Review Test

1.You are summoned urgently to the waiting room of the emergency department by a clerk after she witnessed a 3-year-old boy collapse. You are concerned that he may be in cardiac arrest. Which of the following is the correct order of steps for the initial management of a child found in full cardiopulmonary arrest?

A.Open the airway, check for a pulse, administer rescue breaths, and start chest compressions.

B.Check for a pulse, open the airway, start chest compressions, and administer rescue breaths.

C.Check for a pulse, start chest compressions, open the airway, and administer rescue breaths.

D.Open the airway, administer rescue breaths, start chest compressions, and check for a pulse.

E.Check for breathing and a pulse, and start chest compressions.

2.A 2-year-old boy sustains severe head trauma in a three-story fall. Which of the following statements regarding head injury in a patient of this age is correct?

A.Epidural hematoma has a crescentic density on head computed tomography.

B.The prognosis is better if he has a subdural hematoma rather than an epidural hematoma.

C.Cushing triad is an early sign of increased intracranial pressure.

D.The occipital lobe is the most common site of intracerebral hematoma.

E.Bradycardia is an early sign of herniation.

3.A 1-year-old girl has been involved in a motor vehicle accident, and you suspect she has sustained head injury. On examination, she is unconscious but she opens her eyes to pain and also has abnormal flexion of her extremities to pain. She does not cry but rather grunts with stimulation. What is her Glasgow coma score?

A.4

B.5

C.6

D.7

E.8

4.A 19-month-old male infant has a burn on his right hand that occurred 3 hours ago. On examination, the burn appears to be in a “stocking glove” distribution. The involved area is moist, painful, and red and contains two moderate-sized intact blisters. Which of the following statements regarding this burn is correct?

A.This patient has suffered a superficial partial-thickness burn.

B.This burn will most likely scar.

C.Child abuse is unlikely based on the burn’s characteristics.

D.Blisters should be ruptured and debrided.

E.Hospitalization is not needed.

5.A 2-year-old girl is found submerged in a lake. She is suspected to have been under the water for more than 15 minutes. Paramedics find her apneic and pulseless. On arrival at the hospital, her core body temperature is 82.4°F (28°C). Which of the following statements regarding the management, expected clinical findings, and prognosis in this patient is correct?

A.Management is dependent on whether the lake contains fresh or salt water.

B.Because the child was found apneic and pulseless, resuscitative efforts should not be attempted.

C.Cervical spine immobilization is unnecessary.

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D.Pulmonary function would be expected to improve during the next 18 hours.

E.The prognosis is poor.

6.A 17-year-old girl is brought by her parents to the emergency department after a possible suicide attempt. She discloses that she swallowed 100 aspirin tablets 4 hours ago. Which of the following acid–base relationships would most likely be found on an arterial blood gas study of this patient?

A.Metabolic alkalosis and respiratory acidosis

B.Metabolic alkalosis and respiratory alkalosis

C.Metabolic acidosis and respiratory acidosis

D.Metabolic acidosis and respiratory alkalosis

E.Respiratory alkalosis only

7.A 2-year-old girl is brought to the emergency department by her parents. She swallowed an unknown amount of industrial-strength drain cleaner from her father’s plumbing van

30 minutes ago. Which of the following statements regarding the clinical findings and management of this incident is correct?

A.The drain cleaner will cause coagulation necrosis

B.Activated charcoal should be administered.

C.Nasogastric tube for lavage should be avoided.

D.Lower intestinal perforation is a possible complication.

E.The drain cleaner should be neutralized with acetic acid.

8.A 14-year-old boy is involved in a fistfight with another teenager at school. He is brought to the emergency department 2 hours later with a laceration on the dorsum of his right hand over the knuckle secondary to a human bite. Which of the following statements regarding this human bite is correct?

A.If infection develops, it is usually secondary to both anaerobes and aerobes.

B.If irrigated appropriately, human bites are unlikely to become infected.

C.This wound most likely involves an interphalangeal joint.

D.Antibiotics should not be prescribed until an infection develops because of the risk of selection of resistant organisms.

E.If infection develops, it is most likely caused by Pasteurella multocida.

