Module 3

Welcome back to CHM! During your rotation, please complete all requirements in this module by the end of your rotation.

1. Submit a minimum of 12-15 evaluations (1 per shift)
2. Complete EMS Module
3. Read These Articles
   • Seizures in Children
   • Head Injury
   • Pain Management in Children
   • Physical Abuse
   • Sexual Abuse
4. Procedures: Pediatric Procedural Sedation
   • Intranasal Medication Protocol for CHM ED
   • Sedation Fasting Protocol
   • CPG: Procedural Sedation and Analgesia in the Emergency Department (Ann Em Med, 2014) – optional
   • Conscious Sedation (PIR 2007) – optional
5. Human Trafficking Module *NEW* required

6. Module 3 Quiz

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   1. Answered
   2. Review

   1. Question 1 of 25

      1. Question

      1 points
      Category: Pain Mgmt

      A 2-day-old boy is scheduled to undergo circumcision. He was born after an uncomplicated pregnancy and delivery. His mother is concerned about pain associated with circumcision. Of the following, a true statement regarding pain in the newborn is that:

      • Repeated procedures such as heel sticks result in habituation, with decreasing response to painful stimuli.
      • Neonatal pain response is transient and not as pronounced as in older children and adults.
      • Feeling of pain is a learned phenomenon through postnatal experience with injury.
      • Experiencing pain early in life helps children deal with adversity more effectively later in life.
      • Ascending neural pathways transmitting pain are well developed at birth, but descending inhibitory pathways are not.
      Correct
      

      Newborns historically were believed to experience less pain because of the immaturity of their nervous systems, but recent data support the hypothesis that the perinatal period may be a time of increased sensitivity to pain. Although the ascending pathways of the neonatal nervous system are fully developed, allowing the transmission of painful stimuli,  the descending inhibitory pathways are not established. Thus, painful stimuli may reach the brain without modulation, leading to more pronounced pain sensation in neonates than in children and adults. This hypothesis is supported by clinical data that show a more pronounced physiologic response to pain and higher serum analgesic concentration requirements to produce analgesia among neonates compared with older age groups.

      Incorrect
      

      Newborns historically were believed to experience less pain because of the immaturity of their nervous systems, but recent data support the hypothesis that the perinatal period may be a time of increased sensitivity to pain. Although the ascending pathways of the neonatal nervous system are fully developed, allowing the transmission of painful stimuli,  the descending inhibitory pathways are not established. Thus, painful stimuli may reach the brain without modulation, leading to more pronounced pain sensation in neonates than in children and adults. This hypothesis is supported by clinical data that show a more pronounced physiologic response to pain and higher serum analgesic concentration requirements to produce analgesia among neonates compared with older age groups.
   2. Question 2 of 25

      2. Question

      1 points
      Category: Pain Mgmt

      A 12-year-old girl is admitted after repair of idiopathic scoliosis. She has no other significant medical history. Of the following, the best means of assessing her pain is via:

      • Behavioral indicators.
      • Parental assessment.
      • Nursing staff assessment.
      • Patient self-assessment.
      • Physiologic indicators.
      Correct
      

      Children > age 9 years can self report pain using the Visual Analogue Scale or McGill Pain Questionnaire

      Incorrect
      

      Children > age 9 years can self report pain using the Visual Analogue Scale or McGill Pain Questionnaire
   3. Question 3 of 25

      3. Question

      1 points
      Category: Pain Mgmt

      An 8-year-old boy underwent thoracotomy to remove a chronically infected bronchiectatic left lower lobe. Of the following, a correct statement regarding postoperative pain management in this boy is that:

      • Both nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids have a maximum dose after which a higher dose does not provide additional analgesic benefit (ceiling effect).
      • Pain medication should be administered around the clock, with additional doses in between as required.
      • Opioids should not be used as the first-line drugs in management of postoperative pain because of their adverse effects.
      • Objective means of assessing pain, such as a validated pain scale, are more accurate than patient selfassessment.
      • Different classes of pain medications, such as an NSAID and an opioid, should not be combined.
      Correct
      

      Alpha-2 agonists have been used successfully to treat hypertension since the early 1970s. Their use in the field of pain management has blossomed over the past several years because of diverse responses produced by these
      medications, including analgesia, anxiolysis, and sedation. Alpha-2 agonists have been used successfully in the treatment of intraoperative and postoperative pain and chronic pain as well as in the control of symptoms of withdrawal in opioiddependent individuals. Clonidine and, more recently, dexmetomidine have been shown to be useful in both the operative and intensive care unit settings.

      Clonidine can be administered via an epidural catheter either intra- or postoperatively, prolonging and intensifying surgical anesthesia and postoperative pain management. In combination with opioids, clonidine offers the additional advantage of a reduced dose for each component with correspondingly fewer adverse effects. Epidural clonidine has been used successfully to treat cancer and neuropathic pains. Clonidine also has been used intravenously to decrease the opioid requirement of patients suffering from extensive burns.

      When administered orally or transdermally, clonidine can ameliorate symptoms of opioid or benzodiazepine withdrawal for patients who are being weaned after long stays in the intensive care unit. In this setting, clonidine usually is administered at a dose of 2 to 4 mcg/kg every 4 to 6 hours. Further study is required to define the potential for alpha-2 agonist use in pediatric pain management.

