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Consent for Treating Minors
? Life / limb-threatening emergency
? State-protected right to treatment
?Child abuse
?Sexual y transmitted disease
?Substance abuse
?Outpatient mental health (some states)
? State-defined "emancipated minor" status
?Member of armed forces
?Self-supporting and living on own

Inconsolable Crying (1)
? Intestinal colic ? most common cause of excessive
crying ? 3 or more hours/day for 3 or more day/wk over
a three week period / self-limited / 13% of neonates
?Sudden onset of paroxysmal crying, flushed face,
circumoral palor, tense abdomen, drawing up of legs,
clenched fists
?Normal physical and lab (usual y not required) but colic is
a diagnosis of exclusion
?Colic is a risk factor for abuse / try to help arrange for
caretaker assistance
?Many remedies means we real y don't know what to do /
increase soothing, background noise, strol er or car rides,
assure burping, consider stopping cow's milk

Inconsolable Crying (2)
? Trauma
?Soft tissue or bony trauma (fal s or battered child)
?Strangulation of digit / penis (look under the diaper)
?Corneal abrasion
? Infections
?Meningitis, otitis, UTI, gastroenteritis, diaper dermatitis
(look under the diaper), cel ulitis, joint infections (move
them al ), pneumonia, stomatitis
? Surgical conditions
?Incarcerated hernia (look under the diaper)
?Testicular torsion (look under the diaper)
?Anal fissure (look under the diaper)
?Volvulus / Intussusception

Rapid Breathing in the Neonate
? Pneumonia, bronchiolitis, aspiration
? Dysfunction in other organs systems
?Septicemia, CNS infection, metabolic acidosis
? Congenital diseases
?Diaphragmatic hernia
?Tracheoesophageal fistula, stenosis, web
? Heart disease
?CHF (aortic stenosis, coarctation, PDA)
?Cyanotic heart disease (tetralogy of Fal ot)
? Neuromuscular disease

Vomiting in Infants
? Vomiting (forceful compared to regurgitation =
"spitting up")
?Increased ICP (shaken baby)
?Infections (UTIs, sepsis, gastroenteritis)
?Hepatobiliary disease (usual y have jaundice)
?Inborn metabolism errors (often have low glucose and
metabolic acidosis)
?Malrotation of the gut (bilious vomiting [yellow,
green] = surgical emergency = obstruction distal to
the ampul a of Vater) 1/500 births with half diagnosed in
the first month of life
?Pyloric stenosis (projectile vomiting at the end of
feeding) / most common surgical y correctable cause
of vomiting in newborns / classical y present at 2-6 mo
?Incarcerated hernia / intussusception ? age 2-12 mo

Diarrhea in Infants (1)
? Leading causes of blood in the stool in infants = cow's milk
intolerance / anal fissure / swal owed maternal blood (only
first several days) / swal owing of blood from nipple while
nursing is very far fetched / vaginal bleeding from estrogen
withdrawal / a single event can usual y just be observed /
most cases are idiopathic
? Necrotizing enterocolitis
? Usual y occurs on days 3-10 of life
? Ischemia / death of the intestinal lining with desquamation
? The most common GI emergency in neonates (2000-4000 cases/yr
in US ? mortality approaches 25%)
? Multifactorial causes -- incompletely understood
? Infection &/or hypoxia/ischemia play roles
? Feeding intolerance, abdominal distention, bloody stools, shock
? Usual y child is quite sick / prematurity is a risk
? Late x-ray finding = pneumatosis intestinalis, portal air, free air
? Consult surgeon / broad spectrum antibiotics

Necrotizing Enterocolitis
?Intramural air
?Double density
layering of the
abdominal wal
?Generalized bowel
?Loss of
?Gas lucencies over
the liver (intraportal
?Intramural bowel

Diarrhea in Infants (2)
? Infections
? Viruses = rotavirus (adenoviruses are 2nd most common) / 3-15
months / winter ? vaccines now prevent almost al severe rotavirus
episodes (85-98%) and 74%-87% of al episodes / 2 or 3 doses,
depending on the vaccine brand ? 2, 4 and 6 months of age
? Bacteria = most common summer cause / bloody diarrhea =
Salmonel a & Shigel a / Shigel a = high fevers, febrile seizures then
bloody diarrhea
? Overfeeding and food al ergy
? Anatomic abnormalities ? intussusception (bloody diarrhea
[current jel y stools] a late finding), partial obstruction
? Inflammatory disorders / malabsorption syndromes
? Immunodeficiencies / endocrinopathies
? Antibiotic-associated (particularly amoxicil in-clavulanate
? Secondary lactase deficiency (can result from
gastroenteritis injury to smal bowel) ? results in inability to
break down lactose which then is fermented in the colon
causing gas and an osmotic diarrhea

