Paediatrics

Question 1

Paediatric Ketamine Sedation

EM Rapid Bombs ep 61 - ketamine side effect

sedative
analgesia
dissociative

preserves upper airway reflexes
emergence phenomenon is the most common adverse effect

Answer 1

IV Ketamine

1-2mg/kg
subsequent incremental doses 0.5mg/kg
slow IV push over 1-2min. rapid push associated with respiratory depression.
Advantage - ease of repeat dosing, faster recovery
Clinical onset - 1 min
Effective sedation - 10min
Time to discharge - 60min

IM Ketamine

3-4mg/kg
a repeat dose of 2-4mg/kg can be given after 10min
ketamine can be safely used without IV access
Advantage - no IV necessary
Clinical onset - 4mins
Effective sedation 20min
Time to dischage - 2hrs

SIDE EFFECTS:

Transient tachycardia and hypertension

Laryngospasm (0.3%)

Emergence phenomena - recover in quiet low stimulus environment

Vomiting - prophylactic ondansetron

Hypersalivation

Nystagmus

Apnoea and respiratory depression - if given too rapidly

Muscle twitching and purposeless movements

CONTRAINDICATIONS:

Absolute:

allergy
< 3months
schizophrenia

Relative:

current respiratory illness
known difficult airway
procedures that will stimulate oropharynx
age 3-6 months

VOMITING & LARYNGOSPASM:

1) Stop the procedure.

2) Call for help. Children become hypoxic quickly.
Gentle suction of vomitus under direct vision

3) 100% oxygen BVM maximum PEEP and tight seal
- Attempt manual two persons BVM ventilation

4) try to break the laryngospasm with Larsons manouvre + jaw thrust.
(firm pressure on posterior ramus of mandible)

5) If not able to adequately manually ventilate –> Deepen anaesthesia with propofol 1-2mg/kg IV
–> give suxamethonium 1-2mg/kg and intubate
(IM suxamethonium 3-4mg/kg if no IV)
atropine 20mcg/kg for bradycardia

RATIONALE FOR FASTING

1) Most guidelines state that patients should be fasted for 4-6 hours prior to procedural sedation.
2) Aspiration is not impossible with ketamine, if it is not an emergency procedure - best to wait until fasted

RATIONALE FOR PROCEEDING WITHOUT FASTING

1) Medical emergency e.g. neurovascular compromise of a displaced fracture outweighs the risk of aspiration
2) there is no relationship between adverse respiratory events and fasting times in any studies thus far
3) Maintain airway reflexes with ketamine

Question 2

Paediatric Procedural Sedation

weight = age + 4 x2
ETT = age/4 + 3.5 (cuffed ETT)

Answer 2

Bridging analgesia:
- fentanyl 1.5mcg/kg IN

Family involvement:
- support child, reduce anxiety
- help with distraction

PREPARATION:

Airway assessment:
Previous sedation/anaesthesia
Fasted for non-emergent procedures
Current illness - URTI

PMHx:
Medications:
Allergies:

Equipment:
- suction
- oxygen
- bag valve mask
- OPA, NPA
- monitoring

Drugs:
- ketamine 1-2mg/kg IV
- Premedication with ondansetron to reduce risk of vomiting

Question 3

Paediatric Head Injury

2022.1 Case Based Discussion Station

8yr old with head injury after falling at a playground

Explain how you would decide if the child would need a CT scan

Patient deteriorates and is combative. Discuss Intubation vs sedation for CT.

Interpret CT scan and outline management

Answer 3

PECARN identify patients at very low risk of intracranial injury who do not need a CT scan (all predictor variables negative, no CT required)

PECARN the only prospectively validated decision making rule

PECARN has highest sensitivity in ruling out serious pathology

It helps us to balance the risk of missing a significant injury, and to minimize the risk of radiation-induced cancer in the paediatric population

AGE <2yrs
GCS <14
Altered mental status
Loss of consciousness
Parietal, temporal, occipital haematoma
Not acting normal as per parent
Severe mechanism:
- MVC with patient ejection,
- death of another passenger
- rollover
- pedestrian or bicyclist w/o helmet struck by motorized vehicle;
- fall from >0.9m

AGE >2yrs
GCS<14
Signs of base of skull fracture (racoon eyes, battle sign)
Altered mental status
Intractable vomiting
Severe headache
Dangerous mechanism
- fall >1.5m

MODIFIED PAEDIATRIC GCS:
alteration in verbal response
coos or babbles = 5
irritable cry = 4
cries to pain = 3
moans to pain = 2
no response = 1

If PECARN negative:
CT is not required as per best practice evidence

The purpose of non-con CT brain is to detect critical intracranial injuries that require urgent neurosurgical intervention

Risk associated with procedural sedation required to obtain the CT scan - aspiration, respiratory depression

Radiation exposure increases lifetime risk of developing brain cancer

1: 1500 in 1yr
1: 10,000 10yr old

Concussion will reveal a normal CT scan and is managed conservatively

Question 4

Paediatric Head Injury

2023.2 History taking station

Take a focused history from a parent (role player) of a paediatric patient with a head injury.

After assessment.

The patient does not require CT brain.

Outline your management plan.

Tips:
- Consider non-accidental injury
- Assess cervical spine

Answer 4

HISTORY:

Mechanism:
- when
- how

Red flag symptoms:
- abnormal behaviour
- drowsy/lethargic
- irritable
- headache
- scalp haematoma
- blood coming from ears (haemotympanum)
- clear liquid coming from ears or nose (CSR rhinorrhoea)
- bruising behind ears (battle sign)
- memory impairment
- loss of consciousness
- seizures
- difficulty walking
- intractable vomiting
- other injuries sustatined

RED FLAGS FOR CHILD ABUSE:

PMHx:
- bleeding disorders (haemophilia)
- VP shunts
- Neurodevelopmental disorders (autism) - difficult to assess –> lower threshold to CT

Meds:

IMMUNISATIONS:

ALLERGIES

SOCIAL:
- where do you live
- who lives at home
- access to medical services, car, phone

EXAMINATION:

Scalp haematomas
- high risk if occipital, parietal and temporal as opposed to frontal
- boggy suggestive of skull fracture

Signs of base of skull fracture:
- battle sign
- raccoon eyes
- CSF otorrhoea/rhinorrhoea
- haemotympanum

Assess for signs of raised ICP and brain herniation:
- reduced LOC
- blown pupil
- hemiparesis
- abnormal posturing (decorticate or decerebrate)
- cushings reflex (bradycardia, hypertension)

ASSESSMENT OF CERVICAL SPINE

MANAGEMENT:

• Child with head injury is a very common presentation to the emergency department. It is something that we see and treat a lot.
• The next step in my assessment is to decide whether or not we need to do a CT scan of the head.
• We perform CT scans to looks for serious injuries to the brain that need urgent treatments. For example a bleed on the brain.
• As you may be aware, CT scans are not completely benign tests. They do expose the growing brain to radiation which does increase the lifetime risk of developing brain cancer. This risk is higher the younger the child.

1: 1500 in 1yr old
1: 10,000 10yr old

We use a clinical decision tool to help us identify which patients need to have CT.

This tool helps us to balance the risk of missing a serious brain injury, and to minimise radiation induced cancer in the paediatric population.

Based on the information that I have gathered today. Your risk of having a serious injury inside your head is very low. Almost negligible. <0.05%.

Therefore we will not proceed to a CT scan. We will observe you for 6hrs from the time of injury.

