A 2-year-old boy arrives comatose and unresponsive to the emergency department. The child has dried vomitus on his shirt and pants. The father indicates that he picked up the child from the grandmother’s house 60 minutes ago. The grandmother said that she had dropped her medications on the floor and it was possible that the child ate some pills, but the father does not know the names of the medications.
The most appropriate first step in the management of this child is which of the following?
Correct Answer D:
The first priority in a comatose, unresponsive, vomiting patient is management of airway, breathing, and circulation (ABC’s). Establishment of a secure airway is the first and most important step.
A. Syrup of ipecac should not be used in comatose patients.
B. It will be important to learn what medicines have been ingested, but this is not the first priority.
C. Gastric lavage is not likely to be beneficial more than 60 minutes after an ingestion. In order to prevent pulmonary aspiration, gastric lavage should never be performed in a comatose patient prior to placing an endotracheal tube.
E. This child will require admission to an intensive care unit after stabilization.
Which of the following is not true of Erb’s palsy?
Correct Answer A:
In Ebr's palsy, the fifth and sixth cervical spinal nerves are affected.
B. Frequently seen with large, hypotonic infants that require increased traction on the head and neck during a vaginal delivery.
C. The grasp reflex is not affected and should be intact.
D. Because of the brachial plexus injury in C5 and C6 spinal nerves, the Moro, biceps, and radial reflexes are absent on the injured side.
E Because of the brachial plexus injury in C5 and C6 spinal nerves, the neonate’s arm would be adducted and internally rotated with the elbow extended, the forearm in pronation, and the wrist in flexion.
While examining a 3-day-old infant born at term by normal spontaneous vaginal delivery to a 19-year-old primigravida mother without any perinatal infection or complications, you notice an absence of red reflex in the left eye. Upon closer examination, the pupil in the right eye was clear, but the pupil in the left eye had a milky appearance.
What is the most common cause of this condition?
Correct Answer B:
Congenital cataract (choice B) is the most common cause of leukocoria (white pupil) in an otherwise healthy, full term newborn.
→ Retinoblastoma should (choice A) always be considered in the differential of an asymmetric red reflex. Although uncommon, this diagnosis requires early intervention.
→ Retinopathy (choice C) of prematurity is not seen in full term infants.
→ Congenital glaucoma (choice D) is an uncommon but important diagnosis in infants with an asymmetric red reflex. Tearing, irritability, and a large pupil may also be seen.
→ Ocular toxoplasmosis (choice E) may occur in infants with maternal exposure to Toxoplasma gondii. Infants with severe disease may have chorioretinitis, intracranial calcifications, and mental retardation.
An 7-year-old boy, who was adopted from a poor family from South Korea recently, is seen in the emergency department for evaluation of symptoms of exertional dyspnea, chest pain, and cyanosis. He reports being previously healthy, but was told in the past that he had a heart murmur. He also admits to not being overly physically active as he prefers playing video games.
On exam, you detect a short holosystolic murmur, a right ventricular heave, and a loud pulmonary component of S2. The EKG demonstrates right ventricular hypertrophy, an increase in pulmonary vascularity. Cardiomegaly is seen on chest x-ray.
What is the best explanation for this constellation of findings?
Correct Answer C:
Eisenmenger syndrome results from excess pulmonary vascular resistance and subsequent right ventricular enlargement and failure. This is usually seen in the context of a large VSD, in which the left-to-right shunt has flooded the pulmonary circulation. Over time this results in elevated pulmonary vascular resistance, and the ventricular shunt reverses to a right-to-left shunt which results in cyanosis. The clinical presentation described above is that of increased pulmonary vascular resistance and right-to-left shunt characteristic of Eisenmenger’s syndrome.
You are called to the bedside of a 1-month-old infant who is status post repair of coarctation of the aorta. He has been doing well and his feedings have been restarted. Since this morning, he has become more tachypneic. On exam, the patient has diminished breath sounds on the left with dullness to percussion. CXR shows a large effusion, so you urgently perform a diagnostic thoracentesis. The fluid returned is milky, and the patient continues to deteriorate.
What is the most likely diagnosis?
A thoracic duct injury, in which chyle leaks into the chest cavity, is a relatively common complication after neonatal repair of congenital cardiac disease.
A. A hemothorax would not have milky fluid on thoracentesis.
B. Parenteral nutrition is delivered via venous access, usually in a large vein (subclavian, femoral). If there were venous rupture in the thorax, the fluid obtained would be bloody.
D. A post-op pneumonia causing a parapneumonic effusion would tend to be clear to slightly blood tinged.
E. A hydrothorax would not have milky fluid and generally is associated with edema or fluid in other parts of the body. Causes include hepatic, cardiac, or renal failure.
Click to expand