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2014-09-13 07:31:34
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  1. A 2 yo boy 3/7 intermittent fever, tummy ache. No diarrhoea. He vomited once yesterday. T:37.5C, HEENT N. Abd soft and non-tender. You suspect a urinary tract infection. Give three other possible diagnosis that are important to rule out in a boy of this age (3)
    • -Appendicits
    • -Mesenteric adenitis
    • -Orchitis Intussusception
  2. The urine dipstick is positve for nitirites and leucocytes. Name three of the most likely organisms. (3)
    • -Escheria Coli
    • -Strep B
    • -Klebseiella
    • -Proteus
    • -Enterobacter
    • -Staph
  3. Give four indications for admission in a child with UTI? (4)
    • -Dehydration / inability to tolerate oral fluids / repeated vomiting
    • -Toxic child requiring IV antibiotics
    • -Co-morbidities
    • -Parental concerns / inability to cope
    • -Age < 3/12 ( some guidelines < 6/12)
    • -Pyelonephritis / renal angle tenderness clinically
  4. How should you obtain a urine sample?
    -Not with a bag, should be clean catch MSU
  5. What would you treat this child with?More than 3 months of age with signs of pyelonephritis
    -Treat with oral antibiotics for 10 days if sufficiently well 5 - <1 year="" old="" :="" cephradine="" or="" co-amoxiclav="" augmentin="" br="">- >1 year old : Cephradine or Trimethoprim - If IV antibiotics required Cefuroxime is the drug of choice. - IV antibiotics should be continued until the pyrexia has settled and culture is available from which an appropriate oral antibiotic can be given (total duration of treatment 10 days) More than 3 months of age with signs of cystitis -Treat with oral antibiotics for 3 days if sufficiently well but review if no improvement after 24-48 hours - <1 year="" old="" :="" cephradine="" or="" co-amoxiclav="" augmentin="" br="">- >1 year old : Cephradine or Trimethoprim
  6. A 3 yo brought to ED after unintentional/accidental ingested an unknown quantity of iron tablets. What are the initial symptoms of iron OD ingestion?
    • -Usually occur within 20 minutes, nausea, vomiting, diarrhoea, abdominal pain, hypotension, haematemesis, fever
    • -gastrointestinal symptoms related to the corrosive nature of iron may occur without systemic toxicity
    • -however any symptoms require iron levels.
    • -Lack of symptoms within the first 6 hours makes significant toxicity unlikely.
  7. What symptoms may occur after a number of hours iron OD?
    • -Tachycardia, vasoconstriction, hypotension and shock
    • -Metabolic acidosis can occur.
    • -These are related to fluid shifts from intravascular to extravascular compartments and cellular hypoxia
    • -Multiple organ failure: Occurs 12-48 hours after ingestion (particularly hepatic failure)
  8. How would you investigate this patient Iron OD?(Give five)
    • -AXR if tablet ingestion
    • -ABG/CBG (acidosis)
    • -Glucose (hyperglycaemia)
    • -Serum iron (Peak levels are usually seen at 4 hours.)
    • -Levels taken after four hours may underestimate toxicity because the subject iron may have either been distributed into tissues or be bound to ferritin.
    • -In the case of slow release or enteric coated tablets, levels should be repeated at six to eight hours as absorption may be erratic.
    • -Once desferroxamine is commenced, iron levels are not accurate at most labs using automated methods (including RCH)
    • -FBE (leukocytosis) U&E & Cr, X-match, Clotting (reversible early coagulopathy and late coagulopathy secondary to hepatic injury)
    • -LFTs
    • -AXR may be helpful in evaluating gastrointestinal decontamination after treatment if tablets have been ingested.
  9. How would you manage this patient if an antidote is required / Iron OD?
    • -Consider desferrioxamine in:
    • serum iron levels > 90 micromol/l
    • level 60 - 90 micromol/l and tablets visable on XRay
    • symptomatic (nausea, vomiting, diarrhoea, abdominal pain, haematemesis, fever)
    • any patient with significant symptoms of altered conscious state, hypotension, tachycardia, tachypnoea, or worsening symptoms irrespective of ingested dose or serum iron level.
  10. A 4 year old girl presented with a barking cough and inspiratory stridor. What is the most likely diagnosis?
  11. Give a differential diagnosis.(Two conditions)
    • -Epiglottitis
    • -bacterial tracheitis
    • -laryngeal foreign body.
  12. What is the natural history of the condition?
    -The symptoms are typically worse at night and peak on about the second or third night.
  13. What part of the examination should be omitted?
    • -Avoid distressing procedures eg. Examining throat
    • -anxiety exacerbates croup.
  14. How would you decide if this child required admission?
    • -The decision to admit a child is made after initial treatment and observation.
    • -The presence of ongoing stridor at rest necessitates admission.
    • -The time of the day, parent's compliance, ability of early review should be taken into account if admission/discharged is considered.
    • -Children with pre-existing narrowing of the upper airways (eg. Subglottic stenosis, congenital or secondary to prolonged neonatal ventilation)
    • -children with Downs syndrome are prone to more severe croup and admission should be considered even with mild symptoms.
  15. 8 yr old presents lethargic and dehydrated. Weighs 22 kg. Looks unwell. RR 40, Sats 98% on oxygen. Started on re-hydration fluids. You decide to give a bolus what would you give?
    - 20mls/kg or 10mls/kg = appropriate so either 440mls or 220mls depending on the level of dehydration they thought was appropriate.
  16. Give 4 features of 5% dehydration
    • -Clinically useful signs for detecting 5% dehydration were capillary refill time, abnormal skin turgor, and abnormal respiratory pattern
    • -Dry mucous membranes, sunken eyes, and poor overall appearance are moderately useful
  17. Calculate the maintenance fluid required in the first 8 hrs
    • -first 10 kg = 100ml/kg/24 hrs
    • -second 10 kg = 50ml/kg/24 hrs
    • -subsequent kgs = 20ml/kg/24 hrs
    • i.e for 22kg child = 1540 mls/24 hrs = 513 mls / 8 hours
  18. Give 3 investigations to establish the underlying diagnosis in the ED with the diagnosis considered for each test
    • -Stool spec for gastroenteritis
    • -BM for new presentation of DM
    • -Urinalysis for Urinary sepsis
    • -CXR for pneumonia
  19. A 4 year old boy was brought to the ED after an apparent convulsion. He had a T EMAS of 39.8C.The event lasted approximately 3 minutes. How commonly do febrile convulsions occur?
    • -Febrile convulsions are common
    • -occur in 3% of healthy children between the ages of 6 months and 6 years.
  20. What are the odds of a repeated convulsion during the same illness?
    -Repeated convulsions during the same illness occur in about 10 - 15% of children.
  21. Does paracetamol reduce the risk of further seizures?
    -Paracetamol has not been shown to reduce the risk of further febrile convulsions.
  22. What is the risk of bacterial meningitis in a child who has a fever and a convulsion lasting less than 10 minutes?
    -The risk of bacterial meningitis is between 0.5 and 2%.
  23. What factors increase the risk of future afebrile convulsions?
    • -Risk of future afebrile convulsions (epilepsy) is increased by family history of epilepsy
    • -any neurodevelopmental problem
    • - atypical febrile convulsions (prolonged or focal).
  24. A 4 year old came in with a hx suggestive of a seizure.He was afebrile. Name 5 key considerations during assessment?
    • -Any compromise to ABC.
    • -Duration of seizure including pre-hospital period
    • -Significant past history including seizures, neurological comorbidity including VP shunts, renal failure (hypertensive encephalopathy), endocrinopathies (electrolyte disturbance).
    • -Focal features.
    • -Fever (Febrile convulsion or CNS infection).
    • -Anticonvulsant medications including any acute pre hospital treatment.
    • -Previously successful acute anticonvulsant management.
    • -Evidence of underlying cause that may require additional specific emergency management (Hypoglycemia, electrolyte disturbance including hypocalcemia, meningitis, drug overdose, trauma (consider occult head trauma), stroke and intracranial haemorrhage).
  25. If the child suffers another seizure what steps should be taken?(Give four)
    • -Support airway and breathing, apply oxygen by mask, monitor.
    • -Secure IV access, check bedside BSL and send urgent specimen for calcium / electrolytes or venous blood gas.
    • -Give benzodiazepine.Repeat benzodiazepine after 5 minutes of continuing seizures.If convulsion continues for a further 5 - 10 minutes, commence phenytoin or phenobarbitone.
    • -Consider pyridoxine (100mg IV) in young infants with seizures refractory to standard anticonvulsants.
    • -Seek further assistance if seizure not controlled.
    • -Anticipate need to support respiration.
    • -Thiopentone and rapid sequence induction (RSI) may be required for seizure control.
  26. What is the dose in units/kg of IV midazolam for seizure control? What is the dose of IV diazepam in units/kg for seizure control?
    • -Midazolam-0.15mg/kg.
    • -Diazepam-0.2mg/kg
  27. What is the dose of IV phenytoin in units/kg for seizure control?
    • -20 mg/kg .
    • -Loading dose in a monitored patient over 30 minutes.
  28. What electrolyte is of particular importance to check in dark skinned children?
  29. A 6 year old boy is referred to the ED by his GP with query whooping cough? What bacterium causes this condition?
    -Bordetella pertussis
  30. Who is at greatest risk of complications and name two possible complications/whooping cough?
    -Infants less than 6 months of age are at greatest risk of complications (eg. apnoea, severe pneumonia, encephalopathy) and death.
  31. If untreated how long is a child infectious/whooping cough?
    -Just prior to and for 21 days after the onset of cough.
  32. What is the classical history?
    • -There is generally a history of dry cough and nasal discharge for approximately one week (coryzal phase)
    • -followed by a more pronounced cough which may occur in spells or paroxysms (paroxysmal phase).
    • -Vomiting often follows a coughing spasm.
    • -Young infants may develop apnoea.
    • -Other family members frequently also have a cough (70 - 100% of household contacts are usually infected).
  33. How should a suspected case be investigated/whooping cough?
    • -A nasopharyngeal aspirate for immunofluorescence and culture is the investigation of choice.
    • -The organism is usually undetectable after 21 days, or if effective antibiotic therapy against B. Pertussis has been commenced.
    • -Serology rarely affects clinical management.
  34. With regard to IV midazolam used for procedural sedation in children: What is the onset of action?
    -Onset of action 1-5 mins.
  35. What is the dose /IV midazolam?
    - 0.15mg/kg( maximum of 7.5mg) diluted in 10mls of Normal Saline
  36. Name four adverse side effects /IV midazolam?
    • -Cardiac depression
    • -apnoea and respiratory depression
    • -"paradoxical reaction" (agitation secondary to benzodiazepines)
    • -emergence delirium
    • -midazolam will potentate the effects of other sedative drugs eg. opioids.
  37. What is the reversal agent and what is the dose /IV midazolam?
    • -Flumazenil:Give 5mcg/ kg every 60 seconds to a maximum total of 40 mcg/ kg.
    • -Adult dose: 300-600 mcg.
  38. What discharge criteria should be met if discharge is planned post sedation /IV midazolam?(Give four)
    • Discharge home may be considered (provided other medical factors permit) when the patient meets the following discharge criteria:
    • -The patient can sit up unaided / walk ( developmentally appropriate).
    • -The patient has returned to pre sedation observations (both vital signs and level of sedation).
    • -A responsible adult is present to accompany the patient home (for all ages).
    • -Post sedation care has been discussed with parents/guardians.
    • -Safety and injury prevention must be highlighted.
  39. A neonate is brought to the ED by his parents as he had a fever, cough and wasn?t feeding well. The treating emergency clinician suspected pneumonia. What are the common pathogens involved in neonatal pneumonia?(Name two)
    • -E.Coli
    • -beta-haemolytic strep
    • -chlamydia trachomatis
    • -listeria monocytogenes
    • -CMV.
  40. How would you investigate this patient/neonatal pneumonia?(Give four)
    • -Throat swabs
    • -FBC
    • -cultures
    • -viral titres
    • -mycoplasma antibodies
    • -SpO2
    • -urine cultre
    • -CXR.
  41. How would you treat this patient/neonatal pneumonia?
    • -O2
    • -IV fluids
    • -specialist referral
    • -benzylpenicillin and gentamicin
    • -alternatively cefuroxime or co-amoxyclav.
  42. What are the risk factors for neonatal pneumonia?(Give four)
    • -Prolonged rupture of the fetal membranes (>18 hours)
    • -maternal amnionitis
    • -premature delivery
    • -fetal tachycardia
    • -maternal intrapartum fever
    • -anomalies of the airway (eg, choanal atresia, tracheoesophageal fistula, and cystic adenomatoid malformations)
    • -severe underlying disease
    • -prolonged hospitalization
    • -neurologic impairment resulting in aspiration of gastrointestinal contents.
  43. What are the factors which determine outcome/neonatal pneumonia? (Give four)
    • -Increased mortality is associated with
    • -preterm birth
    • -pre-existing chronic lung disease
    • -immune deficiencies.
    • -Severity of the disease
    • -the gestational age of the patient
    • -underlying medical conditions
    • -infecting organism affect the prognosis of the disease.
  44. A 7 month boy is brought in by the paramedics after the parents had called thinking that their child had died. He was found in his cot not moving and looked blue, Mum immediately picked him up and patted him on the back. She said that he looked blue and that she tried to breathe into his mouth. After a few seconds he appeared to return to a normal colour and Mum called 999.What name is given to what has happened?
    -Acute life threatening event (ALTE)
  45. What needs to happen to this child?
    • -All babies presenting with ALTE should be admitted.
    • -(The risk of a further ALTE is highest in the next 24 hours, but it is an uncommon occurrence).
    • -This provides parental reassurance and allows full assessment of the child.
