American Board of Pediatrics (ABP) initial certification exam for the first time, . PDF version of the Q&A book and go through one or two questions. 6. Dear Colleague: I am pleased to invite you to attend our 25th Annual Pediatric Board Review on August 26 – 30,. in Cleveland, Ohio. This nationally. Comprehensive intense review of General and Subspecialty Pediatrics. ❖ Various Over board-style questions using online pre and post self- assessment.

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Prepare for the Pediatric Board Exam and earn CME credit. • Take the Review the answers and explanations, and identify your knowledge gaps. • Review. Pediatric Board Study Guide: A Last Minute Review is designed for pediatricians who are preparing for the pediatric board examination, as an excellent guide for. High Yield Pediatrics. Shelf Exam Review. Emma Holliday Ramahi .. AR is an ADA deficiency. Pediatric emergency! Need bone marrow transplant by age 1 or.

If you are superstitious and want to go by historical luck, then check out the Pediatric Board Pass Rates. Good luck! This list indicates relative emphasis of each topic in the examination. Boards Books site. McGraw Hill Pediatric Boards. Pediatric Board Review. Pediatrics Board Review. NEW Edition. Pediatric Board Review, Pearls of Wisdom. Critical Life Events Management When death is anticipated, information about expecta- Death tions and effective counseling will help family bereave- ment.

Understanding of death and expression of grief are deter- Every member of the family needs to be included in the mined by chronologic age and levels of cognitive devel- process as appropriate. These are coupled with circumstances of death; Depending on the child developmental stage, a dying and the familys cultural and religious background.

[PDF] Pediatric Board Review: Pearls of Wisdom, Third Edition Full Online

Levels of cognitive and behavioral development differ by The pediatrician can provide information and support by age Table1: It is also appropriate for pediatricians to show emotion. Parents do appreciate the depth of their doctors emo- children with 26 years have preoperational.

Pediatricians need resources and support within the medi- Grief reactions occur in different domains that include the cal community to help cope most effectively with the emotional, cognitive, physical, and social domains: Table 1 Level of cognitive and behavioral aspects of developing an understanding of death by age.

Adapted from Pediatrics in Review, Vol. Existential implications Death as an adversary. Management The timing of transition to an adult health-care practi- The developmental stage of a child will have an effect on tioner should be individualized for each patient and not the childs response to divorce.

Consistency in parenting techniques and discipline as a The portable medical summary should include all rele- way to promote stability and predictability vant medical and care information. Pediatrician should avoid taking sides or overidentifying Encourage patients and families to identify an adult with one parent versus another. Medical professionals should be careful to refrain from providing legal advice and refer those questions to the Management parents legal counsel.

Early discussion of future goals with the patient, family, Pediatricians are encouraged to monitor the emotional and other members of the team to coordinate the process and behavioral adjustment of children of divorced par- Promote independence and shared decision-making ents. Identification of potential obstacles to a successful transi- Parenting plans could result from agreement between two tion in the domains of health care, education, vocation, cooperating parents, mediation, and through the courts.

Parents should be encouraged to acknowledge the sexual- ity of their adolescent and young adult children as well as to foster the development of their social independence. The role of a surrogate decision-maker should be dis- cussed for those with severe intellectual disabilities or mental health conditions. Psychological Issues and Problems Full independence for medical or other decisions may not Blood specimens for complete blood count CBC , serum be appropriate.

Hepatitis C serologies, if Disciplinary approaches depend on the child develop- emigrating from hepatitis C endemic area mental stage. Newborn metabolic screen for infants Time-out for negative behavior is an effective strategy for age 1 year to early adolescence.

Time-out will be effective if parents also provide time-in Media with short nonverbal physical contact on a frequent basis for acceptable behavior. Impact of mass media Extinction occurs when parent should withdraw all atten- Children younger than 2 years of age should not watch tion with an undesirable behavior.

This may initially television TV. In chip system, the child earns a chip for positive behav- Education of parents on links between television viewing, ior ages 37 years. Potential negative effects of TV viewing on children Adoption include Increased aggressive behavior, acceptance of violence, General considerations obscures distinction between fantasy and reality; trivial- Depending on their country of origin, international adop- izes sex and sexuality tees may be at risk for certain infectious diseases, particu- Increased passivity, obesity, and risk of suicidal behavior larly parasitic infections.

