A 4-year-old boy with sickle cell disease presents to the emergency department with fever of 39.5°C (103.1°F), lethargy, and tachycardia. His last vaccination was 6 months ago. BP is 85/50 mmHg, HR 160/min, RR 36/min. He appears ill with capillary refill of 4 seconds. Labs show: WBC 2,500/μL with 60% neutrophils, hemoglobin 6.2 g/dL (baseline 7.5 g/dL), platelets 95,000/μL, reticulocyte count 0.2%. Evaluate the prioritization of management interventions for this presentation.
Q2
A 16-year-old girl presents to the emergency department with confusion, tachycardia (HR 145/min), and temperature of 40.2°C (104.4°F). Her mother reports she has been taking medication for depression. On examination, she has dilated pupils, flushed dry skin, hyperactive bowel sounds, and sustained ankle clonus with hyperreflexia. Labs show: WBC 14,000/μL, CK 2,500 U/L, creatinine 1.4 mg/dL. She takes fluoxetine and recently started a new medication from another provider. Which therapeutic intervention addresses the most likely diagnosis?
Q3
A 10-month-old infant is brought to the emergency department following a brief resolved unexplained event (BRUE). The parents report the infant suddenly became limp, pale, stopped breathing for about 20 seconds, then spontaneously recovered. The infant is now alert, feeding well, and appears normal. Physical examination is unremarkable. The infant was born at term, has normal development, and this is the first such episode. Evaluate the most appropriate management strategy.
Q4
A 7-year-old boy presents to the emergency department with fever to 40°C (104°F), severe sore throat, drooling, and respiratory distress. He is sitting upright in tripod position, appears toxic, and has inspiratory stridor. His immunization status is unknown as the family recently immigrated. Oxygen saturation is 91% on room air. Lateral neck X-ray shows a thumb sign. Which of the following approaches best balances the immediate management priorities?
Q5
A 4-year-old boy is brought to the emergency department after ingesting an unknown quantity of his grandmother's iron tablets 2 hours ago. He initially vomited twice but now appears stable. Vital signs are: BP 100/65 mmHg, HR 110/min, RR 24/min. Abdominal X-ray shows multiple radiopaque tablets in the stomach. Serum iron level is 425 mcg/dL (normal: 50-120 mcg/dL). Which finding would most strongly indicate the need for immediate chelation therapy with deferoxamine?
Q6
A 14-year-old girl presents to the emergency department with severe abdominal pain, nausea, and vomiting for 24 hours. She appears ill with Kussmaul respirations, fruity breath odor, BP 95/60 mmHg, HR 125/min. Labs show: glucose 485 mg/dL, pH 7.15, bicarbonate 10 mEq/L, positive serum ketones, potassium 5.8 mEq/L, sodium 128 mEq/L. After initial IV fluid bolus of 20 mL/kg normal saline, which of the following is the most appropriate next step?
Q7
A 5-year-old boy with known asthma presents to the emergency department with severe respiratory distress. He has been using his albuterol inhaler every hour without relief. On examination, he is sitting upright, has difficulty speaking, respiratory rate is 45/min, oxygen saturation is 88% on room air, and has diffuse wheezing with poor air movement. After initial treatments with oxygen, continuous nebulized albuterol, and IV corticosteroids, he shows minimal improvement. What is the most appropriate next intervention?
Q8
A 2-year-old girl is brought to the emergency department after a witnessed seizure lasting 5 minutes. She has a fever of 39.5°C (103.1°F). On examination, she is postictal but arousable, with no focal neurological deficits and no signs of meningeal irritation. Her immunizations are up to date. Which of the following is the most appropriate management?
Q9
A 6-month-old infant presents to the emergency department with a 12-hour history of inconsolable crying, vomiting, and drawing legs up to the abdomen. Physical examination reveals a palpable sausage-shaped mass in the right upper quadrant and bloody mucoid stool. Ultrasound shows a target sign. What is the most appropriate next step in management?
