INTRO TO PAEDS: Resp, Shock, Seizures, Rashes, DKA, UTI, Surgical abdomen

Question 1

What are causes of wheeze + their features?

Answer 1

Asthma = signs of resp distress, personal/family hx of atopy, >5yo

Bronchiolitis = coryzal sx, <5yo, cold months

Anaphylaxis = sudden onset, known trigger, skin: urticaria, ABCD compromise, any age

Pneumonia = fever, productive cough, any age

Question 2

What are features of moderate asthma exacerbation?

Answer 2

PEFR >50-75%
Normal speech
No severe or life threatening features

Question 3

What are features of severe asthma exacerbation?

Answer 3

PEFR >33-50%
RR and HR:
- >12yo = RR >25/min, HR >110bpm
- 5-12yo = >30/min, HR >125
- 2-5yo = >40/min, HR >140
Inability to complete sentences/feed
Accessory muscle use
SpO2 >92%

Question 4

What are features of life-threatening asthma exacerbation?

Answer 4

PEFR <33%
SpO2 <92%
Reduced consciousness/GCS
Exhaustion
Heart arrhythmias
Hypotension
Cyanosis
Reduced respiratory effort
Silent chest
Normalising PCO2

Question 5

How is a moderate asthma exacerbation treated?

Answer 5

Salbutamol MDI + spacer burst therapy (1 puff every 30-60s, max 10 puffs)

Question 6

How is a severe asthma exacerbation treated?

Answer 6

Bronchodilators: oxygen driven, nebulised salbutamol (>5yo = 5mg, 2-5yo = 2.5mg), continuous over 30-60mins
intermittent every 20-30 min
Nebulised ipratropium bromide (>12yo = 500mcg, 2-12yo = 250mcg)

Steroids: quadruple ICS or PO prednisolone 5d (>5yo = 30-40mg, 2-5yo = 20mg, <2yo = 10mg) or IV hydrocortisone (>5yo = 100mg, 2-5yo = 50mg)

Question 7

How is life-threatening asthma treated?

Answer 7

1. Nebulised salbutamol + ipratropium bromide
2. IV hydrocortisone
3. IV magnesium sulphate
4. IV aminophylline
5. IV salbutamol

Question 8

What is the chronic management of asthma?

Answer 8

1. SABA
2. SABA + low dose ICS
3. Regular preventer (very low dose ICS or LRTA <5yo)
4. Add LRTA or inhaled LABA
5. increase ICS dose
6. specialist care

Question 9

How is anaphylaxis treated?

Answer 9

1. CALL FOR HELP - lie patient flat + raise legs, stop causative agent
2. establish airway, high flow oxygen, IV access + bolus
3. IM adrenaline 1:1000, 0.5mg
4. IV adrenaline if 3 failed IM (ITU admission)

Monitor for at least 6 hours (risk of 2nd wave)

Question 10

What are causes of stridor and features of these?

Answer 10

Inhaled foreign object = sudden onset, previously well, unsupervised child, SOB/choking (any age, toddlers esp.) Mx is anaesthetists

Epiglottitis = septic looking, drooling, tripod pose, high fever, sore throat, dysphagia

Anaphylaxis = sudden onset, known trigger, skin (urticaria, angioedema), ABCD compromise

Croup = low grade fever, coryzal sx, seal-like cough, worse at night, hoarse voice. 6mo-6yo

Question 11

How is epiglottitis managed?

Answer 11

EMERGENCY A-E
1. Secure airway
2. IV ABx = cefotaxime/ceftriaxone
3. Consider corticosteroids

NOTE: avoid looking into throat as high risk of laryngospasm

Question 12

How is croup managed?

Answer 12

IX = Westley croup score, but mainly base mx off clinical signs and sx

MILD = no stridor at rest, single dose PO dexamethasone

MODERATE = stridor at rest, no agitation/lethargy, single dose PO/IM dex or nebulised budesonide, nebulised epinephrine

SEVERE = stridor at rest agitation/lethargy, single dose PO/IM dex or nebulised budesonide, nebulised epinephrine

Question 13

What are early signs of shock in a child?

