? Life / limb-threatening emergency
? State-protected right to treatment
?Child abuse
?Pregnancy
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?Sexual y transmitted disease?Substance abuse
?Outpatient mental health (some states)
? State-defined "emancipated minor" status
?Married
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?Member of armed forces?Self-supporting and living on own
2
Inconsolable Crying (1)
? Intestinal colic ? most common cause of excessive
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crying ? 3 or more hours/day for 3 or more day/wk overa 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
--- Content provided by FirstRanker.com ---
?Normal physical and lab (usual y not required) but colic isa 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 /
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increase soothing, background noise, strol er or car rides,assure burping, consider stopping cow's milk
3
Inconsolable Crying (2)
? Trauma
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?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
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(look under the diaper), cel ulitis, joint infections (movethem al ), pneumonia, stomatitis
? Surgical conditions
?Incarcerated hernia (look under the diaper)
?Testicular torsion (look under the diaper)
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?Anal fissure (look under the diaper)?Volvulus / Intussusception
4
Rapid Breathing in the Neonate
? Pneumonia, bronchiolitis, aspiration
--- Content provided by FirstRanker.com ---
? Dysfunction in other organs systems?Septicemia, CNS infection, metabolic acidosis
? Congenital diseases
?Diaphragmatic hernia
?Tracheoesophageal fistula, stenosis, web
--- Content provided by FirstRanker.com ---
? Heart disease?CHF (aortic stenosis, coarctation, PDA)
?Cyanotic heart disease (tetralogy of Fal ot)
? Neuromuscular disease
?Botulism
--- Content provided by FirstRanker.com ---
5Vomiting in Infants
? Vomiting (forceful compared to regurgitation =
"spitting up")
?Increased ICP (shaken baby)
--- Content provided by FirstRanker.com ---
?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,
--- Content provided by FirstRanker.com ---
green] = surgical emergency = obstruction distal tothe 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
--- Content provided by FirstRanker.com ---
of vomiting in newborns / classical y present at 2-6 mo?Incarcerated hernia / intussusception ? age 2-12 mo
6
Diarrhea in Infants (1)
? Leading causes of blood in the stool in infants = cow's milk
--- Content provided by FirstRanker.com ---
intolerance / anal fissure / swal owed maternal blood (onlyfirst 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
--- Content provided by FirstRanker.com ---
? 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%)
--- Content provided by FirstRanker.com ---
? 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
--- Content provided by FirstRanker.com ---
? Consult surgeon / broad spectrum antibiotics7
Necrotizing Enterocolitis
Findings:
?Intramural air
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?Double densitylayering of the
abdominal wal
?Generalized bowel
dilation
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?Loss ofhaustrations
?Gas lucencies over
the liver (intraportal
gas)
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?Intramural bowelgas
8
Diarrhea in Infants (2)
? Infections
--- Content provided by FirstRanker.com ---
? Viruses = rotavirus (adenoviruses are 2nd most common) / 3-15months / 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 =
--- Content provided by FirstRanker.com ---
Salmonel a & Shigel a / Shigel a = high fevers, febrile seizures thenbloody diarrhea
? Overfeeding and food al ergy
? Anatomic abnormalities ? intussusception (bloody diarrhea
[current jel y stools] a late finding), partial obstruction
--- Content provided by FirstRanker.com ---
? Inflammatory disorders / malabsorption syndromes? Immunodeficiencies / endocrinopathies
? Antibiotic-associated (particularly amoxicil in-clavulanate
[Augmentin])
? Secondary lactase deficiency (can result from
--- Content provided by FirstRanker.com ---
gastroenteritis injury to smal bowel) ? results in inability tobreak down lactose which then is fermented in the colon
causing gas and an osmotic diarrhea
9
Neonatal Jaundice (1)
--- Content provided by FirstRanker.com ---
? 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
--- Content provided by FirstRanker.com ---
? 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
--- Content provided by FirstRanker.com ---
?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
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kernicterus (neurotoxicity)10
Neonatal Jaundice (2)
?AAP advises light treatment in otherwise wel
infants if:
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? 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
--- Content provided by FirstRanker.com ---
