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In-Training Exam High Yield Topics pediatrics

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1 In-Training Exam High Yield Topics pediatrics
ITE High Yield Topics Presentations: This is one of multiple presentations included in our revised 2018 EMF ITE resources. Presentation content is divided by system and includes the highest-yield (highest % on the test) systems: Cardiovascular, Trauma, Gastrointestinal, Pediatrics, Pulmonary, Toxicology, ID and Neurology. Each system presentation has three different sections: Visual Diagnosis, Clinical Concepts and Rapid Fire. Scattered throughout are “Knowledge Bomb” slides that provide a more in-depth summary of certain high-yield topics. Timing: Each presentation in this series is of variable length, thus the time required to lead instruction will also be variable. In general, the expected time range for presentations is minutes. The specific time you’ll need will depend not only on presentation length, but also how much embedded conversation or focused review (“knowledge bomb” content) you intend, in addition to the familiarity of your residents with this content. Emergency Medicine Foundations Curriculum

2 In-training Exam (ITE) Content:
Written to level of EM3 Predicts performance on EM Boards 225 MC questions Given 4.5 hrs to take +/- 25 are visual stimuli – pictures/ekg/xrays Highest yield topics Cardiovascular ~ 10% Trauma ~ 10% Abd/GI ~ 8% Thoracic/Respiratory ~ 8% Procedures/Skills ~8% Note that Geriatrics makes up at least 6% of these and Pediatrics at least 8%

3 Foundations Challenge Overview
Rapid Review of High-Yield Test Topics Visual Diagnosis Clinical Concepts Rapid Fire Work in 2-4 different teams Answer challenge questions for points Point value per challenge varies by difficulty Win test prep and pride Running the Meeting: Start by dividing learners into 2-4 teams and direct them to separate areas of the room You should assign a learner or instructor to serve as scorekeeper and ask for updates on the score when you switch topics Provide and guide reasonable time limits to answer challenge questions Monitor time closely as you move through the review to keep pace with planned content If you have the time/energy, you may consider giving a prize/reward for the winning team

4 Foundations Challenge Rules
Create a Team Name Best Team Name starts the Challenge (as arbitrarily determined by your Instructor) Your team must answer the entire question correctly to win points If you team answers incorrectly, the Challenge Question points can be stolen by the next team If they answer correctly, they get your points AND a chance to answer the next question If they answer incorrectly, the turn passes again to the next team in line You may choose to modify the point assignment system (all or nothing vs. partial credit)

5 pediatrics

6 3 pts Pediatric Abdominal Pain Diagnosis x 3 ?? Visual Diagnosis
Foundations Challenge Visual Diagnosis 3 pts 1- Hirschsprungs Disease (XR with dilated large bowel but transition xone with empty sigmoid colon) 2- Intussusception (target sign on US) 3- Pyloric Stenosis (US with thickened pyloric sphincter, may also see donut or bulls eye on transverse) Images from Ultrasoundcases.info, Dr. Taco Geertsma and UVA pediatric radiology site 1 2 3 Pediatric Abdominal Pain Diagnosis x 3 ??

7 3 pts Pediatric Abdominal Pain Visual Diagnosis Diagnosis x 3 ??
Foundations Challenge Visual Diagnosis 3 pts 1- Hirschsprungs Disease (XR with dilated large bowel but transition xone with empty sigmoid colon) 2- Intussusception (target sign on US) 3- Pyloric Stenosis (US with thickened pyloric sphincter, may also see donut or bulls eye on transverse) Images from Ultrasoundcases.info, Dr. Taco Geertsma and UVA pediatric radiology site Hirschsprung Intussusception Pyloric Stenosis Pediatric Abdominal Pain Diagnosis x 3 ??