Neonatal Jaundice (1)
? Most common cause of readmission
? ED-presenting jaundice:
?Physiologic (>50% of cases)
? Due to hemolysis of fetal RBCs ? just too much for the liver
to handle
? Characterized by bilirubin rising at <5mg/dl per 24 hrs
? Peak of 5-6mg/dl during the 2nd to 4th days of life
? Decrease to <2mg/dl by 5-7 days
?Sepsis-related jaundice
? Higher levels and associated signs of sepsis are likely
?Breast feeding-related jaundice (5-10% of cases)
? Glucuronyl transferase inhibitors in breast milk
? Can reach a peak of 10-27mg/dl by days 10-21
? Cessation of breast feeding leads to a rapid decline over 2-3
days but is not general y advised / Is unlikely to cause
kernicterus (neurotoxicity)

Neonatal Jaundice (2)
?AAP advises light treatment in otherwise wel
infants if:
? 25-48 hrs old and at least 15mg/dl,
?49-72 hrs old and at least 18mg/dl,
?over 72 hrs and at least 20mg/dl
?Direct hyperbilirubinemia requires
admission (implies inability of bilirubin to
pass into the biliary tree or ducts draining
into the duodenum [e.g., biliary atresia])

?Other screening tests = CBC, Coombs test for
hemolytic antibodies

? Most common cause of bowel obstruction
between 3 mo ? 6 yr (2nd most common cause of
acute abdomen in children ? after appendicitis)
? Children ? usual y "idiopathic" (lymphoid
hyperplasia?) Predisposers = Meckel's / polyp /
? Ileocolic most common / US is the
diagnostic method of choice
? "Currant jel y" stools is a late finding and
only seen in 50% (but most have
guaiac-positive stools
? Sudden pain with sudden relief of pain
? Some become very stil , listless and pale between
episodes of pain
? Sausage shaped tumor mass in right abdomen or
epigastrium in 2/3rds

CT Scan -- Intussusception
Google "intussusception yamamoto" for an extraordinary x-ray tutorial

US Study -- Intussusception
Sensitivity for ileocolic intussusception = 98% / Specificity, 98%

Apparent Life-Threatening Event (1)
ALTE Characteristics
? An episode that frightens the observer
? Some combination of
?Apnea (central or obstructive)
?Color change (cyanotic, pale, occasional y plethoric)
?Marked change in muscle tone (usual y limp)
?Choking or gagging
? ALTE is not a diagnosis
? Usual y occurs at 1-3 months (average 2 months -
younger age than SIDS (average 4.5 months)
? Associated with increased risk of SIDS in more
severe episodes

Apparent Life-Threatening Event (2)
ALTE Causes
? CNS infections -- ? LP / septic eval
? Seizures -- ? Chemistries, glucose
? Gastroesophageal reflux (laryngeal stimulation)
? Intracranial hemorrhage, increased ICP -- ? CT
? Botulism -- ? Stool for clostridial cult. / botulinum
? Airway obstruction, pneumonia -- ? CXR
? Low glucose, low calcium -- ? test
? Dysrhythmia, cardiomyopathy, congenital heart
disease -- EKG
? Sepsis ? septic eval with pan cultures
? Non-accidental (battering, OD, Munchausen)
? Idiopathic (apnea of infancy)

Apparent Life-Threatening Event (3)
High Risk ALTE
? Greater than 10 seconds
? Occurs during sleep
? Associated with seizure activity
? Hypotonia ("looked dead")
? Associated with feeding (possible reflux)
? Trauma / abuse

SIDS (1)
? SIDS is the most common cause of death from 1
month to 1 year (most common between 2-4 mo.)
? Peaks in January / increased incidence in Native
and African Americans / mostly males
? Multiple causes suspected
? Risk is inversely related to maternal age
? Risk is directly related to parity
? Infant is at increased risk if sibling had SIDS
? ALTE is associated with an increased risk of SIDS
(some disagree)
? Prematurity has increased risk of SIDS
? Increased risk if mother is a substance abuser