  46. What advice should you give to parents/ Acute life threatening event (ALTE)?
    • -Do not smoke in pregnancy or around your baby (it is carried on you clothes)
    • -Place babies on their Back to Sleep? ?Feet to Foot? ?
    • -Keeps babies heads uncovered and prevents them from wriggling down under the covers
    • -Do not let babies get too hot or cold
    • -Do not share a bed with your baby if you smoke or if they were born prematurely.
    • -Also do not share a bed with your baby if you have been drinking or taking drugs
    • -If your baby is unwell, seek prompt advice
    • -Ensure your baby is fully vaccinated
  47. A 4 year old girl with leukaemia is brought in by her mother, they are on holiday in the area and normally would have gone straight into their local chemotherapy suite as she has not been well and has a temperature. What defines febrile neutropaneia?
    • -Temp>38.5?C on one occasion
    • -Temp>38 on 2 or more occasions recorded more than one hour apart
    • -Neutropaenia: Absolute neutrophil count (ANC) less than 500/ml (< 0.5 x 109) ANC <1.0 and rapidly falling count after chemotherapy
  48. You assess the child, her observations are as follows: Pulse 160, cap refill 4 secs, RR 52, sats 99% in air, what do you do (include any calculations)?
    • -Patient is shocked, needs urgent IV fluid bolus.
    • -Ages 4 years so (4+4) x2= 16kg therefore 20mls pre kg = 230mls of crystalloid.
  49. Which investigations do you send/febrile neutropaneia?
    • -Blood cultures
    • -systemic and waste
    • -Urine dipstix and culture
    • -Throat swab ? bacterial and viral Biochemistry
    • -UE
    • -LFT
    • -CRP
    • -Haematology -DIC screen if septic
  50. Which areas should you pay particular attention to on examination/ febrile neutropaneia?
    • 1. Mouth: teeth, gums, pharynx.
    • 2. ENT: especially examining for tenderness over the sinuses and mastoid sites. Consider NPA for patients with coryzal symptoms
    • 3. Respiratory: respiratory rate and oxygen saturations and requirements must be recorded and documented. Hypoxaemia and normal auscultation may be associated with Pneumocystis pneumonia (PCP).
    • 4. Cardiovascular: Blood pressure must be documented.
    • 5. Upper gastrointestinal: painful swallowing may be suggestive of herpetic or candidal oesophagitis. 6. Abdominal tenderness: right lower quadrant pain may suggest typhilitis (neutropaenic caecal inflammation), as well as appendicitis ? discuss with senior member of staff. 7. Perineum: symptoms of perianal discomfort or pain should always be asked about. If there are symptoms, the perineum should be inspected.
    • 8. Skin lesions: look for petechiae and purpura (evidence of thrombocytopaenia or DIC), consider Pseudomonas, herpetic, fungal aetiology
    • 9. Central venous line (CVL) sites: erythema, swelling, tenderness are suggestive of infection tracking along the line
    • 10. Procedure sites: e.g. Gastrostomy sites, lumbar puncture, posterior superior iliac crests
  51. What do you need to do prior to completing a full history and examination/ febrile neutropaneia?
    • -Treat the shock aggressively, need to cover with powerful antibiotics
    • -Discuss with senior paeds oncologist if available
    • -But do not delay giving antibiotics: First line antimicrobials:
    • 1. IV Ceftazidime 50mg/kg every 8 hours (max 2 grams tds)
    • 2. IV Gentamicin* (see below for exceptions) ? a. < 12 years ? 2.5mg/kg every 8 hours b. > 12 years ? 1.5mg/kg every 8 hours (max 120 mg tds) c. Levels must be taken after the third gentamicin dose (pre + post) d. Adjust initial dose if patient requires gentamicin but has renal impairment and take earlier levels ? usually just give normal dose and take levels with second dose (must be taken). Wait for level before giving dose.
    • 3. Oral fluconazole prophylaxis 3mg/kg once daily ? continue while neutropaenic
    • * IV Flucloxacillin should be used instead of gentamicin in the following cases: ? Renal impairment ? discuss with senior staff member ? Renally toxic chemotherapy protocols, i.e. those containing cisplatin or ifosfamide ? Dose of flucloxacillin 25mg/kg every 6 hours (max 1 gram qds) ?
    • -If patient shows signs of septic shock contact a Senior member of staff as they may require gentamicin irrespective of renal impairment or treatment with renally toxic chemotherapy
  52. Additional antibiotics
    • 1. Consider adding glycopeptide as first line agent if: ? CVL related infection suspected ? Severe mucositis ? Previous MRSA isolate ? IV Teicoplanin 10mg/kg (max 400mg) every 12 hours for 3 doses, then once daily
    • 2. If significant perianal inflammation or possible typhilitis (Neutropaenic colitis) add: ? IV Metronidazole 7.5mg/kg (max 500mg) every 8 hours
    • Febrile at 48 hours ? Discuss possible second line antibiotics with Consultant:
    • -If patient is unwell add: ? IV Teicoplanin 10mg/kg (max 400mg) every 12 hours for 3 doses, then once daily
    • Febrile at 96 hours ? Discuss possible third line antibiotics with Consultant:
    • -Consider empirical treatment for possible fungal infection (Consultant decision only): ? IV Liposomal amphotericin (Ambisome) ? Dose 3mg/kg od (remember to prescribe test dose as per cBNF)
    • Discuss change of antibiotic with Consultant on call: IV Imipenem*
    • a. <12 years="" 15mg="" kg="" qds="" max="" 500mg="" br="">b. >12 years 12.5mg/kg qds (max1g qds)
    • *Use Meropenem if evidence of renal impairment or history of CNS disorders
  53. A 4 yo girl was she was irritable and refusing food:What is the most common causative agent of the condition in the picture?
    -In children primary HSV-1 oral infection usually presents as gingivostomatitis.
  54. What is the incubation period/ HSV-1 oral infection/ gingivostomatitis?
    -ranges from 1 to 26 days (median 6 to 8 days).
  55. Name three locations where lesions can occur/ SV-1 oral infection/ gingivostomatitis.
    • -Lesions can occur anywhere on the pharyngeal and oral mucosa and progress over several days, eventually involving the soft palate, buccal mucosa, tongue, and the floor of the mouth.
    • -Gingivitis and extensions to lips and cheeks can be seen, with consequent difficulties in eating, drinking, and swallowing.
  56. How is the infective agent transmitted/ SV-1 oral infection/ gingivostomatitis?
    -Viral transmission can occur through close contact with oral lesions.
  57. Name three systemic symptoms/SV-1 oral infection/ gingivostomatitis.
    • -Common systemic symptoms and signs include fever, malaise, myalgias, irritability, and cervical lymphadenopathy.
    • -It can last for up to two weeks.
  58. A 10 month old boy was sent to the ED by his GP with a first episode of wheezing. A diagnosis of bronchiolitis was made. Give a differential diagnosis of four conditions?
    • -Viral-triggered asthma or wheezing
    • -pneumonia
    • -chronic lung disease
    • -foreign body aspiration
    • -gastroesophageal reflux disease and/or dysphagia leading to aspiration-congenital heart disease, heart failure, and vascular rings.
  59. What is the most common etiological agent to cause this condition/ bronchiolitis?
    -Respiratory syncytial virus (RSV) is the most common cause.
  60. Name four risk factors for this condition/bronchiolitis?
    • -Prematurity (gestational age <37 weeks)
    • -low birth weight
    • -age less than 6 to 12 weeks
    • -chronic pulmonary disease (bronchopulmonary dysplasia, cystic fibrosis, congenital anomaly)
    • -hemodynamically significant congenital heart disease (eg, moderate to severe pulmonary hypertension, cyanotic heart disease, or congenital heart disease that requires medication to control heart failure)
    • -immunodeficiency
    • -neurologic disease
    • -congenital or anatomical defects of the airways.
    • -Having older siblings, concurrent birth siblings
    • -passive smoke
    • -household crowding
    • -child care attendance
    • -high altitude.
  61. Name three factors associated with increased illness severity/bronchiolitis?
    • -Toxic or ill appearance
    • -oxygen saturation <95% by pulse oximetry while breathing room air
    • -age younger than 3 months
    • -respiratory rate ?70 breaths per minute
    • -atelectasis on chest radiograph.
  62. How would you manage this child/ bronchiolitis?(Name three)
    • -Supportive measures to ensure that the child is clinically stable, well hydrated, and well oxygenated.
    • -Consider a trial of inhaled bronchodilators.
  63. 4 week old baby boy is brought in by his parents who say that he has been vomiting after every feed they say that the vomiting is projectile in nature. You wonder about pyloric stenosis. You establish venous access and give a fluid bolus of 10ml/kg. What age group are affected by pyloric stenosis and what exactly is it?
    • -Pyloric stenosis is hypertrophy of the muscles surrounding the pylorus of the stomach.
    • -It is uncertain whether there is a real congenital narrowing or whether there is a functional hypertrophy of the muscle that develops in the first few weeks of life.
    • -Age affected: Usually presents between 3 and 6 weeks of age Late presentation up to 6 months can occur
  64. What is helpful when making the diagnosis/ pyloric stenosis?
    • -Palpable 'tumour' in right upper quadrant best felt from left during test feed
    • -Visible peristalsis often seen
    • -Diagnosis can be confirmed by abdominal ultrasound
    • -Needs assessment of length, diameter and thickness of the pylorus
    • -A wall thickness of great than 3mm supports the diagnosis
    • -Biochemically a hypochloraemic alkalosis exists
  65. How is it treated/ pyloric stenosis?
    • -Correct dehydration over a 24 - 72 hour period
    • -Nasogastric tube is often required
    • -Ramstedt's pyloromyotomy first described in 1911
    • Transverse right upper quadrant or circumumbilical incision
    • Longitudinal incision in pylorus down to mucosa
    • Incision extend from duodenum onto the gastric antrum
    • Need to try and avoid mucosal perforation pyloromyotomy
  66. Another child comes in with similar symptoms but doesn?t appear too dehydrated and the vomiting is not really projectile. What do you need to do to try to establish the diagnosis?
    • -Do a test feed to assess the nature of the vomiting
    • -Also establish the total amount that they are feeding, should be about 150mls per kg
    • -if they are massively overfeeding then this may represent the main problem.
  67. A 3 yo child attends the department with worried parents who tell you that she refuses to use her left arm. There is no history of trauma. On examination the arm appears to move normally with out discomfort but the child cries when you palpate the arm. There is no swelling or deformity. What is the next appropriate course of action?
    • -With no accurate history a fracture or other soft tissue injury cannot be confidently ruled out.
    • -Therefore an x-ray is the next step. If reasonable doubt surrounds the diagnosis, performing radiography of the extremity before attempting reduction is prudent to avoid manipulation of an extremity with an elbow fracture this is a medico-legal pitfall.
  68. Explain how you would manipulate a ?pulled elbow?
    • -Treatment consists of manipulating the child's arm so that the annular ligament and radial head return to their normal anatomic positions.
    • a. This is accomplished by immobilizing the elbow and palpating the region of the radial head with one hand.
    • b. The other hand applies axial compression at the wrist while supinating the forearm and flexing the elbow.
    • c. As the arm is manipulated, a click or snap can be felt at the radial head. A click noted by the examiner has a positive predictive value of more than 90% in 2 published case series and a negative predictive value of 76% in one case series. Some authors believe the likelihood of successful reduction is increased if pressure is applied over the radial head.
    • Nursemaid's elbow can be reduced by extension of the forearm instead of flexion; however, extension was less effective in achieving reduction in one case series. A recent abstract reports that pronation may be more effective than supination.
  69. What is the age range for a ?pulled elbow?, which arm is more commonly affected and is there any sex preponderance?
    • -Normally 1-4 yrs but 4 months to 15years have been reported, left arm more common as more care givers are right handed.
    • -Girls more common than boys.
  70. How would you manage a failed attempt at manipulation of a ?pulled elbow??
    • -Attempt again up to 3 times but must x-ray if still unsuccessful (if not already x-rayed)
    • -If radiographic findings demonstrate no fracture, repeat attempts at reduction are unsuccessful, and the child does not regain normal function after 30-40 minutes, the safest management is to support the arm in a sling (or splint and sling) and have the child re-evaluated by a physician (usually a primary care physician, not an orthopedist) in 1-2 days.
    • -One case series reported 7 patients meeting these criteria had either spontaneous return of function or successful reduction at follow-up evaluation by day 4.1
  71. A 10 year old boy presented with fever and rash(as seen below in the picture). If acute meningococcal disease is suspected name two appropriate antibiotics which can be started?
    • -Cefotaxime or ceftriaxone are the first choice anibiotics.
    • -If unavailable, use benzyl penicillin.
  72. What is the volume and type of fluid for a fluid bolus/ acute meningococcal disease?
    -20 ml/kg of normal saline.
  73. What other treatments should be considered/ acute meningococcal disease?(Give two)
    • -Consider intubation early.
    • -Give methylprednisolone (10mg/kg) before (or within 30 minutes) first dose of antibiotics.
    • -Consider hydrocortisone 1mg/kg 6 hourly - especially if on inotropes.
    • -Consider immunoglobulin 0.5g/kg over 2 hours.
  74. Name three possible late complications of this disease/ acute meningococcal disease?
    • -Small vessel thrombosis / tissue loss - involve Plastic Surgery early. Analgesia is important for skin necrosis or peripheral gangrene. Opiate infusions may be needed. -Reactive arthritis or pericarditis may occur in a few patients between days 3 to 7.
    • -Fever persisting for more than 7 days -This is common and may be due to: tissue damage (if there is extensive vasculitis), nosocomial infection, subdural effusion (in the case of meningitis), other foci of suppuration, or reactive complications.
    • Uncommon causes include inadequately treated meningitis, a parameningeal focus or drugs.