8 Pediatric Abdominal Pain
Foundations Challenge Knowledge Bomb Pediatric Abdominal Pain Intussusception Lethargic, currant jelly stools, “sausage-shaped mass” XR with obstruction, US with mass (target sign) Treat with barium or air enema Pyloric Stenosis Non-bilious projectile vomiting in first 2 weeks of life Olive-shaped mass, Dx with US (donut or bull’s eye), Tx: IVF and surgery Hirschsprung Disease No myenteric neural ganglia in distal colon, no passage of stool at 48hr, obstruction and vomiting, risks Toxic Megacolon XR: dilated bowel + transition point, with minimal stool in vault Tx: surgery

9 1 pt What is the cause? Visual Diagnosis 3 Day Old, No Prenatal Care
Foundations Challenge Visual Diagnosis 1 pt N. gonorrhoeae 3 Day Old, No Prenatal Care What is the cause?

10 1 pt Visual Diagnosis 3 Day Old, Neisseria gonorrhoeae
Foundations Challenge Visual Diagnosis 1 pt 3 Day Old, No Prenatal Care Neisseria gonorrhoeae

11 Neonatal Conjunctivitis
Foundations Challenge Knowledge Bomb Neonatal Conjunctivitis Chemical Conjunctivitis Mild ssx starting Day 1 2/2 Silver Nitrate drops Nothing to do Neisseria gonorrhoeae Presents Days 2-7 Severe bilateral purulent d/c, high risk of corneal ulceration/blindness Topical erythromycin or IV cefotaxime or PCN G Chlamydia trachomatis Presents Days 5-14 Milder bilateral purulent d/c, risk of pneumonia Oral erythromycin ** If systemic illness or rash, consider HSV Reference: Medscape, emedicine “Neonatal Conjunctivitis”, Author: Emily A McCourt, MD ** Chlamydia is overall the most common cause in neonates.

12 2 pts Visual Diagnosis 13yo M w/ Knee Pain Diagnosis & Treatment??
Foundations Challenge Visual Diagnosis 2 pts Slipped capital femoral epiphysis Image source: Medscape emedicine, “Imaging in SCFE”, Author: Brent Adler, MD 13yo M w/ Knee Pain Diagnosis & Treatment??

13 2 pts Visual Diagnosis SCFE 13yo M w/ Knee Pain Requires surgery
Foundations Challenge Visual Diagnosis 2 pts Slipped capital femoral epiphysis Obese teen Referred pain to the knee Irregular widening of the epiphyseal plate NWB, usually requires surgery 13yo M w/ Knee Pain SCFE Requires surgery

14 3 pts Visual Diagnosis Pediatric Respiratory Distress Diagnosis x 3 ??
Foundations Challenge Visual Diagnosis 3 pts 2 3 1- Croup (XR with Steeple sign) 2- Retropharyngeal Abscess (prevertebral soft tissue swelling) 3- Epiglottitis (Thumbprint sign) Image from Medscape emedicine Imaging in Croup, Author: Lars J Grimm, MD, MHS Image from AppliedRadiology.com Pediatric emergencies of the upper and lower airway, Author: Theresa Chapman, MD Image from ChristEM.com, Acute Epiglottitis, Author Erik Kulstad, MD 1 Pediatric Respiratory Distress Diagnosis x 3 ??

15 3 pts Visual Diagnosis Pediatric Respiratory Distress Retropharyngeal
Foundations Challenge Visual Diagnosis 3 pts Retropharyngeal Abscess Epiglottitis 1- Croup (XR with Steeple sign) 2- Retropharyngeal Abscess (prevertebral soft tissue swelling) 3- Epiglottitis (Thumbprint sign) Croup- parainfluenza virus, barky cough worse at night, stridor, treat with cool/humidified air, steroids (PO vs IV decadron), give racemic epinephrine if stridor at rest, admit for severe or refractory symptoms Retropharyngeal Abscess- sick appearing kid <6yrs, drooling, fever, caused by strep/staph/anaerobes; Tx with IV clinda, ENT/OR Epiglottitis- Sore throat, normal posterior oropharynx, ill-appearing, drooling, in tripod position H.flu if unvaccinated, Staph/Strep if vaccinated, more common in adults now Tx with emergent airway management, if at all unstable/ill appearing get to the OR with ENT for direct visualization/scope; if well appearing/stable consider XR, antibiotics, steroids with ENT consult Croup Pediatric Respiratory Distress

