emergency pediatrics

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CASE 76: A 17-VEAR-OlD WITH KNEE PAIN

A 17-year-old female high school soccer player is brought to an urgent care clinic with a chief complaint of left knee pain. The onset of symptoms occurred during a soccer game the previous day. The athlete states as 'she went to kick the hal! with her right foot she planted her kft foot, felt her left knee buckle and heard a "pop." She then felI to the ground and had to be helped off the field , She experienced immediate swelling in the knee ;lS well as some difficulty straightening the knee. She denied any tingling or numbness in the leg. She is using crutches as walking is painful. She denies any history of previous knee injuries and has played soccer for 7 years.

SELECT THE ONE BEST ANSWER

1. The best initial management for this athlete on the soccer field should include:

(A) ice applied to the knee joint for approximately 20 minutes

(B) application of a knee immobilizer ~fter attempting to straighten the leg to full extension

(C) ambulation on the sidelines to improve the range of motion and decrease the swelling

(D) an immediate dose of ibuprofen 600 to 800 mg PO to prevent inflammation

(E) immediate transport by anlbulance to the nearest emergency room for evaluation

2 . Bas~d. on the history alone, the most likely diagnOS1S 1S:

,- ...

(A) meniscal tear (B) mediai collateral ligament tear (C) anterior cruciate ligament tear (D) posterior cruciate ligament tear (£) patellar dislocation

3. On physical exomination, a moderate knee joint effusion and a 5-degree flexion contracture are noted. Valgus and varus testing performed at 30 degrees of knee flex:ion reveal no jnstability. An anterior drawer perf~)rmed with the knee at 30 degrees of flexi{)t1 and at 90 degrees of flexion reveals increased laxity. A posterior drawer test is negative. McMurray'S test is negative. There is no pain with patdl"r ::ompression, nor is patellar instability noted. Based on the above physical examination, whi ch of the following tests performed is most hdpfuj in confirming your suspected diagnosis?

(A) valgus test (B) varus tesl (C) anterior drav,;er at 90 degrees of flexion (D) anterior drawer at 30 degrees of flexion (E) McMurray'S test

4. Of the following physical findings, which is least likely to confirm the presence of internal derangement of the lmee?

(A) knee joint effusion (B) decreased range of motion (C) instability with a Laehman test

304

CHAPTER 9 GENERAL EMERGENCY AND URGENT CARE 305

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(D) painful clicking with a McMurray's test (E) instability with a valgus test

5. You tell the patient that the swelling in her knee indicates inflammation is present. Which of the follOwing statements is most accurate regarding inflammation?

(B) SIX to 12 weeks of physical therapy in a sports rehabilitation center

(C) arthroscopic surgery and repair (D) arthroscopic surgery and reconstruction (E) complete rest and crutch-assisted ambula

tion for 6 to 12 weeks

"

'-

(A)

(B)

(C)

(D)

Inflammation is primarily an acute response to trauma, infection, and autoimmune diseases. NSAIDs work on joint inflammation by inhibiting prostaglandin synthesis in the arachidonic acid cascade at the cyclooxygenase pathway. Corticosteroids work most effectively on joint inflammation by inhibiting leukotriene production. Inflammation is characterized by erythema, edema, warmth, and pain and has a protective effect on synovium, tendons, bursae, and cartilage.

9. You provide the patient with a brace, refer her to physical therapy and schedule her for follow-up in 10 to 14 days. Upon her return to the office she tells you the swelling has decreased as has her pain; however, she notes severe sharp stabbing sensations of pain when she attempts to straighten her leg completely. Your physical examination reveals a IO-degree flexion contracture, a small joint effusion, and medial joint line tenderness. Attempts to straighten the knee into neutral (full extension at 0 degrees) reproduce sharp pain. Laxity is again noted with a Lachman test. McMurray testing reveals a painful "click." You are now most concerned about the following diagnosis:

\...

"

\..

6. The patient now tells you she is in pain after you have examined her and asks what she should do. Your next step in treatment should be which of the following?

(A) apply an ace wrap (B) knee joint aspiration (C) corticosteroid injection (D) knee joint aspiration followed by a cortico

steroid injection (E) knee brace

7. You are now ready to order a radiologic imaging study of the left knee. Which of the following is most helpful in confirming your diagnosis?

(A) AP and lateral plain radiograph (B) AP, lateral, sunrise, and notch plain radio

graphs (C) CTscan (D) MRI scan (E) no imaging study is needed

8. Which' of the following treatment recommendations is likely to result in complete recovery from the above injury including eventual return to soccer?

(A) custom hinged knee brace for 3 to 6 months

10.

11.

(A) anterior cruciate ligament injury

(B) medial collateral ligament injury (C) meniscal injury (D) AandC (E) all of the above

The patient now tells you she has been unable to go for an MRI because of her insurance and lack of transportation; however, she is planning to go in 10 days. She asks what you want her to do in the meantime. The most appropriate recommendation to make at this point is:

(A) continue the brace and follow-up after the MRI

(B) continue the brace and physical therapy and follow-up after the MRI

(C) resume crutch use, stop physical therapy and await the MRI

(D) referral to an orthopedic surgeon after the MRI

(E) referral to an orthopedic surgeon within 1 week, regardless of the MRI being done

If in the scenario described in question 1, the athlete injured while playing soccer was 12 years old, your differential diagnosis would include ail of the following except:

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306 PEDIATRIC EXAMINATION AND BOARD REVIEW

(A) osteochondritis dissecans (B) physeal injury (C) meniscal tear (D) cruciate ligament injury (E) tibial tubercle avulsion

12. If in the scenario described in question 1, the athlete injured while playing soccer was 12 years old, the most likely diagnosis would be:

(A) osteochondritis dissecans (B) physeal injury (C) meniscal tear (D) cruciate ligament injury (E) tibial tubercle avulsion

13. Which of the following radiographic studies is least likely to reliably demonstrate the suspected diagnosis in the 12-year-old soccer player with a painful, swollen knee and inability to bear weight?

