Tintinalli Chapters 131-134 Carter.

Tintinalli Chapters Carter

B) Neurally mediated syncope C) Bradyasystolic arrest
A 7 year old ring-bearer arrives after a witnessed syncopal episode during a wedding. He is alert and oriented with no complaints. The most likely etiology would be: A) Cardiac syncope B) Neurally mediated syncope C) Bradyasystolic arrest D) Stokes-Adams syndrome The most common cause of benign syncope is B) Neurally mediated syncope Page 838

A) Application of external neck pressure
With this at the top of your differential, which of the following would you expect to elicit from the history? A) Application of external neck pressure B) Headache, visual changes, tinnitus, vertigo and ataxia C) Sensation of warmth, nausea, lightheadedness, and a visual grayout or tunneling of vision D) Dyspnea, chest tightness, lightheadedness, tunnel vision, carpopedal spasm or paresthesias C) NMS symptoms. A is situational syncope, B is atypical migraine, D is hyperventilation Ppg

A) Valvular heart disease B) Congenital complete heart block
A 13-year-old football player experiences sudden cardiac death during a game. There was no history of congenital heart disease. The most likely etiology is: A) Valvular heart disease B) Congenital complete heart block C) Marfan syndrome D) Hypertrophic cardiomyopathy Hypertrophic cardiomyopathy is the most common cause of sudden cardiac death in adolescents without known cardiac disease Pg 838

B) Aberrant coronary arteries C) Atherosclerotic plaque rupture
The autopsy revealed the left ventricular wall thickness within normal limits. So, at this point, which of the following cardiac lesions would you be most suspicious? A) Atrial hypertrophy B) Aberrant coronary arteries C) Atherosclerotic plaque rupture D) Pericardial tamponade B) Aberrant coronary arteries. “The two most common cardiac lesions associated with sudden death among athletes are hypertrophic cardiomyopathy and aberrant coronary arteries.” Pg 839

According to Jerry, what is the most important part of the reservation?
A) The taking B) The holding C) The driving D) The insurance d

B) Family history of sudden death C) Recurrent episodes
A 15-year-old trumpet player was performing during band practice in August and had a syncopal episode lasting ten minutes. They were in full dress and marching on the field. History: several syncopal episodes growing up after he was a ring-bearer, his brother had a sudden cardiac arrest during a football game. Physical: hot, diaphoretic skin. Alert and oriented. Which factor would be least likely responsible for a serious cause of his syncope? A) Heat exhaustion B) Family history of sudden death C) Recurrent episodes D) Prolonged loss of consciousness E) Exertion preceding the event Heat exhaustion would not be a serious cause. Factors for serious cause of syncope: exertion, history of cardiac disease in pt, family hx of sudden death, deafness or cardiac disease, recurrent episodes, recumbent episode, prolonged loss of consciousness, associated chest pain or palpitations, medications that can alter cardiac conduction Pg 838

1. Hematocrit and serum chemistry panel 2. Coagulation panel
Initial laboratory assessment of this patient would include which of the following? 1. Hematocrit and serum chemistry panel 2. Coagulation panel 3. Thyroid function tests 4. ECG 5. Serum lactate A) 1, 2, 3, 4, 5 B) 1, 3, 4, 5 C) 1, 2, 5 D) 1, 3, 4 D) 1, 3, 4: Hematocrit and serum chemistry panel, thyroid function tests, ECG. A coagulation panel and lactate would be unnecessary in this patient. Pg 839

A 15-year-old adolescent presents with a chief complaint of near syncope. What historical information makes you most concerned for a serious etiology? A) The dizziness occurred when the patient got up off the sofa after watching TV for 2 hours. B) The patient skipped breakfast and felt light- headed in front of her locker. C) The patient is a varsity starter on the basketball team and had chest pain during warmups. D) The patient was standing still for a prolonged period of time under spotlights during a chorus performance at school. From 1000 Questions to Help You Pass the Emergency Medicine Boards…. The answer is C (Chapter 131). Syncope is a common cause of pediatric visits to the ED, especially in adolescents. The majority of events are due to neurally mediated syncope. Several factors increase the possibility of a serious cause of syncope. These include exertion preceding the event, recurrent episodes, occurrence while recumbent, prolonged loss of consciousness, associated chest pain and/or palpitations, past medical history of cardiac disease or use of drugs that can alter cardiac conduction, or a family history of sudden death, early cardiac disease, or deafness. The three other choices are all common stories that are more suggestive of neurally mediated syncope, a generally benign condition.

