paeds ILA

Question 1

what is a septic screen?

Answer 1

• blood culture - septicaemia (other bloods to consider = FBC, U&E, CRP, blood gas, coagulation profile, acute phase reactants ESR and CRP)
• urine culture
• stool swab
• CSF - LP unless contraindicated
• chest XR if indicated

Question 2

why is a septic screen performed?

Answer 2

To identify the cause of infection – because in children often the come in with a temperature with no focus

Question 3

how would bacterial meningitis show in the CSF?/

Answer 3

• cloudy and turbid
• opening pressure would be elevated
• WBC elevated >100cell/uL
• low glucose level (<40% of serum glucose level)
• protein level will be elevated

Question 4

what are the common causes of meningitis in newborns and in older children?

Answer 4

newborns: listeria monocytogenes, E.coli, Group B streptococci

Older children: Neisseria meningitides, haemophilia influenza type B

Question 5

how would viral (aseptic meningitis present in the CSF?

Answer 5

• appearance - clear
• opening pressure - normal or elevated
• WCC - elevated (primarily lymphocytes)
  glucose level - normal
  protein level - elevated (>50mg/dl)

Question 6

if there was predominantly polymorphonuclear leukocytes/neutrophils in the CSF what would it suggest?

Answer 6

bacterial meningitis

Question 7

if it was predominantly lymphocytes in the CSF what would it suggest?

Answer 7

viral meningitis

Question 8

if there was a HSV meningitis what would you see that was different to CSF in other viral meningitis?

Answer 8

the glucose may be low where as usually it is normal

Question 9

what are the causes of viral meningitis?

Answer 9

herpes simplex virus 
enterovirus 
varicella zoster virus 
mumps
HIV
adenovirus

Question 10

what would you see in CSF of someone with fungal meningitis?

Answer 10

appearance - cloudy or clear 
opening pressure elevates 
WBC elevated 10-500 cells/uL
glucose low
protein elevated

Question 11

what are the causes of fungal meningitis?

Answer 11

cryptococcus neoformans

candida

Question 12

hoe would TB meningitis show on CSF?

Answer 12

appearance - opaque, if left to settle it forms a fibrin web
opening pressure elevated
WBC - elevated - early PMNs and then mononuclears
glucose level - low
protein level - elevated

Question 13

The microbiologist rings to confirm a CSF white cell count of 500 with no red cells. The cells are predominantly neutrophils. CSF glucose is low and CSF protein raised. Gram film shows gram negative diplococci.
Later, Jon becomes hypotensive with a delayed capillary refill time, and develops tachycardia and a purpuric rash.
diagnosis?

Answer 13

meningococcal septicaemia with meningitis

Question 14

what is the immediate management of meningococcal septicaemia with meningitis?

Answer 14

ABCDE approach 
A - airway 
B - breathing 
C - circulation, IV access, bloods, fluid bolus, antibiotics
D - disability - AVPU
E - environment - temp and glucose

Question 15

if a child presents with meningococcal septicaemia shock what fluids would you prescribe?

Answer 15

20mls/kg 0.9% sodium chloride fluid bolus over 10 mins

if no improvement then repeat but this can lead to pulmonary oedema

Question 16

what fluid bolus would you give in trauma or DKA?

Answer 16

10ml/kg 0.9% sodium chloride over 10 minutes

Question 17

what antibiotics should be given for meningococcal septicaemia?

Answer 17

third gen cephalosporin e.g. IV ceftriaxone
it is able to cross the blood brain barrier and it is a broad spectrum antibiotic with activity again gram positive and negatives to cover most likely organisms

if under 3 months give cefotaxime

Question 18

what causes the purpuric rash in meningitis?

Answer 18

they are caused by bleeding underneath the skin
caused by DIC
consumptive coagulopathy
bacteraemia leads to widespread thrombosis in microvassaculature, platelets being used up and clotting factors not being produced by liver which leads to bleeding tendancy

Question 19

what measures should be taken to stabilise and manage a patient with meningococcal septicaemia?

Answer 19

airway and breathing management - intubation and ventilation
circulation - fluid bolus/fluid management
vasoactive agents - vasosupressors and inotropic agents

Question 20

how would meningitis be spread?

Answer 20

exchange of respiratory secretions

Question 21

what is the first line treated that is recommended to reduce the risk of meningitis in those who have been in close contact with someone who has had it?

Answer 21

prophylactic treatment with rifampicin or ciprofloxacin to eradicate nasopharyngeal carriage - for meningococcal
flu vaccination for those with Hib infection

Question 22

what is classified as close contact when conisdering prophylaxis for meningitis?

