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emergency pediatrics

  1. 1. , - ,...CASE 76: A 17-VEAR-OlD WITH KNEE PAIN (A) meniscal tearA 17 -year-old female high school soccer player is (B) mediai collateral ligament tearbrought to an urgent care clinic with a chief com ­ (C) anterior cruciate ligament tearplaint of left knee pain. The onset of symptoms oc ­ (D) posterior cruciate ligament tear curred during a soccer game the previous day. The (£) patellar dislocation athlete states as she went to kick the hal! with herright foot she planted her kft foot, felt her left knee 3. On physical exomination, a moderate knee jointbuckle and heard a "pop." She then felI to the ground effusion and a 5-degree flexion contracture areand had to be helped off the field , She experienced noted. Valgus and varus testing performed at 30immediate swelling in the knee ;lS well as some diffi­ degrees of knee flex:ion reveal no jnstability. Anculty straightening the knee. She denied any tingling anterior drawer p erf~)rmed with the knee at 30or numbness in the leg. She is using crutches as walk­ degrees of flexi{)t1 an d at 90 degrees of flexion re­ing is painful. She denies any hi story of previous knee veals increased laxity. A posterior drawer test isinjuries and has played soccer for 7 years. negative. McMurrayS test is negative. There is no pain with patdl"r ::ompression, nor is patellarSELECT THE ONE BEST ANSWER instability noted . Based on the above physical ex­ amination, whi ch of the following tests per ­ 1. The best initial management for this athlete on formed is most hdpfuj in confirming your sus­ the soccer field should include: pected diagnosis? (A) ice applied to the knee joint for approxi­ (A) valgus test mately 20 minutes (B) varus tesl (B) application of a knee immobilizer ~fter at­ (C) anterior drav,;er at 90 degrees of flexion tempting to straighten the leg to full extension (D) anterior drawer at 30 degrees of flexion (C) ambulation on the sidelines to improve the (E) McMurrayS test range of motion and decrease the swelling (D) an immediate dose of ibuprofen 600 to 800 4. Of the following physical findings, which is least mg PO to prevent inflammation likely to confirm the presence of internal de ­ (E) immediate transport by anlbulance to the rangement of the lmee? nearest emergency room for evaluation (A) knee joint effusion 2 . Bas~d. on the history alone, the most likely diag ­ (B) decreased range of motion nOS1S 1S: (C) instability with a Laehman test 304
  2. 2. CHAPTER 9 GENERAL EMERGENCY AND URGENT CARE 305 ­ L (D) painful clicking with a McMurrays test (B) SIX to 12 weeks of physical therapy in a (E) instability with a valgus test sports rehabilitation center -­ (C) arthroscopic surgery and repair 5. You tell the patient that the swelling in her knee (D) arthroscopic surgery and reconstruction indicates inflammation is present. Which of the (E) complete rest and crutch-assisted ambula­ follOwing statements is most accurate regarding tion for 6 to 12 weeks inflammation? (A) Inflammation is primarily an acute response 9. You provide the patient with a brace, refer her to physical therapy and schedule her for follow-up to trauma, infection, and autoimmune dis­ in 10 to 14 days. Upon her return to the office "­ eases. she tells you the swelling has decreased as has her (B) NSAIDs work on joint inflammation by in­ -­ pain; however, she notes severe sharp stabbing hibiting prostaglandin synthesis in the arachi­ sensations of pain when she attempts to straighten donic acid cascade at the cyclooxygenase her leg completely. Your physical examination pathway. reveals a IO-degree flexion contracture, a small (C) Corticosteroids work most effectively on joint effusion, and medial joint line tenderness. joint inflammation by inhibiting leukotriene Attempts to straighten the knee into neutral production. (full extension at 0 degrees) reproduce sharp (D) Inflammation is characterized by erythema, pain. Laxity is again noted with a Lachman edema, warmth, and pain and has a protec­ test. McMurray testing reveals a painful "click." tive effect on synovium, tendons, bursae, You are now most concerned about the following and cartilage. diagnosis: 6. The patient now tells you she is in pain after you (A) anterior cruciate ligament injury have examined her and asks what she should do. (B) medial collateral ligament injury Your next step in treatment should be which of (C) meniscal injury the following? (D) AandC (E) all of the above (A) apply an ace wrap (B) knee joint aspiration 10. The patient now tells you she has been unable to (C) corticosteroid injection go for an MRI because of her insurance and lack (D) knee joint aspiration followed by a cortico­ of transportation; however, she is planning to go steroid injection in 10 days. She asks what you want her to do in (E) knee brace the meantime. The most appropriate recommen­ dation to make at this point is: 7. You are now ready to order a radiologic imaging study of the left knee. Which of the following is (A) continue the brace and follow-up after the most helpful in confirming your diagnosis? MRI (B) continue the brace and physical therapy and (A) AP and lateral plain radiograph follow-up after the MRI (B) AP, lateral, sunrise, and notch plain radio­ graphs (C) resume crutch use, stop physical therapy and await the MRI (C) CTscan (D) referral to an orthopedic surgeon after the (D) MRI scan MRI (E) no imaging study is needed (E) referral to an orthopedic surgeon within 1... week, regardless of the MRI being done 8. Which of the following treatment recommenda­"­ tions is likely to result in complete recovery from 11. If in the scenario described in question 1, the the above injury including eventual return to.. athlete injured while playing soccer was 12 years soccer? old, your differential diagnosis would include ail (A) custom hinged knee brace for 3 to 6 months of the following except:~
  3. 3. 306 PEDIATRIC EXAMINATION AND BOARD REVIEW (A) osteochondritis dissecans (A) genu valgum (B) physeal injury (B) pes planovalgus foot deformity (C) meniscal tear (C) Q angle of 15 degrees (D) cruciate ligament injury (D) weak quadriceps muscles (E) tibial tubercle avulsion (E) patellar hypermobility12. If in the scenario described in question 1, the 17. Which of the following activities is least associ­ athlete injured while playing soccer was 12 years ated with increased stress on the patellofemoral old, the most likely diagnosis would be: joint? (A) osteochondritis dissecans (A) jumping (B) physeal injury (B) squatting (C) meniscal tear (C) prolonged sitting (D) cruciate ligament injury (D) stair climbing (E) tibial tubercle avulsion (E) straight leg raises13. Which of the following radiographic studies is 18. Of the following conditions affecting the knee, least likely to reliably demonstrate the sus­ which one should a primary care physician feel pected diagnosis in the 12-year-old soccer most uncomfortable managing without an ortho­ player with a painful, swollen knee and inability pedic consultation? to bear weight? (A) Osgood-Schlatters disease (A) plain radiographs including AP, lateral, notch, (B) patellofemoral pain and sunrise view (C) patellar tendonitis cr (B) scan (D) osteochondritis dissecans (C) MRI scan (E) chronic medial collateral ligament sprain (D) bonescan (E) All are equally sensitive and specific for di­ 19. In a patient with knee pain which of the follow­ agnosis in this case as described. ing is an indication for referral to an orthopedic or sports specialist for evaluation and manage­14. Which of the following knee injuries occurs ment? more commonly in skeletally immature males (A) knee effusion versus females? (B) abnormal range of motion (A) patellar dislocation (C) locking of the joint (B) osteochondritis dissecans (D) pain at the ends of long bones (C) . patellofemoral pain (E) all of the above (D) anterior cruciate ligament injury (E) meniscal injury 20. If the athlete described in question 1 had recov­ ered from her injury and came to you for clear­15. Which of the following conditions is the most ance for return to sports, which of the following common cause of knee pain in adolescent females? statements is true? (A) patellofemoral pain (A) If all swelling and pain have resolved and (B) Osgood-Schlatters disease the athlete demonstrated walking without (C) plica band syndrome any limp or instability, then sports may be (D) chronic medial collateral ligament sprain resumed safely with little risk of re-injury. (£) iliotibial band syndrome (B) In general, bracing is thought to help with swelling acutely via a compressive effect but16. Which of the following physical examination has little demonstrated effectiveness in re­ findings is not associated with an increased risk of injury prevention immediately following a patellofemoral pain? ligament sprain.
