Pediatric Board Review

1. Pediatric Board Review Mark Heller, MD Department of Emergency Medicine Mount Sinai School of Medicine

2. Question 1 An 8 year old male is brought into the ED by his mother. Mom she has noticed that over the last month her son has been limping. When asked why he is limping, the boy states that he has a dull pain in his groin, L thigh, and L knee, that gets worse when he is outside playing. On physical exam there is limited abduction of hip & limited internal rotation in both flexion & extension. The following X-ray is obtained:

4. Question 1 What is the most likely diagnosis? • Toxic Tenosynovitis • Turberculous arthritis • Slipped Capital Femoral Epiphysis • Legg-Calve-Perthes • Tumor

5. Q 1 Answer What is the most likely diagnosis? • Toxic Tenosynovitis • Turberculous arthritis • Slipped Capital Femoral Epiphysis • Legg-Calve-Perthes • Tumor MLH Q1

6. Legg-Calve-Perthes’ Disease • Avascular necrosis of the proximal femoral head • Femoral head collapses with potential for subluxation • Onset between 4 to 9 • 5 to 1 male to female ratio • Presents with: • Limp • Chronic dull pain in groin, thigh, knee • Pain worsens with activity

7. Legg-Calve-Perthes’ Disease • 4 Stages • Widening of the cartilage space • Subchondral stress fracture of the femoral head • Increased femoral head opacification • Deformity of the femoral head • Bone Scan and MRI are the best imaging studies • Ortho consult and admission for traction and surgery

8. Question 2 Which of the following findings most strongly suggests that a patient has chickenpox and not smallpox? • Absence of pustules the proximal arms • Both crusts and papules are present on the right hand • Characteristic lesions are noted in the oropharynx • Greatest density of lesions is on the face and neck • Patient has fever, myalgias, malaise, and headache

9. Q 2 Answer Which of the following findings most strongly suggests that a patient has chickenpox and not smallpox? • Absence of pustules the proximal arms • Both crusts and papules are present on the right hand • Characteristic lesions are noted in the oropharynx • Greatest density of lesions is on the face and neck • Patient has fever, myalgias, malaise, and headache PEER VII Q56

10. Chickenpox • Incidence of varicella declining secondary to Immunizations • More common in children <10 years old • Highly contagious from prodrome until all lesions are crusted over • Rash starts as red macules on scalp or trunk and within a day vesiculate • Rash spreads outward • Sparing palms and soles

11. Chickenpox

12. Chickenpox (continued) • Multiple states of rash on same body part • Low-grade fever, malaise, and headache • Treatment is symptomatic • Varicella-zoster immune globulin and acyclovir for immunocompromised children

13. Smallpox • Natural cases eradicated • Virus only exist in two known laboratories in the world • Possible biological weapon • Rash involves Palms and Soles • Lesions appear in same stage • Vaccine given within 3 days of exposure is protective • Exposed person quarantined for 18 days • 30% mortality for unvaccinated persons

14. Smallpox vs. Chickenpox

15. Question 3 A 17 year old boy with Type I diabetes mellitus presents with diabetic ketoacidosis. A venous blood gas analysis is conducted, and the pH is 7.09. Treating this patient with bicarbonate could result in which of the following complications: • CSF alkalosis • Hypokalemia • Hypotonicity • Increased work of breathing • Rightward shift of the oxyhemoglobin dissociation curve

16. Q 3 Answer A 17 year old boy with Type I diabetes mellitus presents with diabetic ketoacidosis. A venous blood gas analysis is conducted, and the pH is 7.09. Treating this patient with bicarbonate could result in which of the following complications: • CSF alkalosis • Hypokalemia • Hypotonicity • Increased work of breathing • Rightward shift of the oxyhemoglobin dissociation curve PEER VII Q57

17. Pediatric Diabetic Ketoacidosis • 27-40% of new-onset diabetics present in DKA • DKA Definition • Metabolic acidosis (pH < 7.25 or serum bicarb < 15 mEq/L) • hyperglycemia (glucose > 300 mg/dL) • Ketonemia • DKA Presentation • Hyperventilation • Fruity breath odor • Abdominal Pain • Lethargy • Kussmaul’s respirations (Deep and Labored Breathing) • Decreased level of consciousness or coma

18. DKA (continued) • Treatment • Volume Replacement • Calculate Total Fluid Deficit • Normal Saline at 10 to 20 mL/kg over 1 to 2 hours • After initial bolus replace remaining fluid deficit over 24 to 48 hours using 0.45% NS. • At glucose 300 – 250 mg/dL switch to 5% dextrose in 0.45% NS • Insulin Therapy • Regular Insulin infusion of 0.1 U/kg/hr • Increase to 0.2 U/kg/hr if no improvement after 2 hours • No need for bolus