Answer 22

those who have prolonged close contact with the case in a household type setting during seven days before the onset of the illness
e.g. living/sleeping in same household, pupils in same dorm, boyfriend/girlfirend, uni students sharing kitchen in halls

Question 23

when should rifampicin be avoided?

Answer 23

people with severe liver disease
should try to be avoided in those who are on medication for epilepsy

• it is fine in breast feeding

Question 24

what are the side effects of meningococcal prophylaxis?

Answer 24

Side effects of ciprofloxacin – common – diarrhoea, dizzieness, headache, nausea and vomiting.
Side effects of rifampicin – hepatitis, orange urine and tears, interaction the with contraceptive pill, flu like symptoms.

Question 25

Laura, a two year old, presents to her general practitioner with a two month long history of malaise, pallor and reduced appetite. She has occasional febrile episodes, associated with a pink rash, and with a persistent complaint of soreness in her left thigh. Despite walking at the age of 13 months, she is now reluctant to weight bear. Her birth and development history show no concerns and all her immunisations are up to date. what aspects of clinical examination are important?

Answer 25

full clinical examination - particularly CVS, euro, gastro, skin fundoscopy - to check for uveitis height and body weight

Question 26

Laura, a two year old, presents to her general practitioner with a two month long history of malaise, pallor and reduced appetite. She has occasional febrile episodes, associated with a pink rash, and with a persistent complaint of soreness in her left thigh. Despite walking at the age of 13 months, she is now reluctant to weight bear. Her birth and development history show no concerns and all her immunisations are up to date. low grade fever and generalised cervical lymphadenopathy, walks with a limp but no discomfort - rest of examination pretty much unremarkable. DD?? what further tests would you want to perform?

Answer 26

transient synovitis - very common infection (osteomyelitis, septic arthritis) malignancy (leukaemia, lymphoma, neuroblastoma) connective tissue disorder (SLE, RA) juvenile idiopathic arthritis Bloods Xray/USS of limb echo

Question 27

what is juvenile idiopathic arthritis?

Answer 27

Systemic onset – rash, temp Oligoarthritis (less than 4 joints) JIA more common – more common in girls When you are thinking about if a child has JIA then test for their ANA +ve because in increases their risk of chronic anterior uveitis. there will be raised ESR JIA - rash that comes on with temp and inflammation of the synovium

Question 28

in children with JIA who is common to develop uveitis?

Answer 28

girls under 7 years, especially if under 4 years oligoarticular subtype antinuclear antibody (ANA) positive on blood tests

Question 29

how is JIA managed?

Answer 29

it a chronic childhood disease so needs an MDT NSAIDs for early therapy - pain relief, anti-inflammatory and anti pyretic Longterm - DMARD (disease modifying anti-rheumatic drug - methotrexate 2nd line - TNF alpha inhibitors e.g. infliximab alternatives - intra-articular corticosteroid injections - if only a few joints affected, systemic corticosteroids, cytokine modulators teams involved - paediatric rheumatologist, nurses, physics, OTs, social workers, paediatric opthalmologist, dietician, school lesion workers, GP, child psychology

Question 30

Jirou, a three year old boy presents with a seven day history of high fevers. He has now developed red eyes, a rash and is complaining of a sore mouth and throat. On examination he appears miserable and unwell with a diffuse maculopapular rash mainly on his torso. He has bilateral injected conjunctiva, red cracked lips and a strawberry tongue. He has a unilateral 3cm x 2cm cervical swelling, and swollen reddened palms. DD?

Answer 30

Scarlet fever – group A beta haemolytic strep Measles Toxic shock syndrome caused by staphylococcal toxins Staphylococcal scolded skin syndrome – fluid filled blisters Kawasaki disease

Question 31

what is Kawasaki disease and what criteria are used to diagnose it?

Answer 31

Kawasaki disease- a systemic vasculitis, common in children of a Japanese origin Criteria the presence of a fever for five days plus four of the five criteria constitutes Kawasaki disease MY HEART M- mucosal involvement - dry lips and strawberry tongue H - hands and feat with oedema and desquamation E - eyes - non-perulent conjunctivitis A - adenopathy - unilateral, cervical R - rash usually truncal and pleomorphic T temp non remitting for at least 5 days

Question 32

what is the management of Kawasaki disease? and complications of the treatments?

