Empa 6225 Adv Peds/abuse/non-Trauma

Front 1

What is the age for an Snellen chart?

Back 1

MC: 4-6 y/o- able to read letters of alphebet
Stand 20 feet.

p. 761

Front 2

What is the distance for the tumbling E and allen chart for Visual acuity?

Back 2

10 feet

p. 761

Front 3

How long are babies MC cross eyed for?

Back 3

first month of life

p. 761

Front 4

When should an infant/child be able to fixate on an object 1-2 feet away?

Back 4

3-6 months of life

Beyond this age- to 3 yrs...should be able to distract with bright, moving objects, etc.
p. 762

Front 5

What is the MC pupil diameter in abmient light of a child infant and adult?

Back 5

Child: 9.0-10.5mm
Adult: 10.5-13.0 mm

p. 763

Front 6

What might leukocoria be indicative of?

Back 6

A problem with: cornea, lens, or anterior or posterior chamber of the eye.

p. 763

Front 7

When is a bright light eye examination MC tolerated by a child?

Back 7

> 5 y/o.

younger children will MC squint

p. 763

Front 8

What is pupillary escape? Is it Normal?

Back 8

It is NML. It is an initial responsive pupillary constriction and dilation in response to APD examination. (Best to read the Consenual light reflex section p. 763- word "Next check" to"A bright light")

Front 9

What is the extend of a fundoscopic examination in an infant and toddler?

Back 9

Red reflex- performed 1-2 feet away

p. 763

Front 10

What is occular misalignment called?

Back 10

Strabismus

p. 763

Front 11

What is the term for an inward gaze?

Back 11

Esotropia

p. 763

Front 12

What is the term for an outward gaze?

Back 12

Exotropia

p. 763

Front 13

What is the term for upward gaze of the eyes?

Back 13

Hypertropia

p. 763

Front 14

What is the term for a downward deviation of the eyes?

Back 14

Hypotropia

p. 763

Front 15

What is the term for the inward deviation of the eye when the other eye is covered?

Back 15

Esophoria

p. 763

Front 16

What is the term for the outward deviation of the eye when the other eye is covered>

Back 16

Exophoria

p. 763

Front 17

What is the loss of visual acuity not correctable with glasses in otherwise healthy eye>

Back 17

Amblyopia

p. 763

Front 18

What is the presumed age limit for correction of amblyopia before the brain suppresses visual information?

Back 18

10 y/o

p. 763

Front 19

What can be the cause as well as caused by strabismus?

Back 19

amblyopia

p. 763

Front 20

What muscles do the cranial nerves innervate and what is their association?

Back 20

CN VI: LR muscle
CN IV: SO muscle
CN III: All other muscles

LR6,SO4,AO3

p. 763

Front 21

What physiologic feature is noted as provoking a pseudostrabismus?

Back 21

Epicanthal fold

p. 763

Front 22

What is dacrystenosis?

Back 22

narrowing/obstruction of the nasolacrimal duct. Unilateral or bilateral. MC dx in infancy.

p. 764

Front 23

T/F: Child with dacrystenosis will have erythema of the conjunctiva or irritation of the surrounding soft tissue.

Back 23

False

MC some excess tearing, minimal crust, but the conjunctiva is spared. No fever, no irritability

p. 764

Front 24

What is dacrocystitis?

Back 24

inflammation and superinfection with S. Aureus, S. Pneumoniae, S. Epidermidis, H. Influenzae etc. with erythema and swelling inframedullary to eye- with chronic mucopurulent d/c.

p. 764

Front 25

What is a consequence of poorly treated dacrocystitis?

Back 25

Periorbital and/or orbital cellulitis.

p. 764

Front 26

What is a small bluish-hued, palpable mass in the location of the nasolacrimal duct?

Back 26

Dacrycele

p. 764

Front 27

What is an infection of the lacrimal gland MC associated with: Sjogren, sarcoidosis, or thyroid dz?

Back 27

Dacryadenitis

p. 764

Front 28

for suspected bacerial infx: dacryadenitis, what is the PO abx of choice?

Back 28

Keflex- non-MRSA
Bactrim- MRSA

p. 764-765

Front 29

What is the connective tissue extension of the orbital periosteum that extends into the upper and lower lid which acts as a barrier to infx in the eye?

Back 29

Orbital septum

- this is the way of involvement for periorbital cellulitis and orbital cellulitis...
peri-orbit: Pre-septal
Orbit: post-septal

p. 765

Front 30

What is the avg age of periorbital cellulitis?

Back 30

2 y/o

p 765
insect bite, small scratch, but can also be conjunctivitis, dacryadenitis, and hordeolum
MC: Staph and GAS

Front 31

T/F: An individual with a hx of sinusitis, wakes up mild edema and swelling of the eyelid. The swelling improves as the day continues. THis patient has periorbital cellulitis and this is common.

Back 31

False: this is a reactive edema. The swelling will not regress on own if cellulitis.

p. 765

Front 32

What are some significant differences between peri-orbital and orbital cellulitis that help to define dx: peri-orbital cellulitis (6)?

Back 32

1. No decrease in V. acuity
2. no conjunctival injections
3. No impairment in extraoccular movements
4. no proptosis
5. no pain with eye movement
6. no intraorbital pathology

p. 765

Front 33

If uncertain: orbital vs. periorbital cellulitis- what can you use to help in the dx?

Back 33

CT scan...orbital and sinus

p. 765

Front 34

T/F: A child who is well appearing with certain periorbital cellulitis may be d/c'd with oral abx regimen.

Back 34

True

Augmentin: 20 mg/kg PO BID

p. 765

Front 35

What is MC the extension of a sinus infx into the orbit, behind the septum, with the MC age 12 y/o at presentation.

Back 35

Orbital cellulitis- if you did not get this one, strike yourself in the head with a tack hammer...

p. 765

Front 36

What are some of the characterisitics that help to define orbital cellulitis?

Back 36

eyelid or periorbital inflammation, accompanied by the following:
1. proptosis
2. impaired extraoccular movements
3. pain with eye movement
4. decreased visual acuity
5. chemosis
6. APD- afferent pupillary defect

- fever does not have to be present.

p. 765

Front 37

T/F: In an appropriate candidate, and access to enough abx, orbital cellulitis can be managed outpatient.

Back 37

FALSE: all orbital cellulitis patients are sick and need IV abx, as well as contact with ophthalmology, ENT and consideration for surgical debridement. Oral abx will follow improvement in sxs an clinical course, but not initially.

p. 765

Front 38

How will an infant or small child present with corneal abrasion?

Back 38

Inconsolable crying and an otherwise normal exam

Infact, a gtt of proparicaine 0.5% or tetracaine 0.5% in the eye with calming of the child= highly suggestive.
p. 766

Front 39

What is the tx for corneal abrasion? What should be avoided in the tx of corneal abrasion?

Back 39

1. Tx: E-mycin ointment (Cipro or oflox are safe > 1 y/o)
2. Avoid: Topical steroids and oitnments with neomycin

p. 766

Front 40

T/F: If patient has a corneal abrasion there is no concern for tetanous, even if trauma from pet or outside, secondary to the blood supply.

Back 40

False: provide.

p. 766

Front 41

Simple corneal abrasion- when is f/u

Back 41

48 hrs

p. 766- FB sensation beyond 2-3 days- requires further investigation by ophtho

Front 42

What is conjunctivitis in children up to 30 days old?

Back 42

Ophthalmia Neonatorum

p. 766

Front 43

What are the five categories of neonatal conjunctivitis?

Back 43

1. Chemical
2. Gonococcal
3. Chlamydial
4. other bacterial
5. Viral

p. 766
- all can lead to severe morbidity

Front 44

How can you determine/exclude the involvement of the following ophthalmology?
1. Gonococcal
2. Herpes
3. Chlamydia

Back 44

1. Gramstain of d/c- gram Neg diplococci
2. Maternal hx herpes as well as + fluorescein stain and herpetic lesions
3. There is no way- you tx with 14 days E-mycin

p. 766

Front 45

What is the tx for neonatal conjunctivitis- as a chemical cause?

Back 45

Watchful waiting, should resolve in 48 hrs.

MC: Silver nitrate as a source; however, this has been reduced since practice replaced with E-mycin ointment.

p. 766

Front 46

What presents with occular manifestations: b/l bulbar conjunctival erythema, chemosis, and a copious purulent d/c?

Back 46

Gonococcal Conjunctivitis

p. 767

Front 47

How are Gonococcal ophthalmia patients treated?

Back 47

With admission to ensure no disseminated disease.

Also, no evidence of hyperbilirubinemia, provide single dose: Rocephin 50 mg/kg IV Max 125 mg.

p. 767

Front 48

While chlamydia ophthalmia cannot be excluded in the ED, what is the test of choice for this?

Back 48

NAAT- nucleic acid amplification test or a giemsa stain of the d/c

p. 767

Front 49

HSV types I and II...viral ophthalmia...how is this tx'd?
(sxs develop in 6-14 days of life)

Back 49

MC b/l d/c and erythema. Maternal hx: HSV infx, additionally, will often have mucocutaneous involvement.
1. Admission
2. Full sepsis work up (esp with LP and PCR test of CSF)
3. IV acyclovir 20 mg/kg q 8h
4. Topical anti-virals
- to avoid keratitis and disseminated infx.

p. 768

Front 50

Herpes Zoster ophthalmicus V1 distribution as well as HSV- if presenting w/in 72 hrs, how tx'd

Back 50

oral acyclovir:> 2 y/o 20 mg/kg PO q 6 hrs x 5 days: Max dose, 3200 mg/d.
DON'T forget ophthalmology referral.

p. 768

Front 51

What is oculoglandular syndrome?

Back 51

RARE infx caused by Bartonella Henslae (cat scratch dz) or tularemia- causes: ipsilateral conjunctivitis, lymphadenopahty- often axillary.

p. 768

Front 52

Read: 768- Viral conjunctivitis and Bacterial conjunctivitis in children...

Back 52

...because the guys who make these test suck and will likely take a question from this crap, though you've tx'd this in the past.

Front 53

What two organisms are not effectively covered by e-mycin in the tx of conjunctivitis?

Back 53

M. Catarrhalis and H. Influenzae

p 769

Front 54

Why are oral antihistamines discouraged in tx of allergic conjunctivitis?

Back 54

Causes drying of the eyes which in turn worsens sxs.

p. 769

Front 55

What is needed in "typical cases" of Kawasaki dz?

Back 55

1. fever > 5 days
2. dry, erythematous lips/oropharynx
3. enlarged cervical lymphadenopathy
4. non-vesicular rash
5. edema and peeling of the hands and feet
6. Nonpurulent d/c b/l conjunctivitis

p. 769

Front 56

What are the common pathologic signs of pediatric glaucoma?(3-6)

Back 56

1. IOP: > 20
2. Cornea enlarged, edematous/cloudy
3. > 12 mm corneal diameter (<1 y/o), > 13 mm in all others**
- associated with following
4. Blephrospasm
5. red infected eye
6. myopia

p. 769

Front 57

What is the definitive tx for glaucoma?

Back 57

Surgery

p. 769

Front 58

Why do you NOT use pediculosis shampoo's on the eyes?

Back 58

Toxic to the eyes

p. 769

Front 59

What is a very common cause of childhood visual impairment and the most frequent cause of NON-malignant leukocorea?

Back 59

Cataracts

p. 770

Front 60

What are cataracts from in the neonatal period?

Back 60

TORCH
-toxoplasmosis
- other: Syphilis
-Rubella
-CMV
-HSV

p. 770

Front 61

What are the MC presenting signs of retinoblastoma?

Back 61

leukocoria and strabismus

p. 770

Front 62

What is the MC predisposing factor for sinusitis (bacterial)

Back 62

viral URI

p. 771

Front 63

When are ethmoid sinuses formed?

Back 63

The are formed in utero- developed at birth

p. 771

Front 64

When are the sphenoid sinuses formed?

Back 64

3-5 yrs of age

p. 771

Front 65

Frontal sinuses, when are these formed?

Back 65

7-8 yrs of age. Not pneumatized until adolescence

p. 771

Front 66

What is the "gold standard" for dx bacterial sinusitis?

Back 66

Recovery of >10^4 colony-forming units/mL bacteria from paranasal sinuses.

p. 771

Not performed, aspiration is too painful and impractical in the ED

Front 67

T/F: Imaging studies are needed to cofirm the dx of acute bacterial sinusitis in children < 6 y/o with persistent sxs.

Back 67

False

p. 771

Front 68

T/F: A cranial CT WITH contrast is RECOMMENDED for suspected complications of bacterial sinusitis, including preseptal or postseptal cellulitis, subperiosteal abscess, cavernous sinus thrombosis, osteomyelitis of the frontal bone (pott puffy tumor), subdural empyema, epidural or brain abscess, and meningitis.

Back 68

True

p. 771

Front 69

What are regarded as severe sxs of acute bacterial sinusitis?

Back 69

- fever > 39 (102.2)
- purulent nasal d/c for > 3 days
- ill appearing child

p. 771

Front 70

What are regarded as persistent sxs of acute bacterial sinusitis?

Back 70

Nasal or postnasal d/c
and/or
Daytime cough lasting 10-30 days

p. 771

Front 71

What is the primary drug of choice for uncomplicated mild to moderate sinusitis in children?

Back 71

Amox (80 mg/kg/d) PO x 10-14 days

p 772

Front 72

What are regarded as "adequate alternatives" to amx for sinusitis when mild PCN allergy?

Back 72

- 2/3 gen Cephalosporin:
Cefprozil 7.5-15 mg/kg PO bid
Cefuroxime 15 mg/kg PO bid
Cefpodoxime 5 mg/kg PO bid

p. 772

Front 73

What should be done in the ED when a patient has: proptosis or impairment of the extraoccular muscles of the eye? Why?

Back 73

- CT scan
- suggests orbital inflammation and possible extension of an ethmoid sinus infx.

p. 772

Front 74

What do I do with a sinusitis patient that has a SEVERE PCN allergy?

Back 74

provide:
Clarithromycin or Azithromycin

Front 75

What should be suspected in a patient who has hx: chronic sinusitis, nasal polyps, chronic cough and evidence of failure to thrive (FTT)?

Back 75

Cystic fibrosis

p. 773

Front 76

What age group can one begin to see the IgE mediated allergic rhinitis?

Back 76

> 2 y/o

p. 773

Front 77

What is the mainstay of tx for allergic rhinitis?

Back 77

Antihistamines and Intranasal steroids

tho hypertonic (3%) nasal saline significantly improves sxs.

p. 773

Front 78

Where do FB insertion MC occur?

Back 78

MC: Ear canal then the nose.

p. 773

Front 79

Patient with unilateral "foul-smelling d/c" from the nares- what comes to mind?

Back 79

FB

p. 773

Front 80

What is the key to successful removal of FB from a nares of a child?

Back 80

Immobilization

p. 773

Front 81

When do most complications from FB's occur?

Back 81

During the attempt to remove the FB.

p 774- actual aspiration of intranasal FB is very rare

Front 82

How long before a button battery liquifies and causes nasal septal necrosis?

Back 82

7 hrs.

p. 774

Front 83

Why do you not want to instill any type of nasal drops before removal of battery in the nose...

Back 83

...the electrical charge of the battery will produce electrolysis of an electrolyte rich fluid. ie. Severe alkaline burn

p. 774

Front 84

When the d/c is too thick in suspected intranasal FB, what should you get to assist you?

Back 84

Plain radiograph- to characterize/visualize the object

p. 774

Front 85

What do you do for live FBs in nose/ear?

Back 85

Kill it with 2% lidocaine or mineral oil and then attempt removal

p. 774

Front 86

What are some associated sxs, with neck masses, that imply infx?(4)

Back 86

1. fever
2. chills
3. pain
4. recent URI or GI infx
- at the end of the day, this part is intuitive...

p. 782

Front 87

What type of lymph node is MC mobile, firm, not attached to underlying structures, and mildly tender?

Back 87

Bening, reactive

p. 782-783

Front 88

What type of mass is MC: soft, ballotable, and mobile?

Back 88

cystic mass

p. 783

Front 89

What type of mass is MC hard, non-tender, and may be fixed to underlying structures?

Back 89

malignant

p. 783

Front 90

What should be done with a mass, that was tx'd with abx (as suspected reactive) and the mass does not regress?

Back 90

Work-up further. MC with the following:
- CBC
- ESR/CRP
- Cultures
as well as radiologic
- CT, MRI and/or U/S

p. 783

Front 91

What is the MC cause of lymphadenitis in children?

