PEM Source

Your source for all things Pediatric Emergency Medicine

All posts with tag: "respiratory"

PEM Questions

Your next patient, actually your next 10 patients, are brought in by their parents because they have been coughing for 2 weeks. Match the characteristic of the cough with the appropriate treatment (you may use letters twice or not at all). (Cannot answer on-line – jot down your answers and then check back for discussion).

  1. Dry cough worse at night and when out in the cold air
  2. Cough that sounds like a seal or dog barking
  3. Cough with an inspiration between each cough (staccato cough)
  4. Wet phlegmy cough accompanied by nasal congestion
  5. Paroxysms of cough with post-tussive vomiting
  1. Albuterol
  2. Amoxicillin
  3. Azithromycin
  4. Dark honey
  5. Dexamethasone

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What are pediatric emergency physicians seeing more of when COVID prevalence rises?

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You are seeing a toddler with 2 days of cough, congestion, and low-grade fever, who now presents with a worsened barky cough. His vital signs in the ED are temp 38.3 C, HR 110, RR 26, BP 80/40, O2 sat 96% on room air. He has stridor when crying but none at rest. He has no history concerning for foreign body aspiration. He is not happy to be in the ED but is not toxic appearing. He is fully immunized and has no significant past medical history. 

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You are seeing a 12 year-old with 2 weeks of nasal congestion, rhinorrhea, sneezing, and sore throat, especially in the mornings. She has had no fever. On exam, her nasal turbinates are pale and boggy. She has a horizontal crease below the bridge of her nose and her lower eyelids are bluish and puffy.

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You are seeing a 4 month old infant with fever, nasal congestion, and cough for 2 days. The baby is a previously well ex-full term infant with no past medical history, up to date on immunizations. He has been slightly less than usual but still having several wet diapers per day, and is still playful and interactive. On exam, his temperature is 38.4C, HR 135, RR 48, BP 80/40, and O2 sat 93% on room air. He has diffuse mild wheezes and minimal subcostal retractions, but no grunting, nasal flaring, stridor, cardiac murmur, hepatomegaly, or evidence of dehydration. There is no personal or family history of prior wheezing. His parents are able to return to the ED if necessary and can arrange follow-up with their pediatrician. 

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Which child does not meet the criteria for a low-risk BRUE? (Assume for all patients the events are now resolved and resolved immediately after the period of the event, there is no significant PMH, this is the first and only event, the child appears well in the ED)

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(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 3 year old child adopted from another country 6 months ago for abdominal pain. Since then, the child has had chronic nasal congestion and cough as well as failure to thrive which was expected to improve with improved nutrition provided by the adoptive family but has not. The child is afebrile and there are no ill contacts. On exam, there are scant wheezes and O2 sat is 95% on room air. CXR shows hyperinflation. Chart review shows prior visits for respiratory illness, and an episode of rectal prolapse. When asked about the presence of constipation, the parents describe frequent smelly oily stools. [yop_poll id="167"]
(Click the link to comment and to vote - voting not working through email, sorry!) An adolescent is brought in intoxicated with history of drinking large amounts of alcohol at a dorm party. He vomited multiple times at the scene and on arrival to the ED. Initial labs and CXR are normal except for an ETOH level of 390. He is protecting his airway, arousable with deep stimulation, and hemodynamically stable, so the decision is to observe him on a monitor while he slowly sobers up, and then reevaluate him for discharge. However, 2 hours later he is requiring 5L O2 by non-rebreather to maintain an O2 saturation of 97%. He does not show significant respiratory distress or apnea, and a venous blood gas does not reveal CO2 retention or significant acidosis. [yop_poll id="143"]
(Click the link to comment and to vote - voting not working through email, sorry!)A recent JAMA article summarized China’s experience with 72,314 COVID-19 novel coronavirus cases (Wu & McGoogan, JAMA 2020 Feb 24 [Epub ahead of print]). Which of the following is true? [yop_poll id="141"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 17yo girl presents with LUQ abdominal pain and vomiting x 2 days, and SOB x 1 day. Past medical history includes mild intermittent asthma, treatment for community-acquired pneumonia one month ago, and an MVA 1 year ago – she received head CT that was negative and was admitted and observed overnight at that time. Her CXR is below. Diaphragmatic Hernia [yop_poll id="137"]
(Click the link to comment and to vote - voting not working through email, sorry!) Which of the following is/are true of bacterial tracheitis?
  1. Children presenting with bacterial tracheitis tend to be older than children presenting with viral croup
  2. Children with bacterial tracheitis do not respond as well to racemic epinephrine and steroids as children with viral croup
  3. Children with bacterial tracheitis may have a “steeple sign” on xray
  4. Children with bacterial tracheitis most commonly have Strep pneumoniae infection
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(Click the link to comment and to vote - voting not working through email, sorry!) 8yo girl with history of asthma presents with increased work of breathing x 1 day. She is alert but anxious appearing, tachypneic, has retractions and flaring, and her O2 sat is 88% on room air. She has poor air movement and few wheezes are heard. She is given two 5mg albuterol nebulized treatments and oral steroids. An initial venous blood gas had a pH of 7.45 and pCO2 of 34. A repeat blood gas shows a pH of 7.33 and pCO2 48, O2 sat on oxygen with 3rdnebulized albuterol is 91%; her mental status is unchanged [yop_poll id="56"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 17 year old boy comes is brought in to the ED at 2am for severe retrosternal chest pain that awoke him from sleep. He was well prior to going to bed at 11:30pm, and denies fever, cough, radiation of the pain, vomiting, trauma, foreign body ingestion. He has a past medical history of appendectomy 8 months prior, acne for which he takes an oral antibiotic and uses a topical cream daily, and mild intermittent asthma for which he uses an inhaler once or twice a year "when the weather changes." He is a straight A student applying to colleges currently. His physical examination is normal, as is a CXR and ECG. What is the probable cause of his chest pain? [yop_poll id="28"]