Question 5

Head Injury Intubation

Answer 5

Prevent raised ICP - raise head of bed 30 degrees

Anticipate difficult intubation due to potential c-spine injury/in line immobilisation

Blunt sympathetic response from laryngeal manipulation - pre medication with fentanyl 1mcg/kg IV (need to give this 3-5min before induction)

Ketamine 1-2mg/kg for induction - haemodynamically stable

Rocuronium 1.2mg/kg IV

Avoid hypotension:
have vasopressors on stand by
adrenaline 1mcg/kg IV Q5min
adequately fluid resuscitate before induction

Avoid hypoxia - pre-oxygenate with high flow oxygen 15L NRBM

Treat raised ICP:
- 3% NS 3-5ml/kg IV following by infusion 0.1ml/kg/hr to maintain Na+ 155-165
OR
- Mannitol 0.5–1 gram/kg

Maintain SaO2 >90%, PCO2 35-40

Maintain normothermia 36-37

Maintain normoglycemia - check BSL Q1h - especially important in paediatric patients

Maintain SBP >70 + (age x2)
Invasive BP monitoring with arterial line
adrenaline infusion 0.05-1mcg/kg/min

Seizure prophylaxis:
levetiracetam 15-40mg/kg IV

Immediate Neurosurgical attendance to facilitate decompressive craniectomy

Question 6

BRAIN HERNIATION

Answer 6

BRAIN HERNIATION:
uncal herniation:
- compression of the occulomotor nerve –> ispilateral fixed dilated pupil
- contralateral hemiparesis

Central transtentorial herniation:
- bilateral pin-point fixed pupils
- bilateral babiski
- increased tone
- progress to hyperventilation and decorticate posturing

Cerebellotonsillar herniation:
- flaccid paralysis
- bradycardia
- respiratory arrest
- sudden death

Question 7

Paediatric Asthma

Answer 7

Escalate oxygen therapy - High flow nasal prongs, flow rate 2ml/kg, FiO2 100%

Continuous nebulised salbutamol 2x 5mg undiluted vials
add nebulised ipratropium 500mcg every 20min (3 doses)

IV access - blood gass

Methylprednisone 1mg/kg IV

Magnesium 0.2mmol/kg (max 8mmol) IV over 20min

Aminophylline 10mg/kg IV over 1hr

Salbutamol 5mcg/kg/min for 1hr

Request portable chest xray

c)
Use the largest tube possible.
Use lowest FiO2 to achieve SpO2 of 90-92%
Use a small tidal volume, 5-7ml/kg
Use a slow respiratory rate, 8 breaths per minute
Use a long expiratory time, with I:E ratio 1:4
Increase inspiratory flow rate to maximum 60-80L/min
Reset the pressure limits (i.e. ignore high peak airway pressures). .
Use heavy sedation.
Use neuromuscular blockade.
Use minimal PEEP 0cmH2O
Keep the Pplat below 25cmH2o to prevent dynamic hyperinflation.

Question 8

Post Intubation Deterioration in Asthma - Assessment and Management

Answer 8

POST INTUBATION DETERIORATION

1) Disconnect the ETT from the ventilator and decompress the chest
- breath stacking causes dynamic hyperinflation, decreased venous return causing hypotension

2) Use BVM with CO2 capnography to ventilate. Slow ventilation RR 5/min, TV 5-7ml/kg. Can feel lung compliance. This can also rule out EQUIPMENT FAILURE.

3) Assess for TENSION PNEUMOTHORAX
trachea deviated to one side?
chest asymmetry?
auscultation and percussion findings?
proceed to needle decompression and chest tube placement.

Hypovolemia - fluid bolus 20ml/kg 0.9%

Anaphylaxis to induction agents/sedation - adrenaline infusion 0.05-1mcg/kg/min

Excess sedation - especially propofol and fentanyl - reduce sedation infusion rate, consider changing sedation or add a adrenaline infusion

Sepsis - vasopressors + antibiotics

Bronchospasm

Question 9

Paediatric Asthma

2022.1 Teaching Station

Dx: Moderate Asthma for discharge home. Teach parent to use spacer and give discharge advice

Answer 9

SAFE FOR DISCHARGE CRITERIA:
- no oxygen requirement
- no increased work of breathing
- normal behaviour
- bronchodilator stretched to 3hrs
- proper spacer technique
- understand return advice
- safe discharge location
- written asthma action plan
- follow up arranged

DISCHARGE ADVICE

EDUCATION:
- assess knowledge and understanding and address gaps on
symptom recognition and management

WARNING SIGNS OF WORSENING ASTHMA - SEEK MEDICAL REVIEW ASAP
- Night time coughing or wheezing
- Unable to participate in usual activities without wheezing, coughing, or becoming short of breath
- Needing to use reliever medicine every 3-4 hours

• when to seek medical attention
  emergency management

WHEN TO CALL AN AMBULANCE
- Needing to use reliever more frequently with no relief
- Child is distressed and anxious
- Child is sucking in at the throat and ribs when they breath
- Child has a bluish tinge to the lips
- Child is unable to talk due to breathlessness
- If you have concerns or doubts

ROLE OF RELIEVER AND PREVENTER THERAPY:
Reliver - relaxes the muscles encircling the airways to allow them to open

Preventer - reduces airway inflammation preventing exacerbations. must be used morning and night. rinse mouth or brush teeth to prevent oral thrush.

INHALER TECHNIQUE: See video

CLEANING SPACER:
Take the spacer apart if possible.
* Wash in warm soapy water (dishwashing liquid).
* Allow the parts to air dry. Rinsing and drying with a cloth may cause static electricity to build up resulting in the medication clinging to the inside of spacer.
* When dry put spacer back together ready for use.

TRIGGERS:
- cigarette smoking
- thunderstorms
- exercise
- dust and pollen
- cats, dogs
Always carry preventer and spacer

FOLLOW-UP:
Follow-up organised with GP
Discharge letter to GP

ASTHMA ACTION PLAN:
Complete course of oral steroids
Give 4 puffs salbutamol
If no relief after 4min, give a further 4 puffs
If no relief, call ambulance and continue giving 4 puffs every 4min until ambulance arrive

Refer to educational videos
Given written information - asthma education pack

Question 10

Bronchiolitis

2022.1 Station

Answer 10

REASONS FOR ADMISSION:
- oxygen requirement

• marked increased work of breathing with potential need for positive pressure ventilation / NIV
• poor feeding requiring NGT placement (<50% normal intake with evidence of dehydration)
• early in illness i.e. day 1 with potential to deteriorate
• risk factors for severe bronchiolitis:
• premature baby
• <6wks old
• low birth weight/failure to thrive
• lung disease e.g. Cystic fibrosis
• congenital cardiac disease e.g. Tetralogy of fallot,
• immunecompromised

Question 11

Paediatric Seizures

Seizure characteristics:
- Lateralized tongue-biting (high specificity)
- Flickering eye-lids
- Dilated pupils with blank stare
- Lip smacking
- Increased heart rate and blood pressure during event
- Post-ictal phase

Seizure mimics:
- breath holding spells (emotional trigger, 6-18months, quick recovery)
- pseudoseizure (more in adolescents)
- syncope (quick recovery)

Who needs CT scan:
- concerns about non-accidental injury
- altered mentation, focal neurology
- signs of raised intracranial pressure and brain herniation
- history of hydrocephalus with VP shunt

Answer 11

Simple febrile seizures:
- 6 months to 6 years
- occur early in febrile illness
- generalised tonic-clonic
- duration <15min
- recovery to baseline within 1hr
- does not recur within 24hrs

• no greater risk for
  serious bacterial infection (bacterial meningitis) than age-matched controls who have not seized
• treat as normal febrile illness
• if benign febrile illness, can discharge home with counselling

Complex febrile seizures:
- focal seizures
- duration >15min
- incomplete recovery within 1hr
- multiple seizures in 24hrs

Need to further work up to exclude more sinister pathology:
(bacterial meningitis, NAI and brain injury)
- bloods and urinalysis
- consider CT brain and LP

Question 12

Counselling Parent - Febrile Seizure

Answer 12

Febrile seizures are common
1 in 30 children will have a febrile seizure

Usually happens between age 6 months - 6 years

Treating a child’s fever with paracetamol or ibuprofen will not prevent a febrile seizure.