Less time spent in healthier activities Children adopted from institutional or orphanage cares are more at risk for such medical and developmental problems than are their counterparts who have resided in Foster Care foster care. The pediatrician also should help review any information Foster care is a system in which a minor who has been about the childs medical history if available before and placed into a ward, group home, or private home of a state after adoption.

Adoptive parents need to provide sufficient time, security, This is usually arranged through the government or a and love when the adopted child arrives. Family or parental leaves are recommended to provide All legal decisions are made by the state through the fam- consistent caregivers for the child and allow bonding to ily court and child protection agency, the foster parent is occur.

Family-based foster care is generally preferred to other Evaluation of adopted children forms of out-of-home care. Comprehensive physical examination, immunization sta- Foster care is intended to be a short-term solution until a tus and appropriate catch-up immunization permanent placement or adoption can be made. Hearing and vision screening Children in foster care suffer more physical, psychologi- cal, and cognitive problems.

Background Background Nocturnal enuresis is involuntary passage of urine during Functional encopresis is defined as repeated involuntary sleep in children older than 5 years of age and occurs in fecal soiling that is non-organic. Commoner in males than in females and often a positive Enuresis and urinary tract infections are comorbidities family history that need to be addressed.

Nocturnal enuresis is common among school-age chil- Encopresis predisposes to urinary tract infection and dren. Successful treatment of encopresis varies with the age of Daytime wetting could result from stressful events such onset; and relapses are common. Daytime wetting and a difficult temperament are at increased risk for constipation and encopresis.

Psychosomatic Disorders Management Diurnal enuresis after continence is achieved should Somatization prompt evaluation. Somatization disorders occur in children who are geneti- Treatment approaches for nocturnal enuresis includes cally predisposed.

Conversion disorders indicate symptoms and signs of Daytime incontinence could be secondary to environmen- sensory or voluntary motor function e. Patients who have both daytime incontinence and noctur- Psychosomatic disorders with chronic pain may be mani- nal enuresis have a higher degree of functional bladder festations of parental anxiety and parental pressure for a abnormalities and a higher failure rate with conventional child to succeed.

Clinical presentation Reassuring parents about coping with enuresis without The symptoms could be a symbolic attempt to resolve causing psychological problems.

The symptoms often result in increased attention for the The family should be provided guidelines on implement- patient secondary gain. Any form of stress could contribute to psychosomatic dis- Referral to a therapist may be considered if behavior orders; these include bullying, physical or sexual abuse. Sibling rivalry could also manifest with regressive behav- The common symptoms include chronic pain syndromes ior following the birth of a new sibling. Differential diagnosis of conversion symptoms include: Psychophysiology hypochondriasis Separation Anxiety and School Refusal Malingering Somatic delusions General considerations Anxiety disorders are the most common psychiatric ill- Treatment approaches for psychosomatic disorders ness in children and adolescents.

Cognitive and behavioral interventions The neurobiology of anxiety disorders is linked to dys- Use positive and negative reinforcement regulation in the fear and stress response system in the Teach self-monitoring techniques e. Separation anxiety disorder is one of the most common Improve communication between clinicians and school causes of school refusal. Aggressively treat comorbid psychiatric conditions Separation anxiety is developmentally appropriate in the Psychopharmacologic interventions as appropriate preschool child and during the first few months of school in kindergarten or first grade.

School refusal related to anxiety differs from conduct Pain problems and subsequent truancy. Youth who exhibit truancy generally do not report other Dealing with and tolerance to pain vary with a childs symptoms of anxiety or issues of separation from parents.

Pain is subjective, and repeated painful experiences can Treatment result in altered pain sensitivity and behavioral distur- In school refusal due to separation anxiety disorder, the bances. Cognitive behavioral therapy CBT Newborns may be at greater risk for pain wind-up, in Pharmacotherapy: Selective serotonin reuptake inhibitors which repeated painful stimuli produce central sensitiza- SSRIs tion and a resultant hyperalgesic state. This necessitates Decrease stress, sleep hygiene, healthy eating, and regu- adequate management of pain.

