A 12-year-old girl is being discharged from the emergency department (ED) after having her displaced forearm fracture reduced. Which one of the following actions would be considered potentially dangerous?
a.
Prescribe codeine.
b.
Consult state prescription drug monitoring programs (PDMP) and prior medical and pharmacy records.
c.
Use a screening tool, such as CRAFFT, to evaluate for high-risk behaviors.
d.
Prescribe a minimum number of days to decrease risk for misuse and diversion.
A. Codeine is no longer recommended for pain in pediatric patients. This is due to the variation in pharmacogenomics (CYP 2D6) and metabolism to morphine, which can lead to either poor pain control or unintentional opioid toxicity. In adolescent patients, it is recommended that the patient be evaluated for high-risk factors that may lead to opioid use, misuse or diversion. This includes checking the state’s PDMP and screening to evaluate the risk for drug abuse and addiction. There are currently no pediatric-specific guidelines for prescribing opioids, but it is generally recommended not to prescribe opioids for acute pain more than 3 to 7 days in duration. Providers should also emphasize a nonopioid, multimodal approach to pain control, including nonpharmacologic methods and adjunct medications such as nonsteroidal antiinflammatory drugs, acetaminophen, or neuroactive agents.
What is a unique pharmacokinetic property observed in the pediatric population?
a.
Infants have decreased absorption of topically applied medications.
b.
Neonates and infants have higher total body water and larger volumes of distribution and extracellular fluid.
c.
All drug metabolizing enzymes are at full capacity at birth.
d.
All maternal drugs should be considered not safe when breast feeding.
B. Young children can have significant differences in the pharmacokinetic properties based on their physiology. Absorption can be impaired and delayed based on gut pH and motility. Metabolizing enzymes mature at different rates during the first year of life. Young children have a higher total body water and larger volumes of distribution and extracellular fluid. There are several factors to consider when assessing the risk/benefit profile of taking medications while breast-feeding, including limited human data, maternal comorbidities, therapeutic alternatives, properties of the drug, and the benefits of continued breast-feeding, when possible. LactMed is an excellent resource to determine the safety of the drug during breast-feeding.
A healthy, fully vaccinated 11-month-old male infant presents to your department for evaluation of a fever of 38.4°C (101.1°F) this morning that responded to a dose of acetaminophen. The physical examination reveals a well-appearing, afebrile infant with clear lungs. The patient has an unremarkable evaluation and, during the discharge process, his parents ask for advice regarding fever management. Which of the following statements is correct?
a.
Aspirin should not be used in children younger than 15 years because of the risk of Reye syndrome.
b.
Cool water baths and creams should be used to supplement antipyretics, even if they cause some discomfort to the patient.
c.
Ibuprofen cannot be used in this age group because of ongoing renal development.
d.
Over-the-counter (OTC) antipyretics are standardized, contain similar products and formulations, and are thus interchangeable.
A. Counsel parents and caregivers about the management of fever and appropriate indications for and proper use of antipyretics. There is no need to cause discomfort with external cooling methods for fever control. Ibuprofen should not be used in children younger than 6 months because of ongoing renal development. The formulations and dosing of OTC antipyretics are varied and cannot be used interchangeably. The correct answer is A because of the risk of Reye syndrome with aspirin administration during a viral illness in children younger than 15 years.
Which of the following statements regarding pediatric pharmacokinetics is correct?
a.
A thinner stratum corneum and increased body surface area contribute to a greater risk for systemic toxicity from dermally administered drugs.
b.
Ceftriaxone administration in neonates results in increased bilirubin production.
c.
Because of minimal differences in the volume of distribution and renal development, weight-based dosing of gentamicin without attention to age is sufficient.
d.
Quicker gastric emptying and decreased gastric pH in neonates increase systemic absorption of enterally administered medications.
A. Awareness of differences in pediatric pharmacokinetics and specific drug toxicities is of critical significance for the safe and effective use of medications in children. The dosing of gentamicin needs to account for age-based differences in renal development in addition to weight-based differences in distribution volume. Decreased gastric emptying times and an increased pH can prolong exposure to medications before they pass the pylorus. An immature blood-brain barrier can result in kernicterus from bilirubin displacement by ceftriaxone . The correct answer is that a thinner stratum corneum and increased body surface area contribute to a greater risk for systemic toxicity from dermally administered drugs.
Which of the following steps can be taken to reduce pediatric dosing errors?
A.
Adoption of electronic health records with clinical support tools to decrease weight-based dosing errors
B.
Calculation of weight-based dosing for all emergent medications administered in code situations as opposed to using a validated quick reference guide
C.