Q10
A 3-year-old boy is brought to the emergency department with sudden onset of respiratory distress and choking while eating peanuts. On examination, he has stridor, intercostal retractions, and decreased breath sounds on the right side. Oxygen saturation is 88% on room air. Which of the following is the most appropriate immediate management?
Pediatric emergency management US Medical PG Practice Questions and MCQs
Question 1: A 4-year-old boy with sickle cell disease presents to the emergency department with fever of 39.5°C (103.1°F), lethargy, and tachycardia. His last vaccination was 6 months ago. BP is 85/50 mmHg, HR 160/min, RR 36/min. He appears ill with capillary refill of 4 seconds. Labs show: WBC 2,500/μL with 60% neutrophils, hemoglobin 6.2 g/dL (baseline 7.5 g/dL), platelets 95,000/μL, reticulocyte count 0.2%. Evaluate the prioritization of management interventions for this presentation.
A. Fluid bolus, blood cultures and empiric ceftriaxone plus vancomycin, then address anemia (Correct Answer)
B. Exchange transfusion for acute chest syndrome
C. Hydroxyurea initiation and antipyretics with close monitoring
D. Immediate packed RBC transfusion as the primary intervention
E. Broad-spectrum IV antibiotics after blood culture, then fluid resuscitation
Explanation: ***Fluid bolus, blood cultures and empiric ceftriaxone plus vancomycin, then address anemia***
- The patient presents in **septic shock** (tachycardia, hypotension, prolonged capillary refill), requiring immediate **fluid resuscitation** as the first step.
- Due to **functional asplenia**, patients with sickle cell disease are at high risk for fatal sepsis from **encapsulated organisms**, making urgent blood cultures and **empiric antibiotics** (e.g., ceftriaxone) vital following stabilization.
*Exchange transfusion for acute chest syndrome*
- **Acute chest syndrome** typically presents with respiratory distress and new pulmonary infiltrates, which are not the primary findings in this hemodynamic emergency.
- While serious, life-threatening **septic shock** takes priority over interventions for localized vaso-occlusive complications.
*Hydroxyurea initiation and antipyretics with close monitoring*
- **Hydroxyurea** is a long-term maintenance therapy used to increase **HbF** and is never appropriate for managing an acute, life-threatening crisis.
- Relying on antipyretics and monitoring in a patient with **hypotension** and fever would be inadequate and likely lead to clinical deterioration.
*Immediate packed RBC transfusion as the primary intervention*
- Although the patient has an **aplastic crisis** (low reticulocyte count and decreased hemoglobin), crystalloid **fluid boluses** are faster to administer for immediate shock management.
- Transfusion is necessary but should follow or occur alongside **volume expansion** and may carry risks if not managed carefully in a sickle cell patient.
*Broad-spectrum IV antibiotics after blood culture, then fluid resuscitation*
- In cases of **septic shock**, fluid resuscitation for **perfusion** and blood pressure support must occur concurrently with or before antibiotics.
- Delaying fluids while waiting for cultures or antibiotic preparation violates **PALS/Sepsis guidelines** for a patient with clear signs of circulatory collapse.
Question 2: A 16-year-old girl presents to the emergency department with confusion, tachycardia (HR 145/min), and temperature of 40.2°C (104.4°F). Her mother reports she has been taking medication for depression. On examination, she has dilated pupils, flushed dry skin, hyperactive bowel sounds, and sustained ankle clonus with hyperreflexia. Labs show: WBC 14,000/μL, CK 2,500 U/L, creatinine 1.4 mg/dL. She takes fluoxetine and recently started a new medication from another provider. Which therapeutic intervention addresses the most likely diagnosis?
A. Cyproheptadine and benzodiazepines for serotonin syndrome (Correct Answer)
B. Cooling measures and bromocriptine for heat stroke
C. Sodium bicarbonate and activated charcoal for tricyclic overdose
D. Physostigmine for anticholinergic toxicity
E. Dantrolene and supportive care for neuroleptic malignant syndrome
Explanation: ***Cyproheptadine and benzodiazepines for serotonin syndrome***
- The patient exhibits the classic triad of **autonomic instability**, **altered mental status**, and **neuromuscular irritability** (clonus, hyperreflexia) after starting a new medication alongside the SSRI **fluoxetine**.
