Acute illness & emergencies Flashcards
1
Q
Steeple sign on X ray is characteristic of which condition?
A
Croup
2
Q
What is the treatment for croup?
A
Single dose of oral dexamethasone (0.15mg/kg).
3
Q
Which organism most commonly causes croup?
A
Parainfluenza
4
Q
Why does stridor occur in croup?
A
It’s caused by a combination of laryngeal oedema and secretions.
5
Q
What is the peak incidence of croup?
A
6 months - 3 years.
6
Q
Describe the features of croup
A
- Stridor
- Barking cough worse at night
- Fever
- Coryzal symptoms
7
Q
What emergency treatment can be used in croup?
A
- High flow oxygen
- Nebulised adrenaline
8
Q
What is the treatment for meningitis in children < 3 months?
A
IV amoxicillin and cefotaxime.
9
Q
Outline the contraindications to a lumbar puncture
A
ANY SIGN OF RAISED ICP:
- Focal neurological signs
- Papilloedema
- Bulging fontanelle
- DIC
- Signs of cerebral herniation
Also, meningococcal septicaemia, local skin sepsis, bleeding conditions, spinal cord compression, intracranial or cord mass, extensive or spreading purpura, GCS < 13, prolonged or focal seizures, pupillary dilatation.
10
Q
What is the treatment for meningitis in children > 3 months?
A
IV cefotaxime, steroids, fluids.
11
Q
Outline the school exclusion criteria for infections
A
- No exclusion: conjunctivitis, slapped cheek, roseola, infectious mononucleosis, head lice, threadworms, cold sores, molluscum contagiosum, hand, foot & mouth.
- 24 hours after commencing antibiotics: scarlet fever.
- 2 days after commencing antibiotics or 21 days from onset of symptoms: whooping cough.
- 4 days from onset of rash: measles.
- 5 days from onset of rash: rubella.
- All lesions crusted over: chickenpox.
- 5 days from onset of swollen glands: mumps.
- Until symptoms have settled for 48 hours: D+V.
- Until lesions have crusted over or 48 hours after commencing antibiotics: impetigo.
- Until treated: scabies.
- Until recovered: influenza.
12
Q
All children having an asthma attack should be given…
A
Steroids
13
Q
Which organism causes acute epiglottitis?
A
Haemophilus influenzae type B
14
Q
Describe the features of acute epiglottitis
A
- Rapid onset
- Fever, malaise
- Stridor
- Drooling of salvia
- ‘Tripod’ position
15
Q
How is a diagnosis of acute epiglottitis made?
A
By direct visualisation or X-ray.
16
Q
Outline the management for acute epiglottitis
A
- Endotracheal tube may be necessary to protect airway.
- Do not examine throat due to risk of airway obstruction.
- Oxygen.
- IV antibiotics.
17
Q
Outline the diagnostic criteria for whooping cough
A
When a person has an acute cough that’s lasted for at least 14 days without another apparent cause, plus one or more of the following:
- Paroxysmal cough (violent and uncontrolled coughing).
- Inspiratory whoop.
- Post-tussive vomiting.
- Undiagnosed apnoea attacks in young infants.
18
Q
Should household contacts of patients with threadworms be treated with oral mebendazole even if they have no symptoms?
A
Yes
19
Q
Outline the key points of paediatric basic life support
A
- Unresponsive?
- Shout for help.
- Open airway.
- Look, listen and feel for breathing.
- Given 5 rescue breaths.
- Check for signs of circulation - brachial or femoral pulse.
- 15 chest compression: 2 rescue breaths. Chest compressions at a rate of 100-120/min.
20
Q
Which organism most commonly causes scarlet fever?
A
Streptococcus pyogenes (group A strep)
21
Q
Describe the typical features of scarlet fever
A
- Fever lasting 24-48 hours.
- Malaise, headache, N+V.
- Sore throat.
- Strawberry tongue.
- Rash: fine punctate erythema on torso and in flexures, flushed appearance, rough sandpaper texture.
22
Q
Outline the management for scarlet fever
A
- Oral penicillin V for 10 days.
