Pediatric Examination and Board Review (140 page)

(C) mouthwash

(D) multivitamins

(E) household bleach

13.
Which of the following statements is false regarding caustic ingestions?

(A) the vast majority of all reported cases of caustic ingestion occur in children

(B) caustic substances have the potential to cause tissue burns on contact with the eyes, skin, airway/ lungs, and/or the GI tract

(C) alkalis, acids, and antiseptics are all agents capable of causing chemical injury

(D) the transfer and storage of cleaners and caustic substances to alternative household containers has been associated with a decreased risk of ingestion in children

(E) button battery ingestion may cause esophageal obstruction and pressure necrosis and/or caustic injury because of leakage of alkaline material

14.
The presentation of a comatose patient with marked miosis, respiratory depression, hypotension, bradycardia, and hyporeflexia would make you most concerned about the possible overdose of which of the following?

(A) opioids

(B) organophosphates

(C) cocaine

(D) diphenhydramine

(E) pseudoephedrine

15.
The presentation of a confused, diaphoretic patient with miosis, abdominal cramping, fecal and urinary incontinence, profuse sweating, and drooling would cause you to be most concerned about which of the following toxic ingestions?

(A) opioids

(B) organophosphates

(C) cocaine

(D) ethanol

(E) ephedra

16.
Which of the following signs and symptoms is not consistent with an anticholinergic toxic syndrome?

(A) tachycardia

(B) dry, flushed skin

(C) urinary retention

(D) miosis

(E) slightly elevated temperature

17.
Which of the following pair of toxins and antidotes does not match?

(A) opiates and naloxone

(B) benzodiazepines and flumazenil

(C) methanol and ethanol

(D) salicylates and NAC

(E) iron and deferoxamine

ANSWERS

1.
(E)
Simply detecting the presence of the drug ingested is not as helpful as the actual measurement of the serum drug level. Drug screens are helpful in detecting the presence of other ingested substances. Acetaminophen levels are important. However, a 4-hour level is needed to determine the relative risk of hepatic damage and the need to administer NAC. The Rumack-Matthew Nomogram helps to determine the need for NAC.

2.
(A)
The need for gastric lavage for patients with an acetaminophen overdose is rare because of the rapid GI absorption of acetaminophen. Activated charcoal will effectively adsorb acetaminophen and is ideally given in the first 30 minutes to 1 hour postingestion. NAC is an effective antidote that should be given up to 8 hours postingestion. However, NAC should be given after the 4-hour acetaminophen level is back and the Rumack-Matthew nomogram should be used.

3.
(D)
The AAP no longer recommends syrup of ipecac be stored in a household for emergency use.

4.
(B)
Decreases in the death rate are attributable to safer medications and product formulations, not the OTC availability.

5.
(E)
Syrup of ipecac is no longer recommended for toxic ingestions. It can delay emergency department care of the child and limit more effective interventions due to repetitive emesis.

6.
(B)
The current recommendation to use activated charcoal (AC) alone for GI decontamination without the use of a gastric emptying technique such as gastric lavage or syrup of ipecac has improved outcomes. Sorbitol speeds AC clearance but does not improve efficacy. Multiple doses of sorbitol can lead to profuse diarrhea and electrolyte imbalance in small children. The risks of aspiration are largely avoided when AC is used alone.

7.
(A)
The highest priority in the management of any acutely ill patient is the evaluation and support of airway, breathing, and circulation (ABCs).

8.
(C)
Ions, hydrocarbons, metals such as iron, and ethanol do not adsorb. Whole bowel irrigation may be considered.

9.
(B)
Hepatotoxicity is of greatest concern because hepatic metabolism accounts for up to 90% of acetaminophen elimination. It is important to note that in acute toxicity, liver injury usually presents 24-48 hours postingestion. Acetaminophen ingestions of more than 150 mg/kg are associated with highest risk of hepatotoxicity.

10.
(B)
Delay in diagnosis and failure to institute treatment measures are associated with poorer outcomes. Because the early symptoms seen in stage 1 are nonspecific, a heightened awareness of the potential for toxicity and the recognition of patients at risk for toxicity are vital.

11.
(A)
Unlike acetaminophen toxicity, NSAID overdoses do follow fairly benign courses. Children who ingest more than 300 mg/kg should have GI decontamination, evaluation, and observation. Highprotein binding causes urinary alkalinization, hemoperfusion, and hemodialysis to be ineffective in enhancing elimination (dialysis is used in salicylate intoxication). GI side effects are the most common side effects associated with the use of NSAIDs.

12.
(E)
Household bleach is nontoxic. Antidiarrheal products tend to contain salicylates. Both salicylates and ibuprofen can cause significant renal impairment. Many mouthwash products contain ethanol that can cause hypoglycemia. A multivitamin overdose can lead to multiple organ system impairment.

13.
(D)
The transfer of caustic substances to unlabeled or erroneously labeled containers is an associated risk factor for potential ingestion by a child.

14.
(A)
An opioid overdose results in global depression with depressed sensorium as the hallmark.

15.
(B)
This scenario describes the cholinergic syndrome seen in organophosphate poisoning. A useful mnemonic to remember is “SLUDGE”: salivation, lacrimation, urination, defecation, GI cramping, and emesis. Exposure sometimes occurs through unsuspected dermal exposure. Organophosphates are found in many pesticides and insecticides as well as drugs such as neostigmine and physostigmine.

16.
(D)
The anticholinergic effects include all the following except miosis. Dilated pupils, or mydriasis are 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 well as hallucinogenic mushrooms and plants such as jimson weed.

17.
(D)
NAC is the antidote used in acetaminophen toxicity.

S
UGGESTED
R
EADING

AAP Committee on Drugs. Acetaminophen toxicity in children.
Pediatrics.
2001;108(4):1020-1024.

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

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

Barkin RM.
Pediatric Emergency Medicine: Concepts and
Clinical Practice
. St. Louis, MO: Mosby; 1997:463-513.

Fleisher GR.
Textbook of Pediatric Emergency Medicine
. 6th ed. Philadelphia, PA: Lippincott; 2010.

Goldfrank LR.
Goldfrank’s Toxicologic Emergencies
. 9th ed. New York, NY: McGraw-Hill; 2010.

Marx J, Hockberger R, Walls R.
Rosen’s Emergency Medicine.
7th ed. St. Louis, MO: Mosby; 2009.

Chapter 10

GENETICS

CASE 83: A NEONATE WITH A HEART DEFECT AND DYSMORPHIC FEATURES

A newborn is evaluated in the regular nursery. The child was born full term to a 39-year-old mother by a normal spontaneous vaginal delivery. A prenatal ultrasound showed the presence of a congenital heart defect, most likely an atrioventricular (AV) canal defect. The family elected not to have prenatal testing. The family history is otherwise negative.

On physical examination the vital signs are within normal limits. Brachycephaly, up-slanted palpebral fissures, epicanthal folds, protruding tongue, and generalized hypotonia with an otherwise normal neurologic examination are noted.

SELECT THE ONE BEST ANSWER

1.
The most likely diagnosis for this child is

(A) Down syndrome

(B) Edward syndrome

(C) Holt-Oram syndrome

(D) Patau syndrome

(E) Treacher Collins syndrome

2.
Which of the following is not a common feature of Down syndrome in the newborn infant?

(A) small, low-set ears with an overfolded upper helix

(B) transverse palmar (simian) crease

(C) increased gap between toes 1 and 2

(D) rocker bottom feet

(E) excess nuchal skin fold

3.
In a newborn suspected of having Down syndrome, which of the following investigations are routinely indicated in all patients regardless of symptoms?