Name.

Abu dogosh muhamad Group No M1656

Surname
Topic Emergency in pediatrics Date 21/05/21

Exercises Complete the test Points*

1 A 4-year-old boy is brought in by his mother presenting with an acute onset of dyspnoea and 0
pruritic rash. The mother states that they were eating spicy seafood half an hour ago when she 1
noticed that the area around his mouth started to get red and his lips started swelling. Shortly
afterwards, she said he started coughing and getting short of breath. When you examine him,
he is lethargic, has swollen lips with an urticarial rash on his mouth and trunk. He is currently
afebrile and his vital signs are HR 160, RR 45, and BP 70/40. You diagnose this patient as
having anaphylaxis. Select all of the criteria below that led you to this diagnosis.
Choose all that apply Comment your selection:
Acute onset of an illness (minutes to sevral
hours)
Involvement of the skin, mucosal tissue or both
(i.e. generalized hives, pruritus, flushing or
swollen lips, tongue and uvula)
Respiratory compromise (i.e. - dyspnea, wheeze-
bronchospasm, stridor, reduced peak expiratory
flow [maximum speed of expiration] or
hypoxemia)
Reduced BP or associated symptoms of end-organ
dysfunction (i.e. - hypotonia, syncope or
incontinence)
Persistent gastrointestinal symptoms (eg, crampy
abdominal pain or vomiting)

2 After diagnosing the patient with anaphylaxis, what is your first step of management? 0
Choose all that apply 1
Epinephrine (1:1000) 0.01mg/kg IM every 5-15
minutes into the anterolateral thigh
Epinephrine (1:1000) 0.01mg/kg IM every 5-15
minutes into the deltoid
Diphenhydramine (Benadryl) 1mg/kg/dose (50mg
maximum) IM/IV every 4-6 hours
Salbutamol (Ventolin) 5-10 puffs with MDI every
20 minutes or continuous
Salbutamol (Ventolin) 2.5–5 mg by nebulization
every 20 minutes or continuous
Cetirizine 2.5-5mg PO x 1
Ranitidine 1 mg/kg/dose (maximum 50mg)
PO/IV every 8 hours
Prednisone 1 mg/kg (maximum 75mg) PO every
6 hours
Methylprednisolone 1 mg/kg IV (maximum 125
mg) every 6 hours

3 After administering Epinephrine, what is your next step of management? 0

Choose all that apply 1
Epinephrine 1:1000, 0.01mg/kg IM every 5-15
minutes into the anterolateral thigh
Initiate second line pharmacology (H1/H2
antihistamines, corticosteroids, salbutamol)
Initiate ABCs
 Salbutamol (Ventolin) 5-10 puffs every 20
minutes
4 The child is conscious and able to answer questions. He looks flushed. His current BP is
70/40 and his capillary refill rate is delayed at 4 seconds. What is your next step of
management?
Choose all that apply
Epinephrine 1:1000, 0.01mg/kg IM every 5-15
minutes into the deltoid
Diphenhydramine (Benadryl) 1mg/kg/dose (50mg
maximum) every 4-6 hours
Normal saline bolus IV 20ml/kg repeated as
needed
Salbutamol (Ventolin) 5-10 puffs every 20
minutes

5 The child’s vitals have now stabilized and he feels ok to go home. The rash is also 0
improving. What is your next step of management? 1
Choose all that apply
Discharge the patient home