Answer 13

tachypnoea, tachycardia, decreased skin turgor, sunken eyes and fontanelle, delayed CRT, mottled pale or cold skin, core-peripheral temp gap, decreased UO

Question 14

What are late signs of shock in a child?

Answer 14

Kussmaul breathing, bradycardia, confusion/depressed cerebral state, blue peripheries, absent UO, hypotension

Question 15

What categories make up the traffic light system and what are red flag features?

Answer 15

COLOUR
- pale/mottled/ashen/blue

ACTIVITY
- unresponsive to social cues
- appears ill to HCP
- unable to be roused or stay awake
- weak, high-pitched or continuous cry

RESP
- grunting
- tachypnoea - RR >60
- moderate or severe chest indrawing

HYDRATION
- reduced skin turgor

OTHER
- age 0-3mths + temp >38
- age 3-6mth + temp >39
- non-blanching rash
- bulging fontanelle
- neck stiffness
- status epilepticus
- focal neurological signs
- focal seizures
- bile-stained vomiting

Question 16

What are the different tpyes of shock?

Answer 16

Hypovolaemic = excess fluid loss (haemorrhagic or non-haemorrhagic)

Cardiogenic = impaired cardiac function (cardiomyopathies, arrthymias)

Obstructive = obstruction to circulation (tamponade, tension pneumo, emboli)

Distribution = loss of vascular tone (anaphylaxis, septic, neurogenic)

Question 17

How is sepsis managed?

Answer 17

A-E approach
A = assess airway
B = 15L facemask high flow O2
C = IV/IO abx + fluid resus
- 2 large bore cannulae: 20ml/kg 0.9% saline over 5-10mins
- administer 2nd bolus if still signs of shock
- up to 60ml before considering rx w/vasoactives
- IO access if IV access unattainable (below tibial tuberosity medially)
- take blood gas, lactate, glucose, cultures
- abx = if <3mths cefotaxime + amipicillin, if >3mths ceftriaxone

Consult senior clinicians
Consider inotropic support early (epinephrine, norepinephrine)

If ? or confirmed bacterial meningitis also give 0.15mg/kg dexamethasone

Add IV acyclovir to cover HSV encephalitis

Question 18

How is status epilepticus managed?

Answer 18

DEFINITION = seizure lasting >5mins

1. airway, high flow oxygen, check glucose, protect from injury by cushioning head, removing objects, no restraint
2. AT 5 MINS:
   - vascular access available = IV/IO lorazepam
   - no vascular access = buccal midazolam (or rectal diazepam)
3. AT 15 MINS:
   - IV/IO lorazepam
   - call for senior help
4. Phenytoin (reconfirm it’s an epileptic seizure), consider paraldehyde PR whilst preparing or infusing phenytoin
5. AT 25 MINS:
   - senior help needed
   - seek anaesthetic/ICU advice
   - phenytoin IV over 20mins OR if already on it then phenobarbitone IV/IO over 5mins
6. AT 45 MINS:
   - rapid sequence induction of anaesthesia w/thiopental (thiopentone)
   - anaesthetist must be present

Question 19

What are causes of seizures?

Answer 19

METABOLIC = electrolyte abnormalities, hypoglycaemia, hyperglycaemia, inborn errors of metabolism, toxins/poisons

INFECTIVE = meningitis, encephalitis, febrile seizure, sepsis

STRUCTURAL = epilepsy, head trauma/injury, non-epileptic seizures, SOL

CONGENITAL = infantile spasm/West syndrome

OTHER = breath holding attacks, reflex anoxic seizures

Question 20

How are seizures/unwell child investigated?

Answer 20

BEDSIDE: urinalysis, LP (sent for gram stain + MC&S, PCR, biochemistry)
BLOODS: FBC, U&Es, LFTs, blood glucose, ketones, lactate, toxicology, blood cultures, ABG
IMAGING: CT head, MRI brain

Question 21

What are sx of raised ICP?

Answer 21

altered LOC, irritability, restlessness, drowsiness, papilloedema, focal neuro signs, prolonged seizures, constant headache (worse on lying down), sudden vomiting w/o nausea, fixed dilated pupils, asymmetrical

CUSHING’S TRIAD = bradycardia, irregular respirations, hypertension

Question 22

What are contraindications to lumbar puncture?

