Paeds. 1 ~ Short Answer

Question 1.

You are working in a large regional emergency department. You receive a telephone call from a doctor at a small community hospital two hours away by road.

This doctor is a general practitioner with limited emergency experience. He asks for advice regarding an 18 month old boy who presented with fever, pallor and stridor. Despite intramuscular and nebulised steroid the child has severe respiratory distress with stridor.

 

A.) What is your differential diagnosis?

Show Answer

  • Viral croup
  • Epiglottitis
  • Bacterial tracheitis
  • Retropharyngeal abscess
  • Foreign body

(5 marks)

 

B.) How does each of those differ in their presentation?

Show Answer

  • Viral croup
    • Younger child (6m -3 y; peak 1-2 y)
    • Onset 1-3 days
    • Inspiratory and expiratory stridor
    • Barking cough
    • Hoarse voice
  • epiglottitis
    • all ages
    • rapid onset
    • sit erect chin forward
    • does not like to be supine
    • inspiratory stridor
    • drooling
    • muffled voice
    • dysphagia
  • bacterial tracheitis
    • older child by wide age range
    • few days of viral URTI then gets worse over few hours
    • inspiratory and expiratory stridor
    • thick sputum
    • voice usually normal
  • retropharyngeal abscess
    • younger child < 4yrs
    • after URTI or trauma then onset over few days
    • neck stiffness and hyperextension
    • does not like to be supine
    • stridor uncommon
    • muffled voice
    • dysphagia
  • Foreign body aspiration
    • Any age usually < 3 yrs
    • Immediate or delayed presentation
    • Transient or positional cough
    • Voice may change if FB at or above glottis

(10 marks)

 

C.) What would your advice be to the referring doctor?

Show Answer

  • Reassurance ? will be arranging retrieval
  • Get local help if possible
    • Local GP anaesthetist
  • Airway management
    • Keep child calm with distraction and comfort
    • Can try Adrenaline nebs (0.5 mg/kg of 1:1000 up to 6mg)
    • Prepare for intubation or support if deteriorates
    • Arrive at a plan depending on GP’s experience (ETT, LMA, BMV only)
  • Antibiotics
    • Emla
    • Can give if not too distressed or obtunded
    • Ceftriaxone 50 mg/kg
  • Keep open line of communication

(8 marks)

 

D.) What arrangements would you make to transfer this child?

Show Answer

  • Retrieval through state-based retrieval system if available
  • Expert team to child
  • Mode of transport
    • Depends on distance, weather and availability
  • Personnel
    • Expert in difficult child airway – will need definitive airway before transfer
      • Anaesthetics
      • PICU
      • Can try to get an ENT surgeon too
    • Nurse expert in retrieval and difficult airway
  • Equipment
    • For intubation, ventilation, sepsis management
  • Communication systems

(6 marks)

Author: J Haire

Ref: Tintinalli p. 788-91


 

 Question 2.

A 6 week old boy presents with sudden onset of vomiting which started 48 hours ago.

 

A.) List your differential diagnosis

Show Answer

  • Obstructive GIT
    • Pyloric stenosis
    • Malrotation +/- volvulus
    • Incarcerated hernia
    • Hirshprungs disease
    • Imperforate anus
    • Enteric duplications
    • Oesophageal/Intestinal stenosis/atresia
  • Infective
    • Gastroenteritis
    • Viral infection
    • Meningitis
    • Sepsis
  • Renal
    • UTI
    • Obstructive uropathy
    • Renal insufficiency
  • Neuro
    • ICH
    • SOL
    • Hydrocephalus
    • Cerebral oedema
    • Kernicterus
  • Metabolic/endocrine
    • Inborn errors of metabolism
    • Congenital adrenal hyperplasia
  • Other
    • Necrotising enterocolitis
    • Reflux
    • Ileus
    • Milk allergy
    • GI perforation

(8 marks)

 

His parents describe projectile non-bilious vomiting just after a feed. He dehydrated but alert and active, has normal vital signs and appears hungry.