Observe for a minimum of 4-6 hours

Admit the patient to the hospital for
observation

6 After a brief admission for observation, your attending feels comfortable with discharging the 0
patient. The child weighs 18kg. What are your discharge orders? 1
Choose all that apply
Prescribe EpiPen Jr (0.15mg) or Twinject
(0.15mg)
Prescribe EpiPen (0.3mg) or Twinject (0.3mg)
Educate parents, caregivers and older
children/adolescents on how to administer the
EpiPen/Twinject and to administer the medication
as soon as they see any symptoms develop (i.e. –
even if there is just urticarial)
Advise patients to have the EpiPen/Twinject with
them at all times
3 day course of H1 and H2 antihistamines
(cetirizine and ranitidine) PO
Oral corticosteroids
Give patients strict guidelines for avoidance of
the precipitating trigger, and education about
prevention of allergic reactions.
Recommend MedicAlert bracelets
Follow up with their family doctor/pediatrician
Referral to an allergist/immunologist for
additional testing, information and therapy
*points to be completed by assigned teacher

Clinical case A 2-year-old boy has been breathing noisily for 1 day. For the past 3 days he has had a “cold” 0
2 with a runny nose, fever (temperature: up to 100.4°F [38°C]), and a slight cough. 1
The cough has gradually become worse and now has a barking quality. 2
On examination, the child is sitting up and has a respiratory rate of 48 breaths/min with 3
marked inspiratory stridor and an occasional barking cough. His other vital signs include a 4
 heart rate of 100 beats/min and temperature of 101.2°F (38.4°C). He has intercostal 5
retractions, his breath
sounds are slightly decreased bilaterally, and his skin is pale. The remainder of the
examination is normal
Questions to Statement of Preliminary Severe croup with respiratory distress
answer on Diagnosis
clinical case: Reasoning of Preliminary Fever, barking cough, inspiratory stridor, intercostal
Diagnosis Based on retractions, breath sounds decreased bilaterally, pale skin. RR
Symptoms/Signs/Syndrome 48, high.
s described in the Statement
of the Case
Clinical exam/additional Examination of skin for rash, mucosa for color of nose
maneuvers required to discharges, ears examination, throat examination, percussion
confirm the diagnosis with of the lung to check consolidation.
the justification of their need
Laboratory investigations to CBC – check for inflammation – leukocytosis, CRP.
confirm the diagnosis, Chemistry – electrolytes, PH, ABGs. We need to see if the
arguing that each one needs respiratory distress with the high respiratory rate caused
to be performed respiratory alkalosis and electrolyte changes.
Instrumental investigations CXR,
necessary to confirm the
diagnosis arguing the need
to perform each of them
Differential Diagnosis and Severe bronchiolitis, severe pneumonia
its Argumentation
Final Diagnosis and its Severe croup with respiratory distress
Argumentation
Treatment tactics, Racemic epinephrine
medication and/or surgical
treatment and its
argumentation
Prescription of Essential R.p.: Epinephrine 0.5 ml
Drug Sol. Saline 4 ml
D.s. inhalation
Basic information in Prevent distress in the patient so it won't constrict the airway,
Education of humidify the air.
Patient/Recovery of the
patient

Clinical case A mother brings her 14 month-old son into the urgent care clinic with complaints of choking
3 and gagging after eating potato chips 15-20 minutes ago at his grandmother's house. His
mother is unsure if he had eaten anything else with the potato chips and does not think the
child turned blue during the choking and gagging episode.
He returned to his normal activity shortly after the episode occurred, but since then, he has
had a few intermittent coughing spells. The patient has two older siblings who are still at the
grandmother's house.
Exam: VS T 37.2, P 103, R 28, BP 98/55, O2 saturation 96% in RA, height/weight/head
circumference are all 25-50%ile. He is walking around the exam room in no acute distress. He
has a normal physical exam except for an occasional low-pitched, monophonic expiratory
wheeze heard best over the sternal notch. films were unable to be obtained, decubitus films
were performed.
The right lateral decubitus film (right side down) shows air trapping on the right as evidenced
by failure of the mediastinum to shift toward the dependent side. A pediatric surgery consult
is obtained and they take the child to the OR for rigid bronchoscopy. They find a whole
sunflower seed in the right main stem bronchus and remove it. The child is then hospitalized
overnight for observation and chest physiotherapy (CPT) that is ordered for atelectasis seen
on a post-op film. Upon arrival of the patient's grandmother to the hospital, further history
elicited from her is significant for the older siblings eating sunflower seeds. The patient is
discharged the next morning with follow up scheduled with his pediatrician in the next few
days.
Questions 1. True/False: Foreign body aspiration is sufficiently uncommon that it need not be 0
considered in a patient with a chronic cough. 1
☐ True
☐ False
2. Which radiographic imaging study would be the most helpful if a foreign body aspiration is 0
suspected in a child (<3 y.o.)? 1
☐a. PA
☐b. Inhalation/Exhalation
☐c. Lateral
☐d. Decubitus
3. Describe the three clinical phases of foreign body aspiration. 0
1
Foreign body in the larynx – causing cough, dysphonia, hemoptysis, shortness of breathing 2
and cyanosis. Diagnosis made by direct laryngoscope. 3
Foreign body in the trachea- expiratory wheezing, CXR, bronchoscopy.
Foreign body in the bronchi – can cause recurrent pneumonia, expiratory wheezing. CXR,
usually on right bronchus.