SIDS (2)
? Sleeping Position
?Incidence of SIDS is lower in infants sleeping on back
(side sleeping is considered unstable and should be
?SIDS is associated with prone sleeping
?Face-down may lead to upper airway
?Rebreathing expired air results in
? Avoid having the child sleep with other children or
adults, avoid soft bedding, pacifiers reduce the
risk of SIDS, avoid exposure to smoke, never give
honey to a child less than one (infant botulism),
apnea monitors have no effect

Neonatal Pneumonia
? Lungs are the most common site of infection in
? Group B Strep is the most common cause
?Acquired in utero
?Rapid, fulminant il ness
? Other common causes: Strep. pneumoniae, H. flu,
Chlamydia (3 weeks)
? Symptoms: Decreased appetite, fever, rapid
breathing, nasal flaring, grunting, retractions,
? Chlamydia: Afebrile, tachypneic, staccato cough,
conjunctivitis, hyperinflation
? Viral: RSV, adenovirus, parainfluenza virus
? Pertussis: Paroxysms of cough and cyanosis, post-
tussive vomiting

? 50-70% caused by respiratory syncytial virus (RSV) /
large droplet transmission / al need isolation
? Mucous plugging from necrosis of respiratory
epithelium and submucosal edema = airway narrowing
= increased airway resistance and increased work of
? Wheezing, tachypnea, dyspnea, fever
? O2 sat less than 93-90% = admission
? Can be associated with apnea ? premature
infants ? not related to disease clinical severity
? Treatment = isolation / humidified oxygen (most
important) / rehydrate / antipyretics / nebulized epi
(albuterol & ipratropium don't work) / heliox / steroids
(?? efficacy) / ribavirin neb as inpt??
? Up to 4% may have a concomitant UTI (if febrile)

Pertussis (Whooping Cough)
? "URI" lasting two weeks (catarrhal phase) evolves to 2-4
weeks of paroxysmal coughing spasms / inspiratory
whoop (only in 1/3) / post-tussive vomiting fol owed by a
milder residual cough lasting up to months
? Adults = Primary reservoir / children at greatest risk (can
get pneumonia ? leading cause of death)
? Preventable with vaccine / DTaP (5 doses for children) /
Tdap ? single dose for ages 11-64 (can within 18 months
of prior Td)
? Complications: Mucus plugs (obstructed airway),
secondary bacterial infection, increased intrathoracic
pressure (leads to rectal prolapse, ruptured
diaphragm, hernias)
? Treatment goal ? largely to decrease infectivity and
carriage: Erythromycin (best), TMP-SMZ / isolation
? Chemoprophylaxis for household contact

Characteristics of Febrile Seizures
? Simple febrile seizures
?Fever (usual y over 39C)(rate of rise important)
?Age 6 months to 6 years
?Brief, generalized seizures
?Resolve without treatment
?Seizures occur in the first 24 hours of il ness
?Duration 5 minutes or less
?Minimal postictal phase
?Previously normal neurological y
?No other cause
?Tend to occur in families
? Complex febrile seizures
?Longer than 15 minutes, recurs within 24 hrs, focal,
age < 6mo or > 5yr without signs of serious infection
?Ful septic work-up advised

Causes of Seizures Amenable
to Specific Treatment
? Hypoglycemia: D10W (is not uncommon
with gastroenteritis ? check glucose in
these cases)

? Hyponatremia: 3% NaCl (water intoxication by
care giver)
? Hypocalcemia: calcium gluconate
? Hypomagnesemia: magnesium sulfate
? INH ingestion: pyridoxine (mg. for mg. dosing)
? Hypertension: hydralazine

Pediatric Hydrocephalus (1)
? Increased CSF volume, usual y associated
with increased CSF pressure
? Causes
?Congenital: intrauterine infection, congenital
?Acquired: meningitis, IC bleeds, tumors
? Non-communicating: blockage between
ventricles and subarachnoid space
? Communicating: impaired CSF absorption by
arachnoid granulations
? Arnold-Chiari malformation: cerebel ar
malformation with non-communicating

Arachnoid Granulations

Pediatric Hydrocephalus (2)
? Large head, large fontanel es, dilated scalp veins
? Findings of increased CSF pressure
?Headache, vomiting, lethargy, irritability
?Papil edema
?6th nerve weakness, strabismus
?Increased lower extremity tone, positive Babinski
?"Cracked pot" sound
on percussion
?Enlarged ventricles on CT

