Emergencies

Question 1

bacterial causes of meningitis in neonates?

Answer 1

causes of meningitis in those under the age of 3 months:
group B streptococci-most common cause of severe early onset neonatal infection. Risk reduced with intrapartum IV benzylpenicillin 3g given to mum.
E coli and other coliforms
listeria monocytogenes-affects immunocompromised individuals

Question 2

bacterial causes of meningitis in children over the age of 3 months, up to 6 years?

Answer 2

haemophilus influenzae
neisseria meningitidis
strep pneumoniae

Question 3

bacterial causes of meningitis in children over 6 yrs?

Answer 3

neisseria meningitidis

strep pneumoniae-also cause in adults

Question 4

why should a LP NOT be performed if any CIs e.g. signs of raised ICP, are present in case of suspected meningitis?

Answer 4

as risk of cerebellum coning through foramen magnum

Question 5

what investigation confirms meningitis diagnosis and why is it needed?

Answer 5

lumbar puncture

causative organism can be identified which will determine choice of antibiotic and length of course given

Question 6

cerebral complications of meningitis?

Answer 6

cerebral abscess-fluctuating temp., signs of SOL emerge, CT confirmation, needs drainage
hydrocephalus-impaired CSF resorption or blockage of ventricular outlets by fibrin due to vasuclopathy induced by inflammation-non-communc. hydrocephalus
local vasculitis-cranial nerve palsies or other focal lesions
local cerebral infarct-may cause seizures, may lead to epilepsy
hearing loss-most common complication of viral meningitis*
SD effusion-most spontaneously resolve but may need prolonged Abx treatment

Question 7

how are family members of meningitis pt treated?

Answer 7

prophylaxis with rifampicin to eradicate NP carriage given to all household contacts for meningococcal meningitis and H.influenzae infection.
if group C meningococcal cause should have appropriate vaccine

Question 8

symptoms and signs of meningitis in children?

Answer 8

fever
headache
neck stiffness
photophobia
irritability
lethargy
poor feeding/vomiting
hypotonia
drowsiness
LOC
seizures

o/e: fever, purpuric rash-MENIGOCOCCAL SEPTICAEMIA, neck stiffness, bulging fontanelle in infants, opisthotonus, +ve Brudzinski sign-neck flexion with child supine causes knee and hip flexion, +ve Kernig sign-with child lying supine with hips and knees flexed, there is back pain on knee extension.
signs of shock-CRT more than 2 s, raised RR, raised HR
focal neurological signs, altered conscious level, pailloedema

Question 9

LP contraindications?

Answer 9

local infection at LP site
coagulopathy
thrombocytopenia-PLT must be at least 100
CR instability, pt intubated, shock
signs of raised ICP e.g. high BP, low HR, papillodema
focal neurological signs
if it causes undue delay in starting Abx

Question 10

describe the features of the rash seen in meningococcemia

Answer 10

may be initially blanching maculopaular rash

then non blanching purpuric rash

Question 11

when should dexamethasone NOT be given in treatment of meningitis?

Answer 11

septic shock
meningococcal septicaemia
immunocompromised
meningitis following surgery
not more than 12 hrs after starting antibacterial

Question 12

meningitis tment in hospital if meningococcal disease?

Answer 12

• benzylpenicllin sodium OR cefotaxime OR ceftriaxone, 7 day treatment
• not ceftriaxone in neonates as risk of biliary sludging and hyperbilirubinaemia with bilirubin displacement from albumin (which ceftriaxone binds to) and risk of bilirubin encephalopathy

if allergy give chloramphenicol

Question 13

what do we want to know about a pyrexic child?

Answer 13

duration of fever, and if it occurs at part. times during the day
general features-poor appetite, malaise, headache, diarrhoea, vomiting
pain-earache, headache, dysphagia, dysuria, excessive crying
specific-vomiting, diarrhoea, coryza, cough, rash
other children unwell at home? nursery?
any abnormal movements of child?-*febrile convulsions

Question 14

physical examination in a pyrexic child?

Answer 14

general-are they seriously unwell? dehydrated? tachycardic or tachypnoeic
skin-rash?-non blanching petechial or purpuric lesions-meningococcaemia, blanching fine punctate rash-scarlet fever, maculopapular rash beginning on face in measles.
chest-?resp distress-nasal flaring, grunting, tracheal tug, tachypnoea, chest wall recession. signs of bronchiolitis-fine end insp crackles, expir more so than inspir wheeze, pneumonia-coarse crackles, reduced air entry, bronchial breathing, dull percussion note.
ears-bulging red TMs
throat
lymph nodes
CNS-orientatied, are they floppy?, assess for neck stiffness or kernig’s sign in older children.

temperature-pyrexia defined as temp of 38 or higher in a child, measured using thermometer in axilla or infra-red tympanic thermometer.

Question 15

what should always be suspected as cause of fever in a child of any age?

Answer 15

UTI

Question 16

management of fever as a symptom?

