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FRCEM Final SAQ > Paediatric emergencies > Flashcards

Paediatric emergencies Flashcards

1
Q

Regarding HENOCH SCHONLEIN PURPURA:

can you give the :

  1. Differential Diagnosis ( of purpuric rash and
    arthralgia )?
  2. and what are the complications?
A
  1. DDx
Meningococcal disease
ITP
HSP
NAI
HUS
viral rash

DDX for ( arthralgia )
Juvenile idiopathic arthritis,
SLE,
septic arthritis,

  1. COMPLICATIONS( Think haemorage )
    brain = seizures, peripheral neuropathy
    Heart = myocardial infarction, HTN
    Lungs = pulmonary haemorage, pleural effusion
    kidneys = frank microscopic haematuria/proteinuria,
    acute kidney injury
    GIT = Gastro-intestinal haemorage, bowel infarction
    Joints = severe arthritis
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2
Q

What are the Risk factors for bronchiolitis?

CKS NICE 2015

A
  1. born premature
  2. young infant ( < 3 months old )
  3. severe congenital/acquired neurological disorder
  4. congenital cardiac defect
  5. chronic lung disease
  6. immunodeficiency
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3
Q

Indications to admit paediatric patient with acute bronchiolitis?

( NICE CKS 2015 )

A
  1. risk factors for developing severe bronchiolitis ( premature, < 3months, chronic lung disease, congenital cardiac disease etc )
  2. consider social factors ( carers ability to look after an infant with bronchiolitis - i.e. confidence
  3. persistent features of severe respiratory distress e.g grunting, stridor, cyanosis
  4. persistently low SpO2 < 92% when breathing air
  5. inadequeate oral fluid intake ( < 50% of usual daily volume )
  6. apneoa - observed or reported
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4
Q

what advice would you give parents when discharging a young infant with bronchiolitis?

A
  1. people should not smoke in the childs home becuase it increases the risk of them developing severe bronshiolits
  2. how to recognize red flag features of bronchiolitis ( inadequate intake of oral fluids, apneoa, worsening work of breathing, exhaustion )
  3. how to get immediate help if any red flag features develop
  4. arrangements for follow up if necessary
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5
Q

Describe 2 techniques to reduce a pulled elbow in children

A

The supination technique:
Support the elbow with one hand, supinate (palm upwards) the forearm and flex the elbow.

The hyper-pronation technique:
Support the elbow, pronate (palm downwards) the forearm, extend then flex the elbow.

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6
Q

What are the contra-indications to performing reduction of a pulled elbow without taking an xray?

A
  1. obvious deformity of the elbow
  2. fall from a significant height
  3. any swelling or bruising
  4. history consistent with a fracture
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7
Q

Can you categorise according to age the causes of a limping child according to

A - any age

B - 1-3 years

C - 3-10 years

D - 10-16 years

A

A. ANY AGE

Infections: cellulitis, septic arthritis, osteomyelitis
Tumour: neoplasia
Trauma: fracture, haemarthrosis

B. 1-3 years

  • transient synovitis
  • Rickets
  • Todlers fracture
  • DDH

C. 3-10 years

  • Transient synovitis
  • Rickets
  • Leg Length discrepency
  • Perthes

D. 10-16 years

  • Spine- spondylosis
  • Hip - SUFE
  • knee- Osgood schlatter
  • Foot - Freiberg’s
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8
Q

4 year old presents with back pain to the ED.

What red flags would you consider in the history and examination of this patient?

A

HISTORY:
pre-pubertal, fever,weight loss, malaise, night pain, early morning stiffness, recurrent or worsening pain,duration > 4 weeks

EXAMINATION:
Fever, tachycardia, bruising, abdominal mass, focal neuro deficit, bladder/bowel dysfunction

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9
Q

Can you list a differential diagnosis for back pain in children?

A
  1. infection: osteomyelitis
  2. Inflammation: Juvenile Idiopathic Arthritis,spondylosysis
  3. tumour
  4. other: intervertebral disc herniation, disc degeneration, scheurmanns disease
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10
Q

Name the clinical features of Kawasaki’s Disease - what do you need to make the diagnosis?

A

CRASH & BURN

In the presence of a fever lasting > 5 days AND 4 of the 5 below - you can diagnose Kawasaki’s Disease.