4. What would be worse to aspirate: organic or non-organic material? Why? 0

1
Non-organic material will be worst because it can cause irritation and inflammation. 2

5. True/False: Aspirated foreign bodies in children are more likely to be in the right main- 0
stem bronchus than the left main-stem bronchus. 1
☐ True
☐ False
6. Why should a blind finger sweep never be done in a child with a foreign body aspiration? 0
1
Because it usually making the situation worse by pushing it further.

7. What physical exam sign/symptom is most suggestive of foreign body aspiration? 0

☐a. Fever 1
☐b. Polyphonic wheezing
☐c. Cough
☐d. Stridor
☐e. Monophonic wheezing
8. What physical exam sign/symptom is most worrisome in terms of degree of airway 0
compromise? 1
☐a. Fever
☐b. Polyphonic wheezing
☐c. Cough
☐d. Stridor
☐e. Monophonic wheezing
9. True/False: Nuts + Choking = Bronchoscopy 0
☐ True 1
☐ False

Clinical case This 2 month-old male infant with a 4 day history of vomiting and diarrhea is brought to the
4 emergency department by his mother.
Initial findings in the emergency department include:
 Airway: Breath sounds are normal. Airway is patent.
Breathing: Breathing is regular at 45 breaths per minute, unlabored.
Circulation: Proximal pulses are poor, distal pulses are absent, and extremities are cool.
Feeling from the 5th toe upwards, the legs
are cool up to the knee. Capillary refill is 8 seconds. Heart rate is 209 beats per minute, and
blood pressure is 70mmHg systolic.
ECG: There are narrow QRS complexes with sinus tachycardia on the monitor.
The infant does not recognize his parents, is extremely lethargic, and responds to pain only,
with a minimal grimace. You are unable to start an IV line, 100% oxygen is started. The
mucous membranes of the mouth are pink. An intraosseous (IO) is
placed in the left tibia and 20cc/kg of normal saline is infused as rapidly as possible. The
infant is reassessed. Airway and breathing
remain stable. The heart rate is now 195. A repeat bolus of 20cc/kg is given and the patient is
reassessed. After the 3rd fluid bolus is
given, the patient becomes more alert, distal pulses return, and the patient improves
throughout resuscitation. The heart rate has come
down to 160. However, a rapid bedside glucose analysis reveals a blood sugar of only 32,
which is quickly treated.
This case represents a patient in compensated hypovolemic shock (and hypoglycemia)
secondary to vomiting and diarrhea.
Questions 1.Prioritize the initial management of the child with shock: 0
☐a. Administer oxygen 1
☐b. Administer volume resuscitation
☐c. Support a patent airway
☐d. Support blood pressure and perfusion with cardioactive drugs
☐e. Administer antibiotics
☐f. Address oxygen carrying capacity with administration of blood if anemia is present
2. The most sensitive indicator of intravascular volume in the pediatric patient is: 0
☐a. Cardiac output 1
☐b. Preload
☐c. Heart rate
☐d. Stroke volume
3. In the trauma patient with compensated shock, who is otherwise stable blood should be 0
considered as part of volume resuscitation: 1