Non-pharmacologic measures include open communica- Sleep Disorders tion, reassurance, and parental presence. Sucrose use depends on developmental status and condi- Normal sleep Table 2 tion of the patient. Newborns can sleep h in a h period, alternating between 1- and 4-h periods of sleep and 12h of being awake.

At the end of each cycle, the newborn may experience an Children should be allowed to resolve their differences arousal that is not true awakening. Table 2 Appropriate sleep duration by age Age Average sleep duration Newborn h Infants 0 to 1 year h 25 years h years h Adolescents years 9h ideal for this age group. Table 3 Difference between night terrors and nightmares Difference Night terrors Nightmares Sleep stage NREM REM Characteristics A sudden episode of cry or loud scream with Recurrent episodes of awakening from sleep intense fear with recall of an intensely disturbing dream Recall dream No Yes recall dream is immediate and clear Associated features Difficulty in arousing the child Delayed return to sleep after the episode Mental confusion when awakened from an Occurrence of episodes in the latter half of the episode habitual sleep period Amnesia complete or partial for the episode Dangerous or potentially dangerous behaviors REM rapid eye movement, NREM non-rapid eye movement.

By 2 months of age, infants are able to establish a day- Management night cycle. Awaken child 15min before terrors occur. Avoid over- By 4 months, many infants can sleep uninterrupted tiredness. Be calm; speak in soft, soothing, repetitive tones; A child of 1 year should be sleeping h, primarily help child return to sleep.

Protect child against injury. Night waking may be associated with separation anxiety. Full alertness on awakening, with little confusion or dis- orientation Clinical presentation Table3 Delayed return to sleep after the episode Recurrent periods where the individual abruptly wakes from sleeping with a scream accompanied by autonomic Management nervous system and behavioral manifestations of intense Reassure the child that he or she had a bad dream.

Mental confusion when awakened from an episode and Avoid scary movies or television shows. Background Unfounded parental anxiety about the health of a child resulted in disturbances of the parent-child interaction. The parents are overprotective, show separation anxiety, Habit-induced in adolescents as in past history of bulimia unable to set age-appropriate limits, and display exces- nervosa or of intentional regurgitation sive concerns about their childs health. These lead to Trauma-induced as in emotional or physical injury overuse medical services.

Clinical presentation Risk factors Chewing and swallowing of regurgitated food that has History of serious illness or injury in the child come back into the mouth through a voluntary increase Fertility issues in abdominal pressure within minutes of eating or during Illness in any family members eating. Serious maternal problems during and after delivery It can adversely affect normal functioning and the social Precious child lives of individuals.

Prematurity It can also present with weight loss. Exacerbating factors Management Environmental stress Complete history and physical examination Family stress Minimal invasive investigations Lack of social support Reassurance, explanation, and habit reversal Low socioeconomic status Behavioral and mild aversive training Poor rating of mothers health Supportive therapy and diaphragmatic breathing.

Effect on children Exaggerated separation anxiety Sleep disorders Gifted Child Peer relationships, self-control, discipline problems School underachievement Definition Hypochondria Significantly advanced skills and abilities in any develop- They may become abusive to their parents.

Management Clinical presentation Early recognition and treatment Alertness during infancy Inquire the sources of the parental anxiety and reeducat- Early language development.

Provocative and penetrating questions, exceptional curi- osity and a heightened sense of wonder Early development of empathy, concern with truth and Rumination fairness in play, a mature sense of humor, leadership in cooperative play, and perfectionism Background Cognitive and academic skills often exceed social emo- Rumination is effortless regurgitation of undigested food tional and motor skills.

They tend to have asynchronous developmental patterns, No associated retching, nausea, heartburn odors, or very advanced in one domain area compared to the rest. Asperger syndrome Due to overstimulation and understimulation from parents Oppositional defiant disorder. Precipitants of violence by batterers may be Pregnancy Chronic Illness and Handicapping Conditions Efforts by partner to leave the home Seeking separation or divorce General effect of a child with chronic conditions on the Moving to a shelter family Parents of children with handicapping conditions may Effect of violence on children exhibit grief reactions and this could affect the siblings.