CONJUNCTIVITIS ( non-purulent )
RASH ( macular papular erythematous Rash )
ADENOPATHY ( cervical lmpadenopathy- unilateral )
STRAWBERY TONGUE
HANDS &fEET ( Palmar erythema & Swelling )

& BURN ( fever for > 5 days - sudden onset and swinging often above 40 )

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11
Q

Name a serious complication of Kawasaki’s disease and what treatment can be initiated in the ED?

A

Coronary arterial aneurysms.

In ED start treatment with oral aspirin 7.5-12.5mg/kg QDS for 2 weeks.

Patients are admitted to paediatric ward and given IVIG 2g/kg over 12 hours

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12
Q

List cardiac vs non-cardiac complications of Kawasaki’s disease

A

CARDIAC:

cardiac dysrythmia
myocardial infarction
heart failure
sudden cardiac death

NON-CARDIAC:

brain- aseptic meningitis
muscle - Myositis
Joints - acute arthritis
gastro- diahroea, dehydration, hepatitis, pancreatitis

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13
Q

What is the pathophysiology of a penile fracture?

Name the Long term complications of untreated penile fracture?

A

It is traumatic rupture of the corpus cavernosum.

60% wil have permanent erectile dysfunction/ persistent curvature of the penis and pain on intercourse

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14
Q

what are the clinical vs xray vs ultrasound features of intususception?

A

CLINICAL

  1. sausage shape mass in RUQ, with empty feeling in RLQ ( dances sign )
  2. non-bilious vomiting
  3. red current jelly stool

XRAY

  1. target sign ( in RUQ ) round soft tissue mass with concentriclines
  2. crescent sign ( in transverse colon ) cresent shaped lucency surrounding a soft tissue mass )

ULTRASOUND FEATURES ( investigation of choice )

  1. target/doughnut sign in transverse section
  2. sandwhich/pseudokidney in the longitudinal section
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15
Q

What are your immediate management priorities in the ED once you have made the diagnosis of intususception?

and what is the definitive management?

A

ED priorities:

  1. urgent iv fluid resuscitation
  2. keep nil by mouth and insert NGT free drainage
  3. IV analgesia
  4. urgent referal to paed surgical team on call

DEFINITIVE MANAGEMENT:

  1. AIR ENEMA ( contra-indicated in the presence of dehydration,shock or peritonitis )
  2. surgical reduction via laparotomy
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16
Q

Give a differential diagnosis for vommiting in a neonate?

A
  1. pyloric stenosis
  2. intestinal malrotation ( usually bilious vomiting )
  3. inborn errors of metabolism
  4. gastroenteritis
  5. Urinary tract infections
  6. sepsis
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17
Q

What is the gold standard investigation to diagnose pyloric stenosis and what is the definitive procedure to correct it?

A

Investigation - ultrasound abdomen

definitive treatment - Ramstedts pyloromyotomy

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18
Q

name 4 categories of causes for cyanosis in a neonate?

and what test can distinguish cardiac from respiratory cause?

A

A. - sepsis

B. cardiac ( congential heart disease )

C. Respiratory ( ARDS/pneumonia )

D. Haemaglobinopathy ( methaemaglobinaemia/
polycythaemia )

use the hyperoxia test to distinguish cardiac from respiratory cause

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19
Q

What are the causes of congenital cyanotic heart disease? duct dependent pulmonary circulation ? ( clinically suspect if normal femoral pulses

and what are the causes of congenital cyanotic heart disease where the pathology is duct dependent systemic circulation? clinically suspected if absent femoral pulses

A

Duct dependent pulmonary lesions:
Think 5 T’s & 2 E’s ( not T’s and C’s ! )

  1. Transposition of the great arteries
  2. tetrology of fallot
  3. truncus arteriosus
  4. tricuspid atresia
  5. total anomolous pulmonary venous connection
  6. Ebstein’s anomaly
  7. Eisenmenger’s syndrome

Duct dependent systemic lesions:

  1. co-arctation of the aorta ( acyanotic heart disease )
  2. critical aortic stenosis
  3. interupted aortic arch
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20
Q

What is your approach to managing congenital cyanotic heart disease in the ED?

A
  1. administer high flow oxygen to maintain SP02 above 85%
  2. give broad spectrum antibiotics
  3. give fluids judiciously ( 10-30ml/kg )
  4. give prostoglandin ( dinoprostone ) 5-50nanograms/kg/min
  5. urgent referal to paediatric ITU team
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21
Q

What is a differential diagnosis for testicular torsion?