A) Orthostatic syncope B) Cardiac dysrhythmia C) Simple faint
A 14-year-old female is brought in by EMS after a report of a brief syncopal episode while at a haunted house. The medics report it occurred when the chainsaw started up and a hockey-masked figure began to chase them. The most likely etiology for the event would be: A) Orthostatic syncope B) Cardiac dysrhythmia C) Simple faint D) Riley-Day syndrome B) Cardiac dysrhythmia “A cardiac dysrhythmia should be suspected if the syncope is associated with an intense sympathetic stimulus, such as fright, anger, surprise, or physical exertion.” Riley-Day syndrome is an inherited disorder of abnormalities in heart rate and blood pressure Pg 840

According to George, what is better than conjugal sex? A) Prison sex
B) Fugitive sex C) Jail sex D) Animal sex B

A) Myocardial ischemia B) Supraventricular tachycardia
A 17 year-old female presents s/p cardiac arrest resuscitation with the following ECG: This 12-lead electrocardiogram was obtained 48 hours after the patient had a cardiac arrest. The patient had a long history of exertion-related syncope, probably due to recurrent episodes of adrenergic-dependent torsade de pointes. The QT segment was bizarrely inverted in all leads and measured 520 ms even though the RR interval was only 630 ms. Because of the dramatic T-wave changes, the patient was initially misdiagnosed with myocardial ischemia, but a coronary arteriogram and a left ventricular angiogram were normal. Diagnosed with Romano-Ward Syndrome, she was successfully treated with ß-adrenergic blockade and overdrive permanent pacing. Pg 840 Tan, H. L. et. al. Ann Intern Med 1995;122: You suspect: A) Myocardial ischemia B) Supraventricular tachycardia C) Romano-Ward Syndrome D) Sinus tachycardia

B) Sick Sinus E) A-Flutter C) SVT
A 17-year-old male presents s/p syncopal episode with the following ECG. You suspect: A) AV Block D) WPW B) Sick Sinus E) A-Flutter C) SVT WPW Pg 840

A) Atrial dysrhythmias B) Ventricular dysrhythmias
In the previous patient, the risk of sudden death and syncope would be greatest with: A) Atrial dysrhythmias B) Ventricular dysrhythmias C) Atrioventricular block D) Tachycardia-bradycardia syndrome “The risks of sudden death and syncope are greatest in patients who have atrial dysrhythmias such as atrial fibrillation and atrial flutter.” Tachy-brady is sick sinus syndrome Pg 840

A) Ambiguous genitalia and a webbed neck
In children, which of the following is most strongly associated with congenital prolonged QT interval on ECG? A) Ambiguous genitalia and a webbed neck B) Family history of exercise-induced syncope C) Maternal history of recurrent miscarriages D) Profound bradycardia on prenatal ultrasonography E) Syncope after initiating antifungal therapy PEER VII Question 390: Answer B….please see PEER VII answer book for explanation….

A) Discharge home with holter monitoring
An 8-year-old boy is brought in by EMS after a reported syncopal episode during a baseball game. Medics on standby at the field reported a wide-complex tachycardia immediately after the fall. He then regained consciousness and has been alert and oriented since. There have been no dysrhythmias during an 8 hour observation in the ED. Proper disposition of this patient would be: A) Discharge home with holter monitoring B) Discharge home with cardiac echo eval in the AM C) Discharge home with follow up in 24 hours D) Admit D) Admit. “Obviously, any child with a dysrhythmia documented by prehospital providers or on the ECG in the ED must be admitted.” Pg 842

A 20-kg baby requires how much fluid per day?
A) 1000 mL B) 1200 mL C) 1500 mL 1750 mL 2000 mL 100 mL x 10 kg = 1000 mL + (50 mL x 10 kg) = 500 mL, for a total of 1500 mL/day C) 1500 mL/day: 100 mL x 10 kg = 1000 mL + (50 mL x 10 kg) = 500 mL, for a total of 1500 mL/day First 10 kg: 100 mL/kg per d Second 10 kg: 50 mL/kg per d Remaining: 20 mL/kg per d Pg 843

A) Isotonic dehydration B) Hypernatremic dehydration
Dr. Cogbill is seeing a 12 kg boy with a three day history of severe rice-water diarrhea. He diagnoses the boy with cholera. The child has decreased skin turgor and sunken eyes as well as lethargy. He suspects that there is a 10% fluid deficit. You suspect: A) Isotonic dehydration B) Hypernatremic dehydration C) Hyponatremic dehydration D) Hyponatremia with increased total body water Isotonic dehydration. “Sudden massive loss of fluid such as occurs in cholera-associated or rotavirus diarrhea can be fatal if not treated aggressively.” Pg 844