  4. 4. CHAPTER 9 GENER.A.L EMERGENCY AND URGENT CARE 307 (C) An athlete must pass a functional test in ­ made to anteriorly translate the tibia forward. The cluding running, jumping and cutting with­ Lachman test is more clinically sensitive at diag­ out pain or instability prior to participation. nosing ACL (anterior cruciate ligament) tears (D) The athlete must take 8 weeks off from all than an anterior drawer test performed at 90 de­ sports participation because all ligament in ­ grees of knee flexion. In that instance, it is com­ juries take at least th;lt long to heal. mon to find patients guarding or reflexively tight­ (E) None of the above statements is true. ening their hamstring muscles; this results in a L false negative drawer test with decreased anterior translation. The McMurray test is performed with l Answers the patient lying supine. The examiner places one hand anteriorly on the joint lines and then pro­ 1. (A) The best initial treatment for an injured knee ceeds to cup the heel with the opposite hand and is ice applied to the swollen, painful area for ap­ begins to Bex and extend the knee while simulta­ proximately 20 minutes. It is appropriate to fol­ neously internally and externally rotating the tibia low the general RICE (Rest, Ice, Compression, on the femur. The test is positive, indicating a Elevation) principles for acute injury treatment. torn meniscus, if a painful click is felt. However, in the provided choices for an acute knee injury, one should not attempt to "force" 4 . (E) Instability with valgus stress testing indicates the knee into extension as there may be mechan­ an injury to the medial collateral ligament ical limitations such as torn tissue or extreme (sprain versus tear); however, this ligament is ex­ swelling that prevent the knee from reaching full tra-articular in location. An effusion almost al­ extension. The knee joint has maximal space to ways indicates internal derangement, especially.... accommodate swelling at approximately 30 de­ in the setting of trauma. Decreased range of mo­ grees of flexion. Weight bearing should be as tion may be related to the knee effusion. How­ tolerated and in this setting, keeping the athlete ever, the presence of a flexion contracture (or the non-weight-bearing until a full exarriination is inability to straighten the leg entirely) indicates a performed is appropriate. While immediate heightened concern for a mechanical block to use of ibuprofen or another non-steroidal anti­ the knee joint from a tom ACLIPCL, a meniscal inflammatory agent may be helpful for pain, it is tear or a loose body trapped in the joint. An ab­ unlikely to have any immediate effect on the normal Lachman test indicates an intra-articular post-traumatic inflammatory response. Urgent ACL injury and an abnonnal McMurrayS test in­ treatment is prudent in the setting of sports ­ dicates a torn meniscus. related knee injuries. In the absence of gross de­ formity or neurovascular compromise, emergent 5. (B) L-lflarnmation is both an acute and chronic transport is unnecessary. response to trauma, infection and systemic au­ toimmune disease. In the acute phase, inflamma­ 2. (C) A non-contact deceleration Injury to the tion may be a healthy, self-limiting response; knee joint resulting in a painful "pop," immedi­ however, in the chronic phase it is often destruc­ ate swelling, and an inability to fully bear weight tive such as in the setting of arthritis and articu­ following the injury is an anterior cruciate liga­ lar cartilage destruction. Corticosteroids affect ment tear approximately 85% of the time in a inflammation by inhibiting leukotriene produc­ skeletally mature patient. tion, but also by inhibiting prostaglandin synthe ­ sis at the phospholipase A2 pathway. 3. (D) The maneuver most helpful to confirm your diagnosis is the anterior drawer test performed at 6. (E) In the setting of traumatic knee injuries there 30 degrees of flexion, otherwise known as the is no role for acute corticosteroid injections and Lachman test. The Lachman test is performed by no significant therapeutic role for knee joint aspi­ using one hand to stabilize the femur while the ex­ ration. If a joint aspiration is performed, the he ­ aminers opposite hand is placed around the leg at marthrosis tends to re-accumulate quickly thus the level of the tibial tubercle and an attempt is limiting the effectiveness of the therapeutic aspi­
  5. 5. 308 PEDIATRIC EXAMINATION AND BOARD REVIEW ­ ­ ration. An ACE wrap is a relatively ineffective way evaluation. Mechanical blocks of the joint are as- to provide support and compression if a more sup- sociated with higher complication rates such as portive knee brace is available. Knee immobilizers permanent loss of normal range of motion and that do not allow for range of motion are accept- damage to articular cartilage from pinching and -­ able alternatives initially, but their use should be compression with knee joint movement. There- limited to a few days and active range of motion fore, while it would be helpful to expedite the -­ should be encouraged within the limits of pain. MRl, if that seems unlikely to happen, it is ap­ propriate to refer for an orthopedic consultation 7. CD) While plain radiographs of the knee are an 10 to 21 days postinjury in the setting of a pre- appropriate initial srudy, a non-infused MRl of sumed mechanical block. The surgeon may rec- I....... the left knee is helpful in diagnosing ligamentous ommend immediate arthroscopy to address the injuries of the knee, as well as diagnosing other "locked" knee. associated intra-articular injuries such as menis­ ..... cal tears. Some might argue that no imaging 11. CA) Osteochondritis dissecansinjuries are much study is needed in the case described as your di- more common in the skeletally immature athlete; agnosis seems clinically accurate; MIUs are help- however, they are more frequently associated with ful to look for associated injuries such as collat- overuse. The etiology is multifactorial and thought ­ eral ligament, meniscal, and articular cartilage to result from cumulative microtrauma to the sub- injuries. MRIs are generally recommended as chondral bone leading to stress fracture and, ulti­ -­ part of the evaluation for an internal derange- mately, collapse. Treatment of this lesion depends ment of the knee. on whether the cartilage is intact, partially at­ -­ tached or completely detached. 