(A) plain radiographs including AP, lateral, notch, and sunrise view

(B) cr scan (C) MRI scan (D) bonescan (E) All are equally sensitive and specific for di

agnosis in this case as described.

14. Which of the following knee injuries occurs more commonly in skeletally immature males versus females?

(A) patellar dislocation (B) osteochondritis dissecans (C) . patellofemoral pain (D) anterior cruciate ligament injury (E) meniscal injury

15. Which of the following conditions is the most common cause of knee pain in adolescent females?

(A) patellofemoral pain (B) Osgood-Schlatter's disease (C) plica band syndrome (D) chronic medial collateral ligament sprain (£) iliotibial band syndrome

16. Which of the following physical examination findings is not associated with an increased risk of patellofemoral pain?

(A) genu valgum (B) pes planovalgus foot deformity (C) Q angle of 15 degrees (D) weak quadriceps muscles (E) patellar hypermobility

17. Which of the following activities is least associated with increased stress on the patellofemoral joint?

(A) jumping (B) squatting (C) prolonged sitting (D) stair climbing (E) straight leg raises

18. Of the following conditions affecting the knee, which one should a primary care physician feel most uncomfortable managing without an orthopedic consultation?

(A) Osgood-Schlatter's disease (B) patellofemoral pain (C) patellar tendonitis (D) osteochondritis dissecans (E) chronic medial collateral ligament sprain

19. In a patient with knee pain which of the following is an indication for referral to an orthopedic or sports specialist for evaluation and management?

(A) knee effusion (B) abnormal range of motion (C) locking of the joint (D) pain at the ends of long bones (E) all of the above

20. If the athlete described in question 1 had recovered from her injury and came to you for clearance for return to sports, which of the following statements is true?

(A) If all swelling and pain have resolved and the athlete demonstrated walking without any limp or instability, then sports may be resumed safely with little risk of re-injury.

(B) In general, bracing is thought to help with swelling acutely via a compressive effect but has little demonstrated effectiveness in reinjury prevention immediately following a ligament sprain.

CHAPTER 9 GENER.A.L EMERGENCY AND URGENT CARE 307

(C) An athlete must pass a functional test including running, jumping and cutting without pain or instability prior to participation.

(D) The athlete must take 8 weeks off from all sports participation because all ligament injuries take at least th;lt long to heal.

(E) None of the above statements is true. L

l Answers

1. (A) The best initial treatment for an injured knee is ice applied to the swollen, painful area for approximately 20 minutes. It is appropriate to follow the general RICE (Rest, Ice, Compression, Elevation) principles for acute injury treatment. However, in the provided choices for an acute knee injury, one should not attempt to "force" the knee into extension as there may be mechanical limitations such as torn tissue or extreme swelling that prevent the knee from reaching full extension. The knee joint has maximal space to accommodate swelling at approximately 30 de\.... grees of flexion. Weight bearing should be as tolerated and in this setting, keeping the athlete non-weight-bearing until a full exarriination is performed is appropriate. While immediate use of ibuprofen or another non-steroidal antiinflammatory agent may be helpful for pain, it is unlikely to have any immediate effect on the post-traumatic inflammatory response. Urgent treatment is prudent in the setting of sportsrelated knee injuries. In the absence of gross deformity or neurovascular compromise, emergent transport is unnecessary.

2. (C) A non-contact deceleration Injury to the knee joint resulting in a painful "pop," immediate swelling, and an inability to fully bear weight following the injury is an anterior cruciate ligament tear approximately 85% of the time in a skeletally mature patient.

3. (D) The maneuver most helpful to confirm your diagnosis is the anterior drawer test performed at 30 degrees of flexion, otherwise known as the Lachman test. The Lachman test is performed by using one hand to stabilize the femur while the examiner's opposite hand is placed around the leg at the level of the tibial tubercle and an attempt is

made to anteriorly translate the tibia forward. The Lachman test is more clinically sensitive at diagnosing ACL (anterior cruciate ligament) tears than an anterior drawer test performed at 90 degrees of knee flexion. In that instance, it is common to find patients guarding or reflexively tightening their hamstring muscles; this results in a false negative drawer test with decreased anterior translation. The McMurray test is performed with the patient lying supine. The examiner places one hand anteriorly on the joint lines and then proceeds to cup the heel with the opposite hand and begins to 'Bex and extend the knee while simultaneously internally and externally rotating the tibia on the femur. The test is positive, indicating a torn meniscus, if a painful click is felt.

4 . (E) Instability with valgus stress testing indicates an injury to the medial collateral ligament (sprain versus tear); however, this ligament is extra-articular in location. An effusion almost always indicates internal derangement, especially in the setting of trauma. Decreased range of motion may be related to the knee effusion. However, the presence of a flexion contracture (or the inability to straighten the leg entirely) indicates a heightened concern for a mechanical block to the knee joint from a tom ACLIPCL, a meniscal tear or a loose body trapped in the joint. An abnormal Lachman test indicates an intra-articular ACL injury and an abnonnal McMurray'S test indicates a torn meniscus.

