Quiz 2: Electric Boogalooz

A 2-year-old boy presents to the emergency department with irritability. His blood pressure is 60/30 mm Hg, pulse is 250/min, and respiratory rate is 35/min. On examination, he is tachypneic with grunting respirations. An ECG is performed as seen above. Which of the following is the best initial treatment for this patient?

• Adenosine

• Defibrillation

• Vagal maneuvers (e.g. ice bag)

• Synchronized cardioversion

Which of the following languages did Beth study in college?

• Chinese

• Somali

• Russian

• German

Which of the following patients undergoing emergent intubation would most likely benefit from pretreatment with atropine?

• 11 year old being given etomidate and succinylcholine for severe TBI

• 3 year old being given etomidate and rocuronium for seizure

• 4 month old being given etomidate and succinylcholine for bronchiolitis

• 8 year old being given ketamine and rocuronium for asthma

Answer explanation

Atropine is a competitive antagonist for both central and peripheral muscarinic receptors and has the anticholinergic effects of tachycardia and decreased salivation. At higher doses, it also causes hyperthermia, blurred vision, urinary retention, hallucinations, and decreased intestinal peristalsis. It is historically used during intubation in children to prevent the bradycardia that can occur with laryngoscopy or with succinylcholine. Available literature is inconclusive regarding universal use of atropine in children during emergent endotracheal intubation. Based on the limited available data and expert opinion, there are some situations in which atropine should be considered during pediatric intubation. Vagal-induced bradycardia from laryngoscopy is more pronounced in younger infants so atropine can be considered for all intubations in children < 1 year of age. Succinylcholine can cause bradycardia in young children so atropine can be considered in intubations using a single dose of succinylcholine under the age of 5 years and in all children who need multiple doses of succinylcholine. Additionally, some references support the use of atropine in children being intubated for septic shock. The decreased salivation effects of atropine can also benefit when using ketamine and in patients with significant oral secretions, such as those with bronchiolitis, but this effect is delayed and not likely to help during an emergent intubation. Atropine should not be used in children with a possible bowel obstruction or paralytic ileus.

Which workout will Andres never skip?

• Leg Day

• Arm Day

• Chest Day

• Shoulder/Back Day

A 7-year-old boy with a history of cognitive delay presents to the emergency department with his parents for arm pain. His parents do not remember any trauma to the patient’s arm. They report he was running around outside and began crying. The boy’s cognitive delay limits further history and review of systems. His physical exam shows a well-developed, well-nourished child being comforted in his parent’s arms. The X-ray of his arm is above. What is the most appropriate next step in management?

• Completion of the fracture by orthopedics for proper anatomic reduction

• Consultation of Child Protective Services

• Placement of a sugar-tong splint and follow-up with orthopedics in 1 week

• Placement of a volar splint and follow-up with orthopedics in the next 24 hours

Answer explanation

Completion of the fracture (A) is a decision made by orthopedics and is not indicated in greenstick fractures, like this patient’s, with less than 10 degrees of angulation. Greenstick fractures are a common pediatric fracture pattern. Without other signs of trauma or external concerns for abuse, it does not solely indicate a need for consultation of child protective services (B). A volar splint and orthopedic follow-up in 24 hours (D) is not appropriate treatment of a greenstick fracture of the radius. This patient’s fracture should be immobilized in a sugar-tong splint. Appropriate follow-up can be delayed up to one week.

Which of these exotic animals does Lydia have?

• Honey badger

• Parrot

• Ball Python

• Ocelot

A 2-year-old boy presents to the emergency department in cardiopulmonary arrest. The patient was found unresponsive after a few days of fevers, and the family called paramedics. Paramedics began CPR and they placed a supraglottic airway and an intraosseous line during the short transport. On arrival, CPR is in progress and the patient has the above rhythm. A length-based tape estimates a weight of 10 kg. He has no pulse. Which of the following is the most appropriate next step?

• Adenosine 1 mg bolus

• Amiodarone 50 mg bolus

• Defibrillation 20 J

• Synchronized cardioversion 5 J

Answer explanation

An adenosine 1 mg bolus (A) is used for treatment of a 10 kg patient with stable supraventricular tachycardia (SVT). SVT usually presents with a narrow complex rhythm but can present with a monomorphic and regular wide complex rhythm, during which adenosine can be attempted before electricity if the patient has a pulse. An amiodarone 50 mg bolus (B) is recommended for a 10 kg patient without any perfusion with a shockable rhythm when defibrillation is not effective. A 5 J synchronized cardioversion (D) is recommended for a patient with a wide complex tachycardia who has a pulse and is between 5 and 10 kg.

Who is this cutie 3.14?

• Maxwell

• III (Three)

• Mimi

• Sebastian

A 5-year-old boy presents to the emergency department with fever, sore throat, and difficulty swallowing. He has been complaining of a mild sore throat for the last one week. He refuses to extend his neck or turn his head from side to side, however, he is not currently experiencing respiratory distress. A soft tissue radiograph of the neck reveals widening of the space anterior to cervical vertebral bodies. Which of the following is the most likely diagnosis?

• Bacterial tracheitis

• Epiglottitis

• Peritonsillar abscess

• Retropharyngeal abscess

Which of the following is Peter's favorite football team?

• New England Patriots

• Chelsea

• Manchester United

• Manchester City