A
  1. torsion hydatid morgagni
  2. incarcerated hernia
  3. epididimo-orchitis
  4. testicular tumour
  5. scrotal abscess
  6. traumatic haematoma
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22
Q

List points in the history and examination that would suggest testicular tosion?

A

History features:

  • history of undescended testes
  • history of testicular trauma
  • history of testicular torsion in the other testes
  • sudden onset, severe pain
  • pain wakes patient from sleep
  • associated nausea & vomiting

Examination features:

  • Testes is very swollen
  • testes is too tender to touch
  • absent cremasteric reflex
  • Negative prehns sign
  • positive angel sign
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23
Q

List 5 big Complications of DKA in a child ?

A
  1. cerebral oedema
  2. hypoglycaemia
  3. hypokalaemia
  4. aspiration pneuomina
  5. systemic infections
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24
Q

Using a venous blood gas , how would you assess the percentage of dehydration in a child with DKA?

A

> 7.1 = MILD, or MODERATE DKA = 5% dehydration

< 7.1 is SEVERE DKA = 10 % dehydration

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25
Q

When considering insulin therapy in Treatment of DKA in a child - what factors would you consider?

A

IV insulin infusion 0.05 units/kg/hr initially.
only start 1 hour after starting fluid.

INsulin therapy is required to reduce ketone production by the liver and adipose tissue

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26
Q

How do you calcualte the fluid requirement of a child with DKA?

A 6 year old weights 20kg with 5% dehydration , PH 7.15

A

Fluid therapy =( DEFICIT - Resuscitation ) divide this by 48 and then ADD + hourly MAINTENANCE

Deficit = % dehydration x weight in kg
= 5 % x 20 kg = 1000 mls
divide over 48 hours = 21 ml/hr

plus

maintenance 1ml/kg/hr = 20 ml/hr

Total = 41 ml/hour

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27
Q

Using the reduced volume rules how would you calculate the maintenance fluid requirements in a child with DKA?

A

if they weigh < 10kg use 2ml/kg
if they weight 10-40kg use 1ml/kg
if they weigh > 40kg use fixed dose 40ml/kg

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28
Q

classify severe asthma vs life threatening asthma

A

SEVERE:

  • PEFR 33-50%
  • SPO2 < 92%
  • HR depending on age - if 2-5 years then HR >140
  • RR ( if 2-5 years then ) > 40
  • Inability to complete full sentences

LIFE THREATENING:

  • PEFR < 33%
  • confused
  • Exhausted
  • Cyanosis
  • Poor respiratory effort
  • silent chest
  • hypotension
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29
Q

Your acute life threatening ashtmatic patient is not responding to medical therapy with nebulizer and oral steroid therapy.
what second line Intravenous drugs and doses should you now consider?

A
  1. IV Magnesium sulphate 40 mg/kg/day ( best overall )
  2. IV salbutamol 15mcg/kg over 10 minutes
  3. IV aminophylline 5mg/kg over 20 minutes
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30
Q

A child is brought in after sudden collapse on the football field. what causes of syncope would you consider?

A
  1. REFLEX SYNCOPE
    * vasovagal
  2. CARDIAC SYNCOPE
    * arrythmias ( tachyarrythmias- i.e long QT, wpw, brugada, svt and bradyarrythmias )
  • structural heart diseases ( hocm,dcm,AS)
  1. NEUROPSYCHOGENIC SYNCOPE
    * epilepsy
    * psychogenic
    * eating disorders
  2. METABOLIC SYNCOPE
    * hypoglycaemia
    * illicit drugs ( cocaine, amphetamines )
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31
Q

A lifeless new born term baby is brought to the ED what do you do in the 1st 60 seconds after a paediatric arrest call out has been placed?

A
  1. Dry ( dry the baby )
  2. Clock ( start the clock )
  3. Assess Tone ( assess tone, breathing, HR )
  4. Open ( open the airway )
  5. Inflate ( give 5 inflation breaths )
  6. Reasses

If the heart rate is still not strong and chest wall is not moving then

  1. re-position the head and other maneuvres
  2. 2 person technique fpr airway control
  3. Repeat 5 inflation breaths
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32
Q

in a pre-school child - list patterns of bruising that would raise the suspicion of NAI

A
  1. abnormally large bruises
  2. multiple bruises with very similar appearances
  3. Bruises that are patterned ( shaped like fingers )
  4. bruises to the back of the body ( or not on bony prominences )
  5. bruised in locations not easily injured i.e ears, nec, genitalium
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33
Q

what fractures would suggest NAI in children?

