General Paediatrics

Question 1

Define sepsis

Answer 1

systemic inflammatory response to infection (i.e. body has dysregulated immune response to infection)

Question 2

Define sepsis spectrum

Answer 2

mild ——> severe

systemic inflammaotry response syndrome > sepsis > septic shock >multiple organ dysfunction

Question 3

Criteria for SIRS

Answer 3

> /= 2 out of 4 of:

• temperature <36 or >38
• HR >90 adults (or tachycardia for age)
• RR >20 adults (or tachypnoea for age) or PaCO2 <32 (as RR increases CO2 falls)
• WBC >12000 or < 4000, or >10% band cells (immature WBCs)

Question 4

Criteria for sepsis, and common symptoms of sepsis

Answer 4

SIRS + confirmed infection

- fever, chills, sweating, altered mental state, decreased urine output

Question 5

Define septic shock

Answer 5

sepsis + hypotension + drop in tissue perfusion

due to infection +/- inflammation

Question 6

How can temperature of skin relate to septic shock pathophysiology, and prognosis?

Answer 6

warm skin = blood vessels have dilated

can progress to cool skin (bad sign as had sepsis for long time)

Question 7

Criteria for MODS

Answer 7

septic shock + irreversible organ failure

Question 8

Pathophysiology of septic shock

Answer 8

1) WBC recruitment - as pathogen in blood
2) WBC release mediators - release nitrous oxide as WBC want to get to interstitial tissue where pathogens are, which increases blood vessel diameter and leakiness leading to drop in BP (as there is SVr drop as CO x SVR = BP)
3) decreased O2 to tissues/tissue perfusion as leaky vessels -> oedema so decreased O2 transport to tissues

Question 9

3 complications of septic shock

Answer 9

1. DIC - WBCs release ROS -> damage bv -> coagulation factor release to stop blood leaking to extravascular space -> coag factors in extravascular space cant keep up with bleeding in intravascular space
2. ARDS - lungs highly vascularised and sepsis damages lung vasculature so cant carry O2 -> respiratory distress
3. decreased CO - initially increased CO to compensate for drop in SVR and BP in sepsis, but ROS from WBC can dmaage heart

Question 10

Evaluating sepsis in under 5s (NICE)

moderate- high criteria

Answer 10

1. BEHAVIOUR - doesnt wake, respond to social cues, weak high-itched continuous cry, no smile
2. HR - 0-1 years (160+ bpm), 1-2 years (150+ bpm), 3-4 years (140+ bpm), or <60 bpm at any age
3. RR 0-1yr - 60 bpm, 1-2 yrs 50 + bpm, 3-4 yrs 40+ bpm, respiratory distress (grunting, apnoea, sats <90% in air
4. TEMPERATURE <36, or >38 in babay <3months
5. SKIN - mottles, cyanotic (lips+ tongue too), non blanching rash
   (some other moderate criteria:
   - cap refill >3s
   - decreased urine output
   - leg pain, cold hands or feet
   - temperature >39 in 3-6month olds

Question 11

How do signs of sepsis in neonates/infants differ from adults

Answer 11

more non-specific symptoms e.g. apnoea, bradycardia

Question 12

High risk sepsis patients

Answer 12

• PMH or have malignancy
• immunocompromised (organ transplant, bone marrow transplant)
• asplenia (including sickle cell disease)
• central/in-dwelling catheter
• autism?

Question 13

Findings compatible with septic shock

Answer 13

1. Cap refill: cold shock > 3s warm shock <1s
2. mental status: irritable, confused, poor interaction with parents, lethargy, diminished arousability, obtunded
3. pulse quality: cold shock= reduced/weak, warm shock = bounding
4. skin: petichiae, purpura, mottled or cold, flushed, erythroderma other than face

Question 14

Sepsis screen

Answer 14

1. administer O2 via rebreathing face mask, titrate aiming for SpO2 >94%
2. IV/IO access for:
   
   • blood culture (check source of infection)
   • blood gas (glucose and lactate)
   • FBC, CRP, U&E, coagulation
   • lumbar puncture unless contraindicated (e.g. <1m old, severely
     unwell)
   • consider other tests but dont delay Tx for these: urine,
     meningococcal PCR, CSF or line cultures
3. Give IV/IO antibiotics according to hospital guidelines
4. Fluids:
   