- Return to school 24 hours after commencing antibiotics.
- Notifiable disease.
23
Q
List the complications of scarlet fever
A
- Otitis media (most common)
- Rheumatic fever
- Acute glomerulonephritis
- Bacteraemia, meningitis, necrotising fasciitis
24
Q
An infant with bronchiolitis has a persistent high fever >39 and persistent focal crackles. What’s the most likely diagnosis?
A
Secondary bacterial pneumonia
25
Do bronchodilators have any benefit in bronchiolitis?
No as salbutamol ineffective in children < 1. They’re effective in viral-induced wheeze.
26
Describe the features of measles
- Prodromal phase: irritable, conjunctivitis, fever.
- Koplik spots: white spots on buccal mucosa.
- Rash: starts behind ears then to whole body, maculopapular rash.
- Diarrhoea in 10% of patients.
27
Outline the management for measles
- Supportive unless immunosuppressed or pregnant.
- Notifiable disease.
28
List the complications of measles
- Otitis media (most common)
- Pneumonia
- Encephalitis
- Subacute sclerosing panencephalitis
- Febrile convulsions
29
Describe the classic presentation of chickenpox
Increased temperature for 2 days before developing clusters of erythematous vesicles predominantly affecting the torso and face.
30
Which organism causes chickenpox?
Varicella zoster virus
31
Describe the infectivity of chickenpox
- 4 days before rash, until 5 days after the rash.
32
Outline the management of chickenpox
- Calamine lotion to soothe itch.
- Paracetamol to control fever.
- School exclusion: until all lesions have crusted over (5 days after onset of rash).
- IV aciclovir in immunocompromised.
33
What is a common complication of chickenpox?
Secondary bacterial infections of the lesions.
34
Why shouldn’t NSAIDs be used in the management of chickenpox?
Increase risk of necrotising fasciitis
35
Outline the red flags for children < 5 with a fever
- Pale/mottled/ashen/blue colour
- Appears ill to healthcare professional
- No response to social cues or doesn’t wake
- Weak, high-pitches cry
- Grunting or intercostal recession
- RR > 60 breaths/min
- Reduced skin turgor
- Age < 3 months with temperature >= 38
- Non-blanching rash
- Bulging fontanelle
- Neck stiffness
- Status epilepticus
- Focal neurological signs
- Focal seizures
36
Define mesenteric adenitis
- Inflamed mesenteric lymph nodes.
- It is often preceeded by a viral infection.
- It is self limiting.
37
Describe the classical presentation of roseola
6 month - 2 year old with a fever followed by a rash which is maculopapular, painless and non-pruritic, and typically affects the trunk. May also cause febrile seizures.
38
Roseola infantum is caused by which organism?
Human herpes virus 6
39
Which parasite causes head lice/nits?
Pediculus capitis
40
Describe the treatment choices available for head lice
- Malathion
- Wet fine combing
- Dimeticone
- Isopropyl myristate
- Cyclomethicone
- The Bug Buster kit
41
Do household contacts of patients with head lice need to be treated?
No, unless affected.
42
Hand, foot and mouth disease is most commonly caused by which organisms?
Coxsackie A16 and enterovirus
43
Describe the presentation of hand, foot and mouth disease
Low-grade fever, oral ulcers and a characteristic vesicular rash on the palms and soles.
44
Outline the management for hand, foot and mouth disease
- Symptomatic treatment only: general advice about hydration and analgesia.
- Reassurance no link to disease in cattle.
- Children do not need to be excluded from school.
45
Describe the features of threadworms
Perianal itching, particularly at night
46
Which organism causes threadworms?
Enterobius vermicularis
47
Which antibiotic is first line in whooping cough?
Macrolide - clarithromycin, azithromycin or erythromycin, if onset of cough is within the previous 21 days.
48
Differential for a child presenting with petechiae and no fever
ITP
49
True or false: children who have had bronchiolitis as infants are more likely to have viral induced wheeze during childhood.
