2. Moment for a selfish plug for myself.. On
behalf of your education!
• @njoshi8
• #EMConf
• #EMBoardReview
• #FOAM
• #FOAMED
3. • 15 yo boy presents with abdominal pain. He has been ill for 10 days
with malaise, fever, and sore throat. Vitals signs are BP 110/80,
pulse 76, respirations 16, and temp 38.3 (100.9F). Physical
examination is notable for exudative pharyngitis and an enlarged
spleen. Which of the following statements regarding his signs and
symptoms is most accurate?
A) Fatigue resolves with pharyngitis symptoms
B) Petechiae of the palate is pathognomonic
C) Rash is often seen associated with these symptoms
D) Splenomegaly is common
4. • 15 yo boy presents with abdominal pain. He has been ill for 10 days
with malaise, fever, and sore throat. Vitals signs are BP 110/80,
pulse 76, respirations 16, and temp 38.3 (100.9F). Physical
examination is notable for exudative pharyngitis and an enlarged
spleen. Which of the following statements regarding his signs and
symptoms is most accurate?
A) Fatigue resolves with pharyngitis symptoms
B) Petechiae of the palate is pathognomonic
C) Rash is often seen associated with these symptoms
D) Splenomegaly is common
5. What’s the
diagnosis?
• Infectious
mononucleosis
Disease Characteristics?
• Malaise
• Exudative pharyngitis
• Fever
• Lymphadenopathy – posterior
aspect of neck
A – malaise / fatigue can persist
for months; pharyngitis resolves
after 2-4 wks
B – Petechiae can be seen on
soft palate in many types of
pharyngitis
C – Rash is seen only
occasionally; maculopapular rash
develops if pt with EBV is treated
with ampicillin or amoxicillin
7. • A mother brings in her 5 day old daughter for evaluation of sudden-
onset, forceful, green colored vomiting. The baby was born at term
and at home by spontaneous vaginal delivery; she has no respiratory
symptoms. Examination reveals a distended abdomen. Which of the
following is the most likely diagnosis?
A) Duodenal atresia
B) Malrotation with midgut volvulus
C) Necrotizing enterocolitis
D) Tracheoesophageal fistula
8. • A mother brings in her 5 day old daughter for evaluation of sudden-
onset, forceful, green colored vomiting. The baby was born at term
and at home by spontaneous vaginal delivery; she has no respiratory
symptoms. Examination reveals a distended abdomen. Which of the
following is the most likely diagnosis?
A) Duodenal atresia
B) Malrotation with midgut volvulus
C) Necrotizing enterocolitis
D) Tracheoesophageal fistula
9. What is malrotation with midgut
volvulus?
• Infants younger than 1 mon + bilious vomiting
• Acute symptoms
• Rapidly go into shock
Congenitally malrotated bowel twists on mesentary,
near duodenum = obstruction
Compression of superior mesentary artery, vascular
compromise
10. Age Clinical
Associations
Key Associations
Malrotation with midgut
volvulus
Less than 1
month
• Bilious vomiting
(obstruction)
• Shock
• Paucity of small
bowel air
• Or normal!
NEC Preterm • Abd distention
• Nonbilious
vomiting (ileus)
• Diffuse dilated
loops of small
bowel
Duodenal Atresia Less than 24 hrs
of birth
• Vomiting (bilious
or non depedent
on atresia
location)
• Trisomy 21
(Down synd)
Tracheoesophageal
Fistula
Early infancy • Choking,
coughing,
cyanosis WITH
FEEDS
• Rare
12. Increasing emesis 2-6 week old
neonate? • Pyloric Stenosis
• Nonbilious projectile vomiting after feeds
• Dehyration
• Failure to thrive
• Olive shaped mass (hypertrophied pylorus)
Hypochloremic, hypokalemic
metabolic acidosis
13. • A 64 yo man with history of HTN, diverticulosis, remote abdominal aortic
aneurysm repair presents with a 2-day history of black stools, abdominal
discomfort, and low grade fever. He is diaphoretic. Vital signs include
BP 72/46, pulse 138, and respiratory rate 24. Physical exam reveals a
midline abdominal scar, diffuse abdominal tenderness, and bright red
blood in his rectum. Two large bore intravenous lines are placed, and
fluid resuscitation is begun. What is the appropriate next step in
management?