Back 91

Viruses

p. 783

Front 92

What is the MC bacterial source of lymphadenitis in children?

Back 92

Group A Strep
Staph Aureus

p. 783
-see table 118-2, p. 783 for list of common viruses as well as bacterial sources.

Front 93

While MC cervical lymphadenitis will not require tx, in suppurative case is suspected, what is the ideal tx?

Back 93

Amox plus claulonic acid (Augmentin) 30-40 mg/kg/d, divided into BID dosing
-or-
Clindamycin 30-40 mg/kg/d, divided into tid dosing
for 10-14 days
(coverage for Staph and Strep)

p. 783

Front 94

What is it called when a lymph node undergoes liqueficative necrosis?

Back 94

Suppurative Lymphadenitis

-. 784 (these are usually tender and fluctuant)

Front 95

What should you suspect in a patient who has suppurative lymphadenitis w/torticollis or trismus?

Back 95

RPA- obtain contrast CT

p. 784

Front 96

What does Bortonella Henslae (a gram negative bacteria) cause?

Back 96

Cat Scratch Dizease, a Granulomatous dz.

p. 784

Front 97

How do you confirm Cat Scratch Dz?

Back 97

1. careful hx: exposure to cats (kitten)
2. antibody titers
3. PCR
4. cx of lymph node aspirate.

p. 784

Front 98

T/F: Emperic tx of cat scratch dz, with Rifampin, bactrim or e-mycin is indicated, even when awaiting tests.

Back 98

FALSE: While rifampin is appropriate, empiric tx is not. MC this will resolve on its own.
p. 784

Front 99

Toxoplasma Gondii is transmitted how?

Back 99

1. Ingestion of undercooked meat
2. exposure to oocytes in cat feces
3. maternal-fetal transmission

p. 784

Front 100

In immunocomprimised patients, what organ (system/Dz) are MC effected by T. Gondii?

Back 100

CNS and Occular

p. 784

Front 101

What is the MC cause of sialdenitis?

Back 101

Bacteria.

p. 784

Front 102

What are the MC associated sxs of Suppurative Sialdenitis?

Back 102

Fever, pain and chills

p. 784

Front 103

Where is the Stenson's duct MC located?

Back 103

Over the second molar.

p. 784

Front 104

Submandibular gland drains into the Whartons Duct. Where is this located?

Back 104

Adjacent to the lingular frenulum

p. 784

Front 105

What is the therapy for Sialoadenitis?

Back 105

1. abx
2. analgesia
3. increasing salivary production with fluids and lemon gtts.

p. 784

Front 106

What is the MC midline neck mass in children?

Back 106

Thyroglossal Duct Cyst

p. 784
MC (65%) are infrahyoidal.

Front 107

What is a PAINLESS, fluctuant mass that moves with swallowing OR protrusion of the tongue?

Back 107

Thyroglossal duct cyst

p. 784-785

Front 108

What imaging is better for thyroglossal duct cysts, CT or MRI?

Back 108

CT

p. 785

Front 109

What test is important in evaluation of possible throglossal duct cyst?

Back 109

Thyroid studies- may contain ectopic thyroid tissue

p. 785

Front 110

What is the cyst, situated just anterior to the SCM, near the angle of the mandible? MC round, smooth, mobile, and not TTP unless infx

Back 110

Brachial Apparatus Cyst

p. 785

Front 111

How can you tell the difference between the thyroglossal duct cyst and the dermoid cyst?

Back 111

Dermoid cysts do NOT move with tongue protrusion.

p. 786

Front 112

Lymphangioma (Cystic Hygroma)- what is this?

Back 112

A result of sequestration of lymphatic channels that fail to communicate w/the internal jugular system- which in turn leads to the obstruction of the lymphatic channels. MC (75%) are in the neck

p. 786

Front 113

What are soft, painless, and compressible andcan be very large. Can have capillary and cystic compenents with it. Additionally, morbidity is associated with size and compressibilty on adjacent structures?

Back 113

Cystic Hygroma (Lymphangoma)

p. 786

Front 114

What presents as a mass in the neonatal period of life in the SCM?

Back 114

Fibromatosis Colli- histologically involved muscle is replaced by dense fibrous tissue

p. 786

Front 115

What MC presents in teh neonatal period and provokes limited ROM, torticollis

Back 115

Fibromatosis Colli

p. 786

Front 116

What does a solitary posterior cervical mass suggest?

Back 116

Malignancy

p. 787

Front 117

What does supraclavicular mass suggest?

Back 117

Lymphoma

p. 787

Front 118

What does central, midline swelling suggest?

Back 118

- thyroid with ducts
- cysts
- or dermoids as a likely dx

p. 787

Front 119

What is the most common malignancy of the head and neck in children?

Back 119

Lymphoma

p. 787

Front 120

What is the second MC cause of malignancy in the head and neck?

Back 120

Rhabdosarcoma

p. 787

- MC involve orbit, nasopharynx, nasal cavity, and paranasal sinuses

Front 121

What is a neuroblastoma?

Back 121

A malignancy of the sympathetic chain and can originate anywhere, but favors adrenal gland.
MC < 5 y/o, neck masses are better prognosis than the adrenal masses.

Front 122

Some malignancies will metastasize to the to the cervical lymphnodes. Name two, indicated in the book, that are likely to do this.

Back 122

1. Nasopharyngeal carcinoma
and
2. Some GI tumors

p. 788

Front 123

Location in the neck, lymphnodes, will often indicate their origin. Explain>

Back 123

1. Posterior triangle nodes: MC Nasopharyngeal mets
2. Isolated suprclavicular nodes suggest: mediastinal mets.

p. 788

Front 124

Some age specific causes of Pneumonia: 1-3 months

Back 124

Pneumonitis syndrome usually afebrile: chalmydia trichmotis, RSV, other respiratory viruses, Bortella pertusis

p. 811

Front 125

Some age specific causes of Pneumonia: 1-24 months

Back 125

Mild to moderate pneumonia; RSV, other respiratory viruses, strep pneumoniae, Hib, NTHi(non-typable HInfluenzae), Chlamydia Trichomatis, Mycoplasma Pneumonae

p. 811

Front 126

Some age specific causes of Pneumonia: 2-5 yrs

Back 126

Respiratory Viruses, S. Pneumoniae, Hib, NTHi, Mycoplasma Pneumoniae, C. Pneumoniae

p. 811

Front 127

Some age specific causes ofPneumonia: 6-18 yrs

Back 127

Mycoplasma Pneumoniae, S. Pneumoniae, C. Pneumoniae, NTHi, influenza viruses A and B, adenovirus, other Resp. Viruses

p. 811

Front 128

Some age specific causes of Pneumonia: all ages

Back 128

Severe pneumonia requiring intensive care unit admissions, S. Pneumoniae, Staph Aureus, Gp A Strep, Hib, M. Pneumoniae, adenovirus

p. 811

Front 129

What should be the "work-up type" for infants: 0-3 months old, w/suspected pneumoniae?

Back 129

Sepsis work up

p. 811

Front 130

What abx should be provided to 0-3 month old children...with pneumonia?

Back 130

- ampicillin to cover risk listeria and Gp B strep
- gentamicin or cefotaxime for gram neg risk.

p. 811

Front 131

Clinical findings Pneumoniae in infants to 2 yrs old...(older infants, > 3 months), what are they?

Back 131

- tachypnea
- Staccato cough
- scattered rales (usu NO Wheezes)
- B/l interstitiial infiltrates on radiograph

p. 811
Because of the risk of C. Trahomatis, b. pertusis, along with RSV- Macrolides are recommended.

Front 132

What uncommon lung infx etiology is common in Native Reservations, Alaska, and Canadian north and in some inner city populations?

Back 132

TB

p. 811

Front 133

Children with incomplete or no hx of immunizations are susceptible to what organisms for pneumonia?

Back 133

- B. pertussis
- Hib
- all strains of pneumococcus
- measles
- influenza
- VZV

p. 811

Front 134

T/F: the dx of pneumonia can be made clinically?

Back 134

True

p. 812

Front 135

Define Tachypnea in:
1. Newborns-2 months old,
2. 2-11 months old,
3. 1-4 y/o.

Back 135

1. > 60 breaths per min
2. > 50 breaths per min
3. > 40 breaths per min
- this is obtained when child is at rest, not worked up. Assess for full minute
p. 812

Front 136

What effect can fever have on respiratory rate?

Back 136

increase resp rate by 10 breaths per minute, with each increase of 1 degree C

p. 812

Front 137

What are some markers of resp distress?

Back 137

- grunting
- nasal flaring
- tracheal tug
- intercostal indrawing

- Poor feeding and lethargy- indirect signs of respiratory compromise.

p. 812

Hint 137

- lower abd indrawing and gruting suggests severe pneumonia

Front 138

T/F: Cough, particularly and productive cough, is present even in neonates with pneumonia.

Back 138

False: exceedingly rare finding

p. 812

Front 139

What does oxygen saturation of <90% (hypoxia), on room air indicate about amoxicillin success rate.

Back 139

Hypoxia in suspected pneumonia suggests severe pneumonia and indicates a likely Amoxicillin failure

p. 812

Front 140

T/F: The combination of fever; tachypnea, decreased breath sounds, or fine crackles predicts the x-ray positive findings of pneumonia w/a sensitivity of 93-96%.

Back 140

True

p. 812

Front 141

T/F: The absence of tachypnea, respiratory distress, and rales decreased breath sounds accurately excluded the presence of pneumonia w/100% specificity

Back 141

True

p. 812

Front 142

What must be done in order to effectively determine the source of the pneumonia?

Back 142

invasive test

p. 812

Hint 142

bronchoscopy

Front 143

What are some extrapulmonary causes to consider on differential of pneumonia?

Back 143

1. Sepsis
2. Cardiac Anomalies
3. Endocrinopathies
4. Neuromuscular d/o
5. inborn errors of metabolism
6. GI emergencies

p. 813

Front 144

When considering a differential of pneumonia, what are two things that cause pulmonary sxs that are not infectious, but are significant in toddlers?

Back 144

FB aspiration

ingestions of toxins

p. 813

Front 145

What are three tests, when working up pneumonia/pulmonary concerns in peds patients, that may be quick and specific and may obviate the need for more invasive testing?

Back 145

1. Nasopharyngeal assay for RSV
2. Influenza
3. Metapneumovirus

p. 813

Front 146

T/F: Chest radiograph is the gold standard in dx pneumonia.

Back 146

False: neither 100% sensitive nor specific

p. 813

Front 147

What are some of the 8 potential indications for CXR? (list, p. 814)

Back 147

1. Age 0-3 months, sepsis wrk-up
2. < 5 y/o, temp 102.2+, WBC >20,000; no clear source of infx
3. Ambiguous clinical findings
4. Suspicion of a complication, such as pleural effusion
5. Pneumonia, prolonged/unresponsive to current abx tx
6. Suspicion of FB aspirate
7. Suspected congenital lung malformation
8. Follow-up, round pneumonia- to ensure resolution or exclusion of underlying mass

p. 814

Hint 147

Note: A toxic appearing child who has resp sxs: should ALWAYS undergo rads
- remember, cannot tell difference in viral vs bacterial sources on rads

Front 148

There are grossly obvious rads differences on neonate chest films, like what (I know read my mind)

Back 148

1. more pyramidal or trapezoidal in shape
2. cards silhouette- may occupy 60-65% of the chest width
3. Thymus may show, until 6 y/o- when it involutes.

p. 814

Hint 148

When the thymus appears as an infiltrate, lateral view will help

Front 149

How is neonatal pneumoia ALWAYS tx'd.

Back 149

With admission and parenteral abx

p. 814

Front 150

What is not recommended in peds patients, as they depend on cough to clear secretions?

Back 150

Cough Suppressants

p. 816

Hint 150

Exception: narcotic based cough suppressants may be effective- in select patients w/o hx of respiratory compromise.

Front 151

Why should ceftriaxone be avoided in those less than or equal to one month old?

Back 151

Kernicteris

p. 816

Front 152

What macrolide therapy is not approved for this in 1-3 month old age grp?

Back 152

Azithromycin

- not FDA approved.

p. 816

Front 153

What is recommended in in patients > 5 y/o- where strep pneumo is suspected, but macrolides are weakening in efficacy?

Back 153

Double coverage:
Beta-Lactam or First gen Cephalosporin PLUS
Macrolide

p. 816

Hint 153

Duration in most cases: 7-10 days

Front 154

What does Pneumococcal resistance range consist of in N. America and Europe?

Back 154

7.5 to >50%

p. 816

Front 155

FDA approval on macrolide therapies does not include what age group?

Back 155

< 6 months old.

p. 817

Front 156

While there is no evidence-based definition of hypoxia, what have physicians generally chosen as a pulse ox threshold for admission?

Back 156

<90-93%

p. 818

Hint 156

Signs of respiratory distress: >70 breaths in infants, >50 in older children

Surrogate markers of dyspnea in infants: intermittent apnea, grunting, inability to feed

Front 157

What are four ways to prevent pneumonia in children?

Back 157

1. handwashing
2. breast feeding
3. avoidance of smoking and second hand smoke
4. vaccinations

p. 819

Front 158

What are the "five T's" (right to left shunting) cyanotic heart lesions (this is important, appears twice)

Back 158

1. Tetrology of Fallot
2. Tricuspid atresia- including tricuspid atresia and Ebstein anomaly
3. Truncus arteriosus
4. total anomalous pulmonary venous return
5. transposition of the great arteries

p. 819

Front 159

What are some acyanotic lesions?

Back 159

1. Ventricular septal defect
2. atrial septal defect
3. patent ductus arteriosis
4. atrioventricular canal

pulmonary stenosis, aortic stenosis, and aortic coarctation

p. 819

Front 160

Because neonates and small children have relatively noncompliant ventricular walls, what do they do to increase Cardiac Output

Back 160

increase HR.

p. 819

Hint 160

Neonate requires more oxygen, has lower systolic reserve and is therefore more susceptible to CHF

Front 161

For clinical cyanosis to be present, what amt of (mg/dL) deoxyhemoglobin must be present in the system, and to what O2 sat does this correspond with?

Back 161

3-5 mg/dL, 70-80% RA

p. 820

Front 162

What is a TET spell?

Back 162

Episodic Cyanosis throughout infancy and childhood (associated with TOF)

p. 820

Front 163

What is the condition that is associated with Cyanosis in adolescents and young adults, assoc with ASD, VSD?

Back 163

Eisenmenger Complex

p. 820

Front 164

What is the MC cyanotic congenital heart dz manifesting in the postinfancy period?

Back 164

Tetrology of Fallot

p. 820

Front 165

What defects comprise Tetrology of fallot?

Back 165

1. VSD
2. Right Vent Outflow track obstruction
3. Overriding aorta
4. Right Vent Hypertrophy

p. 820

Hint 165

PE: Cyanosis
Heart sound: systolic thrill- at lower and middle left sternal border, loud S2, an aortic ejection click and loud systolic ejection murmur and continuous PDA murmur

Front 166

What is the MC cyanotic heart lesion manifesting in the newborn period?

Back 166

Transposition of the great arteries

p. 820

Front 167

An infant with transposition of the great arteries, depend on the existence of what defects just to survive?

Back 167

VSD, ASD, and PDA

p. 820

Front 168

What is total anolamous venous return?

Back 168

- pulm vein enters into the right atrium (classifed based on where the vein enters), then crosses either the tricuspid valve or to left atrium from ASD

p. 821

Front 169

Total anomalous venous return- how does it MC manifest?

Back 169

- CHF
However, the following will often be seen as well:
- tachycardia
- tachypnea
- hepatomegaly
- cyanosis

p. 821

Front 170

What is the absence (or lack of development of the) tricuspid valve, with the additional findings of: interruption of right vent and pulmonary artery development?

Back 170

Tricuspid atresia

p. 821

Front 171

What is it called when all of the pulmonary, systemic, and coronary circulations originate from a single arterial trunk?

Back 171

Truncus Arteriosis

p. 821

Front 172

T/F: When examinating a potentional cardiac anomaly in a child, all vitals should be obtained and BP should be uptained in upper and lower extremities.

Back 172

True

p. 821

Front 173

T/F: Neonates with cyanosis in the presence of congenital heart disease rarely have respiratory sxs other than tachypnea.

Back 173

True

p. 822

Hint 173

Neonates with lung dz will typically present in respiratory distres, grunting, tachypnea and retractions

Front 174

Why, though most lab tests are not useful in working up congenital heart anomalies, is the hypoxia test useful?

