Provided by PEER VIII. PEER (Physician’s Evaluation and Educational Review in Emergency Medicine) is ACEP’s gold standard in self-assessment and educational review. These questions are from the latest edition of PEER VIII. To learn more about PEER VIII, or to order it, go to acep.org/bookstore.
- In a patient with confusion, a primary psychiatric disorder is suggested by:
B. Fluctuating level of consciousness
C. Gradual onset
D. Visual hallucinations
- A child who accidentally ingested her grandmother’s glyburide developed hypoglycemia and a depressed level of consciousness that were reversed with the administration of dextrose by prehospital providers. Which of the following agents should be administered next?
- Which of the following is the most common single organ system injury associated with death in children?
A. Abdominal injury
B. Cervical injury
C. Head injury
D. Thoracic injury
- Which of the following is the preferred site for emergent intraosseous needle placement in a 6-month-old child?
A. Distal femur
C. Proximal tibia
- The most common type of primary headache is:
A. Cluster headache
B. Migraine headache
C. Tension headache
D. Trigeminal neuralgia
1. The answer is C, Gradual onset.
(Marx, 101-105; Tintinalli, 1940-1941)
A primary psychiatric disorder is most likely to be associated with a gradual onset of symptoms over weeks to months. In DSM IV, the previous terminology of organic brain syndrome has been removed because of the implication that functional mental disorders are not associated with biologic changes in the brain. The current terminology reflects both the symptom and the presumptive cause, for example, depression due to diabetes. Mental disorders directly caused by medical conditions are more likely to present with abnormal vital signs and a sudden onset of symptoms; they can occur in patients of any age and are associated with a fluctuating level of consciousness. These patients are usually disoriented and exhibit disturbances in attention and recent memory. Hallucinations are more likely to be visual or tactile than auditory in those with medical disorders. Primary psychiatric disorders are more likely in patients 12 to 40 years old. These patients are alert and oriented but often agitated and anxious. Immediate memory might be impaired, but recent memory and remote memory are usually intact. Hallucinations are most likely to be auditory. Delusions (a false belief, firmly sustained, not associated with cultural beliefs or ignorance or lack of information) are prominent. On physical examination, if the patient is not agitated, vital signs are typically normal.
2. The answer is C, Octreotide.
(Marx, 1638; Nelson, 722-724, 734-736; Wolfson, 1553)
Sulfonylureas such as glyburide cause the release of preformed insulin that can result in life-threatening, recurrent hypoglycemia. In a child, even a single pill can be life threatening. Octreotide is a synthetic somatostatin analogue that can antagonize the release of insulin. It has been demonstrated to decrease the incidence of hypoglycemic episodes in sulfonylurea poisonings and is the favored treatment after dextrose. Somatostatin is very short acting; octreotide, in contrast, was purposely synthesized as a longer-acting analogue. Octreotide is particularly attractive for use in sulfonylurea poisonings in pediatric patients. It can prevent problems related to frequent dextrose administrations, such as the need for central intravenous access (due to loss of peripheral intravenous access from repeated infusions into small veins) and rebound hypoglycemia (due to intrinsic insulin release in a patient with a normally functioning pancreas). Glucagon should certainly be considered in a patient with hypoglycemia of any etiology in whom intravenous access is delayed and oral administration is not feasible. However, its onset of action is delayed, and it might be ineffective. In a patient with severe hypoglycemia from a sulfonylurea, the intrinsic pathways to reverse hypoglycemia (including glucagon and epinephrine release) have already been maximized, making exogenous administration unlikely to be beneficial. Diazoxide is an infrequently used antihypertension medication that can also antagonize insulin release. It can be considered if octreotide is not available, but it is not as effective, and there are risks (although largely theoretical) of hypotension. The ideal dosing of octreotide remains unclear; it can be administered either intravenously or subcutaneously. Administration does not obviate the need for admission and serial glucose measurements.