  75. Who should receive contact chemoprophylaxis/acute meningococcal disease?
    • -It is important that prophylaxis be given within 24 hours to contacts.
    • -All intimate, household or daycare contacts who have been exposed to index Case within 10 days of onset.
    • -Any person who gave mouth-to-mouth resuscitation to the index Case.
    • -The index case should also receive prophylaxis if penicillin only was used.
  76. A 6-yold boy brought in acutely short of breath. The ambulance crew let you know that he is known to have asthma and that he has been very wheezy over the course of the last 6 hours. They have given him 1 dose of nebulised salbutamol.What important features do you want to elicit to differentiate moderate severe asthma from life-threatening asthma? Please state 3 things that would guide your decision. (3 marks)
    • -Cyanosis
    • -PEFR<33%
    • -Silent chest
    • -Agitation or reduced GCS
    • -Exhaustion
  77. Why is heart rate sometimes not a useful guide of severity?
    -Tachycardia produced by salbutmaol
  78. The initial observations show that he has moderate-severe asthma. The sats are 90% in air what is your initial management please include drug doses.
    • -Give high flow oxygen
    • -Nebulised salbutamol 5mg (driven by oxygen)/as sats< 92% if were above could give inhaled salbutamol via a spacer.
    • -Prednisolone 40mg (as over 5 years)
  79. The child deteriorates and his sats drop to 86% his respiratory rate is now 65 and he appears to be tiring. What do you do know?
    • -Continue with back to back neds driven by high flow oxygen
    • -Give nebulised ipratropium 500 mcg via neb
    • -Give IV salbutamol loading dose of 15mcg/kg
    • -IV aminophylline 5mg/kg over 20 mins then loading dose then maintenance of 500mcg/kg/hr (if already on theophylline omit loading dose)
    • -Importantly call anaesthetist and set up kit for tracheal intubation, alert PICU
  80. Discuss the role of magnesium sulphate in the management of life threatening asthma in children.
    • No marks for mentioning that used in adults.(2 marks 1 for stating that it might be of benefit another for stating that it is still undergoing trials)
    • Answer: IV magnesium does work and there is good evidence for it.
    • Nebulised magnesium may work but there are a number of ongoing clinical trials.
    • So you can give it but ongoing research is needed for nebulised route.
    • Despite a suggestion of benefit in the sub-group of patients with acute severe asthma this treatment is not advocated at this time by the current BTS/SIGN national asthma guidelines (2004).
    • It is mentioned in the most recent edition of the BNF as an unlicensed indication for patients with acute severe asthma.
  81. A 5 yo girl is brought in by her parents who say that she is not right but they cannot identify exactly why. When you ask the girl if she is ok she says that she feels funny?.Her initial observation show that she is tachycardic at 260 b.p.m, what will you do? (2 marks)
    • -ABCD, apply oxygen
    • -Attach 3 lead monitoring and get a 12 lead ECG
    • -Measure BP and cap refill time essentially assess if hameodynamically stable
    • -Obtain IV access in a large proximal vein.
  82. Her ECG is shown (see fig 1): What does it show (1 mark)
    -Narrow complex tachycardia. (SVT)
  83. Her BP is 90/50, but her heart rate is still 260. What will you do? (2 marks)
    -As is haemodynamically stable can try Vagal techniques: Try valsalva but in 5 yr old better to elicit diving reflex, Facial cooling with ice for 15 seconds Immersion wrap the child in a towel and immerse the whole head in a bucket of ice water for 5 seconds (no need to obstruct mouth or nose).
  84. Name a drug that could be used for this child and give the correct dose based on her age. (2 marks)
    -Adenosine dose (5+4=9) x2 = 18kg (estimated weight) therefore giving 0.05mg/kg= 0.9mg or 900mcg.
  85. Are there any drug interactions that you need to know about with your chosen drug? (1 mark)
    -Yes; adenosine's action is prolonged by a factor of 4 by dipyridamole!
  86. The drug that you chose failed to work what will you do next?
    -reassess check that still haemodynamically stable then give further adenosine at doses of 0.1mg/kg then 0.2mg/kg g)
  87. The child fails to respond and seems to be drowsy now you repeat the BP which is now not reading what will you do?
    • -Must have dose for first shock to gain any marks Answer:
    • -Get someone to urgently call the paeds on call anaesthetist.
    • -Draw up some drugs that they may need.
    • -Get the defibrillator attached in sync mode and dial up 0.5joules/kg in this case 10 joules. Give synchronised DC shock.
  88. With regard to Nitrous Oxide:What is the onset of action?
    -Onset of action-20 seconds.
  89. When is the peak effect/ Nitrous Oxide?
    -Peak effect-3 -5 minutes.
  90. What are the two most common side effects/Nitrous Oxide?
    • -Dizziness or light-headedness
    • -mild nausea , vomiting.
  91. Name two more serious possible side effects/Nitrous Oxide?
    • -Expansion of closed gas filed space.
    • -Respiratory depression . Apnoea.
    • -Pulmonary aspiration of gastric contents if protective airway reflexes impaired.
    • -Folate metabolism and vitamin B12 suppression.
  92. What is the reversal agent/Nitrous Oxide?
    • -There is no reversal agent.
    • -Oxygen should be given in full recovery for approximately 5 minutes.
  93. A five year old boy is suspected of having meningitis:What are the normal range of values for neutrophils, lymphocytes, protein and glucose in children of this age?
    • -Neutrophils 0
    • -lymphocytes <5
    • -protein <0.4g/L
    • -glucose (CSF:Blood) >.6 or >2.5mmol/L.
  94. How does the CSF results in neonates differ to older infants?
    • -CSF white cell count and protein level are higher at birth than in later infancy and fall fairly rapidly in the first 2 weeks of life.
    • -In the first week, 90% of normal neonates have a white cell count less than 18, and a protein level < 1.0 g/L.
  95. How do antibiotics prior to lumbar puncture affect the results?
    • -Prior antibiotics usually prevent the culture of bacteria from the CSF.
    • -Antibiotics are unlikely to significantly affect the CSF cell count or biochemistry in samples taken <24 hours after antibiotics.
  96. How do traumatic taps affect CSF results?
    • -Some guidelines suggest that in traumatic taps you can allow 1 white blood cell for every 500 to 700 red blood cells and 0.01g/L protein for every 1000 red cells.
    • -However rules based on a ?predicted? white cell count in the CSF are not reliable.
  97. How do seizures affect CSF results?
    • -Recent studies do not support the earlier belief that seizures can increase cell counts in the absence of meningitis.
    • -It is safest to assume that seizures do not cause an increased CSF cell count.
  98. A 2 yo boy presented with inspiratory stridor and a barking cough. On examination he was febrile and mildly tachycardic.What is the most likely diagnosis?
  99. Give a differential diagnosis?(three conditions)
    • -Acute epiglottitis
    • -peritonsillar and retropharyngeal abscesses
    • -foreign body aspiration or ingestion
    • -allergic reaction
    • -acute angioneurotic edema
    • -upper airway injury
    • -congenital anomalies of the upper airway
    • -laryngeal diphtheria.
  100. What is the most common etiological agent/Croup.?
    -Parainfluenza virus type 1 is the most common cause of acute laryngotracheitis, especially the fall and winter epidemics.
  101. Name four aspects of the examination which are helpful in assessing the degree of upper airway obstruction and severity of illness?
    • -Overall appearance
    • -quality of the voice
    • -degree of respiratory distress
    • -tidal volume
    • -lung examination
    • -assessment of hydration status.
  102. A 2 yo boy presented with inspiratory stridor and a barking cough. On examination he was febrile and mildly tachycardic.-Croup.How would you manage this child?(Give five steps)
    • -Administration of humidified air or humidified oxygen
    • -antipyretics
    • -encouragement of fluid intake
    • -a single dose of oral dexamethasone (0.6 mg/kg) (if fit for discharge)
    • -nebulized epinephrine
    • -pulse oximetry
    • -observation.
  103. A 5 yo girl has a rash on her face (figure 1)What is this rash?
    • -Impetigo: a superficial bacterial skin infection most common among children 2 to 6 years old.
    • -People who play close contact sports such as rugby, American football and wrestling are also susceptible, regardless of age.
  104. Which children are more susceptible to this rash/Impetigo?
    -Children with eczema are much more prone to impetigo.
  105. What is impetigo caused by?
    -It is primarily caused by Staphylococcus aureus, and sometimes by Streptococcus pyogenes.
  106. How is it spread and what is the inoculation period?
    -Direct contact; 1-3 days
  107. What treatment is required Impetigo?
    • -Advice about strict hygiene
    • -Hand washing is the most important way to prevent spread.
    • -Oral antiobiotics to cover staphaureus and topical antibiotic cream also.
    • -It is important to dissolve the scabs with ointment because the bacteria that cause the disease live underneath them.
  108. An 8 day old baby is brought in by his parents with a rapid breathing rate and feeding less than he has been. He has born at term and had an uncomplicated delivery- at baby check at 24 hours nothing abnormal was found. Despite a rapid respiratory rate his chest is clear and he is not grunting. He handles well. He is afebrile and well perfused with a normal CRT <2 seconds. His resp rate is 74 nd his heart rate is 275 BP 76/41. Femoral pulses are palpable bilaterally. There have been no reported apnoeas. You obtain an ECG (figure 1) What is shown?
  109. What is the upper limit of normal resting pulse for a baby of this age?
    -Normally quoted to be 160 b.p.m
  110. What are the 3 categories of things that cause the rhythm shown on the ECG?
    • -1) atrial tachycardia (ectopic, or nonreciprocating, atrial tachycardia)
    • -2) atrioventricular nodal reentrant tachycardia (AVNRT)
    • -3) atrioventricular reentrant (or reciprocating) tachycardia (AVRT).
  111. What is the most common underlying cause in this age group?
  112. What treatment would you try first in this case?
    • -Firstly need to establish if the patient is stable or unstable
    • -If unstable then may need synchronised DC shock.
    • -Assuming that our patient is stable with a good BP then: Infants possess a diving reflex, in which vagal tone will increase in response to a cold stimulus (eg, ice) on the face.
    • -If not successful can move onto drug therapies-> Adenosine, given at a dose of 0.1 mg/kg rapid intravenous push, is the first-line agent.
    • -This may be repeated in doses of 0.3 mg/kg, as needed.
  113. What amount of energy is used when aiming to electrically cardiovert children?
    • -0.5J/Kg
    • -which can be increased to 2J/Kg if needed.
  114. A 4 year old boy is referred in by his GP as he had skin peeling from his hands and feet. He had a febrile illness for the preceeding week with a blanching rash. His GP asked that you rule out Kawasaki disease. On presentation he looked well, was afebrile and had skin peeling from his hands and feet. Below is a picture of his tongue. What are the diagnostic criteria for Kawasaki disease?
    • -Fever for 5 days or more
    • -plus 4 out of 5 of:
    • 1.polymorphous rash
    • 2.bilateral (non purulent) conjunctival injection
    • 3.mucous membrane changes, e.g. reddened or dry cracked lips, strawberry tongue, diffuse redness of oral or pharyngeal mucosa
    • 4.peripheral changes, e.g. erythema of the palms or soles, oedema of the hands or feet, and in convalescence desquamation
    • 5.cervical lymphadenopathy (> 15 mm diameter, usually unilateral, single, non purulent and painful) and exclusion of diseases with a similar presentation: staphylococcal infection (e.g. scalded skin syndrome, toxic shock syndrome), streptococcal infection (e.g. scarlet fever, toxic shock-like syndrome not just isolation from throat), measles, other viral exanthems, Steven's Johnson syndrome, drug reaction and juvenile rheumatoid arthritis.
  115. What are the most serious complications of this condition?
    -There is a risk of coronary complications.
  116. How would you investigate this patient?(Name five)
    • -ASOT / Anti DNAase B
    • -echocardiography (at least twice: at initial presentation and, if negative, again at 6 - 8 weeks)
    • -platelet count (marked thrombocytosis common in second week of illness)
    • -neutrophilia
    • -raised ESR + CRP
    • -mild normochromic, normocytic anaemia
    • -hypoalbuminaemia
    • -elevated liver enzymes.
  117. If Kawasaki disease is confirmed,how would you treat this patient?
    • -Patients require admission to hospital if Kawasaki Disease is diagnosed or strongly suspected and treatment is with
    • -intravenous immunoglobulin (2 g/kg over 10 hours; preferably within the first 10 days of the illness but should also be given to patients diagnosed after 10 days of illness if there is evidence of ongoing inflammation - eg fever, raised ESR/CRP)
    • - +/- aspirin 3 - 5 mg/kg once a day for at least 6 to 8 weeks. Some give a higher dose (10mg/kg 8 hourly for the first few days) but this probably adds nothing over immunoglobulin.
  118. What is the characteristic appearance of the tongue called?
    -Strawberry tongue.
  119. A 6 month old boy is brought in by his Mum, he was fine yesterday but this morning she noticed that he was crying more than normal and that he wasn't moving his left leg as normal. There was no story of trauma. His x-ray is shown below: Describe what is shown in the x-ray
    -Transverse femur fracture of the diaphysis that is angulated but not shortened.
  120. What will you do?
    • -Need to complete a full history and examination.
    • -Then need to contact senior paediatrician.
    • -Social services will need to be contacted and the child will need to be admitted not only for treatment of the fracture but for full NAI investigation.
  121. What is Munchausen by proxy (factitious ilness?)
    -Severe form of child abuse where adult (usually mother) fakes illness in their child, often they will induce physical symptoms by giving medications i.e. headaches (GTN) and they will demand investigations.
  122. What else could have caused the appearances seen above?
    -Osteogenesis imperfecta
  123. An 8 year old boy presents with the below rash on his torso which is itchy.What is the incubation period for this condition?