pass into the biliary tree or ducts draininginto the duodenum [e.g., biliary atresia])
?Other screening tests = CBC, Coombs test for
hemolytic antibodies
11
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Intussusception
? Most common cause of bowel obstruction
between 3 mo ? 6 yr (2nd most common cause of
an
acute abdomen in children ? after appendicitis)
--- Content provided by FirstRanker.com ---
? Children ? usual y "idiopathic" (lymphoidhyperplasia?) Predisposers = Meckel's / polyp /
HSP
? Ileocolic most common / US is the
diagnostic method of choice
--- Content provided by FirstRanker.com ---
? "Currant jel y" stools is a late finding andonly seen in 50% (but most have
guaiac-positive stools
? Sudden pain with sudden relief of pain
? Some become very stil , listless and pale between
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episodes of pain? Sausage shaped tumor mass in right abdomen or
epigastrium in 2/3rds
12
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CT Scan -- IntussusceptionGoogle "intussusception yamamoto" for an extraordinary x-ray tutorial
13
US Study -- Intussusception
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Sensitivity for ileocolic intussusception = 98% / Specificity, 98%14
Apparent Life-Threatening Event (1)
ALTE Characteristics
? An episode that frightens the observer
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? 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
--- Content provided by FirstRanker.com ---
? 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
--- Content provided by FirstRanker.com ---
15Apparent Life-Threatening Event (2)
ALTE Causes
? CNS infections -- ? LP / septic eval
? Seizures -- ? Chemistries, glucose
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? Gastroesophageal reflux (laryngeal stimulation)? Intracranial hemorrhage, increased ICP -- ? CT
? Botulism -- ? Stool for clostridial cult. / botulinum
? Airway obstruction, pneumonia -- ? CXR
? Low glucose, low calcium -- ? test
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? Dysrhythmia, cardiomyopathy, congenital heartdisease -- EKG
? Sepsis ? septic eval with pan cultures
? Non-accidental (battering, OD, Munchausen)
? Idiopathic (apnea of infancy)
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16Apparent Life-Threatening Event (3)
High Risk ALTE
? Greater than 10 seconds
? Occurs during sleep
--- Content provided by FirstRanker.com ---
? Associated with seizure activity? Hypotonia ("looked dead")
? Associated with feeding (possible reflux)
? Trauma / abuse
17
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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
--- Content provided by FirstRanker.com ---
? 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
--- Content provided by FirstRanker.com ---
(some disagree)? Prematurity has increased risk of SIDS
? Increased risk if mother is a substance abuser
18
SIDS (2)
--- Content provided by FirstRanker.com ---
? Sleeping Position?Incidence of SIDS is lower in infants sleeping on back
(side sleeping is considered unstable and should be
avoided)
?SIDS is associated with prone sleeping
--- Content provided by FirstRanker.com ---
?Face-down may lead to upper airwayobstruction
?Rebreathing expired air results in
hypercarbia
? Avoid having the child sleep with other children or
--- Content provided by FirstRanker.com ---
adults, avoid soft bedding, pacifiers reduce therisk of SIDS, avoid exposure to smoke, never give
honey to a child less than one (infant botulism),
apnea monitors have no effect
19
--- Content provided by FirstRanker.com ---
Neonatal Pneumonia
? Lungs are the most common site of infection in
neonates
? Group B Strep is the most common cause
?Acquired in utero
--- Content provided by FirstRanker.com ---
?Rapid, fulminant il ness? Other common causes: Strep. pneumoniae, H. flu,
Chlamydia (3 weeks)
? Symptoms: Decreased appetite, fever, rapid
breathing, nasal flaring, grunting, retractions,
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irritability? Chlamydia: Afebrile, tachypneic, staccato cough,
conjunctivitis, hyperinflation
? Viral: RSV, adenovirus, parainfluenza virus
? Pertussis: Paroxysms of cough and cyanosis, post-
--- Content provided by FirstRanker.com ---
tussive vomiting20
Bronchiolitis
? 50-70% caused by respiratory syncytial virus (RSV) /
large droplet transmission / al need isolation
--- Content provided by FirstRanker.com ---
? Mucous plugging from necrosis of respiratoryepithelium and submucosal edema = airway narrowing
= increased airway resistance and increased work of
breathing
? Wheezing, tachypnea, dyspnea, fever
--- Content provided by FirstRanker.com ---
? O2 sat less than 93-90% = admission? Can be associated with apnea ? esp.in premature
infants ? not related to disease clinical severity
? Treatment = isolation / humidified oxygen (most
important) / rehydrate / antipyretics / nebulized epi
--- Content provided by FirstRanker.com ---
(albuterol & ipratropium don't work) / heliox / steroids(? efficacy) / ribavirin neb as inpt?