5. (B) L-lflarnmation is both an acute and chronic response to trauma, infection and systemic autoimmune disease. In the acute phase, inflammation may be a healthy, self-limiting response; however, in the chronic phase it is often destructive such as in the setting of arthritis and articular cartilage destruction. Corticosteroids affect inflammation by inhibiting leukotriene production, but also by inhibiting prostaglandin synthesis at the phospholipase A2 pathway.

6. (E) In the setting of traumatic knee injuries there is no role for acute corticosteroid injections and no significant therapeutic role for knee joint aspiration. If a joint aspiration is performed, the hemarthrosis tends to re-accumulate quickly thus limiting the effectiveness of the therapeutic aspi


'

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 feimal 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 referapy are important adjunctive treatments to de- ral to a pediatric orthopedist as there is increased crease pain and improve strength and function, risk ofgrowth arrest. Tibial tubercle avulsion injuboth 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 evaluatempts 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 ofACL 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. Clinicreased 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


ral pain and patellar dislocations are associated with underlying patellar instability and malalignment-a clinical finding more common in females. Females tend to have valgus knee alignment that is often associated with flat feet. These cause overpronation and abnormal patellar tracking on the femur. Females often have "looser" lig

\.... aments and relatively weaker supporting muscles such as the quadriceps and hamstring muscles. ACL injuries are more common in females because of the above factors mentioned in addition to frequently having a smaller bony notch on the femur for the ligament to pass through. Hormonal influences are also thought to playa role in increasing a female's risk ofACL injury.

15. (A) Patellofemoral pain .syndrome is the most common cause of adolescent knee pain, particularly in females. It is often referred to as anterior knee pain. J'here are many contributing factors (see next question). Osgood-Schlatter disease is inflammation and pain at the tibial tubercle seen in growing prepubescents. Plica syndrome is a painful band of synovial tissue that snaps on the undersurface of the patella causing pain. Iliotibial band syndrome is a tendonitis causing lateral knee pain-most common in runners .

16. (C) Anterior or patellofemoral pain is associated with a variety of physical findings including flat feet, knock knees (valgus knees) and increased internal hip rotation (femoral anteversion). Obesity also contributes to the presence of anterior knee pain. Functionally, weak quadriceps muscles, tight hamstrings and patellar instability contribute to the development of patellofemoral pain. The Q angle refers to the relationship of the quadriceps and patella vectors as drawn from the anterior superior iliac spine and bisecting the mid-superior pole of the patella followed by a line bisecting the mid-patella and the mid-patellar tendon. An angle >20 degrees is associated with lateral patellar tracking and increased stress on the patellofemoral joint.

17. (E) Patellofemoral pain has often been referred to as "theater knee" because weight-bearing activities and prolonged sitting tend to increase anterior knee pain. Sitting with the knee extended or performing exercises with a straight leg do not require

stress to be placed across the patellofemoral joint, therefore usually do not hurt, and are otten used as early exercises to start strengthening the leg without aggravating the patella and its surrounding structures.

18. CD) In general, overuse injuries are associated with genetic, biomechanical and workload problems. The factors contributing to pain and injury should be initially evaluated and treatment initiated by a primary care physician. Acute traumatic injuries or chronic, overuse injuries that don't respond appropriately to treatment may be referred for further evaluation by an orthopedic or sport" specialist. Osteochondritis dissecans is the most complicated of the above conditions to manage; and the likelihood of needing surgical intervention rises in the older, more skeletally mature athlete.

19. (E) All of the above indicate either a physeal (growth plate) problem or other intra-articular pathology.

20. (C) Ligament sprains vary in the time it takes to heal depending on the location of the illjury and the extent of the original injury. Ligament sprains are often graded 1 to 3: Grade 1 refers to a partial ligament tear with no joint instability. Grade 2 refers to a partial ligament tear with mild to moderate joint instability. Grade 3 refers to a complete tear with joint instability. Treatment of ligament sprains in the acute phase is aimed at decreasing inflammation and restoring strength. The definitive criteria for safe return to sports involve the athlete being able to perform sport-specific exercises such as running, jumping and cutting without pain, wealmess or instability. If the athlete cannot perform sport-specific exercises properly, the risk of re-injury dramatically increases. Bracing is effective initially and provides compression and support to the joint. It also has an important role in assisting faster returns to competition by enhancing joint proprioception, thereby enhancing joint stability.

SUGGESTED READING Bernstein ]: Musculoskeletal Medicine . Rosemont, IL:

AAOS Publications, 2003. Sullivan, lA, Anderson S]: Care ofthe Young Athlete. Rose

mont, IL: AAOS and AAP Publications, 2000.

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310 ' PEDIATRIC EXAMINATION AND BOARD REVIEW

CASE 77: A 15-YEAR-OLD AND A 17-YEAR-OLD

WHO COLLAPSE DURING A MARATHON

You are working in the emergency room on a Saturday afternoon watching the local marathon race on television. The arUlOuncer h2S just stated t.~n the outside temperature is 9soF (3S°C) and the humidity is 80%. You are glad to be inside in the air conditioning, yet you are sorry that you could not volunteer in the medical tent at the race. Suddenly two marathoners are bro~ght in for urgent evaluation.

The first athlete is a is-year-old female who is complaining of spasms in her calf muscles, mild lower abdominal pain, and thirst. She states she was compet;ing in her first marathon, softball is her usual sport, and she didn't tra,in much for this race. She did drink some water every 3 miles at the fluid stations then collapsed at mile 16. Her weight was 8S kg. Her vital signs were: pulse 96 bpm, BP 1l0nO mm Hg, respiratory rate 28, temperature 99.9°F (37.7°C). She was wearing a tight fitting, dark-colored, long sleeve shirt over a tank: top and matching shorts. Upon removal of her garments she was noted to have sunburned .skinwithout . blistering on her face, back, ches~ upper and lower ~xtremities. She appeared profusely sweaty, had tight gastrocnemius muscles with spasms. .