Back 174

Neonates with cyanotic heart dz, even on 100% O2, will not demonstrate an increase in PaO2 >20 mmHg, because of right to left shunting.

p. 922

Hint 174

MC, those with lung dz or sepsis, will improve with oxygen for 20minutes+

Front 175

What happens to blood exposed to air, except those with Methemoglobinemia?

Back 175

MC blood exposed to air turns pink, but in methemoglobinemia- remains chocolate colored.

p. 922

Front 176

What are the prinary diagnostic tests in work up for congenital heart defects in peds patient?

Back 176

1. CXR
2. EKG

p. 822

Front 177

What posseses a classic boot chaped heart on CXR?

Back 177

Tetrology of fallot.

p. 822

Hint 177

EKG: RAD, Right Vent Hypertrophy

Front 178

What dx study may delineate structural heart disease?

Back 178

Bedside Ultrasound, particularly in the hands of a peds u/s individual

p. 822

Front 179

What posses an Egg shaped heart, narrow mediastinum, increased pulmonary vascular markings?

Back 179

Transposition of the great arteries

p. 822

Hint 179

EKG: RAD, Right Vent Hypertrophy

Front 180

What x-ray finding is a snow man sign, significant cardiomegaly, increased pulmonary vascular markings?

Back 180

Total Anomalous Pulmonary Venous return

p. 822

Hint 180

EKG: RAD, Right Vent Hypertrophy, right atrial enlargement

Front 181

What EKG findings have: Biventricular hypertrophy

Back 181

Truncus Arteriosis

p. 822

Front 182

T/F: Neonates have significant amts of oxygen-avid fetal hgb and tolerate desats in the 70's w/o brain tissue hypoxemia.

Back 182

True

p. 822

Hint 182

Oxygen is a potent vasopulmonary vasodilator.
- knowing this means procede with caution

Front 183

Oxygen administration to a cyanotic infant w/congenital heart defects are helpful with those who have: pulm HTN and vasoconstriction...but who may it be more harmful?

Back 183

Patients with PDA and those who depend on PDA for flow.

Hint 183

It should therefore be reserved for those who have evidence of inadequate tissue perfusion, those w/o known heart dz in whom it may be both dx and therapeutic, and those with O2 sat well below known baseline.

p. 822

Front 184

What is the condition that causes Right sided outflow tract obstruction...leading to right to left shunting through VSD. Hypoxia and acidosis cause pulm arterial vasoconstriction, increasing pulm resistance, and exacerbating shunting.

Back 184

TET Spell...

p. 823
- increase pul blood flow, increase preload, increase after load.

Hint 184

Tx: 100% O2, calm child by minimizing stimulation-placing child in parents arms, and flexing childs knees to chest to increase preload.
- may consider morhine as well, then Bicarb for acidosis if needed.

Front 185

What are some cyanotic and acynotic lesions that may present with shock?

Back 185

Cyanotic: TGA, Pulmonary Atresia, hypoplastic right heart syndrome
Acyanotic: severe coarctation of the aorta, critical aortic stenosis, and hypoplastic left vent.

p. 823

Front 186

What in the LE's is essential to dx coarcation of the aorta?

Back 186

decreased pulses

p. 823

Hint 186

Read Differential Dx section: p. 823!!!! Will cover other considerations...this is a must.

Front 187

What measurements in the right (preductal) abd keft (postductal) upper extremities may also reveal a difference in measurements suggesting a duct-dependent flow?

Back 187

Pulse Oximetry measurement

p. 823

Front 188

What is a single heart sound charcteristic of?

Back 188

Hypoplastic left heart syndrome.

p. 823

Front 189

A harsh systolic murmur transmitted to the neck- what is this?

Back 189

Aortic Stenosis

p. 823

Front 190

What x-ray finding: Cardiomegaly and pulmonary edema in neonate, but wil show rib notching in child?

Back 190

Coarctation of aorta

p. 824

Front 191

We know that O2 is a potent pulm vasodilator, what effect does it have on PDA?

Back 191

Vasoconstrictor of the PDA

p. 824

Front 192

What is the single most important therapeutic intervention for a duct dependent lesion?

Back 192

IV Prostaglandin E1 (PGE1)- Alprostadil

p. 824

Front 193

What is the dose of IV Prostaglandin E1?

Back 193

0.1 mcg/kg/min- improvement with in minutes

p. 824

Front 194

What type of line can PE1 ve delivered through and what are some common SE's?

Back 194

1. Any line: umbilical, IO, IV...
2. SE: Vasodilation, flushing, hyperthermia, HoTn, and apnea.

p. 824

Front 195

What syndrome is often associated with endocardial cushion defects?

Back 195

Down's Syndrome...

p. 825

Hint 195

failure to thrive and frequent respiratory infx.

Front 196

T/F: Cyanotic lesions often present early in the neonatal period, where as obstructive duct dependent lesions typically present in the second week of life with feeding difficulties and shock

Back 196

True

p. 825

Front 197

Dig in children. Yup. CHF, stable...it is the ionotrope of choice: improves contractility and output. What is the dose- info...

Back 197

30-40 mcg/kg for term neonates
40-60 mcg/kg for infants and children

p. 825

Front 198

dig- what is the time of delivery on this...

Back 198

Total dose is administered over 16-24 hours: 1/2 initial bolus, 1/4 given in 8-12 hrs after inital dose, remaining 1/4 8-12 hrs later.

p. 825

Front 199

What type of murmur is: low intensity, non-radiating, brief and MC systolic?

Back 199

Innocent flow murmur

p. 825

Front 200

Who should be consulted, for heart defect patient, who needs reverse anti-coag with Vit K and FFP?

Back 200

Cardiologist.

p .826

Front 201

What is the leading cause of endstage cardiomyopathy requiring transplant, affecing children of all ages?

Back 201

Myocarditis

p. 827

Front 202

What are the presenting signs/sxs of myocarditis?

Back 202

MC: preceded by viral URI
additionally, will have:
-fever
-tachypnea
-respiratory distress
-tachycardia
-generalized malaise, myalgias
-vomiting
-decreased activity
-poor feeding

Hint 202

PE:
-decreased cardiac output
-tachy HR
-weak pulses
-cool extremities
-delayed cap refill
-skin mottling
-cyanotic skin
S3-S4 gallop
p.827

Front 203

What does tx of myocarditis depend on?

Back 203

The cause...

p. 827

Front 204

What condition of cardiac inflammation is MC positional-worsened in supine, relieved leaning forward?

Back 204

Pericarditis

p. 827

Front 205

What is the sine qua non of pericadial effusion with cardiac tamponade?

Back 205

Pulsus Paradoxus

- 20 mmHg fall in systolic BP with inspiration

p. 827

Hint 205

Heart sounds: muffled or distant heart sounds, friction rub. Peripheral pulses may be decreased with cool extremities, mottled skin, sluggish cap refill.

Front 206

What is the Mantoux screening test, when+ indicate?

Back 206

TB

p. 827

Front 207

What does emperic tx for pericarditis include?

Back 207

Oxacillin 50 mg/kg or Vanc 10 mg/kg for MRSA
+
Gentamicin 5-7.5 mg/kg in immunocompromised.
No effusion/tamponade: NSAIDS

p. 827

Front 208

What are the signs of Kawasaki/s Dz?

Back 208

1. b/l non-exudative conjunctivitis
2. lymphadenopathy
3. erythema of the mucous membranes
4. rash
5. extremity changes

p. 827

Hint 208

Cardiac complications are the most severe sequelae: coronary artery aneurysms, myocaditis, pericarditis, pericardial effusion, valvular dysfunction, LV dysfunction, arrythmias.

Front 209

What weeks of the illness, Kawasaki's Dz, do most coronary artery aneurysms occur?

Back 209

3-4 weeks

p. 828

Hint 209

MC: MI in first 6 months

Front 210

What is the tx for Kawasaki's Dz?

Back 210

Administration of IVIG 2 gms/kg over 12 hrs...results in rapid and dramatic symptomatic improvement in 90% of patients and prevents aneurysm formation in 95%,'

p. 828

Front 211

IN kawasaki's dz, what is the additional tx that should be provided, aside from IVIG?

Back 211

High dose ASA (20-25 mg/kg every 6 hrs)

Front 212

What are some lab indication risk factors for Coronary Artery Aneurysm in Kawasaki's?

Back 212

Hct < 35%
WBC>12,000
Plts >350,000
CRP >3 mg/dL
Albumin <3.5 gm/dL

p. 828

Front 213

When does infx endocarditis occur?

Back 213

When damaged endocardium is exposed to bacteria.

p. 828

Hint 213

Both conditions are necessary for the development of vegitation formation.

Front 214

What is HACEK, why is it important in endocarditis?

Back 214

HACEK are the common organisms assoc with bacterial endocarditis:
H. INfluenza
Actinobacillus
Cardiobacterium
Eikenella
Kingella

p. 828

Front 215

What is the MC complaint in bacterial endocarditis?

Back 215

Unexplained, persistent fever.

p. 828

Hint 215

Additional, associated sxs:
- cyanotic heart dz
-pneumonia
-new neuro deficits, hematuria, or skin rashes...think of things that can be caused by septic emboli

Front 216

What is the goal of tx for bacterial endocarditis?

Back 216

Eradication of the bacteria: parenteral abx- for a prolonged course MC.

Hint 216

Pen G
Ceftriaxone
-or-
Naficillin

Plus
Gentamicin

Front 217

Prophylactic abx for endocarditis, when should it be given?

Back 217

30-60 minutes prior to procedure

p. 829

Front 218

In MC cases of HCM, a genetic linked defect, contractile function of the heart is NML. So what is the problem?

Back 218

- hypertrophy of the ventricle
- thickened intima, of coronary arteries
- relaxation impairment: increased end diastolic filling pressure
- Asx hypertrophy of the ventricular septum-left vent outflow obstruction
p. 829

Front 219

HCM murmurs- what enhances or decreases the sound of murmur?

Back 219

Maneuvers that increase preload (valsalva, squatting) or increase afterload (handgrip) will decrease the murmur, where as standing (which decreases preload) will increase the murmur.

p. 830

Front 220

HCM suspected, what is definitive dx?

Back 220

cardiac cath with myocardial bx

echo suggests/supports- but not definitive.

p. 830

Front 221

What is the pharmacologic mgt of choice- while waiting for definitve care?

Back 221

BetaBlockers and Calcium Channel blockers.

p/ 830

Front 222

How "acute" abdominal pain defined?

Back 222

< 1 week

p 839

Hint 222

Recommend glancin at age appropriate classifications of abdominal pain. P. 840, Table 124-1.

Front 223

What type of abd pain is increased with movement? (ie, the child prefers to be still)

Back 223

Peritoneal pain

p. 839

Front 224

What type of abd pain is spasmodic in nature, provoking a restelssness or movement?

Back 224

Obstructive pain

p. 839

Front 225

How can you diminish, relax, otherwise voluntary guarding of the abdomen, when performing PE?

Back 225

Have the child flex his/her knees.

p. 840

Hint 225

Also, to reduce anxiety of the patient, clinician can place his/her hands on the childs during palpation

Front 226

When performing PE, what is important to NEVER forget?

Back 226

Genital examination in both boys and girls- to check for hernia and in boys testicular torsion.

p. 840

Front 227

What are two life threatening abdominal conditions in young infants?

Back 227

Necrotizing enterocolitis and malrotation with midgut volvulus

p. 840

Hint 227

additional urgent conditions: incarcerated hernia, testicular torsion and non-accidental trauma.

Front 228

What are some signs of "serious dz" in infant?

Back 228

inconsolability and lethargy

p. 840

Front 229

What type of vominting is suggestive of bowel obstruction and is a true emergency in an infant (possibly caused by malrotation with volvulus or intussusception)?

Back 229

Bilious vomiting (bright yellow or green)

p. 840

Front 230

What dz process is associated witht he failure to pass meconium in the first 24-48 hrs?

Back 230

Hirschsprung's Dz

p. 840

Front 231

When performing a detailed examination, abdomen, genital exam is important: swelling, erythema, or TTP- hernia, hydrocele, and torsion...but what else needs to be considered?

Back 231

Other causes of child's irritability: such as hair tourniquet on penis, or digit as well as consideration for corneal abrasion...

p. 840

Front 232

The ddx of older infants and children (3months to 3 yrs) with abdominal pain? (6)

Back 232

1. intussusption
2. acute gastroenteritis
3. constipation
4. UTI
5. testicular torsion
6. accidental and non-accidental trauma

p. 840

Front 233

Older infant/young child, pulls legs to chest with episodic pain, what is at the top of your differential; and periods of what appears relief/NML behavior?

Back 233

Intussusption...


- and if not, it should be

p. 840

Front 234

What should you do before touching a young child or older infant, when examining?

Back 234

Look at them...
- observe behavior/interaction...

p. 840

Front 235

What are some common causes of abdominal pain in children 3-15 yrs? (6-18)

Back 235

1. appendicitis
2. constipation
3. pain 2/2 non-specific viral syndrome or acute gastroenteritis
4. Strep Pharyngitis
5. UTI
6, Pneumia
Additionally (important, not common)
7. DKA
8. pancreatitis
9. inflammatory bowel dz (IBD)
10. cholelithaisis
11. Sickel cell anemia
12. HSP
13. toxic ingestion
14. testicular torsion
15. ovarian cyst
16. ectopic pregnancy
17. PID
18. renal colic

Front 236

T/F: CBC is a useful screening tool for undifferentiated abdominal pain.

Back 236

False

p. 841

Front 237

What does the sign: pneumatosis intestinalis indicate?

Back 237

necrotizing enterocolitis

p. 841

Front 238

How much risk of exposure is abdominal CT in children, as compared with plain CXR? And what is the lifetime risk of developing CA?

Back 238

1. 600 times more radiation
2. 1 in 1000 lifetime risk of developing malignancy

p. 841

Front 239

If you suspect that a patient is a surigcal candidate, what is an imperative with medication administration?

Back 239

Do not give PO medications.

p. 841

Front 240

What is the MC cause of intestinal obstruction in children: 3 months to 6 yrs of life?

Back 240

Intussuseption

p. 841

Front 241

Meckels Diverticulum, intestinal polyps, congenital duplications, lymphosarcoma, and HSP...all put you at risk for what intestinal complication?

Back 241

Intussusption

841

Front 242

What is the morphine dose in neonates? What is the dose in children?

Back 242

Neonates: 0.05-0.1 mg/kg q 4 hr
Infants and children: 0.1 mg/kg q 2-4 h

p. 841

Front 243

What is the dose of hydromorphone?

Back 243

0.015 mg/kg q 3-6 hrs

p. 841

Front 244

What is the dose of fentanyl?

Back 244

1-2 mcg/kg IV q 30-60 min

p. 841

Front 245

What is the dose of ketorolac, only in those > 6 months?

Back 245

0.5 mg/kg q 6 hrs.

p. 841

Front 246

While current jelly stool in patient with intussusption is only present as a late finding, what is an early expectation/finding?

Back 246

guiac positive

p. 842

Front 247

The presumptive dx of intussusption is usually made by?

Back 247

history

p. 842

- MC, a NML, healthy child between 6-18 months, who is playing, then drops to the floor, crying and drawing up legs (this continues waxing and waning/colick)

Front 248

What is a classic marking on U/S for intussusption?

Back 248

Target sign.

- U/S is sensitive and specific, but only used when uncertain. If certain use air enema...
p. 842

Front 249

This radigraph is ideal for intussusption, because it is dx and therapeutic. THis particular study also avoids risks if perforation is present as well as allows maintained control.

Back 249

Air contrast enema

p. 842

Front 250

How long following the onset of sxs before irreversible ischemia develops in midgut voluvulus?

Back 250

just a few hours...

p. 842

Front 251

Infant with volvulus presents MC how?

Back 251

Constant abd pain, bilious vomiting, abd distention, irritability.
Often appears toci, HoTn, tachyHR. Diffuse TTP.

p. 842-843

Front 252

What plain film result is "highly suggestive of dx: Malrotation with Midgut volvulus?

Back 252

loop of bowel overriding the liver

p. 843

Hint 252

This is a surgical emergency- call surgery immediately.

Front 253

What is needed for evidence of strangulated hernia (MC irritable pt, poor feeding, vomiting, and/or inguinal/scrotal mass)

Back 253

Manual reduction: this is medical and sometimes surgical emergency

p. 843

Front 254

How do you reduce an inguinal hernia?

Back 254

Place child in trendelenberg, apply pressure to inguinal canal with one hand, while the other milks hernia contents. + results- apply steady pressure to hernia
p. 843

Hint 254

s/p reduction- arrange 24-48 hr f/u with surgeon

Front 255

What is the MC surgical emergency in children?