Febrile seizures do not cause brain damage, and there is no increased risk of epilepsy in children who have had simple febrile seizures.

Risk of recurrence is approximately 33% overall with a higher risk
in children
*<18 months of age
* temperature < 40.0°C at first convulsion
* <1hr between onset of fever and first seizure
* family history of febrile seizures

WHAT TO DO:
- stay calm, seizure will stop on its own
- Place your child in recovery position on on a soft surface
- don’t put anything in mouth
- don’t restrain
- don’t place in cold bath
- watch what happens so you can describe to doctor
- time how long seizure lasts

WHEN TO CALL AMBULANCE:
- seizure lasts >5min
- does not wake up after seizure
- looks very unwell or you are concerned

KEY POINTS:
- One in 30 children have a febrile seizure, usually between the ages of six months and six years.
- Nothing can be done to prevent a febrile seizure from occurring.
- During a seizure, remain calm and try not to panic.
- Do not put your child in a bath, restrain them, or put anything in their mouth.
- Febrile seizures are not harmful to your child, and will not cause brain damage.
- If the seizure lasts more than five minutes call an ambulance.

Question 13

Status Epilepticus

2023.1 Case based discussion

5 month old with status epilepticus
- not febrile
- outside the age for febrile convulsions

Differential Diagnosis:

Metabolic derangement:
- hypoglycemia (congenital adrenal hyperplasia, inborn errors of metabolism)

Electrolyte disturbance:
- hyponatremia (dilute formula, congenial adrenal hyperplasia)

Infection:
- meningitis
- encephalitis

Trauma:
- non-accidental injury
- head injury

Neurological:
- malignancy
- hydrocephalus
- raised intracranial pressure

Toxicological:
- Na+ channel blockers (TCA, fleicanide, propanolol)

Haematological:
- Haemophilia A spontaneous intracranial haemorrhage
- sickle cell disease causing stroke

MENINGITIS:

dexamethasone
- blunts the inflammatory response in bacterial meningitis, reduction in mortality
- reduce the rate of neurological complications such as hearing loss

Cefotaxime - H. influenza, S. pneumoniae, N. meningitidis are sensitive to cefotaxime
Receives Hib and pneumococcal vaccine at 2 and 4 months of age, but meningicoccal is not until 12 months

Answer 13

INVESTIGATION:

VBG - Na+, glucose
FBC - leukocytosis, leukopenia in sepsis
CRP

MANAGEMENT:

calculate estimated weight
= (age + 4) x2
= 8kg

High flow oxygen 15L NRBM
jaw thrust +/- nasopharyngeal airway

IV or IO access

Check BSL
<2.6 give 2ml/kg 10% dextrose IV/IO
aim BSL >4

Midazolam 0.2mg/kg IV/IM
Midazolam 0.3mg/kg buccal/IN

Repeat Midazolam 0.2mg/kg IV

2nd line agents:
- Levitiracetam 40mg/kg IV over 5min

• Phenytoin 20mg/kg IV over 20min
• Phenobarbitone 20mg/kg over 20min

3rd line:
RSI + Intubation

Propofol 2mg/kg IV
Rocuronium 1.2mg/kg IV

Post intubation sedation with midazolam infusion 1mcg/kg/min

Give dexamethasone 0.15mg/kg IV and ceftriaxone 50mg/kg IV to cover for meningitis

Treat hyponatremia with 3% hypertonic saline 3-5ml/kg IV (100ml) over 10min, repeat max 3 infusions
aim to raised Na+ by 4-6mmol/L

ASSESSMENT (potential causes and complications)

ASSESSMENT:

SKIN:
- pigmentation in CAH
- cafe au lait spots (neurofibromatosis)
- ash leaf spots (tuberous sclerosis)
- port wine stains (sturge weber syndrome)
- petechiae in bacterial meningitis or haemophilia
- injuries consistent with non-accidental injury

HEAD:
- scalp haematomas
- bulging fontanelles (raised ICP)
- VP shunt

EYES:
- papilloedema
- retinal haemorrhages
- subconjunctival haemorrhages

Hepatosplenomegaly - glycogen storage disease

COMPLICATIONS:
- aspiration
- trauma
- hyperthermia
- rhabdomyolysis and renal failure
- non-cardiogenic pulmonary oedema

INVESTIGATIONS:

BSL

VBG - metabolic acidosis, respiratory failure, Na+, Glucose

Renal function and electrolytes

CK (rhabdomyolysis)

ECG - QRS prolongation, terminal R wave in aVR, arrythmias

CT brain - cerebral oedema, intracranial haemorrhage, tumour, hydrophephalus, stroke in sickle cell disease

CXR - check ETT placement, aspiration, non-cardiogenic pulmonary oedema

If suspect NAI:
Meticulous documentation
Mandatory reporting to child protective services

Question 14

Paediatric Hypoxia and Shock

2021.2 modified simulation

Differential diagnoses:
- status asthmaticus
- tension pneumothorax
- anaphylaxis
- pneumoniae with sepsis
- cardiomyopathy with pulmonary oedema
- myopericarditis with tamponade

Trauma - non-accidental injury
Haemorrhagic shock
Toxicological -

Child deteriorates and requires intubation:
- outline intubation plan

Weight = (Age + 4) x2
ETT = (Age/4) + 3.5 cuffed

High risk features on assessment:
- tachycardia
- hypotension is a late sign
- peripherally shut down, cool peripheries, slow capillary return
- altered mentation

Causes of difficult ventilation:
- tube displacement (check correct placement - ET CO2, CXR
- obstruction (suction tube)
- bronchospasm (salbutamol3x 5mg nebs, ipratropium 3x 250mcg nebs, IV magnesium 40mg/kg IV over 20min)

CAUSES:

ETT displaced/cuff not inflated

Obstruction of ETT/Bronchospasm

Pneumothorax

Equipment malfunction (disconnection of the ventilator, incorrect vent settings, etc.)

Stacking (breath stacking)

STATEGIES:

Disconnect from ventilator, BV tube and feel resistance as you bag

Suction ETT, check for kinks, inadvertent extubation

Treat brochospasm
- salbutamol 15mg/hr nebs
- ipratropium 250mcg nebs q20min
- magnesium 40mg/kg IV over 20min

Check ventilation settings

POCUS - pneumothorax
- absent lung sliding
- absent comet tails
- lung point

Answer 14

MANAGEMENT:

Statement that child is critically unwell in a shocked state

Transfer to resuscitation room and call for senior help

Oxygen:
Respiratory support with HFNP 2ml/kg FiO2 100% target
(positive pressure ventilation will worsen hypotension)

IV access, early IO if no access in 2min
2x tibial IO - one line for fluids, one line for antibiotics

Aggressive fluid resuscitation - 3 X 20ml/kg 0.9% NS IV within the first hour of resuscitation

Urgent antibiotics:
Antibiotics for pneumoniae
ceftriaxone 50mg/kg + flucloxacillin 50mg/kg (to cover for staph aureus pneumoniae)

Vasopressors for fluid refractory shock:
adrenaline infusion
- 6mg 1 in 1000 in 1L 0.9% NS
1ml = 0.1mcg
start infusion at 1ml/kg/hr and titrate up to 10ml/kg/hr
target MAP 70

ASSESSMENT:
- assessment will be happening concurrently with resuscitation

Involve parents - collateral history

Bloods:
- VBG
- FBC (leukocytosis, leukopenia)
- UEC & LFT’s (end organ perfusion)
- CRP
- Blood cultures

Place IDC and obtain urine sample for microscopy and culture

Portable CXR

POCUS
- pneumothorax
- pericardial effusion
- pulmonary oedema
- abdominal free fluid
- guide fluid resuscitation with regular assessment of IVC
- may aid in securing IV line

INTUBATION:
- high risk of cardiac arrest in children with septic shock
- most of the medications for induction will worsen hypotension
- even ketamine will cause hypotension in children who are catecholamine depleted
- need to assess whether intubation is truly indicated
- need to optimise and prepare for safe and controlled intubation

Pre-oxygenated
Fluid resuscitated
Vasopressors infusing

Induction with ketamine 1mg/kg IV
Paralysis with rocuronium 0.6-1.2mg/kg IV

post intubation sedation
central venous catheter placement
monitor UO aim 30ml/kg/hr
Q1h VBG - lactate, glucose
consider hydrocortisone 2mg/kg IV in fluid and vasopressor resistant shock

EARLY INVOLVEMENT PAEDIATRICS/ICU/RETRIEVAL SERVICES

Consider ECMO

Departmental paediatric sepsis protocols and algorithms

Question 15

Paediatric Button Battery Ingestion

2023.2 teaching station

Teach a junior doctor on the assessment and management of a child with a suspected ingested foreign body.