? Up to 4% may have a concomitant UTI (if febrile)
21
Pertussis (Whooping Cough)
--- Content provided by FirstRanker.com ---
? "URI" lasting two weeks (catarrhal phase) evolves to 2-4weeks 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
--- Content provided by FirstRanker.com ---
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),
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secondary bacterial infection, increased intrathoracicpressure (leads to rectal prolapse, ruptured
diaphragm, hernias)
? Treatment goal ? largely to decrease infectivity and
carriage: Erythromycin (best), TMP-SMZ / isolation
--- Content provided by FirstRanker.com ---
? Chemoprophylaxis for household contact22
Characteristics of Febrile Seizures
? Simple febrile seizures
?Fever (usual y over 39C)(rate of rise important)
--- Content provided by FirstRanker.com ---
?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
--- Content provided by FirstRanker.com ---
?Minimal postictal phase?Previously normal neurological y
?No other cause
?Tend to occur in families
? Complex febrile seizures
--- Content provided by FirstRanker.com ---
?Longer than 15 minutes, recurs within 24 hrs, focal,age < 6mo or > 5yr without signs of serious infection
?Ful septic work-up advised
23
Causes of Seizures Amenable
--- Content provided by FirstRanker.com ---
to Specific Treatment? Hypoglycemia: D10W (is not uncommon
with gastroenteritis ? check glucose in
these cases)
? Hyponatremia: 3% NaCl (water intoxication by
--- Content provided by FirstRanker.com ---
care giver)? Hypocalcemia: calcium gluconate
? Hypomagnesemia: magnesium sulfate
? INH ingestion: pyridoxine (mg. for mg. dosing)
? Hypertension: hydralazine
--- Content provided by FirstRanker.com ---
24Pediatric Hydrocephalus (1)
? Increased CSF volume, usual y associated
with increased CSF pressure
? Causes
--- Content provided by FirstRanker.com ---
?Congenital: intrauterine infection, congenitalabnormalities
?Acquired: meningitis, IC bleeds, tumors
? Non-communicating: blockage between
ventricles and subarachnoid space
--- Content provided by FirstRanker.com ---
? Communicating: impaired CSF absorption byarachnoid granulations
? Arnold-Chiari malformation: cerebel ar
malformation with non-communicating
hydrocephalus
--- Content provided by FirstRanker.com ---
25Arachnoid Granulations
26
Pediatric Hydrocephalus (2)
--- Content provided by FirstRanker.com ---
? Large head, large fontanel es, dilated scalp veins? Findings of increased CSF pressure
?Headache, vomiting, lethargy, irritability
?Papil edema
?6th nerve weakness, strabismus
--- Content provided by FirstRanker.com ---
?Increased lower extremity tone, positive Babinskisign
?"Cracked pot" sound
on percussion
?Enlarged ventricles on CT
--- Content provided by FirstRanker.com ---
27Pediatric Hydrocephalus (3)
? Shunting: ventricular catheter, pumping chamber,
one-way flow valve, distal tubing
--- Content provided by FirstRanker.com ---
(usual y ends in peritoneal cavity)? Shunt-related emergencies
?Obstruction (signs of increased
ICP)
?Resistance to compression of
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pumping chamber?Increased ICP (over 20 cm)
?Emergency tap of shunt if comatose, sudden
deterioration, arrest
?Infection: often within 6 months of insertion;
--- Content provided by FirstRanker.com ---
usual y skin flora?Meningeal signs, fever, sepsis
?Vancomycin and ceftazidime
28
Idiopathic Intracranial Hypertension
--- Content provided by FirstRanker.com ---
? Former names are pseudotumor cerebri and "benign"intracranial hypertension
? CSF pressure increased without increase in ventricle
size
? Most common in young, obese women / most diagnosed
--- Content provided by FirstRanker.com ---
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%)
--- Content provided by FirstRanker.com ---
? 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
--- Content provided by FirstRanker.com ---
29Papilledema
Normal Optic Disk
30
for Comparison
--- Content provided by FirstRanker.com ---
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
--- Content provided by FirstRanker.com ---
? "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
--- Content provided by FirstRanker.com ---
reduced pulmonary blood flow is a major part of thepathophysiology)
?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)
--- Content provided by FirstRanker.com ---
?Consider an intraosseous line as a life-saving tool31
Tetralogy of Fallot (2)
? Emergency treatment (continued)
?Knee-chest position to reduce systemic venous return and
--- Content provided by FirstRanker.com ---
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),
--- Content provided by FirstRanker.com ---
?Phenylephrine (increases SVR),?Propranolol (unclear how if works).