The second athlete ' is a 17-year-old male cross

country tulUler who collapsed at mile 23 complaining of dizziness, lightheadedness, headache, nausea, and had vomited twice in the field. His weight was 80 kg. His vital signs were: BP 100/60 mm Hg, pulse 110 bpI1), respiratory rate 36, tympanic temperature 101°F (38.S°C). On examination he appeared confused and disoriented, and his skin was sweaty and hot to the touch. Further examination was unremarkable.


1. Which of the following is the most serious form of heat illness?

(A) fever (B) heat syncope (C) heat stroke (D) heat exhaustion (E) rhabdomyolysis

2. Which diagnosis most likely explains the first athlete's symptoms?

(A) sunburn

(B) dehydration (C) heat exhaustion

(D) heat cramps (E) heat stroke

3. What patient factor was most likely to . predispose the first athlete to heat illness?

(A) obesity (B) dehydration (C) clothing (D) sunburn (E) excessive exercise

4. What environmental conditions predispose an athlete to heat illness?

(A) high ambient temperature (B) high winds (C) high humidity

(D) A and Conly (E) all of the above

5. What is the most important mechanism the body uses for heat dissipation?

(A) conduction (B) convection (C) radiation

(D) evaporation (E) respiration

6. Which of the following statements regarding heat dissipation is false?

(A) Conduction occurs via indirect contact of the body with the environment.

(B) Convection is heat transferred from a solid surface to surrounding gas molecules.

(C) Radiation is the transfer of heat between the body and its environment via electromagnetic waves.

(D) Evaporation is the conversion of liquid to gas.

(E) All of the above are true.

7. Heat cramps are most likely related to the loss of which electrolyte?

(A) Mg+ (B) Na+ (C) K+


(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:

(A) Children are at increased risk for heat illness because of a higher surface area to

12. Which of the following are complications of heat stroke?

' 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) Children's 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

(A) intravenous fluid replacement with normal saline

(B) salt tablets

ing from heat stroke. Which of the following would be least likely to be found in a patient with heat stroke?

(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 patient's curond athlete's symptoms? rent temperature. What is the temperature mea

(A) dehydration surement method you recommend to the nurse?

(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

(A) Heat exhaustion and heat stroke are separate clinical conditions that db not occur in

garding measurement of core body temperature in a patient with heat illness?

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 (41.10C). ~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.


(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 membrane is adjacent to the hypothalamic temperature regulation center.

(E) All of the above

16. The nurse reports to you that the current vital signs for the second athlete are as follows: BP of 90150 mm Hg, pulse of 120, oxygen saruration of 95 % on room air, temperarure of 106.7°F (41'soC). What is the most important initial emergency room treatment for the second athlete?

(A) Prepare the patient for emergent placement of a Swan-Ganz catheter for central venous

. pressure monitoring. (1.3) Begin rapid cooling procedures. (C) Adrrrinistersupplementaloxygen. (D) . Administer room temperature intravenous

flpids using a IlL bolus of 0.9% normal saline over 30 to 60 minutes.

(E) Administer an antipyretic medication stat.

17. In the medical tent, the most effective method to achieve rapid cooling is which of the'following?

(A) whole body immersion in ice water (B) wrapping the body in cold towels . (C) packing the body in ice (D) spraying with water and place in front of faIlS (E) ice packs in the groin and axilla .

18. In the emergency room setting the preferred method of rapid cooling is?

(A) administration of cooled intravenous fluids with 0.9% normal saline

(B) iced gastric lavage (C) ice packs in the groin and axilla (D) rapid whole body sponging with rubbing al

cohol (E) whole body inunersion in ice water

19. You have now initiated rapid cooling and the patient is more lucid, the skin is feeling cooler and clam~y to the touch. At what temperarure do you want to stop rapid cooling?

(A) 37°C (98.6°F) (B) 37.3°C(99°F) (C) 37 .7°C (lOO°F)

20. After an hour, the first athlete feels much better and is ready to go home, You advise her that in the future she should try to prevent heat cramps during competition in strenuous and endurance sports lasting over 1 hour in duration. VVhich of the following recommendations is most effective in the prevention of heat cramps?

(A) salt tablets (B) ; ater only before and during intense endur

ance exercise (C) water and an electrolyte drink before and

dUling intense exercise (D) increased warm-up time and stretching of

calf muscles pre-exercise (E) weight loss

2l. If you were able to give the second athlete any advice prior to his next marathon, you would most likely want him to know all of the following principles except:

(A) The sweat rate for the average endurance athlete in a temperate climate averages 1.0 to

1.2 liters per hour and can exceed 2 liters per hour in conditions of high heat and humidity.

(B) Sweat is hypotonic and is more hypotonic in those athletes who sweat greater volumes.

(C) Athletes should voluntarily drink fluids before , during and after activities.

(D) If an athlete is participating in endurance events, he should start taking salt tablets 2 to 3 days prior to competition.

(E) Proper nutrition, adequate sleep; gradual acclimatization, avoidance of drugs/substances like alcohol, ephedra, and caffeine are important preventive measures.

Answers

l. (C) Heat stroke is the most severe form because it is associated with irreversible tissue damage.

2. (D) Heat cramps are a common mild form of heat illness that tend to occur after exercise and are associated with a large production of sweat during exercise.


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 temperature, 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 establishing 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 administering 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 imtal-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 physuch 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 patient's vital signs, obtain apderlying 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

symp'toms; 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 avoid L 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.