8. (D) ACL injuries usually result in complete liga­ ­ ment tears either midsubstance or from the prox- 12. (B) It is reasonable to assume that a 12-year-old fe­ imal attachment on the posterior femur. The in- male is not yet skeletally mature. Therefore, the ........ jured ligament usually retracts and loses proper highest risk of injury associated with knee trauma anatomic positioning, thereby preventing any is a physeal injury to the distal femur or proximal reasonable chance of healing with conservative tibia. Physeal, or growth plate injuries are best management. While bracing and physical ther- treated with casting and crutches and merit a refer­ apy are important adjunctive treatments to de- ral to a pediatric orthopedist as there is increased crease pain and improve strength and function, risk of growth arrest. Tibial tubercle avulsion inju­ both pre- and postsurgery, the definitive treat- ries can best be diagnosed on a lateral radiograph ment is an ACL reconstruction using a graft. At- of the knee and also merit an orthopedic evalua­ ........ tempts to repair torn ACLs surgically have re- tion. Anterior cruciate ligament injuries do occur "­ suited in high failure rates and complications; in skeletally immature athletes. The management therefore, in general, a surgical reconstruction is of ACL injuries at this age is controversial. the preferred treatment of choice. "- 13. (A) In the setting of physeal injuries, a number of 9. (D) Given the above information, your examina- non-displaced Salter-Harris 1 to 2 fractures can tion suggests ACL and meniscus injury resulting be difficult to see on plain radiographs. Often a in signs of internal derangement. Bucket handle follow-up radiograph obtained 24 to 48 hours meniscal tears are most likely to result in a me- postinjury or 10 to 14 days postinjury will dem­ -­ chanical block in knee joint range of motion. An onstrate the fracture line or a periosteal reaction. MCL injury should demonstrate pain to palpa- MRl, CT, and bone scan are all sensitive and - ­ cion over this extra-articular structure and in- specific for identifying physeal fractures. Clini­ creased laxity with valgus testing. cally, pain at the end of long bones is a physeal injury until proven otherwise.10. (E) A flexion contracture as a sign of internal de­ rangement of the knee at 10 to 14 days post- 14. (B) Osteochondritisdis,secans lesions are most injury is an indication for an immediate surgical common in males 9 to 18 years old. Patellofemo­
  6. 6. CHAPTER 9 GENERAL EMERGENCY AND URGENT CARE 309 ral pain and patellar dislocations are associated stress to be placed across the patellofemoral joint, with underlying patellar instability and malalign­ therefore usually do not hurt, and are otten used as ment-a clinical finding more common in fe­ early exercises to start strengthening the leg with­ males. Females tend to have valgus knee align­ out aggravating the patella and its surrounding ment that is often associated with flat feet. These structures. cause overpronation and abnormal patellar track­ ing on the femur. Females often have "looser" lig­ 18. CD) In general, overuse injuries are associated with .... aments and relatively weaker supporting muscles genetic, biomechanical and workload problems. such as the quadriceps and hamstring muscles. The factors contributing to pain and injury should ACL injuries are more common in females be­ be initially evaluated and treatment initiated by a cause of the above factors mentioned in addition primary care physician. Acute traumatic injuries or to frequently having a smaller bony notch on the chronic, overuse injuries that dont respond appro­ femur for the ligament to pass through. Hor ­ priately to treatment may be referred for further monal influences are also thought to playa role in evaluation by an orthopedic or sport" specialist. increasing a females risk of ACL injury. Osteochondritis dissecans is the most complicated of the above conditions to manage; and the likeli­ 15. (A) Patellofemoral pain .syndrome is the most hood of needing surgical intervention rises in the common cause of adolescent knee pain, particu ­ older, more skeletally mature athlete. larly in females. It is often referred to as anterior knee pain. Jhere are many contributing factors 19. (E) All of the above indicate either a physeal (see next question). Osgood-Schlatter disease is (growth plate) problem or other intra-articular inflammation and pain at the tibial tubercle seen pathology. in growing prepubescents. Plica syndrome is a painful band of synovial tissue that snaps on the 20. (C) Ligament sprains vary in the time it takes to undersurface of the patella causing pain. Iliotibial heal depending on the location of the illjury and band syndrome is a tendonitis causing lateral the extent of the original injury. Ligament knee pain-most common in runners . sprains are often graded 1 to 3: Grade 1 refers to a partial ligament tear with no joint instability. 16. (C) Anterior or patellofemoral pain is associated Grade 2 refers to a partial ligament tear with with a variety of physical findings including flat mild to moderate joint instability. Grade 3 refers feet, knock knees (valgus knees) and increased in­ to a complete tear with joint instability. Treat­ ternal hip rotation (femoral anteversion). Obe­ ment of ligament sprains in the acute phase is sity also contributes to the presence of anterior aimed at decreasing inflammation and restoring knee pain. Functionally, weak quadriceps mus­ strength. The definitive criteria for safe return to cles, tight hamstrings and patellar instability sports involve the athlete being able to perform contribute to the development of patellofemoral sport-specific exercises such as running, jumping pain. The Q angle refers to the relationship of and cutting without pain, wealmess or instability. the quadriceps and patella vectors as drawn from If the athlete cannot perform sport-specific exer­ the anterior superior iliac spine and bisecting the cises properly, the risk of re-injury dramatically mid-superior pole of the patella followed by a increases. Bracing is effective initially and pro ­ line bisecting the mid-patella and the mid-patel­ vides compression and support to the joint. It lar tendon. An angle >20 degrees is associated also has an important role in assisting faster re­ with lateral patellar tracking and increased stress turns to competition by enhancing joint proprio ­ on the patellofemoral joint. ception, thereby enhancing joint stability. 17. (E) Patellofemoral pain has often been referred to SUGGESTED READING as "theater knee" because weight-bearing activities Bernstein ]: Musculoskeletal Medicine . Rosemont, IL: and prolonged sitting tend to increase anterior AAOS Publications, 2003. knee pain. Sitting with the knee extended or per­ Sullivan, lA, Anderson S]: Care ofthe Young Athlete. Rose­ forming exercises with a straight leg do not require mont, IL: AAOS and AAP Publications, 2000.L