Intimate-partner violence may have devastating effects on There is increased risk of child abuse among handicapped children such as physical abuse, injury while protecting children. Use of home medical equipment e. A pediatrician can help the family in the facilitation of The abused partner frequently seeks medical attention, a normal progression of a chronically ill or handicapped hesitation in leaving the office; frequent visits to the child to adult behavior, including separation from parents emergency department and requests for support with and emerging sexuality in spite of chronic illness.

Management Transplantation Early identification and reporting especially if suspected child abuse Growth impairment is common after all solid organ trans- Emergency social work or child protective services plants. Children witnessing intimate partner abuse are more Etiologies of growth impairment may be multifactorial.

There may be psychosocial stresses of chronic illness on the child and other family members. Waiting for future of transplantation and the guilt of real- Child Abuse izing that someone else has to die to receive a lifesaving organ transplant.

Background Financial burden of time lost from work and fear of organ Under state laws physicians are legally obligated to report rejection, organ loss, malignancy, and death any suspected abuse. Support groups for pretransplantation and posttransplan- Neglect is the most common form of child abuse. Failure to thrive may be a manifestation of abuse or neglect in children.

Siblings of abused children are at increased risk of abuse. Waterlines Sparing of the soles of the feet demarcation: Clinical presentation Poisonous ingestions may be manifestations of child abuse. Shaking is a possible cause of coma in the absence of signs of cutaneous trauma. An ophthalmology consultation is needed to identify reti- nal hemorrhage in suspected head trauma due to shaking. Sexual abuse should usually be reported to the law enforcement agency and must be reported to a state child protection agency.

Under state laws, physicians are legally obligated to report suspected abuse although unsubstantiated cases of child abuse produces stress in a family.

The standard of proof in a civil court is the preponderance of evidence. Failure to substantiate child abuse may be due to failure Facial scratches on babies from their fingernails to locate child, failure to locate parents, parents refusal to Bruises that appear in the same stage of healing speak to investigators, duplicate reports, childs refusal to Mongolian spot, coining, cupping, and urticaria pigmen- repeat history, and non-English speaking family.

Many abused and neglected children are not removed Accidental burn injuries usually involve the upper part of from their parents or placed in foster care. Neglect Contact burns will show branding type and mirror the object used.

Factitious Disorder Munchausen Syndrome by Differential diagnosis of inflicted burns includes: Infantile cortical hyperostosis The parents and children with factitious disorder Osteoid osteoma Munchausen syndrome by proxy may exhibit signifi- cant ongoing psychologic problems. Management Mothers have been identified as the sole perpetrators in Skeletal survey is mandatory in suspected child abuse or the majority of cases.

Multidisciplinary child protection team that includes the Fractures are present in a minority of physically abused state social service agencies. Family therapy to address ongoing family issues. Chip fracture of metaphysis is commonly due to wrench- ing or pulling injuries.

Radionuclide bone scan can reveal subtle areas of skeletal Sexual Abuse trauma that may not be seen on plain-film x-ray studies of bones.

Background Physical abuse is the most common cause of serious intra- Incidence of sexual abuse cases that came to the attention cranial injuries during the first year after birth.

Child sexual abuse involves physical contact between the Examination victim and the perpetrator, with or without oral, anal, or Explanations to parents and the child before, during, and vaginal penetration. There may not be touching and the child is made to watch Supportive, non-offending caretakers also can be com- sexual acts or pornography.

Delay between the onset of abuse and disclosure is com- Older patients can indicate if they prefer to undergo the mon. The use of chaperones is essential during the examination Boys are less likely to disclose sexual abuse and might be of pediatric patients.

Examination positions include supine lithotomy, supine Teenagers have the highest rates of sexual assault. The child knows most perpetrators of sexual abuse before Patients who refuse should not be forced to undergo an the abuse occurs.

Physical disabilities, prior sexual victimization, and A normal physical examination does not exclude the pos- absence of a protective parent are other potential risk fac- sibility of sexual abuse or prior penetration.

The majority of sexual abuse victims have normal ano- There is increased incidence of sexually transmitted dis- genital examinations. Findings indicative of trauma include laceration or bruising of the hymen, genital or perianal bruising, and Clinical presentation hymenal transection.

An explicit description and imitation of adult sexual Labial adhesions, vulvar erythema, and anal tags are not behavior by children may indicate either victimization or signs of abuse.