Answer 22

• clinical or radiological signs of raised ICP
• shock
• after convulsions until stabilised
• coagulation abnormalities
• local superficial infection
• respiratory insufficiency

perform delayed LP in children w/?bacterial meningitis when CIs no longer present

Question 23

How to identify type of meningitis from LP?

Answer 23

Bacterial = turbid, high polymorphs, high protein, low glucose

Viral = clear, high lymphocytes, normal or high protein, normal or low glucose

TB = turbid/clear/viscous, high lymphocytes, very high protein, very low glucose

Question 24

What are causes of early onset meningitis?

Answer 24

<72hrs postnatally = GBS, E. Coli (gram -ve rod), Listeria monocytogenes (gram +ve rod)

Question 25

What are causes of late onset meningitis?

Answer 25

>72hrs, within 28d postnatally = strep. pneumo (gram +ve coccus), N. meningitides (gram -ve coccus), Staph aureus (gram +ve diplococci clusters).

Question 26

How should meningoencephalitis be followed up?

Answer 26

- formal audiological assessment: ideally before discharge & <4w of being fit to test (severe profound deafness = urgent assessment for cochlear implants as soon as fit to test) - paediatrician r/v 4-6w after discharge (consider specific morbidities e.g. hearing loss, orthopaedic, skin, psychosocial, neurological and developmental, renal failure) - inform GP/health visitor, school nurse: long term sequelae

Question 27

What are the differences between a simple febrile convulsion and complex FC?

Answer 27

SIMPLE = <15mins, generalised tonic-clonic, no recurrence within 24hrs, no postictal pathology or residual weakness COMPLEX = >15mins, focal convulsion w/ or w/o secondary generalisation, recurrence within 24hrs even if shorter subsequent seizures, Todd's paresis may be present (period of paresis of affected limb)

Question 28

When should a child with febrile seizures be admitted?

Answer 28

- complex febrile seizures - first febrile seizure - reduced GCS before seizure - slow recovery >1hr - clinical signs of meningism - focal neurological deficit - features of septicaemia - unexplained cause of fever

Question 29

How does NAI present and how is it investigated and managed?

Answer 29

SX = bruises, burns, fractures, shaken baby syndrome IX = - Bedside: full exam, body mapping - Bloods: FBC, clotting - Imaging: skeletal survey (repeat at 2w), CT head (if acute), MRI (if non acute), ophthalmology r/v MX = - admit + senior review - contact hospital safeguarding team (may contact social services and/or police) - child may go home while investigation underway

Question 30

What is the difference between measles, rubella and roseola infantum?

Answer 30

MEASLES = conjunctivitis, cough, coryza, fever, Koplik spots on buccal mucosa, rash starting at hairline and spreading downwards over 3d RUBELLA = headache, low grade fever, sore throat, coryza, forchheimer spots on soft palate ROSEOLA INFANTUM = exanthem subitum = 6-36mths, caused by HHV6, abrupt high fever, rash starting on neck and trunk and then spreading to face and extremities after fever is gone

Question 31

What is the routine immunisation schedule?

Answer 31

8w = - diptheria/tetanus/pertussis/polio/Hib/HepB - MenB - rotavirus 12w = - diptheria/tetanus/pertussis/polio/Hib/HepB - pneumococcal - rotavirus 16w = - diptheria/tetanus/pertussis/polio/Hib/HepB - MenB 1yr old = - HiB and MenC - pneumococcal - MMR - MenB

Question 32

What are the diagnostic criteria for Kawasaki's disease?

Answer 32

Prolonged fever >5d +4/5 other sx (CRASH) - conjunctivitis - rash (hands and feet) - adenopathy (cervical) - strawberry tongue - hands and feet swelling/peeling

Question 33

How is Kawasaki's disease managed?

Answer 33

ADMIT IV IG within 10d + high dose aspirin +/- corticosteroids (alt = infliximab, cyclosporin) Arrange echo (risk of coronary aneurysm - need for long term warfarin)

Question 34

Summarise scarlet fever?

