Pediatric Emergency Medicine Board Review Course

The following revisions were made to P2017 after the initial release in November 2016.  Changes 1-7 have been incorporated into books purchased after 5/1/17.  See note below for updates past this point.

1) Page 309. Chapter 36: Toxicologic Emergencies. Answer explanation for 28. There is a correction in the answer explanation regarding the likelihood of seizures and dysrhythmia. The majority of the answer explanation is the same. See the bolded red changes below for the revision:

28) Answer: b. There has been TCA exposure, but no cardiotoxicity. In TCA exposures, the ECG is used to confirm exposure and to prognosticate major toxicity. The final part of the QRS complex, specifically the terminal 40 milliseconds, shows changes that result from exposure to a TCA. These are evident in patients taking the medication therapeutically, as well as patients who have overdosed. These findings are sensitive and specific for exposure, and do not predict toxicity, unless you consider the lack of exposure to negatively predict toxicity, which is one way the ECG is used in these cases. The terminal 40 millisecond changes in TCA exposure include an R wave in aVR, and an S wave in aVL and I. Toxicity may be predicted by QRS width as well as R wave height in aVR. A QRS width > 100 milliseconds is predictive of seizure, and 30% of patients with this widened QRS experienced a seizure in one report. If the QRS width widens to 160 milliseconds, there is a 50% chance the patient will experience a seizure as well as dysrhythmia. Particularly in children, R wave height greater than 10 mm in aVR predicts dysrhythmia. In this patient, there are terminal 40 millisecond changes, meaning exposure, but no evidence of cardiotoxicity on the ECG. The mental status does not predict major toxicity after TCA exposure, and nor do vital signs, though both mental status and vital signs should be monitored closely. In the event of a widened QRS, the typical treatment is the administration of 1 mEq/kg of sodium bicarbonate by fast IV push while running an ECG rhythm strip. If there is QRS narrowing in response to the sodium bicarbonate bolus, a sodium bicarbonate infusion should be strongly considered. [5-Min PEM pp 984-5; Goldfrank’s pp 972-80; Poison & Drug OD pp 97-8]

2) Page 220. Chapter 27: Orthopedic Emergencies. Answer explanation for 11. The answer was incorrect and should appear as follows with the additional edits to the explanation:

Answer: d. X-rays of the hips. This patient has developmental dysplasia of the hip. Typically, this is diagnosed in infancy; however, when not identified in infancy, it may become apparent when the child has a limp at the onset of walking. Often the hip dysplasia is noted when the child has abnormal hip abduction, abnormal gluteal/thigh/labial folds, and limb-length inequality on PE. For children older than 4-6 months, x-ray is the recommended study to evaluate for possible hip dysplasia. In contrast, US is the preferred imaging modality for children less than 4-6 months when the femoral epiphysis is unossified. Physical therapy and NSAIDs are not the appropriate treatments for this child who should follow up with an orthopedic surgeon once the diagnosis is made. Given the history and PE, laboratory evaluation is not warranted. [F&L pp 281; Lovell and Winter pp 991; Rosenfeld UTD]



3) Page 113. Chapter 14. Medical Emergencies: Hematology and Oncology. Question and Answer 11. There is no change in the question and answer in general, except that aspiration and irrigation of the corpus cavernosum is an incorrect answer, but a management option that may be indicated later, rather than aspiration and irrigation of the corpus callosum, which is what is written in the Question and Answer as option d, and is not indicated.

4) Page 363. Chapter 44. Research Methods and Statistics I. Question and Answer 17. The terminology was incorrect, and risk ratio should be replaced by risk difference, as follows:

Question stem: In a randomized controlled trial, 607 children with histories of recurrent, severe lower respiratory tract illnesses were randomized to either receive azithromycin or placebo at the first sign of a respiratory tract infection [Bacharier LB, et al. Early Administration of Azithromycin and Prevention of Severe Lower Respiratory Tract Illnesses in Preschool Children With a History of Such Illnesses: A Randomized Clinical Trial. JAMA 2015;314(19):2034-2044]. 443 children were treated for respiratory tract illnesses (azithromycin group, 223; placebo group, 220), including 92 who had severe lower respiratory tract illnesses (azithromycin group, 35; placebo group, 57). Azithromycin significantly reduced the risk of progressing to severe lower respiratory tract illnesses compared to placebo, with an absolute risk for first respiratory tract infection: 0.05 for azithromycin, 0.08 for placebo, and thus a risk difference of 0.03.

Answer stem: Answer: e. 33. The number-needed-to-treat (NNT) is calculated as the reciprocal of the risk difference, as in this study, or absolute risk reduction, depending on the study design. In this study, the risk difference is 0.03 or 3/100. Therefore, the NNT would be 100/3, or 33.

5) Page 275. Chapter 33. Trauma: Burn Management and Wound Care. Answer 9. The answer explanation is modified slightly, changing "10" to "7" as per the CDC recommendations. The change is bolded and red as noted below:

Answer stem: Answer: d. DTaP and TIG. Clinicians ... Patients ≥ 7 years of age should receive Tdap, although dT will suffice if Tdap is not available. These patients will require Tdap after an interval of 5 years. [F&L pp 1178-94]



6) Page 74. Chapter 9: Medical Emergencies: Gastrointestinal. Question Step 21. "unconjugated" should be changed to "conjugated" as highlighted in red below. The rest of the question and answer is correct.