You administer fluid boluses equaling 40 mL/kg until the patient’s mental status improves. Fluid replacement now consists of replacing _____ % of the estimated volume deficit in the first ______ hours, and the remainder of the deficit in the next _______ hours. A) 25%, 4 hrs, 8 hrs B) 50%, 8 hrs, 16 hrs C) 75%, 12 hrs, 24 hrs D) 100%, 16 hrs, 32 hrs B) “Fluid replacement then consists of replacing 50% of the estimated volume deficit in the first 8 hrs, and the remainder of the deficit in the next 16 hrs.” Pg 845

C) 5% Dextrose, 0.45% Sodium chloride
The attending asks you to write fluid orders for admission. First, which fluid do you choose? A) 0.9% Sodium chloride B) 3% Sodium chloride C) 5% Dextrose, 0.45% Sodium chloride D) 10% Dextrose, 0.45% Sodium chloride c) “In children, D5 0.45% NS can be used for maintenance rehydration in isotonic dehydration.” Pg 845

then ______ mL/hr for the next 16 hrs
Now, for this 12 kg, 10% dehydrated boy, you will write the orders for fluid at ________ mL/hr x 8 hrs, then ______ mL/hr for the next 16 hrs A) 83 mL/hr, 65 mL/hr B) 121 mL/hr, 84 mL/hr C) 159 mL/hr, 102 mL/hr D) 196 mL/hr, 121 mL/hr B) 121 mL/hr, 84 mL/hr See formula and work on pg 845 Maint: 100mL/kg x 10kg/24h = 1000mL + 50mL/kg x 2kg/24h = 100mL. Total 1100 mL/24h or 46mL/h Deficit: 10% of 12kg = 1200 mL; with 600mL/8h (75mL/h) and 600mL/16h (38mL/h) First 8 hours: Maint 46mL/h + Deficit 75mL/h = 121mL/h Next 16 hours: Maint 46mL/h + Deficit 38mL/h = 84mL/h

According to Elaine, what was wrong with Noreen's new boyfriend?
A) He was boring and a long talker B) High Talker C) He smelled D) Low Talker a

A) Isotonic dehydration B) Hypernatremic dehydration
A 6 month old girl is brought by EMS for seizure activity. She has had a three day history of severe diarrhea. Her mother has been treating her with tablespoons of baking soda in her milk every day to “replenish her base.” Results of her serum chemistry are: You suspect: A) Isotonic dehydration B) Hypernatremic dehydration C) Hyponatremic dehydration Hyponatremia with increased body water 165 110 24 4.0 30 1.0 Hypernatremia, elevated bicarb and BUN coupled with dehydration caused by diarrhea is Hypernatremic dehydration. Pg 845

The seizures are controlled with versed 0. 5 mg/kg PR
The seizures are controlled with versed 0.5 mg/kg PR. Free water is carefully administered via NGT. You, again, must write fluid orders. If your goal is 140 mEq/L, over how many hours should the sodium safely be lowered? A) 12 B) 24 C) 48 D) 72 D) 72 “…replacing lost free water in such a way that the serum sodium falls no more than 10 to 15 mEq/L per day.” Starting at 165, the safest and earliest date of correction would be three days out. Also, “it is most important that rehydration be spread out over 48 to 72 hours, rather than the 24 hours used for isotonic dehydration.” Pg 845

B) Place an IV with 20 mL/kg of normal saline, and reassess.
You are seeing a 19-month-old infant who has had diarrhea for 3 days. The child has had a low-grade fever. Stools are not bloody. The parent is uncertain about urine output as there is so much stool on the diapers. The infant is otherwise still active and willing to drink. On exam he is afebrile, heart rate is 124 beats per minute, respiratory rate is 24 breaths per minute, and when you examine his ears he cries and has tears. His lips and tongue are dry. Skin turgor is normal, and capillary refill is 1-2 seconds. What is the MOST appropriate therapy at this point? A) Place an IV bolus with 20 mL/kg of normal saline, check electrolytes, and reassess. B) Place an IV with 20 mL/kg of normal saline, and reassess. C) Order oral rehydration solution 50 mL/kg over 4 hours, and reassess. D) Order oral rehydration solution 20 mL/kg over 24 hours, and reassess. From 1000 Questions to Help You Pass the Emergency Medicine Boards…. The answer is C. This child has signs and symptoms of uncomplicated diarrhea likely secondary to viral gastroenteritis. The vital signs and your exam indicate that the patient is mildly dehydrated. The appropriate treatment is rehydration using an oral rehydration solution like Pedialyte. The appropriate amount is 50 mL/kg over 4 hours plus an additional 10 mL/kg for each additional loose stool the patient has. IV rehydration is not indicated in this patient. IV rehydration is appropriate for severely dehydrated patients and moderately dehydrated patients who are unable to take or tolerate oral rehydration solutions. Electrolytes are rarely useful in the initial management of acutely dehydrated patients who require IV therapy.