?Ketamine ? ? sedates without causing vasodilation
32
Tetralogy of Fallot
--- Content provided by FirstRanker.com ---
Med-Chal enger ? EM33
Boot Shaped Heart of TOF
34
Cyanosis and Clubbing
--- Content provided by FirstRanker.com ---
Hypoxia of shunts is not relievedby supplemental oxygen
35
Med-Chal enger ? EM
HIV in Childhood
--- Content provided by FirstRanker.com ---
? 15-30% of children born to HIV-positive mothers areinfected
? Growth retardation is very common
? Enlarged liver, spleen and nodes are the rule
? Strong association between STDs and HIV in
--- Content provided by FirstRanker.com ---
adolescentsFebrile HIV-Positive Children
? Common bacterial pathogens are the major threat
? Pneumocystis carini infection is the most common
opportunistic infection
--- Content provided by FirstRanker.com ---
? In children with pneumonia, also treat for PCP(TMP/SMX)
? PCP is characterized by disproportionate
hypoxemia compared to clinical findings
36
--- Content provided by FirstRanker.com ---
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
--- Content provided by FirstRanker.com ---
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,
--- Content provided by FirstRanker.com ---
recurrent respiratory infections, prolongedneonatal jaundice, dehydration with
hypochloremic alkalosis, diabetes, rectal
prolapse
37
--- Content provided by FirstRanker.com ---
38
Cystic Fibrosis Emergencies
? Respiratory
?Cor pulmonale
--- Content provided by FirstRanker.com ---
?Hemoptysis?Pneumothorax
?Respiratory failure
? Gastrointestinal
?Obstruction (meconium or otherwise)
--- Content provided by FirstRanker.com ---
?Intussusception? Other
?Dehydration
?Electrolyte depletion (Na+, Cl-, K+ )
?Associated with heavy sweating, GI losses 39
--- Content provided by FirstRanker.com ---
Henoch-Sch?nlein Purpura
? Abdominal pain, GI bleeding, hematuria,
palpable purpura (= vasculitis), arthritis
? Immunological y-mediated vasculitis
? Ages 2-11, whites, winter, males
--- Content provided by FirstRanker.com ---
? Skin lesions are pathognomonic: round,palpable, symmetrical, on dependent areas of
legs and buttocks
? Can get colicky pain, bloody diarrhea and
intussusception
--- Content provided by FirstRanker.com ---
? Migratory, large-joint arthritis? Renal involvement: hematuria, proteinuria
? 4-6 week il ness. Give steroids if symptomatic
? Normal platelets, PT, aPTT
40
--- Content provided by FirstRanker.com ---
Henoch-Schonlein Purpura
"Palpable purpura" classical y reflects a vasculitis-
caused reason for bleeding into the skin
41
Hemolytic Uremic Syndrome
--- Content provided by FirstRanker.com ---
? Acute renal failure associated with microangiopathichemolytic 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
--- Content provided by FirstRanker.com ---
diagnosis? Normal PT, aPTT, fibrinogen (unlike DIC)
? Uremia is almost universal
? UA: hematuria, proteinuria
? Similar to TTP, but kidney involvement is main feature
--- Content provided by FirstRanker.com ---
(vs. CNS involvement in TTP)? Antibiotics not advised ? unclear risk of increasing HUS
42
Hemolytic Uremic Syndrome
--- Content provided by FirstRanker.com ---
Schistocytes / helmet cel s anddecrease platelets
E. coli 0157:H7
43
Meningitis in Children
--- Content provided by FirstRanker.com ---
? Age under two months?E. coli, group B Strep, Listeria (by far, least
common)
?Ampicillin (for Listeria) plus cefotaxime or
gentamicin
--- Content provided by FirstRanker.com ---
? Age over two months?Strep. pneumoniae / Neisseria meningitidis
?H. influenzae (rare)
?Highest mortality: Strep. pneumoniae
?Ceftriaxone (contraindicated in neonates receiving
--- Content provided by FirstRanker.com ---
calcium-containing IV fluids ? can cause a precipitant inthe lungs and kidneys / also increase bilirubin) ?