'


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 . ·Ccim\1l0n . Present in wine cases . Dry, hot skin mote concerning

Treatment Slow cooling · Rapid cooling SlOw volume .repletion Vigorous volUme repletion iforthostatic

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 method for rapid cooling is administration of cooled intravenous fluids. Whole body immersion is not practical. Rubbing alcohol is generally not recommended. Ice packs in the groin and the axilla should be avoided. See Table 77-1 for summary of heat exhaustion versus heat stroke.

19. (0) One of the most common complications of rapid cooling is overcooling and temperatures as low as 88°F (31°C) have been reported (Boston Marathon). Therefore, the ideal temperature at which to stop rapid cooling is 101°F (38.3°C), subsequently allowing the body to further coolon its own. Shivering is a sign of overcooling and actually causes increased heat production and may cause a rebound increase in core temperature.

20. (C) The best prevention ofheat cramps is adequate hydration before and during athletic activities. Appropriate clothing, conditioning, and, in rare cases, modest increases in dietary salt are helpful interventions. Excessive water intake often worsens heat cramps a~ it causes further total body sodium loss.

21. (D) Salt tablets are generally not recommended because the high solute load causes gastrointestinal irritation. However, adding extra table salt to

food is recommended.

SUGGESTED READING Rosen sEmergency Medicine: Concepts and Clinical Practice,

5th ed. St. Louis, MO: Mosby, 2002, pp 20022009.

'- Lugo-Amador N, Rothenhaus T, Moyer P: Heat-re

lated illness. EmeTg Med Clin North Am 22:315-327, 2004.

Barr sr, Costill DL, Fink W]: Fluid replacement during prolonged exercise: effects ofwater, saline or no fluid. Med Sci Sports Exerc 27:2002-2010, 1995.

CASE 18: A 5-YEAR-OLD MALE WITH ABDOMINAL PAIN

A 5-year-old African-American male presents to a pediatric emergency deparonent with a chief complaint of abdominal pain. His pain is periumbilical and is described as diffuse, non-radiating, waxing and waning with no relationship to meals or bowel movements. His pain began after lunch yesterday and he developed vomiting overnight. He has had three non-bilious and non-bloody episodes of emesis, two loose non-bloody stools today, and tactile elevated temperature. He states he is thirsty, but has refused to eat for the last several hours. The patient denies headache, sore throat, dysuria, frequency, or urgency. His past medical history is unremarkable.

His vital signs reveal a blood pressure of 100/60 mm Hg, pulse of 100, respiratory rate of 36 and a temperature of 100.4°F (38°C). Upon examination he is found to have dry mucous membranes, hypoactive bowel sounds with reproducible periumbilical tenderness, mild right lower quadrant tenderness and no rebound tenderness. His rectal exam is unremarkable except for a small amount of soft stool in the rectal vault.


1. What is the most likely diagnosis in this patient?

'

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 "

(C) Tenderness at a point between the umbilicus (A) drug ingestions such as acetaminophen orL . and the anterior superior iliac spine two

salicylates thirds the distance from the umbilicus

(B) diabetic ketoacidosis (D) Extension of the hip posteriorly with the pa(C) pneumonia 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 linlikely to be helpful ill confirming the etiology of

ing interspersed with lymphoid follicles. this patient's 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 antibiotics.

6. Which of the following statements describing (B) All patients should have at least one imaging acute appendicitis in a school-age child is

study.false?

(C) All patients should have a prompt surgical

~ (A) Diarrhea is rarely associated With appendicitis. consultation.


" (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 pain 11. 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) Ultrasonographyoffers 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 comair, 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 demonstratedix 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 elevated lipase and amylase might be present.

12. Which of the following statements is false? (C) A sentineI 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? '

'

.........

-------------------------------------------------

',-

CHA PTER 9 GENERAL EMERGENC Y AND URGENT CARE 317

\...

l.

\....

(A) intravenous hydration (B) intravenous administration of antibiotics (C) nasogastric suction (D) serial abdominal examinations (E) intravenous administration of meperidine

17. Which of the following is least likely to be a potential cause of acute pancreatitis in this 5-yearold?

(A) trauma (B) cholelithiasis (C) viral infection (D) cystic fibrosis (E) urolithiasis

18. You now are asked to evaluate a 2-year-old Afri can-American female who presents with a history of sudden, sharp, crampy episodic right lower quadrant abdominal pain for 1 day and decreased oral intake, Your physical examination reveals no reproducible abdominal tenderness; however, a guaiac positive soft mucous stool on rectal examination is noted. Which of the following abdominal imaging studies would most likely aid you in confirming your suspected diagnosis?

(A) plain radiographs (B) ultrasonography (C) computed tomography (0) barium enema (E) B or 0

19. Had the 2-year-old described in question 18 presented with bilious vomiting, abdominal distention, tenderness, and guarding, which of the following diagnosis would be most likely?

(A) mid-gut volvulus (B) mesenteric adenitis (C) peritonitis (D) gastroenteritis (E) Meckel's diverticulum

20. In any infant or toddler who presents with acute abdominal pain, bilious emesis, and guarding, which of the following imaging studies is the initial study of choice most likely to confinn your suspicions?

(A) magnetic resonance imaging (B) ultrasonography

(C) computed tomography (D) barium enema (E) upper GI

Answers

1. (D) Acute appendicitis is the most likely etiology of this patient's clinical picture. While the presentation could initially be confused with gastroenteritis, the presence of hypoactive bowel sounds, anorexia, pain preceding the onset of any other symptoms, and reproducible tendemess have a higher correlation with appendicitis than any of the other diseases listed.