Pediatric Hydrocephalus (3)
? Shunting: ventricular catheter, pumping chamber,
one-way flow valve, distal tubing
(usual y ends in peritoneal cavity)
? Shunt-related emergencies
?Obstruction (signs of increased
?Resistance to compression of
pumping chamber
?Increased ICP (over 20 cm)
?Emergency tap of shunt if comatose, sudden
deterioration, arrest
?Infection: often within 6 months of insertion;
usual y skin flora
?Meningeal signs, fever, sepsis
?Vancomycin and ceftazidime

Idiopathic Intracranial Hypertension
? Former names are pseudotumor cerebri and "benign"
intracranial hypertension
? CSF pressure increased without increase in ventricle
? Most common in young, obese women / most diagnosed
between ages 20-40 / rare in thin males
? Headache (94%), transient blurred vision (68%), pulse
synchronous tinnitus (58%), pain behind the eye (44%),
double vision (38%), visual loss (30%), pain with eye
movement (22%)
? Papil edema (>90%), increased CSF pressure, CT WNL
? Periodic vision perimetry testing guides the progression
of therapy ? weight loss, symptomatic headache
treatment, acetazolamide or furosemide, steroids, nerve
sheath fenestration, lumbar shunt

Normal Optic Disk
for Comparison

Tetralogy of Fallot (1)
? Most common cause of congenital shunts
? X-ray: boot-shaped ("wooden shoe") heart, decreased
pulmonary vascular markings
? Major problems: RV outflow obstruction and VSD
? "Tet spel s": hypercyanosis, exertional dyspnea,
hemoptysis, seizures, syncope (precipitated by crying or
feeding) ? results in increased right to left shunting
? Emergency treatment
?Blow-by supplemental oxygen (is of limited value since
reduced pulmonary blood flow is a major part of the
?Permit the child to remain with the parents
?Do not provoke the infant by attempting to start an IV line
(especial y if not skil ed at pediatric IVs)
?Consider an intraosseous line as a life-saving tool

Tetralogy of Fallot (2)
? Emergency treatment (continued)
?Knee-chest position to reduce systemic venous return and
increase systemic vascular resistance
?Morphine (decreases ventilatory drive [goal, decrease
hyperpnea] but can decrease vascular resistance via
vasodilatation a negative effect]),
?Bicarbonate (decrease acidosis-induced respiratory drive),
?Phenylephrine (increases SVR),
?Propranolol (unclear how if works).
?Ketamine ?? ? sedates without causing vasodilation

Tetralogy of Fallot
Med-Chal enger ? EM

Boot Shaped Heart of TOF

Cyanosis and Clubbing
Hypoxia of shunts is not relieved
by supplemental oxygen
Med-Chal enger ? EM

HIV in Childhood
? 15-30% of children born to HIV-positive mothers are
? Growth retardation is very common
? Enlarged liver, spleen and nodes are the rule
? Strong association between STDs and HIV in
Febrile HIV-Positive Children
? Common bacterial pathogens are the major threat
? Pneumocystis carini infection is the most common
opportunistic infection
? In children with pneumonia, also treat for PCP
? PCP is characterized by disproportionate
hypoxemia compared to clinical findings

Cystic Fibrosis
? Most common lethal genetic disorder in whites
? Autosomal recessive
? Abnormalities of all exocrine glands
? Causes thick sticky mucous to build up in the
lungs and digestive tract
? Recurrent respiratory infections, pancreatic
exocrine deficiency, high sweat chloride
? Most present by age 1: neonatal SBO
(meconium ileus), failure to thrive, diarrhea,
recurrent respiratory infections, prolonged
neonatal jaundice, dehydration with
hypochloremic alkalosis, diabetes, rectal


Cystic Fibrosis Emergencies
? Respiratory
?Cor pulmonale
?Respiratory failure
? Gastrointestinal
?Obstruction (meconium or otherwise)
? Other
?Electrolyte depletion (Na+, Cl-, K+ )
?Associated with heavy sweating, GI losses 39

Henoch-Sch?nlein Purpura
? Abdominal pain, GI bleeding, hematuria,
palpable purpura (= vasculitis), arthritis
? Immunological y-mediated vasculitis
? Ages 2-11, whites, winter, males
? Skin lesions are pathognomonic: round,
palpable, symmetrical, on dependent areas of
legs and buttocks
? Can get colicky pain, bloody diarrhea and
? Migratory, large-joint arthritis
? Renal involvement: hematuria, proteinuria
? 4-6 week il ness. Give steroids if symptomatic
? Normal platelets, PT, aPTT

