OSCE emergencies (Paediatrics) Flashcards

Question

presentation of pyloric stenosis

Answer 1

occurs in first few weeks of life - failing to thrive - projective vomiting (non- bilious) - feels like a large olvie - can often see peristalsis

Answer 2

hypochloremic hypokalaemic metabolic alkalosis

Answer 3

Ramstedt’s operation- laparoscopic pyloromyotomy

Answer 4

think RSV - ensure adequate intake e.g. with NG or IV fluids - Saline nasal drtops and nasal suctioning to clear secretions - Supplementary oxygen - Ventilatory support as required e.g. high flow humidified oxyegn or CPAP or intubation

Answer 5

think parainfluenza - swelling of the larynx - barking cough Stepwise options in severe croup to get control of symptoms: * Oral dexamethasone * Oxygen * Nebulised budesonide * Nebulised adrenalin * Intubation and ventilation

Answer 6

Think HiB (ask about vaccination) - - IV antibiotics (e.g. ceftriaxone) - Steroids (i.e. dexamethasone)

Answer 7

* Severe, colicky abdominal pain * Pale, lethargic and unwell child * “Redcurrant jelly stool” * Right upper quadrant mass on palpation. This is described as “sausage-shaped” * Vomiting * Intestinal obstruction

Answer 8

diagnosis: US or contrast enema conservative - therapeutic enema surgical - reduction - if bowel is gangrenous -> surgical resection to prevent perforatioa nd ifnection

Answer 9

a toxin produced by the e. coli 0157 bacteria, called the shiga toxin. Shigella also produces this toxin.

Answer 10

E. coli 0157 causes a brief gastroenteritis, often with bloody diarrhoea. The symptoms of haemolytic uraemic syndrome typically start around 5 days after the onset of the diarrhoea. Signs and symptoms of HUS may include: * Reduced urine output * Haematuria or dark brown urine * Abdominal pain * Lethargy and irritability * Confusion * Oedema * Hypertension * Bruising

Answer 11

HUS is a medical emergency and has a 10% mortality. It needs to be managed by experienced paediatricians under the guidance of a renal specialist. The condition is self limiting and supportive management is the mainstay of treatment: * Urgent referral to the paediatric renal unit for renal dialysis if required * Antihypertensives if required * Careful maintenance of fluid balance * Blood transfusions if required * 70 to 80% of patients make a full recovery.

Answer 12

* Have a low threshold for admission to hospital * Treat any infection * Keep warm * Keep well hydrated (IV fluids may be required) * Simple analgesia such as paracetamol and ibuprofen (NSAIDs should be avoided where there is renal impairment) * Penile aspiration is used to treat priapism

Answer 13

Splenic sequestration crisis is caused by red blood cells blocking blood flow within the spleen. This causes an acutely enlarged and painful spleen. The pooling of blood in the spleen can lead to severe anaemia and circulatory collapse (hypovolaemic shock)

Answer 14

Supportive - Blood transfusiona nd fluid resus for anaemia and shock - Splenectomy to prevent sequestration crisis

Answer 15

parvovrius B19 (slapped cheek)

Answer 16

supportive with blood transfusions if necessary. It usually resolves spontaneously within a week.

Answer 17

* Fever or respiratory symptoms, with: * New infiltrates seen on a chest xray

Answer 18

high flow oxygen * Antibiotics or antivirals for infections * Blood transfusions for anaemia * Incentive spirometry using a machine that encourages effective and deep breathing * Artificial ventilation with NIV or intubation may be required

Answer 19

* Less than 3 stools a week * Hard stools that are difficult to pass * Rabbit dropping stools * Straining and painful passages of stools * Worse when eating * Abdominal pain * Holding an abnormal posture, referred to as retentive posturing * Rectal bleeding associated with hard stools * Faecal impaction causing overflow soiling, with incontinence of particularly loose smelly stools * Hard stools may be palpable in abdomen * Loss of the sensation of the need to open the bowels

Answer 20

such as Hirschsprung’s disease, cystic fibrosis or hypothyroidism.

Answer 21

Lifestyle Factors There are a number of lifestyle factors that can contribute to the development and continuation of constipation: * Habitually not opening the bowels * Low fibre diet * Poor fluid intake and dehydration * Sedentary lifestyle * Psychosocial problems such as a difficult home or school environment (always keep safeguarding in mind)

Answer 22

* Pain * Reduced sensation * Anal fissures * Haemorrhoids * Overflow and soiling * Psychosocial morbidity

Answer 23

* Correct any reversible contributing factors, recommend a high fibre diet and good hydration * Start laxatives (movicol is first line) * Faecal impaction may require a disimpaction regimen with high doses of laxatives at first * Encourage and praise visiting the toilet. This could involve scheduling visits, a bowel diary and star charts.