      Incorrect
      

      Alpha-2 agonists have been used successfully to treat hypertension since the early 1970s. Their use in the field of pain management has blossomed over the past several years because of diverse responses produced by these
      medications, including analgesia, anxiolysis, and sedation. Alpha-2 agonists have been used successfully in the treatment of intraoperative and postoperative pain and chronic pain as well as in the control of symptoms of withdrawal in opioiddependent individuals. Clonidine and, more recently, dexmetomidine have been shown to be useful in both the operative and intensive care unit settings.

      Clonidine can be administered via an epidural catheter either intra- or postoperatively, prolonging and intensifying surgical anesthesia and postoperative pain management. In combination with opioids, clonidine offers the additional advantage of a reduced dose for each component with correspondingly fewer adverse effects. Epidural clonidine has been used successfully to treat cancer and neuropathic pains. Clonidine also has been used intravenously to decrease the opioid requirement of patients suffering from extensive burns.

      When administered orally or transdermally, clonidine can ameliorate symptoms of opioid or benzodiazepine withdrawal for patients who are being weaned after long stays in the intensive care unit. In this setting, clonidine usually is administered at a dose of 2 to 4 mcg/kg every 4 to 6 hours. Further study is required to define the potential for alpha-2 agonist use in pediatric pain management.
   4. Question 4 of 25

      4. Question

      1 points
      Category: Pain Mgmt

      A 2-day-old girl is admitted for management of suspected sepsis and dehydration. The management plan includes obtaining blood samples and initiating intravenous antibiotics and fluid therapy. Which of the following statements regarding painful procedures in this patient is true?

      • Development of neural pathways involving pain is not appreciable before 1 week of age.
      • Experiencing pain in the neonatal period has been shown to be of little or no consequence later in life.
      • Oral administration of sucrose water is effective in reducing pain associated with venipuncture.
      • Heel lancing is less painful than venipuncture for obtaining blood samples.
      • Topical anesthetic cream made of lidocaine and prilocaine should not be used in newborns because of the risk of methemoglobinemia.
      Correct
      

      It appears that a spoon full of sugar does help the medicine go down; more accurately, a spoonful of sugar is the medicine! Sucrose water (12% to 50%; typically, 1 packet of sugar in 10 mL of water) administered just prior to a procedure has been shown to decrease the pain associated with heel lance, venipuncture, and immunization. Remarkably, sucrose seems to use opioid pathways. In fact, in a rat model, the  effect of sucrose can be blocked by the use of an opioid antagonist such as naloxone.

      Sucrose can be administered via a pacifier or directly instilled into the mouth with a small syringe. It works best in the neonatal period and loses its efficacy by 4 to 6 months of age. Interestingly, this effect recently was shown to occur with an artificial sweetener (saccharin) as well. The combination of direct parental contact and sucrose seems to have an additive effect on pain reduction.

      Incorrect
      

      It appears that a spoon full of sugar does help the medicine go down; more accurately, a spoonful of sugar is the medicine! Sucrose water (12% to 50%; typically, 1 packet of sugar in 10 mL of water) administered just prior to a procedure has been shown to decrease the pain associated with heel lance, venipuncture, and immunization. Remarkably, sucrose seems to use opioid pathways. In fact, in a rat model, the  effect of sucrose can be blocked by the use of an opioid antagonist such as naloxone.

      Sucrose can be administered via a pacifier or directly instilled into the mouth with a small syringe. It works best in the neonatal period and loses its efficacy by 4 to 6 months of age. Interestingly, this effect recently was shown to occur with an artificial sweetener (saccharin) as well. The combination of direct parental contact and sucrose seems to have an additive effect on pain reduction.
   5. Question 5 of 25

      5. Question

      1 points
      Category: Head Injury

      A 17-year-old boy sustained a head injury while playing hockey. He was unresponsive to verbal stimuli for approximately 2 minutes. After recovering consciousness, he could not recall the events of the past few days, appeared confused, and complained of headache and dizziness for the next hour. Over the next 2 to 3 hours, he appears to have recovered completely, having no symptoms. Results of the neurologic examination are normal. He has had no previous history of head injury. He wants to resume playing hockey as soon as possible. Of the following, the most appropriate recommendation is that he:

      • Can play if his neurocognitive testing results are normal.
      • Can play as long as he continues to be symptom-free on exertion.
      • Can play after 1 week of remaining symptom-free on exertion.
      • Can resume playing now if CT of the head appears normal.
      • Should refrain from playing contact sports in the future.
      Correct
      

      Severity: Grade 2 (Moderate)
      Symptoms: LOC <5 min or PTA >30 min
      Management: Observation, Can play after 1 week of remaining symptom-free on exertion.

      Incorrect
      

      Severity: Grade 2 (Moderate)
      Symptoms: LOC <5 min or PTA >30 min
      Management: Observation, Can play after 1 week of remaining symptom-free on exertion.
   6. Question 6 of 25

      6. Question

      1 points
      Category: Head Injury

      A 3-year-old unresponsive girl is brought to the emergency department. She had fallen 3 hours earlier from a playground monkey bar that was approximately 6 feet high. She had cried immediately and appeared to recover well. One hour later, she started complaining of headache. She subsequently became lethargic, vomited twice, and was difficult to arouse.