2. (C) A psoas abscess usually requires surgical drainage.

3. (E) All of the conditions can present with abdominal pain in children and must be included in the differential diagnosis.

4. (C) The placement of a nasogastric tube should be reserved for patients who appear to have the need for gastric decompression. This would include patients with suspected pancreatitis or some form of bowel obstruction such as a volvulus.

5. (A) Serum electrolytes, BUN, and creatm1l1e may be helpful for assessing a patient's renal and hydration status but otherwise adds little to the diagnostic evaluation of abdominal pain. The urinalysis is useful to exclude the diagnosis of a urinary tract infection while amylase and lipase are useful in differentiating pancreatitis from other causes of abdominal pain such as appendicitis. Lastly, the combination of an increased leukocyte count with an increased blood CRP level can be suggestive of appendicitis in the setting of acute abdominal pain.

6. (A) In children, diarrhea can be associated with the presence of appendicitis up to 30% of the time. Many of the clinical features of acute appendicitis are non-:-specific; however, pain as the initial symptom and pain associated with movement--i.e., jumping up and down, riding in a bumpy car or tapping on the patient's heel--raise clinical suspicion.


7. (B) Bluish discoloration around the umbilicus describes Cullen's sign that, when coupled with Grey Turner's sign (bluish discoloration around the flank), is suggestive of acute hemorrhagic pancreatitis. Rovsing's sign describes referred pain from LLQ to RLQ. McBurney's point describes the classic RLQ appendiceal location for pain. Choices "D" and "E" refer to the classic psoas and obturator signs, respectively, that if present, non-specifically support the diagnosis of acute appendicitis.

. 8. (E)

9. (C) All suspected cases of acute appendicitis should have early surgical involvement as some children will be spared further diagnostic evaluations once the decision for surgical treatment has been made. In the absence of a perforation or peritonitis, antibiotics are not always necessary. Until the diagnosis has been made and the surgical recommendations have been made, pain should be monitored closely, but the administration of medication that could impede the evaluation and monitoring of the patient's status should be avoided.

10. (B) In current medical practice today, ultrasonography is the preferred diagnostic study of choice with >80% to 90% sensitivity and specificity that is comparable with abdominal computed tomography. Abdominal CT is a useful adjunct and is still often performed if the ultrasound is inconclusive. In some cases a CT is obtained as the injtial study; however, it is associated with greater risks as it IS an invasive procedure requiring contrast administration and high radiation exposure.

11. (C) Abdominal radiographs are traditionally not useful in the diagnostic evaluation of appendicitis except in the presence of a fecalith (calcified appendix). The disadvantage of CT is radiation exposure compared with ultrasound imaging that is associated with a high degree of operator dependency and variation. The presence of a nonnal appendix on an ultrasound effectively excludes appendicitis as a diagnosis; however, the inability to visualize the appendix renders the study inconclusive.

12. (D) Not all patients with acute .abdominal pai.'l need an imaging study, but a prompt surgical consultation is recommended.

13. (E) Pancreatitis is not a complication of acute appendicitis. Rather, it must be differentiated from appendicitis in the setting of acute abdominal pam.

14. (E) All of the choices have the associated risk of serious complications if the diagnosis is delayed or misse~. The surgical evaluatiop: ,is an important part fif the work-up of acute ab~ominal pain and the surgical team must be ready to provide operative intervention should conservative treatment measures fail or be deemed inappropriate.

15. (E) All of the choices are true in the setting of suspected acute pancreatitis except that blunt abdominal trauma is actually acommon cause. In fact, it is the most common cause of acute pancreatitis accounting for 13% to 33% of cases.

16. (B) In the setting of acute pancreatitis and the absence of peritonitis or septic shock, antibiotics have little role. Adequate pain control is an important step in treatment for this condition whereas it can interfere with a prompt diagnosis and treatment for acute appendicitis.

17. (E) Blunt trauma to the mid-epigastric area of the abdomen such as being struck with bicycle handlebars is the most common cause of acute pancreatitis in children. Viruses such as coxsackie il, cytomegalovirus, varicella, hepatitis A and B, influenza A and B, and Epstein-Barr virus have been implicated in addition to bacterial and parasitic causes. Gallstones can cause pancreatitis but are usually only seen in this age range in the presence of a hereditary hemolytic anemia such ...... as hereditary spherocytosis or sickle cell disease. Cystic fibrosis can cause acute pancreatitis but the incidence is relatively low in African-Americans. Renal stones should not cause pancreatitis.

18. (E) Barium enemas have traditionally been the gold standard for the diagnosis (100% sensitivity and specificity) and 70% successful reduction rates of intussusception. However, current practice reflects increasing use of ultrasonography '


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 durtions 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. Alal1. 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 poisonline 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 theEmerg Med 3(1):1-2,2002.

home should be discussed at the 6-month L Reynolds S: Missed appendicitis and medical, liability. Clin 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 attrihA BOTTLE OF ACETAMINOPHEN ut3ble to unintentional poisoning in young chilYou 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 forthe patient states she has been sick for 2 days with a

products"cold" and has had fevers up to 101 OF (3 SoC) at home,

(B) an increase in the GTC drug products availa cough and 2 to 3 episodes of vomiting. The little

able for parents to purchase for routinegirl is complaining of "stomach pain." Past medical

household usehistory and family medical history are noncontrihu

(C) improved public education and anticipatory tOry. Medications include acetaminophen every 6

guidancehours.

(D) the establishment of multiple poison control On physical examination, the blood pressure is 9U/

centers50 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 SyTUpHer exam is sigrlificant for mid-epigastric tenderness

of ipecac are true except which~withouL rebound or guarding. Bowel sounds are normal and a rectal exam is unremarkable. The mother (A) The only recommended method of inducarrives 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.