   • aim to restore to normal circulating volume
   • If lactate >2mmol/L give 20ml/kg (10ml/kg if <1m) 0.9%
     NaCl over 5-10mins and repeat if necessary
   • Be aware risk fluid overload,
5. Get help from enior clinician
6. Consider inotropic support (increase cardiac contractility e.f. dopamine, Adr) due to shock

Question 15

Define wheeze

Answer 15

High pitched whistling heard usually on expiration (and sometimes inspiration), that is associated with increased work of breathing

Question 16

Define 2 types of wheeze. Explain the difference between them

Answer 16

Viral episodic wheeze - URTI with wheezing associated only with viral colds

Multiple trigger wheeze - URTI with wheeze associated with exposure to aero allergens, cold, exercise, smoke

Question 17

Does wheeze during preschool years mean the child has asthma?

Answer 17

Not sure.
Child may have fluctuating breathlessness and wheeze that needs treatment over time,
but asthma requires evidence of airway eosinophilic inflammation.

Studies have shown MTW as more airflow obstruction/ pathology associated with asthma.
No link between EVW and increased risk of asthma

Question 18

PC: child with isolated dry cough presents to GP.

Could this be asthma

Answer 18

Isolated dry cough rarely due to asthma

Question 19

Which is most efficacious for delivering wheeze treatment in preschool children: nebulisers, metred dose inhaler or spacer?

Answer 19

Don’t use nebulisers unless child to sick to use inhaler/spacer.

Metred dose inhaler and nebulisers as efficacious as each other

Question 20

Initial treatment for moderate - severe EVW

Next step if symptoms aren’t controlled

Answer 20

Inhaled bronchodilator - salbutamol (b2 agonist) or ipratropium bromide (anticholinergic competitive inhibition muscarinic SM receptors -> bronchodilation)

If symptoms not controlled use:
First EDUCATE on use of inhaler/spacer
Then escalate tx to montelukast (leukotriene receptor agonist), inhaled steroids or both

Don’t use preednisolone if wheeze can be managed in the community

Question 21

Side effects of steroids

Answer 21

Growth restriction and adrenal failure

Question 22

Treatment for multiple trigger wheeze

Answer 22

Consider inhaled steroids or leucotriene receptor antagonist (montelukast) if children have symptoms on most days even without a viral cold

Question 23

New experimental treatments for wheeze

Answer 23

1. Hypertonic saline + salbutamol - reduced admission rates and length of stay. But given risk of bronchoconstriction with hypertonic saline needs to be given in hospital
2. Palivizumab - prevents RSV infection in high risk infants e.g. premature. But very costly so not widely used

Question 24

Scenario
Child well and thriving, but has wheeze, no other concerning features on history or examination.
What is type of wheeze?
Management?

Answer 24

Commonest kind of wheeze
Can be due to post viral cough, pertussis, overanxious parents

Management = reassurance

Question 25

Scenario
Wheeze symptoms in first day of life, chronic wet cough, sudden onset of symptoms, unremitting symptoms, examination signs of chronic illness (clubbing, severe chest deformity, stridor, assymetric signs on auscultation)

Answer 25

Serious condition e.g. immunodeficiency

Rare but need to refer for investigation (especially if suspect foreign body obstruction)

Question 26

Scenario
Otherwise well child with history of vomiting, arching away from breast, poor feeder, inflamed nose, adenotonsillar hypertrophy

Management?

Answer 26

May be minor condition that exacerbated or mimics wheeze e.g. GORD or chronic rhinitis

Management = start empirical trial of treatment, if this doesn’t work refer. NB child with prominent snoring consider referring for sleep study

Question 27

D with wheeze during viral cold but no personal/family history of atopy
Diagnosis?
Management?

Answer 27

EVW

Start on short duration, short acting b2 agonist or anticholinergic

Question 28

Scenario
Child with wheeze during and even in between viral colds, often occurring during exposure to asthma triggers e.g. cold, exercise.
No FH of atopy

Answer 28

MTW

Start on short acting b2 agonist or anticholinergic