If battery passed into stomach.
consideration of endoscopic assessment and removal in:

patients <5 year old OR
the battery is > 2cm in diameter

Answer 15

Life threatening situation
If not detected and managed early has significant mortality and morbidity.

If a parent thinks the child swallowed a coin – assume button battery ingestion until proven otherwise.

More damage with 3V lithium batteries >2cm

Impactions in the proximal and mid oesophagus are most dangerous.

CHEMICAL BURN:
Caustic chemical reaction – this leads to an alkaline burn and liquefactive necrosis through the oesophagus, trachea, and major blood vessels
- tracheoesophageal fistula
- aortoesophageal fistula

TIME is oesophagus:
*Necrosis starts within 15min of ingestion
*The risk of perforation increases dramatically after 12 hours
*Need to have button battery removed within 2hrs to avoid serious injury

PRESENTATION:
Often vague and nonspecific
hx of coaching event
witnessed ingestion
- if parent says that child swallowed a coin is a button battery until proven otherwise

• cough
• chest pain
• wheeze
• vomiting
• hematemesis
• poor feeding/food refusal
• fever

Xray neck and chest (AP and Lateral)
- halo sign seen on AP
- step off sign seen on Lateral

MANAGEMENT:

neutralising agent - sucralfate or honey

can only give this within 12hrs of ingestion as risk of perforation increases after 12hrs

reducing pH and coating the battery to delay alkaline burns to tissue

Honey dose: 2 teaspoons (10 ml) of honey every 10 minutes up to 6 doses

OR

Dosing sucralfate: 1g (10 ml) every 10 minutes up to 3 doses

Needs endoscopic removal

Question 16

Neonatal Resuscitation

2021.1 teaching station

1) Good tone and breathing:
- dry baby and cover head
- place skin to skin on mum
- delayed cord clamping
- continue to monitor

2) HR > 100 but gasping:
- support airway

Answer 16

Baby is born

Assessment:
Term?
Tone?
Breathing or crying?

START TIMER

PREVENT HYPOTHERMIA
>32wks:
- dry with warm towels, cover head
<32wks:
- place wet in plastic bag up to neck
place under radiant heat (ideally in neonatal resuscitare)

STIMULATE:
- rubbing vigorously or flicking feet

POSITIONING:
- roll under shoulders
- tragus in line with sternal notch
- face parallel with the ceiling
- Chin lift + jaw thrust + OPA or NPA

SUCTIONING - is not routine

ATTACH MONITORING:
- pulse oximetry & 3 lead ecg
- count the HR (auscultate the chest)

HEART RATE ASSESSMENT:

HR <100 –> start PPV

POSITIVE PRESSURE VENTILATION:
- lungs are filled with amniotic fluid
T-piece, neopuff, BVM

Avoid over ventilation (barotrauma)
Neonatal TV only 20-30mL
- ventilate enough to see chest rise and fall

Positive inspiratory pressures of 20-25cm H2O (max 40)

Oxygenate with FiO2 21% i.e. room air
over oxygenation increases mortality

it takes 10min for SaO2 to reach 95%

If HR still <100 after 30sec PPV –>
MR SOPA

Mask adjustment
Reposition
Suction
OPA
Pressure (increase PEEP 6-8cm H2O, PIP up to 40cm H2O)
Advanced airway

ADVANCED AIRWAY:
LMA is preferred (can’t use this if < 34wks or < 1.5kg)

Intubation with videolaryngoscopy
Miller size 1 for term
Miller size 0 for preterm

ETT size = age/4 + 4
ETT size 4 for term
ETT size 3 for preterm

ETT depth = 6cm + weight

Induction agents “Rule of 2’s_
20mcg/kg atropine
2mcg/kg fentanyl
2mg/kg suxamethonium

CHEST COMPRESSIONS:
HR < 60
- start chest compression 3:1
- 2 hand encircling technique
- 3 compressions to 1 ventilation
- rate 100-120/min

1/3 AP diameter of chest
allow full recoil
maintain rate 100-120/min

Increase FiO2 to 100%

HR check every 60 sec

FLUIDS AND DRUGS:
IV access:
- Umbilical vein cannulation is preferred
- Can place proximal tibia IO if needed (only in neonates >3kg)

ADRENALINE:
HR < despite PPV and chest compressions

adrenaline 1 in 10,000
100mcg/ml

ETT dose = 100mcg/kg = 3ml
IV/UVC/IO = 10mcg/kg = 0.3ml

0.9% NS 10ml/kg IV

O negative blood 10ml/kg IV

10% gluclose 2ml/kg IV target BSL 4-10mmol/L

Question 17

Crashing Neonate

2016 Station

Differential Diagnosis:

*Sepsis - UTI, cellulitis, pneumoniae, meningitis

*Congenital cardiac disease

*SVT with heart failure

*Myocarditis with pulmonary oedema

*Congenital adrenal hyperplasia

*Inborn errors of metabolism (hypoglycemia)

*Non accidental injury

*necrotizing enterocolitis

Answer 17

Neonates (<28 days corrected age)

Organisms:

• Group B strep agalactiae
• E. coli
• N. meningitidis (immunised at 12 months)
• H. influenza Type B (immunised at 6wks)
• Step pneumoniae (immunised at 6wks)
• Listeria monocytogenes

Antibiotics:
Neonates with suspected meningitis

Cefotaxime 50mg/kg IV Q8h

PLUS
Benzylpenicillin 60mg/kg IV Q8h

PLUS
Acyclovir 20mg/kg IV Q8h (if HSV meningitis suspected)

PLUS
Vancomycin 25mg/kg IV

Add vancomycin for S. pneumoniae, can be resistant to penicillins and cephalosporins.

MANAGEMENT:

cardiac monitoring and pulse oximetry

High flow oxygen non-rebreather mask, target SaO2 >94%

2x IV access or early IO in tibia

Check BSL - if <2.6 –> give 2ml/kg 10% dextrose targeting BSL 4-10mmol/L

Send bloods for VBG, FBC, UEC, LFT, CRP, coags, blood cultures

ECG

Request portable CXR

IDC placement - monitor UO, send urine for microscopy and culture

Broad spectrum antibiotics:
- cefotaxime 50mg/kg
- Benzylpenicillin 60mg/kg
- Aciclovir 20mg/kg
- Vancomycin 25mg/kg

Fluid resuscitate with 20ml/kg 0.9% NS - repeat boluses will be guided by POCUS assessment of IVC and LV

If tissue perfusion inadequate despite 60ml/kg IV crystalloids will commence adrenaline infusion at 0.05mcg/kg/min targeting MAP 70

Place arterial line

Referral to neonatal ICU

Will need intubation prior to transfer
ETT size 3
Miller size 1
Pre-medication atropine 20mcg/kg IV
Induction with fentanyl 2mcg/kg IV
Paralytic with suxamethonium 2mg/kg IV

Question 18

Neonatal Resuscitation

2021.1 Teaching Station

Provide a practical teaching session about neonatal resuscitation to an advanced trainee.