Sexually abused children also can present with nonspe- Investigations cific physical or emotional complaints. Chlamydial infection may be acquired from the mother at Unexplained abdominal pain, genital pain, encopresis, birth and may persist. Sexually transmitted disease in a prepubertal child is pre- A complaint of genital pain and genital discharge may sumptive evidence of sexual abuse.

It is very important to use gold standard tests to diagnose When sexual abuse is suspected, the child should be inter- sexually transmitted diseases in children because of the viewed alone. Verbatim statements by a child may qualify as evidence in Findings diagnostic of sexual contact include pregnancy, a criminal court.

Evidence of seminal fluid is infrequently found in sexu- Medical history taking ally abused children. It is essential to avoid repetitive interviewing of an alleg- Recognize that sexual abuse can recur even when families edly sexually abused child. Repetitive interviewing may create rote quality to Send serologic studies for human immunodeficiency responses, increases likelihood of leading questions, virus HIV , syphilis, and hepatitis B.

Bacterial vaginosis can be unrelated to sexual abuse. The use of anatomically correct dolls for interviewing Polymerase chain reaction testing or culture of genital have advantages in a child who is nonverbal that can point lesions can test for herpes simplex virus.

Specimens from the rectum, male urethra, vagina, and Sexually abused children also can present with nonspe- urine can be tested for Chlamydia trachomatis and Neis- cific physical or emotional complaints.

Throat specimens also can be tested for gonorrhea. Nucleic acid amplification tests NAATs for chlamydia It is very important not to assign blame to the victim in and gonorrhea infections in urine. HIV, trachomatis, gonorrhea, and syphilis are diagnostic Recognize that sexual abuse can recur even when families of sexual abuse when perinatal, transmission from trans- are receiving treatment. Anogenital warts condyloma acuminata and genital her- Suggested Readings pes simplex are suspicious and not diagnostic of abuse.

Laboratory testing at the time of initial presentation, con- 1. Managing child abuse: Pediatric primary care 12, and 24 weeks post-assault. From suspicion of physi- cal child abuse to reporting: Pregnancy testing should be performed where indicated 4. Fortin K, Jenny C. Brown P, Tierney C. Munchausen syndrome by proxy. Prevention and management Treatment plans address physical health, mental health, of pain in the neonate: Holsti L, Grunau RE. Considerations for using sucrose to reduce Prophylactic antibiotics for gonorrhea, chlamydia infec- procedural pain in preterm infants.

Pediatric pain management.

Nelson textbook of pediatrics, 19th ed. Saun- These prophylactic antibiotics generally are not pre- ders Elsevier; Pagel JF.

Nightmares and disorders of dreaming. Am Fam Physi- cian. There is low Zuckerman B.

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Nightmares and night terrors. Parker S, Zuck- risk of spread to the upper genital tract. Developmental and behavioral HIV postexposure prophylaxis involves a day course pediatrics: Psychosocial ble within 72h of potential exposure, and careful follow- issues in pediatric organ transplantation: Emergency contraception should be offered when female Bhargava S.

Diagnosis and management of common sleep prob- pubertal patients present within 72h till h. Pipan M, Blum N. Basics of child behavior and primary care man- Mental health issues need to be addressed and urgent psy- agement of common behavioral problems. Voight RG, Macias chiatric referral if suicidal ideations. MM, Myers SM, editors. Developmental and behavioral pediat- rics. Elk Grove Village: Pediatrics; , p.

Common Early Symptoms, Signs and Clues Physical examination to a Very Ill Child Degree of fever, presence of tachycardia out of proportion to the fever, the presence of tachypnea, and hypotension History all suggest serious infection Altered mental status, e.

Shock Common causes Depressed myocardial contractility, e. Clinical presentation Management Tachycardia Chest radiography reveals cardiomegaly and pulmonary Tachypnea venous congestion Signs of poor perfusion, including cool extremities, weak Elevated central venous pressure CVP , other forms of peripheral pulses, sluggish capillary refill, skin tenting, shock CVP is low and dry mucous membranes Electrocardiography and echocardiography immediately Orthostatic hypotension may be an early sign if there is any suspicion of cardiogenic shock Hypoperfusion, end-organ damage; weak central pulses, Empiric treatment for possible septic or cardiogenic poor urine output, mental status changes, and metabolic shock should not be delayed for echocardiography acidosis.