Back 255

Appendicitis

p. 843

Front 256

What is the perforation rate of appendicitis in children < 4 ys old?

Back 256

90%

p. 844

Front 257

What WBC count has been associated with a decreased likelihood of appendicitis?

Back 257

LOw or NML...
tho, can not depend on elevated WBC to point to Appendicitis...this would be a lame test question, but this is a lame course, so...there you go...
-p. 844

Front 258

What is neither sensitive nor specific in work up for NEC, but serves to increase suspicion?

Back 258

+ occult stool

p. 845

Hint 258

Mainstay: Plain radiographs of the abdomen: Pneumotosis intestinalis...dilated loops of bowel, abnormal gas pattern

Front 259

What is the key to establishment of non-specific abdominal pain?

Back 259

The key: utilize as a working dx, reexamination in 24 hrs and repeat exam over time if sxs continue

p. 845

Front 260

What is the Wessel rule of three's for colic?

Back 260

3 episodes in one week, lasting for 3 hrs per day, lasting for more than 3 weeks- causing significant distress to caregiver

p. 845

Front 261

What is the differential dx of colic?

Back 261

-sepsis
-meningitis
-intussusption
-gastroesphageal reflux
-milk protein intolerance
-corneal abrasion
-hair tourniquet
-incarcerated hernia
-testicular torsion
-non-accidentla trauma

p. 845

Front 262

According to Constipation Guidelines, in the first week of life, what is the avg stools per day for infant?

Back 262

4 stools per day...gradually decreasing over time- depending on the feeds.

p. 846

Front 263

What age do kids MC begin stooling once per day>

Back 263

3 yrs old.

p. 846

Front 264

Constipation/abdominal pain...what should always be assessed?

Back 264

Rectal examination...
check: presence of stool, rectal tone (tonic constriction of the sphincter with empty rectal vault suggest Hirshsprung dz), sensation and size of the vault.

p. 846

Hint 264

Also: carefully examine abdomen- masses or sacral tumors
back: hair, etc that may suggest occult spinal dysraphism

Front 265

Child listless, hypotonic, constipated may have this process (exceedingly rare in the US)

Back 265

Botulism

p. 846

Front 266

Acute tx for constipation in the ED?

Back 266

Disimpaction w/glycerin suppository

p 846

Front 267

Abdominal pain, purpuric rash as well as arthritis...what are you thinking for dx?

Back 267

HSP...

- can be caused: Virus or Grp A strep
- Elevated IgA

Front 268

Cholecystitis presents in what manner, when compared to adults>

Back 268

Atypically...

- diffuse abdominal pain, irritability, pain worsens with respirations, associated with low grade temp.

p. 846-847

Hint 268

Cholecystitis w/o stone: Acalculous cholecystitis.

Front 269

what gallbladder process is suspected in child with shock and signs of poor perfusion?

Back 269

Choleangitis

- think e-coli as well as klebsiella as source

p 846-847

Hint 269

IV hydration, analgesia...bowel rest and if febrile: abx: amp and gent.

Front 270

T/F: The degree of pacreatic enzyme elevation is directly correlated with the degree of illness...

Back 270

False: the degree of the dz is not directly related to the degree of enzyme elevation

p. 847

Front 271

What is the likely dx of a patient who has a cough, abdominal pain, and post tussive vomiting?

Back 271

Pneumonia

p. 847

Hint 271

Patient: fever, tachypnea, or hypoxia

Front 272

What can present as fever, abdominal pain with or w/o vomiting and w/o sore throat?

Back 272

Streptococcus Pharyngitis...

- for this reason, all children > 3 y/o w/abdominal pain, esp if febrile, deserve a thorough oropharyngeal exam

p. 848

Hint 272

tx: benzathine injection x 1
or 10 day course Pen VK

Front 273

What may be present when a child is misdiagnosed with colic or has hx of frequent UTI's?

Back 273

Nephrolithiasis

p. 848

Front 274

MC dx in older children, MC presents with abdominal pain, but may also have: fatigue, weightloss, fever, BRBPR?

Back 274

Inflammatory bowel disease

p. 848

Hint 274

Definitive dx: endoscopy and bx and GI specialist...
- ER may obtain CT.

Front 275

T/F: all children with suspected Upper GI source for their bleeding require lavage.

Back 275

False- only those with PE evidence or hx suggestive of significant blood loss.

BOLD:Use 12F nasogastric tube in small children
14F and 16 F in older children.

p. 850

Hint 275

- read pgs: 848-849- little things, nothing for questions. however, a few charts

Front 276

T/F: mucosal lesions: gastritis, ulcer dz, esophagitis and mallory-weiss tear can be seen in children of any age.

Back 276

True.

p 851

Front 277

What is the Qualitative test used on Hematemisis- to determine fetal vs. maternal blood in infant?

Back 277

Apt test

p. 851

Front 278

T/F: Any child with significant illness or injury (Shock, polytrauma, respiratory failure, burns, head injury, or vasculitis) can develop stress-related peptic ulcer dz.

Back 278

True

p. 851

Front 279

A mother decided to have her baby at home and minmize prenatal mgt. her baby is at risk for Many things...however, is brought in with uncontrolled bloody vominting. What was missed here?

Back 279

Vit K shot

p. 851

Front 280

Dieulafoy lesion- what the heck is that?

Back 280

It is thought to be a developmental malformation of gastric vessels= and an unusual cause of UGI bleeding.

p. 851

Hint 280

definitive dx: endoscopy...

hx of recurrent hematemsis...w/o prodromal sxs.

Front 281

MOP presents with new born baby, vomiting and diarrhea (sometimes bloody). Reports this began 48 hrs ago...no surgical hx. No significant med problems. No sig. Maternal hx. No recent travel or events. Diet: formula, recent change since recall of old formula. What is wrongn with this poor kid?

Back 281

Milk protein allergy

MC occurs: 12-48 hrs after change to formula.

p. 851

Front 282

older infants with sudden hematachezia, painless...what must be considered?

Back 282

- Meckels diverticulum
- congenital malformation, such as small intestine duplication

p. 851

Front 283

What may be the source of painful LGI bleed?

Back 283

- intussusption
- malrotation with volvulus

p. 851 MC: 2mo-2 yrs

Hint 283

2-5 y/o: juvenile polyps, infx gastroenteritis, HUS, and HSP.

Front 284

What is more common in peds patient: UC or Crohn's Dz?

Back 284

Crohn's Dz

p. 853

Hint 284

Crohn's MC: abd pain, weightloss, anorexia, arthralgias
UC MC: bloody diarrhea and abd pain

Front 285

What are the tx goals of UGI and LGI bleeding? (4)

Back 285

1. resuscitation from hemorrhagic shock and restoring intravascular volume
2. restoring NML O2 carrying capacity by transfusion with pRBC's.
3. Identification of source bleeding
4. Stop ongoing blood loss

p. 853

Front 286

What is the drug of choice in esophageal variceal bleeding in children?

Back 286

Octreotide 1 mcg/kg bolus

Adverse SE: hyperglycemia

p. 853

Front 287

T/F:UGI bleeding, octreotide is safe in nonvariceal bleeding.

Back 287

FALSE!
- associated with multiple organ failure, in non-variceal source.
Talk to peds GI provider: Vasopressin may be more appropriate.

Front 288

T/F: Testicular torsion is bimodal age distribution, effecting neonates and early puberty.

Back 288

True

p. 861

Front 289

What does the absence of cremasteric reflex on the left side indicate?

Back 289

Testicular torsion on the left side

p. 861

Hint 289

Surgeon promptly, should not wait on U/S when suspected: < 6 hrs= excellent recovery rate. > 48hrs- patient loses the nut

Front 290

What is done for torsed testicle, when no urologist is available and the patient has been subject to this for excessive amount of time>

Back 290

Manual detorsion. MC torsion with medial rotation, making lateral (outward rotation, opening book) optimal.

p. 861

Hint 290

Provide appropriate/adequate analgesia, consider injection into spermatic cord.

This is not definitive therapy- success rate varies.

Front 291

Pain in testis is abrupt, severe and associated with nausea and vomiting. What is this? How is it different than Torsion of the testicular appendix?

Back 291

Testicular torsion

Torsion of the testicular appendix- is insidious and less severe, and no systemic signs/sxs.

p. 861

Hint 291

Testicular torsion: surgical- b/l orchipexy
Torsion of appendix: limitations on activity as well as oral analgesia

Front 292

What can cause an insidious onset of dysuria, change in urinary frequency or fever. Can becaused by bacterial source as well as enterovirus and adenovirus?

Back 292

Epididymitis

p. 861

Hint 292

u/a may have pyuria and bacteria

- Prehn's sig- relief with testicular elevation, not always present.

Front 293

What is the MC cause of painless testicular swelling in peds patient?

Back 293

Hydrocele

p. 861

Hint 293

non-communicating: static swelling- after closure of processus vaginalis
communicating: swelling increases and decreases w/patent processes vaginalis

Front 294

What is a painless scrotal swelling, that MC occurs in puberty, MC occuring on the left and mass engorgement which is compared to bag of worms?

Back 294

Varicocele

p. 862

Front 295

What is the MC solid tumor of adolescent males?

Back 295

Testicular tumor

p. 862

Front 296

When do almost all causes of NML physiologic phimosis resolve by?

Back 296

age 5 y/o

p, 862

Front 297

Which of the two is a true urologic emergency: phimosis or paraphimosis?

Back 297

Paraphimosis

p. 862

Hint 297

Should be reduced as soon as possible...delay provokes swelling and risk of complications.

Front 298

What provides most of the somatosensory nerve innervation to the shaft of the penis?

Back 298

Dorsal penile nerve

p. 862

Hint 298

Which is why dorsal penile nerve block is so effective. No epi...see image: Figure 127-3, p. 862

Front 299

What is cellulitis of the glans of the penis?

Back 299

Balanitis

p. 863

Front 300

What is cellulitis of the foreskin of the penis?

Back 300

Posthitis

p. 863

Hint 300

Balanopothitis...
celliltis of the glans and foreskin

regardless: warm soaks and system abx

Front 301

A non-paiful erection, that was not caused by sexual stimulation, but MC trauma?

Back 301

High Flow priapism- does not cause ischemia or impotence

p 863

Front 302

A painful erection, that was not caused by sexual stimulation, but MC sickle cell dz?

Back 302

Low flow priapsm- causes ischemia and/or impotence.

p. 863

Hint 302

W/o hx of pelvic, genital or perineal trauma- nearly all priapism is low flow.

Front 303

Hair thread tourniquet: erythematous, painful and edematous distal to site of strangulation, needs hair cut if visualized or the application of deilatory cream, such as Nair. However, what effect does debilatory cream have on synthetic fibers?

Back 303

None. Will not work.
ultimately...Urologyu consult a must

p. 864

Front 304

What is a risk for zipper injury to the penis?

Back 304

Not wearing underwear.

p. 864

Front 305

T/F: You should never forcibly restrain a child for gyn examination.

Back 305

True

p. 864

Hint 305

If it is necessary- perform via procedural sedation

Front 306

When is the female placed into the knee to chest position best used for?

Back 306

Examintion of the perianal and outer vaginal vault examination.

p. 865

Front 307

T/F: You should manually separate labial adhesions.

Back 307

False: This is something that will resolve over time, however, tx is needed, apply topical estrogen follow by patroleum jelly upon resolution of sxs.

p. 865

Front 308

In first 2-3 weeks of life, thin, white slippy d/c: leukorrhea, is common/harmless. However, once older infant and young girl, two possible causes become more likely. What are they?

Back 308

1. vulvovaginitis
2. Foreign body

p. 865

Hint 308

FB: present with foul odor and sometimes slightly bloody- MC cause: Toilet paper
Vulvovaginitis- pain, d/c, pruritis.

Front 309

What causes painless bleeding on underwear in 2-10 y/o females (MC in black females)?

Back 309

Urethral prolapse

p. 865

Hint 309

Tx: topical estrogen x 2 weeks and sitz baths
Stool softner- as constipation can provoke sxs.

Front 310

What is the vast majority of vaginal bleeding in adolecent female?

Back 310

Dysfunctional uterine bleeding

p. 866

Hint 310

First year following menarche- this is common. Best mgt: Estrogen-progesterone pill.

Front 311

What are some common causes of ARF in children? (4)

Back 311

1. glomerulonephritis
2. Sepsis
3. HUS
4. post-operative complications

p. 866

Front 312

What are some indicated medications that are known to cause nephrotoxic injury? (4)

Back 312

1. Amoxicillin
2. Acyclovir
3. Gentamicin
4. Cephalosporin

p. 866

Front 313

Renal Dz: What is caused by dehydration (GI losses), blood loss from trauma, capillary leaks/burns/sepsis/third spacing, limited cardiac output?

Back 313

Prerenal renal failure

p. 866, table 128-1

Front 314

Renal Dz: Tubular dz, myoglobinuria, tumor lysis syndrome, HSP- glomerluar dz, and interstitial dz from medications are causes of what?

Back 314

Renal dz

p. 866, table 128-1

Front 315

Renal Dz: Solitary kidney, urethral obstruction, pelvic mass, nephrolithiasis, cause?

Back 315

Post-renal or obstructive dz

p. 866, table 128-1

Front 316

What renal dz causes: nausea, anorexia, changes in urine output and color, edema, and headache?

Back 316

Renal failure

p, 866

Front 317

What are you thinking in UA, with + hematuria, casts, proteinuria, and active sediment?

Back 317

Glomerulonephritis

- if not, you should be

p 866

Front 318

What are you thinking in UA with proteinuria alone?

Back 318

Nephrotic syndrome

p. 866

Front 319

What does the UA suggest: + RBC on dipstick, not confirmed by microscopy (in the absence of false + dipstick)

Back 319

Myoglobinuria or hemoglobinuria

p. 866

Front 320

Whatcha think'n:
Acute diarrhea/abdominal pain, CBC: low H/H, Low Plt, and schistocytes

Back 320

Hemolytic Uremic Syndrome

p. 867

Front 321

What is the definitive study in most cases of intrinsic renal dz?

Back 321

Renal Bx.

p. 867

Front 322

What is the condition when GFR is < 10% of prediicted for age?

Back 322

ESRD

p 867

Hint 322

- only definitive tx: transplant
- standard tx: dialysis- in those < 2 yrs old this is peritoneal dialysis, assoc with fewer complications

Front 323

What is the MC antecedent infx cause of acute glomerulonephritis...with infx of the pharynx being the MC type of infx.

Back 323

Grp A betahemolytic strep.

p. 867

Front 324

+ proteinuria, proteinemia, as well as edema...

Back 324

Nephrotic syndrome

p. 868

Front 325

What are some of the MC medical problems of patients who are receiving dialysis and present to the ED?

Back 325

1. fever
2. abdominal pain (peritonitis)
3. dyspnea 2/2 fluid overload
4. chest pain (uremic pericarditis)
5. syncope
6. HTN
7. Acid-base, electrolyte d/o.

p. 868

Front 326

Microscopic or gross hematuria, sensorineural hearing loss, fhx of renal failure, cataracts- all togther assoc w/what?

Back 326

Alport syndrome

p. 868

Front 327

MC complaint of patient with Nephrotic syndrome?

Back 327

edema

p. 869

Front 328

What are the two main life threatening events associated with nephrotic syndrome?

Back 328

1. severe infx
and
2. thromboembolic event

p. 869

Front 329

Where is the edema associated with nephrotic syndrome most common to occur?

Back 329

face and periphery

p. 869: therefore, "NO NOT MISTAKE FACIAL EDEMA FOR ALLERGIC RXN"

Front 330

What are the four dx criteria for nephrotic syndrome?

Back 330

1. generalized edema
2. hypoproteinemia/low albumin
3. urine protein/urine creatinine
4. hypercholesterolemia (>200 mg/dL)

p. 869

Front 331

T/F: Give isotonic patients, even if severe edema, if hypovolemic shock is present.

Back 331

True

p. 869

Front 332

T/F: Though the response to steroids varies, the mainstay of tx for nephrotic syndrome is oral corticosteroids.

Back 332

True

p. 869

Front 333

Children w/Nephrotic syndrome are at high risk for, what complication and association with what organism?

Back 333

- peritonitis
- Strep Pneumoniae

-therfore need the Pneumovax

p. 869

Hint 333

Mild/moderate nephrotic syndrome/edema requires...low salt diet

Front 334

How is HTN defined in the peds population?

