Pediatric Examination and Board Review (139 page)

16.
(E)
An upper GI series with a contrast enema is still the gold standard for the diagnosis of volvulus. If the duodenal C-loop crosses to the left of the midline at a level higher than or equal to the pylorus, then malrotation is effectively ruled out. Conversely, a corkscrew column that ends abruptly is highly suspicious for volvulus.

17.
(C)
Pyloric stenosis is the most common disorder requiring abdominal surgery in infancy. Vomiting is the initial complaint and can begin around 3 weeks of age. Parents note that the child has a voracious appetite and then forceful emesis at the end of the feeding or just after. A hypokalemic, hypochloremic metabolic alkalosis may be found in these infants.

S
UGGESTED
R
EADING

Barkin RM.
Pediatric Emergency Medicine: Concepts and Clinical Practice
. St. Louis, MO: Mosby; 1997:726-795.

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

Guzman D. Pediatric surgical emergencies.
Clin Pediatr Emerg Med.
2002;3(1):1–2.

Halter J, Basel T, Nicolette L, et al. Common gastrointestinal problems and emergencies in neonates and children.
Clin Fam Pract.
2004;6(3):731-754.

Reynolds S. Missed appendicitis and medical liability.
Clin Pediatr Emerg Med.
2003;4(4):231.

CASE 82: A 3-YEAR-OLD GIRL WHO DRINKS A BOTTLE OF ACETAMINOPHEN

You are called to evaluate a 3-year-old, 15-kg girl brought in by ambulance. The aunt who arrived with the patient states she was sick last week with a “cold” and had fever up to 101°F (38°C), a cough, and 2-3 episodes of vomiting. Currently, the girl is complaining of “stomach pain.” The aunt states that she left the girl alone for 10 minutes while she took a shower. The aunt found her with an empty bottle of berry-flavored acetaminophen next to her and some drops of it on her shirt.

According to the aunt, the ingestion occurred no more than 30 minutes ago. On physical examination, the BP is 90/50 mm Hg, the pulse is 110, the respiratory rate is 40, and she is afebrile. The child appears uncomfortable. The examination is significant for mild midepigastric tenderness without rebound or guarding. Bowel sounds are normal and a rectal examination is unremarkable. You note that the child has a acetaminophen “mustache” and a berry-like odor to her breath. Mom arrives with the empty acetaminophen bottle. You examine the bottle and see it originally contained 4 oz of acetaminophen suspension (160 mg/5 mL). Mom states the bottle was new because she ran out when her child was sick and restocked her medicine cabinet yesterday.

SELECT THE ONE BEST ANSWER

1.
Which of the following laboratory studies is most likely to be helpful in the management of this 3-year-old patient?

(A) standard urine drug screen

(B) liver function tests

(C) 1 hour serum acetaminophen level

(D) electrolytes, BUN, creatinine, blood glucose

(E) 4-hour serum acetaminophen level

2.
The patient is complaining of nausea. Which of the following statements best describes your initial management steps?

(A) activated charcoal alone

(B) activated charcoal plus gastric lavage

(C)
N
-acetylcysteine (NAC) alone

(D) activated charcoal and NAC

(E) gastric lavage, activated charcoal, and NAC

3.
Which of the following statements regarding childhood poisonings is false?

(A) the ingestion of a potentially poisonous substance by a young child is a common event

(B) death attributable to unintentional poisoning is uncommon in children younger than 6 years

(C) data such as signs and symptoms of toxicity, management strategies in the home, and indications for seeking emergency care are available from local and national poison control centers

(D) the American Academy of Pediatrics (AAP) currently recommends that syrup of ipecac be kept at home for emergency use

(E) the storage of poisonous substances in the home should be discussed at the 6-month wellchild visit

4.
All of the following statements correctly describe reasons for the decrease in the death rate attributable to unintentional poisoning among young children in the last 50 years except

(A) the advent of child-resistant closures for products

(B) an increase in the over-the-counter (OTC) drug products available for parents to purchase for routine household use

(C) improved public education and anticipatory guidance

(D) the establishment of multiple poison control centers

(E) all of the above are true (no exception)

5.
Which of the following statements regarding syrup of ipecac is true?

(A) the only recommended method of inducing emesis is administration of ipecac

(B) syrup of ipecac is a safe emetic

(C) the amount of substance removed from the stomach is solely related to the duration of time from its ingestion to emesis

(D) the induction of emesis using ipecac is the first line of treatment in the pediatric emergency department

(E) the use of home ipecac therapy has the potential to decrease the efficacy of other poison treatments, such as activated charcoal or NAC

6.
Which of the following statements best describes gastrointestinal decontamination in the emergency department setting?

(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 recommended procedure of choice

(C) a cathartic, such as sorbitol, is used with each dose of activated charcoal to improve its efficacy

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

(E) all of the above

7.
A 15-year-old girl is brought to the pediatric emergency department and is unresponsive with no gag reflex. Her friends called 911 when they found her passed out at a party. Which of the following should be your initial step in the management of this patient?

(A) intubate the patient

(B) administer naloxone

(C) obtain a bedside glucose measurement

(D) administer 20 mL/kg of 0.9% normal saline as an IV bolus over 30 minutes

(E) call the poison control center for assistance

8.
Which of the following ingested substances is least likely to adsorb activated charcoal?

(A) acetaminophen

(B) salicylates

(C) iron

(D) beta-blockers

(E) tricyclic antidepressants (TCAs)

9.
Acetaminophen overdose is most frequently associated with toxicity to which of the following?

(A) central nervous system

(B) liver

(C) kidneys

(D) pancreas

(E) bone

10.
Which of the following statements describing acetaminophen toxicity is false?

(A) most cases involve unintentional overdosing

(B) delays in the diagnosis and treatment of acetaminophen intoxication do not adversely affect outcome

(C) the risk of toxicity is increased in patients taking drugs such as carbamazepine that are metabolized via the cytochrome P450 pathway

(D) acetaminophen toxicity includes four phases progressing from mild nonspecific symptoms to onset of organ injury, peaking with maximum organ injury and ending with either recovery or irreversible injury

(E) conditions such as diabetes mellitus, obesity, malnutrition, and/or a family history of hepatotoxic reactions may increase the risk of acetaminophen toxicity

11.
A 3-year-old boy presents to the pediatric emergency department after ingesting half a bottle of ibuprofen. Which of the following statements is true regarding acute NSAID toxicity?

(A) most ibuprofen overdoses follow a benign, rapidly reversible course

(B) plasma NSAID concentrations are useful and should always be obtained

(C) as a result of high protein binding and rapid metabolism, gastric decontamination with activated charcoal is never indicated

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

(E) all of the above

12.
Which of the following household items is least likely to be harmful to a child if swallowed in large quantities?

(A) antidiarrheal medication

(B) ibuprofen