True
50
Describe the symptoms of Kawasaki disease
- High- grade fever > 5 days (resistant to anti-pyretics)
- Dry cracked lips
- Bilateral conjunctivitis
- Peeling/desquamation of skin on fingers and toes
- Cervical lymphadenopathy
- Red rash over trunk
- Strawberry tongue
51
Outline the management of Kawasaki disease
- High-dose aspirin
- IV immunoglobulin
52
What is the main complication of Kawasaki disease?
Coronary artery aneurysm
53
Management for child < 3 years presenting with an acute limp
Urgent paediatric assessment
54
When on high doses of salbutamol, what should be monitored and why?
Serum K+ because it causes K+ to be absorbed from blood into cells (hypokalaemia).
55
Name 2 side effects of salbutamol
Tachycardia and tremor
56
Are boys or girls more affected by croup?
Boys
57
Why does a barking cough occur in croup?
Impaired movement of vocal cords.
58
List some differentials for croup
- Acute epiglottis
- Bacterial tracheitis
- Foreign body inhalation
- Laryngomalacia
- Allergic reaction/acute anaphylaxis
- Angio-oedema (non-allergic)
- Tonsillitis and peritonsillar abscess (quinsy)
59
In which season is croup most common?
Autumn
60
Outline the admission criteria for croup
- Audible stridor at rest
- Sternal wall retractions
- Significant distress and agitation, or lethargy or restlessness
- Tachycardia
- < 3 months of age
- Known upper airway abnormalities (e.g. Laryngomalacia, Down's syndrome)
- Uncertainty about diagnosis
61
Differentials for whooping cough?
- Bronchiolitis
- Pneumonia
- Asthma/viral-induced wheeze
- TB
62
An unvaccinated child presents with a fever, sore throat and difficulty swallowing. They’re sitting forward and drooling. What’s the most likely diagnosis?
Epiglottitis
63
What is the main concern for gastroenteritis?
Dehydration
64
What is the most common cause of gastroenteritis in children?
Rotavirus
65
Why should antibiotics be avoided in E.coli gastroenteritis?
Due to increased risk of haemolytic uraemic syndrome (HUS)
66
Outline management of gastroenteritis in children
- Barrier nursing, infection control, isolation.
- Stay off school until 48 hours after symptoms have completely resolved.
- Stool sample.
- Fluid challenge —> tolerate oral fluids, then manage at home.
- Rehydration solutions.
- IV fluids if can’t tolerate oral fluids or dehydrated.
- Slowly introduce light diet.
- Antidiarrhoeal and antiemetics generally not recommended.
- Antibiotics only given to those at risk of complications once organism is confirmed.
67
List the possible post-gastroenteritis complications
- Lactose intolerance
- Irritable bowel syndrome
- Reactive arthritis
- Guillain–Barré syndrome
68
Define vulvovaginitis and it’s causes
Inflammation and irritation of the vulva and vagina. It is a common condition often affecting girls between the ages of 3 and 10 years, due to sensitive and thin skin/mucosa.
Causes:
- Wet nappies
- Use of chemicals or soaps in cleaning the area
- Tight clothing that traps moisture or sweat in the area
- Poor toilet hygiene
- Constipation
- Threadworms
- Pressure on the area, for example horse riding
- Heavily chlorinated pools
69
Why is vulvovaginitis less common after puberty?
Due to oestrogen
70
What might a urine dipstick show for vulvovaginitis?
Leukocytes but no nitrites
71
Describe the pathophysiology of HUS
- Formation of thromboses consumes up platelets leading to thrombocytopenia.
- Thrombi damage kidney causing an AKI.
- Thrombi partially obstruct small blood vessels, breaking down rbc as they pass through, leading to microangiopathic haemolytic anaemia.
72
Differentials for febrile convulsions
- Epilepsy.
- Meningitis, encephalitis or another neurological infection such as cerebral malaria.
- Intracranial space occupying lesions, for example brain tumours or intracranial haemorrhage.
- Syncopal episode (due to decreased perfusion to the brain).
- Electrolyte abnormalities.
- Trauma (always think about non accidental injury).
- Febrile delirium.
73
An 18 month old infant presents with a 2-5 minute tonic clonic seizure with a high fever. What’s the most likely diagnosis?