Question 19

Tet Spells

EM Rapid bombs - ep 134

Tetrallogy of Fallot
Pulmonary atresia

2-6months

Most episodes are self-limiting

Precipitated by stress, pain, prolonged crying

Answer 19

Imbalance between the pulmonary and systemic vascular resistance

Pulmonary vascular resistance > systemic vascular resistance

Hypoxia and acidosis cause pulmonary arterial vasoconstriction, thus increasing pulmonary resistance and exacerbating right to left shunting.

The management goals are to:

• increase pulmonary blood flow by increasing preload
• promote pulmonary vasodilation (treat hypoxia and acidosis)
• increase afterload and peripheral vascular resistance

MANAGEMENT:
- calm child, place in parents arms, minimal handling
- 100% oxygen 15L NRBM
- knees to chest (increase systemic resistance)
- analgesia (morphine 0.1mg/kg IV or fentanyl 1.5mcg/kg IN)
- fluid bolus 10ml/kg IV
- sodium bicarbonate 2ml/kg IV bolus (treat acidosis and promote pulmonary vasodilation)

third line interventions:
- sodium bicarbonate 2ml/kg IV bolus to treat acidosis and promote pulmonary vasodilation

• phenylephrine 5-20mcg/kg IV Q2min to increase peripheral vascular resistance

fourth line interventions:
- Ketamine 0.5-1mg/kg iv - sedative effects and increases systemic vascular resistance

Refractory tet spells may require RSI and intubation

Question 20

Paediatric Physical Abuse

2021.1 Communication station

Interact with a parent whose child has been treated in the ED for a superficial burn resulting in a notification to child services.

• meet with the parent and explain the concerns raised by the staff
• explain that a social work referral has been made and that a notification has been submitted
  to child services.

Medical conditions mimicking as abuse:
- HSP
- ITP
- haemophilia
- leukemia
- osteogenesis imperfecta (fractures)
- ricketts (fractures)

Answer 20

History:

Assessment of the childs developmental milestones - “what can they do”

vague explanation for how injury occured

recount of events constantly changing

explanation is inconsistent with the child’s developmental capabilities

different witnesses provide different explanations

delay in seeking treatment without reasonable explanation

Examination:

BRUISES:

• pre-mobile infants
• too many bruises
• patterned bruises (hand marks, belt marks, ligature marks)
• bruises in protected areas TEN4FACES

T - torso
E - ears
N - neck
4 - any bruise in infant <4months
F - frenulum
A - angle of jaw
C - cheek
E - eyelids
S - subconjunctival haemorrhage

BREAKS: ‘fractures’
- fracture in non-ambulant child
- femur fracture <18months
- humerus fracture <18months
- multiple fractures or unexpected healing fractures
- metaphyseal fractures ‘bucket handle fractures’
- rib fractures
- complex or bilateral skull fractures

BONKS ‘head injury’
- skull fractures

BURNS
- cigarette burns
- immersion scald burns

BITE MARKS

BABY BLUES:
- anxious

Screening for occult injuries: The workup in suspected pediatric physical abuse:

0-12 months:
- CT or admit for MRI
- skeletal survey
- trauma bloods

12-24 months:
- skeletal survey
- trauma bloods

Question 21

Paediatric Rash

2021.2 RMO interaction

Advise a resident on the assessment and management of a 16 year old patient with a rash, that they were about to see.

Staphylococcal scolded skin syndrome
Scarlett fever

Answer 21

DIFFERENTIAL DIAGNOSIS:
- Measles
- Erythema multiforme
- Toxic epidermal necrolysis
- Steven Johnson syndrome
- Hypersensitivity reaction (anaphylaxis, urticaria)
- Morbiliform drug reaction
- Viral xanthem (rash due to a long list of viral infections)

HISTORY

Prodrome - symptoms before rash development

Where did the rash appear first?

Associated symptoms:
- fever
- cough & coryza
- conjunctivitis
- nausea & vomiting

Vaccination status - particularly MMR

Overseas travel - dengue fever

Exposures
- insect bites
- other people with same rash

Allergies - anaphylaxis, urticaria

Medications - systemic or topical

EXAMINATION:

Completely undress
Examine with good lighting

Vital signs - fever, haemodynamic instability

Morphology:
*colour - red, purple, white
*macules or papules (flat or raised or both)
*shape - circular target lesions
*blisters, vesicles, bullae
*painful or tender
*pruritic - evident scratch marks
*blanching or non-blanching
*sloughing or peeling

Nikolsky sign is slippage of the epidermis from the dermis when slight rubbing pressure is applied

Distribution:
- localised or widespread
- mucous membrane involvement
- soles and palms

Question 22

Erythema Multiforme

• abrupt onset rash preceeded by tingling and burning
• target lesions
  (A red-appearing outer ring with pale centres)
• Affects palms and soles but not mucous membrane
• affects males >3yrs

Cause:
Infection - HSV, mycoplasma pneumoniae
Drugs:
NSAIDS - diclofenac, ibuprogen
Antibiotics - sulphonamides & penicillins
Anticonvulsants - lamotrigine, carbamazepine

Infection:
- mycoplasma pneumoniae
- HSV

Management is supportive

Answer 22

Toxic Epidermal Necrolysis (TEN)

CLINICAL FEATURES:

Occurs in all age groups

No predilection for sex (males = females)

1-2week prodromal illness (cough, coryza, fever, headache, malaise)

Tender erythema - very painful

Mucous membrane involvement - GI, GU, respiratory involvement
(painful eyes, swallowing, dysuria)

Desquamation/sloughing of skin

Blister & bullous formation

Nikolsky positive

> 30% total body surface area affected

CAUSE: medications
NSAIDS - diclofenac, ibuprofen
Antibiotics - sulphonamides & penicillins
Anticonvulsants - lamotrigine, carbamazepine
Allopurinol

COMPLICATIONS:
30% mortality

Similar to burns:
- massive fluid losses
- electrolyte derrangements
- hypothermia
- secondary bacterial infections with S. aureus & pseudomonas

Ocular:
- Purulent conjunctivitis
- Corneal ulcers
- Anterior uveitis

Sloughing of GI, GU and respiratory tract mucosa
- respiratory failure
- oral lesions, dysphagia, diarrhoea, malabsorption, malena
- dysuria

INVESTIGATION:
- skin biopsy

MANAGEMENT:
ICU or burns unit
secure airway - sloughing of respiratory tract
fluid resuscitation
electrolyte correction
sterile dressings
antibiotics if secondary infection

Question 23

Gastroenteritis

2023.1 Communication station

discuss with a parent, the options for paediatric rehydration.