cefotaxime is an alternative
?Steroids prior to antibiotics (somewhat controversial)
(especial y for H. influenzae)
--- Content provided by FirstRanker.com ---
?Chemoprophylaxis for contacts of N. meningitidis44
Cloudy CSF
45
Med-Chal enger ? EM
--- Content provided by FirstRanker.com ---
Hip Disease in Children
Male/
Bilateral
Disease
Age
--- Content provided by FirstRanker.com ---
FemaleRace
Best Film
Other
5-9x more
--- Content provided by FirstRanker.com ---
ORTALANICLICK--
Congenital
common in
Almost
--- Content provided by FirstRanker.com ---
AP--notwith leg flexed,
Hip
Birth
females
--- Content provided by FirstRanker.com ---
1/3never in
dislocate by
Dysplasia
10x more
--- Content provided by FirstRanker.com ---
frogadduction, click
Blacks
common if
on relocation
--- Content provided by FirstRanker.com ---
breechwith abduction
Slipped
Teenagers
12-15
--- Content provided by FirstRanker.com ---
Boys>girlsCapital
Heavy or
Avascular
June-
--- Content provided by FirstRanker.com ---
BlacksFemoral
1/4
AP
necrosis in
--- Content provided by FirstRanker.com ---
tallSeptember
more often
Epiphysis
6-15%
--- Content provided by FirstRanker.com ---
Younger inmost often
girls (8-15)
Legg-Calve-
Perthe's
--- Content provided by FirstRanker.com ---
1/10Arthrography
Frog lateral-
Disease
usual y neg
--- Content provided by FirstRanker.com ---
5Male>
Bilateral in
for
Better
--- Content provided by FirstRanker.com ---
Avascularyears
females
females is
None
--- Content provided by FirstRanker.com ---
subarticularprognosis under
necrosis
rare
lucency
--- Content provided by FirstRanker.com ---
5femoral head
Synovitis may
be 1st sign
46
--- Content provided by FirstRanker.com ---
Pediatric Fluids
? Use totality of clinical findings to estimate degree of
dehydration
? Mild dehydration: 3-5% body weight = 50 mL/kg fluid deficit
? Moderate dehydration: 6-9% body weight = 100 mL/kg
--- Content provided by FirstRanker.com ---
deficit? Severe dehydration: over 9% body weight = 150 mL/kg
deficit
? AAP and WHO advises oral rehydration for mild to moderate
dehydration (not IV)
--- Content provided by FirstRanker.com ---
? Severe dehydration ? repeated IV fluid boluses of 20 mL/kgover 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 ?
