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You are seeing a 3 year old who was running in the house, tripped and fell, hitting his mouth on the coffee table. On exam, his two upper central incisors are pushed up into his gums. None of his teeth, including those two, are loose. There was bleeding initially, but it has stopped spontaneously. He has no apparent pain and is climbing all over the gurney.
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You are seeing a 9 year old African-American child who was hit in the eye with a baseball. On exam there is visible blood layering in the anterior chamber, filling approximately 50% of the anterior chamber. There is no evidence of an open globe injury.
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You are seeing a 15 year old who sustained significant facial trauma. He complains of decreased vision in his right eye. On exam you note proptosis, periorbital swelling, and relative afferent pupillary defect (aka Marcus-Gunn pupil) on the left. The intraocular pressure is measured at 45.
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You are seeing a 6 year old child that was involved in a motor vehicle accident. He was belted in the rear left seat using a regular adult seatbelt. He is alert and crying. His airway is open, there is no evidence of head trauma, trachea is midline, and chest rise is equal with no increased work of breathing. He is tender in the right upper quadrant of his abdomen and has a seatbelt sign across his mid-abdomen. He has no obvious extremity deformities. GCS is 14. His vital signs are HR 160, RR 30, BP 80/40, O2 sat 98% on 5L by face mask non-rebreather.
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You are seeing a 14 year old boy involved in a helmet vs helmet football injury. Which of the following is true regarding his evaluation and management in the ED in regards to his equipment?
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A 16 year old female involved in a motor vehicle accident is brought into your trauma bay; she is obviously gravid and states that she is 8 months pregnant.
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You are seeing a 17 year old boy who fell while skateboarding and sustained an axial loading force to his right thumb. He is exquisitely tender at the base of the thumb (carpometacarpal joint), and you note swelling as well. Which of the following injuries is least likely to be encountered based on this mechanism and exam?
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You are seeing a 2yo who was being carried by a teenager who fell through a glass sliding door. The toddler has a 1.5 inch laceration of the right neck at the level of the thyroid cartilage.
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You are caring for a 9 year old boy involved in a motor vehicle accident. He has a seatbelt sign on his left neck and you palpate subcutaneous emphysema of his upper chest.
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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.
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An 11 year old left-hand dominant boy is brought in after accidentally sustaining an injury from a paint injection gun while helping his father on a project at home. The injury occurred 2 hours ago. On exam, he has a barely perceptible entrance puncture wound at the tip of his right index finger, no deformity or swelling, and a normal neurovascular exam. Radiographs are negative for fracture and his tetanus is up to date.
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A 16yo boy presents with chief complaint of a black “hole” in the center of his vision in his right eye 4 days after being hit by a baseball to the eye. He has periorbital ecchymosis but no evidence of orbital fracture. Visual acuity is 20/60 on right, 20/20 on left. He is PERRL, EOMI without pain, and has normal IOP and slit lamp exam. Fundoscopic shows a deep subretinal hemorrhage in his macular area with a small curvilinear yellow line visible.
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Which of the following elbow radiography findings can be normal in a 2 year old that fell on an outstretched arm and has decreased use of her elbow?
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A 7 year old boy presents to the ED after falling off his bike and impacting his mouth against the handlebar and the ground. Bystanders reported to the parent that there was a tooth on the ground, and per paramedics the parent is on the way in and may or may not have the tooth. Exam reveals a grossly luxated tooth that is very loose, and two sockets of apparently missing teeth.
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A new edition of ATLS (10th edition) was recently released. Which of the following is not a recommendation of the 10thedition of ATLS regarding the trauma patient in shock?
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An 11 year old girl was sitting with lap belt only in the back seat of a minivan involved in a motor vehicle accident where her car was rear-ended. She has a “seat belt sign,” or ecchymosis over her lower abdomen. Her CT abdomen with contrast is normal, but she continues to have tenderness to palpation. However, she states she is hungry.
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You are caring for a 4 year old child struck by a car. The child has significant maxillofacial trauma, a large parietal hematoma, and a GCS score of 7. Attempts to intubate with direct and video laryngoscopy have been unsuccessful due to blood obscuring visualization of the airway, and you are only partially able to oxygenate and ventilate the child with bag-mask ventilation, with an O2 sat on 100% FiO2 of 80%.
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An 18 month old child has sustained an arm fracture. Per the parent, the 4 year old sibling was carrying the child and tripped.
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A 2 year old toddler comes in from the playground crying and rubbing at his right eye. Exam is as above.
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You are triaging patients from a multi-casualty incident. The following patients are seen:
Patient A: Approximately 2 years old, ambulatory, crying, large 8cm parietal hematoma, obvious right humeral deformity
Patient B: Approximately 5 years old, unresponsive, apneic after airway positioning and 5 rescue breaths, weak palpable pulse
Patient C: Approximately 3 years old, responsive to painful stimuli, breathing at 40 breaths per minute, very weak palpable pulse
Patient D: Approximately 7 years old, unresponsive, breathing at 30 breaths per minute, weak palpable pulse
[yop_poll id="25"]
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You have sutured a 2cm forhead laceration on a 4yo boy using 6-0 nylon sutures.