  7. 7. 310 PEDIATRIC EXAMINATION AND BOARD REVIEWCASE 77: A 15-YEAR-OLD AND A 17-YEAR-OLD (B) dehydrationWHO COLLAPSE DURING A MARATHON (C) heat exhaustionYou are working in the emergency room on a Satur ­ (D) heat cramps day afternoon watching the local marathon race on (E) heat stroke television. The arUlOuncer h2S just stated t.~n the out­side temperature is 9soF (3S°C) and the humidity is 3. What patient factor was most likely to . predis­ 80%. You are glad to be inside in the air conditioning, pose the first athlete to heat illness?yet you are sorry that you could not volunteer in the (A) obesity medical tent at the race. Suddenly two marathoners (B) dehydration are bro~ght in for urgent evaluation. (C) clothing The first athlete is a is-year-old female who is (D) sunburn complaining of spasms in her calf muscles, mild lower (E) excessive exercise abdominal pain, and thirst. She states she was com ­ pet;ing in her first marathon, softball is her usual 4. What environmental conditions predispose ansport, and she didnt tra,in much for this race. She did athlete to heat illness? drink some water every 3 miles at the fluid stations then collapsed at mile 16. Her weight was 8S kg. Her (A) high ambient temperaturevital signs were: pulse 96 bpm, BP 1l0nO mm Hg, (B) high windsrespiratory rate 28, temperature 99.9°F (37.7°C). She (C) high humiditywas wearing a tight fitting, dark-colored, long sleeve (D) A and Conlyshirt over a tank: top and matching shorts. Upon re­ (E) all of the abovemoval of her garments she was noted to have sun­ burned .skinwithout . blistering on her face, back, 5. What is the most important mechanism the bodyches~ upper and lower ~xtremities. She appeared pro ­ uses for heat dissipation?fusely sweaty, had tight gastrocnemius muscles with (A) conductionspasms. . (B) convection The second athlete is a 17 -year-old male cross (C) radiationcountry tulUler who collapsed at mile 23 complaining (D) evaporationof dizziness, lightheadedness, headache, nausea, and (E) respirationhad vomited twice in the field. His weight was 80 kg.His vital signs were: BP 100/60 mm Hg, pulse 110 6. Which of the following statements regardingbpI1), respiratory rate 36, tympanic temperature 101°F heat dissipation is false?(38.S°C). On examination he appeared confused anddisoriented, and his skin was sweaty and hot to the (A) Conduction occurs via indirect contact oftouch. Further examination was unremarkable. the body with the environment. (B) Convection is heat transferred from a solidSELECT THE ONE BEST ANSWER surface to surrounding gas molecules. (C) Radiation is the transfer of heat between the 1. Which of the following is the most serious form body and its environment via electromag ­ of heat illness? netic waves. (A) fever (D) Evaporation is the conversion of liquid to (B) heat syncope gas. (C) heat stroke (E) All of the above are true. (D) heat exhaustion (E) rhabdomyolysis 7. Heat cramps are most likely related to the loss of which electrolyte? 2. Which diagnosis most likely explains the first (A) Mg+ athletes symptoms? (B) Na+ (A) sunburn (C) K+
  8. 8. CHAPTER 9 GENERAL EMERGENCY AND URGENT CARE 311 (D) CI­ entation, myalgias, tachycardia, na.usea, vom­ (E) Ca+ iting, or hypotension. (E) Both conditions result in reversible tissue 8. When caring for a preadolescent athlete, all of damage if an accurate diagnosis and prompt the following statements accurately describe heat initiation of treatment occurs. illness except: 12. Which of the following are complications of heat (A) Children are at increased risk for heat ill­ stroke? ness because of a higher surface area to mass ratio. (A)permanent neurologic deficits­ (B) Younger athletes have slower rates of accli­ (B)hepatic failure-­ matization. (C) urerrua (C) Children are at decreased risk for heat illness (D) dissemirfated intravascular coagulation because the circulating blood volume is less. (E) all of the above (D) Children are less efficient at sweating. (E) Childrens motor movements are less effi­ 13. All of a sudden you are called to the bedside of cient than adults during exercise. the second athlete and you observe generalized tonic-clonic seizure activity and posturing. The 9. The best initial treatment of choice in the emer­ patient feels hot and dry to the touch. You are gency room for the first athlete is? concerned now that the second athlete is suffer­ ing from heat stroke. Which of the following (A) intravenous fluid replacement with normal would be least likely to be found in a patient with saline heat stroke? (B) salt tablets (C) unlimited oral intake of a standard electro­ (A) a temperature of 101°F (38.S°C) lyte solution (B)an elevated creatine phosphokinase (D) unlimited oral intake of water (C) urine specific gravity obl.030 (E) massage and gentle calf stretching (D) lactic acidosis (E) blood pressure of 100/60 mm Hg 10. Based on the initial presentation above, what is the most likely diagnosis accounting for the sec­ 14. You instruct the nurse to obtain the patients cur­ ond athletes symptoms? rent temperature. What is the temperature mea­ surement method you recommend to the nurse? (A) dehydration (B) heat stroke (A)rectal (C) heat exhaustion (B)oral (D) heat syncope (C) axillary (E) rhabdomyolysis (D) tympanic (E) the easiest and fastest method of her choice 11. Which of the following statements is true re­ garding heat exhaustion and heat stroke? 15. Which of the following statements is true re­ garding measurement of core body temperature (A) Heat exhaustion and heat stroke are sepa­ in a patient with heat illness? rate clinical conditions that db not occur in the same patient suffering from heat illness. (A) Rectal thermometers are used only in pa­ (B) Hemoconcentration, urinary concentration, tients who feel "hot" to the touch. and hypertension are common occurrences (B) Rectal thermometers are preferred but need in both conditions. only to be able to measure up to 106°F (C) Both conditions can result in hyperpyrexia (4 1.1 0C). ~105° F (40.5°C). (C) Oral temperatures are notoriously unreli­ (D) Both conditions may cause an athlete to ex­ able in exertional heat illness because of perience weakness, fatigue, dizziness, disori­ tachypnea and compliance.