Answer 24

Supportive - pain relief - antiemetic - broad spectrum antibiotics Surgical - laparoscopic appendicetomy

Answer 25

* Bleeding, infection, pain and scars * Damage to bowel, bladder or other organs * Removal of a normal appendix * Anaesthetic risks * Venous thromboembolism (deep vein thrombosis or pulmonary embolism)

Answer 26

1) Warm the baby -> vigorous drying stimulates breathing 2) Calculate APGAR 3) Stimulate breathing - check for airway obstruction e.g. meconium 4) Inflation breaths: two cycles of five inflation breathes 5) If no response chest compression (

Answer 27

occurs in neonates as a result of hypoxia during birth. - Hypoxia is a lack of oxygen - Ischaemia refers to a restriction in blood flow to the brain - Encephalopathy refers to malfunctioning of the brain

Answer 28

1. there are events that could lead to hypoxia during the perinatal or intrapartum period, 2. acidosis (pH < 7) on the umbilical artery blood gas 3. poor Apgar scores, features of mild, moderate or severe HIE (see below) or evidence of multi organ failure.

Answer 29

Anything that leads to asphyxia (deprivation of oxygen) to the brain can cause HIE. For example: * Maternal shock * Intrapartum haemorrhage * Prolapsed cord, causing compression of the cord during birth * Nuchal cord, where the cord is wrapped around the neck of the baby

Answer 30

- Neonatal resus - Optical ventilation and circulatory support, nutrion and acid balance - Treatment of seixures - **Therapeutic hypothermia**

Answer 31

Cooling blankets - Target of between 33 and 34°C, measured using a rectal probe. - This is continued for 72 hours, after which the baby is gradually warmed to a normal temperature over 6 hours.

Answer 32

is a disorder affecting premature neonates, where part of the bowel becomes necrotic. It is a life threatening emergency. Death of the bowel tissue can lead to bowel perforation. Bowel perforation leads to peritonitis and shock.

Answer 33

1. Very low birth weight or very premature 1. Formula feeds (it is less common in babies fed by breast milk feeds) 1. Respiratory distress and assisted ventilation 1. Sepsis 1. Patient ductus arteriosus and other congenital heart disease

Answer 34

* Intolerance to feeds * Vomiting, particularly with green bile * Generally unwell * Distended, tender abdomen * Absent bowel sounds * Blood in stools

Answer 35

Blood tests: * Full blood count for thrombocytopenia and neutropenia * CRP for inflammation * Capillary blood gas will show a metabolic acidosis * Blood culture for sepsis Imaging - Abdominal xray (dilated loops of bowel, thickened wall, gas in bowel wall, pneumoperitoneum)

Answer 36

Supportive - Nill by mouth - IV fluid - NG decompression - TPN - Antibitoics Surgery - excision of dead bowel (may get short bowel syndrome)

Answer 37

Inadequate surfactant leads to high surface tension within alveoli. This leads to atelectasis (lung collapse), as it is more difficult for the alveoli and the lungs to expand. This leads to inadequate gaseous exchange, resulting in hypoxia, hypercapnia (high CO2) and respiratory distress.

Answer 38

Antenatal steroids (i.e. dexamethasone) given to mothers with suspected or confirmed preterm labour increases the production of surfactant and reduces the incidence and severity of respiratory distress syndrome in the baby. Premature neonates may need: * Intubation and ventilation to fully assist breathing if the respiratory distress is severe * Endotracheal **surfactant**, which is artificial surfactant delivered into the lungs via an endotracheal tube * Continuous positive airway pressure (CPAP) via a nasal mask to help keep the lungs inflated whilst breathing * Supplementary oxygen to maintain oxygen saturations between 91 and 95% in preterm neonates

Answer 39

Complications Short term complications: * Pneumothorax * Infection * Apnoea * Intraventricular haemorrhage * Pulmonary haemorrhage * Necrotising enterocolitis Long term complications: * Chronic lung disease of prematurity * Retinopathy of prematurity occurs more often and more severely in neonates with RDS * Neurological, hearing and visual impairment

Answer 40

* The use of a ventilator. * Surfactant or antibiotics to open their lungs and clear any infection. * Extracorporeal membrane oxygenation (ECMO). * A radiant warmer to help control your baby's temperature. * Continuous positive airway pressure (CPAP).

Answer 41

Aspirate the joint prior to antibiotics and send the sample for gram staining, crystal microscopy, culture and antibiotic sensitivities

Answer 42

Empirical IV antibiotics should be given until the sensitivities are known. Antibiotics are usually continued for 3 – 6 weeks in total. Choice of antibiotic depends on the local guidelines. Example regimes are: Flucloxacillin plus rifampicin is often first line

Answer 43

* Sore throat * Painful swallowing * Fever * Neck pain * Referred ear pain * Swollen tender lymph nodes Additional symptoms that can indicate a peritonsillar abscess include: * Trismus, which refers to when the patient is unable to open their mouth * Change in voice due to the pharyngeal swelling, described in textbooks as a “hot potato voice” * Swelling and erythema in the area beside the tonsils

Answer 44

Management - needle aspiration or surgical incision and drainage to remove the pus from the abscess. - Co-amoxiclav - Clarithromycin if penicillin allergic Some ENT surgeons give **steroids** (i.e. dexamethasone) to settle inflammation and help recovery, although this is not universal.