- **Cyproheptadine**, a serotonin antagonist, is the specific treatment for severe cases, while **benzodiazepines** help control agitation and autonomic hyperactivity.
*Cooling measures and bromocriptine for heat stroke*
- While this patient is hyperthermic, **heat stroke** does not typically present with focal neuromuscular signs like **clonus** or **hyperreflexia**.
- **Bromocriptine** is a dopamine agonist used for Neuroleptic Malignant Syndrome, not environmental heat stroke, which is managed primarily with aggressive external cooling.
*Sodium bicarbonate and activated charcoal for tricyclic overdose*
- **Tricyclic antidepressant (TCA) toxicity** presents with the "3 Cs": **coma, convulsions, and cardiotoxicity** (QRS widening on ECG).
- TCA toxicity results in decreased bowel sounds and **central nervous system depression**, whereas this patient has **hyperactive bowel sounds** and neuromuscular excitation.
*Physostigmine for anticholinergic toxicity*
- Anticholinergic toxicity presents with **dry skin** and **mydriasis**, but it is characterized by **absent bowel sounds** and a lack of clonus or hyperreflexia.
- **Physostigmine** is contraindicated if TCA overdose is suspected and would not address the **hyperreflexic neuromuscular findings** seen in serotonin syndrome.
*Dantrolene and supportive care for neuroleptic malignant syndrome*
- **Neuroleptic Malignant Syndrome (NMS)** is characterized by **"lead-pipe" rigidity** and bradyreflexia, which distinguishes it from the **clonus** seen here.
- NMS typically has a slower onset (days to weeks) compared to the rapid onset of **serotonin syndrome** following a medication change.
Question 3: A 10-month-old infant is brought to the emergency department following a brief resolved unexplained event (BRUE). The parents report the infant suddenly became limp, pale, stopped breathing for about 20 seconds, then spontaneously recovered. The infant is now alert, feeding well, and appears normal. Physical examination is unremarkable. The infant was born at term, has normal development, and this is the first such episode. Evaluate the most appropriate management strategy.
A. Discharge home with apnea monitor and cardiology follow-up
B. Admit for continuous cardiorespiratory monitoring and full diagnostic workup
C. Discharge after 4-hour observation period with parental reassurance and primary care follow-up (Correct Answer)
D. Order ECG, chest X-ray, and pertussis testing before deciding on disposition
E. Initiate empiric treatment for gastroesophageal reflux and admit overnight
Explanation: ***Discharge after 4-hour observation period with parental reassurance and primary care follow-up***
- This infant qualifies as **lower-risk BRUE** because he is >60 days old, was born at term, the event lasted <1 minute, and there were no concerning physical findings or prior episodes.
- For lower-risk patients, management focuses on a **brief observation period (1-4 hours)**, parental reassurance, and ensuring follow-up rather than extensive testing or hospitalization.
*Discharge home with apnea monitor and cardiology follow-up*
- **Home apnea monitors** are not recommended as they have not been proven to reduce the risk of SIDS or capture clinically significant events in lower-risk patients.
- Cardiology follow-up and monitoring are unnecessary interventions for a patient with a completely normal exam and no history of **congenital heart disease**.
*Admit for continuous cardiorespiratory monitoring and full diagnostic workup*
- Admission is strictly reserved for **higher-risk BRUE** cases, such as those with recursive episodes, premature birth (<32 weeks), or those requiring **CPR** by a professional.
- Comprehensive diagnostic workups in lower-risk infants carry a very low yield ( <1%) for identifying serious underlying pathology and increase **healthcare costs**.
*Order ECG, chest X-ray, and pertussis testing before deciding on disposition*
- Extensive testing like **chest X-rays** or **pertussis swabs** is not indicated in an asymptomatic, well-appearing infant without respiratory distress or cough.
