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A 7 year old boy falls off his bike onto his outstretched arm and sustains a supracondylar fracture. The fracture originates in the metaphysis and a portion of it extends into the physis (growth plate) without extending through to the epiphysis. How is this fracture classified? A. Salter I B. Salter II C. Salter III D. Salter IV E. Salter V - correct answer B. Salter II A mother brings her 3 year old daughter into the emergency department for an arm injury. The mother was holding her hand to cross a busy street. She pulled hard on her daughter's arm to hurry across the street and the child began to cry. Since the incident the child has kept her arm against her body in a slightly flexed and pronated position. She is tender over the radial head and refuses to move her elbow, but there is no swelling or ecchymosis. What is the most appropriate management for this girl? A. Obtain immediate X-rays of the elbow to rule out fracture B. Obtain immediate orthopaedic consult for presumed elbow dislocation C. Apply pressure to the radial head while flexing and supinating elbow D. Apply posterior elbow splint and follow-up with orthopedics within one day E. Apply traction to elbow and splint under conscious sedation - correct answer C. Apply pressure to the radial head while flexing and supinating elbow A 17 year old boy injured his right shoulder playing football. He tried to arm-tackle a player when his right arm was pulled away from his body and back (abducted and extended). He felt a sudden pain in his shoulder. He presents to the emergency department holding his arm in slight abduction and external rotation by his good arm. He has severe pain with adduction or internal rotation. What is the most common fracture associated with this injury? A. Avulsion fracture of the greater tuberosity of the humerus B. Compression fracture of the posteriolateral aspect of the humeral head (Hill-Sachs deformity) C. Clavicle fracture D. Acromioclavicular joint separation E. Fracture of the anterior glenoid lip (Bankart's fracture) - correct answer B. Compression fracture of the posteriolateral aspect of the humeral head (Hill-Sachs deformity) What is the most common heart rhythm seen in pediatric arrest? A. Wolff-Parkinson-White syndrome B. ventricular fibrillation C. paroxysmal atrial tachycardia D. bradycardia E. atrial fibrillation - correct answer D. bradycardia The answer is C. Bradycardia, the most common rhythm seen in pediatric arrest (which in turn is usually hypoxemic in etiology), can be a harbinger of progression to asystole if untreated. Outside of the arrest situation, the most common rhythm disturbance encountered is paroxysmal atrial tachycardia; however, patients with supraventricular tachycardias are usually stable. Wolff-Parkinson-White syndrome can also present in infants but is not as common and is not often seen in the arrest situation. -- For further reading, see Tintinalli, et al., Emergency Medicine: A Comprehensive Study Guide, 4th edition, page 86. Which of the following factors in the fetus is NOT associated with an increased risk for neonatal resuscitation? A. prematurity B. alkalosis (as assessed via fetal scalp capillary monitoring) C. multiple gestation D. thick meconium in amniotic fluid E. intrauterine growth failure - correct answer B. alkalosis (as assessed via fetal scalp capillary monitoring) The answer is B. Acidosis (by fetal scalp capillary monitoring), not alkalosis, is associated with an increased risk for neonatal resuscitation. Along with the factors listed above, postmaturity, abnormal fetal heart rate per monitor, congenital infection, and fetal malformation or edema diagnosed by ultrasound are other fetal factors associated with an increased risk of neonatal resuscitation. -- For further reading, see Tintinalli, et al., Emergency Medicine: A Comprehensive Study Guide, 4th edition, page 73. A 27 year old G2P1 female presents to the emergency department in labor at 41 weeks estimated gestational age. The amniotic sac breaks on admission and has thick, brown-tinted fluid. Prior to other steps in resuscitation, the newborn infant should: A. be resuscitated with a bag-valve mask for 45 to 60 seconds. B. receive 500,000u penicillin-G intramuscularly. C. receive 8 mg doxycyline intravenously. D. have his/her trachea suctioned. E. be left unswaddled. - correct answer D. have his/her trachea suctioned. The answer is D. In order to prevent aspiration of meconium, the infant should have his/her airway suctioned. (This recommendation is the standard of care at this time, but is becoming somewhat controversial. Some believe the introduction of the endotracheal tube may further contaminate the distal respiratory tract with meconium.) Using a bag-valve mask before suctioning could precipitate meconium aspiration. A dose of penicillin should not delay resuscitation. Doxycycline is contraindicated in patients younger than 8 years. Swaddling and placing of the newborn in an incubator helps to prevent hypothermia. All of the following are true regarding chest compressions in the infant EXCEPT: A. Chest compressions should be initiated whenever an infant's heart rate is less than 60 bpm. B. An appropriate