A
  1. RIb fractures in the absence of major trauma
  2. femoral fractures in children not of walking age
  3. tib/fib fractures in children under 18 months
  4. metaphyseal fractures in very young children
  5. spiral or oblique fractures i.e. humerus
  6. ANy skull fractures
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34
Q

In a child with status epilepticus- he is unresponsive to 2 doses of benzodiazepines and the phenytoin infusion - what drug would you choose for RSI?

A

thiopentone 2-5mg/kg

35
Q

A child has a painful swollen knee and a swollen 4th metatarsal.

what is the differential for dactylitis?

A
  1. psoriatic juvenile idiopathic arthropathy,
  2. sickle cell disease,
  3. tuberculous osteomyelitis and
  4. sarcoid arthropathy.
36
Q

A 13 month old child is brought to ED with drowsiness and is otherwise well and immunizations ares up to date. her GCS drops further while in the ED. what is your differential diagnosis for an unconcious child?

A
  1. Side effect from cough medicine
  2. Trauma (occult or NAI)
  3. Post convulsive state
  4. Hypoglycaemia
  5. Bacterial meningitis
  6. Herpes Simplex Encephalitis (HSE)
  7. Hyperammonaemia
  8. Non-hyperglycaemic Ketoacidosis
  9. Diabetic Ketoacidosis
  10. Raised ICP
37
Q

what inhaled therapy would you prescribe for a child with severe croup?

A

nebulized adrenaline 5ml of 1:1000

nebulised budesonide 2mg

38
Q

What are the big 4 differentials for a patient presenting with croup?

A

consider the differential diagnoses for croup. The big four:

Acute epiglottitis
Bacterial tracheitis
Foreign body, inhaled or aspirated
Allergic reaction / anaphylaxis

39
Q

what are the hallmark clinical features of croup?

A
  1. hoarse voice
  2. barking cough
  3. stridor
40
Q

What are the components of the westley croup score?

MDcalc

A

LOOK for 3 , LISTEN for 2!

Look for Level of conciousness and retractions , Look at the sats monitor,

Listen without stethoscope for stridor, and with stethoscope for air entry

  1. level of conciousness
  2. chest wall retractions
  3. cyanosis
  4. stridor
  5. air entry
41
Q

What are the contra-indications for intra-nasal diamorphine?

A
  1. < 10kg
  2. epistaxis
  3. prior administration of opiates/sedatives
  4. head injury +/ neurological problem
  5. allergies
  6. airway/ upper respiratory problems
42
Q

An unwell 9 year old boy presents with a potassium of 6.2mmol/l. he has no arrythmia on the ECG.

  1. what is your innitial management?
  2. how would your management change if the patient preseted with an arrythmia?
  3. you have given the salbutamol nebulizer - but after repeat serum potassium remain high. what would you do now?

as per APLS hyperkalaemia management

A
  1. initial management of hyperkalaemia without arrythmia according to APLS algorythym:
  2. 5-10mg nebulised salbutamol
  3. Hyperkalaemia with an arrythmia:

give IV 10% calcium chloride 0.1mmol/kg

  1. Serum potassium remains high despite salbutamol nebulizer:

you would assess the PH

if PH < 7.34 —> give sodium bicarbonate 1mmol/kg IV
if PH > 7.35 —> give glucose 10% 5ml/kg &insulin
0.05units/kg/hr

43
Q

Which circumstanaces in a paediatric cardiac arrest would you administer soium bicarbonate 8.4%
( 1ml/kg ) ?

A
  1. Hyperkalaemia
  2. tricyclic antidepressant overdose
  3. prolonged arrests.
44
Q

A paediatric patient in VF arrest receives a shock at 4joules/kg. when should you administer adrenaline?

A

adrenaline should ONLY be administered AFTER the 3rd shock in VF arrest, and then following every ALTERNATE shock!

45
Q

An active adolescent playing football complains of intermittent episodes of knee pain while playing football, initially mild and intermittent but getting worse.