Answer 34

Strep A Sx = sandpaper rash, strawberry tongue, sore throat, rheumatic fever Ix = throat culture, rapid antigen test Mx = phenoxymethylpenicillin

Question 35

Summarise erythema infectiosum?

Answer 35

parvovirus b19 sx = slapped cheeks, coryza mx = supportive

Question 36

Summarise hand, foot and mouth disease?

Answer 36

Coxsackie virus A16 sx = small blisters hand and feet and around mouth mx = supportive

Question 37

Outline how to investigate abdominal pain?

Answer 37

BEDSIDE = abdo + external genitalia exam, obs, urinalysis, pregnancy test (if relevant) BLOODS = FBC, U&Es, LFTs, clotting, G&S, XM, amylase, glucose, ketones, lactate, blood cultures IMAGING = non-contrast CT abdo, abdo USS, AXR, erect CXR

Question 38

What are causes of a wide anion gap?

Answer 38

WIDE = >30mmol/L LTKR: Lactate, Toxins, Ketones, Renal

Question 39

What are causes of a normal anion gap?

Answer 39

NORMAL = 4-12mmol/L ABCD: Addisons, Bicarb loss (GI or renal loss), Chloride excess, Diuretics (acetozalamide)

Question 40

What is the diagnostic criteria for DKA?

Answer 40

Hyperglycaemia (BM>11.1)+ metabolic acidosis (pH<7.3/bicarb <15) + ketonaemia (>3) Severity​: MILD: pH 7.2-7.29, bicarb <15 = 5% dehydration​ MOD: pH 7.1-7.19, bicarb <10 = 7% dehydration​ SEVERE: pH <7.1, bicarb <5 = 10% dehydration​

Question 41

How is DKA managed?

Answer 41

1 = FLUIDS - Bolus volume - if in shock 20ml/kg over 15min, if not shocked then 10ml/kg - Deficit volume - deficit % x 10 x body weight mL/h - added to maintenance over 48h - Maintenance volume - over 48h, 0.9% NaCl 100/kg for first 10kg, 50/kg for 10-20kg, then 20/kg above 20kg, +40mmol KCl per 1L fluid once UO 2 = INSULIN - 1-2hrs after fluid therapy - IV actrapid 0.05-0.1 units/kg/hr - target rates: BM decreased >3/hr, ketones decreased >0.6 or bicarb increased >0.3 - continue long-acting SC insulin at usual dose and time - once BM <14 add dextrose (5% if BM 8-14; 10% if BM <8) - 2mL/kg bolus 10% dextrose if BM < 4 (hypoglycaemia) 3 = MONITORING - every 1hr = neuro obs, capillary glucose - every 2-4hr = electrolytes, blood gases, ketones

Question 42

How is a UTI diagnosed in children and how is it managed?

Answer 42

UTI = pure growth of single organism >10^5 CFU/L Rx = 3/7 trimethoprim PO - IV abx if <3mo - 7-10d course if upper UTI

Question 43

How are UTIs investigated according if under 6 months?

Answer 43

Single confirmed UTI, responds rapidly to treatment IX = USS urinary tract

Question 44

What is an atypical UTI and how is it investigated?

Answer 44

FEATURES = seriously ill, septicaemia, poor urine flow, abdominal or bladder mass, raised serum creatinine, failure to respond to abx within 48hrs, non E. coli organisms IX = - USS urinary tract during acute episode - DMSA scan 4-6mths later if <3yo - MCUG if age <6mo

Question 45

What is recurrent UTI and how is it investigated?

Answer 45

FEATURES = 3 or more episodes of cystitis/lower UTI OR 2 or more episodes of UTI if any episode involved upper UTI (renal angle tenderness) IX = - USS urinary tract - DMSA 4-6mo later - MCUG if <6mo

Question 46

How is surgical abdomen in children managed generically?

Answer 46

1. NBM 2. NGT on free drainage 3. IV fluids 4. IV analgesia (avoid opioids if ?obstruction) 5. IV Abx 6. liaise w/surgical SpR 7. liaise w/CEPOD (dedicated theatre lists for emergencies)