position for performing chest compressions is to encircle the chest with both hands and place the thumbs side by side on the sternum. C. Compressions should be performed at a rate of 90 per minute. D. Chest compressions should be accompanied by a ventilatory rate of 30 per minute. E. Correct depth of compressions is one-third the anteroposterior diameter of the chest. - correct answer A. Chest compressions should be initiated whenever an infant's heart rate is less than 60 bpm. In pediatric resuscitation the following drugs may be given by the endotracheal route, EXCEPT: A. epinephrine B. digoxin C. naloxone D. atropine E. lidocaine - correct answer B. digoxin The answer is B. The drugs which may be given by endotracheal route can be remembered by the mnemonic "LEAN" — lidocaine, epinephrine, atropine, naloxone. Up to 10 times the IV dose diluted to 5mls and followed by 3-5 positive pressure breaths is necessary to achieve equivalent plasma concentrations. Digoxin must be given by the IV route. Which of the following is the commonest type of pediatric rhythm in the setting of cardiopulmonary arrest? A. asystole B. ventricular tachycardia C. atrial flutter D. atrial fibrillation E. supraventricular tachycardia - correct answer A. asystole In the post-arrest setting, which of the following is the drug of choice in treating hypotension in a child: A. dobutamine bolus B. dobutamine infusion C. epinephrine infusion D. dopamine infusion E. nitroprusside infusion - correct answer C. epinephrine infusion The answer is C. While dopamine is the drug of choice in adults, epinephrine infusion is the initial treatment of choice in pediatric patients. As coronary artery disease is rare in children, there is less of a concern regarding its dysrhythmogenic effects and the risk of myocardial infarction. Dobutamine and dopamine infusions also play a role in resuscitating the hypotensive child, but are not first choice agents. Dobutamine bolus alone and nitroprusside have no role to play. Low body temperatures in newborns can lead to severe physiologic consequences, which include all EXCEPT: A. metabolic acidosis B. increased oxygen consumption C. hypoglycemia D. apnea E. hyperglycemia - correct answer E. hyperglycemia The answer is E. Due to low fat stores, inability to generate heat by shivering, and relatively large surface-to-volume area, the newborn infant is not easily able to maintain body temperature. Metabolic acidosis, increased oxygen consumption, hypoglycemia, and apnea are all physiologic consequences of hypothermia. Which of the following vital signs is a cause for concern in the term newborn? A. heart rate of 165 B. respiratory rate of 50 C. heart rate of 95 D. respiratory rate of 70 E. systolic blood pressure of 65 - correct answer C. heart rate of 95 The answer is C. Bradycardia (defined in Rosen's text as a heart rate of <100) can be a critically important manifestation of neonatal distress; therefore, caregivers must be familiar with expected vital signs in newborns. Which of the following describes the most commonly indicated initial approach in neonatal resuscitation? A. establish effective ventilation B. chest compressions C. medications D. dry, warm, position, suction, stimulate E. oxygen - correct answer D. dry, warm, position, suction, stimulate Which of the following statements regarding intraosseous (IO) access is INCORRECT? A. Marrow and fat emboli are recognized complications of IO access B. Anterior compartment syndrome is a recognized complication of IO access C. Tibial fracture is a recognized complication of IO access D. Long bone fracture is a contraindication of IO access E. Drug delivery by endotracheal route is preferred over the intraosseous route - correct answer E. Drug delivery by endotracheal route is preferred over the intraosseous route Management of a 4 year old child with a two-week history of malodorous purulent nasal drainage should include, as an initial step: A. Referral to an otolaryngologist B. Oral amoxicillin for 10-14 days C. Speculum examination of the nares D. Social services consultation to investigate potential child abuse - correct answer C. Speculum examination of the nares The answer is A. A commonly missed diagnosis is that of a nasal foreign body in a child who does not provide a history of object insertion into the nares. Children with nasal foreign bodies are often treated with antibiotics for presumed recurrent sinusitis. Nasal foreign bodies may be asymptomatic until the development of secondary signs, such as unilateral purulent discharge or recurrent epistaxis. Proper initial management is examination of the nares with a speculum. Should no foreign body be identified, a CT scan may be indicated. -- For further reading see Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th edition, Chapter 53. A pediatric patient is brought in by his mother, who notes he's had persistent nasal drainage. Plain films for sinusitis are obtained, and one image is shown in the Figure. Of the choices listed, which is the best next step for this patient? [image] A. admission for IV antibiotics and oral decongestants B. discharge on antibiotics C. MRI to further assess the sinuses D. removal of foreign body - correct answ