Back 334

> 2 Std deviations above age-based means, Systolic and Diastolic measure

p. 870

Hint 334

However, it is also defined as:
"avg systolic BP and /or diastolic BP that is at the 95th percentile or higher for gender, age and height on three or more occasions.

p 870

Front 335

What is a BP > 99th percentile for age and sex with evidence of acute endorgan damage.

Back 335

HTN crisis.

p. 870
Htn Crises is also defined as: "severely elevated BP exceeding the 99th percentile for age and sex with evidence of end stage organ damage".

Hint 335

Organ systems MC affected: CNS, Renal and cardiac

Front 336

What are some common causes of HTN in newborn?

Back 336

Renal: thrombosis, stenosis, anomalies
Heart: coarctation
Endo: PHeochromacytoma, cushing disease

p. 870

Front 337

What are some common causes of HTN in PreSchool/Kindergarten (<6 y/o)?

Back 337

Renal: parenchymal disease, vascular dz
Heart: Coarc
Endo: Pheo, Cushing Dz

p. 870

Front 338

What are some common causes of HTN in School age children 6-10 y/o

Back 338

Endo: Pheo and Cushing dx

p. 870

Front 339

What are some causes of HTN in adolescence?

Back 339

Essential HTN
Renal: Parenchymal, vascular
Endo: pheo, cushing dz
Drug abuse

p. 870

Front 340

What is the goal in BP reduction for HTN?

Back 340

< 25% reduction in first 8 hrs, followed by gradual reduction to NML levels in the next 26-48 hrs.

p. 870

Front 341

T/F: HSP renal involvement, should begin corticosteroid therapy and contact urology.

Back 341

False: Corticosteroid therapy is controversial and may cause recurrence of renal involvement, contact Urology first.

p. 876-871

Front 342

What is the MC cause of acute renal failure in young children?

Back 342

Hemolytic Uremic Syndrome (HUS)

p. 871

Hint 342

Epidemics: MC summer
Sporadically: can be 2/2 strep pneumoniae (invasive infx), oral contraceptive use, as well as prengnancy and malignancy.
Children < 10 y/o

Front 343

Epidemic HUS is associated with undercooked meat, unpasteurized milk and contaminated veggies and fruits- by what organism?

Back 343

E. Coli 0157:H7

p. 871

Hint 343

This produces a shiga toxin

e-coli enteritis, dz starts with N/V/bloody diarrhea, w or w/o fever. W/in one week the child has pallor, oiguria, irritability, lethargy, seizures and encephalopthy

Front 344

What are the three cardinal features of HUS?

Back 344

1. Acute Renal failure
2. Thrombocytopenia
3. Microangiopathic hemolytic anemia

p. 871

Front 345

What is contraindicated in pediatric diarrheal illnesses and may increase risk of HUS?

Back 345

Abx therapies as well as antimotility drugs

p. 871

Hint 345

oh, and plt transfusion not a good idea, worsen the thrombotic process...
Hemodialysis may be needed. 90% will survice and fully recover

Front 346

Hematuria is defined as:

Back 346

> 5 rbc's per hpf

p. 871

Front 347

What is a common finding in the urine, that appears pink or orange in the diaper that freaks out the care giver, but UA is negative for blood?

Back 347

Amorphous sediment

p. 871

Front 348

Hydralazine and Sodium Nitroprusside are what type medications

Back 348

Vasodilators

p. 871

Hint 348

Hydralazine: 0.1-0.5 mg/kg
Nitroprusside: -.3-8.0 mcg/kg

Front 349

What medication for the tx of BP is a beta and alpha blocker?

Back 349

Labetolol

p. 871

Hint 349

0.2-1.0 mg/kg

Front 350

Fast acting on and off: Beta blocker>

Back 350

Esmolol 100-500 mcg/kg/min

p. 871

Front 351

What GCS score is regarded as associated with severe head trauma?

Back 351

< 8

p. 888

Front 352

What GCS score is regarded as associated with moderate head trauma?

Back 352

9-13

p. 888

Front 353

What are MC associated with minor head injury in peds patient?

Back 353

13-15, with NML neurologic examination/mental status

p. 888

Hint 353

The american academy of pediatrics- defines, children with MHI as, "those who have no abnormal or focal findings on neurologic examination (including fundoscopic), and who have no physical evidence of skull fx.

Front 354

Why is frontal head trauma not as severe in those < 10 yrs old?

Back 354

Frontal sinuses have not developed yet, so the bone is more dense.

p. 888

Front 355

Determine the time of a head injury as well as subsequent temporal changes or persistent sxs. Worsening sxs: suggeests what. Where as persistent sxs suggests what?

Back 355

- worsening sxs: intracranial injury
- persistent sxs: amnesia/concussion

p. 889

Front 356

A scalp hematoma in a child < 2 y/o is associated with increased risk of what?

Back 356

Skull fx and intracranial hemorrhage

p. 889

Front 357

When a child is suspected as having sustained non-accidental trauma, what consultation may be useful?

Back 357

Ophthalmologist- who can do a more appropriate fundoscopic exam- for retinal hemorrhage...

p. 889

Front 358

In preverbal children, what hx from caregivers may indicate intracranial hemorrhage?

Back 358

behvior change- may be the earliest indicator, as well as/specifically irritability or lethargy

p. 889

Front 359

What are some high risk factors associated with < 2 y/o, that according to experts suggest need for more comprehensive head examination? (9) What do you do?

Back 359

1. depressed mental status
2. focal neurologic deficits
3. < 24 hr skull fx
4. Basilar/depressed skull fx
5. irritability
6. Seizure
7. Vomiting > 5 times in 6 H
8. LOC> 1 min
9. Bulging fontenelle

- get CT!!!
p. 890

Front 360

What do you do with head trauma patient that you feel is intermediate risk intracranial hemorrhage: vomting 3-4 times, LOC < 1 min, resolved irritability/lethargy, changes in behavior, skull fx > 24 hrs?

Back 360

- observe for 6 H or get head CT

- intermediate risk

p. 890

Front 361

T/F: Asymptomatic infants and children (not vomiting, NML neuro exam and mental status) who are at least 2-4 hrs postinjury can safely be d/c'd to reliable caregivers w/o imaging.

Back 361

True

p. 891

Front 362

Patients who are d/c'd to follow-up outpatient mgt for MHI, need careful instructions provided. What should they be told?

Back 362

Seek immediate care for the following:
1. lethargy
2. irritability
3. focal deficits
4. vomiting in 24 hrs

Front 363

What is the incidence of delayed deterioration (in head injury) when CT scan is NML?

Back 363

Zero

p. 891

Front 364

What does dizziness, unsteadiness, confusion, disorientation or amnesia with or w/o intrcranial hemorrhage indicate?

Back 364

Concussion

p. 891

Hint 364

" A complex pathophysiologic process affecting the brain, induced by traumatic biochemical forces"

Front 365

What type of concussion is, "gradual resolution over 7-10 days, w/o limitations on playing and training while symptomatic and w/no further intervention"

Back 365

Simple concussion

p. 892

Hint 365

Tx: rest until resolution in sxs with a graded return to activity

Front 366

What type of concussion is defined as, "persisting sxs or cognitive impairment, sxs with exertion, or specific sequelae".

Back 366

Complex concussion

p. 892

Hint 366

Tx: refer to sports medicine specialist or others with concussion exertise. These children may require neuropsych testing before returning to sports

Front 367

What is second impact syndrome?

Back 367

The vulnerability of the brain to minor impact during the post concussive period.

p. 892

Front 368

What are the six steps of "return to play program, following concussion" and how long should the patient remain asx between each step?

Back 368

1. No activity, complete rest
2. Light aerobic activity
3. Sports specific activity
4. Non-contact training drills
5. Full contact training after medical clearance
6. Game play

p 892

Front 369

Why is Sickle cell anemia a complication?

Back 369

Decreased ability to change shape...2/2 sickling shape, impedes flow

p. 924

Front 370

The interruption of blood flow, from the sickling blood cell in sickle cell anemia leads to what (3)

Back 370

1. poor tissue perfusion
2. acidosis
3. hypoxia
- which can lead to further sickling

p. 924

Front 371

Why do most sxs consistent with SCA (sickle cell anemia) not occur until after 4 month of life?

Back 371

Because until about the fourth month, fetal hemaglobin predominates, until replaced by regular hemoglobin. Fetal hemoglobin is uneffected by this.

p. 924

Hint 371

(reaches baseline low levels of fhb- just prior to 1 y/o)

Front 372

Which is one of the first organs effected by sickle cell?

Back 372

Spleen

- which is why, after recurrent infarcts, the patient is so susceptible to infxs: to encapsulated bacteria

p. 924

Front 373

Vaso occlusive crises cause severe extremity pain. What are some common triggers?

Back 373

1. stress
2. cold
3. dehydration
4. altitude
5. hypoxia
6. illnesses

p. 924

Front 374

What effect can vaso-occlusive dz have on bones?

Back 374

Can lead to infarction of the bone. Leading to pain
Fat emboli can be a complication.

p. 924

Front 375

What are some signs and sxs of fat embolism?

Back 375

1. ARDS
2. Hypoxia
3. Systemic sxs of petechiae, AMS, liver damage, and renal failure
- all this can occur w/o extremity pains.

p. 924

Front 376

What can occur in those less than 2 y/o, does not often occur when older than 5 y/o, and may be the only initial presenting complaint in someone with SCA?

Back 376

Dactylitis

p. 924

Front 377

A child presents to you, a febrile, with inguinal pain with weightbearing. No known reported hx of trauma. hx + for SCA. What is at the top of differential after vasoocclusive dz?

Back 377

AVN of the femoral head

p. 924

Front 378

T/F: ESR is a reliable lab in SCA patients.

Back 378

False

p. 925

Front 379

What is the difference in leukocytosis in SCA and that associated with infx?

Back 379

Left shift will occur only in infx

p. 925

Front 380

After the extremities and back, what is the next site of pain for vaso-occlusive disease

Back 380

the abdomen

p. 925

Front 381

Gallstones are common in SCA, and may occur as early as what age?

Back 381

2-4 y/o

p. 925

Front 382

Vasoocclusive crises of the abdomen is associated with ischemia to the:

Back 382

mesenteric, splenic, and hepatic systems...

p. 925

Front 383

What is frequently a complication of pneumonia in SCA?

Back 383

Acute chest crisis...due to pulmonary ischemia as well as infarction.

p. 925

Hint 383

Acute chest crisis is higher incidence in children than adults> but in children is associated w/better outcomes

Front 384

Any combination: pleuritic CP, cough, fever, and dyspnea...SCA is assoc with what?

Back 384

Acute Chest pain

Hint 384

PE: hypoxia, tachypnea, rales, rhonchi- though dehydration can decrease rales...

Front 385

What disease not only complicates the dx of acute chest crisis in SCA, but also increases the likelihood acute chest syndrome will develop (by four to six fold)

Back 385

Asthma

p. 926

Front 386

What is the leading cause of death in patients of all ages from SCA?

Back 386

Infection

p 926

Hint 386

Splenic dysfunction as well as inability to form IgG...puts patient at risk, particularly to encapsulated bacteria

Front 387

What age group is at greatest risk for sepsis, SCA?

Back 387

those patients: 6 months to 3 years old.

p. 926

Hint 387

H. Influenzae and Strep Pneumoniae are more common in the very young, and E Coli and Salmonella in older children.

Front 388

When considering SCA, what are the following:
- Temperature >104
- WBC's > 30,000, <5,000
- Plt < 100,000
- Hgb < 5 gm/dL
- Ill appearing/poor perfusion/HoTn
- Infiltrate in CXR
- hx of pneumococcal sepsis

Back 388

Risk factors for Bacteremia...


p. 926
- SCA children have greater risk: Meningitis, sepsis, pneumonia, as well as osteomyelitis

Hint 388

Dx eval:
- CBC
- Bcx
- O2 Sat measurement
- CXR
- UA

Front 389

What presents as: fever, coryza, and slapped cheek appearance, with circumoral pallor followed by diffuse maculopapular rash?

Back 389

Parvovirus B19...

p. 926

Hint 389

Gloves and Socks Syndrome:
- well demarcated painful erythema and edema of the hands and feet that evolves into petechiae, purpura, vesicles, and skin sloughing

Front 390

Regardless of the clinical presentation, what is the risk of Parvovirus B19 in SCA patient?

Back 390

Transient Aplastic Crisis...

p. 926

Hint 390

Retic count drops after 5 days, followed by decline in Hgb: aplastic crisis

Front 391

How much more common is Stroke in SCA, than in general population?

Back 391

250 times more common in SCA children than in general population.

p. 926

Hint 391

Can present as: Fleeting neuro sxs,. such as occurs with TIA, or can also occur: hemiparesis, seizure, AMS, or coma.
- also, higher risk, aneurysm, as well as intrcranial hemorrhage.
- Neuro sxs can also occur in acute chest crisis

Front 392

SCA patient, with painful, swollen, edematous tender penis...what is the cause and risk?

Back 392

- priapism
- risl can lead to fibrosis and subsequantly impotence...if not managed effectively.

p 927

Front 393

What is the typical peds transfusion rate/duration?

Back 393

10 cc/kg over 2 hrs

p. 927

Front 394

When is a tansfusion for SCA indicated? (3)

Back 394

1. Sx anemia
2. Hgb < 6 gms/dL, low retic count (aplastic anemia)
3. acute crisis w/ hgb below 10 gm/dL

p. 927

Hint 394

Aplastic anemia, tx'd MC with simple transfusion and close f/u

Front 395

Blood transfusions; what type are used in hx of allergic rxns?

Back 395

leukoreduced

p. 927

Front 396

Blood transfusions; what type are used for those who may be candidates for bone marrow transplant?

Back 396

irratiated cells

p. 927

Hint 396

`

Front 397

Why are meperidine and fentanyl medications that are no longer used in pain mgt SCA?

Back 397

Meperidine- SE profile
Fentanyl- short acting

p. 928

Front 398

Why is 5% dextrose in .45% NS more ideal than 0.9 NS in hydration of SCA patient?

Back 398

2/2 to the increased permeabilityof pulmonary vasculature and cardiomyopathy...

p. 928

Front 399

What should be done with the disposition of the patient who requires 2+ doses of narc mgt for SCA?

Back 399

Admission for pain mgt...

p. 928

Front 400

T/F: for SCA patient, O2 is a good therapy even if not hypoxic.

Back 400

False. O2 is only good for tx of patients w/hx of hypoxia.

p. 928

Front 401

Does alteplase (t-PA) have a role in children for mgt of a stroke related to SCA?

Back 401

None..

-p. 928

Front 402

Stroke mgt for SCA patient?

Back 402

1. control hyperpyrexia
2. correct hypoglycemia
3. treat hypoxia
4. treat hypovolemia
5. urgent exchange transfusion

p. 928

Hint 402

Neurosurg consult is recommended for hemorrhagic stroke

Front 403

What must be done for a child with SCA, > 1 y/o, with a fever, but has been stable for 4 hrs and has a good follow up arrangement?

Back 403

Prior to d/c- provide dose of rocephin...pending cx results...
p. 928

Front 404

Poor feeding, vomiting, and AMS are the MC manifestations of what?

Back 404

Metabolic emergencies.

p, 948

Front 405

How is hypoglycemia defined?

Back 405

Plasma glucose level < 45 mg/dL in sx patients, < 35 mg/dL in asx patients.

p 948

Front 406

Neonates may manifest hypoglycemia w/o adrenergic stimulation, such TachyHR, etc. How might they manifest sxs?

Back 406

- lethargy
- seizure
- apnea

p. 948

Front 407

What is one of the most critical lab tests in a neonate, infant or child who appears ill or AMS?

Back 407

Bedside serum glucose

p. 948

Front 408

What is the next step in ill child with AMS following d-stick?

Back 408

Evaluation of urine for ketones...
Ketonuria is characterisitc of ketotic hypoglycemia, adrenal or growth hormone deficiency, and other inborn errors of metabolism

p. 948

Hint 408

lack of ketones- hyperinsulinism or fatty acid oxidation

Front 409

What does it imply, when you give glucagon to hypoglycemic patient and they improve.

Back 409

Glucose normalizes, then the presence of hepatic stores if validated and the hypoglycemia is 2/2 hormonal deficiency.

p. 948

Front 410

What does it imply, when you give glucagon to a hypoglycemic patient and the patient fails to improve?

Back 410

poor glycemic stores

p. 948

Front 411

What is the primary parental tx for hypoglycemic patient?