9.A 5-year-old girl is brought to a rural emergency department after being bitten on the leg by a rattlesnake. The bite occurred 30 minutes ago. No antivenin is available at the hospital, and transfer to another hospital is pending. Which of the following should be performed immediately?

A.Local wound care, leg immobilization, and supportive care only.

B.Incise the wound and apply suction to remove the venom.

C.Apply direct pressure to the wound.

D.Apply a tight tourniquet proximal to the wound to prevent venom from spreading.

E.Rub ice over the fang marks.

The response items for statements 10 and 11 are the same. You will be required to select one answer for each statement in the set.

A.Black widow spider

B.Brown recluse spider

For each of the following patients, select the most likely spider bite.

1.A 5-year-old girl with severe muscle cramps and hypertension.

2.A 10-year-old boy with fever, chills, vomiting, and disseminated intravascular coagulation 24 hours after a suspected bite. Five days later, a necrotic, ulcerated skin lesion is evident.

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The response items for statements 12–14 are the same. You will be required to select one answer for each statement in the set.

A.Distributive shock

B.Septic shock

C.Cardiogenic shock

D.Hypovolemic shock

E.Neurogenic shock

For each patient, select the most likely type of shock.

1.A 10-month-old female infant presents with hypotension. An electrocardiogram reveals supraventricular tachycardia.

2.A 10-year-old boy presents with a 2-day history of high fever, chills, vomiting, diarrhea, and weakness. Examination reveals hypotension with bounding pulses and warm extremities.

3.A 5-year-old boy presents with acute onset of wheezing, urticaria, stridor, and hypotension.

4.A 2-year-old girl is brought to the emergency department after ingesting her mother’s prenatal vitamins 60 minutes ago. Which of the following statements regarding the clinical findings, diagnosis, and management of this type of poisoning is correct?

A.Activated charcoal is effective.

B.Basophilic stippling is seen on peripheral blood smear.

C.A test dose of deferoxamine should be the first step in management.

D.An abdominal radiograph may reveal the ingested poison.

E.Shock is uncommon.

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Answers and Explanations

1.The answer is E [I.B]. The CABs (Circulation, Airway, Breathing) should begin every resuscitation of a child. If the victim is unresponsive, the rescuer should shout for help and activate the emergency response system. While looking for breathing, the rescuer should simultaneously feel for a pulse. The airway should be opened by either a chin lift–head tilt maneuver or by a jaw-thrust maneuver if the patient has suspected neck or cervical spine injury. If the patient is bradycardic or asystolic, chest compressions are administered.

2.The answer is E [III.E.1.d]. In children younger than 4 years, bradycardia is often the initial sign of cerebral herniation. Epidural hematomas have a lenticular appearance on head computed tomography, whereas subdural hematomas generally have a crescentic appearance. Patients with subdural hematomas generally have a worse prognosis compared with those with epidural hematomas, because of the bleeding directly on the surface of the brain parenchyma. Cushing triad (in which bradycardia is seen with hypertension and an irregular breathing pattern) is a late finding of increased intracranial pressure. The frontal and temporal lobes are the most common sites of intracerebral bleeding.

3.The answer is D [Table 20-1]. The Glasgow coma score (GCS) is used to assess the level of neurologic impairment on the basis of the patient’s physical examination. It includes assessment of three components: eye opening, motor response, and verbal response. This scoring system has been modified for the nonverbal pediatric patient. This patient has a GCS score of 7; she opens her eyes to pain (2), has abnormal extremity flexion to pain (3), and grunts with stimulation (2). A GCS of less than 8 signifies severe head injury.

4.The answer is A [VI.B.2.c, IV.B.2.a, and IV.C]. This patient’s burn is classified as a superficial partial-thickness burn on the basis of the presence of pain, blisters, and erythema. Superficial partial-thickness burns involve the epidermis and outer dermis and do not scar. Child abuse must be considered for well-demarcated burns (e.g., “stocking glove” distribution) that suggest submersion injury. If intact, blisters should not be ruptured because the risk of infection and loss of fluid from the skin would increase. All patients with burns to the hands, feet, perineum, face, and skin overlying joints should be hospitalized for treatment.