16 3 pts Visual Diagnosis Pediatric Staph & Diagnosis x 3 ??
Foundations Challenge Visual Diagnosis 3 pts 2 1 1- Impetigo (yellow crusted lesions, classically face) 2- Scarlet Fever (diffuse sandpaper rash) 3- Staph Scalded Skin (extensive bullous formation, skin sloughing) Image from 247wellness.org, “Staph Scalded Skin” Image from britishskinfoundation.org “Impetigo” Image from “The return of Scarlet Fever” 3 Pediatric Staph & Strep Skin Infections Diagnosis x 3 ??

17 1) Impetigo 2) Scarlet Fever 3) Staph Scalded Skin
Foundations Challenge Visual Diagnosis 3 pts 2 1 1- Impetigo (yellow crusted lesions, classically face) 2- Scarlet Fever (diffuse sandpaper rash) 3- Staph Scalded Skin (extensive bulla formation, skin sloughing) Impetigo- crusty lesion on face, tx with topical mupirocin vs oral keflex; Bullous Impetigo- bulla formation, tx with topical and systemic mupirocin/keflex; Scarlet Fever 2/2 GAS- sore throat, strawberry tongue, sandpaper rash (peels at 2wks), pastia lines (linear petechiae); give ABX (penicillin) to reduce rheumatic fever (does nothing to reduce the risk of glomerulonephritis) Staph Scalded Skin- extensive bullous formation, tx admit and IV abx 3 1) Impetigo ) Scarlet Fever ) Staph Scalded Skin

18 1 pt Visual Diagnosis Aspirated Foreign Body Right or Left???
Foundations Challenge Visual Diagnosis 1 pt Right side Image from: Foreign Body Aspiration. ME Warshawsky. eMedicine.The lateral decubitus film. An aid in determining air-trapping in children. MA Capitanio MA and JA Kirkpatrick. Radiology. May 1972;103(2):460-2 Aspirated Foreign Body Right or Left???

19 1 pt Visual Diagnosis Aspirated Foreign Body Right
Foundations Challenge Visual Diagnosis 1 pt Right sided foreign body- right lateral decubitus film with air trapping noted to right lung (lack of the usual collapse 2/2 foreign body) Peds Respiratory Foreign Body- coins, peanuts, beans most common; high suspicion if "choking" episode at home, eval with lateral decubitus XR (inflated dependant side with +FB), XR normal in 40%, if in doubt get CT or bronch Aspirated Foreign Body Right

20 1 pt Visual Diagnosis Pediatric Fractures: Distal Radius:
Foundations Challenge Visual Diagnosis 1 pt Distal Radius- Type II Salter Harris, “Above” the epiphyseal plate Image from cdemcurriculum.com, Author Todd Peterson, MD Pediatric Fractures: Salter-Harris Classification Distal Radius: What Type?

21 1 pt Visual Diagnosis Pediatric Fractures:
Foundations Challenge Visual Diagnosis 1 pt Distal Radius- Type II Salter Harris, “Above” the epiphyseal plate Pediatric Fractures: Salter-Harris Classification Distal Radius: Type II

22 Salter-Harris Classification
Foundations Challenge Knowledge Bomb Salter-Harris Classification SALTER describes the relationship to the epiphyseal plate: Type I- Slip at plate level Type II- Above (proximal) Type III- Lower (distal) Type IV- Through Everything (prox and distal) Type V- Rammed at plate level Tips: More advanced = more likely to have growth disturbance I and V can have normal XR II is most common

23 Name 2 causes of jaundice occurring at 24-72hr of life?
Foundations Challenge Clinical Concepts 2 pts Name 2 causes of jaundice occurring at 24-72hr of life? Jaundice 24-72hr of life: Physiological jaundice Breast Feeding Jaundice Decreased conjugation: Crigler-Najjar, Gilbert’s