Febrile convulsions
74
Other than ITP, name two more causes of low platelet count
- Heparin induced thrombocytopenia
- Leukaemia
75
What are the complications of ITP?
- Chronic ITP
- Anaemia
- Intracranial and subarachnoid haemorrhage
- Gastrointestinal bleeding
76
What rescue medications are used for recurrent febrile seizures?
- Rectal diazepam
- Buccal midazolam
77
Do antipyretics reduce the chance of febrile convulsions occurring?
No
78
When should an ambulance be called when a child is having a febrile convulsion?
If it lasts > 5 mins
79
What differentiates anaphylaxis from a non-anaphylactic allergic reaction?
Compromise of airway, breathing or circulation.
80
Describe the effect of adrenaline for anaphylaxis
- Alpha receptors: increases BP via vasoconstriction.
- Beta receptors: increases cardiac contractility, bronchodilation.
81
Which drug is started empirically in suspected encephalitis until results are available?
Aciclovir
82
Outline the complications of encephalitis
- Lasting fatigue and prolonged recovery
- Change in personality or mood
- Changes to memory and cognition
- Learning disability
- Headaches
- Chronic pain
- Movement disorders
- Sensory disturbance
- Seizures
- Hormonal imbalance
83
An adolescent with a sore throat, who develops an itchy maculopapular rash after taking amoxicillin. What’s the most likely cause?
Infectious mononucleosis
84
If mycoplasma pneumonia is suspected, which antibiotic should be given?
Macrolide e.g. erythromycin
85
What is the most likely causative agent for bacterial pneumonia in children?
Streptococcus pneumoniae
86
What is the first line treatment for children with pneumonia?
Amoxicillin
87
List differentials for tonsillitis
- Peritonsillar abscess (quinsy)
- Pharyngitis
- Glandular fever
- Tonsillar malignancy
- Epiglottitis
- Meningitis
88
Where do nosebleeds originate from?
Kiesselbach’s plexus - aka Little’s area.
89
Outline the management of severe nosebleeds
Hospital admission:
- Nasal packing using nasal tampons or inflatable packs.
- Nasal cautery using silver nitrate stick.
- Naseptin after treating nosebleed to reduce any crusting, inflammation and infection - contraindicated in peanut or soy allergy.
90
Normal pCO2 in an acute asthma attack indicates what?
That it is life-threatening - suggesting reduced respiratory effort.
91
A 3-year-old girl is brought to the GP by her mother with a 3-day history of sore throat that is worse when swallowing, headaches and malaise.
On examination, her temperature is 39.2ºC, her pulse is 106 bpm, and her respiratory rate is 62 /min. She appears unwell and is fatigued. Her tonsils are symmetrically erythematous and enlarged, with white patches present. The uvula is central and no stridor is present. Tender cervical lymphadenopathy is present. She has had no cough.
Her only past medical history includes an allergy to penicillin.
What is the most appropriate next step in her management?
Immediately refer to hospital (respiratory rate of >60 per minute (at any age) is a red flag according to the NICE paediatric traffic light system).
92
Differentials for non-balancing rash
- Meningococcal septicaemia
- Leukaemia
- ITP
- HUS
- HSP
- Non-accidental injury
- Viruses e.g. influenza, enterovirus
93
What sign is pathognomonic for measles?
Koplik spots
94
List conditions associated with group A strep infection
- Tonsillitis
- Scarlet fever
- Post-streptococcal glomerulonephritis
- Acute rheumatic fever
- Impetigo
95
Varicella zoster virus is part of what family of viruses?
Human herpes virus
96
How can immunity to chickenpox be checked?
VZV antibodies
97
How can a formal diagnosis of chickenpox be made?
Viral PCR of skin swabs
98
Define nappy rash
It is contact dermatitis in the nappy area. It is usually caused by friction between the skin and nappy and contact with urine and faeces in a dirty nappy.
99
Petechiae vs purpura
- Petechiae are small (< 3mm), non blanching, red spots on the skin caused by burst capillaries.
- Purpura are larger (3 – 10mm) non-blanching, red-purple, macules or papules created by leaking of blood from vessels under the skin.