☐a. Immediately after the airway is secured and intravenous access
☐b. After 20 cc/kg of isotonic fluid has been administered without clinical response
☐c. After 40 cc/kg of isotonic fluid has been administered without clinical response
☐d. After 60 cc/kg of isotonic fluid has been administered without clinical response
☐e. After isotonic fluid administration has resulted in inadequate clinical response and the
patient requires operative repair
4. Which circulatory finding is the hallmark of the diagnosis of late (decompensated) shock? 0
☐a. Capillary refill of 4 seconds 1
☐b. Altered mental status
☐c. Depressed anterior fontanelle
☐d. Hypotension
☐e. Absent distal pulses
5. An alert, 6 month-old male has a history of vomiting and diarrhea. He appears pale and has 0
an RR of 45 breaths per minute, HR of 180 beats per minute, and a systolic blood pressure of 1
85 mm Hg. His extremities are cool and mottled with a capillary refill time of 4 seconds.
What would best describe his circulatory status?
☐a. Normal circulatory status
☐b. Early (compensated) shock caused by hypovolemia
☐c. Early (compensated)shock caused by supraventricular tachycardia
☐d. Late (decompensated) shock caused by hypovolemia
☐e. Late (decompensated) shock caused by supraventricular tachycardia
6. Appropriate initial management for the child described in question 6 would include which 0
of the following? 1
☐a. Initiation of oral rehydration therapy
☐b. Placement of an intraosseous line, fluid bolus of 20 ml/kg of normal saline
☐c. Placement of an intravenous (IV) line, fluid bolus of 20 ml/kg of normal saline
 ☐d. Placement of an IV line, adenosine 0.1 mg/kg IV

Bibliography:
1. Paediatric lecture note:
https://pediatrie.usmf.md/en/node/13981/lecture-notes

2. Nelson Textbook of Pediatrics, 21e

3. Nelson Essential of Pediatrics, 7e

4. UpToDate

5. APLS: The pediatric emergency medicine resource/American Academy of Pediatrics, American College of
Emergency Physicians, Fifth Edition, Jones and Bartlett 2012
6. Clinical manual of emergency pediatrics, Fifth Edition, Ellen F. Crain, Jeffrey C. Gershel, Cambridge
University Press 2010
7. Textbook of pediatric emergency medicine, Sixth Edition, Gary Fleisher, Stephen Ludwig, Wolters Kluwer
2010
8. European Resuscitation Council guidelines 2015, 2020
9. Pocket book of hospital care for children: Second edition ,World Health Organization,2013
Tests for final exam, are available on: https://pediatrie.usmf.md/en/node/13981/tests

1.You respond to a child or an infant that is found down. What is the next action after determining 0
unresponsiveness? 1
☐a. Apply AED.
☐b. Tell a bystander to call 911.
☐c. Look for a parent.
☐d. Provide rescue breaths.

2. Which of the following describes the brachial pulse location? 0

☐a. Wrist - thumb side 1
☐b. Elbow - inside near forearm
☐c. Upper arm - inside
☐d. Neck - either side of the trachea

3. Effective communication is key in all resuscitation attempts. Which of the following are components of 0
effective team communication? 1
☐a. Knowledge sharing
☐b. Clear communication
☐c. Mutual respect
☐d. All of the above