--- Content provided by FirstRanker.com ---
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
--- Content provided by FirstRanker.com ---
?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
--- Content provided by FirstRanker.com ---
? 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
--- Content provided by FirstRanker.com ---
with respiratory depression and extrapyramidal effects? General y avoid antidiarrheal medications ? safety and
efficacy issues
48
Pediatric ACLS (1)
--- Content provided by FirstRanker.com ---
? Defibril ation = 2 J/kg (double dose ifunsuccessful)
? Cardioversion = 0.5 J/kg
? ET intubation: Cuffed or uncuffed acceptable
? ET size: (16 + age)/4 = diameter of 5th finger
--- Content provided by FirstRanker.com ---
? Air leaks are normal with an uncuffed tube atpeak inspiratory pressures
? Surgical cricothyrotomy is not recommended
for children younger than 10 yrs
? Narrowest part of airway: cricoid cartilage
--- Content provided by FirstRanker.com ---
? Fluid resuscitation: 20 mL/kg NS boluses49
Pediatric ACLS (2)
? Asystole is the most common arrest rhythm
? Epinephrine is the drug of choice in asystole
--- Content provided by FirstRanker.com ---
? Epinephrine is the inotrope of choice inchildren
? Bradycardia is 2nd most common arrest rhythm
? Always intubate, ventilate and oxygenate
before giving drugs ("A-B-C" in children)
--- Content provided by FirstRanker.com ---
? Correctable causes of EMD: hypovolemia,tension pneumothorax, tamponade
? Vfib and Vtach are rare; think hyperkalemia,
tricyclics, hypothermia
50
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Acid-Base Blood Gas Diagram
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Med-Chal enger ? EM
Apgar Score
Score of
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Component ofScore of 1
Score of 2
0
Acronym
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blue atblue all
Skin color
extremities
normal
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Appearanceover
body pink
Heart rate
absent
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<100>100
Pulse
grimace/
no
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sneeze/cough/pul sReflex
feeble cry
response
away
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Grimaceirritability
when
to stimuli
when stimulated
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stimulatedMuscle tone
none
some flexion
active movement
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Activityweak or
Respiration
absent
strong
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Respirationirregular
Additional Mnemonic: How Ready Is The Child?
H = heart rate, R = resp. effort, I = irritability, T = tone, C = color
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Neonatal Resuscitation Priorities
? Dry, warm, positioning, suction, tactile
stimulation
? Oxygen
? Bag-valve-mask ventilation
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? Chest compression? Intubation
? Drugs: epi, fluids, bicarb, naloxone, dopamine
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Pediatric Pearls (1)
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? Neonates increase respiratory volume almost exclusively by increasingtheir 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
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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
emergency
? Fever of 39C (102.2) in the presence of a UTI = pyelonephritis (only
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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
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have bacteremia rates of 0.5-0.7%? The incidence of meningitis in febrile infants less than three months of
age is about 1%
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Pediatric Pearls (2)
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? The safest approach to febrile children less than 30 days of age is sepsistesting, 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)
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? Analgesics (oral or topical if no TM perf) is an important aspect of treatingotitis 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
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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
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anus with an empty rectum suggests Hirschsprung disease? Strep throat can cause abdominal pain in kids over 3 ? check the throat
55
Pediatric Pearls (3)
? Although uncommon, a UTI can co-exist with a viral infection
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? Nitrite testing has less sensitivity for a UTI when caused by Gram +bacteria
? In seizures lasting over 5 minutes unresponsive to benzos, the drugs of
choice are fosphenytoin or phenobarbital / vaproic acid has rarely caused
liver failure
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? Migraine headaches in children ? rather sudden onset, intensify over 10minutes, 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)
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? Most serious causes of headaches wil have concomitant neurologicfindings
? 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
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swel ing causing increase CSF pressure and altered mental status? Children having concussions should not be al owed to participate in
56
contact sports until cleared by another physician in fol ow-up
Pediatric Pearls (3)
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? Although uncommon, a UTI can co-exist with a viral infection? Nitrite testing has less sensitivity for a UTI when caused by Gram +
bacteria
? In seizures lasting over 5 minutes unresponsive to benzos, the drugs of
choice are fosphenytoin or phenobarbital / vaproic acid has rarely cause
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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
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decrease cerebral perfusion)? Most serious causes of headaches wil have concomitant neurologic
findings
? In adolescents with altered mental status due to alcohol, concomitant
hypoglycemia may also be present ? look for it
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? Blunt head trauma in children can be accompanied by diffuse cerebralswel ing causing increase CSF pressure and altered mental status
? Children having concussions should not be al owed to participate in
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contact sports until cleared by another physician in fol ow-up
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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
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? 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
cardiomyopathy)
? Other risk factors for serious causes of syncope ? family history of sudden
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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
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? Benzos should be considered second line drugs in the treatment ofpsychiatric disorders in children due to the potential to cause disinhibition
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PEDIATRICS QUESTIONS
59
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All but one of the following is classically
associated with a mechanical cause for
vomiting in an infant?