100
What are the 3 parameters for GCS?
- Eye opening
- Verbal response
- Motor response
101
List the differentials for decreased level of consciousnes
- Septic shock
- Raised ICP
- Meningitis
- Encephalitis
- Hypoglycaemia
- Prolonged seizures/epilepsy
- DKA cerebral oedema
- TBI
- Hypoxia
102
Outline signs of raised ICP
- Change in behaviour
- Drowsiness/decreased altertness
- High pitched cry
- Nausea/vomiting
- Headaches
- Blurred vision
- Abnormal reflexes
- Dilated pupils
- Abnormal breathing
- Papilloedema
- Bulging fontanelle
103
Outline the causes of raised ICP
- TBI
- Hydrocephalus
- Brain tumour
- Meningitis
- Encephalitis
104
Outline management for a child with raised intracranial pressure
- IV fluids if there’s hypovolaemia
- Sedation and analgesia
- CSF drainage
- Mannitol or hypertonic saline
- Hyperventialtion
- Decompressive craniectomy
- Hypothermia
105
Outline the features of hypernatraemic dehydration
- Jittery movements
- Increased muscle tone
- Hyperreflexia
- Convulsions
- Drowsiness or coma
106
Which team is used to manage appendicitis?
< 10 - paediatric surgeons
> 10 - adult general surgery
107
List the key differential diagnoses of appendicitis
- Ectopic pregnancy
- Ovarian cysts
- Meckel’s diverticulum
- Mesenteric adenitis
- Appendix mass (omentum surrounds and sticks to inflamed appendix, forming a mass)
108
What is mesenteric adenitis?
Inflammation of mesenteric lymph nodes, causing abdominal pain in RIF. May be associated with fever, N+V and diarrhoea. Commonly secondary to a viral infection (e.g. gastroenteritis, tonsillitis or URTI).
109
How is mesenteric adenitis diagnosed?
Abdominal US - also helps to rule out appendicitis.
110
How is mesenteric adenitis managed?
It is usually self-limiting that resolves within 4 weeks.
Hydration and analgesia.
111
Management of viral induced wheeze
Episodic viral wheeze:
- Treatment is symptomatic only.
- First-line is treatment with short acting beta 2 agonists (e.g. salbutamol) or anticholinergic via a spacer.
- Next step is intermittent leukotriene receptor antagonist (montelukast), intermittent inhaled corticosteroids, or both.
- There is now thought to be little role for oral prednisolone in children who do not require hospital treatment.
Multiple trigger wheeze:
- Trial of either inhaled corticosteroids or a leukotriene receptor antagonist (montelukast), typically for 4-8 weeks.
112
How would coronary artery aneurysms be screened for as a result of Kawasaki disease?
Echocardiogram
113
Outline the criteria for immediate head CT in children
- Loss of consciousness lasting more than 5 minutes (witnessed).
- Amnesia (antegrade or retrograde) lasting more than 5 minutes.
- Abnormal drowsiness.
- Three or more discrete episodes of vomiting.
- Clinical suspicion of non-accidental injury.
- Post-traumatic seizure but no history of epilepsy.
- GCS less than 14, or for a baby under 1 year GCS (paediatric) less than 15, on assessment in the emergency department.
- Suspicion of open or depressed skull injury or tense fontanelle.
- Any sign of basal skull fracture (haemotympanum, panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign).
- Focal neurological deficit.
- If under 1 year, presence of bruise, swelling or laceration of more than 5 cm on the head.
- Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist or vehicle occupant, fall from a height of greater than 3 m, high-speed injury from a projectile or an object).
114
What is the number one cause of painless massive GI bleeding requiring a transfusion in children between the ages of 1 and 2 years?
Meckels diverticulum
115
Infant with vague signs such as poor feeding, grunting, lethargy
? Neonatal sepsis
116
Abx in neonatal sepsis
IV benzylpenicillin with gentamicin
117
A child develops a pink maculopapular rash, initially on the face before spreading to the whole body. Suboccipital and postauricular lymphadenopathy is present.
Rubella