  9. 9. 312 PEDIATRIC EXAMINATION AND BOARD REVIEW (D) Tympanic membrane temperarure .measure ­ (D) 38.3°C (101°F) ment has been proven to reflect true core . (E) 39.6°C (103 °F) temperature because the tympanic mem ­ brane is adjacent to the hypothalamic tem ­ 20. After an hour, the first athlete feels much better perature regulation center. and is ready to go home, You advise her that in (E) All of the above the future she should try to prevent heat cramps during competition in strenuous and endurance16. The nurse reports to you that the current vital sports lasting over 1 hour in duration. VVhich of signs for the second athlete are as follows: BP of the following recommendations is most effective 90150 mm Hg, pulse of 120, oxygen saruration in the prevention of heat cramps? of 95 % on room air, temperarure of 106.7°F (A) salt tablets (41soC). What is the most important initial emer­ (B) ; ater only before and during intense endur ­ gency room treatment for the second athlete? ance exercise (A) Prepare the patient for emergent placement (C) water and an electrolyte drink before and of a Swan-Ganz catheter for central venous dUling intense exercise . pressure monitoring. (D) increased warm-up time and stretching of (1.3) Begin rapid cooling procedures. calf muscles pre-exercise (C) Adrrrinistersupplementaloxygen. (E) weight loss (D) . Administer room temperature intravenous flpids using a IlL bolus of 0.9 % normal sa­ 2l. If you were able to give the second athlete any line over 30 to 60 minutes. advice prior to his next marathon, you would (E) Administer an antipyretic medication stat. most likely want him to know all of the following principles except:17. In the medical tent, the most effective method to (A) The sweat rate for the average endurance achieve rapid cooling is which of thefollowing? athlete in a temperate climate averages 1.0 to (A) whole body immersion in ice water 1.2 liters per hour and can exceed 2 liters per (B) wrapping the body in cold towels . hour in conditions of high heat and humidity. (C) packing the body in ice (B) Sweat is hypotonic and is more hypotonic in (D) spraying with water and place in front of faIlS those athletes who sweat greater volumes. (E) ice packs in the groin and axilla . (C) Athletes should voluntarily drink fluids be­ fore , during and after activities.18. In the emergency room setting the preferred (D) If an athlete is participating in endurance method of rapid cooling is? events, he should start taking salt tablets 2 to 3 days prior to competition. (A) administration of cooled intravenous fluids (E) Proper nutrition, adequate sleep; gradual ac­ with 0.9% normal saline climatization, avoidance of drugs/substances (B) iced gastric lavage like alcohol, ephedra, and caffeine are impor­ (C) ice packs in the groin and axilla tant preventive measures. (D) rapid whole body sponging with rubbing al­ cohol (E) whole body inunersion in ice water Answers19. You have now initiated rapid cooling and the pa­ l. (C) Heat stroke is the most severe form because tient is more lucid, the skin is feeling cooler and it is associated with irreversible tissue damage. clam~y to the touch. At what temperarure do you want to stop rapid cooling? 2. (D) Heat cramps are a common mild form of (A) 37°C (98.6°F) heat illness that tend to occur after exercise and (B) 37.3°C(99°F) are associated with a large production of sweat (C) 37 .7°C (lOO°F) during exercise.
  10. 10. CHAPTER 9 GENERAL EMERGENCY AND URGENT CARE 313 3. (B) Dehydration and volume depletion as a result 12. (E) All of the above are potential complications ~ from sweating without adequate fluid replace- of heat stroke. Rhabdomyolysis, dysrhythmias, ment is the most important risk factor for heat- acidosis, adynamic ileus, electrolyte imbalances, L related illness. All of the listed factors contribute and seizures are also seen. to an increased risk of heat illness. ... 13. (A) Heat stroke is associated with temperatures 4. (D) Heat and humidity are most important. Once ~40.5°C (l05°F). ambient temperature equals or exceeds skin tem ­ perature, conduction, convection, and radiation 14. (A) In the setting of severe heat illness, it is critical cease to be effective methods of heat loss. Once to try to accurately measure core temperature. A ambient humidity exceeds 75% then the effective- rectal temperature is the preferred method with a ness of evaporation decreases. Low winds are as- probe 10 to 15 em in length. sociated with decreased heat dissipation. 15. (C) Rectal temperature measurement is the gold 5. CD) Evaporation (via sweating) is the dominant standard and it is recommended that probes be mode of heat dissipation or heat loss in the body. accurate to at least 112°F. Tympanic membrane measurement has not correlated well with 10-cm 6. (A) Conduction requires direct contact of the rectal probe temperature measurements in re- body with surrounding objects and air. search studies, despite the hypothesis described in answer D. ~ 7. (B) Heat cramps are thought to be caused by a total body loss of sodium and are exacerbated by 16. (B) In the setting of suspected heat stroke, it is vi­ .. excessive sweating. tal that you initiate treatment before firmly estab­ lishing the diagnosis. In fever, the set point for 8. (C) Children are at increased risk for heat illness temperature regulation is elevated and often re- because circulating blood volume is less and the sponds to the use of antipyretics. In the setting of ability to circulate blood volume increases blood heat illness, the set point for temperature regula­ flow to the periphery resulting in a greater ability tion is maintained yet hyperthermia results be- to dissipate heat. cause more heat is gained than lost. In hyperther ­ mia, antipyretics are likely to be ineffective and 9. (C) The best initial treatment for heat cramps is alternate methods of body cooling are necessary. drinking an electrolyte solution (or administer ­ ing 1 tsp of table salt dissolved in 500 mL of wa- 17. (A) Whether in the medical tent or in the emer ­ ter). The underlying cause of heat cramps is to- gency room it is critical to initiate treatment im­ tal-body salt depletion. Cramping is often made mediately. The most important initial treatment is worse by excessive intake of hypotonic fluids the institution of rapid cooling. The treating phy­ such as water. Gentle massage and stretching sician must also follow the general principles of may be a helpful adjunct to treatment of tlle un- ABC, monitor the patients vital signs, obtain ap­ derlying problem. Intravenous fluid use is gener- propriate laboratory tests, and start intravenous ally reserved for the more severe cases. rehydration. The most effective way to achieve rapid cooling is whole body in1mersion in ice wa-L 10. (C) ter. Unfortunately this method is usually not prac­ tical. The most common way to initiate rapid 11. (D) Both conditions have similar initial signs and cooling is through the use of water sprays and fans symptoms; however they represent a continuum of (maximizes convection). One may also pack the...... disease process. If left untreated or unrecognized, athlete in ice or cold, wet towels. It is important to heat exhaustion can quickly become heat stroke expose as much skin as possible. One should avoidL at which time extreme hyperpyrexia (>4D.5°C placing ice packs over the major vessels in the [105°FJ-not seen in heat exhaustion), coma, sei- groin and axilla as this may result in peripheral- zures, and irreversible tissue damage can occur. vasoconstriction and less efficient cooling.­
