Pediatric Examination and Board Review (137 page)

9.
(D)
One of the most common complications of rapid cooling is overcooling, and temperatures as low as 88°F (31°C) have been reported (Boston Marathon). Therefore, the ideal temperature at which to stop rapid cooling is 101°F (38.3°C), subsequently allowing the body to further cool on its own. Shivering is a sign of overcooling and actually causes increased heat production and may cause a rebound increase in core temperature.

10.
(C)
Heat stroke is the most severe form because it is associated with irreversible tissue damage.

11.
(D)
Heat and humidity are most important. Once ambient temperature equals or exceeds skin temperature, conduction, convection, and radiation cease to be effective methods of heat loss. Once ambient humidity exceeds 75%, the effectiveness of evaporation decreases. Low winds are associated with decreased heat dissipation.

TABLE 80-1
Heat Exhaustion Versus Heat Stroke

12.
(D)
Evaporation (via sweating) is the dominant mode of heat dissipation or heat loss in the body.

13.
(A)
Conduction requires direct contact of the body with surrounding objects and air.

14.
(B)
Heat cramps are thought to be caused by a total body loss of sodium and are exacerbated by excessive sweating.

15.
(C)
Children are at increased risk for heat illness because circulating blood volume is less and the ability to circulate blood volume increases blood flow to the periphery, resulting in a greater ability to dissipate heat.

16.
(D)
Both conditions have similar initial signs and symptoms; however, they represent a continuum of disease process. If left untreated or unrecognized, heat exhaustion can quickly become heat stroke at which time extreme hyperpyrexia (>40.5°C [105°F]—not seen in heat exhaustion), coma, seizures, and irreversible tissue damage can occur.

17.
(E)
All of the above are potential complications of heat stroke. Rhabdomyolysis, dysrhythmias, acidosis, adynamic ileus, electrolyte imbalances, and seizures are also seen.

18.
(C)
Rectal temperature measurement is the gold standard, and it is recommended that probes be accurate to at least 112°F. Tympanic membrane measurement has not correlated well with 10-cm rectal probe temperature measurements in research studies, despite the hypothesis described in answer D.

19.
(D)
Salt tablets are generally not recommended because the high solute load causes gastrointestinal irritation. However, adding extra table salt to food is recommended.

S
UGGESTED
R
EADING

Barkin RM.
Pediatric Emergency Medicine: Concepts and Clinical Practice
. St. Louis, MO: Mosby; 1997:430-433.

Barr SI, Costill DL, Fink WJ. Fluid replacement during prolonged exercise: effects of water, saline or no fluid.
Med Sci Sports Exerc.
1995;27:2002-2010.

Fleisher GR.
Textbook of Pediatric Emergency Medicine
. 6th ed. Philadelphia, PA: Lippincott; 2010.

Lugo-Amador N, Rothenhaus T, Moyer P. Heat-related illness.
Emerg Med Clin North Am.
2004;22:315-327.

Marx J, Hockberger R, Walls R.
Rosen’s Emergency Medicine
:
Concepts and Clinical Practice.
7th ed. St. Louis, MO: Mosby; 2009.

CASE 81: A 5-YEAR-OLD BOY WITH ABDOMINAL PAIN

A 5-year-old African American boy presents to a pediatric emergency department with a chief complaint of abdominal pain. His pain is periumbilical and is described as diffuse and nonradiating, worsening with no relationship to meals or bowel movements. His pain began after lunch yesterday and he developed vomiting overnight. He has had three nonbilious and nonbloody episodes of emesis, two loose nonbloody stools today, and a tactile temperature. He states he is thirsty but has refused to eat for the last several hours. The patient denies headache, sore throat, dysuria, frequency, or urgency. His past medical history is unremarkable.

His vital signs reveal a BP of 100/60 mm Hg, pulse of 100, respiratory rate of 36, and a temperature of 100.4°F (38°C). Upon examination he is found to have dry mucous membranes, hypoactive bowel sounds with reproducible periumbilical tenderness, mild right lower quadrant (RLQ) tenderness, and rebound tenderness. His rectal examination is unremarkable except for a small amount of soft stool in the rectal vault.

SELECT THE ONE BEST ANSWER

1.
What is the most likely diagnosis in this patient?

(A) gastroenteritis

(B) acute pancreatitis

(C) peritonitis

(D) acute appendicitis

(E) cholecystitis

2.
Initial management steps for this patient in the emergency department should include all of the following except

(A) make the patient NPO (nothing by mouth)

(B) administer IV fluids

(C) place a nasogastric tube to low intermittent wall suction

(D) obtain prompt surgical consultation

(E) draw appropriate laboratory studies

3.
Which of the following laboratory studies is least helpful in confirming the etiology of this patient’s abdominal pain?

(A) serum electrolytes, blood urea nitrogen (BUN), and creatinine

(B) urinalysis

(C) C-reactive protein (CRP)

(D) white blood cell count with differential

(E) amylase and lipase

4.
All of the following are common causes of acute abdominal pain in children that do not require surgical treatment except

(A) mesenteric adenitis

(B) gastroenteritis

(C) psoas abscess

(D) pyelonephritis

(E) constipation

5.
Which of the following is/are considered common extra-abdominal cause(s) of abdominal pain in children?

(A) ingestion of drugs such as acetaminophen or salicylates

(B) diabetic ketoacidosis

(C) pneumonia

(D) group A streptococcal pharyngitis

(E) all of the above

6.
Which of the following statements describing acute appendicitis in a school-age child is false?

(A) diarrhea is rarely associated with appendicitis

(B) the onset of abdominal pain frequently precedes the appearance of any other symptoms

(C) tenderness upon rectal examination is a nonspecific finding in appendicitis

(D) anorexia and low-grade fever may be associated symptoms

(E) pain may be either constant or colicky but almost always worsens with movement

7.
Which of the following physical examination findings is least likely to correlate with a diagnosis of acute appendicitis?

(A) referred tenderness from the left lower quadrant (LLQ) to the RLQ during palpation

(B) bluish discoloration around the umbilicus

(C) tenderness at a point between the umbilicus and the anterior superior iliac spine two-thirds the distance from the umbilicus

(D) extension of the hip posteriorly with the patient lying prone elicits pain

(E) abduction of the right hip with the patient lying supine elicits pain

8.
Which of the following statements is true regarding the management of acute appendicitis in children?

(A) all patients should receive immediate IV antibiotics

(B) all patients should have at least one imaging study

(C) all patients should have a prompt surgical consultation

(D) all pain medicine should be held until a surgeon evaluates the patient

(E) all of the above

9.
Which of the following statements is true regarding imaging studies in children with acute appendicitis?

(A) CT offers the advantages of better contrast sensitivity, the capability of viewing all tissue layers, reduced operator dependence, and is the safest imaging modality

(B) ultrasonography offers the advantage of low cost, no radiation exposure, and little variation among operators

(C) abdominal radiographs are most helpful in diagnosing other causes of abdominal pain, such as constipation, bowel obstruction, or free air