 

B.) What is the most likely diagnosis?

Show Answer

  • Pyloric stenosis

(1 mark)

 

C.) What findings on examination would favour this diagnosis?

Show Answer

  • Gastric waves going from left to right
  • Firm olive-shaped mass under liver edge

(2 marks)

 

D.) What investigation would you ask for to confirm the diagnosis?

Show Answer

  • Ultrasound

(1 mark)

 

E.) You obtain a VBG. What does it show?

Paedia Pix 1 SA

Show Answer

  • Metabolic alkalosis
  • Partial respiratory compensation
  • Normal Na
  • Hypokalaemia
  • Hypochloraemia
  • Hypocalcaemia
  • Slightly raised glucose
  • Slightly raised lactate

(4 marks)

 

F.) Investigations confirm your suspected diagnosis. What is your management now?

Show Answer

  • Referral paediatric surgery
  • Fluids
    • 10-20 ml/kg NSaline fluid bolus if moderate-severe dehydration
    • Give deficit + maintenance to replace over 48 hours of ½ NSaline + 5% Dextrose
    • Add 10 mmol KCl to each 500 ml bag
    • Review fluid balance and VBG every 4-6 hours adjust fluids as needed
    • Aim for correction in 48 hours
    • Metabolic alkalosis needs to be corrected before OT
  • Stop oral feeds

(5 marks)

 

G.) During the next hour the infant has an apnoeic episode, what is the likely cause?

Show Answer

  • Due to compensation for the metabolic alkalosis

(1 mark)

Author: J Haire

Ref: Tintinalli p. 830, 839; Cameron p 158-9; RCH guidelines


 

 Question 3.

A 3 year old child is brought into the emergency department having ingested “at least 20” of her mother’s iron tablets.

 

A.) What are the classic stages of severe iron poisoning?

Show Answer

  • 0-6 hrs
    • Direct corrosive effect on GIT
    • Vomiting, diarrhoea , abdo pain
    • Can have large fluid losses
  • 6-12 hours
    • Progressive increase in Fe absorption and distribution
    • Some resolution of symptoms
  • 12-48 hours
    • Disruption of cellular metabolism
    • Vasodilatation and 3rd space loss ? shock
    • AGMA
    • Hepatorenal failure
  • 2-5 days
    • Acute liver failure ? jaundice, coma, hypoglycaemia, coagulopathy, elevated aminotransferases
    • High mortality
  • 2-6 weeks
    • Delayed effects
      • Cirrhotic liver disease
      • GIT fibrosis/strictures

(10 marks; not all detail; idea of time frames and main characteristics of stages)

 

B.) What investigations would you perform to confirm Fe ingestion/toxicity?

Show Answer

  • Serum Fe concentration at 4-6 hour
    • Peak levels > 90 mcmol/L predict toxicity
  • VBG
    • AGMA for toxicity
  • AXR
    • Confirm ingestion
    • Monitor decontamination

(6 marks)

 

C.) You confirm ingestion and the child starts to show signs of toxicity. What is your management?

Show Answer

  • Resuscitation + supportive care
    • Fluids
      • Bolus if needed
      • Ongoing replacement and careful fluid balance
    • Decontamination
      • Whole bowel irrigation via NGT
      • Consider endoscopic removal if WBI fails or not able to be done
    • Enhanced elimination
      • None
    • Antidotes
      • Desferrioxamine chelation therapy if severe systemic toxicity present or predicted by serum Fe level > 90 mcmol/L)
    • Consultation
      • Toxicologist
    • Disposition
      • PICU

(6 marks)

 

 D.) What else needs to be investigated?

Show Answer

  • Possibility of NAI
  • Unusual for 3 year old to ingest such a large number of tablets.

(2 marks)

Author: J Haire

Ref: Tox handbook p. 251-3


 

Question 4.

Concerned parents present with their 5 day old baby with jaundice.

 

A.) What is the differential diagnosis for jaundice in this baby?