  11. 11. 314 PEDIATRIC EXAMINATION AND BOARD REVIEW Table 77-1. HEAT EXHAUSTION VERSUS HEAT STROKE feat Exhau$tion HeatStroke . . " . Signs and symptoms Vagtle malaise, fatigue, headache, :pausea, dizziness . eNS dysfuncti~h (coma, seizures, delirium). Core tempera,wre . Normal or elevated < man 4O.0°C Elevated >40.5°C . Sweating . ·Ccim1l0n . Present in wine cases . Dry, hot skin mote concerning Treatment Slow cooling · Rapid cooling SlOw volume .repletion Vigorous volUme repletion if orthostatic and hypotensive <90/60 mm Hg Antipyretics . Ineffective .... Intlffective End organ injury Reversible injury . Often irreversible end organ damage - ­ 18. (A) In the emergency room setting, the preferred Lugo-Amador N, Rothenhaus T, Moyer P: Heat-re­ method for rapid cooling is administration of lated illness. EmeTg Med Clin North Am 22:315-327, cooled intravenous fluids. Whole body immer­ 2004. Barr sr, Costill DL, Fink W]: Fluid replacement during sion is not practical. Rubbing alcohol is generally prolonged exercise: effects of water, saline or no fluid. not recommended. Ice packs in the groin and the Med Sci Sports Exerc 27:2002-2010, 1995. axilla should be avoided. See Table 77-1 for sum­ mary of heat exhaustion versus heat stroke. CASE 18: A 5-YEAR-OLD MALE WITH 19. (0) One of the most common complications of ABDOMINAL PAIN rapid cooling is overcooling and temperatures as A 5-year-old African-American male presents to a pe ­ low as 88°F (31°C) have been reported (Boston diatric emergency deparonent with a chief complaint Marathon). Therefore, the ideal temperature at of abdominal pain. His pain is periumbilical and is de ­ which to stop rapid cooling is 101°F (38.3°C), scribed as diffuse, non-radiating, waxing and waning subsequently allowing the body to further coolon with no relationship to meals or bowel movements. its own. Shivering is a sign of overcooling and ac­ His pain began after lunch yesterday and he devel­ tually causes increased heat production and may oped vomiting overnight. He has had three non-bil­ cause a rebound increase in core temperature. ious and non-bloody episodes of emesis, two loose non-bloody stools today, and tactile elevated tempera ­20. (C) The best prevention of heat cramps is adequate ture. He states he is thirsty, but has refused to eat for hydration before and during athletic activities. Ap­ the last several hours. The patient denies headache, propriate clothing, conditioning, and, in rare cases, sore throat, dysuria, frequency, or urgency. His past modest increases in dietary salt are helpful inter­ medical history is unremarkable. ventions. Excessive water intake often worsens heat His vital signs reveal a blood pressure of 100/60 cramps a~ it causes further total body sodium loss. mm Hg, pulse of 100, respiratory rate of 36 and a temperature of 100.4°F (38°C). Upon examination21. (D) Salt tablets are generally not recommended he is found to have dry mucous membranes, hypoac ­ because the high solute load causes gastrointesti­ tive bowel sounds with reproducible periumbilical nal irritation. However, adding extra table salt to tenderness, mild right lower quadrant tenderness and food is recommended. no rebound tenderness. His rectal exam is unremark ­ able except for a small amount of soft stool in the rectal vault.SUGGESTED READINGRosen s Emergency Medicine: Concepts and Clinical Practice, SELECT THE ONE BEST ANSWER 5th ed. St. Louis, MO: Mosby, 2002, pp 2002 ­ 2009. 1. What is the most likely diagnosis in this patient?
  12. 12. ­ CHAPTER 9 GENERAL EMERGENCY AND URGENT CARE 315 -­ L (A) gastroenteritis (B) The onset of abdominal pain frequently pre­ (B) acute pancreatitis cedes the appearance of any other symptoms. (C) peritonitis (C) Tenderness upon rectal examination is a (D) acute appendicitis non-specific finding for appendicitis. (E) cholecystitis (D) Anorexia and low grade fever may be associ­ ated symptoms. 2. All of the following are common non-surgical (E) Pain may be either constant or colicky in causes of acute abdominal pain in children except? nature, but almost always. worsens with movement. (A) mesenteric adenitis (B) gastroenteritis 7. Which of the following physical examination (C) psoas abscess findings is le~st likely to correlate with a diagno­ (D) pyelonephritis sis of acute appendicitis? (E) constipation (A) Referred tenderness from the left lower 3. Ail of the following are considered common extra- quadrant to the right lower quadrant during abdominal causes of abdominal pain in children palpation"­ except? (B) Bluish discoloration around the uqlbilicus (A) drug ingestions such as acetaminophen or (C) Tenderness at a point between the umbilicusL . and the anterior superior iliac spine two­ salicylates thirds the distance from the umbilicus (B) diabetic ketoacidosis (C) pneumonia (D) Extension of the hip posteriorly with the pa­ tient lying prone elicits pain (D) group A streptococcal pharyngitis (E) Abduction of the right hip with the patient (E) all of the above lying supine elicits pain 4. Initial management steps for this patient in the 8. Which of the following statements is true re- emergency department should include all of the garding the appendix? following except which? (A) The appendix is funnel~shaped in infants and (A) Make the patient NPO (nothing by mouth). becomes conical shaped around 2 years of age. (B) Administer intravenous fluids. (B) The appendix may be located anterior, ret­ (C) Place a nasogastric tube to low intermittent rocecal, or subcecal. wall suction. (C) The appendix may be located in any of the (D) Obtain prompt surgical consultation. four abdominal quadrants .(right upper, left (E) Draw appropriate laboratory studies. upper, right lower, left lower). (D) The appendix is a diverticulum that extends 5. Which of the following laboratory studies is least from the inferior tip of the cecum with a lin­ likely to be helpful ill confirming the etiology of ing interspersed with lymphoid follicles. this patients abdominal pain? (E) All of the above. (A) serum electrolytes, BUN, and creatinine (B) urinalysis 9. Which of the following statements is true re­ (C) C-reactive protein garding the management of acute appendicitis in (D) white blood cell count with differential children? (E) amylase and lipase (A) All patients should receive intravenous anti­ biotics. 6. Which of the following statements describing acute appendicitis in a school-age child is (B) All patients should have at least one imaging study. false? (C) All patients should have a prompt surgical~ (A) Diarrhea is rarely associated With appendicitis. consultation.