- Guidelines suggest that an **ECG** may be considered but is not mandatory; however, broad testing
Question 4: A 7-year-old boy presents to the emergency department with fever to 40°C (104°F), severe sore throat, drooling, and respiratory distress. He is sitting upright in tripod position, appears toxic, and has inspiratory stridor. His immunization status is unknown as the family recently immigrated. Oxygen saturation is 91% on room air. Lateral neck X-ray shows a thumb sign. Which of the following approaches best balances the immediate management priorities?
A. Immediate intubation in the emergency department
B. Obtain blood cultures and start IV antibiotics before airway intervention
C. Direct visualization of the epiglottis with tongue depressor
D. Keep child calm, give oxygen, and arrange controlled intubation in OR with ENT backup (Correct Answer)
E. Nebulized racemic epinephrine and corticosteroids
Explanation: ***Keep child calm, give oxygen, and arrange controlled intubation in OR with ENT backup***
- This child presents with classic **acute epiglottitis**; the priority is maintaining a patent airway while minimizing **agitation**, which can trigger complete airway obstruction.
- Controlled **intubation in the operating room** with a multidisciplinary team (Anesthesiology and ENT) ensures a surgical airway (tracheostomy/cricothyrotomy) can be established if the glottis becomes completely occluded.
*Immediate intubation in the emergency department*
- Attempting intubation in an uncontrolled setting without **surgical backup** is risky due to the high probability of a difficult airway and total laryngeal spasm.
- The child should not be manipulated or placed in a **supine position** in the ED as this can facilitate immediate respiratory arrest.
*Obtain blood cultures and start IV antibiotics before airway intervention*
- While antibiotics are necessary to treat the likely agent, ***Haemophilus influenzae*** **type b**, airway stabilization must always precede diagnostic tests or IV access.
- Painful stimuli like **venipuncture** can cause the child to cry or struggle, leading to acute **laryngospasm** and loss of the airway.
*Direct visualization of the epiglottis with tongue depressor*
- Using a **tongue depressor** is strictly contraindicated because it can cause reflex laryngospasm and **sudden airway occlusion**.
- Physical examination of the oropharynx should only be performed in a **controlled environment** like the operating room where the airway can be immediately secured.
*Nebulized racemic epinephrine and corticosteroids*
- This is the standard treatment for **Croup (laryngotracheobronchitis)**, which presents with a barking cough and "steeple sign," not epiglottitis.
- **Epiglottitis** is a bacterial emergency that does not respond to epinephrine and requires definitive **airway management** and antibiotics.
Question 5: A 4-year-old boy is brought to the emergency department after ingesting an unknown quantity of his grandmother's iron tablets 2 hours ago. He initially vomited twice but now appears stable. Vital signs are: BP 100/65 mmHg, HR 110/min, RR 24/min. Abdominal X-ray shows multiple radiopaque tablets in the stomach. Serum iron level is 425 mcg/dL (normal: 50-120 mcg/dL). Which finding would most strongly indicate the need for immediate chelation therapy with deferoxamine?
A. Serum iron level >400 mcg/dL
B. Presence of radiopaque tablets on X-ray
C. History of vomiting after ingestion
D. Development of metabolic acidosis with altered mental status (Correct Answer)
E. Total iron binding capacity <400 mcg/dL
Explanation: ***Development of metabolic acidosis with altered mental status***
- Immediate **deferoxamine chelation** is indicated for patients with systemic toxicity, such as **anion gap metabolic acidosis**, shock, or **altered mental status**.
- While iron levels guide management, clinical status is the primary driver for intervention because iron shifts rapidly from the **extracellular to intracellular compartment**.
*Serum iron level >400 mcg/dL*
- Although a level >350-500 mcg/dL suggests toxicity, it is not an absolute indication for chelation if the patient remains **asymptomatic**.
- Laboratory values must be correlated with clinical symptoms and the **time since ingestion** to determine the need for chelation.
*Presence of radiopaque tablets on X-ray*
- Visualizing tablets on X-ray confirms ingestion and may indicate a need for **whole bowel irrigation**, but it does not measure **systemic toxicity**.