      On examination, her heart rate is 70 beats/min, blood pressure is 130/90 mm Hg, and respirations are 18 breaths/min. Her Glasgow Coma Scale score is 6. Her right pupil is dilated and reacts sluggishly to light. A diffuse 6-cm swelling anterior and superior to her right ear and right hemotympanum are noted. After intubation and manual ventilation, CT of the head is obtained, which shows blood accumulation along the right lateral inner table of the skull, with a sharp convex margin and shift of the midline to the left. Which of the following is most likely to be associated with this injury?

      • Tear of meningeal artery.
      • Diffuse axonal injury.
      • Ethmoid bone fracture.
      • Rupture of the bridging veins.
      • Cavernous sinus thrombosis.
      Correct
      

      The convex shape of the hematoma is characteristic of an epidural hemorrhage.

      Studies report intracranial injuries in 6% to 30% of children who present with minor blunt trauma. Injuries include subdural, epidural, subarachnoid, intraventricular, and intraparenchymal hemorrhages; cerebral contusion;
      shearing injuries; and diffuse axonal injury. Epidural hematomas are rapid hemorrhages caused by tears of the meningeal arteries or veins and often are convex, as blood accumulates between the skull and dura mater. Epidural hemorrhages often are associated with temporal bone fractures. Patients sustaining epidural hemorrhages may have a lucent period for several hours after the initial injury, followed by rapid deterioration in mental status. When clinically unrecognized, such hemorrhages may be fatal. Patients who have epidural hemorrhages require close observation and immediate neurosurgical consultation and evaluation for possible surgical evacuation. The prognosis of isolated epidural hemorrhage after surgical evacuation is very good because injuries causing epidural hematomas generally do not damage the cerebral cortex.

      Incorrect
      

      The convex shape of the hematoma is characteristic of an epidural hemorrhage.

      Studies report intracranial injuries in 6% to 30% of children who present with minor blunt trauma. Injuries include subdural, epidural, subarachnoid, intraventricular, and intraparenchymal hemorrhages; cerebral contusion;
      shearing injuries; and diffuse axonal injury. Epidural hematomas are rapid hemorrhages caused by tears of the meningeal arteries or veins and often are convex, as blood accumulates between the skull and dura mater. Epidural hemorrhages often are associated with temporal bone fractures. Patients sustaining epidural hemorrhages may have a lucent period for several hours after the initial injury, followed by rapid deterioration in mental status. When clinically unrecognized, such hemorrhages may be fatal. Patients who have epidural hemorrhages require close observation and immediate neurosurgical consultation and evaluation for possible surgical evacuation. The prognosis of isolated epidural hemorrhage after surgical evacuation is very good because injuries causing epidural hematomas generally do not damage the cerebral cortex.
   7. Question 7 of 25

      7. Question

      1 points
      Category: Head Injury

      After receiving a helmet-to-helmet tackle while playing football, a 15-year-old boy was unresponsive to verbal stimuli for approximately 10 minutes. After he regained consciousness, it took him 4 hours to recall the events of the past few days. A CT scan of the head showed no abnormalities. Over the next 24 hours, he had a headache and ringing in his ears. One week after the event, he is completely symptom-free and says that he feels fine and wants to play football again. Allowing him to play football at this time would put him at increased risk of which of the following if he suffers a similar injury?

      • Rupture of bridging veins.
      • Intraventricular hemorrhage.
      • Intracerebral hematoma.
      • Diffuse cerebral edema.
      • Tear of meningeal artery.
      Correct
      

      Patients who undergo rapid acceleration or deceleration injuries to the head, as seen in motor vehicle accidents, falls, and abusive trauma (severe shaking), may develop DAI. DAI describes a widespread shearing injury of the white matter and should be suspected if a patient presents with diffuse subarachnoid bleeding and cerebral edema. Patients experiencing DAI frequently develop increased intracranial pressure (ICP). DAI also may occur after relatively minor head trauma to a person who recently had a first concussion (second impact syndrome).

      Incorrect
      

      Patients who undergo rapid acceleration or deceleration injuries to the head, as seen in motor vehicle accidents, falls, and abusive trauma (severe shaking), may develop DAI. DAI describes a widespread shearing injury of the white matter and should be suspected if a patient presents with diffuse subarachnoid bleeding and cerebral edema. Patients experiencing DAI frequently develop increased intracranial pressure (ICP). DAI also may occur after relatively minor head trauma to a person who recently had a first concussion (second impact syndrome).
   8. Question 8 of 25

      8. Question

      1 points
      Category: Head Injury

      A 5-year-old girl is brought to the emergency department after being struck by an automobile while crossing the street. At presentation, her Glasgow Coma Scale score is 9. Vital signs are: respirations, 20 breaths/min; heart rate, 140 beats/min; and blood pressure, 75/48 mm Hg. She has bruising and swelling of her right frontal and parietal area as well as a scalp laceration. Her pupils are normal and reactive to light. Abrasion and swelling are noted over her left leg. She is intubated orotracheally and ventilated manually. Of the following, the most appropriate plan for fluid management is:

      • Administration of normal saline (20 mL/kg) over 30 minutes.
      • Administration of 20% mannitol (1 g/kg) over 30 minutes.
      • Administration of 5% dextrose (20 mL/kg) over 30 minutes.
      • Restriction of fluid to two-thirds maintenance.
      • Administration of half-normal saline with 5% dextrose (20 mL/kg) over 30 minutes.
      Correct
      