Tips and Tricks

We are seeing unprecedented numbers of cases of RSV, and many of our patients are older school-age children. Ever wonder when those kids can return to school? RSV is contagious up to 8 days after symptom onset, so children can return to school on the 9th day after symptoms started. However, young infants and immunosuppressed children may shed active virus for up to 4 weeks.

Part of the new AAP BRUE algorithm’s definition of low-risk BRUE (Brief Resolved Unexplained Event) is that the event duration was < 1 minute. I always ask the caretaker to walk me through what happened step by step, using “and then what” prompting. I have had parents that told me the event lasted 2 minutes whose step-by-step description varied from “I picked her up, called for my husband to call 911, and blew in her face and she started coming around” (probably < 1 minute) to “I picked her up, ran to my neighbor’s house, she was still blue, we laid her on the couch, my neighbor gave mouth-to-mouth, and I called 911” (probably > 1 minute). Another trick I use is to say, “OK let’s say it starts when I say “now”, let me know when you think it stopped… now,” while timing with a stopwatch (available on your phone) – when your baby’s not breathing, 15 seconds can seem like 5 minutes; this helps get a more realistic estimate.
Easily remember the approximate Oxygen-Hemoglobin dissociation curve as follows: PaO2 40 corresponds to SaO2 70% PaO2 50 corresponds to SaO2 80% PaO2 60 corresponds to SaO2 90% This rule along with a lot of other handy RT knowledge can be found here Read more about PaO2 vs SaO2 at airwayjedi.com here

Controversies

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Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other!

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Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other!

You have diagnosed an 11 year old boy who has a PMH of mild intermittent asthma with COVID (he has been symptomatic with fever, vomiting, cough, and myalgias for 2 days). Currently, his RR is 20, SaO2 98% on room air, and his lungs are clear to auscultation. He has home albuterol MDI with spacer available. You discharge him with a portable pulse oximeter. For what persistent SaO2 would you tell the parent to bring him back to the ED?

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(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! Couldn't put every possibility, so pick the one closest to what you are doing. Also, your choice may depend on your hospital's recommendations and your PPE availability [poll id="46"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! You are seeing a 29 day old afebrile former 35 weeker brought in by ambulance. The patient was given a few sips of "gripe water" for runny nose, appeared to choke and gasp for air, turned blue briefly, then recovered. The entire episode was about a minute. There was no tone change. The baby has no birth complications. The baby's vital signs and physical exam are normal in the ED, pulse ox is 100% on room air, RSV testing is negative. What would be your management? [poll id="33"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! [poll id="20"]
It's RSV season and you're seeing a 30 day old ex-39 week infant with a runny nose. The resident has ordered a POC RSV, which is positive. The baby is afebrile, feeding well, and nontoxic. Do you admit the infant just for being RSV positive due to the risk of apnea in this age group? [poll id="11"]
You're seeing a 10yo who weighs 40 kg for acute asthma exacerbation. Do you give decadron or prednisone? If you give decadron, do you give 0.6 mg/kg or a lower dose? What is your maximum dose of decadron for asthma? Click post to read and add comments [poll id="4"]

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