- **Radiopacity** may also diminish as tablets dissolve, making it an unreliable sole indicator for starting chelation therapy.
*History of vomiting after ingestion*
- Vomiting is common in the **initial gastrointestinal stage** (Stage 1) of iron poisoning due to the direct corrosive effect on the gastric mucosa.
- Isolated GI symptoms can often be managed with supportive care and monitoring unless they progress to **systemic instability**.
*Total iron binding capacity <400 mcg/dl*
- **Total iron binding capacity (TIBC)** was traditionally used to calculate free iron, but it is no longer considered a reliable indicator for chelation therapy.
- Modern management focuses on **serum iron levels** rather than TIBC because the latter can be falsely elevated during acute iron overdose.
Question 6: A 14-year-old girl presents to the emergency department with severe abdominal pain, nausea, and vomiting for 24 hours. She appears ill with Kussmaul respirations, fruity breath odor, BP 95/60 mmHg, HR 125/min. Labs show: glucose 485 mg/dL, pH 7.15, bicarbonate 10 mEq/L, positive serum ketones, potassium 5.8 mEq/L, sodium 128 mEq/L. After initial IV fluid bolus of 20 mL/kg normal saline, which of the following is the most appropriate next step?
A. Start IV insulin infusion at 0.1 units/kg/hr immediately
B. Continue IV fluids and start insulin when potassium <5.3 mEq/L (Correct Answer)
C. Administer sodium bicarbonate to correct acidosis
D. Give IV potassium supplementation before insulin
E. Repeat fluid bolus before starting insulin therapy
Explanation: ***Continue IV fluids and start insulin when potassium <5.3 mEq/L***
- In **Diabetic Ketoacidosis (DKA)**, patients have a total body potassium deficit; however, serum levels may be elevated due to **transcellular shifts** caused by acidosis and insulin deficiency.
- Starting insulin immediately can cause a rapid shift of potassium into cells, leading to severe **hypokalemia** and potential **arrhythmias**, so levels must be managed alongside fluid resuscitation.
*Start IV insulin infusion at 0.1 units/kg/hr immediately*
- While insulin is necessary to suppress **ketogenesis**, it should follow adequate **volume resuscitation** (usually 1-2 hours) to avoid hemodynamic collapse.
- Immediate insulin without monitoring potassium shifts in a patient with potential cardiac instability is avoided until the metabolic profile is stabilized via fluids.
*Administer sodium bicarbonate to correct acidosis*
- Bicarbonate therapy in pediatric DKA is generally contraindicated as it is associated with an increased risk of **cerebral edema**.
- Acidosis naturally corrects with **fluid resuscitation** and **insulin therapy**, which halts the production of ketoacids.
*Give IV potassium supplementation before insulin*
- In this case, the serum potassium is **5.8 mEq/L** (elevated), so additional supplementation is not indicated until levels drop into the normal range.
- Potassium should only be added to maintenance fluids once the patient is **producing urine** and the serum potassium is within or below the normal range (<5.3 mEq/L).
*Repeat fluid bolus before starting insulin therapy*
- While the patient was hypotensive, a second bolus is only indicated if **clinical signs of shock** persist after the first 20 mL/kg dose.
- Excessive fluid administration in children with DKA increases the risk of **cerebral edema**, the leading cause of mortality in pediatric DKA cases.
Question 7: A 5-year-old boy with known asthma presents to the emergency department with severe respiratory distress. He has been using his albuterol inhaler every hour without relief. On examination, he is sitting upright, has difficulty speaking, respiratory rate is 45/min, oxygen saturation is 88% on room air, and has diffuse wheezing with poor air movement. After initial treatments with oxygen, continuous nebulized albuterol, and IV corticosteroids, he shows minimal improvement. What is the most appropriate next intervention?