    The incubation period is from 10 to 21 days (most commonly 14 to 16)
  124. Name four common locations for the rash?
    -The lesions may occur anywhere but the scalp, face, trunk, mouth and conjunctivae are the most typical locations.
  125. Name four complications of this condition?
    • -Chickenpox is generally a benign and self limiting disease but may be associated with complications including
    • -bacterial superinfection (particularly group A beta haemolytic streptococcus and Staph aureus)
    • -pneumonia
    • -encephalitis
    • -cerebellitis
    • -hepatitis
    • -arthritis and Reye syndrome.
  126. Name two groups of patients who are more likely to suffer complications?
    -in infants, people over 15 years of age and immunocompromised children.
  127. What infectious precautions should be taken?
    • -The patient is infectious from one to two days before the onset of the rash until the lesions have fully crusted over.
    • -Children must be excluded from school until fully recovered (all lesions crusted over) or at least one week after the eruption first appears.
    • -If possible, hospitalisation should be avoided, because of the infectious risk to other patients.
    • -Any admitted child with active chickenpox or zoster should be isolated.
  128. A 4 yo children who have all developed a widespread rash as seen below. They have high temperatures and have generalised coryzal symptoms including sore throat, conjunctivitis. They tell you that none of the children have had their immunisations as they don't agree with it. What is the diagnosis? (1 mark)
  129. What are the two life threatening complications that you need to be vigilant for/ Measles? (2 marks)
    • -Pneumonia
    • -encephalitis
  130. What actions do you take/Measles? (3 marks)
    • -Advice family of the condition
    • -Inform the HPA as measles is a notifiable illness
    • -Look for secondary bacterial infection
  131. The mother is very concerned about her youngest child aged 4 years old and demands that she is admitted to hospital. You think that she is relatively well with normal vital signs. What do you tell her? (1 mark)
    -Explain that it is self limiting disease and that if things were not improving in 3 days then she needs to seek medical attention. Or if the child becomes more unwell i.e. any features of pneumonia or encephalitis.
  132. How long will the children be infective for/measles? (1 mark)
    -From onset of symptoms until 5 days after the rash disappears.
  133. A 13 yo girl presents with the following rash that covers her arms, legs and trunk. What is the rash?
    -Erythema multiforme
  134. What conditions were traditionally thought to be linked to this condition/ Erythema multiforme?
    • -Stevens-Johnson syndrome (SJS) was considered an extreme variant of EM for many years, while toxic epidermal necrolysis (TEN) was considered a different entity.
    • However, in 1993, a group of medical experts proposed a consensus definition and classification of EM, SJS, and TEN based on a photographic atlas and extent of body surface area involvement.
    • 1 According to the consensus definition, SJS was separated from the EM spectrum and added to TEN. Essentially SJS and TEN are considered severity variants of a single entity.
  135. The two spectra are now divided into (1) EM consisting of erythema minor and major (EMM) and (2) SJS/TEN. The clinical descriptions are as follows:
    • * EM minor - Typical targets or raised, edematous papules distributed acrally
    • * EM major - Typical targets or raised, edematous papules distributed acrally with involvement of one or more mucous membranes; epidermal detachment involves less than 10% of total body surface area (TBSA).
    • * SJS/TEN - Widespread blisters predominant on the trunk and face, presenting with erythematous or pruritic macules and one or more mucous membrane erosions; epidermal detachment is less than 10% TBSA for SJS and 30% or more for TEN.  
  136. What causes it?
    • -The major cause of EM is herpes virus.
    • It appeared to play a smaller role in SJS/TEN.
    • In fact, recent or recurrent herpes was the principle risk factor for EMM.
    • -Drugs were found to be a more common trigger for SJS/TEN.
    • -Approximately 50% of cases are idiopathic, with no precipitating factor identified.
  137. Many potential triggers have been implicated as possible causes of EM, SJS, and TEN. Most notably causes are
    • -infectious agents and drugs.
    • -All 3 disorders are linked to drugs with TEN being exclusively attributed to this factor.
    • -Infectious causes are more common in children and are implicated more commonly in EM.
    • -Herpes simplex infection is the most common cause in young adults and is strongly associated with recurrent EM.
    • -The most prevalent bacterial precipitant is Mycoplasma pneumoniae.
    • * Viral o Herpes simplex I & II o Adenovirus o Coxsackievirus B5 o Echoviruses o Enteroviruses o Epstein-Barr o Hepatitis A o Hepatitis B o Measles o Vaccinia o Varicella o Influenza o Mumps o Poliovirus
    • * Bacterial o Mycoplasma pneumoniae o Proteus species o Salmonella species o Tuberculosis o Vibrio parahaemolyticus o Psittacosis o Catscratch disease o Brucella species o Tularemia o Gonorrhea o Typhoid fever o Diphtheria o Lymphogranuloma venereum o Cholera o Yersinia enterocolitica
    • * Fungal o Histoplasmosis o Coccidioides species
    • * Postvaccination o Bacille Calmette-Gurin (BCG) o Oral polio vaccine o Vaccinia o Tetanus/diphtheria
    • * Drugs o Sulfonamides, including hypoglycemics o Nonsteroidal anti-inflammatory drugs (NSAIDs) o Anticonvulsants o Barbiturates o Antituberculous drugs o Antibiotics o Pyrazolones o Phenylbutazone, oxyphenbutazone, and phenazone o Salicylates
    • * Malignancy
    • * Hormonal
    • * Collagen vascular disease
    • * Immunologic disorders (sarcoidosis, vasculitides, transient selective C4 deficiency)
    • * Physical/mechanical factors (tattooing, radiotherapy, cold, sunlight, contactants)
    • * Risk factors o Previous history of EM o Male sex
    • * Herpes simplex infection
  138. Aside from a recent viral illness the young girl feels well in herself. What investigations do you perform on the emergency department?
    -NONE- there is no need.
  139. What treatment is required?
    • -Again none only symptomatic treatment as it is usually self limiting
    • -parental and patient education are obviously important.
    • -Steroid use is controversial.
    • -Patients who have herpes-induced erythema multiforme (EM) may benefit from acyclovir.
    • -Advise of significant risk of recurrence, especially in EM.
  140. A 6 year old boy is brought to the ED as he has trouble breathing after eating a peanut.How is anaphylaxis defined?
    • Anaphylaxis is a multi-systemic allergic reaction characterised by at least one
    • -respiratory or cardiovascular feature
    • -and at least one gastrointestinal or skin feature.
  141. Name four common causes of anaphylaxis in children?
    • -Foods (the most common cause) - Egg, nuts, cow milk, soy, shell-fish, fish and wheat Bites/stings
    • -Bee, wasp, jumper ants
    • -Medications- Beta-lactams, monoclonal antibodies, anaesthetics
    • -Others -including exercise induced anaphylaxis, idiopathic anaphylaxis, and latex anaphylaxis
  142. What blood investigation may be helpful if the diagnosis is in doubt?
    -A raised serum tryptase may confirm the diagnosis of anaphylaxis but should only be ordered if the diagnosis is unclear.
  143. What is the usual dose of adrenaline IM?
    -Intra-muscular adrenaline 0.01ml/kg of 1/1000 (maximum 0.5ml), into lateral thigh.
  144. What is the volume and type of fluid required for any associated shock?
    -Normal Saline 10-20ml/kg boluses.
  145. A 4 year old girl presents with purpuric rash on the extensor surfaces of limbs (mainly lower) and buttocks, joint pain/swelling and abdominal pain. Henoch-schonlein purpura is diagnosed. How would you investigate this patient?
    • -Urine analysis should be performed, and if haematuria is present the sample should be sent for microscopy to quantify the RBC count.
    • -Other investigations may include: Full blood count, urea, electrolytes with creatinine ,and blood culture.
  146. How would you manage this patient?
    • -Document the child's blood pressure
    • -Consider a surgical consult if abdominal features are prominent.
    • -Testicular torsion can be hard to differentiate from the pain of vasculitic testicular pain.
    • -There are some data to support the use of prednisolone. It probably helps prevent the development of long term renal complications.
    • -Consider prednisolone 1mg/kg for two weeks in all cases (not just those with haematuria). The use of prednisolone can also reduce the duration of abdominal and joint pain and may reduce the risk of recurrent episodes.
  147. What are the indications for admission?
    • -abdominal complication-arrange early surgical consultation.
    • -Renal complication eg nephritis, nephrotic syndrome.
    • -Also consider admission for symptomatic treatment:severe joint pain treatment is bed rest and analgesia,abdominal pain ,painful subcutaneous oedema.
  148. If this patient is to be discharged from the ED what points need to be made in the letter to there primary care physician?
    • -If discharged from the ED then it is imperative that appropriate follow-up is arranged to ensure adequate symptom control and resolution of the disease.
    • -Short term support can occur in the ED but follow-up care should soon be transferred to the GP (emphasise the need for ongoing BP and urine review in the letter) or a paediatrician - an appointment may be made in the General Medical Outpatient Clinic.
    • -The rash is usually the last manifestation to remit and appears to worsen if the child is very active.
    • -Some recommend an annual BP and urinalysis for life.
  149. What is the cause of this condition?
    -The cause is unknown but there may be a recent history of an upper respiratory tract infection.
  150. A 13 year old national standard ice skater is sent in by her podiatrist who has recently made her some new inserts for her skates. She is very distressed as she has an important competition in 2 weeks time. She is complaining of pain in the right forefoot and says that its gets progressively worse when she walks and has been unable to skate for the last 2 days. There is no history of trauma.What could be going on and what do you do to investigate?
    • -Frieberg's disease.
    • -Foot x-ray to start.
    • -Might show flattening, widening or fragmentation of the metatarsal head, or narrowing of the MTPJ.
  151. What would you advise?
    • -NSAIDS and rest in the first instance.
    • -orthopaedic referral.
    • -Persistent cases can be treated with excision of the MT head or osteotomy.
  152. What is Osgood-Schlatter's disease?
    • -It is another osteochondritis affecting the tibial tuberosity.
    • -It is a traction apophysitis of the tibial attachment of the patellar tendon normally seen in teenagers boys >girls.
    • -The tuberosity is prominent and tender.
  153. How should you treat plantar fasciitis?
    • -NSAIDS and rest, elevate the foot.
    • -Heel pads can help.
    • -Severe persistent cases can be treated with local steroid injections and sometimes surgical division of the plantar fascia.
  154. A 10 year old boy was in a cubicle in the ED waiting to be seen and suddenly his mom ran out of the cubicle shouting for help as her son had become unresponsive. The nursing staff confirm that the boy has no pulse and begin CPR. Other staff members arrive and attach a monitor which shows asystole.After resuming CPR what medication should be given?
    • -Adrenaline IV/IO: 0.01mg/kg(1:10000: 0.1mL/kg).
    • -This may be repeated every 3-5 minutes.
  155. After how many cycles of CPR should the rhythm be checked again?
    -5 cycles.
  156. What is the compression to breath ratio for one cycle of CPR?
  157. Name eight possible contributing causes to asystole?
    • -Hypovolaemia, hypoxia, hydrogen ion(acidosis), hypokalaemia/hyperkalaemia, hypoglycaemia, hypothermia
    • -toxins, tamponade(cardiac), tension pneumothorax, thrombosis(coronary or pulmonary),and trauma.
  158. If after the first rhythm check the monitor shows VF what is the energy level(J/kg) the child will be shocked at initially?
  159. A first time mother of a 15 day old boy is concerned that he cries frequently and appears unsettled.She also has concerns regarding his sleeping and feeding.He is being breast fed.He was born at term.Mom is concerned that her son has lost weight during his first week of life. What advice would you give her in this regard?
    • -Normal newborns may lose 5 to 10 percent of their birth weight during the first 3 to 7 days of life.
    • -A weight loss of up to 10 percent is acceptable if the infant's examination and behavior are normal.
    • On average, infants gain between 20 and 30 g per d in the first 3 months of life
    • -and between 15 and 20 g per d for the next several months.
    • -It is important to weigh the infant completely undressed.
  160. Mom is concerned that her son has 6-7 bowel motions per day and asks if he may have gastroenteritis?
    • -Breast-fed infants frequently will produce six or seven stools per day, whereas formula-fed infants generally produce one to two stools per day.
    • -The stools of breast-fed infants are softer. An excessive intake of human milk or maternal use of laxatives further increases the water content of the infant's stool.
    • -Overfeeding or use of formula that is too concentrated or too high in sugar content also can produce loose stools.
  161. What condition should be considered if the child did not pass meconium in the first 48 hours of life?
    -may be suggestive of Hirschsprung disease.
  162. Mom is concerned about her son's sleeping pattern.What advice can you give in this regard?
    • -Infants are not born with the ability to sleep through the night.
    • -Instead, they awaken every 20 min to 6 h, and sleep periods are spread evenly across the day and night.
    • -By 3 months of age, most of their sleep occurs at night, and by 6 months, most infants are sleeping through the night.
  163. Mom is concerned that her baby is breathing rapidly.What advice can you give in this regard?
    -The normal respiratory rate is 30 to 60 breaths/min in infants.
  164. A 4 year old boy was brought to the ED by his mother as he had a two week history of cough. What are the clinical features of whooping cough?(Give four)
    • -Cough may persist for several weeks, an inspiratory noise (whoop) after a bout of coughing
    • -coughing may culminate in vomiting
    • -cough typically worse a night
    • -conjunctival haemorrhage secondary to severe coughing.
  165. What is the pathogen involved?
    -Bordetella pertusis.
  166. How would you investigate this patient?(Give four)
    • -Blood for viral titres
    • -mycoplasma antibodies
    • -FBC
    • -CXR.
  167. How would you treat this patient?(Name three)
    • -Erythromycin, avoidance of other children
    • -arrange GP follow up
    • -prophylaxis for unimmunised infant siblings
    • -notifiable disease.