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Which of the following cervical spine findings would you expect to be less common in a young child as compared to an adolescent or adult?
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A 3 year old comes in after falling 3 feet from the top of a kiddie slide onto cement, hitting his head. His only +PECARN symptom is 2 episodes of vomiting in the 2 hours since the fall. The medical student seeing him states to you that he is PECARN+ and he has discussed CT with the parents. What is the approximate risk of clinically important traumatic brain injury in this patient?
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A 17yo boy comes in with complaint of inability to breathe from the right nares. He was seen 2 days ago by his PMD and prescribed amoxicillin for sinusitis, but is not improving. He denies placing any foreign body in his nose. He was in an altercation at school and was hit in the nose 4 days ago. Which of the following would be the most appropriate treatment of this patient’s condition?
http://rhinitis.hawkelibrary.com/album09/83_G
A. Change antibiotics to amoxicillin-clavulanate
B. Attempt removal of foreign body
C. Incision and drainage and nasal packing
D. Referral to otorhinolaryngologist for polyp removal
Also, if you’re interested in the Peds ID Antibiotics Question of the Week, you can find it here
A 10yo girl is sitting lapbelted in the rear of an SUV that is involved in a rear-end collision at 40mph. She complains of abdominal pain, and has an ecchymosis from the lapbelt going across her lower abdomen. Of the following, which is the LEAST likely injury the patient may have:
A. Small bowel injury
B. Kidney injury
C. Horizontal vertebral body fracture in lower spine
D. Spinal cord injury
Check back in a few days for my answer and others' comments
Also if you're interested in the Peds ID question of the week, go here
A 20kg child sustains a 15% body surface area burn. The best answer for the rate of IV fluids that should be administered over the first 8 hours is:
A. 60 cc/hr
B. 75 cc/hr
C. 120 cc/hr
D. 135 cc/hr
E. 150 cc/hr
A 10yo was a rear seat passenger in a high-speed MVA, belted only with a lapbelt, and had a hyperflexion injury mechanism during impact. The patient cannot move his legs, and does not have lower extremity sensation to light touch or temperature sensation, but does have intact proprioception and vibration sense. What is the injury?
A child is brought in with a stab wound to the right neck just superior to the cricoid cartilage. What zone of the neck is this? What is the significance of the zones?
A 2 year old is brought in that has chewed on an electrical cord. He has a scab in the corner of his mouth and no active bleeding and is otherwise well appearing with no other trauma. What delayed complication can occur?
Asking Saves Kids: Firearms are now the leading cause of death for U.S. children aged 1-19 years. While school mass shootings make headlines, suicides make up the majority of these deaths. Accidental shootings by curious children who access unsecured firearms also contribute. It should be a standard part of our practice to assess access to firearms when seeing children who are depressed or suicidal, expressing homicidal thoughts, or are current victims of gun or gang violence. But if there’s time during the visit, it doesn’t hurt to run through an injury prevention checklist (helmets, carseat/seatbelt, unsecured firearms) with all our patients / parents. Find resources here
Patient won't or can't urinate for point-of-care pregnancy test, and quantitative hCG will take too long? Put a couple drops of whole blood on the POC cassette. Read more on ALiEM here, and below
It is commonly taught that a patient’s palmar hand represents approximately 1% of his/her body surface area (BSA), a useful tool when estimating the BSA of burns. But does one use the palm including or excluding the fingers? Adult studies support that the palmar hand including fingers actually represents about 0.8% BSA. Despite this widespread teaching, there are surprisingly few pediatric studies. Pediatric studies support the palmar hand without fingers to = 0.5% BSA, and with fingers close to 1% BSA. What is considered pediatric for using this estimation method? One original study included children to age 13 years, and another to age 17 years; puberty may be a useful cutoff age. How well the palm estimates BSA may also vary by gender, race, and degree of obesity. Ref: Thom D, Burns 2017 Feb; 43(1):127-136.
The SAMPLE mnemonic is typically used to remember the important brief history needed for trauma patients: Symptoms, Allergies, Meds, Past medical history, Last meal, and Events leading up to the trauma. Think of the mnemonic as SAMPLE-PT and add in Pregnancy (history, testing) and Tetanus status.
Also, ABCDE is used to recall Airway, Breathing, Circulation, Disability, Exposure in managing trauma patients. Keep going in the alphabet and add on FAST, Gastric tube (NG or OG) and Glucose check, Hemoglobins (serial), IV (two large-bore).
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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!
A 7 year old boy presents after injuring his lateral soft palate with a straw. He is completely asymptomatic and exam other than what is shown is normal.
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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!
For pediatric blunt trauma patients...
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www.jems.com
A 2 year old toddler comes in from the playground crying and rubbing at his right eye. Exam is as above.
[yop_poll id="33"]
en.wikipedia.org
(Click the link to comment and to vote - voting not working through email, sorry!)
[yop_poll id="10"]
http://rhinitis.hawkelibrary.com/album09/83_G
A. Change antibiotics to amoxicillin-clavulanate
B. Attempt removal of foreign body
C. Incision and drainage and nasal packing
D. Referral to otorhinolaryngologist for polyp removal
Also, if you’re interested in the Peds ID Antibiotics Question of the Week, you can find it 
[poll id="42"]