  13. 13. 316 PEDIATRIC EXAMINATION AND BOARD REVIEW "­ (D) AU patients should receive pain medication (E) Males have a higher lifetime risk of suffer- until adequate pain control is achieved. ing from appendicitis than females. "-­ (E) All of the above. 13. A delay in diagnosin.g acute appendicitis in chil­10. In the 5-year-old patient described above, which dren can have serious consequences. Which of of the following imaging studies is most likely to the following is least likely to occur as a direct -- yield a definitive diagnosis and is the current pre- result of a delayed diagnosis? ferred study of choice? -­ (A) death (A) abdominal radiographs (B) bowel obstruction "­ (B) ultrasonography (C) perforation (C) barium enema (D) peritonitis "­ (D) upper GI (E) pancreatitis (E) CT ....­ 14. Which of the following causes of abdominal pain11. Which of the following statements is true re- ,in children is considered a surgical emergency "­ garding imaging studies in children with acute besides appendicitis? . . ; a,ppefldicitis? - (A) intussusception (A) Computed tomography offers the advantages (B) peritonitis -­ of better contrast sensitivity, the capability of (C) malrotation with midgut volvulus "Viewmg all tissue layers, reduced operator de- (0) A and Conly pendence and is the safest imaging modality. (E) all of the above (B) Ultrasonogra phyoffers the advantage of low cost, no radiation exposure and little 15. You now return to the bedside of your patient and variation among operators. you find him lyjng on his side with his knees " "(C) Abdominal radiographs are most helpful in curled up. His mother tells you that he fell off his diagnosing other causes of abdominal pain "­ bike and landed on the handlebars the same day such as constipation, bowel obstruction, free he started having abdominal pain: He is now com­ air, or renal stones. plaining of worsening periumbilical pain and also (0) Ultrasonography offers 100% sensitivity and mid-back pain. You find that he has hypoactive specificity to accurately exclude the possibil- bowel SOlUlds, guarding and right upper quadrant ity of appendicitis as a cause of acute ab- pain. All of the following statements are true re­ dominal pain in children as long as either a garding your suspected diagnosis except: normal appendix is visualized or the appen­ (A) A complete blood count ffiight demonstrate dix is not visualized at all. a leukocytosis with a bandemia. (E) AU of the above statements are true. (B) Abnormal liver function tests as well as an el­ evated lipase and amylase might be present.12. Which of the following statements is false? (C) A sentine I loop of small bowel seen best on a (A) Appendicitis is the most common surgical plain radiograph is often diagnostic. "­ abdominal emergency in children. (D) Ultrasonography is the cornerstone of diag­ (B) Missed appendicitis is one of the top reasons oosis for the suspected condition. "­ for malpractice claims in the emergency de- (E) Blunt abdominal trauma is a relatively rare partment. cause of this condition. (C) In cases involving appendicitis in children, a well-documented chart will not prevent a 16. An ultrasound confirms the presence of an en- "­ lawsuit. larged edematous pancreas and mild pancreatic (D) All children with acute onset of abdominal duct dilatation. Which of the following is the ....... pain should have an imaging study regard- least important step in appropriate management less of the clinical diagnosis. of this patient? ­ ­ .........
  14. 14. ,-­ CH A PTER 9 GENERAL EMERGENC Y AND URGENT CARE 317 ------------------------------------------------- (A) intravenous hydration (C) computed tomography (B) intravenous administration of antibiotics (D) barium enema (C) nasogastric suction (E) upper GI (D) serial abdominal examinations (E) intravenous administration of meperidine Answers 17. Which of the following is least likely to be a po­ tential cause of acute pancreatitis in this 5-year­ 1. (D) Acute appendicitis is the most likely etiology old? of this patients clinical picture. While the pre­ sentation could initially be confused with gastroen­ (A) trauma teritis, the presence of hypoactive bowel sounds, (B) cholelithiasis anorexia, pain preceding the onset of any other (C) viral infection symptoms, and reproducible tendemess have a (D) cystic fibrosis higher correlation with appendicitis than any of (E) urolithiasis the other diseases listed. ... 18. You now are asked to evaluate a 2-year-old Afri­ 2. (C) A psoas abscess usually requires surgical can-American female who presents with a history drainage. of sudden, sharp, crampy episodic right lower l. quadrant abdominal pain for 1 day and decreased 3. (E) All of the conditions can present with ab­ oral intake, Your physical examination reveals no dominal pain in children and must be included in reproducible abdominal tenderness; however, a the differential diagnosis. guaiac positive soft mucous stool on rectal exam­ ination is noted . Which of the following abdom­ 4. (C) The placement of a nasogastric tube should be inal imaging studies would most likely aid you in reserved for patients who appear to have the need confirming your suspected diagnosis? for gastric decompression. This would include pa­ (A) plain radiographs tients with suspected pancreatitis or some form of (B) ultrasonography bowel obstruction such as a volvulus. (C) computed tomography (0) barium enema 5. (A) Serum electrolytes, BUN, and creatm1l1e (E) B or 0 may be helpful for assessing a patients renal and hydration status but otherwise adds little to the 19. Had the 2-year-old described in question 18 pre­ diagnostic evaluation of abdominal pain. The sented with bilious vomiting, abdominal disten­ urinalysis is useful to exclude the diagnosis of a tion, tenderness, and guarding, which of the fol­ urinary tract infection while amylase and lipase lowing diagnosis would be most likely? are useful in differentiating pancreatitis from other causes of abdominal pain such as appendi­ (A) mid-gut volvulus citis. Lastly, the combination of an increased leu­ (B) mesenteric adenitis kocyte count with an increased blood CRP level (C) peritonitis can be suggestive of appendicitis in the setting of.... (D) gastroenteritis acute abdominal pain. (E) Meckels diverticulum 6. (A) In children, diarrhea can be associated with 20. In any infant or toddler who presents with acute the presence of appendicitis up to 30% of the abdominal pain, bilious emesis, and guarding, time. Many of the clinical features of acute ap­ which of the following imaging studies is the ini­ pendicitis are non-:-specific; however, pain as the tial study of choice most likely to confinn your initial symptom and pain associated with move­ suspicions? ment--i.e., jumping up and down, riding in a (A) magnetic resonance imaging bumpy car or tapping on the patients heel--raise (B) ultrasonography clinical suspicion.