  168. What are the complications of this condition?(Name two)
    • -Prolonged illness
    • -neurological damage
    • -bronchiectasis.
  169. A 20 day old baby boy is brought in by Mother and father. They were sent in by the health visitor who had been for a routine visit this morning. Grandmother had shown the health visitor a lump that she had noticed over the baby's collar bone. Describe what is shown in this radiograph (fig 1)?
    • -There is a mid-shaft fracture of the right clavicle with callus formation.
    • -There is also soft tissue swelling.
  170. What is it important to establish?
    • -Need a full history of events, who noticed it when how etc.
    • -Details of the birth, was it traumatic?
    • -General rapport between parents and the child
    • -Speak directly to health visitor to establish if there were any concerns.
    • -Also must examine carefully for any evidence of Erb's palsy
  171. What is Erb?s Palsy? What is the prognosis?
    • -Erb's palsy leads to a weakness of a newborn baby's arm.
    • -It is caused by a stretch injury to the brachial plexus.
    • -50% of cases are associated with shoulder dystocia
    • -Prognosis is of course variable but: Depends upon degree of damage
    • -Effective hand grasp throughout is associated with a good prognosis
    • -Function may return within a few months
    • -Some may have be left with permanent damage
  172. How would you manage the features shown in the radiograph?
    -It will heal well with conservative management.
  173. Which health care professional is particularly helpful to consult in this scenario?
    • -Consultant paediatric radiologist to confirm the age of the fracture.
    • -Also health visitor to confirm any concerns and paediatricians for any other advice required.
  174. A 6 month old infant presented with increased work of breathing, fever and wheeze in his chest. He was alert and pink in air. His SpO2 was 95% in RA and he was feeding well. What is the most likely diagnosis?
  175. What is the most common aetiological agent?
  176. How would you classify this child?(Mild/Moderate/Severe)
    -As this child is alert and pink in air, is feeding well and saturating above 90% on RA he would be classified as mild bronchiolitis.
  177. How would you manage this patient?
    • -This child can be managed at home.
    • -Advise parents of the expected course of the illness, and when to return if there are problems.
    • -Also recommend smaller, more frequent feeds and a review by their GP within 24 hr.
  178. When is the peak severity of this condition?
    -Peak severity is usually at around day 2-3 of the illness.
  179. A 3 year old is brought in by her parents as she is not using her left arm. What is the differential diagnosis?(Give three)
    • -Fracture
    • -joint pathology
    • -neurological process
    • -an infective process.
  180. Name four findings on examination of a 'pulled' elbow?
    -Not using the affected limb, elbow in extension and the forearm in pronation, distressed only on elbow movement, no swelling, deformity or bruising of the elbow or wrist on palpation tenderness is usually absent (remember the clavicle), marked resistance and pain with supination of the forearm.
  181. When are plain radiographs indicated?
    • -Plain radiographs are indicated when a differential diagnosis is suspected:
    • significant tenderness
    • swelling
    • bruising or deformity
    • reduction fails.
  182. How would you treat this patient?
    • -Perform a reduction manoeuvre,expect distress and pain.
    • -A click may be felt over the radial head and review after ten minutes.
  183. Name two reduction techniques?
    -Supination-flexion and pronation flexion.
  184. A 10 year old boy was in a cubicle in the ED waiting to be seen and suddenly his mom ran out of the cubicle shouting for help as her son had become unresponsive. The nursing staff confirm that the boy has no pulse and begin CPR. Other staff members arrive and attach a monitor which shows VF. At what energy level(J/kg) should the child be shocked initially?
  185. After the shock is delivered what is the next step?
    -Give 5 cycles of CPR and recheck rhythm after 5 cycles.
  186. At what energy level should the second shock be delivered at?
  187. What medication should be given at this stage and at what dose?
    • -Adrenaline IV/IO: 0.01mg/kg(1:10000: 0.1mL/kg).
    • -This may be repeated every 3-5 minutes.
  188. If CPR is ongoing what medication should be considered and at what dose?
    -Amiodarone 5mg/kg IV/IO (or lidocaine 1mg/kg IV/IO).
  189. A 4 year old boy was playing with his brother magnetic set. He swallowed 4 magnetic balls yesterday but Mum has only just found out. He is completely well in himself but she wanted to get him checked over. What do you tell Mother?
    -That you need to confirm that they are in his gut by taking an abdominal x-ray.
  190. What signs do you ask Mum to look out for?
    • -Look out for any abdominal pain or vomiting, ensure that he is having normal bowel movements.
    • -If he appears at all unwell then needs to be seen immediately.
  191. What do you do with this child? Do you admit them or send them home?
    • -Needs surgical referral, may not need to come in but some authors propose that if multiple magnets are found on imaging then they should be removed.
    • -Probably should come in for close observation.
  192. What complications could potentially ensue?
    • -There are case reports of volvulus
    • -perforation and obstruction when 1 or more magnets has been ingested.
    • -Or when 1 magnet and a further metallic object has been ingested.
  193. A 4 yo boy + two week history of cough. What are the clinical features of whooping cough?(Give four)
    • -Cough may persist for several weeks
    • -an inspiratory noise (whoop) after a bout of coughing
    • -coughing may culminate in vomiting
    • -cough typically worse a night
    • -conjunctival haemorrhage secondary to severe coughing.
  194. What is the pathogen involved/whooping cough?
    -Bordetella pertusis.
  195. How would you investigate this patient/ whooping cough?(Give four)
    • -Blood for viral titres
    • -mycoplasma antibodies
    • -FBC
    • -CXR.
  196. How would you treat this patient/whooping cough?(Name three)
    • -Erythromycin, avoidance of other children
    • -arrange GP follow up
    • -prophylaxis for unimmunised infant siblings
    • -notifiable disease.
  197. What are the complications of this condition/whooping cough?(Name two)
    • -Prolonged illness
    • -neurological damage
    • -bronchiectasis.
  198. A 9 yold boy + 2 hour h/o acute pain in his left testicle. He feels sick and looks pale. The left testicle looks swollen and red and is acutely painful.You suspect that this may be a testicular torsion. What do you need to do?
    • -Contact the surgeons ASAP
    • -time is important.
  199. What happens anatomically in torsion?
    • -Torsion is a twisting of the spermatic cord, which is caused by contraction of the cremaster muscle.
    • -This interferes with the arterial supply to the testicle and eventually leads to infarction.
  200. What procedure will likely be undertaken/testicular torsion?
    -Exploration +/- orchidopexy and fixation both sides.
  201. You later find out that the reason it hurts so much is that his older brother kicked him in the scrotum 2 hours ago but he hadn't wanted to tell anyone. You wonder if he may have ruptured the testicle. What is the next step?
    • -Investigation: Ultrasonography is not sensitive in detecting testicular rupture, so early surgical exploration is recommended (Cameron et al, 2004).
    • -Treatment: Surgical investigation and repair is the recommended treatment.
    • -Conservative management has a longer recovery time and a higher rate of complications.
  202. Which organisms are most likely to cause epididymo-orchitis in the over 40 age group?
  203. An infant was brought to the ED after she suffered a head injury.Explain the AVPU mental status assessment?
    • -A-Alert
    • -V-Responds to voice
    • -P-Responds to pain (Purposefully or non-purposefully)
    • -U-Unresponsive.
  204. How does the verbal response of the glasgow coma scale differ between children and adults?
    • -Orientated is equivalent to appropriate words or social smile, fixes, follows which scores five.
    • -Confused is equivalent to cries but consolable which scores four.
    • -Inappropriate words is equivalent to persistently irritable which scores three.
    • -Incomprehensible words is equivalent to restless & agitated which scores two.
  205. Name five important points to be looked for in the secondary survey?
    • -Neck and cervical spine: deformity, tenderness, muscle spasm.
    • -Head: scalp bruising, lacerations, swelling, tenderness, bruising behind the ear (Battles sign).
    • -Eyes: pupil size, equality and reactivity, fundoscopy.
    • -Ears: blood behind the ear drum, CSF leak.
    • -Nose: deformity, swelling, bleeding, CSF leak .
    • -Mouth: dental trauma, soft tissue injuries.
    • -Facial fractures.
    • -Motor function: examine limbs for presence of reflexes and any lateralising weakness.
    • -Perform a formal Glasgow Coma Score Consider the possibility of non-accidental injury during secondary survey especially in infants with head injury.
    • -Other injuries (see major trauma guidelines)
  206. Describe four features of a minor head injury in infants?
    • -No loss of consciousness.
    • -One or less episodes of vomiting.
    • -Stable, alert conscious state .
    • -May have scalp bruising or laceration.
    • -Normal examination otherwise.
  207. Name four common causes of head injury in children?
    • -Causes include falls
    • -sporting accidents
    • -road traffic accidents
    • -non-accidental injury.
  208. A 3 week old boy presents with vomiting.Pyloric stenosis is suspected. What are the features of the vomiting in this condition?(Give three)
    • -Progressively more forceful
    • -may be projectile non-bilious
    • -blood stained in up to 10% of cases.
  209. What are the risk factors for this condition/Pyloric stenosis?(Give three)
    • -Male
    • -firstborn
    • -caucasian
    • -parental history of HPS (higher if mother affected).
  210. What features may you find on examination/Pyloric stenosis?(Give three)
    • -Assess degree of dehydration.
    • -Weigh and plot on growth chart with previous weights if available.
    • -Look for jaundice (1-2% of infants with HPS)
    • -Look for gastric peristalsis (waves of muscle contraction across the abdomen passing from the left upper quadrant to the right lower quadrant).
    • -Feel for a pyloric mass (best felt in the right upper quadrant with the infant supine. Approximates the size and shape of an olive. Best felt from left side. Wait for several minutes.)
    • -Signs may be more obvious following a feed.
  211. What investigations should be done/Pyloric stenosis?(Give four)
    • -Take blood for FBE, U&E, Acid-Base, Glucose (bilirubin if jaundice present).
    • -Hypochloraemic Hypokalaemic Metabolic Alkalosis may be seen.
    • -If diagnosis not yet established, abdominal ultrasound is the investigation of choice (95% sensitive).
  212. How would you manage this child/Pyloric stenosis?(Give four)
    • -Fluid resuscitation may be necessary with 10-20ml/kg boluses of normal saline, for patients with moderate to severe dehydration.
    • -Commence IV Fluids (0.45% Saline / 5% Dextrose + 10mmol KCl / 500mls) at 100mls/kg/day initially.
    • -Review after 4-6 hours.
    • -Stop oral feeds Insert a nasogastric tube if vomiting continues despite stopping feeds. -Replace nasogastric losses with IV normal saline.
    • -Repeat U&E, Acid-Base 4-6 hourly initially and adjust fluid accordingly.
    • -The aim for most infants should be to fully correct fluid and electrolyte deficits within 48 hours.
    • -Initial KCl may be required if significant hypokalaemia Replace deficit, in addition to maintenance, in those infants who are clinically dehydrated (weight is a good marker of the degree of dehydration).
  213. A 6 yo boy + fall on his right wrist. X Ray reveals a colles fracture. The decision is made to manipulate the boy's wrist using ketamine for proceural sedation.What are the advantages of using ketamine for procedural sedation? (Give two)
    • -Ketamine provides sedation, analgesia, amnesia, and immobilization
    • -while usually preserving upper airway muscle tone, airway protective reflexes, and spontaneous breathing.
  214. What is the dose range when using ketamine for procedural sedation intravenously?
    - 0.5mg to 2 mg/kg.
  215. What is the duration of action of ketamine?
    - 10 to 20 minutes.(though typical duration of effective dissociation is 5-10 min)
  216. Name three side effects/ Ketamine?
    • -increased salivation
    • -vomiting
    • -unpleasant hallucinations
    • -laryngospasm rarely occurs.
  217. What are the disadvantages of giving ketamine via the IM route?(Give two)
    • -Longer recovery times
    • -more vomiting.
  218. A 2 yold boy 3/7 ho intermittent fever and tummy ache. No diarrhoea. He vomited once yesterday. On examination his temperature is 37.5C, and examination of his ear, nose throat and chest are normal. His abdomen is soft and non-tender. You suspect a urinary tract infection. Give three other possible diagnosis that are important to rule out in a boy of this age (3)
    • -Appendicits
    • -Mesenteric adenitis
    • -Orchitis
    • -Intussusception
  219. The urine dipstick is positve for nitirites and leucocytes. Name three of the most likely organisms. (3)
    • -Escheria Coli
    • -Strep B
    • -Klebseiella
    • -Proteus
    • -Enterobacter Staph
  220. Give four indications for admission in a child with UTI? (4)
    • -Dehydration / inability to tolerate oral fluids / repeated vomiting
    • -Toxic child requiring IV antibiotics
    • -Co-morbidities
    • -Parental concerns / inability to cope Age < 3/12 (some guidelines < 6/12)
    • -Pyelonephritis / renal angle tenderness clinically
  221. Ho should you obtain a urine sample?
    -Not with a bag, should be clean catch MSU
  222. What would you treat this child with/UTI?
    • More than 3 months of age with signs of pyelonephritis Treat with oral antibiotics for 10 days
    • -if sufficiently well < 1 year old -> Cephradine or Co-amoxiclav (Augmentin)
    • - > 1 year old -> Cephradine or Trimethoprim
    • -If IV antibiotics required Cefuroxime is the drug of choice.