Back 411

IV dextrose

Dose of dextrose: 0.5-1.0 gm/dL regardless of the route of administration.
Newborns should receive: 5 cc/kg 10% dextrose, infants and children: 2 cc/kg od 25% dextrose...

p. 949

Front 412

How should maintenance dextrose be provided with D10, for hypoglycemia in child? (Hint, it is 1.5 times the NML maintenance rate for infants and children?

Back 412

6-8 mg/kg/min D10

Hint 412

See Table: 137-1 p. 949, as well as figue: 137-1.
If IV, IO, or NG unavailable, Glucagon: 0.3 mg/kg/IM

Front 413

What should be provided in the suspected adrenal insufficiency patient?

Back 413

Hydrocortisone, 25 grams IV or IM for neonates, 50 grams for toddlers and school aged children, and 100 grams for adolscents.

p. 949

Hint 413

Sepsis is in differential of patient with AMS: may need to give abx: Ampicillin and gentamicin or ceftriaxone

Front 414

Why do most inborn errors of metabolism delay presentation until after enteral feedings begin?

Back 414

Because most metabolic toxins cross the plancenta and are cleared by maternal enzymes

p. 949

Hint 414

inborn errors of metabolism= I didn't fully get this the first time reading it...see p. 949-951, just read it.

Front 415

Organic acidemias are associated with significant anion Gap Acidosis- often higher than what?

Back 415

30-50 mEq/L.

p. 951

Hint 415

Need to Look at table 137-2, p. 951

Front 416

Regardless of the cause for Metabolic Crisis, neonates, infants and children present with 3 things that must be addressed immediately, what are they?

Back 416

-Acidosis
-dehydration
-encephalopathy

p. 951

Hint 416

The goal therefore in tx: 1. restore lost volume, 2. provide energy substrate to prevent progressive catabolism, 3. help with elimination of toxic metabolite.

Front 417

Why must one paralyze an infant cautiously who has inborn metabolic errors,: metabolic crisis

Back 417

Insufficient ventilation can worsen metabolic acidosis...(resp acidosis)

p. 951

Front 418

What is the dose recommendation for BiCarb, in metabolic acidosis from inborn errors of metabolism, when the ph <7.0?

Back 418

0.5 mEq/kg/hr

p. 951
- all patients in metabolic crisis should be kept NPO in order to remove potential inciting metabolic substrates.

Hint 418

However, not every inborn error of metabolism gets bicarb: this is controversial- so waiting until pH is < 7.0, this is appropriate.

Front 419

What effect do steroids have on ammonia?

Back 419

Increase this...hyperammonia.


p. 952

Front 420

CAH, 75% of all children will present with what lab/PE findings?

Back 420

- virilization
- elevated K
- low sodium

- 952

Hint 420

- MC will present in the 2nd week of life:
lethargy, irritability, poor feeding, vomiting, poor weight gain. May present with significant dehydration and even shock.

Front 421

In Congenital Adrenal Hyperplasia, where there is an increase in adrenal corticotropic hormone secondary to a decrease in the feedback loop, what happens to the skin, where?

Back 421

- hyperpigmention in the skin folds: labia, scrotum as well as the nipples.

p. 952

Hint 421

- can also show as: virilization in females- clitoromegaly

Front 422

What is the classic electrolyte problem exhibited in patient with CAH?

Back 422

- low serum sodium
- elevated serum potassium

p. 952

Hint 422

potassium may be as high as 6-12 mEq/L; but cardiac function is often preserved and no EKG abnormalities are often present.

Front 423

Why do you NOT give insulin and glucose to CAH patients with hyperkalemia?

Back 423

It can cause profound hypoglycemia.

p. 953

Hint 423

Instead: IV calcium gluconate, then IV sodium bicarb
-NS and hydrocrotisone tx is appropriate for the mangement of most patients with CAH

Front 424

What should individuals who are suspected of being involved in intimate partner abuse be asked?

Back 424

If Hi/Si and provided immediate Mental Health consultation-for concrete plan or + findings.

p. 1983-1984

Front 425

When dealing with intimate partner abuse, what is of paramount concern?

Back 425

Safety of the abused and children

p. 1984

Front 426

What are some high risks for potentially lethal situations with regard to intimate partner abuse?

Back 426

1. escalating frequency of violence
2. threat or actual use of weapons- particularly firearms
3. obsession with abused individual/stalking
4. homicide or suicidal threats and attempts or evidence of violent behavior outside the home

p. 1985

Hint 426

Additioanlly, substance abuse of the individual threatening the patient.

Front 427

What are the most dangerous times for the victim of intimate partner abuse?

Back 427

- during the time of disclosure
- during the time of the attempts to leave the relationship

p. 1985

Front 428

Who should survivors of intimate partner abuse be referred to?

Back 428

intimate violence experts

p 1985

Front 429

Why should intimate partner violence advocates not contact the patient directly?

Back 429

Because this could jeopardize the patient.


p. 1985

Front 430

T/F: All individuals who are sexually assaulted sustain some injury.

Back 430

False

p. 1980

Hint 430

Lack of an injury does not mean sexual assault did not occur.

Front 431

T/F: Every part of the forensic evidence should be used, and caution is advised against trying to tailor the kit to the patient (this is how mishaps occur) and the nature of the assault.

Back 431

False: the kit is tailored to the nature of the expressed assault.

p, 1981

Hint 431

After evidence is collected- a chain of custody must be maintained and the kit secured.

Front 432

CDC recommends preventive tx following sexual assault. What is it?

Back 432

Cetriaxone 125 mg IM
plus
Metronidazole 2 gm PO
plus
Azithromycin 1 gm PO
plus
Doxyclycline 100 mg PO bid x 7 days

p. 1981, table 291-4,

Hint 432

PEN G, benzathine 2.4 million units IM, divided as 1.2 per each buttock...for syphilis
(e-mycin, 500 mg PO qid x 15 days if emergent, allergy)

Front 433

What are the two common emergent contraceptive pills?

Back 433

1. Levonorgestrel only 1.5 mg in single doseor two doses 0.75 mg (12 hrs apart)
2, Combined estrogen-progestin- two doses of 100 mcg ethinyl estradiol plus 0.5 mg levonorgestrel 12 hrs apart.

p. 1982

Front 434

When should you consider sedation in a patient who has a FB in ear?

Back 434

when the patient will not remain calm (is aggitated) or when prior attempts to remove have failed.

p. 976

Front 435

When is deep sedation appropriate in the removal of ear FB?

Back 435

1. When FB has been on place for long time
2. when FB is not visible
3. When the child is uncooperative or mentally handicapp.

p. 976

Hint 435

IV ketamine is ideal drug of choice for deep sedation

Front 436

What is the risk with Oral Jet Irrigators (for ear irrigation)?

Back 436

Creates pressure sufficient enough to cause TM rupture

p. 977

Front 437

T/F: The pressure from a metal syringe creates enough pressure to cause TM rupture.

Back 437

False

p. 977

Front 438

Who should manual ear syringing methods not be used on for ear irrigations?

Back 438

Those with hx of TM perforation or weakness

p. 977

Front 439

Ear currettes and right angle hooks can scoop out smooth spherical FB's in the ear, however, they can cause abrasions, bleeding and trauma in the canal. Therefore they are not recommended when FB is where in the ear?

Back 439

the inner 2/3 of the canal.

p. 977

Front 440

What instrument is ideal for the removal of FB's that are irregular shaped and soft?

Back 440

Alligator Forceps.

p. 977

Front 441

T/F: Majority of nasal FB's can be removed by ER provider, w/o ENT provider or sedation.

Back 441

True

p. 978

Front 442

What is one FB, that regardless of location, needs to be removed emergently!?

Back 442

Button Batteries. In the moist nasal environment, the battery may create an electrical current, which results in liquification necrosis- which of course leads to tissue damage.

p. 978

Front 443

What is the least invasive + pressure technique to remove nasal FB?

Back 443

Having the patient blow his/her nose!

p. 978

Front 444

What is the "big kiss" technique of positive pressure assistance for removal of FB?

Back 444

Parent or provider (ya right- not gonna happen) applies mouth to mouth of patient, occluding the patent nares- blows to forcibly dislodge the FB

p. 978

Hint 444

- may be tried four times

Front 445

Bag-valve-mask- positive pressure technique for FB removal from the nose?

Back 445

pt in trendelenburg, and otherwise concept same as the big kiss method

p. 978

Front 446

What is a way to dislodge a FB from the nose, when the object is visible and there is a space between the object and the nasal mucosa, and the object is not easily removed with instrument?

Back 446

Foley catheter/balloon catheter (they may be small enough- see page 981)

p. 979

Hint 446

catheter should be lubed with lidocaine jelly

Front 447

What is a non-invasive way to remove magnets that are adhered to another magnet or ring in the nose?

Back 447

Using a stronger magnet on the outside of the nose, to remove the strenght of the pull on the inside of the nose.

p 981

Front 448

What should be done after removal of FB from nose or ears?

Back 448

Examination, to ensure no additional FB or damage from the attempted removal.

p 981

Front 449

17% of children with FB in their ear have additional existing pathology...what's up with that?

Back 449

Often FB is placed into the ear in effort to relieve the irritation or itching. Look for existing pathology and tx accordingly (otitis media)

p. 981

Hint 449

Additionally, 28% of children with FB's in ear/nose have pica

Front 450

What is one thing that is not essential in LP examination of children?

Back 450

Opening pressures are not necessary

p. 982

Front 451

What is something that has to be done, prior to LP, in child w/hx of thrombocytopenia or factor deficiency?

Back 451

replace factor or platelets prior

p. 982

Front 452

What is a useful technigue to soothe an infant prior to LP?

Back 452

Sucking on pacifier dipped in sucrose...supposed to act as an analgesic agent, calm the patient and decrease crying

p. 982

Front 453

What is the peak age of Nursemaid's elbow?

Back 453

2-3 yrs old.

p. 983

however, range is 6 months to 7 yrs.

Front 454

Nursemaid's elbow, MC occurs in which extremity?

Back 454

left- because the child is often pulled with the guardians right hand

p. 983

Front 455

How long after relief of nursemaids elbow with the patient typically begin to use arm?

Back 455

Tho relief is immediate, the child will often not use the extremity for 5-10 minutes.

p. 983

Hint 455

HOWEVER, no use of relief with in 30 minutes- get radiogrpah, there may be a fx. if neg, but the child persists discomfort, f/u with ortho in one week.

Front 456

What is a method for daily caregivers to organize resources for healthcare of a special needs child?

Back 456

Emergency Care Plan

p. 953

Hint 456

Copies should be available at the child's home as well as any place that he/she frequently visits/attends.

Front 457

What is the term given to describe a collection of non-progressive disorders of movement and posture originating from the injury sustained by the developing brain w/in the first 3-5 yrs of life?

Back 457

Cerebral palsy

p. 953

Front 458

CP may be associated with other CNS sequelae, such as what (5 things)

Back 458

1. seizures
2. cognitive impairments
3. sensory abnormalities
4. communication abnormalities
5. behavioral abnormalities

p. 953

Front 459

CP can be calssfied base on 3 criteria?

Back 459

1. motor abnormality (spastic, dyskinetic,ataxic,hypotonic, and mixed)
2. Distribution (diplegia, hemiplegia, quadriplegia)
3. degree of involvement

p. 953

Front 460

CP patients w/seizures: refractory seizures, what may you need to ask caregiver?

Back 460

Ask about baseline serum glucose. May need a ketogenic diet, administering dextrose may increase seizures previously controlled by therapeutic ketosis.

p. 955

Front 461

Why should you avoid mineral oil in children with aspiration hx?

Back 461

- can cause aspiration pneumonitis/pulmonary complications

- p. 956

Front 462

What neural tube defect includes: spinal cord, meninges, and certebral column?

Back 462

Meningomyelocele

p. 956

Hint 462

- complications of sensory and motor control of voluntary and autonomic activities at or below the spinal lesion

Front 463

What occurs in 75% of meningomyelocele patients>

Back 463

Hydrocephalus
- requiring early shunt placement...

p. 956

Front 464

Patient with hx of hydrocephalus. Has recent hx of AMS, irritability, N/V, vision disturbances, neck pain, HA, seizures...FOP/MOP report that this happened in the past, prompting neurosurg involvement. What is likely the cause?

Back 464

Shunt malfunction

p 956

Front 465

What does new onset stridor in patient with hx of meningomyelocele suggest?

Back 465

Chiari II malformation...

p. 956

Hint 465

Obtain Emergent MRI of the craniocervical junction and monitor the child closely for progression of stridor to complete airway obstruction.

Front 466

What does even minor head trauma with Chiari II malformation require cervical immobilization?

Back 466

2/2 to the instability of the craniocervical junction.

p. 956

Front 467

UTI in meningomyelocele patient? Often straight caths etc must be performed, 2.2 to hx of retention. Why should only sx patients be given abx?

Back 467

because bacterial colonization is common

p. 956

Hint 467

Do not attempt recatherization in the ED for sxs, for fear of compounding the underlying injury, but instead obtain Urology consultation.

Front 468

What are the areas distal to neural tube defect that are susecptible to burns and pressure sores?

Back 468

Insensate areas


p. 956

Front 469

What describes a heterogenous d/o of brain development that affects: behavior, social interaction, language and communication, and often features repetitive motor activities.

Back 469

Autism

p. 956

Hint 469

Interaction is often difficult: sensory defensiveness, unusual social behaviors, aggressive self protective responses to medical procedures/exams.

Front 470

What is cognitive impairment and decreased adaptive behaviors resulting from injury, disease, or abnormality occuring before 18 y/o?

Back 470

MR (mental retardation)

p. 957

Front 471

With the socially difficult/ackward patient, what is the best means to effective manage communication/interaction?

Back 471

THe child's caregiver is a great resource to tell you how to communicate/manage the patient.

p. 957

Front 472

What is a particular area of concern with deceleration injuries in Down's Syndrome children?

Back 472

Atlantoaxial subluxation or dislocation...

p. 957

Front 473

What is the condiction of serious, potential life-threatening complication of cord injuries proximal to the midthoracic level?

Back 473

Autonomic dysreflexia

p. 957

Hint 473

Consists of paroxysmal sympathetic and parasympathetic hyperactivity initiated below by stimuli below the level of the lesion: bladder overdistention, fecal impaction, or flushing, pounding HA, HTN, bradycardia, and pilerection.

Front 474

T/F: Ventriculaer appearance of NML size on CT effectively r/o ventricular shunt malformation

Back 474

False: can be 2/2 to surround loss of tissue compliance.

p. 958

Front 475

How is DKA defined in the pediatric chapter?

Back 475

- metabolic acidosis < 7.3
- Serum Bicarb < 15 mEq/L
- hyperglycemia (>300 mg/dL)
- ketonemia
p. 959

Front 476

MC cause of DKA in children with known DM?

Back 476

lack of compliance

p. 959

Front 477

What should be considered in a child with DKA and a depressed level of consciousness?

Back 477

Cerebral edema

p. 959

Front 478

While abdominal pain and vomiting can occur in DKA, what does focal pain, not responsive to fluid mgt and associated with fever suggest?

Back 478

underlying intra- abdominal proceess

p. 959

Front 479

Elevated glucose in the presence of ketonemia, ketonuriaand acidosis almost always indicates what?

Back 479

DKA

p. 959

Hint 479

HOWEVER, any condition causing prolonged vomiting or excessive fasting can cause ketoacidosis- however, glucose not commonly elevated: no hx DM, consider- ethylene glycol, isopropyl alcohol, and salicylates.

Front 480

What is the most dreaded complication associated with DKA, and accounts for 57-87% of all peds related deaths from DKA?

Back 480

Cerebral edema

p. 959

Front 481

What is some specific risk factors associated with overt life threatening cerebral edema:(4)

Back 481

1. young age (MC < 5 y/o, rare> 20)
2. severe hyperosmolarity
3. persistent hyponatremia
4. severe acidosis

p. 959

Hint 481

cerebral edema MC occurs 6-12 hrs after onset of therapy. Pt appears to be improving, just prior to deterioration

Front 482

Premonitory sxs of cerebral edema (50%); are:(4)

Back 482

- HA
- Seizure
- declining MS
- papillary edema

p. 959

Hint 482

However, cerebral edema may also be the first sign as well

Front 483

Standard tx for cerebral edema?

Back 483

Mannitol (0.5-1gm/kg IV bolus) and ET intubation if necessary

p. 959

Hint 483

Also consider 3% Hypertonic Saline 10 cc/kg over 30 minutes
ET/vent: allow vent to compensate for metabolic acidosis

Front 484

What is the PH difference of VBG vs ABG?