Henoch-Schonlein Purpura
"Palpable purpura" classical y reflects a vasculitis-
caused reason for bleeding into the skin

Hemolytic Uremic Syndrome
? Acute renal failure associated with microangiopathic
hemolytic anemia and thrombocytopenia
? E. coli 0157:H7, other bacteria and viruses
? Acute diarrheal il ness with bloody stools
? Schistocytes (helmet cel s) on blood smear suggest the
? Normal PT, aPTT, fibrinogen (unlike DIC)
? Uremia is almost universal
? UA: hematuria, proteinuria
? Similar to TTP, but kidney involvement is main feature
(vs. CNS involvement in TTP)
? Antibiotics not advised ? unclear risk of increasing HUS

Hemolytic Uremic Syndrome
Schistocytes / helmet cel s and
decrease platelets
E. coli 0157:H7

Meningitis in Children
? Age under two months
?E. coli, group B Strep, Listeria (by far, least
?Ampicillin (for Listeria) plus cefotaxime or
? Age over two months
?Strep. pneumoniae / Neisseria meningitidis
?H. influenzae (rare)
?Highest mortality: Strep. pneumoniae
?Ceftriaxone (contraindicated in neonates receiving
calcium-containing IV fluids ? can cause a precipitant in
the lungs and kidneys / also increase bilirubin) ?
cefotaxime is an alternative
?Steroids prior to antibiotics (somewhat controversial)
(especial y for H. influenzae)
?Chemoprophylaxis for contacts of N. meningitidis

Cloudy CSF
Med-Chal enger ? EM

Hip Disease in Children
Best Film
5-9x more
common in
with leg flexed,
never in
dislocate by
10x more
adduction, click
common if
on relocation
with abduction
Heavy or
necrosis in
more often
Younger in
most often
girls (8-15)
Frog lateral-
usual y neg
Bilateral in
females is
prognosis under
femoral head
Synovitis may
be 1st sign

Pediatric Fluids
? Use totality of clinical findings to estimate degree of
? Mild dehydration: 3-5% body weight = 50 mL/kg fluid deficit
? Moderate dehydration: 6-9% body weight = 100 mL/kg
? Severe dehydration: over 9% body weight = 150 mL/kg
? AAP and WHO advises oral rehydration for mild to moderate
dehydration (not IV)
? Severe dehydration ? repeated IV fluid boluses of 20 mL/kg
over 20 min -- NS (al are calorie depleted ? give D5NS?)
Give until signs of rehydration noted ? more alert, improved
perfusion, normalized vital signs
? Up to 9% of children with gastroenteritis are hypoglycemic ?
always check a glucose in these cases
? Ful age appropriate diet after rapid rehydration (4-6 hours) 47

IV Fluid Calculations
in Pediatric Dehydration
? Maintenance fluids for 24 hours
?100 mL/kg for each of the first 10 kg of weight
?50 mL/kg for each of the second 10 kg of weight
?20 mL/kg for each remaining kg of weight
? Fluid deficit for 24 hours
?10 mL/kg for each % of dehydration
? Ongoing losses in 24 hrs not replaced by oral fluids
?10 mL/kg for persistent fever
?10 mL/kg for each loose stool
? General y avoid the use of sedating antiemetics
(promethazine, prochlorperazine) ? may be associated
with respiratory depression and extrapyramidal effects
? General y avoid antidiarrheal medications ? safety and
efficacy issues

Pediatric ACLS (1)
? Defibril ation = 2 J/kg (double dose if
? Cardioversion = 0.5 J/kg
? ET intubation: Cuffed or uncuffed acceptable
? ET size: (16 + age)/4 = diameter of 5th finger
? Air leaks are normal with an uncuffed tube at
peak inspiratory pressures
? Surgical cricothyrotomy is not recommended
for children younger than 10 yrs
? Narrowest part of airway: cricoid cartilage
? Fluid resuscitation: 20 mL/kg NS boluses

Pediatric ACLS (2)
? Asystole is the most common arrest rhythm
? Epinephrine is the drug of choice in asystole
? Epinephrine is the inotrope of choice in
? Bradycardia is 2nd most common arrest rhythm
? Always intubate, ventilate and oxygenate
before giving drugs ("A-B-C" in children)
? Correctable causes of EMD: hypovolemia,
tension pneumothorax, tamponade
? Vfib and Vtach are rare; think hyperkalemia,
tricyclics, hypothermia