    • -IV antibiotics should be continued until the pyrexia has settled and culture is available from which an appropriate oral antibiotic can be given (total duration of treatment 10 days)
    • More than 3 months of age with signs of cystitis Treat with oral antibiotics for 3 days
    • -if sufficiently well but review if no improvement after 24-48 hours
    • - < 1 year old-> Cephradine or Co-amoxiclav (Augmentin)
    • - > 1 year old ? Cephradine or Trimethoprim
  223. A 13 day baby boy is brought in, he left the neonatal unit three days ago. Mum says that he has a bowel disorder that needs an operation, they are currently doing washouts of his rectum as he cannot pass stool himself. Mum is a little concerned as he has vomited his feeds this afternoon and wonders if his abdomen is a little distended. You ask if the baby had a rectal biopsy whilst on the NICU, they says yes and you also find out that he is otherwise completely healthy and was not ventilated whilst on the NICU. What is the diagnosis?
    -Hirschprung's disease
  224. You examine the child carefully. What important signs are you looking for? Do you order any tests?
    • -General ABCDE approach
    • -need to assess if the baby is septic
    • -need to think about intestinal obstruction.
    • -Looking for distended bowel loops.
    • -Check BM
    • -temperature
    • -full set of observations cap refill etc.
    • -Order a plain abdominal film looking for obstruction and signs of necrotising enterocolitis NEC.
    • -Full set of bloods including cultures/CRP/WBC
  225. The AXR (fig 1)was taken in the ED what does it show and what will you do?
    • -It shows Pneumatosis intestinalis, which is pathognomonic for NEC.
    • -An urgent surgical consultation is needed and further imaging ultrasound if a skilled provider is available or left lateral decubitus imaging to rule out a pneumoperitoneum.
    • -If this is the case then surgery will be indicated.
    • -Baby needs to be NBM, have an NG tube inserted and have IV antibiotic started.
    • -Needs to be managed on PICU.
    • -If free gas was shown then needs an urgent laparotomy.
  226. What is the approximate mortality of this condition?
    -50% mortality but higher in severe NEC
  227. A 5 year old boy has eaten some mushrooms and is brought in vomiting he is haemodynamically stable and only ate them 30 minutes ago he found them in his 17 year old brother's room. Parents are concerned that they may be magic mushrooms? What is the dose of activated charcoal in children?
    - 1mg/kg
  228. What 2 conditions are essential to be met prior to considering its administration?
    • -That it is within one hour of ingestion (unless slow release preparations are ingested could consider giving later)
    • -That there is adequate airway protection either via an ET tube or a fully conscious patient. (Aspiration can be fatal)
  229. Is there any place for giving it in this scenario?
    • -Firstly the child is vomiting so is unlikely to be able to take the charcoal.
    • -Activated charcoal can be used if death cap mushroom (Amanita phalloides) are ingested but there is no role for it in this scenario.
  230. Name to treatments for ingestion of antifreeze.
    -Ethanol or alcohol dehydrogenase inhibitor (fomepizole)
  231. What is the dose of naloxone in children?
    • -Neonate 5-10 micrograms/kg, repeated every 2-3 minutes if required
    • -Child 1 month 12 years 5-10 micrograms/kg; if response inadequate, give a subsequent dose of 100 micrograms/kg (max. 2 mg)
    • -Child 12-18 years 1.5-3 micrograms/kg; if response inadequate, give subsequent doses of 100 micrograms every 2 minutes
  232. A 4 year old boy is brought in by his Mother. He developed a cough which has worsened in the night and she became worried about his breathing. The cough is described as barky with a loud inhalation noise. He seems well when you see him but very sleepy. His observations are normal. What is croup and what age croup are affected?
    • -laryngotracheitis usually caused by parainfluenza virus.
    • -It affects children 6 months to 6 years.
  233. List 4 differential diagnoses:
    • -Epiglottitis
    • -Bacterial tracheitis
    • -Inhaled foreign body
    • -Angioedema
  234. Although the child you assess appears well his Mum assures you that he was not well 3 hours ago. What will you do with this child? (2 marks)
    • -Give one dose of 0.3mg/kg dexamethasone orally.
    • -Steroid treatment reduces the severity and duration of symptoms.
    • -Dexamethasone is cheaper, easier to give and as effective as nebulised budesonide.
    • -Consider discharge.
  235. What treatments could you use in life threatening croup? Write out a treatment scheme.
    • -Think ABC
    • -Give 100% oxygen with continuous cardiac and oxygen saturation monitoring.
    • -Call anaesthetic and senior paediatric help urgently.
    • -Give nebulised L-epinephrine 1 in 1000 solution.
    • -Age< 1yr: 2.5mls L-epinephrine, diluted with 2.5mls normal saline.
    • -Age> 1yr: 5mls L-epinephrine undiluted.
    • -Effective at 10-30 minutes, but can get rebound with worsening obstruction as effect wears off after 60 - 90 minutes.
    • -Can be given continuously if necessary.
    • -Give nebulised budesonide 2mg if this will not delay airway management.
    • -Transfer to high dependency/ ITU.
    • -Nebulised epinephrine should be given on general paediatric wards only as a holding measure in a child being transferred to ITU.
    • -Intubation. Ideally by a senior paediatric anaesthetist with gas induction, in a controlled environment.
    • -If child is in extremis, intubation by the most experienced person present. The cords will be swollen, an ETT several sizes smaller than predicted may be necessary. Do not cut the tube.
    • a) Give dexamethasone 0.6 mg/kg IV.
    • Do not attempt to gain IV access until airway is secure.
    • b) Give antibiotics only if bacterial tracheitis suspected.
  236. What advice would you give to Mum on discharge about methods to improve croup?
    • -Be clam and reassuring
    • -Give cool fluids to drink
    • -Try to create steam by turning the shower on and shutting the door as this can improve symptoms
  237. A 6 yr old child is brought in fitting; he has been fitting for 5 minutes, is attached to monitors and is receiving oxygen. He has been unwell for the last 3 days with a runny nose. He hasn't had his immunisations. His temperature is 39.6C and he weighs 20kg.Fill in the names, doses and timings of the drugs in the algorithm (see fig 1 for answers) for treating the fitting child: There should be 5 boxes in the algorithm that you draw.Some lesions were noted in the child's mouth (fig 2): What are the lesions called and what if the diagnosis?
    -Kopliks spots and Measles
  238. Name 8 other notifiable diseases:
    • -Any 8 from
    • -Acute encephalitis-Anthrax
    • -Botulism-Bruscellosis
    • -Cholera
    • -Diphtheria-Dysentery
    • -Food poisoning
    • -HIV/AIDS
    • -Legionella-Leptospirosis-Leprosy
    • -Malaria-Measles-Meningitis-Meningococcal Septicaemia-Mumps
    • -Opthalima neonatorum
    • -Paratyphoid-Plague-Polio
    • -Rabies-Relapsing fever-Rubella
    • -SARS, Scarlet fever, Small pox, Syphilis
    • -TB-Tetanus- Typhoid fever- Typhus
    • -Viral haemorrhagic fever, Viral hepatitis
    • -Whooping cough
    • -Yellow fever.
  239. A 10 year old diabetic boy is brought to the ED suffering from diabetic ketoacidosis.How would you assess the degree of dehydration?
    • -Mild/nil (<4%) No clinical signs
    • -Moderate (4-7%) easily detectable dehydration eg. reduced skin turgor, poor capillary return.
    • -Severe(>7%) poor perfusion, rapid pulse, reduced blood pressure ie. shock.
  240. How would you investigate this patient?
    • -Blood glucose
    • -urea, electrolytes.
    • -Arterial or capillary acid/base.
    • -Urine
    • -ketones
    • -culture.
    • -Check for precipitating cause eg. infection (urine, FBE, blood cultures; consider CXR).
  241. How would you treat this patient?(Give three)
    • -Rehydration
    • -Insulin
    • -Potassium.
  242. What should be kept in mind when interpreting the sodium level?
    -Measured serum sodium is depressed by the dilutional effect of the hyperglycaemia.
  243. What are the warning signs of cerebral oedema?
    • -Headache
    • -irritability
    • -lethargy
    • -depressed consciousness
    • -incontinence
    • -thermal instability.
  244. A neonate is brought to the ED by his parents as he had a fever, cough and wasn't feeding well. The treating emergency clinician suspected pneumonia.What are the common pathogens involved in neonatal pneumonia?(Name two)
    • -E.Coli
    • -beta-haemolytic strep
    • -chlamydia trachomatis
    • -listeria monocytogenes
    • -CMV.
  245. How would you investigate this patient?(Give four)
    • -Throat swabs
    • -FBC
    • -cultures
    • -viral titres
    • -mycoplasma antibodies
    • -SpO2
    • -urine cultre
    • -CXR.
  246. How would you treat this patient?
    • -O2
    • -IV fluids
    • -specialist referral
    • -benzylpenicillin and gentamicin
    • -alternatively cefuroxime or co-amoxyclav.
  247. What are the risk factors for neonatal pneumonia?(Give four)
    • -Prolonged rupture of the fetal membranes (>18 hours)
    • -maternal amnionitis
    • -premature delivery
    • -fetal tachycardia
    • -maternal intrapartum fever
    • -anomalies of the airway (eg, choanal atresia, tracheoesophageal fistula, and cystic adenomatoid malformations)
    • -severe underlying disease
    • -prolonged hospitalization
    • -neurologic impairment resulting in aspiration of gastrointestinal contents.
  248. What are the factors which determine outcome? (give four)
    • -Increased mortality is associated with preterm birth, pre-existing chronic lung disease, or immune deficiencies.
    • -Severity of the disease, the gestational age of the patient, underlying medical conditions, and the infecting organism affect the prognosis of the disease.
  249. A 4 year old boy is brought to the ED by his parents. They complained that he had been distressed that morning but could not explain why. He had no history of trauma or fever but had become abruptly distressed. On examination his heart rate was 200/min. There was also evidence of poor perfusion.Before ordering an ECG give three basic management steps?
    • -ABC's
    • -O2
    • -attach monitor/defibrillator.
  250. His ECG revealed narrow QRS complexs and was thought to be a probable supraventricular tachycardia. What is the next step?
    -Vagal maneuvers.
  251. If this fails and but IV access is readily obtained what medication should be given and at what dose?
    -Adenosine. 0.1mg/kg by rapid bolus.
  252. What other treatment modality should be considered?
    • -Synchronised cardioversion. 0.5 to 1J/kg.
    • -If this is not effective increase to 2 J/kg.
  253. Name eight possible contributing causes to paediatric tachycardias with poor perfusion(5H's and 5T's)?
    • -Hypovolaemia, hypoxia, hydrogen ion(acidosis), hypokalaemia/hyperkalaemia, hypoglycaemia, hypothermia
    • -toxins, tamponade(cardiac), tension pneumothorax, thrombosis(coronary or pulmonary),and trauma.
  254. A six year old boy presents with a rash over his buttocks and at the back of his upper thighs as shown in the picture below. Henoch-Schonlein Purpura is suspected. HSP typically presents with the triad of:(?)
    • -Purpuric rash on the extensor surfaces of limbs (mainly lower) and buttocks
    • -joint pain/swelling
    • -abdominal pain.
  255. What is the cause of this condition?
    -The cause is unknown but there may be a recent history of an upper respiratory tract infection.
  256. What may be shown on the urine dipstick?
    • -Haematuria is present in 90% of cases, but only 5% are persistent or recurrent.
    • -Less common renal manifestations include proteinuria, nephrotic syndrome, isolated hypertension, renal insufficiency and renal failure (<1%). Renal involvement may only present during the convalescent period.
  257. What joints are usually involved?
    • -Swelling and arthralgia of large joints are often the patient's main complaint.
    • -In most situations this pain resolves spontaneously within 24-48 hours.
  258. How would you investigate this patient?
    • -Urine analysis should be performed, and if haematuria is present the sample should be sent for microscopy to quantify the RBC count.
    • -Other investigations may include: Full blood count ,urea, electrolytes with creatinine, blood culture.
  259. A 1 year old boy is brought in by his parents after hitting his face on a wooden bar in the park, his mouth bled profusely after the event and he appears to have lost his front tooth. By the time you see him the bleeding has settled. What piece of information is crucial in this case?
    • -Did the parents see the tooth; do they have it with them?
    • -If they didn't there is a chance that it could have been aspirated and go on to cause a lung abscess.
  260. What would you do?
    -Chest x-ray including lateral to look for foreign body.
  261. Another child presents with a laceration to the lip. What important features must you look for during the examination?
    • -Must ensure that the laceration doesn't cross the vermilion border.
    • -If it does it will need suturing as even a 1mm discrepancy will leave a scar.
  262. Unlike the cosmetically important facial lacerations that are almost always closed primarily, certain small intraoral lacerations may be left open without repair. What are the indications for closure? Indications for intraoral closure ? -Mucosal laceration that creates a flap that interferes with chewing
    • -Mucosal laceration that is large enough to trap food particles
    • -Wounds longer than 2 cm
  263. A 3 year old child is sent in by their GP as having a non-blanching rash and the GP wonders if it might be meningococcal disease. He gives the child IM penicillin and sends them straight in to see you.Please give 4 differential diagnoses for a true non-blanching rash. Not including ITPP, HUS, HSP or acute leukaemias which are all distinct and usually not difficult to diagnose.
    • -Meningococcal disease (MCD)
    • -Sepsis with other bacteria
    • -Viral illness
    • -Trauma/NAI
  264. Describe how a child with ITP normally presents.
    • -Usually well children with multiple bruises and ppetechiae noticed over severall days.
    • -Often seen after a viral illness.
    • -Can get conjunctival haemorrhage, nose bleeds and bleeding gums.
  265. Does the fact that the child has been treated with penicillin affect the management principles that you will follow?
    -No, you would treat as you would another child but these children do require a senior paediatric review prior to discharge.
  266. Define a purpuric rash.
    • -Lesions >2mm in diameter -are non-blanching.