  1. what is the most likely diagnosis?
  2. what would the xray show?
  3. what is the pathophysiology?
A
  1. Osgood -Schlatter disease
  2. soft tissue swelling
    and fragmentation of the tibial tuberosity.
  3. small avulsion fractures caused by traction on the patella tendon on the tibial tuberosity
46
Q

In a patient with meningococcal septicaemia - what metabolic complications would you anticipate?

A
  1. hypoglycaemia
  2. hypocalcaemia
  3. hypokalaemia
  4. hypomagnamesiema
  5. anaemia
  6. acidosis
  7. coagulopathy
47
Q

Which groups of people would require meningococcal prophylaxis if in contact with a suspected case of meningococcal septicaemia?

A
  1. kissing contacts ( boyfriend/gf )
  2. HCW who have had direct contact with droplet/respiratory secretions prior to completion of 24 hours of antibiotics
  3. household members who have had prolonged close contact within 7 days BEFORE the onset of illness.
48
Q

In a 6 month old with non-bilious vomiting- what is the target sign described on ultrasound of the abdomen?

In which other condition can you find target sign?

A

Thickened Pyloric muscles, forming a hypoechoeic muscle around the mucosa is the target sign = Pyloric stenosis

“hypertrophied, hypo echoic muscle around the mucosa”

other condition to find target sign: Intususception on abdominal ultrasound.

49
Q

What are 2 pathological lead points for intususception?

A
  1. Enlarged Peyer’s patch
  2. Meckel’s diverticulum
  3. Polyp- Peutz-Jegher’s syndrome, Juvenile or Familial
    polyps
  4. Henoch-Schonlein purpura
  5. Lymphoma
  6. Cystic fibrosis
  7. Haemangioma
50
Q

In a 7 year old with an acute asthma attack -

Name 4 clinical features requiring Intensive care referral?

A

Life threatening features of Asthma as per BTS guidelines

  1. Silent chest
  2. Poor respiratory effort
  3. Altered consciousness(confusion/coma)
  4. Cyanosis
  5. Hypotension
  6. exhaustion
51
Q
  1. In a child with asthma - what dose of prednisolone would you administer?
  2. If they are already taking a maintenance dose of prednisolone - what dose of steroids would you now give?
A
  1. under 2 years of age give 10mg po
    aged 2–5 years ,20 mg po
    children >5 years , 30–40 mg po
  2. Those already receiving maintenance steroid
    tablets should receive 2 mg/kg prednisolone up to a maximum dose of 60 mg.
52
Q

What are the life threatening features of asthma in a child?

A
  1. SP02 < 92%
  2. PEFR < 33%
  3. Blue ( cyanosis )
  4. silently ( silent chest )
  5. confused ( acute confusion )
  6. and exhausted child! ( exhaustion )
53
Q

in children with a short duration of acute severe asthma symptoms presenting
with an SpO₂ <92% - what drugs would you consider adding to the nebulized salbutamol?

BTS asthma 2019

A

Consider adding 150 mg magnesium sulphate to each nebulised salbutamol and ipratropium in
the first hour

54
Q

What drugs would you consider in the second line management of asthma in a child?

as per BTS asthma July 2019 Guideline.

A

Second line treatment of acute asthma

  1. Consider early addition of a single bolus dose of intravenous salbutamol (15 micrograms/
    kg over 10 minutes) in a severe asthma attack where the patient has not responded to initial
    inhaled therapy.
  2. Aminophylline is not recommended in children with mild to moderate acute asthma.
    Consider aminophylline for children with severe or life-threatening asthma unresponsive to
    maximal doses of bronchodilators and steroids.
  3. In children who respond poorly to first-line treatments, consider the addition of intravenous
    magnesium sulphate as first-line intravenous treatment (40 mg/kg/day).
55
Q

What are the classical features of a febrile convulsion?

A
  • age 6 month to 6 years
  • generalized tonic clonic seizure
  • lasting less than 15 minutes
  • complete recovery within 1 hour
  • and not recurring within the same febrile illness
56
Q

What incidence of patients will have a further febrile convulsion after presenting to the ED?

A

30% of patients will have a second febcon,
15% will have a 3rd febcon,
7 % will have 3 or more occurences

57
Q

Which patient would you admit that present with a febrile convulsion for a paediatric assessment?