  15. 15. 318 PEDIATRIC EXAMINATION AND BOARD REVIEW 7. (B) Bluish discoloration around the umbilicus 12. (D) Not all patients with acute .abdominal pai.l describes Cullens sign that, when coupled with need an imaging study, but a prompt surgical Grey Turners sign (bluish discoloration around consultation is recommended. the flank), is suggestive of acute hemorrhagic pan­ creatitis. Rovsings sign describes referred pain 13. (E) Pancreatitis is not a complication of acute ap­ from LLQ to RLQ. McBurneys point describes pendicitis. Rather, it must be differentiated from the classic RLQ appendiceal location for pain. appendicitis in the setting of acute abdominal Choices "D" and "E" refer to the classic psoas pam. and obturator signs, respectively, that if present, non-specifically support the diagnosis of acute 14. (E) All of the choices have the associated risk of appendicitis. serious complications if the diagnosis is delayed or misse~. The surgical evaluatiop:,is an impor­. 8. (E) tant part fif the work-up of acute ab~ominal pain and the surgical team must be ready to provide 9. (C) All suspected cases of acute appendicitis operative intervention should conservative treat­ should have early surgical involvement as some ment measures fail or be deemed inappropriate. children will be spared further diagnostic evalua­ tions once the decision for surgical treatment has 15. (E) All of the choices are true in the setting of been made. In the absence of a perforation or suspected acute pancreatitis except that blunt ab­ peritonitis, antibiotics are not always necessary. a dominal trauma is actually common cause. In Until the diagnosis has been made and the sur­ fact, it is the most common cause of acute pan­ gical recommendations have been made, pain creatitis accounting for 13% to 33% of cases. should be monitored closely, but the administra­ tion of medication that could impede the evalua­ 16. (B) In the setting of acute pancreatitis and the tion and monitoring of the patients status should absence of peritonitis or septic shock, antibiotics be avoided. have little role. Adequate pain control is an im­ portant step in treatment for this condition10. (B) In current medical practice today, ultra­ whereas it can interfere with a prompt diagnosis sonography is the preferred diagnostic study of and treatment for acute appendicitis. choice with >80% to 90% sensitivity and speci­ ficity that is comparable with abdominal com ­ 17. (E) Blunt trauma to the mid-epigastric area of puted tomography. Abdominal CT is a useful the abdomen such as being struck with bicycle adjunct and is still often performed if the ultra­ handlebars is the most common cause of acute sound is inconclusive. In some cases a CT is ob­ pancreatitis in children. Viruses such as coxsackie tained as the injtial study; however, it is associ­ il, cytomegalovirus, varicella, hepatitis A and B, ated with greater risks as it IS an invasive influenza A and B, and Epstein-Barr virus have procedure requiring contrast administration and been implicated in addition to bacterial and para­ high radiation exposure. sitic causes. Gallstones can cause pancreatitis but are usually only seen in this age range in the11. (C) Abdominal radiographs are traditionally not presence of a hereditary hemolytic anemia such ...... useful in the diagnostic evaluation of appendicitis as hereditary spherocytosis or sickle cell disease. except in the presence of a fecalith (calcified ap­ Cystic fibrosis can cause acute pancreatitis but pendix). The disadvantage of CT is radiation ex­ the incidence is relatively low in African-Ameri­ posure compared with ultrasound imaging that is cans. Renal stones should not cause pancreatitis. associated with a high degree of operator depen ­ dency and variation. The presence of a nonnal 18. (E) Barium enemas have traditionally been the appendix on an ultrasound effectively excludes gold standard for the diagnosis (100% sensitivity appendicitis as a diagnosis; however, the inability and specificity) and 70% successful reduction to visualize the appendix renders the study in ­ rates of intussusception. However, current prac­ conclusive. tice reflects increasing use of ultrasonography ­
  16. 16. CHAPTER 9 GENERAL EMERGENCY AND URGENT CARE 319 L with pneumatic reduction by an air enema. Suc­ The last dose was given 4 to 6 hours prior and she left cess rates approach 90% ~ith fewer complica­ the bottle in the ;oom in case she needed it again dur­ tions than barium enemas. ing the riight. SELECf THE ONE BEST ANSWER 19. (A) The presence of bilious emesis should prompt a thorough evaluation for bowel obstrUction. Alal­ 1. Wruch of the following statements regarding rotation with intermittent volvulus is one cause in childhood poisonings is false? the toddler to preschool-age child. (A) The ingestion of a potentially poisonous 20. (E) An upper GI with a contrast enema is still the substance by a young child is a common gold standard for the diagnosis of volvulus. If the event. duodenal C-Ioop crosses to the left of the mid­ (B) Death atnibutable to unintentional poison­ line at a level greater than or equal to the pylorus, ing is uncommon in cruldren younger than then malrotation is effectively ruled out. Con­ 6 years of age. versely, a corkscrew column that ends abruptly is (C) Data such as signs and symptoms of toxicity, rughly suspicious for volvulus. management strategies in the home, and in­ dications for seeking emergency care are available from local and national poison SUGGESTED READING control centers. Halter J: CCrTunon gastrointestinal problems and emer­ (D) The American Academy of Pediatrics cur­ gencies in neonates and children. Clin Fam PrlUt 6(3): rently recommends that syrup of ipecac be 731,2004. kept at home for emergency use. Guzman D: Pediatric surgical emergencies. Clin Pediotr (E) The storage of poisonous substances in the Emerg Med 3(1):1-2,2002.L Reynolds S: Missed appendicitis and medical, liability. Clin home should be discussed at the 6-month Pediotr Emerg Med 4(4):231,2003. well-child visit. 2. All of the following statements correctly describe CASE 79: A 3-YEAR-OLD GIRL WHO DRINKS reasons for the decreases in the death rare attrih­ A BOTTLE OF ACETAMINO PHEN ut3ble to unintentional poisoning in young chil­ You are called to evaluate a 3-year-old l5-kg female dren in the last 50 years except: brought in by ambulance. The aunt who arrived with (A) the advent of child-resistant closures for the patient states she has been sick for 2 days with a products "cold" and has had fevers up to 101 O (3 SoC) at home, F (B) an increase in the GTC drug products avail­ a cough and 2 to 3 episodes of vomiting. The little able for parents to purchase for routine girl is complaining of "stomach pain." Past medical household use history and family medical history are noncontrihu­ (C) improved public education and anticipatory tOry. Medications include acetaminophen every 6 guidance hours. (D) the establishment of multiple poison control On physi cal examination, the blood pressure is 9U/ centers 50 lrun Hg, the pulse is 110, respirarory rate is 40, d[(l (E) all of the above are true tympanic temperature is 99.soF (37.rC). The child appears ill, somewhat diaphoretic and in mild pain. 3. All of the following scatements regarding SyTUp Her exam is sigrlificant for mid-epigastric tenderness of ipecac are true except which~ withouL rebound or guarding. Bowel sounds are nor­ mal and a rectal exam is unremarkable. The mother (A) The only recommended method of induc­ arrives and brings an empty bottle to you and states "I ing emesis is administration of ipecac. think my baby drank her medicine." You examine the (B) Syrup of ipecac is a safe emetic. bottle and see it contains 4 oz of acetaminophen sus­ (C) The amount of substance removed from the l pension 160 mglS mL. Mom states the bottle was stOmach is directly related to the duration of newly opened yesterday and she gave only two doses. time from its ingestion to emesis.