Acid-Base Blood Gas Diagram
Med-Chal enger ? EM

Apgar Score
Score of
Component of
Score of 1
Score of 2
blue at
blue all
Skin color
body pink
Heart rate
sneeze/cough/pul s
feeble cry
to stimuli
when stimulated
Muscle tone
some flexion
active movement
weak or
Additional Mnemonic: How Ready Is The Child?
H = heart rate, R = resp. effort, I = irritability, T = tone, C = color

Neonatal Resuscitation Priorities
? Dry, warm, positioning, suction, tactile
? Oxygen
? Bag-valve-mask ventilation
? Chest compression
? Intubation
? Drugs: epi, fluids, bicarb, naloxone, dopamine

Pediatric Pearls (1)
? Neonates increase respiratory volume almost exclusively by increasing
their respiratory rate vs. increasing depth of ventilation (and are obligate
nose breathers)
? Newborn infants, especial y premature ones, can have periods of apnea.
Spel s lasting more than 20 second with bradycardia, cyanosis or a
change in muscle tone warrant investigation
? Bradycardia in neonates is almost always due to hypoxia
? A respiratory rate over 60 or grunting should always be considered an
? Fever of 39C (102.2) in the presence of a UTI = pyelonephritis (only
5-10% wil have bacteremia)
? The incidence of bacteremia/sepsis in febrile children three months of age
or less is about 2-3% (il appearance or significantly abnormal labs [CBC]
can have higher rates)
? Immunized children 3-36 months of age who are wel appearing but febrile
have bacteremia rates of 0.5-0.7%
? The incidence of meningitis in febrile infants less than three months of
age is about 1%

Pediatric Pearls (2)
? The safest approach to febrile children less than 30 days of age is sepsis
testing, admission and empiric antibiotics
? The AAP advises testing for a UTI in al febrile girls and in uncircumcised
boys less than 2 years of age if there is no apparent focus of infection
(one year in circumcised boys)
? Analgesics (oral or topical if no TM perf) is an important aspect of treating
otitis media
? According to AAP guidelines, high-dose amoxicil in (80-90mg/kg/day) is
the first line drug of choice for OM
? Variation in the pattern of stridor suggests a foreign body (are most
common 1-3 yo) / Sudden onset is most reliable finding
? X-rays can confirm a FB but not exclude one / >75% are radiolucent
? Look for hemangiomas on the skin in a child with stridor as there may be
a hemangioma in the airway causing it
? In a constipated child a rectal exam that reveals tonic constriction of the
anus with an empty rectum suggests Hirschsprung disease
? Strep throat can cause abdominal pain in kids over 3 ? check the throat

Pediatric Pearls (3)
? Although uncommon, a UTI can co-exist with a viral infection
? Nitrite testing has less sensitivity for a UTI when caused by Gram +
? In seizures lasting over 5 minutes unresponsive to benzos, the drugs of
choice are fosphenytoin or phenobarbital / vaproic acid has rarely caused
liver failure
? Migraine headaches in children ? rather sudden onset, intensify over 10
minutes, maximum at 1 hour
? About a third of migraines in children are unilateral
? Ergotamines should not be used in basilar or hemiplegic migraine (may
decrease cerebral perfusion)
? Most serious causes of headaches wil have concomitant neurologic
? In adolescents with altered mental status due to alcohol, concomitant
hypoglycemia may also be present ? look for it
? Blunt head trauma in children can be accompanied by diffuse cerebral
swel ing causing increase CSF pressure and altered mental status
? Children having concussions should not be al owed to participate in
contact sports until cleared by another physician in fol ow-up

Pediatric Pearls (3)
? Although uncommon, a UTI can co-exist with a viral infection
? Nitrite testing has less sensitivity for a UTI when caused by Gram +
? In seizures lasting over 5 minutes unresponsive to benzos, the drugs of
choice are fosphenytoin or phenobarbital / vaproic acid has rarely cause
liver failure
? Migraine headaches in children ? rather sudden onset, intensify over 10
minutes, maximum at 1 hour
? About a third of migraines in children are unilateral
? Ergotamines should not be used in basilar or hemiplegic migraine (may
decrease cerebral perfusion)
? Most serious causes of headaches wil have concomitant neurologic
? In adolescents with altered mental status due to alcohol, concomitant
hypoglycemia may also be present ? look for it
? Blunt head trauma in children can be accompanied by diffuse cerebral
swel ing causing increase CSF pressure and altered mental status
? Children having concussions should not be al owed to participate in
contact sports until cleared by another physician in fol ow-up

