Pediatric emergency management

Pediatric emergency management US Medical PG Question 1: A 24-year-old man is rushed to the emergency room after he was involved in a motor vehicle accident. He says that he is having difficulty breathing and has right-sided chest pain, which he describes as 8/10, sharp in character, and worse with deep inspiration. His vitals are: blood pressure 90/65 mm Hg, respiratory rate 30/min, pulse 120/min, temperature 37.2°C (99.0°F). On physical examination, patient is alert and oriented but in severe distress. There are multiple bruises over the anterior chest wall. There is also significant jugular venous distention and the presence of subcutaneous emphysema at the base of the neck. There is an absence of breath sounds on the right and hyperresonance to percussion. A bedside chest radiograph shows evidence of a collapsed right lung with a depressed right hemidiaphragm and tracheal deviation to the left. Which of the following findings is the strongest indicator of cardiogenic shock in this patient?

• A. Jugular venous distention (Correct Answer)
• B. Hyperresonance to percussion
• C. Subcutaneous emphysema
• D. No right chest raise
• E. Tracheal shift to the left

Pediatric emergency management Explanation: ***Jugular venous distention*** - In this trauma patient with tension pneumothorax, **jugular venous distention (JVD)** is the strongest indicator that the patient is developing **obstructive shock** with cardiovascular compromise. - JVD indicates **impaired venous return** to the heart due to increased intrathoracic pressure compressing the vena cava and right atrium. - While this is technically **obstructive shock** (not pure cardiogenic shock), JVD represents the cardiovascular manifestation indicating that the mechanical obstruction is now critically affecting cardiac filling and output. - Among the options listed, **JVD is the only finding that directly reflects cardiovascular compromise** and impending circulatory collapse. *Hyperresonance to percussion* - This finding indicates **air in the pleural space**, characteristic of pneumothorax. - While it confirms the diagnosis of pneumothorax, it is a **respiratory finding** rather than a direct indicator of cardiovascular compromise or shock state. *Subcutaneous emphysema* - This indicates **air in subcutaneous tissues** from chest wall injury or air leak. - It confirms significant chest trauma but does not directly indicate the severity of cardiovascular compromise or shock. *Tracheal shift to the left* - **Tracheal deviation** away from the affected side is a classic sign of **tension pneumothorax** indicating mediastinal shift. - While this confirms tension physiology, it is primarily an **anatomical/structural finding** rather than a direct hemodynamic indicator like JVD, which specifically reflects impaired venous return and cardiovascular compromise.

Pediatric emergency management US Medical PG Question 2: A 40-year-old Caucasian male presents to the emergency room after being shot in the arm in a hunting accident. His shirt is soaked through with blood. He has a blood pressure of 65/40, a heart rate of 122, and his skin is pale, cool to the touch, and moist. This patient is most likely experiencing all of the following EXCEPT:

• A. Decreased sarcomere length in the myocardium
• B. Increased stroke volume (Correct Answer)
• C. Confusion and irritability
• D. Decreased preload
• E. Increased thromboxane A2

Pediatric emergency management Explanation: ***Increased stroke volume*** - The patient is experiencing **hypovolemic shock** due to significant blood loss, meaning their **cardiac output** is severely compromised. - In shock, the heart attempts to compensate by increasing **heart rate**, but **stroke volume** is typically decreased due to reduced **preload**. *Decreased sarcomere length in the myocardium* - In situations of significant blood loss and **decreased preload**, there is less venous return to the heart, leading to reduced end-diastolic volume. - According to the **Frank-Starling law**, reduced end-diastolic volume results in shorter initial sarcomere length, which reduces the force of contraction and thus, **stroke volume**. *Confusion and irritability* - **Hypovolemic shock** leads to widespread **tissue hypoperfusion**, especially to vital organs like the brain. - Reduced cerebral blood flow results in impaired brain function, manifesting as **confusion, irritability**, and altered mental status. *Decreased preload* - Significant blood loss leads to a reduction in the **total circulating blood volume**. - This reduction directly decreases the venous return to the heart, thus lowering the **end-diastolic volume** and subsequently, the **preload**. *Increased thromboxane A2* - In response to **vascular injury and bleeding**, the body initiates hemostasis, a critical component of which is platelet aggregation. - **Thromboxane A2** is a potent vasoconstrictor and platelet aggregator released by activated platelets to form a **platelet plug** and help stop bleeding.