Show Answer

  • “Too High” jaundice (24 hrs – 10 days
    • Mild dehydration/insufficient milk supply (breastfeeding jaundice)
    • Breast milk jaundice
    • Haemolysis
    • Breakdown of extravasated blood e.g. cephalohaematoma
    • Polycythaemia
    • Infection
    • Increases enterohepatic circulation e.g. bowel obstruction
  • All
    • Hypothyroidism
    • Haemolysis
    • Hepatitis
    • Biliary atresia

OR

  • Unconjugated hyperbilirubinemia
    • Physiological
    • Breast milk jaundice
    • Breastfeeding jaundice
    • Sepsis
    • Haemolysis
      • Rhuses incompatibility
      • ABO incompatibility
    • Excessive RBC breakdown
      • Cephalohaematoma
      • Polycythaemia
    • Git obstruction/ileus
    • Prematurity
    • Hypothyroidism
  • Conjugated hyperbilirubinemia
    • Biliary atresia
    • Choledochal cyst
    • Neonatal hepatitis (congenital infection, ?1AT, idiopathic)
    • Metabolic abnormalities (galactosaemia, fructose intolerance)
    • Complication of TPN

(8 marks)

 

B.) List 6 important aspects of history that need to assessed in regards to jaundice in the neonate?

Show Answer

  • Other symptoms indicating infant unwell e.g. lethargy, poor feeding, vomiting, fevers
  • Weight gain
  • Feeding Hx
  • Urinating history (output, indicating dehydration)
  • Onset of jaundice i.e. < 48 hours or > 3 days
  • Antenatal and birth Hx (prematurity, birth trauma, maternal infections, anti-D)
  • Maternal Hx (blood group, viral serology)
  • Family Hx of haemolytic disease
  • Dark urine or pale stools (biliary obstruction)

(6 marks)

 

C.) List 4 features of examination important in you assessment of this baby?

Show Answer

  • Vitals including temp
  • Vigorous/lethargic
  • Degree of dehydration
  • Level of jaundice
  • Plethora
  • Hepatosplenomegaly

(4 marks)

 

D.) What is your initial investigation and how will this help?

Show Answer

  • Total and split bilirubin
  • Confirms hyperbilirubinemia i.e. > 200-250 mcmol/L in this age range
  • Conjugated hyperbilirubinemia if > 15% of total bilirubin

(2 marks)

 

 E.) The investigation confirms an unconjugated hyperbilirubinemia. What further investigations will you perform?

Show Answer

  • If evidence that baby unwell or febrile
    • Septic screen
      • VBG & BSL
      • FBC, CRP, BC, U&Es, LFTs,
      • LP
    • If not unwell
      • FBC, film and reticulocyte count
      • Group and Coombs
      • Consider
        • TFTs
        • Urine MCS
        • Reducing substances
        • G6PD

(5 marks)

 

F.) You decide this is physiological jaundice. What treatment options are available and how are they decided?

Show Answer

  • Decided on basis of tables of bilirubin levels and degree of risk of baby (if born at term or premature and other risk factors)
  • Phototherapy
  • Exchange transfusion

(3 marks)

Author: J Haire

Ref: Tintinalli p. 742-744 & RCH/NETS guidelines


 

Question 5.

A 2½ year old girl presented with a history of injuring her feet on hot bitumen. Her feet have been cleaned.

Paedia Pix 2 SA

A.) Describe the injury

Show Answer

  • 2-3 %
  • Superficial and partial thickness superficial (superficial dermal)
  • Special area

(3 marks)

 

B.) How would you address analgesia in this child?

Show Answer

  • PO paracetamol +/- codeine
  • IN fentanyl 1.5 mcg/kg
  • If very painful consider IV opiates
  • NO may help dressings

(3 marks)

 

C.) What is your management of the injury?