A. Intubation and mechanical ventilation
B. IV magnesium sulfate administration (Correct Answer)
C. Add ipratropium bromide to nebulizer treatments
D. Chest X-ray to rule out pneumothorax
E. Initiate BiPAP ventilation
Explanation: ***IV magnesium sulfate administration***
- **IV magnesium sulfate** is the treatment of choice for severe **status asthmaticus** that does not respond to initial standard therapies like oxygen, continuous **beta-agonists**, and systemic **corticosteroids**.
- It works by inducing **bronchial smooth muscle relaxation** and has been shown to improve pulmonary function and reduce hospitalization rates in pediatric patients.
*Intubation and mechanical ventilation*
- Reserved as a last resort for **impending respiratory failure** characterized by altered mental status, **silent chest**, or worsening **respiratory acidosis**.
- It is avoided when possible in asthma due to high risks of **barotrauma**, **hemodynamic instability**, and difficulty with lung recruitment.
*Add ipratropium bromide to nebulizer treatments*
- **Ipratropium bromide** should ideally be administered simultaneously with the first three doses of **albuterol** in the emergency department setting.
- Since the patient has already undergone "initial treatments" and failed to improve, adding it now is less likely to provide the necessary acute escalation required for stabilization.
*Chest X-ray to rule out pneumothorax*
- While a **pneumothorax** is a possible complication of severe asthma, imaging should not delay life-saving **pharmacological intervention** in an acutely deteriorating patient.
- Management should prioritize clinical stabilization; a **chest X-ray** is indicated only if there is a high clinical suspicion or failure to respond to maximal therapy.
*Initiate BiPAP ventilation*
- **BiPAP** is a non-invasive option sometimes used in older children, but its evidence in pediatric asthma is less robust than pharmacological interventions like **magnesium sulfate**.
- It may be considered to reduce the **work of breathing**, but it should follow or be concurrent with **IV magnesium** in the escalation pathway.
Question 8: A 2-year-old girl is brought to the emergency department after a witnessed seizure lasting 5 minutes. She has a fever of 39.5°C (103.1°F). On examination, she is postictal but arousable, with no focal neurological deficits and no signs of meningeal irritation. Her immunizations are up to date. Which of the following is the most appropriate management?
A. CT head followed by EEG
B. Empiric IV antibiotics and admission
C. Lumbar puncture before discharge
D. Oral antipyretics and reassurance with discharge instructions (Correct Answer)
E. IV lorazepam and admission for observation
Explanation: ***Oral antipyretics and reassurance with discharge instructions***
- The patient presents with a **simple febrile seizure**, defined by a generalized onset, duration **less than 15 minutes**, and a single episode within a 24-hour period in the setting of fever.
- Management of simple febrile seizures focuses on **supportive care**, identifying the source of the fever, and **parental education** as they are benign and do not increase the risk of epilepsy significantly.
*CT head followed by EEG*
- **Neuroimaging** is not recommended for simple febrile seizures as it does not change management and exposes the child to unnecessary radiation.
- **EEG** is generally reserved for complex febrile seizures or children with persistent neurological deficits and is not predictive of seizure recurrence here.
*Empiric IV antibiotics and admission*
- **Empiric antibiotics** are only indicated if there is a high clinical suspicion of **bacterial meningitis** or sepsis, which is absent in this stable, immunized child.
- Routine admission is unnecessary for a **simple febrile seizure** once the child has returned to their baseline mental status and a source of fever is addressed.
*Lumbar puncture before discharge*
- **Lumbar puncture** is not routinely indicated in children older than 18 months who have no **meningeal signs** (e.g., Kernig’s or Brudzinski’s) and are fully immunized.
- This patient is **arousable**, has no focal deficits, and is up-to-date with vaccinations (reducing the risk of *S. pneumoniae* or *H. influenzae* meningitis).
*IV lorazepam and admission for observation*
- **Benzodiazepines** like IV lorazepam are only indicated for **active seizures** lasting longer than 5 minutes (status epilepticus), but this seizure has already resolved.
- Admission for observation is not required for a **simple febrile seizure** if the patient is neurologically intact and the parent can provide adequate follow-up.