A) Obtain vascular surgery consultation
B) Order abdominal and pelvic CT scans and start intravenous antibiotics
C) Start nasogastric lavage and obtain endoscopy consultation
D) Start proton-pump inhibitor and octreotide infusion
14. • A 64 yo man with history of HTN, diverticulosis, remote abdominal
aortic aneurysm repair presents with a 2-day history of black stools,
abdominal discomfort, and low grade fever. He is diaphoretic. Vital
signs include BP 72/46, pulse 138, and respiratory rate 24. Physical
exam reveals a midline abdominal scar, diffuse abdominal
tenderness, and bright red blood in his rectum. Two large bore
intravenous lines are placed, and fluid resuscitation is begun. What
is the appropriate next step in management?
A) Obtain vascular surgery consultation
B) Order abdominal and pelvic CT scans and start intravenous
antibiotics
C) Start nasogastric lavage and obtain endoscopy consultation
D) Start proton-pump inhibitor and octreotide infusion
15. What is the concerning
pathophysiology?
• Aortoenteric fistula (AEF) – primary
complication of AAA, can occur anytime
after repair
• Bowel gets eroded by the aneurysm
– Local infection
– Abscess
– Sentinel bleed from local vessel in bowel wall
16. Other answers
• Order abdominal and pelvic CT scans and start
intravenous antibiotics
• Consider scan if pt is STABLE, can show if there is
local infection from fistula
• Start nasogastric lavage and obtain endoscopy
consultation
• Helpful in locating source of bleed?
• Endoscopy if UGIB
• Start proton-pump inhibitor and octreotide infusion
• Used for suspected variceal bleeding
17. • Several people present with facial flushing and throbbing headache
25 minutes after eating tune at a sushi restaurant. What is the most
likely diagnosis?
A) Allergic reaction
B) Ciguatera poisoning
C) Scombroid poisoning
D) Tetrodotoxin poisoning
18. • Several people present with facial flushing and throbbing headache
25 minutes after eating tune at a sushi restaurant. What is the most
likely diagnosis?
A) Allergic reaction
B) Ciguatera poisoning
C) Scombroid poisoning
D) Tetrodotoxin poisoning
19. Classic symptoms of scombroid – facial
flushing, throbbing headache
Source? Histidine rich dark meat fish, bacteria
converts histidine to histamine like
substances
Symptoms 20-30 mins post ingestion
•Diarrhea, abdominal cramping,
hypotension (rarely)
•Fish has sharp, metalic, peppery taste
Treatment
•Antihistamines
•IVF
20. • Ciguatera (neurotoxin)
– 15 mins – 24 hrs
– Na channels
– Symptoms: GI, cardiac,
neuro
– Bradycardia,
paresthesia (hot and
cold reversal)
• Tetrodotoxin
– Na channel block
– Paresthesias – rarely
respiratory paralysis
21. • A 60 yo man with history of cirrhosis presents with abdominal pain
and tense ascites. Paracentesis is performed, and the ascitic fluid
granulocyte count is 275 cells/mm3. What is the appropriate next
step?
A) Discharge with a prescription for pain medications
B) Obtain surgery consultation
C) Start ceftriaxone
D) Wait for culture results
22. • A 60 yo man with history of cirrhosis presents with abdominal pain
and tense ascites. Paracentesis is performed, and the ascitic fluid
granulocyte count is 275 cells/mm3. What is the appropriate next
step?
A) Discharge with a prescription for pain medications
B) Obtain surgery consultation
C) Start ceftriaxone
D) Wait for culture results
23. ???Diagnosis??? How to make the
diagnosis???
• Spontaneous Bacterial Peritonitis
– Paracentesis
– Ascitic fluid analysis, cell count, culture
– PMN > 250 = high incidence of SBP
– Definitive diagnosis with culture
24. Spontaneous Bacterial Peritonitis
• IV Ceftriaxone for empiric antibiotic coverage
• Portal hypertension from cirrhosis creates
bowel edema, facilitates transmural migration of
enteric flora into immunocompromise peritoneal
cavity
• Flora: gram negative enterobactera (E.Coli,
Salmonella, Klebsiella); Strep Pneumo
26. • 50 yo woman presents complaining of a funny feeling in the back of
her throat when she swallows; she thinks she has fish bone stuck in
her throat. She has no respiratory distress or stridor, and her voice is
normal. What is the next step in management?
A) Barium swallow
B) Bronchoscopy
C) Discharge home
D) Plain radiographs
27. • 50 yo woman presents complaining of a funny feeling in the back of
her throat when she swallows; she thinks she has fish bone stuck in
her throat. She has no respiratory distress or stridor, and her voice is
normal. What is the next step in management?