19. DKA (continued) • Treatment • Correction of Electrolyte Abnormalities • Potassium is critical • Add 30 to 40 mEq K to each litter of maintenance fluids • Bicarbonate Therapy • Not recommended • May lead to • Hypokalemia • Cerebral Edema • Hypernatremia • Worsening tissue hypoxia

20. Question 4 A 20 year old woman presents with a painful right ear. She has no history of ear problems but swims several times a week. Examination reveals erythema of the external auditory canal with some purulent discharge and a perforation in the tympanic membrane. The treatment option most likely to damage her ear is: • Ciprofloxacin otic and hydrocortisone otic suspension • Hydrocortisone and acetic acid otic solution • Neomycin/polymyxn/hydrocortisone otic suspension • Ofloxacin otic solution • Penicillinase-resistant penicillin

21. Q 4 Answer A 16 year old female presents with a painful right ear. She has no history of ear problems but swims several times a week. Examination reveals erythema of the external auditory canal with some purulent discharge and a perforation in the tympanic membrane. The treatment option most likely to damage her ear is: • Ciprofloxacin otic and hydrocortisone otic suspension • Hydrocortisone and acetic acid otic solution • Neomycin/polymyxn/hydrocortisone otic suspension • Ofloxacin otic solution • Penicillinase-resistant penicillin PEER VII Q59

22. Otitis Externa • Inflammatory process involving the auricle, external auditory canal, and surface of the TM • Caused by gram-negative eneric organisms, Staph aureus, Pseudonomas, or fungi • Peak age 9 to 19 years • Erythema, edema of EAC, white exudate on EAC and Tm • Pain with motion of tragus or auricle

23. Otitis Externa (continued) • Treatment • Fluoroquinolone otic drops • Oral antibiotics if auricular cellulitis is present or TM is perforated (Quinolones, Cephalosporins, or penicillinase-resistant pcn) • Hydrocortisone and acetic acid otic solution have a pH 3.0 which can be toxic to the middle ear in perforations

24. Otitis Externa

25. Otitis Media • Infection of the middle ear • Infants and Young Children (peaks at 6 to 18 months) • 25 to 30 million office visits per year • Strep pneumoniae most prevalent cause • Symptoms include fever, poor feeding, irritability, vomiting, earache, otorrhea • Signs include dull, bulging, immobile TM • Light reflex is of no diagnostic value • Treatment • Amoxicillin 80 mg/kg/day PO divided q8 – q12 for 10 days (High-dose amox therapy)

26. Otitis Media

27. Otitis Media

28. Name That Celebrity

29. Name That Celebrity Britney Spears

30. Name That Celebrity

31. Name That Celebrity Drew Barrymore

32. Name That Celebrity

33. Name That Celebrity Eminem

34. Question 5 A 2 year old girl is brought in by her parents for persistent fever for the past 5 days. On examination, she has bright red injected lips, pharyngeal erythema, cervical lymphadenopathy, conjunctivitis, and a scarlatiniform rash. Which of the following is an essential element in the therapy of this child’s disease? • Amoxicillin-clavulanate • Benzathine Penicillin • Droplet isolation precautions • Intravenous immune globulin • Plasma Exchange

35. Q 5 Answer A 2 year old girl is brought in by her parents for persistent fever for the past 5 days. On examination, she has bright red injected lips, pharyngeal erythema, cervical lymphadenopathy, conjunctivitis, and a scarlatiniform rash. Which of the following is an essential element in the therapy of this child’s disease? • Amoxicillin-clavulanate • Benzathine Penicillin • Droplet isolation precautions • Intravenous immune globulin • Plasma Exchange PEER VII Q61

36. Kawasaki Disease • Clinical Findings • Fever for at least 5 days • Bilateral conjunctivitis • Changes of the oral mucosa (erythematous lips, strawberry tongue, erythematous oropharynx) • Changes of the hands and feet (erythema, edema, desquamation) • Rash (scarlatiniform or morbilliform exanthem on trunk) • Cervical Lymphadenopathy • Peak incidence at 1 to 2 years • Season distribution – winter/spring • No clear agent identified

37. Kawasaki Disease • Immune response during KD leads to systemic vasculitis • Treatment • Single infusion of Intravenous Immune Globulin (2 g/kg IV over 8 to 12 hours) • Aspirin 80 to 100 mg/kg/day in four divided doses • ASA continued until afebrile, then reduced to 3 to 5 mg/kg daily for 6 to 8 weeks • Untreated KD will cause coronary artery aneurysm in 20 – 25% of patients • Risk of aneurysm reduced to 3 – 4% with treatment