B) Consult a surgeon for a saphenous vein cutdown.
A 6-week-old infant presents with nonbloody, watery diarrhea for 2 days. The parent states the stools are now occurring every minutes. The infant has become progressively lethargic and now won't drink. He has a temperature of 37.0°C, heart rate is 198 beats per minute, and respiratory rate is 40 breaths per minute. The infant is listless and does not cry with needle sticks. He has a sunken fontanel and dry mouth. Capillary refill is 4 seconds, and there is tenting of the skin. The nurses have been unable to place a peripheral IV. What should you do next? A) Place an intraosseous line and administer a 20 mL/kg bolus of normal saline over minutes, then reassess. B) Consult a surgeon for a saphenous vein cutdown. C) Order oral rehydration solution 50 mL/kg over 4 hours, and reassess. D) Place an intraosseous line and administer a 20 mL/kg bolus of D5 & 1/4; normal saline over 1 hour, then reassess. From 1000 Questions to Help You Pass the Emergency Medicine Boards…. The answer is A. This patient is severely dehydrated based on history, vital signs, and physical exam. The heart rate of 198 beats per minute indicates that this child is at the limit of compensated shock and is at risk for cardiovascular collapse. Immediate vascular access is needed. An intraosseous line can be life-saving in this situation where peripheral access has been unsuccessful. An intraosseous needle can be inserted into the proximal tibia in seconds. Normal saline 20 mL/kg should be infused ("pushed") rapidly using a syringe and stopcock. Immediately reassess the patient and continue fluid resuscitation as indicated. Such patients may require mL/kg before vital signs are improved. Consulting a surgeon for access for a saphenous cutdown would take too long in this situation. Oral rehydration therapy is not appropriate for a severely dehydrated patient in shock. Using glucose-containing solutions for IV boluses is contraindicated because of the excessive amount of glucose administered, which will lead to hyperglycemia and osmotic diuresis.

Initial bolus of 500 mL normal saline followed by
You are treating a 25-kg child with presumed acute appendicitis. The patient is mildly dehydrated, has normal electrolytes, and needs to be NPO until he goes to the OR. Which of the following fluid orders is MOST appropriate? A) Initial bolus of 500 mL normal saline followed by D5 1/2 NS plus 20 mEq KCl/L at 67 mL/hour. B) Initial bolus of 500 mL D5 1/2 NS plus 20 mEq KCl/L followed by D5 1/2 NS plus 20 mEq KCl/L at 67 mL/hour. C) Initial bolus of 100 mL normal saline followed by D5 1/2 NS plus 20 mEq KCl/L at 67 mL/hour. Initial bolus of 500 mL normal saline followed by D10 1/2 NS plus 20 mEq KCl/L at 67 mL/hour. From 1000 Questions to Help You Pass the Emergency Medicine Boards…. The answer is A (Chapter 132). This patient is best treated with an initial bolus of isotonic fluid followed by appropriate maintenance fluids preoperatively. A 20 mL/ kg bolus for a 25-kg child would require 500 mL of either normal saline or lactated Ringer's solution. Maintenance fluids are calculated as follows: (100 mL ´ 10 kg) + (50 mL ´ 10 kg) + (20 mL ´ 5 kg) = 1600 mL per day. This daily total is divided by 24 to give an hourly infusion rate of 67 mL/hour. Glucose-containing fluids should not be used for boluses as this will lead to hyperglycemia. Fluids containing 5% dextrose, rather than 10%, are typically used for maintenance fluid in children.

Abdominal examination Color of the vomitus History of constipation
For young infants who are vomiting, which of the following is most likely to differentiate acute malrotation with midgut volvulus from pyloric stenosis? Abdominal examination Color of the vomitus History of constipation Presence of high fever Resting tachycardia From PEER VII question 357: Answer B. The abdominal examination is usually normal in the early stages of both acute malrotation with mudgut volvulus and pyloric stenosis. The historical description of a palpable “olive” and a peristaltic wave for cases of pyloric stenosis is now rarely seen because of early testing with ultrasound (or an upper GI) once the diagnosis is considered (typically prompted by any episode of forceful vomiting). Constipation and high fever are not characteristic findings in either acute malrotation with midgut volvulus or pyloric stenosis and therefore do not differentiate them. A resting tachycardia is too nonspecific and can be seen with many clinical entities, including pain… Pyloric stenosis is an obstruction at the level of the distal stomach and so bilious vomitus is not expected. Acute malrotation with midgut volvulus involves locations of the GI tract more distal and bilious vomiting is a hallmark of this disorder….see PEER VII question 357 for more….