A
  1. first febrile convulsion - admit to paeds
  2. under 18 months with diagnositc uncertainty or features of recurrence of complex febrile seizure
  3. Any focal neurological deficit
  4. decreased Level of conciousness prior to seizures
  5. child was on recent antibiotics
  6. parent or carers anxiety/difficulty coping
58
Q

what are the non-cardiac complications of Kawasaki’s?

A

Other clinical features associated with Kawasaki’s disease-

  1. Aseptic meningitis- in up to 25%
  2. Urethritis- up to 75%
  3. Polyarthralgia
  4. GI symptoms- Obstructive jaundice, Abdominal pains and diarrhoea
59
Q

What are the complications of button battery ingestion?

A
  1. oesophageal erosions, ulceration, necrosis
  2. oesophageal perforation
  3. oesophageal stricture and fistula
  4. gastro-intestinal heamorage
  5. Gastro-intestinal perforation
60
Q

What re the common viral and bacterial cause of bilateral conjunctivits in a neonate?

A

VIral causes:

adenovirus
herpes simplex virus

Bacterial causs

neisseria gonorhoea
chlamydia trachomatis
staph aureus
strep aureus
HiB
61
Q

what is the pathophysiology of HSP?

A

It is an IgA maediated vasculitis of the small blood vessels

62
Q

What are the clinical features of HSP?

A

Clinical features of HSP:

  1. Malaise, low grade fever
  2. Hepatosplenomegaly
  3. Lymphadenopathy
  4. Abdominal pain (may develop bloody diarrhoea,Intussusceptions.) Abdominal pain and bloody diarrhoea may precede the typical purpuric rash. HSP may also cause nausea and vomiting
  5. Arthritis/ arthralgia. Joint pain, especially in the knees and ankles. Joints may also be swollen and tender but permanent deformity does not occur
  6. Testicular pain and/ or swelling
  7. Headaches
63
Q

What are the complications of an undiagnosed retained foreign body aspiration ( like a peanut )

A
  1. complete airway obstruction
  2. atelectasis
  3. pneumonia
  4. bronchiectasis
  5. abscess
64
Q

a child with a B.M of 2.4 ( hypoglycaemia is < 2.6mmol/l ) following a bad episode of D&V

  1. she is tolerating small amounts of oral fluids and is not drowsy - what treatment would you give her?
  2. she start vomiting and is unable to tolerate orals -
    and is drowsy - what would you do now?
  3. her BM remains low and she is unresponsive and you now have IV access- what treatment would you give ?
A
  1. if < 1 year - give milk feed
    if > 1 year old : give 10-20g or oral glucose ( glucogel )
    and follow up after 15 minutes with long acting CHO -
    bread
  2. give im glucogon ( if < 25kg - 0.5mg , if > 25kg - 1mg im glucagon )
  3. 10 % dextrose 2ml/kg
65
Q

What are the causes of hypoglycaemia in paeds?

A
  1. Other -
    * gastro-enteritis
    * sepsis
    * DKA
  2. Endocrine
    * hyperinsulinism
    * adrenal insufficiency
    * growth hormone deficiency
    * hypopituitirism
    * hypothyroidism
  3. Metabolic
    * disorders of carbohydrate metabolism
    * disorders of gluconeogenesis
    * glycogen storage disorders
  4. Other
    * drug related - insulin, alcohol, aspirin, sulphonylureas
66
Q

5 low risk features of an infant presenting with a BRUE?

A

Low risk stratification for BRUE-

  1. born > 32 weeks G?A
  2. age > 60 days
  3. 1st episode
  4. event lasted less than 1 minute
  5. no CPR was performed by a trained healthcare professional

The accepted definition of a BRUE is:

*Duration of less than one minute
*Age under 1 year
*Patient returned to baseline health following event with
normal observations and appearance
*Not explained by medical condition
*More than one of the following:

#Cyanosis or pallor
#Absent, Decreased or irregular breathing
#Marked change in tone (hypertonia or hypotonia)
#Altered response
67
Q

in a 2 year old with a cough followed by vomiting. you have diagnosed Whooping cough.

What are the 3 phases of symptoms?

A

3 phases of symptoms in whooping cough :

  • catarhal phase - lasts 1-2 weeks
    URTI symptoms- low grade fever, nasal discharge, conjunctivitis, sore throat
  • paroxysmal phase - onset 1 week after catarhal phase and lasts 1-6 weeks
    Typically consist of a short expiratory burst followed by an inspiratory gasp, causing the ‘whoop’ sound.
  • convalascent phase - lasts up to 3 months.
    where symptoms gradually improve
68
Q

in a 2 year old with a cough followed by vomiting. you have diagnosed Whooping cough.