    • -Spontaneous bleeding into the skin usually appears as a rash known as purpura
  267. If the lesions were purpuric and the child had a mild temperature what would be your initial management?
    • -To give IV broad spectrum antibiotics
    • -third generation cephalosporin. Ceftriaxone 80mg/kg (od) or cefotaxime 50mg/kg (tds)
  268. The lesions are confined to the area above the nipple line and you think that the child is otherwise quite well. Explain the thoutht process that you will use to decide whether or not to admit him to hospital.
    • -If the lesions are not purpuric i.e. they are less than 2mm and the child is well, i.e. not irritable, lethargic and haemodynamically stable
    • -then you can look for the distribution of the rash if it is confined to the SVC distribution then the child can be discharged as long as there is a focus of infection and there are no concerns over NAI.
  269. A 10 year old girl presents with an earring embedded in the earlobe with an associated local infection. You decide to do a nerve block. draw a diagram to indicate the site of injection and the nerve involved Great auricular nerve block -Subcutaneous injection infiltrate 1cm below the ear lobe from the posterior border of the SCM to the angle of the mandible.
  270. Calculate the dose of Lidocaine 1% for this girl, show calculation
    • - 10 years = 28kg (age+4) x2
    • -Max dose = 3mg/kg, ie 84 mg Max dose of 1% lidocaine is 8.4mls
  271. What systems and symptoms does LA affect in overdose
    • -Perioral and lingular paraesthesia and numbness
    • -CNS: Lightheaded, dizzy, LOC, Seizure
    • -CVS: Arrhythmia, Cardiac arrest
  272. A 5 year old presents with a headache, fever and vomiting. Meningitis is suspected. What are the usual organisms causing bacterial meningitis in children of this age group(give three)?
    • -in children over 2 months of age are:
    • -streptococcus pneumoniae
    • -neisseria meningitidis
    • -haemophilus influenzae type b (Hib uncommon after age 6).
  273. What organisms should be considered in children under 2 months of age?
    • -Group B streptococcus
    • -E. coli
    • -other Gram-negative organisms, listeria monocytogenes, S. pneumoniae, N. meningitidis, haemophilus influenzae type b.
  274. What does a purpuric rash suggest?
    -meningococcal septicaemia.
  275. What is the rational for giving steroids?
    -Steroids protect against neurological sequelae.
  276. When should steroids be given?
    -The benefit is probably greatest if steroids are given at least 15 minutes before the first dose of antibiotics.
  277. The above film is of a 4 year old girl who presents 5 days after a fall onto her left arm. Mum is concerned as she has noticed a swelling over the outer aspect of the arm. What is the abnormality on the film? How would you describe it?
    -Mid-shaft fracture of the ulna, this is a plastic deformity with clear bowing of the ulna.
  278. One of your consultants happens to be a round and casually lets you know that the films are inadequate. What do they mean and what do you need to do now? What abnormality do you not want to miss here?
    • -You need a true lateral at the elbow joint as you do not have one.
    • -You don't want to miss a dislocation of the radial head and hence a Monteggia fracture dislocation.
    • -This is a common pitfall if you don't request the correct films.
  279. What is a greenstick fracture?
    • -Almost exclusively occurs during infancy and childhood.
    • -The bending of a bone with incomplete fracture, involving the convex side only.
    • -Green stick fractures are characterized by a break in the bone which partially extends across and then along the length of the bone forming the characteristic fracture pattern for which it is named.
  280. A 3 month old baby + mother had come upon the child in his cot apnoeic and off colour. This was thought to be an apparent life threatening event (ALTE). How would you manage this patient?
    • -Take blood (FBC, UE, glucose, calcium, magnesium, phosphate)
    • -admit for monitoring.
  281. What are the risk factors for SIDS(Name four)?
    • -Passive smoking
    • -males
    • -winter months
    • -sleeping prone
    • -premature babies
    • -twins
    • -apnoeic spells in first week of life
    • -lower socioeconomic groups
    • -sibling with SIDS
    • -maternal illicit drug abuse.
  282. What advice can you give the above patient to prevent SIDS?(Give four)
    • -Avoid overheating
    • -avoid duvets and excess bedding
    • -sleep supine
    • -consider apnoea alarm
    • -avoid infant sharing bed with parent.
  283. What is the definition of SIDS?
    -Sudden infant death in infancy with no cause identified after autopsy.
  284. What is the aetiology of SIDS?
    -Aetiology is unknown.
  285. A 3 month old is brought to the ED with increased work of breathing, cough and runny nose of one days duration.A diagnosis of bronchiolitis is considered. What are the risk factors for this condition?
    • -Infants with broncho-pulmonary dysplasia
    • -congenital heart disease may have more severe problems with bronchiolitis.
  286. What are the usual aetiological agents/bronchiolitis?
    • -RSV
    • -parainfluenza 3
    • -adenovirus.
  287. When is the usual peak severity of the condition/bronchiolitis?
    • -The illness usually peaks on day 2-3
    • -with resolution of wheeze and respiratory difficulty over 7-10 days.
    • -The cough may persist for weeks.
  288. What are the signs of moderate severity bronchiolitis?
    • -Poor feeding
    • -lethargy
    • -marked respiratory distress
    • -underlying cardiorespiratory disease
    • -O2 saturation < 90%
    • -age < 6 weeks.
  289. What should parents be told about the cough?
    -The cough may persist for weeks.
  290. A 3 yo boy + fever and was pulling at his ear. His mother reported that he was more irritable than usual and appeared lethargic. What are the common aetiological agents which cause acute otitis media?
    • -Viral (25%)
    • -streptococcus pneumoniae (35%)
    • -non-typable strains of haemophilus influenzae (25%)
    • -moraxella catarrhalis (15%).
  291. What features may be found on examination/acute otitis media?(Name four)
    • -The usual middle ear landmarks (handle of malleus, incus, light reflex) are not well seen.
    • -The tympanic membrane (TM) is dull and opaque, and may be bulging.
    • -The TM colour varies but is characteristically yellow-grey. On pneumatic otoscopy TM mobility is reduced.
    • -There may be associated signs of URTI, such as coryza, red tonsillopharynx, cough etc.
    • -The features suggest the infection is viral. Many febrile or crying children have red TMs (just as they have red cheeks). A red TM alone is not acute otitis media.
  292. What are the possible complications of this condition/acute otitis media?(Name four)
    • -Perforation of the TM results in purulent otorrhoea, and usually relief of pain.
    • -Febrile convulsions are commonly related to AOM.
    • -Suppurative complications such as mastoiditis, suppurative labyrinthitis or intracranial infection (meningitis, extradural or subdural abscess, brain abscess) are very uncommon.
    • -Other potential complications include facial nerve palsy, lateral sinus thrombosis, and benign intracranial hypertension.
  293. How would you treat this patient?
    • -Most cases of AOM in children resolve spontaneously.
    • -Antibiotics provide a small reduction in pain beyond 24 hours in only about 5% of children treated.
    • -The modest benefit must be weighed against the potential harms related to antibiotic use, both for the individual patient (adverse effects) and at a population level (resistance pressure).
    • -It has been shown that not using antibiotics for otitis media is acceptable to parents if the reasons are explained clearly.
    • -Pain is often the main symptom, so adequate analgesia is very important
    • -Analgesia guideline. Paracetamol 20-30 mg/kg for 2-3 doses/day should be given if pain is significant.
    • -Short-term use of topical 2% lignocaine drops applied to the tympanic membrane has been shown to be effective for severe acute ear pain.
    • -Decongestants, antihistamines and corticosteroids have not been shown to be effective in AOM.
  294. What factors have been shown to reduce the risk of serous otitis media ("glue ear")?(Name one)
    • -Parental smoking is an important avoidable risk factor.
    • -The use of dummies should be limited to settling, as prolonged use has been shown to be associated with otitis media.
  295. You take a red phone call informing you that a 7 year old child cardiac arrest is coming in, he was pulled out of a frozen lake in the a nearby national park. What things do you need to prepare?
    • -The following may well be required
    • -Experienced team
    • -Defibrillator and resuscitation drugs
    • -Warming equipment Warming blanket Overhead heater Warming infuser
    • -Appropriate fluids in warm cupboard, 42C for fluids.
  296. What is the approximate weight of this child and what dose of adrenaline would you give in cardiac arrest?
    • -Weight (age+4) x2 = 22kg
    • -Dose of adrenaline 0.1ml/kg = 0.22mg normally 1:10,000 comes made as 1mg in 10 mls. Therefore 220 micrograms is the required dose. (Adult dose is 1mg of 1:10,000)
  297. At what temperature is it normally thought that the heart will not respond to defibrillation/treatment of arrhythmias?
    - 32 C
  298. What factors need to be thought about in terms of the aetiology in this case? (Please list things that might have occurred that you would need to bear in mind)
    • -Inadequate swimming skills
    • -Epilepsy
    • -Alcohol or drug ingestion
    • -Trauma to head and neck from diving (must control the c-spine)
    • -Poor supervision NAI
  299. The core temp is 29 C and the child is in cardiac arrest explain what you will do? f) List 4 complications of near drowning?
    • -Manage as per APLS protocols.
    • -Return the heart to sinus rhythm.
    • -Improve tissue perfusion and oxygenation.
    • -Raise core temperature to >32C.
    • -Maintain good effective CPR over a prolonged period by rotating staff.
    • -Joint agreement for cessation of resuscitation.
    • -A patient isn't dead until warm and dead.
    • Answer:
    • -Pneumonia
    • -Pulmonary oedema
    • -Cerebral oedema
    • -Hypotension
    • -Re-warming shock
    • -DIC
    • -Rhabdomyolysis and acute renal failure
    • -Electrolyte disturbances
  300. A 4 yo boy after accidently ingesting aspirin tablets.Name four possible symptoms?
    • -Tinnitus
    • -vomiting
    • -hyperventilation
    • -lethargy, coma, seizures
    • -hyperthermia
    • -dehydration
    • -hypoglycaemia
    • -non cardiogenic pulmonary oedema.
  301. What would blood gases be likely to show salycilate OD?
    • -Initial respiratory alkalosis (may be transient)
    • -followed by paradoxical aciduria (pH <6)
    • -then metabolic acidosis & hypokalaemia (? ongoing respiratory alkalosis).
  302. In what patients should treatment be considered / Salycilate OD?
    -Acute ingestion >150mg/kg, all symptomatic patients , and an ingestion of unknown quantity.
  303. How would you investigate this patient/ Salycilate OD?
    • -Serum salicylate level at presentation (on patients requiring treatment)and 2 hrly if symptomatic or enteric coated preparation.
    • -Urea & electrolytes, creatinine, acid-base, glucose.
  304. How would you manage an asymptomatic patient/ Salycilate OD?
    • -Charcoal 1g/kg (if <1 hour since ingestion unless enteric coated preparation)
    • -observe 6 hours & discharge if still asymptomatic.
    • -If the tablets are enteric coated preparations, serial salicylate levels (2 hourly).
    • -Consider admission if levels have not plateaued at 6 hours post ingestion and consider an I.V. bicarbonate infusion 1mmol/kg/hr to correct any acidosis (pH <7.3).
  305. A 6 yo boy presents with sudden onset abdominal pain. On examination his left testicle is tender and swollen. What is the differential diagnosis?(Name four)
    • -Torsion of the testis
    • -torsion of the appendix testis (hydatid of Morgagni)
    • -epididymoorchitis
    • -incarcerated inguinal hernia
    • -idiopathic scrotal oedema
    • -hydrocele
    • -henoch Schonlein purpura
    • -testicular or epididymis rupture.
  306. What features in the history and examination would make a testicular torsion more likely?
    • -Sudden onset testicular pain and swelling
    • -occasionally nausea, vomiting.
    • -Note: pain may be in the iliac fossa.
    • -Discolouration of scrotum; exquisitely tender testis, riding high.
  307. What features in the history and examination would make a torsion of the appendix testis(hydatid of Morgagni) more likely?
    • -More gradual onset of testicular pain.
    • -Focal tenderness at upper pole of testis
    • -"blue dot" sign - necrotic appendix seen through scrotal skin
    • -Note: Difficult to distinguish from testicular torsion.
  308. What features in the history and examination would make epididymoorchitis more likely?
    • -Onset may be insidious
    • -fever, vomiting, urinary symptoms
    • -rare in pre-pubertal boys, unless underlying genitourinary anomaly, when associated with UTI.
    • -Red, tender, swollen hemiscrotum; tenderness most marked posteriolateral to testis. -Pyuria may be present.
  309. What features in the history and examination would make a hydrocele more likely?
    • -Swollen hemiscrotum in well, settled baby.
    • -Soft, non-tender swelling adjacent to testis
    • -transilluminates brightly.
  310. A boy presents with a suspected Bell's palsy.What are the important points in the history?(Give five)
    • -Ask about the evolution of weakness. Bell's palsy usually comes on very quickly (over hours or no more than a couple of days).
    • -Ask about preceding viral infections or trauma to the head or face.
    • -Ask about hyperacusis (increased sensitivity to sound) and altered taste. Both are common in Bell's palsy.
    • -Ask about facial pain. Mild pain in the face or behind the ear is common in Bell's palsy. Severe pain suggests that the lesion may be caused by the varicella zoster virus (VZV).
    • -Confirm that all facial nerve branches are involved diffusely (with particular reference to the muscles of the upper half of the face, which are spared in upper motor neuron lesions).
    • -Perform a thorough neurological examination (rest of cranial nerves, peripheral power, tone, reflexes and coordination).
    • -Examine for signs of otitis media, mastoiditis or parotitis.
    • -Look for skin lesions or blisters on the face or in the ear canal.
    • -Confirm that blood pressure and temperature are normal.
    • -Hypertension may rarely be associated with Bell's palsy.
  311. How would you manage this child?(Give three points)
    • -Eye care: All children with any inability to completely close their eye should have eye care: Lubricating (hypromellose) ocular drops at least three times during the day. Pad eye shut at night after application of lubricating ocular ointment.