24 2 pts Name 2 causes of jaundice occurring at 24-72hr of life?
Foundations Challenge Clinical Concepts 2 pts Name 2 causes of jaundice occurring at 24-72hr of life? Physiologic Jaundice Jaundice 24-72hr of life: Physiological jaundice: Rises <5mg/dl/day, peaks at day 3-5 a 15 (inc destruction of RBCs w/ immature conj) Breast Feeding Jaundice - failure of getting enough breast milk -> increase feedings, supplement with formula Decreased conjugation: Crigler-Najjar, Gilbert’s Breast Feeding Jaundice Decreased Conjugation (Crigler-Najjar, Gilbert’s)

25 Neonatal Jaundice 1st 24hr 24-72hr 72hr-7days > 7 days
Foundations Challenge Knowledge Bomb Neonatal Jaundice Differential 1st 24hr 24-72hr 72hr-7days > 7 days ABO/Rh incompatibility G6PD deficiency Hereditary spherocytosis Polycythemia Ileus or obstruction Infection Physiologic Jaundice Breast Feeding Jaundice Decreased Conjugation: Crigler-Najjar, Gilbert’s Congenital Infections Hepatitis Metabolic Disorder Biliary Atresia Breast Milk Jaundice Breast Feeding Jaundice: failure of getting enough breast milk -> increase feedings, supplement with formula Breast Milk Jaundice: enzymes in the breast milk cause inhibition of hepatic metabolism of bilirubin

26 congenital heart lesions.
Foundations Challenge Clinical Concepts 3 pts Name 3 of the 5 cyanotic congenital heart lesions. Cyanotic: caused by right to left shunt 5 T’s 1- Truncus Arteriosus 2- Transposition of the great vessels 3- Tricuspid Atresia 4- Tetralogy of Fallot 5- Total Anolamous Pumonary Venous Return

27 3 pts Name 3 of the 5 cyanotic congenital heart lesions.
Foundations Challenge Clinical Concepts 3 pts Name 3 of the 5 cyanotic congenital heart lesions. Truncus Arteriosis Transposition of the Great Vessels Tricuspid Atresia Cyanotic: caused by right to left shunt Tetralogy of Fallot Total Anomalous Pulmonary Venous Return

28 3 pts Viral Exanthem Match-up Clinical Concepts Measles/Rubeola
Foundations Challenge Clinical Concepts 3 pts Viral Exanthem Match-up Petechiae on hard palate, rash x3d head -> trunk Measles/Rubeola Rubella High fever then rash Erythema Infectiosum (Parvovirus B19) Vesicles at different stages Measles/Rubeola: Koplik's spots (white lesions on buccal mucosa), cough, coryza, conjunctivitis, look sick Rubella: suboccipital LNs, petechiae on hard palate, rash head to trunk lasting 3d; Erythema Infectiosum: Parvo, slapped cheek, central clearing (aplastic crisis in sickle cell); Varicella: vesicles in different stages (emergency if immunosuppressed), spares palms/soles, Tzank smear, consider secondary infection; Roseola: high fever followed by rash Extra: Hand/Foot/Mouth- coxsackie, blisters on buccal mucosa then body Varicella “Slapped” cheeks Koplik’s spots Cough, coryza, conjunctivitis Roseola