5.The answer is E [V.D–F]. A poor prognosis is associated with age younger than 3 years, submersion times greater than 5 minutes, and the need for cardiopulmonary resuscitation, all of which are present in this patient. In general, however, the outcome of drowning in children is better than that in adults, because children have a primitive dive reflex that preferentially shunts blood to vital organs such as the brain, heart, and liver. Management is the same regardless of the type of water in which the patient was submerged. Despite the apnea and asystole, this patient should be resuscitated, and efforts at resuscitation should continue until the core body temperature reaches at least 89.6°F (32°C). Head and neck trauma should always be suspected, and therefore cervical spine immobilization is important. Pulmonary function tends to deteriorate during the 12–24 hours after submersion injury.

6.The answer is D [VIII.D.2.d]. Salicylates are weak acids and cause an anion-gap metabolic acidosis. However, salicylates also directly stimulate the respiratory centers in the brainstem. The stimulation of the respiratory center causes hyperventilation, which overcompensates the metabolic acidosis, producing a respiratory alkalosis. Therefore, the most common acid–base finding in a patient who has ingested a toxic amount of salicylates is a metabolic acidosis and a respiratory alkalosis.

7.The answer is C [VIII.D.5.b–c]. Drain cleaners are alkalis, which typically cause severe deep burns to the mouth and esophagus by liquefaction necrosis. In contrast, acids cause coagulation necrosis that produces superficial damage. Because the esophagus may be injured, a nasogastric tube for suction or lavage is contraindicated. Activated charcoal should be

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avoided as well because it interferes with endoscopy. Neither acids nor alkalis cause lower intestinal perforation. Neutralization with an acid produces an exothermic reaction that results in further injury.

8.The answer is A [IX.D]. Human bites have a very high infection rate despite appropriate wound cleaning. Infection is typically a mixed infection consisting of both aerobes and anaerobes. The hand, specifically the metacarpophalangeal joint, is most commonly bitten in a fistfight. Antibiotics should always be prescribed. Infection with Pasteurella multocida occurs in cat and dog bites, but not in human bites. Other infections such as syphilis, human immunodeficiency virus, and hepatitis B also may be transmitted by human bites.

9.The answer is A [X.C.3]. Management of a rattlesnake bite involves the immediate administration of snake antivenin. If antivenin is unavailable, the victim should be transported to a facility that has antivenin. Local wound care (including tetanus prophylaxis if needed)

and immobilization of the affected extremity are all that are needed until antivenin becomes available. Incision and suction are not recommended, and direct pressure, tourniquets, and ice may aggravate the injury.

10.The answers are A and B, respectively [X.A and X.B]. The black widow spider (Latrodectus species) generally produces few local symptoms; however, muscle cramps and systemic hypertension are pathognomonic. The brown recluse spider (Loxosceles species) produces significant local signs and symptoms in some patients, including a deep necrotic ulcerated skin lesion. In some patients, systemic symptoms, such as disseminated intravascular coagulation, vomiting, fever, chills, hemolysis, and joint pain, may occur 24–48 hours after the bite.

11.The answers are C, B, and A, respectively [II.B.2.d, II.B.2.b and II.B.2.c]. The 10-month-old female infant with supraventricular tachycardia has cardiogenic shock, which is generally caused by cardiac dysrhythmias. The 10-year-old boy has signs and symptoms of infection. Shock associated with infection may include septic shock and hypovolemic shock. However, bounding pulses and warm extremities are found only in the initial hyperdynamic stage of septic shock. The 5-year-old boy has signs and symptoms of anaphylaxis. Shock associated with anaphylaxis is distributive shock, which may also be secondary to spinal cord injury and drug poisoning.

12.The answer is D [VIII.B.4.b, VIII.D.3.d and Table 20-5]. Prenatal vitamins contain iron, a cause of childhood poisoning. Iron tablets are radiopaque and may be seen on imaging studies of the abdomen. There are four clinical stages of iron ingestion, including the first stage in which gastrointestinal bleeding can occur along with shock and vasodilation. Management of suspected iron ingestion includes whole-bowel irrigation if poisoning is severe, and treatment with deferoxamine, an iron chelator. Activated charcoal is not effective for iron ingestion. Basophilic stippling is seen in lead intoxication. A test dose of deferoxamine may be very helpful in the management of this patient, but it would not be the first step in management.

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