(D) The induction of emesis using ipecac is an unpleasant experience.

(E) The use of home ipecac therapy has the potential to decrease the efficacy of other poison treatments such as activated charcoal or N-acetylcysteine.

4. Which of the following statements correctly describes the indications for administration of an emetic as treatment for a potentially toxic ingestion?

(A) anytime a young child ingests a potentially toXic substance

(B) to achieve gastric emptying prior to administration of activated charcoal or N-acetylcysteine resulting in increased efficacy of the treatment intervention

(C) when the 'child seems too lethargic to tolerate ~ctivated charcoal

(D) anytime a health care professional recommends its use

(E) none of the above

5. Which of the following statements best describes gastrointestinal decontamination in the emergency room ~etting?

(A) The initial management steps should always include gastric lavage or administration of an antiemetic.

(B) The use of activated charcoal alone without gastric emptying IS the current recommended procedure of choice,

(C) A cathartic such as sorbitol is often used to improve the efficacy of activated charcoal.

(D) The risk of aspiration is decreased when a gastric emptying teclrnique is performed in conjunction with the administration of activated charcoal.

(E) All of the above.

6. Which of the following should always be your initial step in the managemem of an overdose patient?

(A) the ABCs (airway, breathing, circulation) (B) Administer naloxone. (C) Obtain rapid bedside glucose measuremem. (D) Administer 20 rnLlkg of 0.9% normal saline

as an intravenous bolus over 30 minutes. (E) Call the poison control center for assistance.

7. Which of the following laboratory studies is least likely to be helpful in the management of this 3year-old patient?

(A) standard urine drug screen (B) liver function tests (C) prothrombin time (D) electrolytes, BUN, creatinine, blood glucose (E) serum acetaminophen level

8. Your laboratory tests results reveal increased AST and ALT levels about twice the normal range. The acetaminophen level is elevated. The patient is complaining of wOniening abdominal pain. \Vbich of the following statements best describes your initial management steps?

(A) activated charcoal alone (B) activated charcoal plus gastric lavage (C) N-acetylcysteine alone (D) activated charcoal and N-acetylcysteine (E) gastric lavage, activated charcoal and N-ace

tylcysteine

9. Which of the following ingested substances is least likely to adsorb activated charcoal?

(A) acetaminophen (B) salicyla tes (C) Iron (D) ~-blockers

(E) TCAs

10. Acetaminophen overdose is most frequently associated with roxicity to which of the following)

(A) central nervous system (B) liver (C) kidneys (D) pancreas (E) bone

11. Which of the following statements describing acetaminophen toxicity is false?

(A) The majority of cases involve unintentional overdosing.

(B) Delays in the diagnosis and treaonent of acetaminophen intoxication do not adversely affect outcome.

(C) The risk of toxicity is increased in patients taking drugs such as carbamazepine that


L are metabolized via the cytochrome P450 (E) Button battery ingestion may cause esophpathway. ageal obstruction and pressure necrosis and!

(D) Acetaminophen toxicity includes four phases or caustic injury because of leakage of alkaprogressing from mild non-specific symp line material. toms to onset of organ injury, peaking with maximum organ injury and ending with eI 15. The presentation of a comatose patient WItn

ther recovery or irre~ersible injury. marked miosis, respiratory depression, hypoten(E) Conditions such as diabetes mellitus, obe sion, bradycardia, and hyporeflexia would make

sity, malnutrition, and/or a family history you most concerned about the possible overdose of hepatotoxic reactions may increase the of which of the following? risk of acetaminophen toxicity.

(A) opioids

"

12. Suppose this patient had ingested a potentially toxic amount of ibuprofen suspension. Which of the following statements is true regarding acute NSAID toxicity?

(B) (C) (D) (E)

organoRhosphates cocaine diphenhydramine pseudoephedrine

'-(A) .The majority of ibuprofen overdoses follow 16. The presentation of a confused diaphoretic pa

a benign, rapidly reversible course. tient with miosis, abdominal cramping, fecal and

L (B) Plasma .. NSAID concentrations are useful urinary incontinence, profuse sweating, and drool. and sllOuld always be obtained. ing would cause you to be most concerned about

\.. (C) As a result of high protein binding and rapid which of the following toxic ingestions? metaboUsm, gastric decontamination activated charcoal is never indicated.

with (A) opioids

(D) GI toxicity is rarely associated with NSAID use or overdose.

(B) (C)

organophosphates cocaine

\.. (E) All of the above. (D)

(E) ethanol ephedra

"'13. Which of the following household items is least

likely to be harmful to a child if swallowed in 17. Which of the following signs and symptoms is not

large quantities? consistent with an anticholinergic toxic syndrome?

\.. (A) antidiarrheal medication (A) tachycardia

\... (B) (C)

ibuprofen mouthwash

(B) (C)

dry, flushed skin urinary retention

~ (D) multivitamins (D) mIOSIS

(E) bleach (E) slightly elevated temperature

\.... 14. Which of the following statements is false re 18. Which of the following pairs of toxins and anti

' garding caustic ingestions? dotes does not match?

'-(A) The vast majority of all reported caustic in

gestions occur in children.

(A) (B)

opiates and naloxone benzodiazepines and flumazenil

\.. (B) Caustic substances have the potential to

cause tissue burns on contact with the eyes,

(C) (D)

methanol and ethanol salicylates and N-acetylcysteine

" skin, airwayllungs, and/or the GI tract. (E) iron and deferoxamine

(C) Alkalis, acids, and antiseptics are all agents

~ capable of causing chemical injury. (D) The transfer and storage of cleaners and Answers

"-. caustic substances to alternative household containers has been . associated with a de 1. (D) The AAPno longer reconunends syrup of

creased risk of ingestion in children . ipecac be stored in a household for emergency use.