29 3 pts Viral Exanthem Match-up Clinical Concepts Measles/Rubeola
Foundations Challenge Clinical Concepts 3 pts Viral Exanthem Match-up Koplik’s spots Cough, coryza, conjunctivitis Measles/Rubeola Rubella Petechiae on hard palate, rash x3d head -> trunk Erythema Infectiosum (Parvovirus B19) “Slapped” cheeks Measles/Rubeola- Koplik's spots (white lesions on buccal mucosa), cough, coryza, conjunctivitis, look sick Rubella- suboccipital LNs, petechiae on hard palate, rash head to trunk lasting 3d; Erythema Infectiosum- Parvo, slapped cheek, central clearing (aplastic crisis in sickle cell); Varicella- vesicles in different stages (emergency if immunosuppressed), spares palms/soles, Tzank smear, consider secondary infection; Roseola- high fever followed by rash; Extra: Hand/Foot/Mouth- coxsackie, blisters on buccal mucosa then body Varicella Vesicles at different stages Roseola High fever then rash

30 Simple Febrile Seizures.
Foundations Challenge Clinical Concepts 2 pts Name 2 features of Simple Febrile Seizures. Simple Febrile Seizures: 6mo-6yr (NOT less than 6mo); fever, <15min, single episode/24hr, generalized, no neuro hx and normal exam, no special workup needed; Complex- anything else

31 Simple Febrile Seizures.
Foundations Challenge Clinical Concepts 2 pts Name 2 features of Simple Febrile Seizures. 6mos-6yrs Single Episode Fever Generalized Simple Febrile Seizures: 6mo-6yr (NOT less than 6mo); fever, <15min, single episode/24hr, generalized, no neuro hx and normal exam, no special workup needed; Complex- anything else < 15 min Normal Exam

32 Infant + Poor Feeding + Recurrent PNA
Foundations Challenge RAPID FIRE 3 pts Infant + Poor Feeding + Recurrent PNA Diagnosis??? Croup ssx  Toxic Diagnosis??? Tracheoesophageal Fistula Bacterial tracheitis 10cc/kg of blood, (20cc/kg of IVF) Peds Trauma + Hypotension Initial Bolus of Blood???

33 Infant + Poor Feeding + Recurrent PNA
Foundations Challenge RAPID FIRE 3 pts Infant + Poor Feeding + Recurrent PNA Tracheoesophageal Fistula Croup ssx  Toxic Bacterial Tracheitis Pediatric patient with respiratoy distress with feeding and recurrent pneumonia-> Tracheoesophageal Fistula Croup symptoms -> then become toxic, what’s the diagnosis? Bacterial tracheitis Peds trauma + hypotension, initial bolus: 10cc/kg of blood, 20cc/kg of IVF Peds Trauma + Hypotension Blood: 10cc/kg

34 Intermittent Abd Pain + Lethargy
Foundations Challenge RAPID FIRE 3 pts Intermittent Abd Pain + Lethargy Diagnosis??? Complication of Kawasaki ??? Intussusception coronary artery aneurysm D10 in infants (5cc/kg) Neonate + Low Glucose What do you give???

35 Intermittent Abd Pain + Lethargy
Foundations Challenge RAPID FIRE 3 pts Intermittent Abd Pain + Lethargy Intussusception Complication of Kawasaki Coronary Artery Aneurysm Intermittent abd pain + Lethargy: Intussusception Feared complication in Kawasaki: coronary artery aneurysm, treat initial disease with IVIG and high dose aspirin What is the appropriate administration of glucose for hypoglycemia in neonates and kids (Rule of 50) D10 in infants (5cc/kg), D25 in kids (2cc/kg), D50 in teens/adults (1cc/kg) Neonate + Low Glucose 5cc/kg of D10

36 3 pts 2yo + Recurrent RML PNA 5yo + Failed Airway
Foundations Challenge RAPID FIRE 3 pts 2yo + Recurrent RML PNA Diagnosis??? 5yo + Failed Airway What to do??? aspirated foreign body needle cric with transtracheal ventilation toxic synovitis Antalgic gait s/p Viral Illness Diagnosis???