For young children who are moderately dehydrated, which of the following is a contraindication to oral rehydration? High fever Occasional vomiting Poor compliance Sunken eyes Viral exanthema From PEER VII question 361: Answer C. see answer book for a thorough explanation

Kramer and Neumann hatch a plan to collect cans and bottles in NYC and return them to what location for the refund? Hackensack, N.J. “The Hamptons” Saginaw, Michigan Del Boca Vista, Florida C

Before dialysis, the next most appropriate step would be:
An 18-month old male with chronic renal failure presents with the following ECG: Before dialysis, the next most appropriate step would be: A) Adenosine 0.1 mg/kg bolus B) D50 1 to 2 mL/kg slow IVP C) Hydrocortisone 50 mg/m2 Q 6 hours D) Calcium gluconate 10% 100 mg/kg IV Answer D: Hyperkalemia treated first with calcium.

Widening of QRS complex Paresthesias
You are seeing a child with chronic renal insufficiency managed with daily peritoneal dialysis. The child was at his father's home over the weekend and missed 2 days of dialysis. The patient is complaining of weakness, and his serum potassium is 8.1 mEq/L. Which of the following is the MOST ominous manifestation of hyperkalemia? Weakness Peaked T waves Widening of QRS complex Paresthesias From 1000 Questions to Help You Pass the Emergency Medicine Boards…. Question The answer is C (Chapter 132). Hyperkalemia can cause weakness and paresthesias; however, it is the effect on cardiac conduction that is most dangerous. Peaked T waves are the earliest cardiac manifestation of hyperkalemia, followed by prolongation of the PR interval. If potassium levels reach approximately 8 mEq/L or more, ST-segment depression and widening of the QRS complex occurs. This ominous finding may precede bradycardia, arterioventricular block, ventricular dysrhythmias, and asystole. Any patient with electrocardiogram changes requires emergent therapy to reverse cardiac conduction toxicity.

D) Retropharyngeal abscess
You are seeing a 12-month-old, previously well, fully immunized child with stridor. The patient had upper respiratory track infection symptoms for 2-3 days and then developed fever that has progressed to a maximum of 104°F over the past 2 days. The patient is alert and appears nontoxic. She has a muffled voice, is drooling, and is not interested in drinking. A soft tissue film of the neck is obtained. What is the MOST likely diagnosis in this patient? A) Bronchiolitis B) Epiglottitis C) Croup D) Retropharyngeal abscess From 1000 Questions to Help You Pass the Emergency Medicine Boards…. Question The answer is D (Chapter 133). Stridor, muffled voice, and drooling indicate upper airway obstruction, and the presence of fever suggests an infectious etiology. The soft tissue film of the neck is abnormal (see in the Questions section). Retropharyngeal abscesses occur in children between 6 months and 3-4 years, with most occurring at or before 12 months. There is typically an antecedent upper respiratory infection followed by increasing fever. The location of the abscess in the posterior pharyngeal region leads to muffling of the voice, stridor, and drooling secondary to dysphagia. The diagnosis is suggested by a widening of the prevertebral soft tissue space seen on soft tissue films of the neck (see Figures 16-2 and 16-3). Epiglottitis can also cause high fever, drooling, and stridor. However, the onset of epiglottitis is typically abrupt. This child is also fully immunized, making Haemophilus influenzae type B infection unlikely. Croup is the most common cause of stridor in infants and young children. It often begins with upper respiratory symptoms before the classic barking cough and stridor develop. Fever in croup is usually low grade. Bronchiolitis is a lower respiratory tract infection that causes cough, tachypnea, crackles, and wheezes rather than stridor.

Lateral neck film of a 12-month-old infant with fever, muffled cry, and drooling. The white arrows show the prevertebral area that is significantly increased in width. The black arrow shows an area of air within the infected region, suggestive of abscess formation. Diagram of a retropharyngeal abscess. The grey area represents the area of lymphatic tissue that becomes infected and enlarged. This results in the increased width of the prevertebral space and compression of the upper airway.

