Pediatric Emergency Medicine Question Review Book

While we, the editors, believe that our work represents an endeavor of the highest quality, we recognized that we are not perfect, and we could always improve the project. As noted in the book itself, we had asked the readers to send comments and suggestions for improvement to the email address "pemqbook@yahoo.com."  To minimize the number of times we revised the book, comments were accepted for February 28 and April 30, 2009 deadlines, and revisions are posted below with dates of change. If the PEMQBook 2009 book was purchased after April 30, 2009, no further changes were made.

Full Revision Explanations

1) Chapter 6, Question 16: This question should be changed to read as follows:

A 16 yo female with type I diabetes mellitus is brought in by her mother for mental status changes. Her mother reports a chronic history of noncompliance and is not sure if she has been using her insulin. On examination, the patient is arousable but sleepy, with a HR of 120 and a BP of 100/60. Her bedside glucose is 450 mg/dL and her venous blood gas shows a pH of 7.1. Your first step in the management of this patient is:

a.    Insulin bolus of 0.1 units/kg
b.    Lactated Ringers bolus of 20 ml/kg over 15 minutes.
c.    Sodium bicarbonate 2 meq/kg IV
d.    Mannitol 2 gm/kg IV infusion
e.    Normal saline bolus of 10 ml/kg over 1 hr

Answer: e. This patient is presenting in diabetic ketoacidosis (DKA), which is the leading cause of mortality in children with diabetes. The literature is controversial as to the risk factors for cerebral edema; still, most experts now agree on a slow correction of electrolytes and dehydration. Most endocrinologists suggest a maximum initial bolus of 10 ml/kg of isotonic fluid over 1 hour unless the patient is hypotensive. Insulin boluses and bicarbonate boluses are now thought to be potentially dangerous. Mannitol is used for treatment of cerebral edema but should not be given until adequate fluid rehydration has occurred and should be given at a starting dose between 0.25 gm/kg and 0.5 gm/kg.  [Ref: 1) Cooke DW and Plotnick L. Management of Diabetic Ketoacidosis in Children and Adolescents. Pediatrics in Review. 2008;29:431-6. 2) Dunger DB, Sperling MA, Acerini CL, et al. European Society for Paediatric Endocrinology/Lawson Wilkins Pediatric Endocrine Society consensus statement on diabetic ketoacidosis in children and adolescents. Pediatrics. 2004;113 (2):e133-e140. ]

2) Chapter 6, Question 17: Answer option c was changed to "Give mannitol 0.25 g/kg IV"

3) Chapter 20, Question 5: Answer option c should be changed to: "Treat for cyanide poisoning." The answer explanation should read as follows:

Answer: c. Cyanide is a by-product of combustion and can be present in house fires. The clinician must consider cyanide poisoning when a patient presents with persistent acidosis despite adequate fluid resuscitation and normal carbon monoxide levels. Two components of the traditional Lily Cyanide kit (amyl nitrite and sodium nitrite) induce methemoglobinemia. This is a potentially harmful effect in a patient who may already have diminished oxygen carrying capacity.  Instead of using the whole kit the clinician can choose to use just the sodium thiosulfate component or the newer Cyanokit® which contains hydroxocobalamin. Hydroxcobalamin (a precursor of vitamin B12) binds with cyanide to form cyanocobalamin, which is then excreted in the urine. [Ref: 1) "Acute Cyanide Poisoning: Novel Approaches for Intervention in the Prehospital and Hospital Setting" symposium held at The Westin Seattle Grand Ballroom III in Seattle, Washington, on October 9, 2007. 2) http://www.drugs.com/pro/cyanokit.html]

4) Chapter 20, Question 7: There is some controversy with what represents 1% body surface area, and therefore the answer options were re-worded. The answer options should be modified as noted:

c.    Using the child’s palm and fingers as an estimate of 5% BSA, you should consider the area over the torso alone.
d.    Using the child’s palm and fingers as an estimate of 1% BSA, you should consider the area over the torso and right arm.
e.    Using the child’s palm and fingers as an estimate of 1% BSA you should consider the area over the torso alone.

Answer: e. Only partial thickness (2nd degree) and full thickness (3rd degree) burns should be considered in the evaluation of % BSA. In this case the clinician would only consider the area of the torso. As a child’s body composition is quite different than an adult, the “Rule of Nines” does not translate well. You may either use the child’s palm and fingers to estimate 1% BSA or specific tables designed for children (such as the Lund Browder chart). While some sources estimate that 1% BSA is best estimated by the palm alone, others suggest that 1% BSA is better represented by the palm with the fingers.  Given the choices in this question, choice e is the best answer.

5) Chapter 20, Question 28: The answer explanation should be re-worded as follows:

Answer: b. While minor injury to the ears can be repaired in the ED, special attention should be paid to the choice of anesthetic. Tight adherence of the skin over the helix makes local injection painful and difficult. For this reason, regional blocks are superior to local infiltration. In addition, regional blocks do not distort landmarks. As the ear helix is composed of cartilage, epinephrine should be avoided in the ear. In addition, for this regional block, epinephrine is not necessary since epinephrine is most commonly used to decrease bleeding at the site. [Ref: 1) King, Henretig. Textbook of Pediatric Emergency Procedures. Lippincott, Williams and Wilkins. Philadelphia 2007. 2) Ludwig, Fleisher. Textbook of Pediatric Emergency Medicine. Lippincott Williams and Wilkins; Philadelphia 2006]

6) Chapter 28, Question 26: The correct answer is b. The answer explanation is correct. 

7) Chapter 12, Question 20: Diazoxide should be replaced with acetazolamide in both the answer choices and the answer explanation. We mistakenly wrote diazoxide instead of the correct answer acetazolamide (Diamox®).

8) Chapter 18,Question and Answer 14: The original question involved a displaced open fracture, and the answer choices and explanation did not adequately address the management of this injury. The question stem was changed to a non-displaced fracture. As such, the answer explanation was modified. The last sentence was replaced with: "This injury is considered an open fracture. Traditionally, the use of oral antibiotics has been advocated. A recent report suggested a low incidence of infection overall, and no significant difference in infection rates between those treated with oral antibiotics and those treated with placebo. However, the study was not adequately powered to show statistically significant differences. (Altergott C, Garcia FJ, Nager AL. Pediatric fingertip injuries: do prophylactic antibiotics alter infection rates? Ped Emerg Care. 24(3):148-52, 2008)."

9) Chapter 19, Question 18: The anterior superior iliac spine is injured with forceful contraction of the sartorius muscle, and not the rectus femoris muscle, as originally written.

From the Editors:

Thank you for your comments. Unless there is an unequivocal error, we first send the comments to the author, and then review the author's responses with each of the editors. The revisions section is the result of this process.

If a comment was reviewed and was not determined to warrant a change, it does not appear in this section.

If the changes did not substantially change the meaning or interpretation of the question, they were not included in the list: 1) minor typographical changes; 2) sentence structure and word choices; 3) re-numbering of questions (Ch 12 and 22 have misnumbered questions). However, all of these changes were made directly to the book for all future prints.