How would you make the clinical diagnosis?

A

Presence of an Acute cough that has lasted for 14 days or more without another apparent cause, and has one or more of the following features:

  • Paroxysmal cough.
  • Inspiratory whoop.
  • Post-tussive vomiting.
  • Apnoeic attacks in young infants.

PIPA has a cough for > 14 days!

cough…. whoop …., vommit…., apnoea….

69
Q

in a 2 year old with a cough followed by vomiting. you have diagnosed Whooping cough.

How would you manage this patient if they had no indications to admit to hospital?

A

A. If admission is not needed, prescribe an antibiotic if the onset of cough is within the previous 21 days.

A macrolide antibiotic is recommended first-line:
Prescribe clarithromycin for infants less than 1 month of age.

Prescribe azithromycin or clarithromycin for children aged 1 month or older, and non-pregnant adults.

Prescribe erythromycin for pregnant women.

B. Notify Public Health England

70
Q

in a 2 year old with a cough followed by vomiting. you have diagnosed Whooping cough.

How would you manage this patient if you think they need admission? what are the indications to admit?

A

Arrange admission if the person:

  1. Is <6 months of age AND acutely unwell.
  2. Has significant breathing difficulties (for example apnoea episodes, severe paroxysms, or cyanosis).
  3. Has a significant complication (for example seizures or pneumonia).
    Note: inform the

hospital of the need for appropriate isolation before the person is admitted.

71
Q

what are the serious complications of Whooping cough?

A

Serious complications of pertussis include:

2 in the LUNGS:

Apnoea.
Pneumonia ( caused by secondary bacterial infection).

2 in the BRAIN:

Seizures.
Encephalopathy (rare in adults).

72
Q

In a patient with whooping cough,

what are the complications directly relating to increased intra-thoracic and intra-abdominal pressure due to violent or prolonged coughing?

A

Increased intra-thoracic and intra-abdominal pressure due to violent and/or prolonged coughing can cause:

  1. Pneumothorax.
  2. Umbilical and inguinal hernias, and rectal prolapse.
  3. Rib fracture and herniation of lumbar intervertebral discs.
  4. Urinary incontinence.
  5. Subconjunctival or scleral haemorrhage, and facial and truncal petechiae.
  6. Frequent post-tussive vomiting can lead to severe dehydration and/or malnutrition.
73
Q

A mother brings her 3 year old to the ED and you diagnose whooping cough.

she asks wether she can send her child to nursery the next day. WHat advice would you give?

A

Advice on exclusion from nursery, school, or work

The PHE guidance states that children and healthcare workers with suspected whooping cough should :

stay off nursery, school, or work until 48 hours of appropriate antibiotic treatment has been completed,

OR

21 days after onset of symptoms if not treated [PHE, 2016b].

This is primarily to prevent the spread of infection, as pertussis is most infectious at this stage.

74
Q

How would you clinically differentiate between bacterial tracheitis and acute epiglottitis?

A

Think of 5 differentiating features:

speed of onset, voice, cough, xray , adrenaline response

BACTERIAL TRACHEITIS:

  • rapid onset with fever >39
  • hoarse voice
  • productive cough
  • partial or no response to adrenaline nebs
  • steeple sign on lateral neck xray

ACUTE EPIGLOTTITIS:

  • very very rapid onset with fever > 39
  • muffled voice ( with dysphagia + drooling )
  • suppressed/no cough
  • NO response to adrenaline nebs
  • Thumbprinting sign on lateral Neck xray
75
Q

What are considered high risk factors for development of a BRUE?

A
  1. prematurity
  2. age < 10 weeks
  3. previous apnoea episode
  4. airway abnormalities
  5. history of GORD
76
Q

A toddler has suffered a febrile convulsion. the mother is worried about further attacks and the risk of epilepsy. what advice do you give her?

A
  • 30% risk of recurrent febrile convulsions
  • 10% risk of recurrence within the next 24 hours
  • risk of long term epilepsy is 6%
77
Q

A boy has accidently inhaled a peanut. what are the potential complications of an inhaled foreign body?