      Fluid management is critically important in patients sustaining moderate or severe TBI. Maintaining systolic blood pressure allows adequate perfusion of all organs and ensures adequate cerebral perfusion pressure. Many clinicians are hesitant to hydrate the patient who has TBI aggressively for fear of increasing ICP. Several studies have demonstrated that hypotension is a sensitive predictor of morbidity and mortality. In fact, hypotension may lead to a twofold increase in mortality. Current recommendations for managing severe head trauma include maintaining systolic blood pressure in the normal range by infusing 20 mL/kg of isotonic crystalloid in boluses to prevent hypotension. If the blood pressure is normal, but increased ICP as well as uncal herniation are  suspected, mannitol (0.5 to 1 g/kg) should be administered. Mannitol decreases ICP acutely. Hypertonic saline has been used successfully to decrease ICP and provide fluid resuscitation after TBI.

      Incorrect
      

      Fluid management is critically important in patients sustaining moderate or severe TBI. Maintaining systolic blood pressure allows adequate perfusion of all organs and ensures adequate cerebral perfusion pressure. Many clinicians are hesitant to hydrate the patient who has TBI aggressively for fear of increasing ICP. Several studies have demonstrated that hypotension is a sensitive predictor of morbidity and mortality. In fact, hypotension may lead to a twofold increase in mortality. Current recommendations for managing severe head trauma include maintaining systolic blood pressure in the normal range by infusing 20 mL/kg of isotonic crystalloid in boluses to prevent hypotension. If the blood pressure is normal, but increased ICP as well as uncal herniation are  suspected, mannitol (0.5 to 1 g/kg) should be administered. Mannitol decreases ICP acutely. Hypertonic saline has been used successfully to decrease ICP and provide fluid resuscitation after TBI.
   9. Question 9 of 25

      9. Question

      1 points
      Category: Child Abuse

      A 7 yo child who is brought in to the ED by his mother for evaluation of burns to both hands that she reports he received today from washing his hands. On exam, he has multiple visible injuries including a black eye, a swollen deformed nose, multiple loop marks on his arms and partial thickness burns to the dorsum of both hands. He discloses to you that his mother caused all these injuries, and she has been hurting him and his sister for as long as he can remember. You inform the mother of your concerns and tell her you are making a report to Children’s Protective Services. The mother tries to leave with the child. Which of the following is the most appropriate approach to treatment and disposition?

      • Treat the child and then let him leave with another family member
      • Transfer the mother and child to another hospital for higher level of care
      • Take protective custody of the child, notify Children’s Protective Services immediately, and treat the child
      • Forcibly remove the mother from the hospital and treat the child
      • Have the mother sign the child out Against Medical Advice(AMA)
      Correct
      

      Physicians, nurses, teachers and others who are responsible for children are mandated reporters and, as such, are required by law to report any suspicion of child abuse to protective services. In this situation, a report must be made. Failure to do so would be a Class A misdemeanor. Physicians and police officers have the ability to take protective custody of any child deemed to be in imminent danger. This ensures the safety of the child. This child has disclosed abuse and has clear physical evidence of abuse. Once you have taken custody, you are then required to make a report to Children’s Protective Services who will then go to court and have the state obtain custody of the child. None of the other answers are appropriate choices to ensure the safety of this child.

      Reference:
      Wood JN, Ludwig S. Child Abuse. Fleisher GR, Ludwig S (eds). Textbook of Pediatric Emergency Medicine, 6th ed. Lippincott Williams & Wilkins 2010, pp 1656-1700. pp 1656-1700

      Incorrect
      

      Physicians, nurses, teachers and others who are responsible for children are mandated reporters and, as such, are required by law to report any suspicion of child abuse to protective services. In this situation, a report must be made. Failure to do so would be a Class A misdemeanor. Physicians and police officers have the ability to take protective custody of any child deemed to be in imminent danger. This ensures the safety of the child. This child has disclosed abuse and has clear physical evidence of abuse. Once you have taken custody, you are then required to make a report to Children’s Protective Services who will then go to court and have the state obtain custody of the child. None of the other answers are appropriate choices to ensure the safety of this child.

      Reference:
      Wood JN, Ludwig S. Child Abuse. Fleisher GR, Ludwig S (eds). Textbook of Pediatric Emergency Medicine, 6th ed. Lippincott Williams & Wilkins 2010, pp 1656-1700. pp 1656-1700
   10. Question 10 of 25

       10. Question

       1 points
       Category: Child Abuse

       A 2 mo infant presents to the ED in full arrest with CPR in progress. The baby’s father, who was watching the infant, reported he found the infant unresponsive in the crib. According to the father, he has no medical problems. On exam there is a firm, bulging fontanel, the pupils are dilated, and the funduscopic examination is shown here:

       

       The findings shown in the photograph are most consistent with what diagnosis?