A) Barium swallow
B) Bronchoscopy
C) Discharge home
D) Plain radiographs
28. • Radiographs are indicated in every pt with
history suggestive of foreign body ingestion
• Good for radiopaque objects
– Directly see object
– Indirectly see signs such as soft tissue swelling
• Bronchoscopy useful for visualization and
removal
• CT – useful if xrays not diagnostic
• Barium swallow – contraindicated if esophageal
perforation suspected
• Discharge only after thorough work up
29. • FB in esophagus tend to lodge at area of
esophageal narrowing:
• Most common site of esophageal foreign
body in children?
• Most common site in adults?
- C6 (children less than 4 yrs)
- Lower esophageal sphincter /
diaphragmatic hiatus (T10-11)
31. Alkaline Disc Button Battery
Ingestion
•90% will pass through
esophagus
•Corrosive
•Esophageal strictures, burns,
necrosis, perforation
• Double density circular appearance at border
• Similar in size to coins
32. Your heart should skip a beat!
J Paediatr Child Health. 2013 Apr;49(4):330-2. doi: 10.1111/j.1440-1754.2012.02511.x. Epub 2012 Jul 31.
Oesophageal complication from button battery ingestion in an infant.
Liao AY, McDonald D.
33. • 60 yo man with history of alcohol abuse presents with epigastric pain.
Initial laboratory test results are as follows: WBCs 20,000; blood
glucose 450; AST 375, lipase 400. What is the appropriate
disposition?
A) General medical floor
B) ICU
C) Observation unit
D) Surgical floor
34. • 60 yo man with history of alcohol abuse presents with epigastric pain.
Initial laboratory test results are as follows: WBCs 20,000; blood
glucose 450; AST 375, lipase 400. What is the appropriate
disposition?
A) General medical floor
B) ICU
C) Observation unit
D) Surgical floor
35. NON-GALLSTONE PANCREATITIS (1974) GALLSTONE PANCREATITIS (1982)
At Admission
Age >55 yr Age >70 yr
White blood cells >16,000/mm3 >18,000/mm3
Blood glucose >200 mg/dL >220 mg/dL
Serum lactate dehydrogenase >350 IU >400 IU/L
Serum aspartate aminotransferase
>250 IU/L
>250 IU/L
During Initial 48 hr
Hematocrit decrease of >10 % >10%
Blood urea nitrogen increase of >5 mg >2 mg/dL
Serum calcium <8 mg/dL <8 mg/dL
Arterial po2 <60 mm Hg NA
Serum base deficit >4 mEq/L >5 mEq/L
Fluid sequestration >6 L >4 L
36. Causes of pancreatitis
• Gallstone obstruction
• Alcohol abuse
• Leads to pancreatic autodigestion
37. • 58 yo woman with history of cholelithiasis presents with epigastric
abdominal pain, nausea, vomiting, and shortness of breath. She is
obese and diaphoretic with diffuse inspiratory crackles. Her current
vitals signs are blood pressure 80/40, pulse 135, respirations 45,
temperature 99, o2 on room air 70%. Lipase level is 3,000. What is
the next appropriate step?
A) Abdominal ultrasonography
B) CT
C) Emergent cholecystectomy
D) Intubation
38. • 58 yo woman with history of cholelithiasis presents with epigastric
abdominal pain, nausea, vomiting, and shortness of breath. She is
obese and diaphoretic with diffuse inspiratory crackles. Her current
vitals signs are blood pressure 80/40, pulse 135, respirations 45,
temperature 99, o2 on room air 70%. Lipase level is 3,000. What is
the next appropriate step?
A) Abdominal ultrasonography
B) CT
C) Emergent cholecystectomy
D) Intubation
39. Severe pancreatitis with Resp
Failure (ARDS)
• Pancreatitis leads to release of inflammatory
mediators that sets up systemic inflammatory
response and multiorgan failure
• Image when making diagnosis on stable pt
• Ultrasound useful if considering gallstones
• Treatment: aggressive fluid resuscitation, pain
control
• Early cholecystectomy can be dangerous in
pancreatitis – consider ERCP to relieve
pancreatic duct obstruction
41. • Which of the following is the defining triad of hemolytic uremic
syndrome?
A) Abdominal distention, headache, hypertension
B) Abdominal pain, purpura, swollen joints
C) Anemia, high creatinine, low platelets
D) Cyanosis, low back pain, vomiting
42. • Which of the following is the defining triad of hemolytic uremic
syndrome?