Answer 32

IV Immunglobulin in the first 10 days and aspirin (to reduce risk of thrombosis) IVIG- anaphylaxis, renal failure, headache, myalgia, N&V Aspirin - reyes, bleeding/bruising, GI upset children with giant coronary aneurysms may require long term warfarin

Question 33

what further investigations would you perform for Kawasaki disease?

Answer 33

echo - to look for coronary artery aneurysm magnetic resonance angiography cardiac catheterisation and angiography

Question 34

what is the long term prognosis of Kawasaki disease?

Answer 34

- usually an acute, self limiting illness, - overall mortality is less than 0.05% - if left untreated it can be associated with significant morbidity and mortality - IVIG immediately improves outcome

Question 35

what is the emergency management of an unwell child with 5% dehydration?

Answer 35

A - intubation if needed B- 100% oxygen C - perfusion, blood sample, HR, BP, fluids Blood investigations

Question 36

what would be suggestive of DKA and so not to give normal fluid bolus?

Answer 36

if the child had been drinking a lot and peeing a lot

Question 37

child is 5% dehydrated with DKA - what fluids do you give them?

Answer 37

only give fluid bolus if necessary - 10mls/kg 0.9% sodium chloride deficit: assume 5% deficit if pH >7.1, assume 10% deficit if pH below 7.1 - give deficit fluids over 48 hours 10% deficit - 100mls/kg 5% deficit 50mls/kg DKA reduced maintenance volume rues <10kg - 2ml/kg/hour 10-40kg - 1mls/kg/hour >40 kg - 40mls/hour *ensure all fluids contain potassium chloride apart from bolus

Question 38

in someone with DKA when should you start insulin

Answer 38

1-2 hours after fluid administration 0.05-1 unit/kg/hour monitor - cap blood glucose, vital signs, fluid balance, level of consciousness

Question 39

some one with DKA, their blood glucose is now <14, how do you manage?

Answer 39

if ketones <3: 0.9% NS, glucose 5%, KCL 20mmmol in 500ml and maintain or reduce insulin 0.05 unit/kg/hour ketones >3: glucose 10%, KCL 20 mol in 500ml and maintain insulin at 0.05-0.1 unit/kg/hour

Question 40

what are the complications of DKA management?

Answer 40

hypoglycaemia, hypokalaemia, hpoxaemia, pulmonary oedema | cerebral oedema is a rare but potentially fatal complication - avoid rapid fluid and electrolyte replacement

Question 41

what are the symptoms of DKA?

Answer 41

increased thirst, polyuria, recent unexplained weight loss or excessive tiredness along side any of the following symptoms - nausea and vomiting - abdominal pain - hyperventilations - dehydration - decreased level of consciousness

Question 42

10 day old neonate with TSH very high? what is the likely diagnosis?

Answer 42

congenital hypothyroidism

Question 43

what are the most likely causes of congenital hypothyroidism?

Answer 43

world wider - iodine deficiency in the uk - dysgenesis thyroid gland defects - a missing or ectopic or poorly developed thyroid gland consanguineous (cousins) (dyshormonogeneis) - a problem with the hormone production line

Question 44

how can you distinguish between dygenesis and dyshormonogenesis causes of congenital hypothyroid?

Answer 44

radioisotope and USS examination

Question 45

what is the screening for congenital hypothyroid and what has this helped prevent?

Answer 45

Guthrie test | prevents cretinism - stunted mental and physical growth

Question 46

what does the Guthrie test screen for?

Answer 46

congenital hypothyroidism sickle cell disease CF inherited metabolic diseases

Question 47

how is congenital hypothyroidism managed?

Answer 47

thyroxine - levothyroxine

Question 48

what are the differentials for an unwell neonate (collapsed and shocked)?

Answer 48

``` sepsis/infection congenital heart defects surgical emergencies inborn errors of metabolism congenital adrenal hyperplasia ```

Question 49

what would you see on investigations for CAH?

Answer 49

``` hyponatremia hyperkalemia hypoglycaemia acidosis elevated hydroxyprogesterone rapid ACTH stimulation test plasma renin-aldosterone ```

Question 50

how would a baby girl with CAH present?

Answer 50

ambiguous genitalia

Question 51

could CAH be managed antenatally? | hoe is CAH managed subsequently?

Answer 51

dexamethasone | glucocorticoid (hyrdrocortisone) and mineralocorticoid (fludrocortison) with sodium chloride supplementation

Question 52

how do males with CAH present?

Answer 52

they usually present with a neonatal salt losing crisis - usually within the 1st 4 weeks of life

Question 53

long term complication of meningitis (always comes up in exams)

Answer 53

SENSORINEURAL DEAFNESS