Leads to mild hyperactivity that interferes with normal sleep patterns
For a previously healthy toddler with mild croup, the administration of oral dexamethasone: Is indicated only for moderate-to-severe croup, because mild croup is self-limited Is indicated only if the parents are unable to provide cool mist at home Is precluded by an unacceptably high rate of uncontrollable vomiting after administration Leads to mild hyperactivity that interferes with normal sleep patterns Leads to quicker resolution of symptoms when compared with observation From PEER VII: Answer is E. Three recent randomized, controlled studies are relevant to the current management of croup. Bjornson et al performed a double-blind, randomized, placebo-controlled trial of a single dose of oral dexamethasone for mild croup. In this study of 720 children, the authors found that oral dexamethasone administration led to fewer returns for medical care, quicker resolution of croup symptoms, less lost sleep and less parental stress than placebo. See the explanation for question 347 for more….

What was Kramer’s famous line in the Woody Allen movie?
“ You’re as good looking as any of the other girls, you just need a nosejob!” “Look away I’m hideous!” “These pretzels are making me thirsty!” “Giddyap!” C

For a child with stridor, which of the following best differentiates croup from bacterial tracheitis? Drooling and fever Normal CXR Productive cough Rhinorrhea prodrome Stridor at rest From PEER VII Question 368. Answer C. Croup is a viral disorder that is usually mild and does not have an associated productive cough. These children are usually well appearing and playful. Bacterial tracheitis, on the other hand, is a bacterial infection that is often diagnosed when copious purulent secretions are noted in the trachea during endotracheal intubation for respiratory failure….please see answer to question 368 for more…..

Which of the following statements regarding the use of ketamine for procedural sedation and analgesia is correct? Advantages include the maintenance of protective airway reflexes and the absence of cardiovascular effects Concurrent use of benzodiazepines to prevent emergence reactions does not significantly prolong clinical recovery time Development of intense myoclonic jerking movements indicates the presence of a latent seizure disorder and should be treated with a benzodiazepine D) Induces dissociation between the cortical and limbic systems, resulting in amnesia, sedation and analgesia E) Laryngospasm is rare, but when it occurs an emergent surgical rescue airway is often needed PEER VII Question 379: Answer D. It does have a catecholamine release which increases heart rate, blood pressure and cardiac output. Benzo’s increase recovery by 30%. Not associated with seizures (although myoclonic jerks are seen), laryngospasm occurs but does not need intubation or surgical airway…..see question 379 in PEER VII for more….

You are seeing an 18-month-old child with signs and symptoms of viral laryngotracheobronchitis. Recent prospective clinical trials have shown that which of the following medications will decrease the need for hospital admission in patients with this disease? Levoalbuterol Dexamethasone Humidified oxygen Albuterol From 1000 Questions to Help You Pass the Emergency Medicine Boards…. Question The answer is B (Chapter 133). Croup (laryngotracheobronchitis) is the most common cause of acute stridor in children between 6 months and 3 years. Most children with croup require no specific treatment other than reassurance and supportive care with fluids and antipyretics. Stridor at rest is an indication for treatment in the ED. Medications that decrease edema in the epithelial lining of the upper airway will improve symptoms. Epinephrine and dexamethasone are both effective. Nebulized epinephrine often provides immediate improvement in stridor. However, the effects typically wear off after 2-3 hours and do not alter the natural course of the disease. In contrast, dexamethasone, a potent steroid, takes hours to take effect, but its anti-inflammatory effects last up to 1-2 weeks. Multiple clinical trials have demonstrated that dexamethasone decreases the need for hospital admission and overall duration of symptoms in patients with croup. Bronchodilators such as albuterol and levoalbuterol have no effect on upper airway edema and thus have no role in the management of croup. Though commonly used (e.g., croup tents), humidified oxygen has not been shown to significantly alter the course of croup.

According to Jerry, why did Tim Whatley convert to Judaism?
A) To get more patients B) For the jokes C) To get more women b

Which of the following pain assessment scales is designed to objectively measure pain in infants and nonverbal toddlers? CRIES scale FACES pain scale OUCHER Visual analog scale. From 1000 Questions to Help You Pass the Emergency Medicine Boards…. Question The answer is A (Chapter 134). The CRIES scale is a non-self-report tool that was developed to assess pain in infants. It takes into account cry quality, need for oxygen, changes in heart rate and blood pressure, expression, and state of sleepiness. The FACES, OUCHER, and visual analog scales are all self-reported, subjective scales commonly used to rate pain in children. The FACES scale can be used in children 3 years and older. The OUCHER pain scale becomes reliable at age 4 years and up. Visual analog scales are particularly useful in the repeated evaluation of pain over time in response to treatment.