4. What is a simple mnemonic for aid in the assessment of mental status? 0

☐a. AVPU 1
☐b. SAMPLE
☐c. ABCDE
☐d. NRP

5. What is the proper sequence for AED operation? 0

☐a. Apply pads, turn on AED, deliver shock, and clear individual. 1
☐b. Apply pads, clear individual, deliver shock, and analyze rhythm.
☐c. Turn on AED, apply pads, deliver shock, and resume CPR.
☐d. Turn on AED, analyze rhythm, CPR, and deliver shock.
6. Which of the following sounds suggest an upper airway obstruction? 0
☐a. Stridor 1
☐b. Burping
☐c. Rales
☐d. Apnea

7. A five-year-old child is laughing and playing with his siblings. Moments later, the child was 0
noted to be coughing with asymmetric chest rise. What is the most likely cause? 1
☐a. Trauma
☐b. Airway obstruction
☐c. Stroke
☐d. Pericardial tamponade

8. A four-month-old female infant is noted to be febrile and grunting. What underlying 0

problem does grunting suggest? 1
☐a. Behavior problem
☐b. Upper airway obstruction
☐c. Lung tissue disease
☐d. Diabetes

9. You are treating a child with a toxin ingestion, resulting in bradycardia. Atropine is advised by 0
poison control. Why is the minimum dose 0.1 mg IV? 1
☐a. Rebound tachycardia
☐b. May worsen bradycardia
☐c. Apnea
☐d. Cardiac arrest

10. What is the drug of choice in managing symptomatic bradycardia? 0

☐a. Adenosine 1
☐b. Epinephrine
☐c. Lidocaine
☐d. Dopamine

11. Your team is treating a child with symptomatic bradycardia. His heart rate is 22 bpm, and you 0
are having difficulty obtaining blood pressure. Epinephrine and atropine have had no effect. 1
What would be the next most appropriate action?
☐a. Faster CPR
☐b.Transthoracic pacing is an option for treatment of symptomatic bradycardia when drug
☐c. High dose epinephrine
☐d. Terminate resuscitation

12.Which of the following is not a life-threatening arrhythmia? 0

☐a. Torsades de pointes 1
☐b. Ventricular fibrillation
☐c. Ventricular tachycardia
☐d. Sinus tachycardia

13. You are treating a 13-year-old male who has a history of congenital heart disease. The 0
monitor shows a narrow complex rhythm with a heart rate of 175 bpm, and he has a palpable 1
pulse. Which of the following is a possible diagnosis?
☐a. SVT with aberrancy
☐b. Sinus tachycardia
☐c. Torsades de pointes
☐d. Ventricular tachycardia

14 You are treating a 10-year-old child who has SVT. What is the appropriate first dose for adenosine? 0
☐a. 1 mg 1
☐b. 6 mg
☐c. 0.1 mg/kg with a maximum dose of 6 mg
☐d. 12 mg

15. A seven-year-old child is struck by a car and found to be hypotensive. What is the most likely cause of 0
the low blood pressure? 1
☐a. Anaphylactic shock
☐b. Hypovolemic shock
☐c. Cardiogenic shock
☐d. Obstructive shock

16. What type of shock results in bounding peripheral pulses and a wide pulse pressure? 0
☐a. Septic 1
☐b. Cardiogenic
☐c. Traumatic
☐d. Hemorrhagic

17. You are treating a pediatric person with low blood pressure. What amount of fluid is recommended for 0
bolus therapy? 1
☐a. 100 mL
☐b. 1 liter
☐c. 5 mL/kg
☐d. 20 mL/kg

18. Your team responds to a car accident where a 14-year-old is found in cardiac arrest. Which is 0
a potentially reversible cause? 1
☐a. Aortic dissection
☐b. Traumatic brain injury
☐c. Tension pneumothorax
☐d. Spinal cord rupture

19. Which of the following are reversible causes of cardiac arrest? 0

☐a. Hyperthermia 1
☐b. Hypoxia
☐c. Tetanus
☐d. Theophylline overdose

20. Which of the following are useful to determine end-organ perfusion? 0

☐a. Urine output 1
☐b. Mental status
☐c. Skin color
☐d. All of the above