the hospital for monitoring and supportive care
Admit to the hospital for monitoring and supportive care
A 7-month-old infant with a history of BPD (ex-26 weeker) presents with increased work of breathing, poor oral intake, and lethargy. His mother reports that he has been congested and coughing for the past three days. His home oxygen requirement is typically 0.5 L/min, but he now requires 1.5 L/min to maintain SpO2> 90%. His vital signs are HR 160/min, RR 60/min with intercostal retractions, temp 38.2C, SpO2 91% on 1.5 LPM O2. Which of the following is the most appropriate next step in managing this patient?
A. Obtain a chest X-ray to evaluate for pulmonary edema or infection
B. Administer an intravenous fluid bolus of 20 mL/kg normal saline
C. Start high-dose inhaled corticosteroids
D. Discharge home with instructions to increase oxygen flow as needed
Obtain a chest X-ray to evaluate for pulmonary edema or infection
A 16-year-old boy presents after a high-speed motor vehicle accident. He is alert but reports severe neck pain and an inability to move his legs. On examination, he has warm, flushed skin and is hypotensive with a HR of 60/min, BP 80/50 mmHg, RR 18/min, and SpO2 96% on RA. There is decreased sensation below the level of T4. Which of the following is the most appropriate next step in managing this patient?
A. Administer a 20 mL/kg bolus of normal saline
B. Start an intravenous infusion of norepinephrine
C. Place the patient in Trendelenburg position to increase blood pressure
D. Administer intravenous atropine to increase heart rate
Start an intravenous infusion of norepinephrine
Neurogenic shock is characterized by loss of sympathetic tone, leading to decreased vascular resistance and hypotension with bradycardia.