Back 484

VBG is 0.03 less than ABG

p. 960

Front 485

T/F: Current consensus statements on DKA management of all children with DKA require cardiac monitor. Qtc prolongation occurs frequently during DKA and is correlated with ketosis.

Back 485

True.

p. 961

Hint 485

This Qtc prolongation can lead to torsades de pointes...

Front 486

What should be the emphasis of mgt of DKA for the ER provider?

Back 486

1. perfusion status
2. electrolyte disturbances
3. hyperglycemia
4. Ketonemia

p. 961

Hint 486

Table: 139-3, p. 961

Front 487

Once vitals signs in DKA patient are NML, what should ER provider not do?

Back 487

Correct the fluid deficit too rapidly.

p. 961

Front 488

What should maintenance fluid potassium be?

Back 488

30-40 mEq/L

p. 961

Front 489

What is the insulin infusion dosage per hr for DKA?

Back 489

0.1 units/kg/hr

p;. 961

Front 490

When glucose in DKA mgt normalizes to < 250 mg/dL, what should be added to IV fluids?

Back 490

Dextrose- with the goal of maintaining glucose level: 150-300 mg/dL until resolution of ketoacidosis.

p. 961

Front 491

Insulin rate should not be less than?

Back 491

<0.05 units/kg/hr

p. 961

Front 492

Bicarb is not advised as it has not been shown to be of benefit. Except for those whose PH is below what value and possess hemodynamic compromise?

Back 492

< 7.0

Front 493

Stable, new DM, polyuria, polydipsia. Not in DKA. What is the SC dose insulin?

Back 493

0.1 units/kg regular insulin- first dose. However, this is along with hydration...po or IV

p. 962

Front 494

If a patient with known DM presents with hyperglycemia,without illness or injury...how do you adjust insulin?

Back 494

10% of NML dose added to current regimen, as regular insulin- SC.

p. 962

Hint 494

If intercurrent illness or injury: 5% of daily insulin dose every 4-5 hrs until condition resolves.

Front 495

What type of Bipolar d/o presents MC in children: manic depressive form, or mood cycling form?

Back 495

Rapid mood cycling, mixed variant form occurs more commonly in children and adolescents.

p. 970

Front 496

All psychotic patients, regardless of age, require prompt eval and tx. Why?

Back 496

- because they are risk for suicide; self-injurious behavior, victimization, and aggression

p. 970

Front 497

What is the MC reason for psychosis in children?

Back 497

- drug use

p. 970

Hint 497

MC hallucination: auditory 80%

Front 498

Why are benzo's a second line drug in children with acute psychosis?

Back 498

Because disinhibition is common in this age group, and may worsen acute aggitation.

p. 970

Hint 498

Use: haloperidol, zyprexia? see chart 141-3, p. 969

chapter: 967-971...just got the highlighted portions.

Front 499

T/F: Flat and inverted T waves are common in the Newborn.

Back 499

True

p. 984

Front 500

How do you figure the Qtc?

Back 500

Qtc=QT/sq root of R-R interval

p. 984

Hint 500

should be < 0.49 in first 6 months
<0.44 there after

Front 501

What is the best lead for measurement of P wave amplitude?

Back 501

Lead II

p. 984

Front 502

T/F. First degree AV block, mobitz type I and junctional rythms need to be worked up for congenital heart disease/

Back 502

False: this can all be NML in the children

p 985

Front 503

First degree AV block can occur in the NML pediatric heart, but also in:

Back 503

Acute Rheumatic Fever, some congential heart anomalies (ASD), endocardial cushion defects, postop cards patients and those with digitalis toxicity...

p. 985. MC no tx is needed.

Front 504

What is unique about the QRS complex in complete congenital heart blocks?

Back 504

The QRS complex has a NML duration for age. THis is because the pacemaker is above the bundle of his bifurcation.

p. 985

Front 505

What is the QRS complex prolonged in acquired complete heart block?

Back 505

Because the pacemaker is below the level of the bifurcation...

p. 985

Front 506

Sinus bradycardia in complete heart block, what's the initial tx?

Back 506

atropine 0.02 mg/kg
(minimum 0.1 mg, max 0.5 mg)
p. 985

Front 507

What does the HR > 220 in an infant, and >180 in a child suggest?

Back 507

SVT

p. 985

Hint 507

Causes sinus tach: severe dehydration, fever, pain, hemorrhage, hyperthyroidism, sepsis, and drug toxicity- ingestion or iatrogenic

Front 508

Vagal maneuvers slow accelerated HR of presumed SVT and Pwaves are visible, what is the dx?

Back 508

sinus tachycardia

p. 985

Front 509

What is the MC form of ventricular preexcitation syndome in children?

Back 509

WPW

p 985

Hint 509

Short PR interval (<0.12 seconds)
Prolonged QRS complex (>0.12 seconds), with classic delta wave

Front 510

Arrythmias occur in 50% of patients with WPW, and are usually associated with what?

Back 510

narrow complex tachycardia.

p. 986

Hint 510

MC thru AV reentrance (antegrade conduction through AV node w/retrograde conduction through accessory pathway-orthodromic conduction- of which a-fib is associated)

Front 511

Antidromic tachycardia can occur in WPW as well. The retrograde conduction that occurs with this can cause what type of dysrythmia?

Back 511

v-fib and ultimately death

p. 986

Front 512

What medications do you NOT give to WPW?

Back 512

Dig and verapamil can cause lethal arrythmias, do not give flecainide to patients with WPW either.

p. 986

Front 513

Why should all wide complex arrythmias be treated as ventricular tachycardia?

Back 513

Because SVT with abberration is rare in children

p 986

Hint 513

V-tach is MC seen in the presence of underlying congenital heart dz

Front 514

What effect does amiodorone have on the QT interval?

Back 514

prolongs it

p. 986

Front 515

What are common presenting signs and sxs of prolonged QT syndrome?

Back 515

- presyncope
- syncope
- palpitations
- sudden cardiac death

p. 987

Front 516

What are the risk factors for sudden cardiac death in prolonged QT syndrome?

Back 516

- male gender
- prior syncope
- QTc > 500 milliseconds

Hint 516

medications associated with prolonged QT table 143D-9

Front 517

What lead should be used to calculate QTc?

Back 517

Lead II, calculated over 3-5 consecutive beats.

p 988

Hint 517

Prolonged QTc:
>470 males
>480 females

Front 518

What is the ED mgt of prolonged QTc syndrome?

Back 518

Avoidance of therapies that make this Crap worse: particularly abx.

Front 519

Salter Harris fx: which type has the lowest incidence of growth disturbances?

Back 519

Type I

p 893

Front 520

Why does a fx through the physic risk growth disturbances?

Back 520

It is sensitive to changes in blood supply...

p. 892

Front 521

When should you suspect Salter Harris type 1 fx?

Back 521

When TTP over the physis

p. 892

Front 522

Which salter harris type I fracture does not need regular ortho f/u for growth perimeters?

Back 522

Distal fibula fx...not associated with groth arrest.

p. 892

Hint 522

Review salter harris fx
EL, M, E,EM, crush...

Front 523

T/F: Type III salter harris fx's are intraarticular.

Back 523

True

p. 893

Hint 523

Open reduction may be required: contact ortho

Front 524

What is the MC tx need of a Salter harris type IV fx?

Back 524

Open reduction, internal fixation...

p. 893

Front 525

Which Salter Harris fx dx is often difficult to make and easily confused with another?

Back 525

W/o hx- may confuse Salter Harris ! with V, but the hx MC suggests a large compressive force and often ntable effusion with Salter harris V.

p. 895

Front 526

When should buckle fx, also called Torus fx, be followed up in Ortho?

Back 526

w/in 1 week

p. 895

Front 527

What determines the need for reduction in a greenstick fx?

Back 527

The degree of angulation...

p. 895

Hint 527

more stable and less painful then common fx

Front 528

Bowing or bending fx (also called plastic fx) is limited to where?

Back 528

Long bones of the forearm and leg

p. 895

Hint 528

dx is made radiographically
needs ortho: MC tx, is fx completion with reduction/realignment

Front 529

What should one be concerned about in < 2 y/o child with clavicle fx?

Back 529

Child abuse

p. 896

Front 530

MC clavicle fx site?

Back 530

Middle third of the clavicle

p. 896

Front 531

What humeral fx is uncommon in children?

Back 531

fx of the humeral diaphysis...

assess radial nerve on initial examination as well as following reduction attempt.

Front 532

Why must you consider abuse in a child with diaphyseal fx of the humerus?

Back 532

Because of the amt of force needed to cause a fx in this area

p. 896

Front 533

When a fx is sustained in the diaphysis of the humerus, which is more UNSTABLE: a transverse or spiral fx?

Back 533

Transverse fx

p. 896

Front 534

Which fx's, comparatively are most commonly missed in children?

Back 534

Elbow fx

p. 896

Front 535

Explain what CRITOE signifies?

Back 535

Order of closure of the elbow
Capitellum- by 1 yr
Radial head- by 3 yr
Internal (medial) epicondyle- by 5 yr
Trochlea- by 7 yr
Olecranon- by 9 yr
External (lateral) epicondyle-11 ys

p. 898

Front 536

Which fat pad may be NML in the elbow, the anterior or posterior fat pad?

Back 536

Anterior fat pad

p. 896

Hint 536

Posterior fat pad= fx. Hemiarthrosis from intraarticular injury

Front 537

What does an anterior fat pad, that appears as a sail sign indicate?

Back 537

-possible pathology.

(probable fx)
p. 896

Front 538

What are the MC fx types in children < 8 y/o?

Back 538

Supracondylar fx

p. 897

Hint 538

ie MC cause- FOOSH

Complications= uncommon, but can be transient neuropraxia to volkmann's ischemic contracture

Front 539

Elbow fx; which strcutures are the greatest threat for damage- with a Posterolateral displaced fx?

Back 539

brachial artery and median nerve...damage can lead to compartment syndrome.

p 897

Front 540

Why is a splint with sugar tong more appropriate that volar with the forearm?

Back 540

complete and even greenstick fx because the fx of the radius and ulnar have a tendency to become more displaced if not effecively immobilized.

p. 900

Front 541

What is a monteggia fx?

Back 541

Fx of the ulna with dislocation of the radial head

p 901

Hint 541

needs immediate referral to Orthopedist

Front 542

What is a galleazzi fx?

Back 542

A fx of the radius with dislocation of the DISTAL radiulnar joint

p. 902

Hint 542

Very uncommon- but Must have ortho referral/exam

Front 543

What is the hallmark finding of wrist carpal bone injury?

Back 543

pain out of proportion to the injury

p. 902

Front 544

What type of fx is a distal phalaynx fx with a subungual hematoma?

Back 544

Open fx.

p. 902

Hint 544

Abx: controversial.

My experience with a hand surgeon was one prick, he indicated a need- and would sell you down the river with blame if not done...but, not gospel.

Front 545

Pelvic fx in pediatric population is rare, except for avulsion fx. Yet, non-avulsion fx occur as well- what is the MC cause?

Back 545

Pedestrian vs. MVC

p. 902

Front 546

Pelvic fx requires A LOT of force in pediatric patient. What MUST be considered/effectively r/o in this event?

Back 546

multisystemic organ damage

p. 902

Hint 546

MC- hemorrhage comes from other injuries, not pelvic vessels.

Front 547

What should you be thinking in a child who has a femur fx and no hx of walking?

Back 547

-abuse

p. 903

Front 548

HoTN in isolated femur fx in a young child, what should be investigated?

Back 548

Source of other injury; isolated femur fractures in an of themselves do not cause HoTn.

p/.. 903

Front 549

MC Cause of hip disability in adolescents?

Back 549

SCFE- slipped capital femoral epiphysis

p. 903

Front 550

What imaging should be done in a patien w/chronic pain in the groin, hip, thigh, or knees?

Back 550

B/L hip radiographs to r/o SCFE

p. 903

Front 551

Every child with suspected SCFE needs prompt...

Back 551

Ortho referral-
this answer was a gimme...

p. 903

Front 552

The Ottawa knee rules apply to those older than or equal to what age?

Back 552

2 y/o

p. 904

Front 553

Fx distal femoral physis: what artery lies close to the distal femoral metaphysis and may be injured with peroneal nerve?

Back 553

Popliteal Artery

p. 904

Front 554

Type III tibial tuberosity fracture, into the joint is at risk for...?

Back 554

Compartment syndrome

p. 904

Hint 554

Type I and type II fractures are MC treated with immobilization...

Front 555

Toddlers fx, what is this?

Back 555

Isolated spiral fx of the distal tibia.

p. 904

Hint 555

Pt is often observed not wishing to bear weight: limping or just refusing to ambulate

Front 556

While trauma to the metatarsals and phalanges is common, what is the risk associated w.crush injuries?

Back 556

vascular damage and compartment syndrome

p. 905

Front 557

What is the MC way for a patient to get osteomyelitis?

Back 557

Hematogenous spread

p. 906

Hint 557

MC source/cause: Staph Aureus

-see Table 133-2, p. 906

Front 558

T/F: The earliest signs of spetic arthritis are often subtle

Back 558

True'

p. 906

Front 559

What is the difference in the presentation of older infant, toddler and child with septic arthritis, vs the presentation of infant?

Back 559

Older infant, toddler, child: fever and localizing signs
Infants: pseudoparalysis- not using it.

p. 906

Front 560

What are some risk factors for septic arthritis?

Back 560

1. immune deficiency
2. SSA
3. RA
4. IBD

-. 907

Front 561

What labs are obtained in a septic arthritis patient? How do you obtain a definitive dx?

Back 561

-CBC
- ESR/CRP
- Throat cx

Definitive dx: aspirate of joint fluid-ie arthrocentesis

907

Front 562

What are some common signs/sxs reported by septic arthritis patient?

Back 562

- temperature>101.3
- CRP > 20
- Leukocytosis (>12,000)
- severe pain
- tenderness to palpation
- spasm and refusal to walk

p. 907

Front 563

What is the tx for septic arthritis?

Back 563

Vancomycin
Clindamycin
-or-
Linezolid (when vanc resistance is high)

p/907

Hint 563

Prognosis is related to the duration of sxs prior to dx: >4 days= orthopedic complications

Front 564

What presents with:
High Fevers >102.2 for at least 2 weeks, chills. Often associated w/faint erythematous macular rash (colescing on trunk, hands, etc). Polyarticular associated?

Back 564

Juvenile Idiopathic Arthritis (JIA)

p. 907

Hint 564

Also associated with: hepatospleenomegaly, lymphadenopathy, as well as pleuritis and pericardial effusion.

Front 565

Most well known form of avascular necrosis of the femoral head?

Back 565

Legg Calve Perthes Disease

p. 907

Hint 565

MC age onset: 4-9 y/o, MC unilateral

Front 566

What is needed to est the dx of Acute Rheumatic Fever?

Back 566

2 major jones criteria or 1 major and 2 minor jones criteria
and antecedent (MC2-6 weeks)
of strep infx

. p 909

Front 567

What type of arthritis is MC associated with Acute rheumatic fever?

Back 567

migrating , fleeting, polyarticular arthritis

p 909

Front 568

What may be the sole presenting sx acute rheumatic fever?

Back 568

Chorea

p 909

Front 569

Acute Rheumatic fever, what is the greatest risk of morbidity and mortality associated with it?

Back 569

Carditis

p.909

Front 570

What criteria, for Jones Criteria are the following?
Carditis (new/changing murmurs, cardiomegaly,HF, pericarditis); Migratory polyarthritis, Chorea, Erythema Marginatum, Subcutaenous nodules?

Back 570

Major Criteria

p. 909

Front 571

What are the following in jones criteria?
Fever, arthralgia, + hx of acute rhem fever, elevated ESR or CRP, prolonged PR on EG, and Antistreptococcal- rising titer.

Back 571

Minor criteria

p. 909

Front 572

Acute Rheumatic fever, outpatient or inpatient?

Back 572

Inpatient of course

p. 909

Front 573

T/F:Even in Acute Rheumatic fever, ASA is not given- because of the risk for Reyes Syndrome. Only for Kawasaki's Dz

Back 573

It is given, when arthritis. To achieve serum concentrations: 20-30 mg/dL...then reduce after one week. However, weight risk...esp in other seasonal inflammatory conditions...

Front 574

Carditis and HF, assoc with Acute Rheumatic Fever. What is the tx? For how long?

Back 574

Prednisone 1-2mg/kg/d until 2 weeks after resolution of sxs

p. 909

Front 575

What is the tx for rheumatic fever?