       • Normal spontaneous vaginal delivery
       • Abusive head trauma (AHT)
       • Coughing due to pertussis
       • Sudden infant death syndrome
       • Increased intracranial pressure
       Correct
       

       The picture demonstrates retinal hemorrhages, which have been reported in as many as 85% of surviving victims of abusive head injuries and in 100% of fatalities. Retinal hemorrhages from abuse are unique in that they can be unilateral or bilateral, present in all 3 layers of the retina, extend out to the periphery, and are described as too numerous to count. They may be present with or without extra-axial hemorrhages or other injuries. They may present as the only manifestation of abuse. The remaining answers are incorrect. Retinal hemorrhages cannot be dated. In the majority of cases they do not result in permanent vision loss. Retinal hemorrhages from birth are usually few in number but may be numerous, and are localized to the posterior pole or the intraretinal layer. The majority resolve by 10 days, and almost all by 6 weeks. Retinal hemorrhages associated with increased intracranial pressure are also few in number and located at the posterior pole. An ophthalmology consult is indicated within the first 24 hours of presentation, but can be delayed if the child’s neurological status is tenuous. It should not be delayed more than 72 hours. Cardiopulmonary resuscitation is not associated with retinal hemorrhages. Pertussis and SIDS are likewise not associated with retinal hemorrhages.

       Reference:

       • Keenan H. Epidemiology of Abusive Head Trauma. Child Abuse and Neglect. 2011.
       • Watts P, et. al. Newborn Retinal Hemorrhages: A Systematic Review. Journal American Academy of Ophthamology and Strabismus. 2013;17(1): 70-78.

       Incorrect
       

       The picture demonstrates retinal hemorrhages, which have been reported in as many as 85% of surviving victims of abusive head injuries and in 100% of fatalities. Retinal hemorrhages from abuse are unique in that they can be unilateral or bilateral, present in all 3 layers of the retina, extend out to the periphery, and are described as too numerous to count. They may be present with or without extra-axial hemorrhages or other injuries. They may present as the only manifestation of abuse. The remaining answers are incorrect. Retinal hemorrhages cannot be dated. In the majority of cases they do not result in permanent vision loss. Retinal hemorrhages from birth are usually few in number but may be numerous, and are localized to the posterior pole or the intraretinal layer. The majority resolve by 10 days, and almost all by 6 weeks. Retinal hemorrhages associated with increased intracranial pressure are also few in number and located at the posterior pole. An ophthalmology consult is indicated within the first 24 hours of presentation, but can be delayed if the child’s neurological status is tenuous. It should not be delayed more than 72 hours. Cardiopulmonary resuscitation is not associated with retinal hemorrhages. Pertussis and SIDS are likewise not associated with retinal hemorrhages.

       Reference:

       • Keenan H. Epidemiology of Abusive Head Trauma. Child Abuse and Neglect. 2011.
       • Watts P, et. al. Newborn Retinal Hemorrhages: A Systematic Review. Journal American Academy of Ophthamology and Strabismus. 2013;17(1): 70-78.
   11. Question 11 of 25

       11. Question

       1 points
       Category: Child Abuse

       A 2 mo infant presents to the ED in full arrest with CPR in progress. The baby’s father, who was watching the infant, reported he found the infant unresponsive in the crib. According to the father, he has no medical problems. On exam there is a firm, bulging fontanel, the pupils are dilated, and the funduscopic examination is shown here:

       

       This patient has a prolonged PT and PTT. What is the most likely cause?

       • Hemophilia A
       • Idiopathic thrombocytopenia purpura (ITP)
       • von Willebrand disease
       • Vitamin K deficiency
       • Abusive head trauma (AHT)
       Correct
       

       The most appropriate answer in this clinical situation is AHT. Injury of the brain parenchyma results in a cascade of fibrinolysis and thrombosis leading to abnormal coagulation studies and DIC, leading to prolonged PT and PTT values. This is a self-limited phenomenon and does not require treatment for correction. ITP does not present with elevated PT or PTT. Von Willebrand disease does not cause an elevation in PT, and only in significant disease does it cause an elevation of the PTT. Vitamin K deficiency presents in infants who do not receive Vitamin K supplementation in the delivery room or those with liver disease, cystic fibrosis or other significant illness. Infants who do not receive Vitamin K present within the first 12 weeks of life, and can present with a subarachnoid hemorrhage, but rarely with retinal hemorrhages. Cystic fibrosis and liver disease causing Vitamin K deficiency would be associated with other systemic signs and symptoms consistent with these illnesses. Hemophilia is an x-linked genetic disorder that presents with profoundly elevated PTT. Often, it is associated with other signs of bruising and bleeding. A good review of systems and family history would assist in excluding this diagnosis.

       Reference:
       Greeley C. Conditions Confused with Head Trauma. Child Abuse and Neglect. 2011, pp 441-451.

       Incorrect
       

       The most appropriate answer in this clinical situation is AHT. Injury of the brain parenchyma results in a cascade of fibrinolysis and thrombosis leading to abnormal coagulation studies and DIC, leading to prolonged PT and PTT values. This is a self-limited phenomenon and does not require treatment for correction. ITP does not present with elevated PT or PTT. Von Willebrand disease does not cause an elevation in PT, and only in significant disease does it cause an elevation of the PTT. Vitamin K deficiency presents in infants who do not receive Vitamin K supplementation in the delivery room or those with liver disease, cystic fibrosis or other significant illness. Infants who do not receive Vitamin K present within the first 12 weeks of life, and can present with a subarachnoid hemorrhage, but rarely with retinal hemorrhages. Cystic fibrosis and liver disease causing Vitamin K deficiency would be associated with other systemic signs and symptoms consistent with these illnesses. Hemophilia is an x-linked genetic disorder that presents with profoundly elevated PTT. Often, it is associated with other signs of bruising and bleeding. A good review of systems and family history would assist in excluding this diagnosis.