Show Answer

  • First aid
    • 20 min cool running water
    • Keep child warm
    • Cling wrap if will need ongoing assessment
  • Consult with burns unit as special area and will need follow-up
  • ADT if needed
  • Blisters
    • Discuss with local burns team and evidence limited
    • Likely will need de-roofing as large and over foot
    • If so will need sedation
  • Dressings
    • Also discuss with burns unit
    • Likely low-adherent dressing e.g. Mepitel or Melolin

(7 marks)

 

 D.) What else needs to be considered?

Show Answer

  • NAI possibility

(1 mark)

Author: J Haire

Ref: RCH & Victorian burns management guidelines


 

Question 6.

This 4 year old child presents to your emergency department after a fall at home.

Paedia Pix 3 SA

A.) Describe the injury

Show Answer

  • Deep laceration too upper lip
  • Involves vermillion border and orbicularis oris

(2 marks)

 

B.) What are the logistical options for closing this wound?

Show Answer

  • GA and closure by plastics in OT
  • Ketamine sedation in ED and closure by plastics
  • Ketamine sedation in ED and closure by plastics

(3 marks; 3 viable options)

 

C.) What is the best option and why?

Show Answer

  • Plastics under GA in OT
  • Will need deep sedation
  • Will take some time
  • Need good surgical conditions and expertise to get good cosmetic outcome

(3 marks)

 

D.) Describe how you would close this wound in ED?

Show Answer

  • Ketamine sedation
  • Layered closure
  • Small i.e. 6/0 sutures to minimise scarring
  • Careful attention to aligning the vermillion border

(4 marks)

Author: J Haire

 


 

 Question 7.

A two month old baby girl has been intubated for respiratory distress and drowsiness. The PaO2 is 82% post intubation.

Paedia Pix 4 SA

A.) Describe the abnormalities in the x-ray

Show Answer

  • Opacity entire left lung
  • Collapse upper and lower lobes left lung
  • ETT in R main bronchus
  • R lung inflated normally

(2 marks)

 

B.) What steps would you take to improve the oxygenation?

Show Answer

  • Remove from ventilator and use BMV or T-piece
  • FIO2 100%
  • Note cm at lips of ETT
  • Listen to air entry over left side and feel how hard it is to ventilate (baseline)
  • Pull ETT back in 0.5 cm increments and then feel for improvement in ventilation, listen over left side for improvement in air entry and watch for improved O2 sats
  • Once improvement established note cm at lips of ETT
  • Secure ETT well
  • Place back on ventilator
  • Get repeat CXR
  • If not improvement then look for another cause of low O2 sats

(4 marks)

Author: J Haire

 


 

Question 8.

A previously well 3 year old boy is brought to the emergency department by his parents following a fall from play equipment at home. He has injured her left leg. An X-ray has been taken.

Paedia Pix 5 SA

A.) Describe the abnormalities on the x-ray

Show Answer

  • Mid-shaft spiral fracture of femur
  • Complete separation 1-2 cm
  • Rotated
  • closed

(4 marks)

 

B.) Describe your management

Show Answer

  • Resuscitation
    • Potential for major haemorrhage
    • IV access x 2
    • Manage circulatory compromise with fluids and blood
  • Definitive
    • Splint
    • Will likely need traction – Thomas splint
    • Likely will need sedation for application
  • Supportive
    • Analgesia
    • Maintain normothermia
    • Calm environment
    • Distraction
    • Parental involvement and reassurance
  • Monitoring
    • Neurovascular for compartment syndrome

(8 marks)

 

C.) What are your options for analgesia?

Show Answer

  • Background PO paracetamol +/- codeine
  • IN fentanyl 1.5 mcg/kg
  • IV opiates (morphine 0.1 mg/kg)
  • Femoral N block

(3 marks)

 

 D.) What other consideration is there?

Show Answer

  • Investigation for NAI

(1 mark)

 

E.) What is the disposition for this child?

Show Answer

  • OT for traction/ORIF and/or
  • Admit orthopaedics with paeds involvement re NAI +/- paeds surgery as trauma

(2 marks; reasonable answer)

Author: J Haire

 


 

 

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