Calculating Maintenance Fluid:
4:2:1 rule

4ml/kg for first 10kg
2ml/kg for second 10kg
1ml/kg for remaining

Answer 23

DIFFERENTIAL DIAGNOSIS:
- appendicitis
- UTI
- pneumoniae
- Myocarditis
- Inflammatory bowel disease
- travellers diarrhoea
- Intracranial pathology (brain tumour) with vomiting

HISTORY:

Diarrhoea:
- how often
- any blood or malena
- what is the usual bowel habit
chronic diarrhoea - do they have inflammatory bowel disease

Vomitting:
- how often
- bilious
- haematemesis

Dehydration:
- less urine
- concentrated, strong smell

• viral symptoms - cough, coryza
• sick contacts
• day care
• overseas travel
• tank water
• drinking unpasturised milk
• exposures to animals

EXAMINATION:
Weight loss
Lethargy & malaise
Tachypnoea & tachycardia & hypotension
Shocked state
Dry mucous membranes - dry
Absent tears
Eyes and fontanelle - sunken
Poor skin tugor
Slow capillary return
Extremities - coled, pale, mottled
POCUS assessment of IVC and LV

INVESTIGATIONS:
Urinalysis
BSL to check for hypoglycemia
Ketones - DKA

Bloods if you suspect Haemolytic Uraemic Syndrome

Bloods - if needing IV rehydration - need to check baseline electrolytes particularly Na+

Stool cultures:
- travel to endemic countries
- more than 10 lose stools per day
- blood and mucus (need to rule out infection in order to do work up for inflammatory bowel disease)

REHYDRATION:
record weight
stop formular feeds
continue breast feeding
small amounts frequently
fluid balance chart (ins and outs)

Oral rehydration:
- reduced risk of complications
less electrolyte derrangements
less cerebral oedema
no phlebitis and cellulitis associated with IV lines

Aim for 10 mL/kg/hr of electrolyte drinks such as hydrolyte or paedialyte

Can try diluted apple juice in 1:1 ratio with water but is not appropriate for prolonged use as does not contain any electrolytes

NG rehydration:
- if NG tube is not tolerated –> IV rehydration

IV rehydration:

ONDANSETRON:
- to aid rehydration

2mg for 8-15kg
4mg for 15-30kg
6mg >30kg

Don’t give to kids with prolonged QTc or congenital heart disease

Other antiemetics are not given due to side effects - extrapyramidal side effects, akithesia, dystonic reactions, oculogyric crisis

Do not give a prescription for ondansetron to take home
- one dose should be effective
- if ongoing vomiting you will need to be re-assessed

Anti-diarrhoea medications are not recommended

Probiotics don’t improve symptoms

Antibiotics can cause a serious condition called haemolytic uraemic syndrome if they are infected with E. coli. This can lead to renal failure requiring dialysis.

Haemolytic uraemic syndrome
E. Coli 0157:H7
classic triad
-acute kidney injury
-microangiopathic haemolytic anaemia
-thrombocytopenia

Indications for antibiotics:
- Suspect C. diff
- Salmonella Typhoid

DISCHARGE ADVICE:

Do not use anti-diarrhoea medications - cause paralytic ileus

Probiotics don’t improve symptoms but are not harmful

Emphasise the importance of small volumes more frequently - otherwise will vomit

Continue breast feeding
Avoid formula - rehydrated with electrolyte drinks (hydralyte)

Early introduction of food

Return to ED if:
- not tolerating oral fluids
- bloody stool
- fevers
- abdominal pain
- lethargy

Follow up with GP
Given written information
Check patients understanding
Answer any questions that they might have

Question 24

Neonatal Jaundice

2021.2 RMO interaction

Discuss with a junior doctor the assessment and management of a 4 day old male infant, whose parent is concerned about jaundice.

Differential Diagnosis:

Physiological jaundice is the most common cause >50% of cases. Occurs day 2-7)

Breast feeding jaundice:
- poor milk supply, poor latch/tongue tie
- dehydration and reduced excretion of bilirubin (presents first week of life)

Breast milk jaundice - enzyme increase enterohepatic circulation

Infection:
- maternal TORCH infection
- vertical transmission of Hep B
- bacterial sepsis

Haematological:
- ABO incompatibility
- inherited haemolytic disorder (G6PD deficiency, sickle cell disease, spherocytosis)

Trauma:
- instrumental delivery causing cephalohaematoma

Surgical:
- biliary atresia

Endocrine:
- hypothyroidism

Toxicological:
- paracetamol
- drugs that induce haemolysis (cephalexin, NSAIDs)

As bilirubin levels rise, cross blood-brain-barrier and cause bilirubin encephalopathy

chronic hyperbilirubinaemia and neurologic dysfunction can develop into kernicterus which is a permanent neurologcical sequelae marked by:
- choreathetoid cerebral palsy
- deafness
- gaze palsies
- dental enamel dysplasia

Answer 24

RED FLAGS:
*age of onset <24hrs
*fever or unwell
*dark urine pale stools (biliary obstruction)

HISTORY:

Obstetric History:
*Maternal infections during pregnancy - TORCH infections (results from antenatal infectious serology - routinely test for Hep B, HIV, rubella, syphylis)
*Maternal hepatitis B - vertical transmission to neonate
*Mothers blood group, rhesus status and antibody screen
*Previous jaundice baby, need for phototherapy

Birth History:
*Premature birth - risk factor
*Birth trauma/instrumental delivery
*Age of onset of jaundice (<24 always pathological)

*Neonatal screening - congenital disorders - hypothyroidism, in-born errors of metabolism

Feeding:
*Breast fed - feeding well, good latch, making urine, wet nappies

Symptoms of bilirubin encephalopathy:
*altered mentation, lethargy, floppy, weak cry
*poor feeding
* high pitched cry, irritability
*seizures

Symptoms of biliary obstruction:
*Pale stools/dark urine - biliary atresia
*Delayed passage of meconium - Cystic fibrosis

Sepsis:
*Fever, respiratory distress - suggestive of acquired sepsis

Medications:
*drugs that cause haemolysis (cephalexin, NSAIDs)
*Medications that can cause hepatotoxicity (paracetamol)

Family History:
*Inherited RBC membrane defects - spherocytosis
*inherited red cell enzyme deficiencies - G6PD deficiency
*sickle cell disease
*thyroid disorders

EXAMINATION:

skin and sclera

large anterior fontanelle, macroglossia - congenital hypothyroidism

cephalohaematoma

suck - weak?

fever, tachycardia, tachypnoea, hypotension, mottled - acquired infection/sepsis

splenomegaly - sickle cell disease

hepatomegaly - in viral hepatitis

abdominal mass - choledochal cyst (biliary obstruction)

INVESTIGATIONS:

Total serum bilirubin - can plot values on hourly normogram

Measure conjugated and unconjugated levels - can narrow differential diagnoses
>20% conjugated is pathological

Congugated hyperbilirubinaemia suggest biliary atresia or hepatitis

*Blood group and antibodies (mum and infant) - ABO/Rh incompatibility

*direct Coombs test - positive = ABO incompatibility
(checks to see if there are antibodies bound to red blood cells)

*FBC - Anaemia

*Blood film - spherocytes

*LDH, reticulocytes = high in haemolysis

*LFT’s - derranged in hepatitis
*Maternal hepatitis screen

*Septic screen - urine, CSF, CXR, blood cultures, CRP

*G6PD screen (this is not included in the newborn screening tests)

*Thyroid function - hypothyroidism

*US - biliary atresia & choledochal cyst

Question 25

The Limping Child

Differential Diagnosis:

*Septic arthritis

*Transient synovitis - most common 70%
- males > females
- young children
- preceding viral illness
- full ROM
- improves with NSAIDs
- may have joint effusion on USS

SUFE (slippled upper femoral epiphysis)
- overweight adolescent

*Perthes:
avascular necrosis of the femoral head
- males >females
- age 4-10yrs

*Malignancy
- osteosarcoma
- leukemia

*Inflammatory:
- Henoch-Schonleine Purpura
- Rheumatic fever with arthritis
- Inflammatory bowel disease with arthritis

*Haematological:
- Sickle cell anaemia with avascular necrosis/pain crisis
*haemophilia - spontaneous haemarthrosis

*Trauma - occult fracture

*Non-accidental injury

*Referred pain from lower spine or knee

*Testicular pathology (torsion, epididymo-orchitis)

*Groin pathology (abscess, inguinal hernia)

*Appendicitis, psoas abscess

Answer 25

Symptom - location of pain, duration,
Functional - able to weight bare, jump, range of motion
Trauma - to testes, hips, knees, spine, wounds or penetrating injures
Recent infections - viral illnesses, boils or carbuncles
Infective symptoms - fever, dysuria, vomting, diarrhoea, rash
Past history - inguinal hernias, abdominal surgeries

b)
Signs of sepsis

Rashes and lymphadenopathy - purpura in HSP

Other joints involved - Polyarthritis

GAIT

abdominal exam - RIF tenderness, rovsings +ve in appendicitis
psoas sign - fixed flexion in psoas abscess

groin/scrotal/testicular exam

cardiac murmurs to suggest rheumatic fever

look feel move spine, hips and knees, ankles

Question 26

BRUE

2023.1 History station

Take a focused history from a parent of an unwell child and to formulate an appropriate management plan.