       Reference:
       Greeley C. Conditions Confused with Head Trauma. Child Abuse and Neglect. 2011, pp 441-451.
   12. Question 12 of 25

       12. Question

       1 points
       Category: Child Abuse

       The patient’s brain CT is shown here:

       

       Which of the following statements is most accurate regarding the CT findings?

       • The presence of old and new subdural hemorrhages impliesmore than one episode of injury
       • The old subdural is likely due to birth trauma
       • The new subdural is likely a re-bleed from birth trauma
       • These represent benign effusions of infancy
       • This represents CT volume averaging
       Correct
       

       Multiple subdural hemorrhages of different densities on head CT are consistent with separate episodes of head injury. The American Academy of Pediatrics no longer uses the term Shaken Baby Syndrome when referring to children who have been the victims of non-accidental head injuries. They have adopted the term Abusive Head Trauma (AHT). AHT has the highest mortality and morbidity of all forms of abuse. Societal risk factors include socioeconomic and emotional stress. Family factors include single family homes, drug and alcohol dependency, and young maternal age. Children under 4 years old are at highest risk. Males have been identified as the perpetrator in 60% of cases, including fathers and boyfriends. Physical abuse often follows a crying episode by the child. Extracranial injuries include bruising, fractures and intra-abdominal injuries. A subdural hemorrhage associated with birth is usually asymptomatic and resolves by 3 months of age. The phenomenon of re-bleed is often used as an explanation by defense attorneys to explain mixed subdural hemorrhages. The outer vasculature of a subdural can bleed resulting in an acute subdural. When they occur, they are small in size and are not clinically significant. They do not result in cardiopulmonary arrest. Benign extra-axial fluid collection of infancy is felt to be an imbalance between CSF production and absorption. The collections are hypodense and clinically asymptomatic. They can be distinguished from a chronic subdural by the absence of a neomembrane. Volume averaging should not be confused with multiple subdural hemorrhages; it is seen at interface of bone and brain tissue.

       Reference:
       Tung G. Imaging of Abusive Head Trauma. Child Abuse and Neglect 2011 pp 373-392.

       Incorrect
       

       Multiple subdural hemorrhages of different densities on head CT are consistent with separate episodes of head injury. The American Academy of Pediatrics no longer uses the term Shaken Baby Syndrome when referring to children who have been the victims of non-accidental head injuries. They have adopted the term Abusive Head Trauma (AHT). AHT has the highest mortality and morbidity of all forms of abuse. Societal risk factors include socioeconomic and emotional stress. Family factors include single family homes, drug and alcohol dependency, and young maternal age. Children under 4 years old are at highest risk. Males have been identified as the perpetrator in 60% of cases, including fathers and boyfriends. Physical abuse often follows a crying episode by the child. Extracranial injuries include bruising, fractures and intra-abdominal injuries. A subdural hemorrhage associated with birth is usually asymptomatic and resolves by 3 months of age. The phenomenon of re-bleed is often used as an explanation by defense attorneys to explain mixed subdural hemorrhages. The outer vasculature of a subdural can bleed resulting in an acute subdural. When they occur, they are small in size and are not clinically significant. They do not result in cardiopulmonary arrest. Benign extra-axial fluid collection of infancy is felt to be an imbalance between CSF production and absorption. The collections are hypodense and clinically asymptomatic. They can be distinguished from a chronic subdural by the absence of a neomembrane. Volume averaging should not be confused with multiple subdural hemorrhages; it is seen at interface of bone and brain tissue.

       Reference:
       Tung G. Imaging of Abusive Head Trauma. Child Abuse and Neglect 2011 pp 373-392.
   13. Question 13 of 25

       13. Question

       1 points
       Category: Child Abuse

       Of the following clinical scenarios, which is the most suspicious for abuse?

       • A 2 yo with a fracture of the right humerus with a lytic lesion at the fracture site
       • A 2 mo admitted for respiratory distress is found to have 2acute rib fractures. He has a history of severe prematurity, prolonged ventilator course, bronchopulmonary dysplasia,and is on home oxygen and furosemide.
       • An 11 yo with Duchene Muscular Dystrophy with a fracture of the femur after falling out of his wheel chair
       • A 5 yo with blue sclera and history of multiple fractures who presents with a tibia fracture after falling out of bed
       • An otherwise healthy 3 mo who presents to the ED with new onset seizures and is found to have multiple healing posterior rib fractures
       Correct
       

       When evaluating children with fractures, it is important to be aware of conditions that can be confused with abuse. By obtaining a complete history, review of systems, family medical history, performing a thorough medical exam, and then obtaining pertinent laboratory or radiological studies, misdiagnosis can be avoided. The 3 mo infant has no clinical reason to have rib fractures, and so his injuries are most consistent with abuse. Patients with seizure disorders have occasionally sustained limb fractures during status but not typically rib fractures. Posterior rib fractures are the result of squeezing. Infants with severe prematurity and very low birth weight (less than 1500 grams), who have had a prolonged ventilator course and on furosemide, are at high risk for poor bone mineralization and decreased bone density. This places them at increased risk for fractures. This risk does not persist into early childhood. The toddler has sustained a pathologic fracture associated with a lytic lesion. Children with muscular dystrophy or other disorders, who have limited mobility, will develop osteoporosis, a reduction in bone mass, and are susceptible to fractures with minor trauma. The 5 yo, by history and exam, has osteogenesis imperfecta, which is a genetic disorder with abnormal collagen production resulting in decreased bone formation and increased bone turnover. This results in loss of bone strength and occurrence of fractures with minor trauma.