Spinal cord trauma and spinal or epidural SIRS is triggered by an infection, is defined as sepsis anesthesia; unlike other forms of shock, neurogenic shock Overwhelming inflammation resulting in hypo- or hyper- exhibits hypotension without reflex tachycardia thermia, tachycardia, tachypnea, and either an elevated or Septic shock in some children presents with vasoplegia depressed white blood cell count Table1. Supplemental oxygen O2 and maintain airway.

Treat hypoglycemia, hypocalcemia. Titrate fluids, epinephrine or norepinephrine, add vasodilators or vasopressors depending on the type of shock cold or warm, blood pressure level, and the percentage of ScvO2. Persistent catecholamine resistant shock: Refractory shock: ECMO Algorithm for goal-directed management of hemodynamic Algorithm for goal-directed management of hemodynamic support in septic shock summary. Table 1 Difference between cold shock and warm shock Cold shock Warm shock Low cardiac output and high SVR High cardiac output and low SVR Tachycardia, mottled skin, cool extremities with prolonged capillary Tachycardia, plethora, warm extremities with flash capillary refill, refill, and diminished peripheral pulses bounding pulses, and a widened pulse pressure Low or normal blood pressure Low blood pressure Dopamine with or without epinephrine may reverse the shock Dopamine with or without norepinephrine may reverse the shock SVR systemic vascular resistance.

Table 2 General evaluation of accident victim. Adapted from: Committee on Trauma, American College of Surgeons Assess airway patency while immobilizing 1. Open and secure airway the cervical spine 2. Maintain cervical spine immobilization B. Assess adequacy of oxygenation via pulse oximetry and 1. Assisted ventilation as needed 3. Treat life threatening chest injuries, including: Tension pneumothorax Open chest wound Flail chest Cardiac tamponade C. Assess adequacy of circulation and perfusion 1.

Treat significant hemorrhage D. Assess neurologic status by examining pupil equal- 1. Consider adjunctive therapies oncotic agents, diuretics E.

Examine for other life-threatening injuries 1. These disorders should cardiovascular agents are necessary be suspected and treated promptly The choice of agent depends largely on the underlying cause and the clinical presentation of shock ECMO Extracorporeal membrane oxygenation Selection of an appropriate agent is based on its known Although ECMO has a definitive role in the treatment of effects on inotropy, chronotropy, SVR, and PVR cardiogenic shock refractory to maximum pharmacologic support, its role in the treatment of refractory septic shock Inotropic agents has been less clear Dopamine, dobutamine, and epinephrine work on beta1 receptors in the myocardium increase cytoplasmic calcium concentration and enhance myocardial contractility Acute Respiratory Distress Syndrome.

Management Clinical criteria No treatment for ARDS is definitive Comatose without spontaneous movement or respiratory Early anticipatory management may avoid late complica- effort tions and poor outcome No response to auditory or visual stimuli Treat the primary cause e. Ocular movements: Surviving Sepsis Campaign.

International guidelines for man- agement of severe sepsis and septic shock: Crit Care Med. Apnea test ; No respiratory effort in response to apnea, and a rise in 2. American College of Critical Care Medicine. Clinical practice PaCO2, as documented by blood gas assessment parameters for hemodynamic support of pediatric and neonatal sep- tic shock: Ancillary studies 3. Report of Special Task Force. Guidelines for the determination of Electroencephalogram EEG brain death in children. Emergency Care.

Poisoning Amount of exposure, number of pills, number of the remaining pills, amount of liquid remaining Time of exposure Background Progression of symptoms Children less than 6years have the greatest risk.

Consider associated ingestions and underlying medical Adolescent exposure either intentional or occupational conditions Plant ingestions either substance experimentation or attempted self-harm General measures for toxic exposures The website http: Lanski and O.