Pediatric emergency management US Medical PG Question 3: A 15-year-old boy is brought to the emergency department one hour after sustaining an injury during football practice. He collided head-on into another player while wearing a mouthguard and helmet. Immediately after the collision he was confused but able to use appropriate words. He opened his eyes spontaneously and followed commands. There was no loss of consciousness. He also had a headache with dizziness and nausea. He is no longer confused upon arrival. He feels well. Vital signs are within normal limits. He is fully alert and oriented. His speech is organized and he is able to perform tasks demonstrating full attention, memory, and balance. Neurological examination shows no abnormalities. There is mild tenderness to palpation over the crown of his head but no signs of skin break or fracture. Which of the following is the most appropriate next step?

• A. Discharge without activity restrictions
• B. Discharge and refrain from all physical activity for one week
• C. Observe for 6 hours in the ED and refrain from contact sports for one week (Correct Answer)
• D. Administer prophylactic levetiracetam and observe for 24 hours
• E. Administer prophylactic phenytoin and observe for 24 hours

Pediatric emergency management Explanation: ***Observe for 6 hours in the ED and refrain from contact sports for one week*** - This patient experienced a brief period of **confusion, headache, dizziness**, and **nausea** immediately after a head injury, which are symptoms consistent with a **mild traumatic brain injury (mTBI)** or **concussion**. - Although his symptoms have resolved at presentation, observation in the ED for a few hours is prudent to ensure no delayed onset of more severe symptoms, and he should **refrain from contact sports** for at least one week as part of concussion management. *Discharge without activity restrictions* - Discharging without activity restrictions is unsafe given the initial symptoms of **confusion** and the potential for delayed symptom presentation or complications from a concussion. - Concussion management requires a period of **physical and cognitive rest** to allow the brain to heal and prevent **second impact syndrome**. *Discharge and refrain from all physical activity for one week* - While refraining from all physical activity for one week is part of concussion management, discharging immediately without any observation period after initial neurological symptoms could be risky. - An observation period allows for monitoring of any **worsening neurological signs** or symptoms that might indicate a more serious injury. *Administer prophylactic levetiracetam and observe for 24 hours* - **Prophylactic anticonvulsants** like levetiracetam are typically not recommended for routine management of **mild traumatic brain injury** or concussion. - Their use is generally reserved for patients with more severe injuries, evolving conditions, or those who have had **seizures post-trauma**. *Administer prophylactic phenytoin and observe for 24 hours* - Similar to levetiracetam, **phenytoin** is an anticonvulsant and its prophylactic use is not indicated for **mild head injuries** or concussions. - Anticonvulsant prophylaxis is associated with potential side effects and is reserved for specific high-risk scenarios, such as **severe TBI** or **penetrating head trauma**.

Pediatric emergency management US Medical PG Question 4: A 7-month-old boy is brought to the ED by his mother because of abdominal pain. Two weeks ago, she noticed he had a fever and looser stools, but both resolved after a few days. One week ago, he began to experience periodic episodes during which he would curl up into a ball, scream, and cry. The episodes lasted a few minutes, and were occasionally followed by vomiting. Between events, he was completely normal. She says the episodes have become more frequent over time, and this morning, she noticed blood in his diaper. In the ED, his vitals are within normal ranges, and his physical exam is normal. After confirming the diagnosis with an abdominal ultrasound, what is the next step in management?

• A. Supportive care
• B. Broad-spectrum antibiotics
• C. Air contrast enema (Correct Answer)
• D. Abdominal laparotomy
• E. Abdominal CT scan

Pediatric emergency management Explanation: ***Air contrast enema*** - An **air contrast enema** is both diagnostic and therapeutic for **intussusception**, which is strongly suggested by the patient's symptoms (colicky abdominal pain, drawing legs to chest, currant jelly stools). - It uses air pressure to **reduce the intussusception**, avoiding surgery if successful and the bowel is not compromised. *Supportive care* - While supportive care (IV fluids, pain control) is important, it does not address the underlying mechanical issue of **intussusception** and would not resolve the condition. - Delaying definitive treatment for intussusception can lead to **bowel ischemia, necrosis, and perforation**, which are life-threatening. *Broad-spectrum antibiotics* - Antibiotics are not the primary treatment for **intussusception**, as it is a mechanical obstruction, not typically a primary infection. - They might be considered if there are signs of **perforation or peritonitis**, but the immediate goal is reduction. *Abdominal laparotomy* - An **abdominal laparotomy** is a surgical intervention reserved for cases where **non-operative reduction** (like an air enema) fails or if there are signs of **bowel perforation or gangrene**. - It is not the *first-line* next step after diagnosis, especially if non-invasive options remain viable. *Abdominal CT scan* - An **abdominal CT scan** can diagnose intussusception but is typically not the preferred initial imaging because it involves **radiation exposure** and **does not offer therapeutic benefit**, unlike an air contrast enema. - Abdominal ultrasound is usually sufficient for diagnosis and safer for pediatric patients.