Ketamine and midazolam Midazolam C) Fentanyl and midazolam
You are caring for an 8-year-old child with a significantly angulated distal radius and ulna fracture. You are asked by your orthopedic consultant to provide procedural sedation for closed reduction of the injury. The patient has a past medical history of poorly controlled seizures but is otherwise well. Which drug or combination of drugs would be MOST appropriate in this patient? Ketamine and midazolam Midazolam C) Fentanyl and midazolam D) Oxycodone. From 1000 Questions to Help You Pass the Emergency Medicine Boards…. Question The answer is C (Chapter 134). Ketamine and midazolam are commonly used for painful procedures in children. However, poorly controlled seizures are a contraindication to the use of ketamine. There is also no data to support the coadministration of midazolam with ketamine to prevent unpleasant emergence reactions from ketamine. Midazolam alone would not be appropriate as it provides anxiolysis and sedation but no analgesia. Oxycodone is a potent oral analgesic and might be appropriate for home use in this patient after discharge. However, titration of sedation and analgesia is more difficult using oral medications, so oral opiates are used less often when the degree of pain and duration of the procedure are unpredictable.

Children without intravenous access Patients with history of asthma
In which of the following situations should ketamine be used with caution? Children without intravenous access Patients with history of asthma Patients in whom other analgesics were not fully effective in controlling pain Patients with suspected increased intracranial pressure. From 1000 Questions to Help You Pass the Emergency Medicine Boards…. Question 2-3 The answer is D (Chapter 38). There are concerns that ketamine may cause an increase in intracranial pressure and thus it would be contraindicated in someone who already has documented elevated intracranial pressure. One of the benefits of ketamine is that it can be given in an intramuscular dose. It is often given in combination with antisialagogues such as atropine or glycopyrrolate in the same syringe. Ketamine is associated with some bronchodilatatory properties, which may make it a good agent to use in patients with preexisting asthma. Unsuccessful complete analgesia is not a contraindication of ketamine.

(A) moderate tonsillar hypertrophy on exam
7 year old boy presents for yearly well-child exam. No complaints and overall exam appears normal. His mother mentions that his school performance has been gradually worsening. His teachers have noticed him repeatedly drifting off to sleep during afternoon classes. He does snore loudly while sleeping and constantly breathes through his mouth during the day. Which of the following warrants referral for tonsillectomy and adenoidectomy? (A) moderate tonsillar hypertrophy on exam (B) recurrent Otitis media with effusion (C) two episodes of tonsillar infection within the past 2 years (D) airway obstruction during sleep (E) nasal voice From USMLE Step 3 Study Guide Answer D—Pediatric OSA.

(B) group A streptococcus (C) Hemophilus influenzae
2 y/o African-american boy presents with a chief complaint of fever to 40oC (104oF). The child is brought in by his parents with notable drooling on exam and ill appearing. His mother notes that over the past 2 to 3 days he has had a progressive decrease in appetite. The child is sitting quietly on the stretcher with findings as noted: His mucous membranes are dry. He has shotty cervical lymphadenopathy but cries with palpation of the neck and resists on attempted movement of the neck. Capillary refill is noted to be greater than 2 seconds. With crying, the child is noted to have intercostal and subcostal retractions. On auscultation of the lungs, the child has clear breath sounds, but you note audible stridor. The physical exam otherwise is unremarkable. What is the most likely pathogen in this case? (A) Mycobacterium (B) group A streptococcus (C) Hemophilus influenzae (D) respiratory syncytial virus (RSV) (E) coxsackievirus USMLE Step 3 Study Guide: B retropharyngeal abscess. GAS, anaerobes and S aureus are common. H flu is not prevalent due to vaccines.

A) Streptococcus pneumoniae B) Streptococcus pyogenes
Which organism is currently found in only a minority of cases involving epiglotittis? A) Streptococcus pneumoniae B) Streptococcus pyogenes C) Staphlococcus aureus D) Haemophilus influenzae D “Since the introduction of the H. flu vaccine, the incidence and demographics of this disease have changed remarkably. Pg 849

Retropharyngeal abscess Peritonsillar abscess Bacterial Tracheitis
The classic symptoms of this disease include an abrupt onset over several hours of high fever, sore throat, stridor, dysphagia and drooling. Retropharyngeal abscess Peritonsillar abscess Bacterial Tracheitis Viral croup Foreign body aspiration Epiglottitis F) Epiglotittitis Page 849