37 3 pts 2yo + Recurrent RML PNA 5yo + Failed Airway
Foundations Challenge RAPID FIRE 3 pts 2yo + Recurrent RML PNA Aspirated Foreign Body 5yo + Failed Airway Needle Cric Dx: Recurrent RML pna - aspirated foreign body Failed airway in a pediatric patient (<8-10yr)? Cricothyroidotomy is contraindicated in this age group; should to needle cric with transtracheal ventilation; can attach syringe without plunger to 7.0mm cap for BVM ventilation OR 3.5mm ETT cap can be attached to the angiocatheter Limp/antalgic gait after viral illness: toxic synovitis Antalgic gait s/p Viral Illness Toxic Synovitis

38 When do you start chest compressions in a young child?
Foundations Challenge RAPID FIRE 3 pts When do you start chest compressions in a young child? ??? Joules to defibrillate children? ??? HR < 60bpm (or pulseless) 2J/kg Knee-chest position (increase preload) Tet spell initial management? ???

39 3 pts When do you start chest compressions in a young child?
Foundations Challenge RAPID FIRE 3 pts When do you start chest compressions in a young child? HR < 60 (or pulseless) Joules to defibrillate children? 2J/kg Start chest compressions in kids if pulseless or HR < 60bpm Tet-spell treatment Knee-chest position (increase preload), O2, morphine Joules to defib a kid: 2J/kg; Cardiovert: 0.5J/kg Tet spell initial management? Knee-chest position

40 Painless rectal bleeding < 5yr
Foundations Challenge RAPID FIRE 3 pts Painless rectal bleeding < 5yr Diagnosis??? Bilious emesis <1yr Diagnosis??? Meckel’s diverticulum Midgut Volvulus Necrotizing Enterocolitis Premature + Gas in bowel wall Diagnosis???

41 3 pts Painless rectal bleeding < 5yr Bilious emesis <1yr
Foundations Challenge RAPID FIRE 3 pts Painless rectal bleeding < 5yr Meckel’s diverticulum Bilious emesis <1yr Midgut Volvulus Painless rectal bleeding in kid < 5y/o Meckel’s diverticulum (dx Meckel’s scan) Bilious emesis, kid < 1y/o, blood streaked stool, palp abd mass Midgut volvulus Gas/air in bowel wall- Necrotizing Enterocolitis: occurs in premature newborns, translocation of bacteria into intestinal wall, XR with dilated bowel, gas in wall, Tx surgical consult and admit Premature + Gas in bowel wall Necrotizing Enterocolitis

42 Poor Family + Infant with Seizure
Foundations Challenge RAPID FIRE 3 pts Poor Family + Infant with Seizure Cause??? Grandma’s House + AMS + Pinpoint Pupils Toxic Ingestion??? Hyponatremia from dilute feeds Clonidine Trauma/abuse Boyfriend Babysits + Crying Diagnosis???

43 3 pts Poor Family + Infant with Seizure
Foundations Challenge RAPID FIRE 3 pts Poor Family + Infant with Seizure Hyponatremia from Diluted Formula Grandma’s House + AMS + Pinpoint Pupils Clonidine Dx: Poor family, infant with seizure Hyponatremia from dilute feeds; Tx with hypertonic saline (5ml/kg 3%) Dx: kid at grandma's house with AMS, pinpoint pupils Clonidine ingestion, give narcan Dx: Boyfriend babysits trauma/abuse Extra: Dx: AMS, kid with ETOH ingestion: hypoglycemia (replete per rule of 50) Boyfriend Babysits + Crying Trauma / Abuse

44 Good Luck!!!

45 References Foundations Teaching Content: References:
Dr. Kristen Grabow Moore, MD, MEd Assistant Professor, Emory University Dr. Andrew Ketterer, MD, MA Medical Education Fellow, Beth Israel Deaconess References: Life in the Fast Lane HippoEM Board Review Rivers Written Board Review Medscape emedicine Northwestern EM Chief Residents Authors: Dr. Kristen Grabow Moore, Emory University and Dr. Andrew Ketterer, Beth Israel Deaconess Medical Center Content Revision Winter 2018 References: Life in the Fast Lane HippoEM Board Review Rivers Written Board Review Medscape emedicine Northwestern EM Chief Residents


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