Limiting hospital pharmacist presence in the emergency department to avoid delays in bedside care
D.
Medication reconciliation should occur with just the patient present to limit primary caregiver influence
A. A multifaceted approach using clinical support systems and readily available reference tools are essential for the delivery of optimal emergent pediatric care. Caregivers are an integral part of medication reconciliation. ED pharmacists have been proven to increase departmental accuracy in pediatric medication management. Validated quick reference guides for code drug administration have been shown to decrease errors and improve efficiency.
With most neonatal deliveries, which resuscitative measures are usually sufficient?
a.
Administer fluids.
b.
Bag-mask ventilation.
c.
Intubate.
d.
Warm, dry, stimulate, and position.
d. Drying, warming, positioning, and stimulating the infant are usually sufficient resuscitative measures in most deliveries.
For a term newborn with cyanosis, respiratory distress, and a heart rate more than 100 beats/min, which of the following is not initially indicated?
a.
Apply 100% oxygen.
b.
Position airway.
c.
Suction.
d.
Warm, dry, and stimulate
a. 100% oxygen is not indicated for initial resuscitation in all neonates born at 35 weeks’ gestation or later; avoiding unnecessary supplemental oxygen is thought to minimize free radical creation in the brain and decreases the incidence of retinopathy of prematurity. Initial resuscitation with room air is recommended. For select newborns less than 35 weeks’ gestation, initial FiO 2 of 21% to 30% may be required to achieve normal oxygen saturations.
In a typical neonatal resuscitation, what is the preferred compression-to-ventilation ratio?
a.
3:1
b.
5:1
c.
10:2
d.
15:2
e.
30:2
a. Unlike pediatric or adult cardiopulmonary resuscitation (CPR), neonatal CPR is performed at a ratio of three compressions to one breath, with a goal of approximately 90 compressions with 30 synchronized breaths (120 “events”) per minute. If the cause of the bradycardia is known to be cardiac, a ratio of 15:2 is acceptable
A nonvigorous and crying newborn is delivered with copious meconium-stained fluid. What is the correct recommended resuscitative measure?
a.
Bag-mask ventilate.
b.
Intubate.
c.
Suction at maternal perineum before cutting umbilical cord.
d.
Gentle mouth suctioning if needed, followed by warming, drying, and stimulation.
d. For infants born with meconium-stained amniotic fluid, routine intubation and endotracheal tube suctioning are no longer recommended because they have shown no consistent benefit. Vigorous and nonvigorous infants born through even thick meconium should instead have gentle mouth suctioning, if needed, followed by warming, drying, and stimulation.
After drying, stimulating, and bag-mask ventilation, what is the next step in resuscitation of a newborn that appears floppy and apneic and with a heart rate of 50 beats/min?
a.
Give a normal saline bolus of 20 mL/kg.
b.
Give epinephrine (0.1 mg/mL) intravenous (IV) at a dose of 0.1 mg/kg.
c.
Intubate.
d.
Start with a chest compression-to-ventilation ratio of 3:1.
d. With a heart rate less than 60 beats/min in a neonate, intubation may be considered, but compressions should be started. If the low heart rate persists, IV epinephrine (0.1 mg/mL) may be considered at a dose of 0.01 mg/kg.
You are treating a 4-month-old with bronchiolitis. While being observed in the ED, the child becomes bradycardic and then loses pulses. What should be the primary focus of your initial minutes of the resuscitation?
a.
Preparing to insert an endotracheal tube to improve oxygenation and ventilation
b.
Correction of potential acidosis with bicarbonate
c.
Vascular access to administer epinephrine
d.
Uninterrupted compressions with ventilations via bag-mask device
d. At the beginning of the arrest, the most important elements are restoration of perfusion and ventilations with compressions and ventilations. Early insertion of an endotracheal tube is likely to impede compressions, and initial ventilations should occur with a bag valve mask and oral airway. Vascular access will be needed but is not as time sensitive. Bicarbonate should be given only if there is a clear indication.
After return of circulation, which action is most critical to improve a child’s prognosis?
a.
Empiric amiodarone to prevent arrhythmias
b.
Avoidance of hypotension
c.
Induced hypothermia to 33°
d.
Strict glucose control less than 110 mg/dL with an insulin drip
e.
Maintenance of oxygen saturation at 100%
b. A single episode of hypotension increases mortality and therefore efforts should be made to avoid it. Induced hypothermia does not appear to improve outcomes in pediatric arrest. Strict glucose control, hyperoxemia, and empiric amiodarone are not beneficial and may induce harm.