Back 575

Benzathine 600,000 units IM < 27 Kg
Benzathing 1.2 million units IM for eveyone else

Hint 575

PO PCN can also be provided. E-mycin when PCN allergy all for 10 days

Front 576

How long does a rheumatic fever, w/o carditis prophylactic abx? What about those with hx of carditis?

Back 576

= 5 yrs
= lifetime

p. 909

Front 577

What are some gross ways to differentiate Transient Synovitis from Septic Arthritis?

Back 577

Reactive arthritis:
Full ROM is MC preserved
Does not appear toxic
Severe pain and spasms are absent
Sometimes No fever
Mean WBC and ESR are significantly lower than septic arthritis=BUT, you cannot rely on this to r/o or rule in this dx.

p. 909

Front 578

What is more sensitive, when examinating transiet synovitis of the hip, what is more sensitive than plain film for detecting an effusion...

Back 578

U/S

p. 909

Hint 578

Tx: rest and NSAIDs

Front 579

I am not doing cards for the final chapter: Oncology/Hematology Emergencies in children...ch 136...too much info. I will be rereading this.

Back 579

Good luck with your test. Hope this helped.

-howell

Front 580

What does hypoglycemia, in the abscence of urine Ketones imply?

Back 580

Inborn error of metabolism: with fatty acid oxidation defect

p. 951

Front 581

What does hypoglycemia, in the presence of urine Ketones imply?

Back 581

Organic Acidemia

p. 951

Front 582

What ammonia level in newborn, neonate, tells of inborn error of metabolism with the Urea cycle?

Back 582

> 200 micromoles/L

- remember, ammonia is formed from the deamination of amino acids- excreted as urea in the urine. Urea is produced in hepatocytes.

Hint 582

After protein feedings, the ammonia level may reach > 400 micromoles/L

Front 583

While NS is appropriate fluid administration in inborn errors of metabolism; why is dextrose administration also helpful and appropriate?

Back 583

Dextrose solution IV helps with the Urine output (as does NS), yet the dextrose helps with the substrate essential to eliminate/reduce the catabolism.

p. 951

Front 584

What is the MC cause of inborn metabolic erros of metabolism associated with encephalopathy?

Back 584

Hyperammonemia

p. 952

Front 585

What should be considered in patients who have a serum ammonia level > 600 micromoles/Liter?

Back 585

Dialysis

p. 952

Front 586

T/F: Acute Leukemia's are the MC CA in children.

Back 586

True

Front 587

T/F: AML can be caused by the tx for ALL.

Back 587

True

p. 929

Front 588

T/F: the complication rate is higher in ALL than in AML

Back 588

False, the complication rate, particularly with infx's, is greater in AML than in ALL

p. 929

Front 589

Most signs and sxs associated with leukemia have to do with bone marrow infiltration and failure. What are the s/sxs MC associated with this?

Back 589

-Pallor
-fatigue
-easy bruising
-and infx are common

Hint 589

Think of Leukemia in a patient who has frequent, easy epistaxis and abnormally located brusing.

p. 929

Front 590

What is a likely dx of a patient with:
- low to NML plt count
- Low WBC (<4,000/mL^3)
-and a hx of nighttime pain?

Back 590

Leukemia

p. 929- nealry 2/3 will have hepato or spleenomegaly at the time of dx

Front 591

T/F: Almost all children with leukemia have some form of hematologic abnormality, including elevated or depressed WBC's, very few have the extremely elevated WBC's thought to be the typical presentation of leukemia.

Back 591

True

p.929

Front 592

What is the purpose of intrathecal tx for CA for inducation tx?

Back 592

Intrathecal tx for CA (leukemia for ex) aims to eliminate the CNS as a sanctuary for residual dz.

p. 929

Hint 592

Similar to the intention of the "consildation phase of tx" which seeks to eliminate the prospects of residual dz.

Front 593

Why is survival with tx less in AML than in ALL?

Back 593

Because it is more difficult to induce remission in AML than in ALL, and many children do not survive the tx intensity/strength.

p. 930

Front 594

T/F: Maintenance therapy after remission is key to tx of AML.

Back 594

False: maintenance therapy is of no benfit.

p. 930

Front 595

If transfusion is desired in a child with Leukemia, who has anemia...what are the Hb and Plt goals?

Back 595

Hgb, tx: >8-10
Plt: > 50,000-100,000

p. 930

Front 596

What is the plt count that risk spontaneous intracranial hemorrhage?

Back 596

< 5,000/mL

p. 930

Front 597

What is the platelet count in thrombocytopenic leukemia child, that warrants prophylactic transfusion? (in the absence of other bleeding risks)

Back 597

<10,000/ml^3

p. 930

Front 598

What if a patient with thrombocytopenia, hx of leukemia, is about to undergo an invasive procedure? (where there is a bleeding risk)

Back 598

plt counts should exceed >50,000-100,000/mL^3

p. 930`

Hint 598

0.1 unit/kg, results in a 30,000-50,000/mL3 increase

Front 599

Which is DIC MC associated with: AML or ALL?

Back 599

AML

p. 931

Front 600

1 unit pRBC's is expected to raise the Hb level_____gm/dL in patient w/o active hemorrhage.

Back 600

3

p. 931

Front 601

A dose of plts is 0.1 units/kg and is expected to raise plt count by____ to____.

Back 601

30,000-50,000

p. 931

Front 602

Who should contact prior to transfusing blood products in child, with hx of CA/tx?

Back 602

pediatric Oncologist

p. 931

Front 603

What is cryoprecipiate?

Back 603

Blood product rich in: vWF, Facot VIII, and fibrinogen..

p. 931

Front 604

Clinicially significant hyperleukocytosis occurs when WBC's are:
>________ in AML
and
>________ in ALL

Back 604

> 200, 000 in AML
> 300, 000 in ALL

p. 931

Hint 604

- this can lead to white thrombi of aggregates of leukocytes

ED tx for this: IV hydration, urinary alkalinazation, and administration of allopurinol for tumor lysis syndrome.

Front 605

What should be avoided in hyperleukocytosis condition?

Back 605

Anything that increases blood viscosity...
pRBC's and diuretics...

p. 932

Hint 605

PLts do not increase viscosity

leukopharesis is temporizing measure.

Front 606

How much will cryoprecipate increase fibrinogen by?

Back 606

50 mg/dL...

p. 932

Hint 606

0.1 unit/kg increases fibrinogen by 50 mg/dL

Front 607

What does Reed-Sternberg cell result indicate?

Back 607

Hodgkins lymphoma

p. 932`

Front 608

What is the MC malignancy in 15-19 y/o age group?

Back 608

Hodgkins Lymphoma

p. 932

Front 609

How does Hogkins Lymphoma MC present?

Back 609

Rubbery, painless lymphnode. MC: supracelavicular or cervical.

p. 932

Front 610

How is hodgkins lymphoma confirmed?

Back 610

Lymph node bx

p. 932

Front 611

A patient with significant lymphadenopathy. What medication is not to be given if lymphoma is in the differential?

Back 611

steroids

p. 932

Front 612

Hodgkin's Lymphoma begins where? Non-Hdgkins lymphoma begins where?

Back 612

Hodgkins Lymphoma begins anywhere w/in the lymphatic systems and then spreads to lymphnodes

Non-Hodgkins lymphoma- a Ca of lymphatic system, that can begin from ANY other organ system in the body.

p. 932-933

Front 613

The most common solid tumor of childhood (boys and girls)

Back 613

CNS tumors

p. 933

Front 614

T/F: children with HA's are statistically more likely to have CA.

Back 614

False. While HA is a common hx of individual with CA, the existence of HA does not impart risk

p. 933

Front 615

T/F: Most CNS malignancies are best identified on head CT, which superior visualization of the tumor in relation to surrounding structures.

Back 615

False
- these tumors are visualized on CT, but MRI is superior.

p. 933

Front 616

Frequently, vasogenic edema surrounding a CNS tumor can cause motor weakness and contribute to increase in ICP, what do you give if you do not suspect CNS lymphoma?

Back 616

Dexamethasone single IV dose, 1 mg per yr of age to max of 10 mg.

p. 934

Front 617

opsoclonus-myoclonus, MC associated with which CA?

Back 617

Neuroblastoma

p. 934

Hint 617

Tho not only associated with this. So the presence of this does not yield the dx. Besides this is rare.

Front 618

T/F: Neuroblastoma leads to HTN 2/2 to the production of increased catecholeminas.

Back 618

False.

It leads to the increase of precursors to catecholemines. This is a differentiating characteristic of pheochromacytoma- which does produce catecholamines...

p. 934

Front 619

What is a Wilms Tumor (ie, other name)

Back 619

Nephroblastoma

p. 934

Hint 619

MC affects children < 10 y/o
MC: Abdominal swelling and mass.

Front 620

Large abdominal mass, what should you suspect? And, why should you limit abdominal examinations as well as vigorous palpation when examining the patient?

Back 620

1. Wilm's Tumor (Nephroblastoma)
2. Vigorous palpation risk capsular rupture, and spilling of CA contents.

p. 934

Front 621

Germ Cell Tumors, who do these effect: boys or girls?

Back 621

Trick question: Boys and Girls, however, testicular tumors more common than ovarian.

p. 935

Hint 621

Testis tumors- throughout age spectrum
Ovarian tumors- MC onset puberty

Front 622

What is the MC bone tumor and is identified MC in adolescence?

Back 622

Osteosarcoma

p. 935

Front 623

What is the leading cause of death with Ewing Sarcoma?

Back 623

Pulmonary Mets

p. 936

Front 624

What has a classic "moth eaten" appearance on radiograph. MC patient presents with Tender, Painful soft tissue mass.

Back 624

Ewing Sarcoma

p. 936

Front 625

In the context of febrile cancer patient, neutropenic fever is defined as ANC less than what?

Back 625

<500/mL^3 (or ANC <1000, with expected decline to 500 mL^3)

p. 937

Front 626

In CA, when determining neutropenic fever...how ios fever conservatively defined?

Back 626

- single oral temp: 101
- a temp 100.4 for more than 1 hr
- two brief elevations 100.4 in 12 hr period

p. 937

Front 627

Why, in a CA patient, is a rectal temperature, even in peds patient NOT recommended?

Back 627

Bactermia is believed to be induced by this.

p. 937

Front 628

Typhlitis, what the heck is that?

Back 628

A non-focal infx ascending colitis...will often manifest as a deceptively mild abd pain- this is because the child cannot mount an appropriate inflammatory response in neutropenic state.

p. 937

Hint 628

tx: Metronidazole or Clindamysin

Front 629

Neutropenic patient, fever. What are the following indications with regard to the ICU admission:
- fever
- prolonged cap refill time
- tachycradia
- diastolic HoTn

Back 629

- indications of likely admission

p. 937

Front 630

Blood Cx in Neutropenic patients, prior to Abx administration is important. Amt taken has an impact on the yield. What is the general rule?

Back 630

1 cc/year of age, minimum 3 cc and max 9 cc.

p. 937

Front 631

What is the condition upon which there is a rapid turn over of CA cells, with a release intracellular potassium, phosphate and uric acid?

Back 631

Tumor Lysis Syndrome

p. 938

Hint 631

- MC triggered by Chemotherapy
- but may also be from sepsis as well as other causes.

Front 632

What is the most immediate threat to life in Tmor lysis syndrome?

Back 632

Hyperkalemia

p. 938

Hint 632

Needs tx, now
- 5% dextrose/0.25% NS solution with 40-80mEq sodium bicarb per liter at two to four times maintenance to produce a urinary output of > 100 cc/m^2 w/specific gravity of <1.010 and urinary pH of 7 to 7.5

Front 633

in a neutropenic patient, with hyperkalemia, why do you n ot treat with rectal kayoxalate?

Back 633

Same reason not to take temperature, risk of bacteremia.

p. 938

Front 634

Ca > 15, patient with sxs of muscle weakness, AMS, coma, polyuria, and dehydration, vomiting and bradycardia. How do you tx this poor kiddo?

Back 634

NS 2-3 times maintenance.

4cc/kg for first 10 kg
2 cc/k for next 10 kg
1 cc/kg for the remainder...

p. 938

Front 635

SIADH, is commonly associated with CA as well as the tx for CA. MC sxs associated with SIADH are related to hyponatreamia: fatigue, lethargy, confusion, coma and seizures. How do you tx?

Back 635

3% Normal Saline
4 cc to 6 cc/kg- until seizures stop

p. 938

Front 636

Superiormediastinal syndrome may be lethal, in the presence of RSI. Why?

Back 636

The syndrome itself is 2/2 to the existence of a mass causing compression on trachea and adjacent structures...often the compression prevents passage of the ET tube...now, after paralysis of patient you are screwed...

p. 939

Hint 636

use other measures: elevating head of the bed. bilevel positive pressure and consideration pof heliox.

Front 637

Typhilitis (also called neutropenic colitis), commonly involves the terminal ileum and cecum. But what is it?

Back 637

Necrotizing colitis, w/o a source.

p. 939

Hint 637

= MC polymicrobial in nature

Front 638

What condition is just as common as Typhilitis in patients with Leukemia??(it is another GI issue, and will often also manifest into the RLQ)

Back 638

Appendicitis

p. 939

Front 639

A child with hx of CA, presents with back pain. What must yoy consider?

Back 639

Spinal tumor

p. 939

Front 640

If patient has cord compression, secondary to vasogenic edema, what is required for tx inorder to improve of even resolve sxs: sensory, motor disturbances?

Back 640

corticosteroids


p. 939

Hint 640

Cord Compression is a neurologic emergency; Dexamethasone 1 mg/yr of age to a max of 10 mg; an emergent MRI and neuro surg provider

Front 641

How is hemophilia commonly dx?

Back 641

Prolonged aPTT, but a NML PT and PLT count

p. 941

Front 642

When a hemophilia patient has premonitory sxs: warmth, burning, stiffness, or tingling sensation. What should be the goal in raising the factor level?

Back 642

raising the factor level to 50%

p 941

Front 643

T/F: An appropriate adage in hempophila tx is: "when in dobt tx". So for hemiarthrosis, correct levels to 50% with a second infusion 12 hrs later for factor VIII deficiency and 24 hrs for Factor IX deficiency.

Back 643

true

p. 941

Front 644

Spontaneous muscle hematomas can present with severe pain as well as limited ROM. What is unusual event/occurrence with this, but should NOT ever be missed (think neurovascular complication)

Back 644

Compartment syndrome and nerve compression

- right, crap man, you are smart!!!!
p. 941

Front 645

Treatment of ilipsoas hemorrhage in hemophiliac patient, aggressive, how?

Back 645

80-100% factor replacement and pain control (uh, and of course...admission)

p. 941

Front 646

What is the leading cause of death in hemophilia?

Back 646

Intracranial Hemorrhage

p. 941

Hint 646

- this is GREAT risk even in patients with mild case of the disease. In fact initally after a trauma, may seem NML, but the bleeding is oozing in nature and may take time to show.

Front 647

how are all minor head traumas with hemophilia tx'd initially?

Back 647

100% factor replacement

p. 941

Hint 647

Intraoral leasions, frenulum or other intraoral lacerations= factor replacement to 50%

Front 648

Hemphilia, painless atraumatic heamturia, MC cause?

Back 648

renal

p. 941

Front 649

Raising the clotting activity in hemophilia, to 100% requires what units?

Back 649

50 units/kg, Factor VIII
100 units/kg, Factor IX

p. 941

Front 650

Hemophilia, what if you do not have the resources available to restore 100% factor. Are there alternatives?

Back 650

yes,
Cryoprecipitate 0.5 units/kg for Factor VIII
FFP 15-20 cc/kg for factor IX

just be attentive to fluid volume...

p. 945

Front 651

Type 3 vWD often appears similar to severe hemophilia. However, vWD also can be contributory to FVIII deficiency, how?

Back 651

vWillebrands factor will promote platelet activation, but will also, prevent activation and clearance. If it is missing, then it is not available to prevent this clearance leading to the deficiency.

p. 945

Front 652

What is the agent MC used in vWD, non-type III.

Back 652

DDAVP

- do not substitute nasal DDAVPfor stimate- the concentrations are different.

p. 945

Hint 652

raises serum vWF and FVIII to 3-5 times

Front 653

After DDAVP is administered for vWD, why do you limit water intake of the next 24 hrs

Back 653

to prevent hyponatremia

p. 945

Front 654

What is the leading cause of anemia in childhood?

Back 654

Iron deficiency

p. 946

Hint 654

This is uncommon >3-4 y/o, and is present should raise concern for occult bleed