How to answer the multifaceted "next best step" questions?

[SlaveOfTCMC]

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The general idea of "which of the following diagnostic steps will change your management" is quite clear.

What of the next best management choice? In the hospitals, I often see everyone doing certain steps simultaneously. OFten there is a logic. However, some of these questions seem to really be picking hairs...

For instance:

They describe a boy with salicylate toxicity.
THen they also mention he has a glucose of 45 and poor skin turgor, poor capillary refill, and hypotension

they ask next best step

two choices:

D5W + 1/2NS

or

bicarbonate


apparently bicarbonate was the choice in this case.

This *may* seem like a bad question, as it neglected the C in ABCDE.

Just wanted to get you opinion on this one

 

[SlaveOfTCMC]

they say an 8 year old child struck his head while skateboarding. there were no witnesses. the boy seems fine, has no confusion or somnolence.


at the ER, the next best step is:

I figure, he may have an epidural hematoma and may be in the lucid phase. of course with "no witnesses" and the "child not talking (because of the nature of the question)" one has to go out to rule out with a CT


but the answer was "tell parents to watch for signs of CNS dysfunction"


hm...



(btw these questions are from the Kaplan QBank)

 

[Rollo]

What were the explanations?

 

[turkeyjerky]

So, for the first question, bicarbonate is prolly gonna do more zero support the circulation than anything else--since the poor state of the patient is likely due to extreme acidosis. Also, you know that the other choice is wrong b/c hypotonic fluids are never the answer in a hypotension patient.

For number two, the patient isn't displaying any red flags thT would necessitate imaging--the risk of radiation outweighs the risk of an ICH in this case (see the PECARN trial for evidence).

You got these questions wrong because of a deficit in knowledge, not in reasoning.

 

[Braves123]

So, for the first question, bicarbonate is prolly gonna do more zero support the circulation than anything else--since the poor state of the patient is likely due to extreme acidosis. Also, you know that the other choice is wrong b/c hypotonic fluids are never the answer in a hypotension patient.

For number two, the patient isn't displaying any red flags thT would necessitate imaging--the risk of radiation outweighs the risk of an ICH in this case (see the PECARN trial for evidence).

You got these questions wrong because of a deficit in knowledge, not in reasoning.

I forget if loc was an indication for ct in pecan. But I think short loc normal GCS and no neuro symptoms equals no scan.

 

[turkeyjerky]

I forget if loc was an indication for ct in pecan. But I think short loc normal GCS and no neuro symptoms equals no scan.

<5 sec LOC doesn't affect mgmt, >5 sec LOC leads one to observe the child (or have parents do so)