A 6-year-old male with Trisomy 21 presents with decreased responsiveness and not eating. His temperature is 39°C, heart rate is 150, blood pressure is 80/55, respiratory rate is 24, oxygen saturation is 98%, and glucose is 90 mg/dL. He receives cefepime and 20 mL/kg of lactated Ringers but his vital sign abnormalities persist. On examination, he is lethargic with a neck that is supple, lungs that are clear to auscultation, cool extremities, and capillary refill of 3 seconds. What is the next best step in the management?
a.
Hydrocortisone 50 mg/m 2
b.
Vancomycin 50 mg/kg
c.
Epinephrine 0.05 mcg/kg/min
d.
Lactated Ringers 20 mL/kg
D. This child is in septic shock. He received an initial fluid bolus but has ongoing signs of decreased perfusion. In the absence of signs of pulmonary edema, the next step should be to administer another bolus of isotonic fluids. He may benefit from epinephrine and vancomycin but after a second bolus is initiated.
A 4-month-old girl presents after changing color and tone at home. She was feeding and started to choke. She turned red-purple in her face and upper body while her arms stiffened. After 30 seconds, she spit up some formula, and the episode resolved. She was born full-term and has no other medical issues. In the ED she is asymptomatic and has a normal physical examination. What is your next step in the management of this patient?
a.
Discharge after 2 hours of observation
b.
Classify the event as a high-risk BRUE and admit to the hospital
c.
Obtain a pH probe to assess for GERD
d.
Obtain an ECG and blood glucose
a. Choking in the setting of feeding with complete resolution of the symptoms after vomiting suggests reflux. As a potential etiology is apparent based on the history, this event should not be classified as a BRUE. Diagnostic testing is not necessary; pH probes are not specific for GERD and are rarely helpful in the ED.
Which of the following medications have shown a mortality benefit for children in arrest without a clear etiology?
a.
Calcium chloride 20 mg/kg
b.
Sodium bicarbonate 1 mEq/kg
c.
Epinephrine 0.01 mg/kg
d.
Normal Saline 20 mL/kg
c. There are no randomized control trials of medications in pediatric arrest. However, observational studies suggest that epinephrine is beneficial. Other medications are only beneficial for specific indications, such as glucose for hypoglycemia.
Describe this fracture?
SEYMOUR
- transverse fracture of distal phalanx at the physis in Peds
= SH1 or SH2
- typically crush injury in a door, etc.
- may have associated nail bed injury (avulsion of nail at germinal matrix) = OPEN #
List 9 injuries associated with BCVI in children?
- basilar skull fracture
- C-spine fracture
- jugular venous injury
- CN injury
- brain infarct
- hanging
- LeFort fracture
- facial fracture
- clavicle fracture
What is the leading bacterial cause of PNA outside of the neonatal period?
Streptococcus pneumoniae
List 1st line therapies for peds PNA (inpt and outpt)
Amoxicillin = outpatient
Ceftriaxone OR Ampicillin = inpatient
List 3 signs/symptoms of pertussis in infants
Apnea
Staccato cough
Cyanotic episodes
What is the most likely bacterial PNA cause in kids with Cystic Fibrosis?
Pseudomonas aeruginosa
List 4 unusual/atypical causes of PNA in kids
- Pseudomonas aeruginosa
- Legionella pneumophila
- Pneumocystis jiroveci
- Rickettsial infections
List 6 pediatric co-morbidities that alter protective mechanisms againt PNA
1) Congenital anatomic abnormalities
- cleft palate
- tracheoesophageal fistulas
- pulmonary sequestration
- congenital cystic adenomatoid malformation
2) Immune deficiencies
- congenital
- acquired
- medication induced
3) Neurologic alterations that predispose to aspiration
- coma
- seizures
- cerebral palsy
- general anesthesia
4) Alterations in quality of secreted mucus
- CF
Define tachypnea in 3 pediatric age groups
(<1, 1-5, >5 yrs)
<1 yr = >50 breaths/min
1–5 yr = >40 breaths/min
> 5 yr = >30 breaths/min
-
Toxicology346
-
General3
-
Electrolytes, Metabolism, Endocrine, & Rheum197
-
Pediatrics207
-
GI258
-
Ortho394
-
Infectious Disease389
-
Trauma312
-
Psych89
-
Enviro313
-
Cardiovascular475
-
Respiratory157
-
Neuro418
-
Ophtho139
-
OBGYN + Urology316
-
Nephro24
-
Heme/Onc168
-
Dermatology116
-
Resuscitation146
-
Head & Neck94
-
Bonus Chapters107
-
Special Populations & Geriatrics49
-
Hard Stuff/High Yield93
