Podcast Ep 38: Pediatric Intubation, Megaloblastic Anemia, & More

Believe you can and you’re halfway there.

-Theodore Roosevelt

Welcome back to Roshcast episode 38, the last episode of 2018! Before we jump into this week’s episode, we have a few people to recognize. First, congrats to Zain who won the trauma ring tone challenge last episode and will be receiving a Rosh Review subscription. Special mention goes out as well to Clark, David, and Ryker who all responded soon after Zain. We should also recognize Sarah, who won the EM Clerkship-RoshCast crossover challenge and won a free copy of Case Files Emergency Medicine. Stay tuned for more contests to come! Let’s head back to the Rosh Blog and start out with a recent Rapid Review.

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• Central cord usually presents with sensory and motor deficits, with the upper extremities being affected more than the lower extremities. It’s most commonly caused by an extension injury.
• Anterior cord syndrome presents with complete loss of motor, pain, and temperature below the level of the injury, but you would retain proprioception and vibration sensation. Anterior cord is most often caused by a flexion or vascular injury.
• Brown Sequard classically occurs after penetrating trauma. It results in ipsilateral loss of motor, vibration, and proprioception with contralateral loss of pain and temperature.

Now onto this week’s podcast

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Question 1

A 3-day-old girl presents with decreased feeding and is found to be limp and minimally responsive. After intubation, at what rate should breaths be delivered?

A. 10–16 per minute

B. 20–30 per minute

C. 40–60 per minute

D. 70–80 per minute

Teaching Image 

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Question 2

In a malnourished patient, which of the following sources of megaloblastic anemia is expected to develop first?

A. Folic acid deficiency

B. Hypothyroidism

C. Liver disease

D. Vitamin B12 deficiency

Teaching Image 

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Question 3

What medication should be first-line treatment in moderate musculoskeletal back pain?

A. Acetaminophen

B. Cyclobenzaprine

C. Diazepam

D. Oxycodone

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Question 4

An 18-year-old man presents to the ED with a 4 cm laceration to the right side of his chin. Which of the following nerve blocks is most appropriate?

A. A mental nerve block

B. A posterior superior alveolar nerve block

C. A stellate ganglion block

D. An apical nerve block

Teaching Image 

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Question 5

A previously healthy 5-year-old girl presents to the ED with left lower extremity pain and an inability to bear weight for 1 day. Mom denies any recent trauma. On exam, the patient has a T 37.9°C, HR 130/min, and RR 28/min. Her left lower extremity is slightly flexed and externally rotated. Lab evaluation reveals a WBC of 8,000, a C-reactive protein of 1 mg/dL, and an erythrocyte sedimentation rate (ESR) of 7 mm/hr. Radiographs are negative for fracture. The patient’s range of motion has improved following administration of ibuprofen. What is the most appropriate course of action in this patient?

A. Intravenous antibiotics and admission to the hospital

B. MRI to rule out osteomyelitis or septic arthritis

C. Orthopedic consultation for arthrocentesis

D. Treatment with NSAIDs and discharge with follow-up arranged for the following day

Teaching Image 

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Question 6

Which of the following is most likely to present as a ductal-dependent cardiac lesion?

A. Atrial septal defect

B. Coarctation of the aorta

C. Isolated ventricular septal defect

D. Mitral valve prolapse

Teaching Image 

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• For infants, from birth to 1 year old, who require mechanical ventilation, set the rate at 30–60 breaths per minute. For toddlers, ages 1–3 years old, set the rate at 24–40 breaths per minute. For preschoolers, ages 3–6 years old, set the rate at 22–34 breaths per minute. For children 6–12 years old, set the rate at 18–30 breaths per minute. And lastly, for those 12 and older set the rate at 12–16 breaths per minute.
• To estimate pediatric systolic blood pressure, use the formula 70 plus 2 times the age in years.
• In the setting of malnutrition, folic acid deficiency and vitamin B12 deficiency can both lead to a megaloblastic anemia.
• NSAIDs are first-line treatment for musculoskeletal lower back pain.  
• A supraorbital nerve block anesthetizes the ipsilateral forehead and scalp.
• An infraorbital nerve block anesthetizes the area between the lower eyelid and the upper lip.
• A posterior superior alveolar nerve block anesthetizes the second and third maxillary molars, as well as part of the first maxillary molar.
• An inferior alveolar nerve block anesthetizes the ipsilateral mandibular teeth, lower lip, and chin.
• An apical nerve block anesthetizes a single tooth.
• The mental nerve block anesthetizes the chin as well as the skin and mucous membranes of the lower lip. Remember that the mental nerve is a branch of the inferior alveolar nerve.
• Transient synovitis is the most common cause of acute hip pain in children ages three to ten years old. Treatment for transient synovitis is NSAIDs and rest.
• Ductal dependent cardiac lesions include coarctation of the aorta, transposition of the great vessels, tetralogy of Fallot, tricuspid atresia, interrupted aortic arch, and hypoplastic left heart syndrome.
• To temporarily preserve patency of the ductus arteriosus, treat with prostaglandin E1, or alprostadil, at a dose of 0.05–0.1 mcg/kg/min.

Supplemental resources mentioned in the episode:

• Friedman BW, Irizarry E, Solorzano C, et al. Diazepam is no better than placebo when added to naproxen for acute low back pain.” Ann Emerg Med. 2017;70(2):169–176..
• Friedman BW, Dym AA, Davitt M, et al. Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back pain: a randomized clinical trial. JAMA. 2015;314(15):1572–1580.
• Williams CM, Maher CG, Latimer J, et al. Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. Lancet. 2014;384(9954):1586–1596.
• Dental emergencies management strategies that improve outcomes

That wraps up RoshCast Episode 38. Don’t forget to follow us on Twitter @RoshCast and @RoshReview. We can also be reached by email at RoshCast@RoshReview.com and are open to any feedback, corrections or suggestions. You can also help us pick questions by identifying ones you would like us to review. To do so, write “RoshCast” in the submit feedback box as you go through the question bank. And finally, if you have a minute, make sure to rate us and leave comments on iTunes to help spread the word about RoshCast.

Until next time,
Jeff and Nachi