Pediatric emergency management US Medical PG Question 5: A 7-year-old boy presents to the pediatric emergency department for knee pain. The child fell while riding his skateboard yesterday. He claims that ever since then he has had swelling and knee pain that is severe. His parents state that he has trouble walking due to the pain. The child has a past medical history of seasonal allergies and asthma. His current medications include loratadine, albuterol, and fluticasone. His temperature is 99.5°F (37.5°C), blood pressure is 95/48 mmHg, pulse is 110/min, respirations are 17/min, and oxygen saturation is 98% on room air. On physical exam, you note a young boy laying on the stretcher in pain. Cardiopulmonary exam is within normal limits. Inspection of the patient's left knee reveals an erythematous knee that is tender and warm to the touch. Passive movement of the knee elicits pain. The patient refuses to walk so you are unable to assess his gait. Which of the following is the best initial step in management?

• A. ESR, CRP, and CBC
• B. Arthrocentesis (Correct Answer)
• C. CT scan
• D. Antibiotics
• E. Supportive therapy and further physical exam

Pediatric emergency management Explanation: ***Arthrocentesis*** - The patient presents with classic signs of **septic arthritis**, including acute onset of severe knee pain, warmth, erythema, tenderness, and refusal to bear weight, especially following a minor trauma which can sometimes be a precipitating factor or merely draw attention to existing infection. - **Arthrocentesis** is the most crucial diagnostic and therapeutic step in suspected septic arthritis, as it allows for fluid analysis (cell count, Gram stain, culture) to identify the causative organism and guide targeted antibiotic therapy. *ESR, CRP, and CBC* - While these labs (erythrocyte sedimentation rate, C-reactive protein, and complete blood count) are important for assessing the degree of **inflammation** and **infection**, they are not the definitive initial step for diagnosing septic arthritis. - These tests support the suspicion of infection but do not provide the specific bacterial diagnosis or immediate relief of joint pressure that arthrocentesis offers. *CT scan* - A CT scan is generally not the initial diagnostic modality for **acute septic arthritis** unless there is a concern for osteomyelitis or other bony involvement not clearly visible on plain radiographs or if aspiration is difficult. - **Plain radiographs** are usually the first imaging study to rule out fracture or other bony pathology, but they cannot diagnose joint infection. *Antibiotics* - While antibiotics are essential for treating septic arthritis, initiating them **before arthrocentesis** can **sterilize the joint fluid**, making culture results negative and hindering the identification of the specific pathogen. - Empirical antibiotics should only begin *after* joint fluid has been aspirated for diagnostic purposes. *Supportive therapy and further physical exam* - Supportive therapy (e.g., pain control, immobilization) is important but **insufficient** as the sole initial management for suspected septic arthritis, which is a **medical emergency**. - Delaying definitive diagnosis and treatment (arthrocentesis) can lead to **rapid joint destruction** and long-term morbidity, outweighing the benefit of further physical exam beyond initial assessment.

Pediatric emergency management Flashcard 1 of 5

Question: DTaP vaccine and anaphylaxis is managed with _____ DTaP vaccine and encephalopathy/neuro disorder is managed with _____

Answer: do not give any more DTaP

Extra Information:  https://onlinemeded.org/spa/pediatrics/vaccinations/acquire?ref=anki 

Pediatric emergency management Flashcard 2 of 5

Question: What is the mnemonic for the criteria for Kawasaki disease? _____

Answer: Conjunctival injection Rash Adenopathy (cervical) Strawberry tongue Hand-foot changes fever

Extra Information:  https://onlinemeded.org/spa/rheumatology/vasculitis/acquire?ref=anki 

Pediatric emergency management Flashcard 3 of 5

Question: Evidence of physical abuse in a child includes _____ (e.g. ribs, long bone spiral, multiple in different stages of healing)

Answer: fractures

Pediatric emergency management Flashcard 4 of 5

Question: What is the major risk factor for sudden infant death syndrome (SIDS)? _____

Answer: Second-hand smoke (nicotine, CO)

Pediatric emergency management Flashcard 5 of 5

Question: What is the likely diagnosis in a child that presents with fever and signs of heart failure ~1 week after an URI? _____

Answer: Viral myocarditis

Extra Information:  * preceded by ~1 week of flu-like symptoms Watch Myocarditis [https://dashboard.sketchy.com/study/medical/courses/medical-pathophysiology/units/medical-pathophysiology-cardiac/videos/medical-pathophysiology-cardiac-myocardial-and-pericardial-disorders-myocarditis?utm_source=anki&utm_medium=partnership&utm_campaign=february_update&utm_content=medical] https://onlinemeded.org/spa/cardiac?ref=anki