A) Abdominal distention, headache, hypertension
B) Abdominal pain, purpura, swollen joints
C) Anemia, high creatinine, low platelets
D) Cyanosis, low back pain, vomiting
43. HUS
• Microangiopathic hemolytic anemia
• Nephropathy
• Thrombocytopenia
• Young children, after minor resp illness or
gastroenteritis
• E.Coli O157:H7
• Associated symptoms: HTN, irritability, seizures,
abdominal pain, bloody diarrhea, toxic
megacolon, intussusception, coma
45. • 3 yo boy is brought in by his mother for evaluation of facial swelling. She
says he has been progressively more tired over the past few days, has
eaten less than usual, and has had a stomache ache. Vital signs are
blood pressure 100/56, pulse 110, resp 20, temp 98.6, and o2 sat 98%.
On physical examination, he is awake and alert with very mild
tachycardia. He has appreciable swelling of the face, hands, and feet.
Lab eval reveals Hgb 15.5, BUN 9, Cr 0.5, albumin 1.8. UA reveals
elevated protein but is otherwise normal. Which of the following is the
best management strategy for this patient?
A) Admission to a basic pediatric unit for initiation of corticosteroid therapy.
B) Admission to an ICU for invasive blood pressure monitoring.
C) Diuresis with furosemide in the ED followed by discharge home.
D) Emergent hemodialysis in the ED followed by admission.
46. • 3 yo boy is brought in by his mother for evaluation of facial swelling. She
says he has been progressively more tired over the past few days, has
eaten less than usual, and has had a stomache ache. Vital signs are
blood pressure 100/56, pulse 110, resp 20, temp 98.6, and o2 sat 98%.
On physical examination, he is awake and alert with very mild
tachycardia. He has appreciable swelling of the face, hands, and feet.
Lab eval reveals Hgb 15.5, BUN 9, Cr 0.5, albumin 1.8. UA reveals
elevated protein but is otherwise normal. Which of the following is the
best management strategy for this patient?
A) Admission to a basic pediatric unit for initiation of corticosteroid therapy.
B) Admission to an ICU for invasive blood pressure monitoring.
C) Diuresis with furosemide in the ED followed by discharge home.
D) Emergent hemodialysis in the ED followed by admission.
47. Nephrotic Syndrome - Proteinuria,
Hypoalbuminemia, Edema
• Admission to peds floor for nephro eval
• ICU not needed – pt not in shock
• Renal failure rare with nephrotic synd
• Diuresis not indicated because no signs of
fluid overload
48. Pediatr Nephrol. 2013 Aug 30. [Epub ahead of print]
The nephrotic syndrome: pathogenesis and treatment of edema formation and
secondary complications.
Cadnapaphornchai MA, Tkachenko O, Shchekochikhin D, Schrier RW.
49. • 3 week girl brought in for evaluation of sudden onset explosive
bloody diarrhea. She has history of poor weight gain and infrequent
stool production. On physical examination, she is not jaundiced but
has fever, abdominal distention, and signs of dehydration. She cries
weakly when the abdomen is palpated. Rectal examination reveals
an empty vault, but at the end of the examination, she has another
episode of explosive diarrhea. Which of the following should be
included in the management of her condition?
A) Abdominal ultrasonography
B) Esophagogastroduodenoscopy
C) Exchange transfusion
D) Rectal decompression
50. • 3 week girl brought in for evaluation of sudden onset explosive
bloody diarrhea. She has history of poor weight gain and infrequent
stool production. On physical examination, she is not jaundiced but
has fever, abdominal distention, and signs of dehydration. She cries
weakly when the abdomen is palpated. Rectal examination reveals
an empty vault, but at the end of the examination, she has another
episode of explosive diarrhea. Which of the following should be
included in the management of her condition?
A) Abdominal ultrasonography
B) Esophagogastroduodenoscopy
C) Exchange transfusion
D) Rectal decompression
51. Hirschsprung Disease
• Congenital megacolong
• Congenital aganglionosis of colon
• Absence of ganglions starts distally at anus and
present for variable distance proximally
• Definitive therapy: surgical resection of
aganglionic segment
• ED Management: gastric and rectal
decompression, broad spectrum abx,
fluid/electrolyte replacement
52. Clinical Features
• Neonates: failure to pass meconium
• Infants brought to the ED:
– constipation and obstipation
– Vomiting, irritability, and abdominal distention
• Children who appear ill with fever should be
evaluated for enterocolitis and toxic
megacolon
53. • Ultrasound will not be helpful
• EGD can assess for UGIB, but minimal role
in LGIB
• Exchange transfusion for severe neonatal
jaundice