Lower risk criteria for subsequent SIDS
*age >60 days
*gestational age ≥32 weeks
*first episode of BRUE
*no CPR required by a trained medical provider
*lasted <1min
*no historical features of concern
-possible NAI
-family history of sudden unexplained death
-toxic exposures
*no concerning examination findings
-bruising

Infants with a high-risk BRUE may still have a benign cause for their symptoms but should be admitted for observation, pulse oximetry (or cardiac telemetry if clinical suspicion of arrhythmia) and paediatric review

Testing:
BSL
ECG (arrythmias, QTc prolongation)
Nasopharyngeal viral swabs and pertussis

COUNSELLING:
- acknowledged highly anxiety provoking and parents often feel that their child has nearly died
- It is common for no specific diagnosis to be made after evaluation and a period of observation
- cause thought to be from exaggerated airway reflexes in the setting of feeding, reflux, or increased upper airway secretions
- no tests required
- period of observation, discharge home with early GP follow up if feel reassured and safe to go home
- may need overnight observation for parental reassurance

Answer 26

CLINICAL FEATURES:
- <1yr of age
- brief <1min unexplained event
*Features:
- cyanosis
- pallor
- absent, decreased or irregular breathing
- change in tone
- altered level of responsiveness
*Not explained by identifiable medical conditions

return to baseline soon after
reassuring history
normal obs and physical exam

Assessment is aimed at trying to identify a medical cause. The differential is broad.

Airway obstruction:
- inhaled foreign body
- laryngospasm

Infection:
- pertussis
- sepsis (pneumoniae, UTI, cellulitis)

Congenital cardiac disease
- arrythmias
- prolonged QTc

Abdominal:
- intussusception
- incarcerated hernia
- testicular torsion

Metabolic:
- hypoglycemia
- hyponatremia
- inborn errors of metabolism

Toxic ingestion

Non-accidental injury

HISTORY:

Description of event:
- choking, gagging
- struggling to breath, apnoea
- colour change
- conscious state (responsiveness)
- tone
- abnormal movements
- abnormal eye movements

Circumstances/environment
- awake or asleep
- relationship of event to feeding
- preceded by vomiting
- position (lying, supine, on side)
- sleeping arrangement (co-sleeping, bedding, objects nearby that could be swallowed, cause choking or suffocation)
- preceding illness

End of event:
- duration of event
- circumstances of cessation (self resolved, repositions, stimulated, mouth to mouth, CPR)

Recovery phase:
- rapid or gradual

Past medical history including previous similar events
Preceding/intercurrent illness
Sick contacts

Family history of sudden death or significant childhood illness

Patient medications, medications or other drugs within the home

Social history – parental supports, psychosocial assessment

Question 27

Kawasaki’s

Autoimmune vasculitis

DDx:
Scarlet fever

Answer 27

Diagnosis:
- fever > 5days PLUS 4 of the following
(can have less than 4 if coronary artery abnormalities on echo)

POLYMORPHOUS RASH

CERVICAL LYMPHADENOPATHY

PALMAR & SOLE ERYTHEMA + OEDEMA
- progress to desquamation

BILATERAL CONJUNCTIVITIS:
- non purulent
- painless
- limic sparing

STRAWBERRY TONGUE:
- red, cracked bleeding lips

Investigations:
ECG - MI
FBC - anaemia, high WCC, high platelets
CRP/ESR - critically high
LFT’s - raised ALT, low albumin

Urinalysis - sterile pyuria

Echo at presentation, 2wks, 6-8wks - coronary artery aneurysms

COMPLICATIONS:
Coronary artery aneurysms –> MI
Myocarditis
Conduction defects
Hepatitis
Arthritis
Urethritis/dysuria

MANAGEMENT:
Echo at presentation, 2wks, 6-8wks
Aspirin 5mg/kg orally daily until normal echo
IV immunoglobulin 2g/kg IV
Limited evidence for corticosteroids

Question 28

Neonatal Sepsis

Major pathogens in infants <2 months of age:

Escherichia coli
Group B Streptococcus
Listeria monocytogenes is uncommon
HSV infection should be considered in differential diagnosis of sepsis
Major pathogens in older children:

Neisseria meningitidis
Streptococcus pneumoniae
Staphylococcus aureus (MSSA or MRSA)
Group A Streptococcus (GAS)

Answer 28

• *Not vaccinated against meningicoccal until 12months
• *Immunised against pneumococcus and H influenzae from 6 weeks

Neonates <2months

• Group B strep agalactiae
• E. coli
• N. meningitidis (immunised at 12 months)
• H. influenza Type B (immunised at 6wks)
• Step pneumoniae (immunised at 6wks)
• Listeria monocytogenes
• Herpes Simplex Virus

Antibiotics:
Neonates with suspected meningitis

Cefotaxime 50mg/kg IV Q8h

PLUS
Benzylpenicillin 90mg/kg IV Q8h

PLUS
Acyclovir 20mg/kg IV Q8h (if HSV meningitis suspected)

Add vancomycin if Gram-positive diplococci on Gram stain or if you suspect S. pneumoniae (sinusitis or otitis media). S. pneumoniae can be resistant to penicillins and cephalosporins.

Question 29

Stridor

12 month old with stridor

Answer 29

CROUP:
- parainfluenza, influenza, RSV, metapneumovirus
- seal like barking cough

INHALED FOREIGN BODY:

• food, peanuts, seeds
• Sudden onset coughing, choking, aphonia

ANAPHYLAXIS
face and tongue swelling, wheeze and urticarial rash

RETROPHARYNGEAL ABSCESS:

• Polymicrobial, Staph aureus, Strep pyogenes, oral anaerobes
• neck stiffness and hyperextension
• muffled hot potato voice
• drooling
• dysphagia

PERITONSILLAR ABSCESS:

• Polymicrobia, oral anaerobes, Strep pyogenes, Staph aureus,
• preceeding pharyngitis
• no cough
• torticolis
• trismus
• can’t lie flat
• drooling
• muffled hot potato voice

BACTERIAL TRACHEITIS

• Staph aureus, Strep pneumoniae, Strep pyogenes, Haemophilus influenzae, Moraxellar catarrhalis
• toxic looking child
• markedly tender trachea
• cough with thick sputum
• raspy voice or normal
• no drooling
• no dysphagia

EPIGLOTTITIS:

• Haemophillus influenza, Strep pneumoniae, Staph aureus
• rare in children due to Hib vaccinations
• no cough
• can’t lie flat
• prefer to sit up right with chin forward
• drooling
• muffled hot potato voice
• dysphagia
• “thumbprint sign”

VOCAL CORD DYSFUNCTION

Question 30

Henoch-Schonlein Purpura

Answer 30

Henoch-Schonleine Purpura
Most common vasculitis of childhood
- deposition of IgA and IgC3 in walls of blood vessels supplying kidneys and GI tract
Majority preceded by URTI (any respiratory pathogen)
Assoicated with some medications and vaccinations
Peak incidence 5-7yrs (adult cases have been reported)
Male = females
Usually self limiting

classic tetrad of

1) Palpable purpura (100% of patients)
- NO thrombocytopenia
- affects buttocks and legs
- non-blanching
- not pruritic