    • -Steroids: The role in treatment of Bell's palsy in children is unclear, however streroids appear to benefit adults, particularly if given within 72 hours of onset and if complete palsy present.
    • Prednisolone (1mg/kg/day PO daily for 10 days) may be considered for Bell's palsy presenting within 72 hours of onset.
    • -Antivirals: aciclovir may only be considered if vesicular rash present.
  312. What other advice would you give this child and their parents regarding the evolution of the illness?
    • -In the first three weeks, facial weakness may get worse.
    • -Any deterioration beyond this time should be investigated.
    • -Many children will recover within 6 weeks of onset.
    • -More than 95% of children have a full recovery by 12 months
    • -Children may also experience a temporary change in hearing or how much saliva they appear to make.
    • -Eye care is important to prevent scratches to the eye.
  313. What follow up would you organise for this child?
    • -Referral to a neurologist is suggested for children < 2 years of age
    • -atypical features on history or examination or in the absence of any recovery by 4 weeks.
    • -Referral to ENT should occur if evidence of otitis media, mastoiditis or parotitis.
    • -For the other cases, a paediatrician or general practitioner should review in 3-5 days, then as needed to monitor for corneal ulceration.
  314. A 8 year old girl is brought to the ED by her parents with what is thought to be an anaphylactic reaction.Name 10 possible examination findings?
    • 1.Respiratory features:
    • respiratory distress (tachypnoea, hypoxia, cyanosis)
    • upper respiratory tract signs
    • -tongue swelling
    • -stridor
    • -hoarse voice or change in character of the cry
    • -subjective feeling of swelling or tightness in the throat.
    • Lower respiratory tract signs
    • -persistent cough
    • -wheeze
    • -subjective feeling of chest tightness.
    • 2.Cardiovascular features
    • hypotension
    • impairment or loss of consciousness
    • pale and floppy infant.
    • 3.Gastrointestinal features
    • vomiting
    • diarrhoea
    • abdominal pain.
    • 4.Skin features
    • angioedema
    • urticaria/erythema
    • generalised pruritus.
  315. What investigation may be helpful if the diagnosis is in doubt?
    • -A raised serum tryptase may confirm the diagnosis of anaphylaxis but should only be ordered if the diagnosis is unclear, such as in unexplained and life-threatening cardiac or respiratory collapse.
    • -Serum tryptase returns to normal within hours of anaphylaxis, and a normal serum tryptase does not exclude anaphylaxis, particularly in the case of food induced anaphylaxis.
    • -Serum tryptase is unstable and must be transported to the laboratory quickly.
  316. What is the treatment of choice and what is the dose?
    • -Intra-muscular adrenaline 0.01ml/kg of 1/1000 (maximum 0.5ml)
    • -into lateral thigh is the treatment of choice for anaphylaxis
    • -which should be repeated after 5 minutes if patient not improving.
  317. Name three other therapies that should be considered?
    • -Nebulised salbutamol is recommended if the patient has respiratory distress with wheezing.
    • -Anti-histamines may be given for symptomatic relief of pruritus.
    • -Second generation anti-histamines are preferred (promethazine can cause hypotension).
    • -Corticosteroids may be considered at the discretion of the treating physician, especially for bronchospasm, although the limited evidence available does not support their use.
  318. In a recovered child what factors should influence the decision to admit the child for overnight observation?
    • -Greater than one dose of adrenaline (including nebulised adrenaline) required
    • -a fluid bolus was required
    • -if the child lives a long distance from medical services.
  319. A 9 month baby girl is brought in with difficulty breathing and short history of being generally unwell and poor feeding. She has a temperature of 38.2C and has saturations of 93% in room air. What is the normal respiratory rate in a child of 9 months? (1 mark)
    - 30-40 breaths a minute.
  320. When is the bronchiolitis season? (1 mark)
    -Late autumn to early spring
  321. Name 3 viruses that cause bronchiolitis stating which one is most common. (3 marks)
    • -Respiratory syncitial virus (RSV) is the most common (70-80%).
    • -Others include, adenovirus, influenza, parainfluenza, metapneumo-virus.
  322. Some children are at increased risk of severe illness and would almost always be admitted. List 3 circumstances where this would be the case. (3 marks)
    • Any of the following:
    • -Infants <6 weeks
    • -Ex-Preterm Infants
    • -Chronic Lung Disease
    • -Congenital Heart Disease
    • -Immunodeficiency
  323. On the history and information above what would you do with this child, list three criteria on which you would base your decision please include some specific objective measurements? (3 marks)
    • -It depends but answer should include a senior paeds review.
    • -Any one of these features may be sufficient to prompt admission and not all are required.
    • -Marked recession/respiratory distress or grunting respirations
    • -Oxygen saturations <92%
    • -Respiratory rate >70/minute
    • -Taking <50% usual feeds or concerns regarding hydration status
    • -History of apnoea
    • -Appears unwell or lethargic
  324. Describe the role of drug treatments in bronchiolitis (2 marks)
    • -Nebulised Ribavirin: minimal evidence shows it to be effective in reducing length of hospital stay and ventilatory support in severely affected patients. -Consultant approval required before commencing ribavarin therapy.
    • -1 mark awarded for stating that the mainstay of treatment is supportive rather than medication based.
  325. What is the most important thing that needs to be considered when admitting and nursing children with bronchiolitis?
    -Limiting cross infection by any sensible means described in the answer.
  326. You wish to insert an IV cannula into a 15 day old term baby and decide to use sucrose for analgesia. What is the mechanism of pain relief?
    • -The mechanism is an orally mediated increase in endogenous opioid.
    • How long do the analgesic effects last/ ucrose for analgesia?
    • -Analgesic effects last 5-8 minutes.
  327. What are the contraindications to using sucrose?
    • -Infants with known fructose or sucrose intolerance.
    • -Critically ill infants receiving appropriate intravenous analgesia and sedation who have low pain scores on handling.
  328. Up to what age may sucrose be effective/ ucrose for analgesia?
    • -Oral sucrose is most effective as a mild analgesic agent for infants in the first month of life.
    • -It has also been shown to have analgesic and calming effects up to 18 months of life.
  329. What is the approximate dose per procedure in this age group(0-1 month)/ ucrose for analgesia?
    - 0.2-1ml of 24-33%.
  330. A 3 yol boy after a theophylline overdose.What symptoms may be expected?(Give four)
    • -CNS :agitation, hyperventilation, headache, convulsions
    • -Cardiovascular :arrhythmias
    • -GIT :nausea & vomiting (may be intractable), thirst, diarrhoea.
  331. What patients require treatment / theophylline overdose?
    • -Acute ingestion of >10mg/kg
    • -ingestion while on maintenance theophylline
    • -ingestion of unknown quantity, all symptomatic patients.
  332. How would you investigate this patient?(Give four)
    • -Theophylline levels should be determined on all patients requiring charcoal.
    • -Consider serial levels at 2 hours then every 2 hours until peak reached or decline demonstrated.
    • -If slow release preparation has been taken: admit, continue levels at 4 hourly intervals after decline or plateau to ensure detection of secondary peak.
    • -Seizures are common at levels >330 micromol/L.
    • -Haemoperfusion commonly needed at levels > 550 micromol/L.
    • -U&E, Cr and Glucose on all patients.
  333. How would you manage this patient?
    • -Asymptomatic: Charcoal 1g/kg. Observe 4 hours.
    • -If no symptoms, discharge if not slow release medication.
    • -If ingestion of slow release preparation, admit for observation and serial drug levels.
    • -Symptomatic: Charcoal 1g/kg initially unless altered conscious state (protect airway first) then 0.5g/kg 4 hourly, and whole bowel irrigation with colonic lavage solution 30ml/kg/hr.
    • -Cardiac monitoring.
    • -I.V. fluid resuscitation & maintenance of adequate hydration is vital.
    • -If depressed conscious state, arrhythmias or intractable vomiting contact I.C.U. as likely to need intubation.
    • -Severe intoxication may require haemoperfusion.
    • -If agitated, may need sedation with a benzodiazepine or phenobarbitone.
  334. A 6 yo boy was drowsy and poorly communicative. On examination his heart rate was 40 and his extremities appeared poorly perfused. Name two basic initial management steps with this child?
    • -O2
    • -Attach monitor/defibrillator
    • -support ABC's.
  335. If despite the above steps the child is still bradycardic with poor perfusion what is the next management step?
    -Perform CPR if depite oxygenation and ventilation HR <60/min with poor perfusion.
  336. If the bradycardia is persistent and symptomatic what medication is indicated? (Assume the child does not have increased vagal tone or primary AV block)
    • -Adrenaline(IV/IO) 0.01mg/kg(1:10000; 0.1mL/kg) or 0.1mg/kg (1:1000: 0.1mL/kg) via endotracheal tube.
    • -This can be repeated every 3-5 minutes.
  337. If the bradycardia is persistent and symptomatic and the child has increased vagal tone or primary AV block what medication is indicated?
    -Atropine 0.02mg/kg and may be repeated.
  338. What other treatment modality should be considered/bradycardia?
    -Cardiac Pacing.
  339. A red phone call tells you that a 6 year old girl is on the way who is shocked. She is a type 1 diabetic and has been well over the last few days; today she had some vomiting and abdominal pain. You assess her and begin to treat her gaining IV access and instigating a fluid bolus. Her BM is 1.4. Mother tells you that she has been getting recurrent low BM readings over the last few weeks that they haven?t been able to explain.What will you do?
    • -Give 5ml/kg 10% dextrose bolus followed by maintenance fluids.
    • -If unable to gain IV access and not drowsy or unresponsive give sugar orally (eg.100ml coke, lemonade, orange juice, 2-3 dextrose tablets, milk feed, Glucogel)
    • -If drowsy or unresponsive give IM Glucagon 0.5 mg < 25 kg, 1 mg > 25 kg
  340. You sent off some routine bloods initially and they come back, WBC normal, K+ 6.1, Na+ 128. You are concerned as the child has not responded to your initial fluid bolus; you give another bolus and seek advice from the consultant paediatrician. What is the possible diagnosis?
    • -Undiagnosed primary adrenal insufficiency with acute adrenal crisis.
    • -Other autoimmune diseases may be a clue to the presence of Addison's disease. E.g. recurrent hypoglycaemia in a child with type 1 diabetes mellitus
  341. What is the management/adrenal insufficiency with acute adrenal crisis? (include any drug doses)
    • -IV hydrocortisone 25mg (<10 kg), 50 mg (10-25 kg), 100mg (> 25kg)
    • -continue 6 hourly until well with no diarrhoea/vomiting and stable blood sugar and electrolytes.
    • -If unable to gain IV access give IM hydrocortisone
  342. Explain the pathophysiology of diabetes insipidus.
    • -Diabetes insipidus (DI) is a condition characterized by excretion of large amounts of severely diluted urine, which cannot be reduced when fluid intake is reduced.
    • -It denotes inability of the kidney to concentrate urine.
    • -DI is caused by a deficiency of antidiuretic hormone (ADH), also known as vasopressin, due to the destruction of the back or "posterior" part of the pituitary gland where vasopressin is normally released from, or by an insensitivity of the kidneys to that hormone.
    • -It can also be induced iatrogenically by various drugs.
  343. A 9 yol boy after prodrome of fever, malaise, and pharyngitis he had developed a pruritic rash shown in the picture. What is the diagnosis?
    • -Chicken pox.
    • What is the incubation period and how is this disease transmitted/ Chicken pox?
    • -The average incubation period for varicella infection is 14 to 16 days
    • -although this interval can range from 10 to 21 days.
    • -Transmission occurs in susceptible hosts via contact with aerosolized droplets from nasopharyngeal secretions of an infected individual or by direct cutaneous contact with vesicle fluid from skin lesions.
  344. What areas do the lesions cover/Chicken pox?
    -typically has lesions in different stages of development on the face, trunk and extremities.
  345. Name three complications of this Chicken pox?
    • -The most frequent complication among healthy children is bacterial skin superinfection.
    • -Others include encephalitis, reye syndrome, hepatitis and pneumonia.
  346. Name three general measures to treat Chicken pox?
    • -Antihistamines
    • -fingernails should be closely cropped
    • -paracetamol.
    • -Acyclovir may be used in selected cases.
  347. A 4 year old boy was brought to the ED by a parent with a painful ear. What is the diagnosis?
    -Otitis media.
  348. What are the risk factors for Otitis media?(Name four)
    • -The peak age-specific attack rate occurs between 6 and 18 months of age
    • -the spread of bacterial and viral pathogens is common in daycare centers
    • -non-breast fed babies
    • -Exposure to tobacco smoke and ambient air pollution increases the risk of OM
    • -children who use a pacifier
    • -children in developing areas
    • -family history
    • -social and economic conditions
    • -sleep position
    • -season (increased incidence during the fall and winter months)
    • -altered host defenses
    • -underlying disease (eg, cleft palate, Down syndrome, allergic rhinitis).
  349. What are the common species of bacteria accounting for most of the bacterial isolates from middle ear fluid?(Name two)
    • -Streptococcus pneumoniae
    • -Haemophilus influenzae
    • -Moraxella catarrhalis.
  350. How would you manage this patient/Otitis media?(two points)
    • -Analgesia(paracetamol or ibuprofen)
    • -antibiotics(amoxicillin)
    • -organise follow up to ensure resolution.
  351. What are the complications of this condition/Otitis media?(Name four)
    • -Mild conductive hearing loss
    • -vestibular, balance, and motor dysfunctions
    • -tympanic membrane perforation
    • -inflammation of the mastoid and/or mastoiditis
    • -petrositis and labyrinthitis.
    • -Intracranial complications are rare in developed countries they include meningitis, epidural abscess, brain abscess, lateral sinus thrombosis, cavernous sinus thrombosis, subdural empyema, and carotid artery thrombosis.