....


2. (B) Decreases in the death rate are attributable to 10. (B) Hepatotoxicity is of greatest concern because safer medications and product reformulations, hepatic metabolism accounts for' up to 90% of not the OTC availability. acetaminophen elimination. It is important to

note that in acute toxicity, liver injury usually 3. (C) The amount of substance removed from the presents 24 to 48 hours postingestion. Acetamin

stomach is inversely reiated to time between in- ophen ingestions >i50 mg/kg are associated with gestiori an4 emesis. 'In theory, immediate admin- highest risk of hepatotoxicity. istratior{ ofipecac will result in greater, but not

\...,complete, removal of the ingested toxin from the 11. (B) Delays in diagnosis and failure to institute stomach. treatment measures are associated with poorer

'- outcomes. BecallSe the early symptoms seen in

4. (E) Currently there is no recommended use in stage 1 are non-specific, a heightened awareness the home or in the emergency department for of the potential for toxicity and the recognition the administration of an emetic such as syrup of of patients at risk for toxicity are vital. ',-,

ipecac. Lethargy and vomiting are both noted contraindications because of the risk of aspira- 12. (A) Unlike acetaminophen toxicity, NSAID overtion. Induction of vomiting can actually decrease doses do follow fairly benign courses. Children the effectiveness of activated charcoal or N-ace- who ingest >300 mglkg should have GI decontylcysteine in the presence of ongoing emesis. tamination, evaluation and observation. High-

protein binding causes urinary alkalinization, he5. (B) The ~ent recommendation to use activated moperfusion and hemodialysis to be ineffective

charcoal (AC) alone for GI decontamination within enhancing elimination (dialysis is used in saliout the use of a gastric emptying technique such as cylate intoxication). GI side effects are the most gastric lavage or syrup of ipecac has demonstrated common side effects in general that are associsimilar or superior results. Sorbitol speeds AC clear- ated with the use of NSAIDs. ance but does not improve efficacy. The risks of aspiration are largely avoided when AC only is used. 13. (E) Bleach is non-toxic. Antidiarrheal products

tend to contain salicylates. Both salicylates and 6. (A) The highest priority in the management of ibuprofen tend to cause significant renal im

any acutely ill patient is the evaluation and sup- pairment. Many mouthwash products contain port of airway, breathing, and circulation. ethanol that can cause hypoglycemia. A multivi

tamin overdose can lead to multiple organ sys7. (A) Simply detecting the presence of the drug in- tern impairment.

gested is not as helpful as the actual serum measurement of the drug level. Drug screens are 14. (D) The transfer of caustic substances to unlahelpful in detecting the presence of other in- beled or erroneously labeled containers is an assogested substances. ciated risk factor for potential ingestion by a child.

8. (D) The need for gastric lavage in isolated aceta- 15. (A) An opioid overdose results in global depresminophen overdose is rare because of the very sion with a depressed sensorium as the halhnark. rapid GI adsorption of acetaminophen. Activated "

charcoal will effectively adsorb acetaminophen 16. (B) This scenario describes the cholinergic syn" and is ideally given in the first 4 hours (up to 6 to drome seen in organophosphate poisoning. A

8 hours) postingestion. N-acetylcysteine is an ef- useful mnemonic to remember is "SLUDGE": fective antidote that should be given ideally up to salivation, lacrimation, urination, defecation, GI 8 hours postingestion. cramping, and emesis. Exposure sometimes oc

curs through unsuspected dermal exposure. Or9. (C) Ions, hydrocarbons, metals such as iron, and ganophosphates are found in many pesticides

'-ethanol do not adsorb. Whole bowel irrigation and insecticides as well as drugs such as neostigmay be considered. mine and physostigmine. '-

L


17. (D) The anticholinergic effects include all the following except miosis. Dilated pupils, or my

'- driasis is seen. Remember mad as a hatter, red as a beet, dry as a bone, and hot as a hare. Anticholinergics are found in drugs such as atropine as weil as hallucinogenic mushrooms and plants such as jimson weed.

18. (D) N-acetylcysteine is the antidote used in acetaminophen toxicity.

SUGGESTED READING Schneider S, Wax P: Caustics. In; Mark, J (ed); Rosen's

Emergency Medicine, 5th ed., Vol 3. St. Louis, MO; Mosby, 2002, pp 2115-2119.

'-

Kulig K: General Approach to the Poisoned Patient. In: Mark, J (ed): Rosen's Emergency Medicine, 5th ed., Vol 3. St. Louis, MO: Mosby, 2002, pp 20632068.

Bizovi K, Parker S, Smilkstein M: Acetaminophen. In: Mark, J (ed): Rosen's Emergency Medicine, 5th ed., Vol 3. St. Louis, MO: Mosby, 2002, pp 20692075.

Seger D. Murray L. Aspirina and Nonsteroidal Agents. In: Mark., J (ed): Rosen's Emergency Medicine, 5th ed., Vol 3. St. Louis, MO: Mosby, 2002, pp 2076208l.

AAP Policy Statement. Poison treatment in the home. Pediatrics 112(5):1182-1185, 2003.

AAP Committee on Drugs. Acetaminophen toxicity in children. Pediatrics 108(4):1020-1024, 200l.

Abbruzzi G, Pediatric toxicologic concerns. Emerg Med Clin N Am 20(1): 223-247, 2002.

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