2) Colicky abdominal pain (50%)
- GI bleeding may occur

3) Large-joint arthritis (70-85%)
- symmetrical lower limbs arthralgia/arthritis
- refuse to weight bear

4) renal disease (50%)
- haematuria & proteinuria
- hypertension

Hypertension

Painful non-pitting oedema - usually periorbital

Palpable purpura, petechiae and ecchymoses - symmetrical

Arthralgia/arthritis of large joints lower limbs

Generalised abdominal pain and tenderness
- intussuseption is complication

Haematuria and proteinuria in nephrotic syndrome

b) Differential diagnoses:
Immune thrombocytopaenic purpura
Thrombotic thrombocytopenia purpura
Meningicoccal septicaemia
Leukemia

c)

Urine analysis - presence of haematuria and proteinuria acute nephritic syndrome

Urine protein/creatinine ratio - >250mg/mmol in nephrotic syndrome

Albumin
UEC - assess renal function

FBC

• thrombocytosis present in 65%
• thrombocytopenia uncommon and suggests another cause such as ITP or TTP
• any features suggestive of leukemia

Lipase - rule out pancreatitis

ESR elevated in 75%

ASOT and anti-DNAse B - to rule out post streptococcal glomerulonephritis (post strep GN)

ANA, dsDNA, ANCA, C3 and C4 levels - to rule out other autoimmune causes e.g. SLE

Abdominal US - rule out intussusception

Erect CXR and abdominal xray - to rule out bowel perforation

d)
Intussusseption
Spontaneous bowel perforation
Pancreatitis
Renal failure/nephrotic syndrome/nephritic syndrome
Pulmonary alveolar haemorrhage
Intracranial haemorrhage

Management:
simple analgesia - paracetamol and NSAIDs for arthritis and abdominal pain
can trial corticosteroids - prednisone 1-2mg/kg daily
Avoid NSAIDs with concurrent steroids
monitoring of BP and regular urine analysis check for haematuria and proteinuria

Discuss with a nephrologist:

acute nephritic syndrome - macroscopic haematuria, proteinuria, oedema, hypertension and oliguria

nephrotic syndrome - urinary protein/creatinine ratio >250 mg/mmol, a serum albumin < 25 g/L and the presence of oedema

Renal impairment and hypertension

Question 31

Congenital heart disease

Answer 31

• transposition of the great arteries
• coarctation of the aorta
• truncus arteriosis
• pulmonary atresia
• hypoplastic left heart syndrome
• Deliver 100% oxygen for 5–10 min
• Congenital cyanotic heart disease cannot increase Pao2 to 100 mm Hg.

Question 32

Acute Paediatric Ataxia

Answer 32

POST INFECTIVE CEREBELLAR ATAXIA
5-10days after an illness
- varicella
- mycoplasma
- EBV
may have dysarthria and nystagmus
self limiting - usually full recovery within 21days

Guillan-Barre’/Miller-Fisher Variant:
- associated ophthalmoplegia

TOXINS
- alcohol
- benzodiazepines
- antiepileptics (carbamazepine, phenytoin)
- carbon monoxide

TRAUMA/NAI

CEREBELLAR STROKE - sickle cell disease

INFECTION:
- meningitis/encephalitis

MALIGNANCY:
- posterior fossa tumours

METABOLIC:
- hypoglycemia

MIGRAINE:
- basilar migraine

CONVERSION DISORDERS

NUTRITIONAL DEFICIENCIES:
- vitamin E, thiamine, pyridoxime, B12

Question 33

Neonatal Vomiting

Answer 33

PYLORIC STENOSIS

• occurs in neonates 2weeks to 2 months old.
• projectile vomiting of feeds (non-bilious)
• feeds after vomiting (hungry!)
• upper abdominal distension with peristaltic wave seen
• succussion splash
• palpable 1cm mass just right of the midline ‘olive sign’
• dehydration from vomiting
• hypochloraemic metabolic alkalosis
• US duodenal wall >4mm, pyloric canal length >14mm
• barium meal - elongated pyloric canal and string sign

INVESTIGATIONS:
*VBG - hyponatremic, hypokalemic, hypochloraemic, metabolic alkalosis from vomiting
*US - duodenal wall thickness>4mm, antral wall >14mm
*Barium meal - elongated pylorus with string sign

Admit IV fluids, electrolyte replacement, and Ramsteads pyloroplasty

MALROTATION WITH MIDGUT VOLVULUS:

AXR - ‘double bubble’ sign
CT - whirlpool sign

DUODENAL ATRESIA:
AXR - double bubble sign

NECTROTIZING ENTEROCOLITIS:

• premature birth
• AXR pneumotosis intestinalis (air within the bowel wall)

Jejunoilleal illeus

MECONIUM ILEUS IN CYSTIC FIBROSIS

• salty skin in Caucasian - sweat chloride test
• failure to thrive
• delayed passage of meconium >48yrs
• thick secretions –> GI obstruction
• recurrent lung infections

HIRSCHSPRUNG DISEASE:

• associated down syndrome
• delayed passage of meconium >48hrs
• ribbon like stools
• AXR funnel like transition zone

INTUSSUSEPTION:

• can happen at any age but mainly 6months - 2yrs
• vomiting
• red currant jelly stool
• right sided sausage mass
• target sign on US
• air enema is contraindicated in bowel perforation

ENCARCERATED INGUINAL HERNIA

Question 34

Paediatric Vomiting

Differential Diagnosis:

Answer 34

INTUSSUSEPTION:

• 6 to 18 months
• intermittent severe distress, well between episodes
• drawing up of legs
• pallor
• sausage shaped mass in RLQ
• red currant jelly PR - late sign

Abdo US - mass
ARX - ‘target sign’, ‘dance sign’, ‘meniscus sign’ SBO or perforation

MALROTATION WITH MIDGUT VOLVULUS

• Males > females
• 50% occur by 1yr of age
• sudden onset bilious vomiting

ENCARCERATED INGUINAL HERNIA:
firm, tender, irreducible groin swelling

APPENDICITIS:

• RIF tenderness and rebound tenderness
• Rovsings
• US abdo

GASTROPARESIS

RAISED ICP:
- hydrocephalus
- early morning headache and vomiting
- altered mentation

MALIGNANCY:
- brain tumour

ENDOCRINE:
- DKA
- Congenital adrenal hyperplasia

INFECTION:
- pneumoniae
- UTI
- gastroenteritis

TOXIC INGESTION

NON-ACCIDENTAL INJURY - head trauma with intracranial haemorrhage

INGESTED FOREIGN BODY - button battery

Question 35

Necrotizing Enterocolitis

“Bilious emesis in premature neonate”

EM Board Bombs ep. 221

Need to know how to interpret AXR
- pneumotosis intestinalis

Answer 35

• Mainly affectes Premature neonates
• Can occur in 10% of full term neonates with comorbidities (congenical cardiac disease)
• Typically occurs in the first 2 weeks of life
• Overall mortality is 15% to 30%, with many survivors left with short bowel syndrome and growth retardation.

Clinical featrues:
- poor feeding,
- lethargy,
- abdominal distention,
- bilious vomiting,
- fever,
- apnea,
- abdominal tenderness
- blood in the stool increases the likelihood of necrotizing enterocolitis

IMAGING:
erect AXR
Lateral decubitus AXR
erect CXR

bowel obstruction - dilated loops of bowel, air fluid levels
pneumotosis intestinalis
pneumoperitoneum
riglers sign
portal venous gas

Pneumatosis intestinalis and portal venous gas are both pathognomonic

MANAGEMENT:
NBM
NG tube - decompression
Fluid resuscitation
Broad spectrum antibiotics
- ampicillin (gram positive)
- gentamycin 7mg/kg (gram negative)
- metronidazole (anaerobes)
Urgent surgical review
+/- surgery for bowel resection
Disposition - ICU