38. Question 6 A 4 year old boy presents after sticking a fork into a home electrical outlet with his right hand and getting shocked. His right elbow was on the ground at the time. Although he cried initially, he has remained asymptomatic. Physical examination reveals two extremely small first-degree burns on his right hand and elbow, a 12-lead EKG is normal. The most appropriate disposition is: • Admit to a monitored bed for 24 hours • Admit to a non-monitored bed for serial peripheral vascular examinations • Discharge home • Observe in the emergency department for 6 hours, if no dysrhythmias occur, discharge home. • Perform echocardiography in the emergency department

39. Q 6 Answer A 4 year old boy presents after sticking a fork into a home electrical outlet with his right hand and getting shocked. His right elbow was on the ground at the time. Although he cried initially, he has remained asymptomatic. Physical examination reveals two extremely small first-degree burns on his right hand and elbow, a 12-lead EKG is normal. The most appropriate disposition is: • Admit to a monitored bed for 24 hours • Admit to a non-monitored bed for serial peripheral vascular examinations • Discharge home • Observe in the emergency department for 6 hours, if no dysrhythmias occur, discharge home. • Perform echocardiography in the emergency department PEER VII Q96

40. Electric Shock • Three populations • Toddlers – household electrical sockets and cords • Teenagers – power lines • Adults – work with electricity • Voltage gives idea of potential damage • Admit any electrical injury over 600 V • Household V ranges 110 to 220 V • Asymptomatic on presentation and have normal EKG can be discharged home

41. Question 7 For young children with sickle cell disease, which of the following tests is most useful in differentiating a splenic sequestration crisis from an aplastic crisis? • Erythrocyte Sedimentation Rate • Hemoglobin Level • Peripheral WBC Count • Platelet Count • Reticulocyte Count

42. Q 7 Answer For young children with sickle cell disease, which of the following tests is most useful in differentiating a splenic sequestration crisis from an aplastic crisis? • Erythrocyte Sedimentation Rate • Hemoglobin Level • Peripheral WBC Count • Platelet Count • Reticulocyte Count PEER VII Q146

43. Sickle Cell Disease • Sickle Cell Emergencies • Vaso-oclusive Crisis • Hematologic Crisis • Infections • All SCD children with fever, pain, respiratory distress or change in neurological function require a thorough ED evaluation • 8% of AA population are carriers • 0.15% (1/500) are homozygous • 20-30% of all deaths from SCD occur before 5

44. Sickle Cell Disease

45. Sickle Cell Disease (continued) • Vaso-Oclusive Crisis • Intravascular sickling • Tissue ischemia and infarction • ED Management • Aggressive hydration • Analgesics • Acute Chest Syndrome • Pneumonia, Pulmonary Infarction, Pulmonary Emboli • CXR, CBC, Retic Count, Blood Cultures • IV hydration, Analgesic, Abx, Transfusion • All warrant hospital admission

46. Sickle Cell Disease (continued) • Hematological Crisis • Acute Sequestration Crisis • Spleen traps large portion of circulating blood • Hypotension, shock and death • Often preceded by viral infections (Parvovirus B19) • CBC shows profound anemia • Reticulocyte Counts are Elevated • Transfuse PRBC • Admission

47. Sickle Cell Disease (continued) • Hematological Crisis • Aplastic Episode • Precipitated by Viral or Bacterial infections • Present with gradual onset of pallor, dyspnea, fatigue, and jaundice • CBC shows low hematocrit (10% or lower) • Reticulocyte Counts are Decreased • Transfuse PRBC • Admit

48. Sickle Cell Disease (continued) • Infections • SCD children are functionally asplenic • Higher risk for bacterial infections, especially encapsulated organisms • Routine Haemophilus influenzae and pneumococcal vaccinations • Fevers are managed aggressively • Treat with antibiotics covering Strep pneumoniae and H. influenzae (eg, ceftriaxone) • Low threshold for admission

49. Question 8 A 17 year old man presents with left eye irritation. He was walking in a park and accidentally ran into a tree branch. He believes the branch scratched his eye. Examination reveals a corneal abrasion. The best treatment option is: • Erythromycin ophthalmic ointment, no patch. • Erythromycin ophthalmic ointment, patch • Homatropine, no patch • Homatropine, patch • Topical anesthetic

50. Q 8 Answer A 17 year old man presents with left eye irritation. He was walking in a park and accidentally ran into a tree branch. He believes the branch scratched his eye. Examination reveals a corneal abrasion. The best treatment option is: • Erythromycin ophthalmic ointment, no patch • Erythromycin ophthalmic ointment, patch • Homatropine, no patch • Homatropine, patch • Topical anesthetic PEER VII Q 160