Answer 16

undress child
antipyretics-paracetamol e.g. calpol, ibuprofen, NOT aspirin-risk of Reye’s syndrome
sponging or tepid baths-lukewarm water to allow vasodilatation and evaporative heat loss.

Question 17

likely differential in child with fever and itchy vesicular rash?

Answer 17

chickenpox

Question 18

how can pupuric rash of meningococcaemia be differentiated from henoch-schonlein purpura and idiopathic thrombocytopenic purpura?

Answer 18

HSP and ITP-absence of fever

ITP-low PLT count

Question 19

what diagnosis is suggested in child with fever and an enanthem?

Answer 19

enanthem=small spots in mucous membranes
chickenpox-vesicles break down rapidly forming shallow ulcers
measles-koplik spots seen in prodromal period only-like salt grains on red bkground-tiny white specks. measles-maculopapular rash starts on face, spreads d.wards with cough, coryza and conjunctivitis.

Question 20

when does a viral exanthem (skin rash) require a serological diagnostic confirmation?

Answer 20

if maculopapular rash in a pregnant girl-need to measure rubella titres

Question 21

why might blood culture in meningococcameia be -ve?

Answer 21

pt should have been given IM benzylpenicillin before hospital admission

Question 22

why should position of ear be noted in enlarged neck glands?

Answer 22

displacement of ear upwards and outwards feature of parotid gland swelling e.g mumps-paramyxovirus

ear may be pushed forwards and outwards with acute mastoiditis e.g. following acute otitis media.

Question 23

what investigation could be used to distinguish parotid swelling from other lymph glands?

Answer 23

serum or urine amylase-elevated in mumps

Question 24

features of a non-specific viral infection?

Answer 24

‘flu’ often used to describe symptoms:
brief but acute illness with fever, malaise, chills, headache, cough and myalgia
non-specific erythematous rash
usually due to influenza infection

Question 25

define pyrexia of unknown origin (PUO)?

Answer 25

prolonger fever-more than 1wk in young children an 2-3wks in adolescent, with no apparent infection site

Question 26

important consideration of cause of pyrexia of unknown origin in child with congenital HD?

Answer 26

infective endocarditis

Question 27

what should be considered in a boy with remitting fever (daily fluctuations but never returning to normal), variable rash and later joint pain?

Answer 27

systemic juvenile idiopathic arthritis:
rarest form, where joint symptoms may not be present at outset. remitting fever, variable rash, hepatosplenomegaly, anaemia, weight loss or abdo pain.
ANA and rheumatoid factor -ve

distinguish from polyarticular-painful swelling and restricted movement in large and small joints, girls, ANA may be positive, and pauciarticular-girls under 4 yrs, fewer than 5 joints-knees, ankles, elbows, ANA may be +ve, risk of chronic anterior uveitis.

Question 28

how can factitious fever be suspected from child’s examination?

Answer 28

absence of tachycardia and sweating assoc. with peaks of fever on temperature chart

Question 29

when would an alternative to IV/IO lorazepam be given, and what would be given, in the management of status epilepticus?

Answer 29

if IV/IO access cannot be obtained

PR diazepam or buccal midazolam

Question 30

if seizure in status epilepticus still persisting after 5mins following lorazepam, what is next step?

Answer 30

2nd dose of lorazepam
if still persist then call anaesthetist
whilst waiting can give PR paraldehyde
monitor ECG, and give phenytoin IV/IO over 20 mins, consider midazolam or phenobarbitone instead if already on phenytoin, over 10 mins
if seizure over 45mins at any time, do rapid sequence induction with thiopentone by anaesthetist

Question 31

routine investigations in status epilepticus?

Answer 31

blood glucose, Ca2+, Mg2+, Us and Es, ABGs
depending on hx and exam: FBC, CRP, LFTs, , blood and urine culture, septic screen, LP, ammonia, lactate and metabolic screen.
MRI if prolonged focal seizure and persisting focal neurological signs.

Question 32

ADRs of BZD treatment of status epilepticus?

Answer 32

resp depression
sedation, drowsiness, unsteadiness, ataxia
thrombophlebitis, urticaria
increase in aggression

Question 33

IV diazepam is decided to be administered for status epilepticus as IV lorazepam is unavailable, what else MUST be prescribed?

Answer 33

flumazenil in the as required section, for reversal of severe ADRs-resp depression.

Question 34

how can the risk of serious illness in children with a fever be assessed?

Answer 34

NICE traffic light system, green-low risk, amber-intermediate, and red-high
based on child’s colour, activity, RR, HR and hydration-amber-reduced urine output-ask about wet nappies in infant, and other e.g. amber-fever for 5 or more days, temp 39 or more, rigors in a child aged 3-6mnths, limb or joint swelling, limb pseudoparalysis-non WB/not using.
red-non-blanching rash, bulging fontanelle, focal neurological signs, neck stiffness, focal seizures, status epilepticus, temp 38 or higher in child 0-3mnths of age.

Question 35

what is kawasaki disease?