A.Bilious vomiting
B.Projectile vomiting
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C.A tender, tense mass under the diaperD.A low glucose and metabolic acidosis
E.Current jel y stools
Peds 1
Which of the following is consistent with a
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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
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Peds 2A 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.
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What is the most likely diagnosis?A.Rotavirus
B.Salmonel a
C.Shigel a
D.E. coli
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E.EnterovirusPeds 3
A neonate presents to the ED with jaundice.
Which of the following considerations is the
most important in determining the need for
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admission?A.The presence of greater elevations of direct
reacting bilirubin in comparison to indirect
reacting bilirubin
B.A history of breast feeding
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C.A negative Coombs testD.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,
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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
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casesB.The addition of ipratropium to nebulization therapy
produces substantial additional benefit
C.The risk of apnea is directly related to the severity of
disease
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D.Heliox is contraindicated in these patientsE.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
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infection. Which of the following is most typicalof 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
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C.Respiratory failure is common in terminal patientsD.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
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Peds 6Regarding pertussis, which of the following
statement is most correct?
A.Vomiting frequently precedes coughing paroxysms
B.Rarely lasts more than two weeks
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C.Most patients develop an inspiratory "whoop" withcoughing
D.Complications of increased intrathoracic pressure
include rectal prolapse
E.Children are the primary reservoir
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Peds 7Concerning 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
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for decreasing mortality from S. pneumoniaeC.N. meningitidis is associated with the highest
mortality
D.Chemoprophylaxis is appropriate for contacts of
patients with most forms of meningitis
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E.Group B strep is acquired from the motherPeds 8
A patient with a ventriculoperitoneal shunt
presents to your ED. Things to remember about
these patients include:
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A.Headaches may represent shunt dysfunction withdecreased 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.
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C.Resistance to compression of a pumping chamber isconsistent 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
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months after their insertionPeds 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
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significantly elevated. What would you expect tobe 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
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contraindicatedD.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
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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
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B.A belief that forcing plenty of water wil abort or treatchildhood 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
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intervalE.All of the above
Peds 11
A 4-year-old child with episodic severe
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abdominal pain for the last three hours has theultrasound study noted. What is a frequent
associated finding with this disorder?
A.A protruding mass into the
bowel lumen
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B.A palpable mass in the leftlower quadrant
C.Bloody very soft stools is an
early finding in this disorder
D.Is a rare cause of bowel
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obstruction in a young childE.Is associated with projectile
vomiting
Peds 12
Which of the following is appropriate
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therapy for "tet" spells in the setting oftetralogy of Fallot?
A.Increase peripheral resistance
B.Increase venous return
C.Increase ventilatory efforts
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D.Avoidance of bicarbonate therapyE.Avoidance of sedation
Peds 13
Henoch-Schonlein purpura and hemolytic
uremic syndrome have which of the
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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
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E.Both have abnormal aPPTsPeds 14
A four-month old child presents with
inconsolable crying. Which statement is most
true related to this condition?
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A. Taking the diaper off may reveal multiple causes ofinconsolable 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
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providerD. Pain caused by a volvulus is associated with bilious
vomiting
E. Pain associated with an intussusception is
characterized by constant, unrelenting crying
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Peds 15Which of the following is a true statement
concerning pediatric gastroenteritis?
A.A check for hypoglycemia should be routine in patients
with gastroenteritis
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B. Moderate dehydration should routinely be treated withIV 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
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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.
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What is the approximate maintenance fluidthat is required over a 24 hour period?
A.500ml
B.1000ml
C.1500ml
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D.2000mlE.2500ml
Peds 17
A child is clinically dehydrated. Which of
the approximate fluid deficits are correct.
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A.Mild dehydration represents a loss of 3-5% of body weightand 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
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body weight and a fluid deficit of approximately 150ml/kgD.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
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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
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D.Contrary to adult CPR, bicarbonate therapy is associatedwith 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
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Peds 19What 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
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catheter stimulation?A.2
B.4
C.6
D.8
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E.10Peds 20
Pediatrics Answer Key
1. D
11.E
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2. D12.A
3. C
13.A
4. A
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14.C5. E
15.A
6. C
16.A
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7. D17.C
8. E
18.D
9. C
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19.E10.B
20.C
Question 20 ? Answer Explanation
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