A
  1. pneumonia
  2. atelectasis
  3. pneumothorax
  4. broncho-oesophageal fistula
  5. bronchiectasis
  6. bronchospasm
78
Q

Which factors are prognostic indicators for long term sequele in Perthe’s Disease?

A
  • age
  • limitation of movement
  • radiologically visible involvement of the femoral head
  • lateralisation of the femoral head in the acetabulum
  • lateral epiphyseal calcification
  • metaphyseal cyst formation
79
Q

What Risk factors for child abuse can you list?

A

Risk factors for child maltreatment (NICE CKS, 2019) include:

  1. Family and environmental risk factors:
    *Poverty and financial pressures, poor housing
    *Maltreatment of other children within the family, intra-
    familial violence.
  2. Parental risk factors:
    * Substance misuse
    * A history of domestic abuse, including sexual violence or exploitation, and/or maltreatment as a child.
    * Emotional volatility or having problems managing anger.
    * A history of violent offending.
    * Mental health problems which have a significant impact on the tasks of parenting.
    * Known maltreatment of animals.
    * Poor education.
    * Lack of parenting knowledge.
    * Learning difficulties.
  3. Child risk factors:
    * Physical and/or mental impairment.
    * Living in the care system.
    * Being a twin or multiple.
80
Q

In a suspected NAI case - the parent refuse overnight admission and do not consent to you disclosing any information to the duty child safeguarding consultant or to any other child protection agencies.

How will you manage this patient?

A

Explain to the parent that their consent is not required and the child must be assessed by the paediatric team (and is most likely to be admitted) for their safety and safeguarding (principle of paramountcy) (0.5 marks).

Ensure the other child/children at home are being safeguarded (0.5 marks).

Can you share this confidential information without the parents consent?

Yes, you can share confidential information with the appropriate agency/safeguarding team without consent in this scenario because this child, your patient, and their sibling, are at risk of significant harm.

In general, NICE guidelines (2019) recommended that:

If there is any uncertainty about when to consider or suspect maltreatment, or about the immediate risk of harm to the child, advice should be sought from a named professional for child safeguarding or a senior colleague.
Consent should be obtained before sharing confidential information unless this will increase the risk of harm to the child/young person.
If there is suspicion that child maltreatment is occurring, children’s social care should be contacted to discuss the need for a referral. If the child is thought to be in immediate danger, the police should be informed.
If hospital admission is needed, the admitting paediatrician should be made aware of any safeguarding concerns.

81
Q

You treat a 13 year old child who has suspected NAI.

Can you obtain consent from the child if aged 13 , to disclose confidential information to other organizations?

A

Additional Information on consent and confidentiality in paediatric patients

Obtain consent from the child/young person if they have capacity, if they don’t have capacity, a person with parental responsibility should be asked to consent on behalf of the child/young person (NICE CKS, 2019).

A child/young person who has capacity to understand or make their own decisions may give (or refuse) consent to share information (NICE CKS, 2019).
It is generally expected that a child over the age of 12 has sufficient understanding and it is presumed by law that a young person aged 16 and older has capacity to consent to medical treatment (NICE CKS, 2019).
Where parental consent is required, the consent of one such person is sufficient. If the parents/carers are in conflict, careful consideration should be given to whose consent will be sought. In the situation where parents are separated, the consent is usually sought from the parent with whom the child resides (NICE CKS, 2019).

82
Q

A child with a fever and a red flag feature should have 4 investigations performed. ( in children > 3 months age )

what are these?

CG47- feverish illness in children

A
  1. FBC
  2. CRP
  3. Blood culture
  4. urine testing

3 other investigations to consider:

  • serum electrolytes and blood gas
  • CXR
  • LP
83
Q
  1. Which specific investigation would you perform in a child < 6 months age with a UTI?
  2. when is this test indicated?

resource:
NICE cg 54 _UTI

A
  1. Ultrasound during the acute infection if they have:
    • atypical UTI
    • recurrent UTI
    • do not respond well to treatment within 48 hours
84
Q
  1. which specific investigation would you perform in a child with a UTI age 6 months- 3 years ?
  2. when is this test indicated?
A
  1. MCUG
  2. COnsider MCUG in child 6 months-3 years with UTI if:
  • family history of VUR
  • poor urine flow
  • non-e-coli infection

FRCEM Final SAQ (16 decks)

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