Physical examination of an acutely ill child reveals bilateral tonsillar erythema and exudate. The uvula and anterior pillar of the tonsil appear to be displaced. Which of the following is the least appropriate initial treatment A) Penicillin IV B) Needle Aspiration C) Observation D) Pain control C) observation. “The majority of cases are treated as outpatients with needle aspiration, antibiotics and pain control.” Pg 856

The classic symptoms of this disease include a 1- to 5 day prodrome consisting of cough, coryza and occasionally other upper respiratory infection-type symptoms. There is biphasic stridor which is unaffected by position but increases with crying or agitation. The voice is often hoarse but not muffled. Typically, the third and fourth days are the worst, and then the child starts to improve. Retropharyngeal abscess Peritonsillar abscess Bacterial Tracheitis Viral croup Foreign body aspiration Epiglottitis D Croup Pg 852

According to Elaine, what was the best part of her date with the lawyer?
A) Making out B) The movie C) The yada, yada D) The Bisque D

A) Ampicillin/sulbactam B) Clindamycin C) Vancomycin D) Ceftazadime
A 3 year old child with a muffled voice and meningismus is found to have swelling to the prevertebral soft tissues >14 mm at C6. Which of the following provides the broadest coverage of the potential etiologic agents? A) Ampicillin/sulbactam B) Clindamycin C) Vancomycin D) Ceftazadime A) Retropharyngeal abscess, “In patients who are not allergic to penicillin, amp/sulbactam provides the broadest coverage of the potential etiologic agents.” Pg 857.

The classic symptoms of this disease include severe inspiratory and expiratory stridor, cough with occasional thick sputum production, a raspy or hoarse voice and no dysphagia. They may also complain of a gnawing or burning substernal chest discomfort. Retropharyngeal abscess Peritonsillar abscess Bacterial Tracheitis Viral croup Foreign body aspiration Epiglottitis C. Bacterial Tracheitis Pg 854

Which of the following should be considered in all children given a diagnosis of unilateral wheezing? Retropharyngeal abscess Peritonsillar abscess Bacterial Tracheitis Viral croup Foreign body aspiration Epiglottitis E) Foreign Body aspiration. Pg 855

Which of the following shows bilateral decubitus PA chest radiographs with a fully inflated lung with the ipsilateral diaphragm inferiorly displaced on one side and diaphragmatic elevation, rib splinting and decreased relative volume on the other. Retropharyngeal abscess Peritonsillar abscess Bacterial Tracheitis Viral croup Foreign body aspiration Epiglottitis E. Foreign Body Pg 855

Which of the following is the least likely to be a dangerous object for aspiration?
(Drew’s Mom) “The most dangerous objects are those that are cylindrical or small, smooth and round.” Pg 855 A 5-year-old child aspirated two magnets that were surgically removed from his lung. A 13-month-old girl reportedly suffocated when one-half of a Pokemon ball covered her nose and mouth. An 18-month-old girl reportedly also had a ball-half stuck over her face, causing her distress. However, the girl's father (on the second attempt) pulled the ball-half from her face. Playskool received reports that a 19-month-old boy from Martinsburg, W.V., and a 2-year-old boy from League City, Texas, suffocated when oversized, plastic toy nails sold with the tool bench toys became forcefully lodged in their throats.

Patients experiencing which of the following presents acutely ill with fevers, chills, dysphagia, trismus, drooling or a muffled “hot potato” voice. Retropharyngeal abscess Peritonsillar abscess Bacterial Tracheitis Viral croup Foreign body aspiration Epiglottitis B) Peritonsillar abscess Pg 856

Patients suffering from which of the following presents acutely ill with high fever, decreased oral intake, stiff neck, muffled voice, persistently hyperextended neck, inspiratory stridor, and possibly respiratory distress and tachypnea. Retropharyngeal abscess Peritonsillar abscess Bacterial Tracheitis Viral croup Foreign body aspiration Epiglottitis A) Retropharyngeal abscess Pg 857

(A) antibiotic therapy
What is the most important first management step in the previous patient? (A) antibiotic therapy (B) assessment of the airway and emergency ENT consult (C) IV access (D) CT of the neck (E) PO dexamethasone USMLE Step 3 Study Guide Answer B unable to handle secretions. Keep calm and avoid painful exam.

How did George get the upper hand with his girlfriend Noel?
A) Paid for all meals B) Acted like a tough guy C) Said he was an architect D) Preemptive break-up d

Tintinalli Chapters 131-134 Carter.

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Tintinalli Chapters 131-134 Carter.

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