Pediatric Pearls (4)
? Children presenting in metabolic crisis, regardless of cause, wil have
some combination of dehydration, metabolic acidosis and encephalopathy
? Don't give insulin and glucose to treat hyperkalemia in children ? may
result in severe hypoglycemia
? Unless clearly vasovagal, al children with syncope should have an EKG
? Syncope associated with exertion suggests a structural problem of the
heart (aortic stenosis, coarctation of the aorta, hypertrophic
? Other risk factors for serious causes of syncope ? family history of sudden
death, recurrent episodes (suggests arrhythmia), recumbent episodes
(suggests arrhythmia), prolonged spel s (hypotension with hypoperfusion
of the brain), chest pain, palpitations, medications that alter conduction
? Loss of consciousness occurs simultaneously with shaking movements
with seizures but after loss of consciousness with syncope
? Benzos should be considered second line drugs in the treatment of
psychiatric disorders in children due to the potential to cause disinhibition


All but one of the following is classically
associated with a mechanical cause for
vomiting in an infant?

A.Bilious vomiting
B.Projectile vomiting
C.A tender, tense mass under the diaper
D.A low glucose and metabolic acidosis
E.Current jel y stools
Peds 1

Which of the following is consistent with a
high-risk ALTE?

A.Occurred while the infant was awake
B.Child became hypertonic and rigid
C.No associated seizure activity
D.Associated with feeding
Peds 2

A 2-year-old child presents with lethargy, high
fever and a seizure. You position the child for a
lumbar puncture and, in the process, notice a
first episode of diarrhea with some blood in it.
What is the most likely diagnosis?

B.Salmonel a
C.Shigel a
D.E. coli
Peds 3

A neonate presents to the ED with jaundice.
Which of the following considerations is the
most important in determining the need for

A.The presence of greater elevations of direct
reacting bilirubin in comparison to indirect
reacting bilirubin
B.A history of breast feeding
C.A negative Coombs test
D.Lack of evidence of hemolytic antibodies
E.All of the above are similarly important
Peds 4

A 6-month-old child presents with low-grade fever,
cough, wheezing and low-grade intercostal retractions.
There is no family history of asthma nor any history
consistent with foreign body aspiration. Which of the
following is true of this disorder

A.Albuterol aerosols are highly effective in most of these
B.The addition of ipratropium to nebulization therapy
produces substantial additional benefit
C.The risk of apnea is directly related to the severity of
D.Heliox is contraindicated in these patients
E.All admitted cases require isolation
Peds 5

An 15-year-old with cystic fibrosis comes to your
ED with what appears to be a severe chest
infection. Which of the following is most typical
of these patients

A.They typical y have the "pink puffer" pathophysiology in
distinction to the "blue bloater"
B.Bronchospasm is a primary pathology in these patients
C.Respiratory failure is common in terminal patients
D.Dehydration with concomitant hyperchloremic acidosis often
accompanies other pathology in these patients
E.Dysfunction of exocrine glands is the core pathology in this
sex-linked genetic disorder
Peds 6

Regarding pertussis, which of the following
statement is most correct?

A.Vomiting frequently precedes coughing paroxysms
B.Rarely lasts more than two weeks
C.Most patients develop an inspiratory "whoop" with
D.Complications of increased intrathoracic pressure
include rectal prolapse
E.Children are the primary reservoir
Peds 7

Concerning pediatric meningitis, which of
the following is a true statement?

A.Listeria is most common after two months of age
B.Steroids are unequivocal y beneficial, particularly
for decreasing mortality from S. pneumoniae
C.N. meningitidis is associated with the highest
D.Chemoprophylaxis is appropriate for contacts of
patients with most forms of meningitis
E.Group B strep is acquired from the mother
Peds 8

A patient with a ventriculoperitoneal shunt
presents to your ED. Things to remember about
these patients include:

A.Headaches may represent shunt dysfunction with
decreased intracranial pressure
B.Fevers in patients with shunts should cause one to consider
meningitis which is general y caused by enteric pathogens
from the gut.
C.Resistance to compression of a pumping chamber is
consistent with shunt obstruction
D.As with benign intracranial hypertension, ventricle size is
usual y normal
E.Most fevers associated with shunts occur more than six
months after their insertion
Peds 9

A 15-year-old presents with recurring headaches
over a six-month period. The CT scan and the
CSF are normal except the pressure is
significantly elevated. What would you expect to
be additional considerations in this case?