Background Common symptoms Jimson weed and deadly night shade produce anticholin- Lethargy ergic toxins, e. Apnea Cause anticholinergic symptoms Treatment Clinical presentation anticholinergic symptoms Supportive care, e. Dry mouth, decrease sweating, and urina- needed tion Electroencephalogram EEG , blood gases Red as a beet: Flushing Toxicity usually resolve in 24h Blind as a bat: Mydriasis, blurred vision Mad as a hatter: Agitation, seizures, Hallucinations Hot as a hare: Hyperthermia Opiates Bloated as a Toad ileus, urinary retention Heart runs alone tachycardia Common opiates Management Morphine, heroin, methadone, propoxyphene, codeine, Activated charcoal meperidine Physostigmine may be indicated to treat severe or persis- Most cases are drug abuse tent symptoms Symptoms Common triad of opiate poisoning pinpoint pupil, coma, Carbamazepine Ingestion respiratory depression Drowsiness to coma Miosis Mild ingestion Change in mood Central nervous system CNS depression Analgesia Drowsiness Respiratory depression Vomiting Hypotension with no change in heart rate HR Ataxia Decreased gastrointestinal GI motility Slurred speech Nausea and vomiting Nystagmus Abdominal pain.

Treatment Activated charcoal Phenothiazine Ingestion Supportive measures Charcoal hemoperfusion can be effective for severe intoxication Common drugs Promethazine Phenergan , prochlorperazine, and chlor- promazine Clonidine Symptoms Antihypertensive medication with -2 adrenergic receptor Hypertension blocking ability Cogwheel rigidity Commonly used in children with attention deficit hyper- Dystonic reaction spasm of the neck, tongue thrusting, activity disorder ADHD oculogyric crisis A dose as small as 0.

Clinical presentation Produces cardioactive glycosides. First 24h They are also found in lily of the valley Convallaria. Regular aspirin at home includes: Anti-diarrheal medica- Plasma Level of Acetaminophen g per mL tions, topical agents, e. Acetaminophen poisoning and toxicity. Pediatrics Diagnosis Patients with a history of potentially toxic ingestion more Classic blood gas of salicylic acid toxicity is respiratory than 8h after ingestion should be given the loading dose of alkalosis, metabolic acidosis, and high anion gap NAC and decision to continue treatment should be based on Check serum level every 2h until it is consistently down acetaminophen level or liver function test trending NAC therapy is most effective when initiated within 8h of ingestion Management Liver transplant if severe hepatotoxicity Initial treatment is gastric decontamination with activated Consult poison control center at charcoal, volume resuscitation, and prompt initiation of sodium bicarbonate therapy in the symptomatic patients Goal of therapy includes a urine pH of 7.

Management Hydrocarbon Ingestion Stabilization of patient is the most important initial step specially protecting the airway, and ventilation support as Products contain hydrocarbon substances needed, activated charcoal in appropriate patients Mineral spirits, kerosene, gasoline, turpentine, and others Obtain ECG as soon as possible ECG indication for sodium bicarbonate therapy include: Emesis and lavage are contraindicated Activated charcoal should be avoided due to risk of induc- Clinical presentation ing vomiting Pain, drooling, vomiting, and abdominal pain Observation and supportive care, each child who is not Difficulty in swallowing, or refusal to swallow symptomatic should be observed for at least 46h in Stridor, and respiratory distress are common presenting Emergency department ED symptoms Neither corticosteroids or prophylactic antibiotics have Esophageal stricture caused by circumferential burn and shown any clear benefits require repeated dilation or surgical correction.

Management Methanol Ingestion Emesis and lavage are contraindicated Endoscopy should be performed within h in symp- Toxicity primarily caused by formic acid tomatic patients, or on basis of history and characteristics of ingested products Clinical presentation Drowsiness, nausea, and vomiting Metabolic acidosis Organophosphate and Insecticide Exposure Visual disturbances; blurred and cloudy vision, feeling being in snow storm, untreated cases can lead to blindness.

Clinical presentation Most head trauma are not serious and require only obser- Headache, malaise, nausea, and vomiting are the most vation.

Iron Ingestion Indication for head CT scan Change in mental status Background Loss of consciousness more than 1min It is a common cause of pediatric poisoning. General principles of wound care Background The time and mechanism of injury because these factors Most are plantar puncture wounds from nails, punctures relate to subsequent management options.