3. The answer is C, Head injury.
(Fleisher, 1233-1248; Marx, 262-265)
Trauma is the leading cause of death in children. In fact, 50% of all deaths of children 1 to 14 years old are because of trauma, with up to 22 million children injured annually. The most common single organ system injury associated with death in the injured child is head trauma. It is also the highest cause of injury among pediatric patients, although the injury pattern in children is different from that in adult trauma patients. Trauma deaths occur predominantly among males, with the highest frequency at age 8. Blunt trauma is the major mechanism of injury; motor vehicle crashes account for 90% of the injuries to children. Because children are smaller and more compact and lack musculature and adipose, and because of the more anterior location of the liver and spleen, multiorgan injury is the rule, not the exception. Heat loss also is a significant factor because of the higher surface area. A pediatric patient is more susceptible to secondary brain injury, which can lead to a worse neurologic outcome. Also, the younger child’s brain is more prone to hyperemia and edema from the shearing effect after the trauma than an older child’s is.
4. The answer is C, Proximal tibia.
(Marx, 267; Roberts, 436)
The proximal tibia is the preferred site for intraosseous infusion in this age group, followed by the distal tibia and the distal femur. Other sites have been used, but the humerus, clavicle, and calcaneus are held in less regard. The distal femur can be an alternative site for children but is hindered by the extra tissue in this area, which makes palpation of landmarks more difficult. The most common site for intraosseous infusion in adults is the distal tibia. Alternatively, the sternum may be used in adults, as it is large, flat, and easily accessed. Establishing intraosseous infusion access involves knowing the intraosseous infusion needle or apparatus; stabilizing the site (such as using a rolled towel under the knee/tibia area); prepping the site with an antiseptic agent such as chlorhexidine, betadine, or alcohol; anesthetizing the skin and bony surface if the patient is awake and alert; and using the proper force and direction of the needle. The sites of insertion vary depending on the bone, as follows:
- Proximal tibia – 1 to 3 cm below the tuberosity, over the flat medial aspect, in a slightly caudad direction to avoid the growth plate
- Distal tibia – On the medial surface at the junction of the medial malleolus and shaft of the tibia, just posterior to the greater saphenous vein, this time directed cephalad, away from the growth plate
- Distal femur – 2 to 3 cm above the external condyles in the midline in a cephalad direction, away from the growth plate
5. The answer is C, Tension headache.
(Marx, 1356-1366; Wolfson, 749-750)
Tension headaches, which have a lifetime prevalence as high as 78% of the general population, are the most common type of primary headache. Primary headaches are those that have no identifiable underlying cause. Secondary headaches, otherwise known as organic headaches, are those with an underlying structural etiology. Tension headaches typically consist of bilateral bandlike or squeezing pain that affects the head or neck or both. The pain is mild, often with focal points of tenderness, and is not usually associated with additional symptoms such as nausea, vomiting, or worsening with physical activity. Over-the-counter medications such as acetaminophen or ibuprofen, in conjunction with stress relief activities, often are successful. Cluster headache, the only headache that is more common in men, is typically seen in middle-aged smokers. The headaches tend to come in clusters and are recurrent, often with multiple episodes in 1 day. Patients complain of unilateral throbbing pain affecting the eye and surrounding area. Physical examination might reveal unilateral conjunctival injection, nasal congestion, lacrimation, or rhinorrhea. Thirty percent of patients can also have a partial Horner syndrome (miosis and ptosis). Cluster headaches can be successfully aborted with sumatriptan or high-flow oxygen. Additional therapies such as nerve blocks or steroids are more controversial and are not routinely recommended. Trigeminal neuralgia is pain located in the distribution of the trigeminal nerve. The pain is described as knifelike, lancinating, a sharp cutting or tearing sensation, or shocklike and severe. Episodes typically last 1 to 2 minutes and can be elicited by activities of daily living such as brushing teeth, chewing, or talking. Patients should be referred for outpatient evaluation to ensure there is no underlying mass lesion.