A.The patient can be expected to be a thin male
B.Papil edema may be present on the eye exam
C.Acetazolamide, furosemide or steroids are
D.Is rarely associated with tinnitus
E.Visual acuity is a more sensitive measure of the
progression of this condition than is visual field testing
Peds 10

Which of the following can be clues to the
diagnosis of recurrent generalized seizures in a
previously well, afebrile child?

A.A newly positive PPD skin test in another family
member who resides with the child
B.A belief that forcing plenty of water wil abort or treat
childhood il nesses
C.A 60-year old uncle who lives with the family who
has had an amputation of the right foot
D.A rhythm strip that shows a markedly prolonged QT
E.All of the above
Peds 11

A 4-year-old child with episodic severe
abdominal pain for the last three hours has the
ultrasound study noted. What is a frequent
associated finding with this disorder?

A.A protruding mass into the
bowel lumen
B.A palpable mass in the left
lower quadrant
C.Bloody very soft stools is an
early finding in this disorder
D.Is a rare cause of bowel
obstruction in a young child
E.Is associated with projectile
Peds 12

Which of the following is appropriate
therapy for
"tet" spells in the setting of
tetralogy of Fallot?

A.Increase peripheral resistance
B.Increase venous return
C.Increase ventilatory efforts
D.Avoidance of bicarbonate therapy
E.Avoidance of sedation
Peds 13

Henoch-Schonlein purpura and hemolytic
uremic syndrome have which of the
following characteristics in common?

A.Both are associated with low platelets
B.Both are associated with characteristic skin lesions
C.Both involve kidney dysfunction
D.Both are cause by bacterial infections
E.Both have abnormal aPPTs
Peds 14

A four-month old child presents with
inconsolable crying. Which statement is most
true related to this condition?

A. Taking the diaper off may reveal multiple causes of
inconsolable crying
B. Colic is caused by feeding-related problems
C. Assessing an infant for the presence of a corneal
abrasion is routinely easily accomplished by a single
D. Pain caused by a volvulus is associated with bilious
E. Pain associated with an intussusception is
characterized by constant, unrelenting crying
Peds 15

Which of the following is a true statement
concerning pediatric gastroenteritis?

A.A check for hypoglycemia should be routine in patients
with gastroenteritis
B. Moderate dehydration should routinely be treated with
IV fluids
C. Because viral enteritis is caused by viruses invading
GI cel s, occult blood is routinely found in these cases
D. Age-appropriate diet should not be instituted until it is
clear the child can tolerate the BRAT diet (bananas,
rice, apples, toast)
E. Dehydration should be treated conservatively (half of
deficit over 8 hours, the remainder over 16 hours) Peds 16

A 20kg child presents with dehydration.
What is the approximate maintenance fluid
that is required over a 24 hour period?

Peds 17

A child is clinically dehydrated. Which of
the approximate fluid deficits are correct.

A.Mild dehydration represents a loss of 3-5% of body weight
and a fluid deficit of approximately 50ml/kg
B.Moderate dehydration represents a loss of 6-9% of body
weight and a fluid deficit of approximately 100ml/kg
C.Severe dehydration represents a loss of greater than 9% of
body weight and a fluid deficit of approximately 150ml/kg
D.All of the above statements are correct
E.At least one of the above statements is incorrect
Peds 18

Which of the following is a true statement
regarding pediatric cardiac arrests?
A.Most are cause by ventricular tachycardia or fibril ation
B.Dopamine is the inotrope of choice
C.Early use of drug therapy has been determined to be an
essential part of successful resuscitation of pediatric arrests
D.Contrary to adult CPR, bicarbonate therapy is associated
with improved outcomes
E.Electromechanical dissociation may be associated with
decreased breath sounds on one side of the chest and
tracheal deviation to the opposite side
Peds 19

What is the APGAR score of a neonate with the
following characteristics ? heart rate 90, strong
respiratory efforts, decreased muscle tone,
bluish extremities, feeble cry on intranasal
catheter stimulation?

Peds 20

Pediatrics Answer Key
1. D
2. D
3. C
4. A
5. E
6. C
7. D
8. E
9. C

Question 20 ? Answer Explanation

This post was last modified on 24 July 2021