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