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Copious irrigation Digits Most puncture wounds can be managed in the outpatient Ears setting with an antibiotic, dressing and warm soaks Nose Most infected puncture wounds are caused by S. Additional imaging and intravenous antibiotics may be Irrigation. It is critical that the laceration be dry and Face 35days well approximated to avoid application below the epider- Scalp 57days mal surface, which may cause the wound to gape open or Trunk 57days lead to a Dermabond Oma Extremities days Evenly spaced suture placement: The general rule is Joints days sutures should be spaced the same distance as they are placed from the wound edge.

For irregular wound shapes, approximate the midpoint of the wound first and then Animal and Human Bites work laterally Dog Bites Lip lacerations Lip laceration require special care if the injury crosses the Dog bite causes a crushing-type wound. Human Bites Management Debridement and removing devitalized tissue It is an effective means of preventing infection Three general types of injuries can lead to complications: Time and location of event The choice between oral and parenteral antimicrobial Type of animal and its status i.

Imaging studies Radiography is indicated if any concerns exist that deep structures are at risk e. Snake Bites Radiography Baseline chest radiograph in patients with pulmonary edema Background Plain radiograph on bitten body part to rule out retained Most snakebites are non poisonous and are delivered by fang non poisonous species.

Dysautonomia that can include nausea, vomiting, mal- Scorpion Stings aise, sweating, hypertension, tachycardia, and a vague feeling of dysphoria Background Management The only scorpion species of medical importance in the Analgesics should be administered in doses sufficient to USA is the Arizona bark scorpion Centruroides Sculptu- relieve all pain ratus.

Background Management Dark, violin-shaped mark on the thorax Maintenance of a patent airway and mechanical ventila- Venom causes significant local skin necrosis tion in severe cases Victims may be managed solely with supportive care: Selection can be based on It is the most serious seizure duration as follows: Lorazepam 0. Pentobarbital anesthesia patient already Ventricular fibrillation intubated ; or midazolam, loading dose 0.

Cotton gauze occlusive dressing to protect the damaged Types skin from bacterial contamination: Kleinman ME etal. Circulation , , suppl. SS, Fig. Hypotension Acutely altered mental status Search for and Consider vagal Signs of shock treat cause maneuvers no delays.

Adenosine if stable 0. Bradycardiamost common pre-arrest rhythm in chil- AV mode blocks dren with hypotension, hypoxemia and acidosis Fig. Circulation , , Yes No suppl3, pp. S shockable? Rhythm No shockable?

Rhythm Yes Yes Step Shock shockable? No Yes Yes Step Shock Rhythm shockable?

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Wingert WA, Chan L. Rattlesnake bites in southern California and Suggested Readings rationale for recommended treatment. West J Med. Clinical presentation and treat- 1. Graeme KA. Toxic plant ingestions. Wilderness medicine, 5th ment of black widow spider envenomation: Mosby; Ann Emerg Med.

Kliegman RM, Stanton 5. Clinical presenta- BF, St. Nelson Text tion and outcome of brown recluse spiderbite. Elsevier Saunders; Envenomation by the 8. Herndon DN, editor.

In practice, these two factors are closely related. Finally, a longer time spent on regular academic activities is associated with better academic outcomes, both statistically and intuitively. Acknowledgments This study would not have been completed without the help of Dr Kawee Numpacharoen, who helped write the computerized automation program for data extraction.

Footnotes The author reports no conflicts of interest in this work.

Pediatric Board Review Course

References 1. National Resident Matching Program. American Board of Pediatrics. Accreditation Council for Graduate Medical Education.

Physician board certification and the care and outcomes of elderly patients with acute myocardial infarction.

J Gen Intern Med. Specialty board certification and clinical outcomes: the missing link. Acad Med. Anesthesiologist board certification and patient outcomes. Sutherland K, Leatherman S.

Does certification improve medical standards? Falcone JL.Shock shockable? Conclusion Passing the ABP certifying exam relies on the competitiveness of individual residents and the quality of the training environment. Infantile cortical hyperostosis The parents and children with factitious disorder Osteoid osteoma Munchausen syndrome by proxy may exhibit signifi- cant ongoing psychologic problems. Background Background It is 22q Passing was the best birthday present I ever had.

Risk factors for lead poisoning APP bright future recommend urine dipstick testing in Living in or regularly visiting a house built before sexually active male and females between age or remodeling before The results can also be used to improve pediatrics residency programs.

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