Answer 35

idiopathic self-limiting systemic vasculitis
typically affects children aged 6mnths-5years, peak incidence-between 1 and 2 years
boys more commonly than girls
Asian ethinicity-?genetic susceptibility
thought that disease occurs in those susceptible with abnormal immune response to infective trigger, causing systemic vasculitis affecting small and medium sized arteries
major complication of coronary artery aneurysm formation

Question 36

classical features of kawasaki disease?

Answer 36

fever in child lasting 5 days or more, abrupt onset, 39 or more
marked irritability of child, out of proportion to degree of fever
bilateral conjunctivitis, non-purulent
lip, mouth and/or tongue inflammation-lip fissuring, stawberry tongue
desquamation, erythema and swelling of extremities
cervical lymphadenopathy-unilateral, non tender, anterior cervical chain usually
non-vesicular widespread rash, often itchy, starts with erythema of the extremities-palms, soles, perineum

features may appear in turn then go so ensure all asked about in hx

Question 37

investigations for kawasaki disease?

Answer 37

no diagnostic investigations available
urinalysis may show sterile pyuria, proteinuria may/may not be present
FBC-leukocytosis, neutrophilia
raised ESR and CRP
thrombocytosis
LFTs-raised transaminases and bilirubin
abdo USS-GB distension
ECG-conduction abnormlaities
ECHO-CA aneurysms and dilatation, assess LV/valvular function, serial ECHO to detect occult CA disease as illness evolves.

Question 38

kawasaki disease management?

Answer 38

admit to IP ward-paed or paed cardiology, bed rest
IV Ig
aspirin-despite risk of Reyes syndrome-encephalopathy, use accepted for anti-pyretic and anti-platelet functions
poss. corticosteroids for severe cases
F/U ECHO
PCI and coronary artery bypass grafting

Question 39

kawasaki disease pneumonic?

Answer 39

FEBRILE:
fever-5 days or more, abrupt onset, 39 or higher
extremities-desquamation-erythema and swelling
bulbar conjunctivitis-bilateral, non-purulent
rash-non-vesicular, widespread, often itchy, starts palms and soles and perineum
internal organ involvement (worry of CA aneurysms)
lymphadenopathy-unilateral, non-tender
enanthem-strawberry tongue, mouth erythema, lip fissuring

Question 40

most common cause of death in children aged between 1 month and 1 year?

Answer 40

sudden infant death syndrome (SIDS)

Question 41

what is advocated in the ‘back to sleep’ campaign, which has reduced the incidence of sudden infant death syndrome in the UK?

Answer 41

• infants should be put to sleep on their back
• overheating by heavy wrapping and high room temperature should be avoided
• infants should be placed in the ‘feet to foot’ position (feet at end of bed)
• parents should not smoke near their infants
• parents should seek medical advice promptly if their infant becomes unwell
• parents should have the baby in their bedroom for the 1st 6mnths of life
• parents should avoid bringing their baby into their bed when they are tired or have taken alcohol, sedative meds or drugs
• parents should avoid sleeping with their infant on the sofa, settee or armchair.

Question 42

what is sudden infant death syndrome?

Answer 42

sudden and unexpected death of an infant or young child for which no adequate cause is found after a thorough postmortem examination.
occurs most commonly at 2-4mnths of age

Question 43

factors associated with sudden infant death syndrome?

Answer 43

infant: aged 1-6mnths, peak at 3 mnths
premature, low birth weight
gender-boys
multiple births

parents: young maternal age
low income
single unsupported mother
poor or overcrowded housing
high maternal parity
maternal smoking during pregnancy, and parental smoking after birth

environment: infant sleeps prone
infant overheated from high room temp and too many clothes and covers, part. when ill.

Question 44

management of the sudden unexpected death of an infant?

Answer 44

-resuscitation, unless inappropriate
-care of parents by specific staff member, obtain hx
-baby pronounced dead-detailed clinical exam. by consultant, remove ETT+IO needles, retain venous lines, retain child’s clothes+any bedding and nappy for police.
investigations: NP aspirate for virology+bacteriology, blood for toxicology, metabolic screen (on Guthrie card), chromosomes if dysmorphic, blood culture, urine catheter specimen-for BC, toxicology+freeze immed., LP-CSF for virology+routine culture, if clinically indicated.
SUDI paediatrician, coroner, police+primary care team informed
-breaking news to parents-by paediatrician, explain police and coroner involvement, but that doens’t mean blaming parents for death, explain need for postmortem, and retaining tissue as part of medical record, give parents opportunity to donate tissues and organs.
-offer parents chance to see and hold their child
-initial strategy-SUDI paediatrician and police officer, social services r/v-prev. involvement and child protection issues
-home visit within 24hrs-police-talk to parents, examine place where baby died, detailed hx, report complied for coroner
-postmortem
-case discussion-multi-agency meeting
-f/u and bereavement counselling-d/c final postmortem results, consider implications for future pregnancies, ?need for genetic counselling, bereavement counselling.