Question 9: A 6-month-old infant presents to the emergency department with a 12-hour history of inconsolable crying, vomiting, and drawing legs up to the abdomen. Physical examination reveals a palpable sausage-shaped mass in the right upper quadrant and bloody mucoid stool. Ultrasound shows a target sign. What is the most appropriate next step in management?
A. Immediate surgical consultation for laparotomy
B. Air or hydrostatic enema reduction under fluoroscopy (Correct Answer)
C. NPO status with nasogastric decompression and IV antibiotics
D. CT scan of the abdomen with IV contrast
E. Observation with serial abdominal examinations
Explanation: ***Air or hydrostatic enema reduction under fluoroscopy***
- This is the **first-line treatment** and diagnostic tool for stable patients with **intussusception**, demonstrating high success rates in reduction.
- It is indicated when there are no signs of **bowel perforation** or **peritonitis**, with the procedure performed under **radiological guidance**.
*Immediate surgical consultation for laparotomy*
- Surgery is reserved for cases involving **perforation**, **peritoneal irritation**, or when **radiologic reduction** has failed.
- While a consultant should be available, **non-operative reduction** is the preferred initial step in a hemodynamically stable infant.
*NPO status with nasogastric decompression and IV antibiotics*
- These are important **supportive measures** for bowel obstruction but do not treat the underlying **mechanical telescoping** of the bowel.
- Stabilizing the patient with **IV fluids** is necessary, but the definitive management must address the **intussusception** itself.
*CT scan of the abdomen with IV contrast*
- **Ultrasound** is the gold standard for diagnosis, showing the characteristic **target sign** or **pseudokidney sign**, making a CT scan unnecessary.
- CT scan involves significant **radiation exposure** and delays the definitive management of the condition.
*Observation with serial abdominal examinations*
- **Intussusception** is a surgical emergency that can lead to **bowel ischemia**, necrosis, and death if left untreated.
- **Observation** is inappropriate as it allows the condition to progress toward irreversible **vascular compromise**.
Question 10: A 3-year-old boy is brought to the emergency department with sudden onset of respiratory distress and choking while eating peanuts. On examination, he has stridor, intercostal retractions, and decreased breath sounds on the right side. Oxygen saturation is 88% on room air. Which of the following is the most appropriate immediate management?
A. Perform the Heimlich maneuver immediately
B. Administer 100% oxygen and prepare for rigid bronchoscopy (Correct Answer)
C. Order a chest X-ray to confirm foreign body location
D. Administer nebulized epinephrine and corticosteroids
E. Perform blind finger sweep of the oropharynx
Explanation: ***Administer 100% oxygen and prepare for rigid bronchoscopy***
- Sudden respiratory distress, **stridor**, and **unilateral decreased breath sounds** after eating peanuts are classic for **foreign body aspiration** requiring stabilization and removal.
- **Rigid bronchoscopy** is the gold standard for definitive diagnosis and removal of aspirated objects in children while maintaining a secure airway.
*Perform the Heimlich maneuver immediately*
- The **Heimlich maneuver** is only indicated for complete airway obstruction where the child cannot cough, speak, or breathe.
- Since the child is currently breathing (indicated by stridor and unilateral sounds), this maneuver could convert a **partial obstruction** into a complete one.
*Order a chest X-ray to confirm foreign body location*
- While imaging can show signs like **air-trapping** or **atelectasis**, clinical diagnosis of aspiration with the potential for airway compromise takes precedence over imaging.
- Delaying treatment for an X-ray in an unstable patient with **hypoxemia (88% saturation)** is dangerous; many foreign bodies are also **radiolucent**.
*Administer nebulized epinephrine and corticosteroids*
- These medications are used to treat inflammatory conditions like **croup** or **anaphylaxis**, not mechanical airway obstructions.
- Using them in this context would inappropriately delay the necessary **mechanical removal** of the peanut.
*Perform blind finger sweep of the oropharynx*
- **Blind finger sweeps** are strictly contraindicated in pediatric patients as they can push the object deeper into the **larynx** or trachea.
- This action increases the risk of turning a stable situation into a total **airway obstruction**.