       Reference:
       Bennett B, Clyde Pierce M. Bone Health and Development. Child Abuse and Neglect. 2011, pp 260-275.

       Incorrect
       

       When evaluating children with fractures, it is important to be aware of conditions that can be confused with abuse. By obtaining a complete history, review of systems, family medical history, performing a thorough medical exam, and then obtaining pertinent laboratory or radiological studies, misdiagnosis can be avoided. The 3 mo infant has no clinical reason to have rib fractures, and so his injuries are most consistent with abuse. Patients with seizure disorders have occasionally sustained limb fractures during status but not typically rib fractures. Posterior rib fractures are the result of squeezing. Infants with severe prematurity and very low birth weight (less than 1500 grams), who have had a prolonged ventilator course and on furosemide, are at high risk for poor bone mineralization and decreased bone density. This places them at increased risk for fractures. This risk does not persist into early childhood. The toddler has sustained a pathologic fracture associated with a lytic lesion. Children with muscular dystrophy or other disorders, who have limited mobility, will develop osteoporosis, a reduction in bone mass, and are susceptible to fractures with minor trauma. The 5 yo, by history and exam, has osteogenesis imperfecta, which is a genetic disorder with abnormal collagen production resulting in decreased bone formation and increased bone turnover. This results in loss of bone strength and occurrence of fractures with minor trauma.

       Reference:
       Bennett B, Clyde Pierce M. Bone Health and Development. Child Abuse and Neglect. 2011, pp 260-275.
   14. Question 14 of 25

       14. Question

       1 points
       Category: Child Abuse

       Which of the following clinical scenarios is the most concerning for being an abusive injury?

       • A 6 mo who fell from her mother’s arms onto a tile kitchen floor and has a non-depressed linear parietal skull fracture
       • A 3 yo toddler who fell running across a wet kitchen floor and sustained a spiral fracture of the right femur
       • A 3 mo infant with bronchiolitis who has multiple posterior rib fractures with callous formation
       • A 2 yo who fell running in the park and has a buckle fracture of the radius
       Correct
       

       When assessing fractures for an abusive injury, consider 2 questions: 1) Is the child developmentally capable of performing such an act? and 2) Will the mechanism described result in the injury? The 9, 3 and 2 year olds are all capable of these actions and the scenarios could result in the fractures described. A 6 mo who is dropped onto tile could sustain a simple linear skull fracture. Falls greater than 4 feet, onto a hard surface, can cause non-life-threatening skull fractures. Skull fractures that are complex and cross suture lines are more circumspect for abuse. A healthy, normal 3 mo baby should not have healing rib fractures from a respiratory illness. This is an abusive injury until proven otherwise. Other fractures highly suggestive of abuse are metaphyseal fractures of the long bones, specifically of the humerus, femur and tibia. The x-ray below illustrates callus formation of posterior rib fractures.

       

       Reference:
       Kaczor K, Clyde Pierce M. Abusive Fractures. Child Abuse and Neglect. 2011, pp 275-296.

       Incorrect
       

       When assessing fractures for an abusive injury, consider 2 questions: 1) Is the child developmentally capable of performing such an act? and 2) Will the mechanism described result in the injury? The 9, 3 and 2 year olds are all capable of these actions and the scenarios could result in the fractures described. A 6 mo who is dropped onto tile could sustain a simple linear skull fracture. Falls greater than 4 feet, onto a hard surface, can cause non-life-threatening skull fractures. Skull fractures that are complex and cross suture lines are more circumspect for abuse. A healthy, normal 3 mo baby should not have healing rib fractures from a respiratory illness. This is an abusive injury until proven otherwise. Other fractures highly suggestive of abuse are metaphyseal fractures of the long bones, specifically of the humerus, femur and tibia. The x-ray below illustrates callus formation of posterior rib fractures.

       

       Reference:
       Kaczor K, Clyde Pierce M. Abusive Fractures. Child Abuse and Neglect. 2011, pp 275-296.
   15. Question 15 of 25

       15. Question

       1 points
       Category: Child Abuse

       A 4 mo infant presents with swelling and tenderness to his left foot and ankle. Arrows in the ankle radiographs below reveal findings most consistent with:

       

       • No fracture, but a normal ossification center
       • A fracture from a twisting mechanism
       • A fracture from a direct blow
       • A fracture as the result of traction
       • No fracture, but a normal epiphysis
       Correct
       

       This infant has sustained a metaphyseal fracture of his distal tibia. These fractures are either from violent shaking or traction as when the child is pulled. This is not the fracture pattern seen with a fall or twist. It is not a normal variant, ossification center, or epiphysis.

       Reference:
       Kaczor K, Clyde Pierce M. Abusive Fractures. Child Abuse and Neglect. 2011, pp 275-296.

       Incorrect
       

       This infant has sustained a metaphyseal fracture of his distal tibia. These fractures are either from violent shaking or traction as when the child is pulled. This is not the fracture pattern seen with a fall or twist. It is not a normal variant, ossification center, or epiphysis.

       Reference:
       Kaczor K, Clyde Pierce M. Abusive Fractures. Child Abuse and Neglect. 2011, pp 275-296.
   16. Question 16 of 25

       16. Question

       1 points
       Category: Sedation

       Patients May easily progress from one level of sedation to a deeper level of sedation.

        

       • True
       • False
       Correct
       

       Incorrect
       
   17. Question 17 of 25

       17. Question

       1 points
       Category: Sedation

       _______ is a drug induced depression of consciousness during which patients respond purposefully to verbal commands either alone or accompanied by light tactile stimulation. No intervention is needed to maintain patent airway and spontaneous ventilation is adequate. CV function is usually maintained.

       • Minimal Sedation
       • Moderate Sedation
       • Deep Sedation
       • General Anesthesia
       Correct
       

       Pediatric patients often require sedation for procedures to decrease anxiety, improve cooperation, or provide pain relief. It is important to remember that conscious sedation, now termed moderate sedation and analgesia, is only one point in a continuum. During moderate sedation and analgesia, the patient is easily arousable to verbal or tactile (not painful) stimuli. It is essential to follow established guidelines for proper observation and monitoring of patients to ensure their safety and identify when they drift into deeper levels of sedation.

       Incorrect
       

       Pediatric patients often require sedation for procedures to decrease anxiety, improve cooperation, or provide pain relief. It is important to remember that conscious sedation, now termed moderate sedation and analgesia, is only one point in a continuum. During moderate sedation and analgesia, the patient is easily arousable to verbal or tactile (not painful) stimuli. It is essential to follow established guidelines for proper observation and monitoring of patients to ensure their safety and identify when they drift into deeper levels of sedation.
   18. Question 18 of 25

       18. Question

       1 points
       Category: Sedation

       ________is a drug induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway and PPV may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. CV function may also be impaired

       • Minimal Sedation
       • Moderate Sedation
       • Deep Sedation
       • General Anesthesia
       Correct
       

       Incorrect
       
   19. Question 19 of 25

       19. Question

       1 points
       Category: Sedation

       ________is a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and CV functions are unaffected.

       • Minimal Sedation
       • Moderate Sedation
       • Deep Sedation
       • General Anesthesia
       Correct
       

       Incorrect
       
   20. Question 20 of 25

       20. Question

       1 points
       Category: Sedation

       _______ is a drug induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimluatio. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. CV function is usually maintained.

       • Minimal Sedation
       • Moderate Sedation
       • Deep Sedation
       • General Anesthesia
       Correct
       

       Incorrect
       
   21. Question 21 of 25

       21. Question

       1 points
       Category: Sedation

       All patients undergoing procedural sedation must be continually monitored with:

        

       • pulse oximeter
       • ECG monitor
       • CO2 monitor
       • thermometer
       Correct
       

       Monitoring should include continuous pulse oximetry, visual or ausculatory assessment of ventilation, and noninvasive blood pressure measurement every 5 minutes. Monitoring of the electrocardiogram is not required for moderate sedation/analgesia unless the patient has a history of significant cardiovascular disease.

       Incorrect
       

       Monitoring should include continuous pulse oximetry, visual or ausculatory assessment of ventilation, and noninvasive blood pressure measurement every 5 minutes. Monitoring of the electrocardiogram is not required for moderate sedation/analgesia unless the patient has a history of significant cardiovascular disease.
   22. Question 22 of 25

       22. Question

       1 points
       Category: Sedation

       Emergency equipment that should be readily available f9r use during procedural sedation include all of the following EXCEPT:

        

       • ECG monitor
       • pulse oximeter
       • suction
       • Nitrous oxide
       Correct
       

       Because respiratory depression is the most likely complication associated with conscious sedation, size appropriate resuscitation equipment, including ventilation bag and mask, as well as an oxygen source, should be immediately available. Basic resuscitation medications, including naloxone (opioid antagonist) and flumazenil (benzodiazepine antagonist), also should be on site.

       Incorrect
       

       Because respiratory depression is the most likely complication associated with conscious sedation, size appropriate resuscitation equipment, including ventilation bag and mask, as well as an oxygen source, should be immediately available. Basic resuscitation medications, including naloxone (opioid antagonist) and flumazenil (benzodiazepine antagonist), also should be on site.
   23. Question 23 of 25

       23. Question

       1 points
       Category: Sedation

       History and physical examinations for procedural sedation are valid for ______ but should always be reviewed just prior to the procedure.

        

       • 24h
       • 1 week
       • 2 weeks
       • 30 days
       Correct
       

       Incorrect
       
   24. Question 24 of 25

       24. Question

       1 points
       Category: Sedation

       Which of the following conditions is associated with INCREASED complications during sedation?

        

       • Short neck
       • History of prematurity
       • Micrognathia
       • Sleep apnea
       • All of the above
       Correct
       

       Incorrect
       
   25. Question 25 of 25

       25. Question

       1 points
       Category: Sedation

       Routes of midazolam administration include:

       • IM
       • IN
       • IV
       • PO
       • all of the above
       Correct
       

       Incorrect
       
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