Paeds. 2 ~ Short Answer

Question 1

A child presents with a fever with no focus of infection found.

 

A.) What is the most likely diagnosis in all of these children?

Show Answer

  • Viral infection

(1 mark)

 

 B.) What other conditions may be the cause?

Show Answer

  • Serious bacterial infection
    • UTI
    • Meningitis
    • Occult bacteraemia

(3 marks)

 

C.) List 6 patient groups that are more likely to have a serious infection

Show Answer

  • Neonates(< 1 month)
  • Incompletely immunised children
  • Immunocompromised
  • Asplenic
  • Patients who have received prior oral antibiotics i.e. partially treated
  • Fever + prolonged convulsion
  • Underlying medical conditions e.g. CF, congenital HD
  • Children with iatrogenic foreign bodies e.g. CVLs, VP shunts

(6 marks)

 

D.) What is the definition of fever in Australia?

Show Answer

  • Temp > 38°C rectal/tympanic; 37.5°C oral; 37.2°C axilla

(1 mark)

 

 

E.) For each of these age groups describe the work-up and management of a child that presents with a fever without focus

a.) < 1 month corrected age (or < 3.5 kg if older)

Show Answer

  • Full sepsis work-up (FBC/film, BC, urine MCS via SPA, LP +/- CXR
  • Admit empirical antibiotics

(2 marks)

 

b.) 1-3 months corrected age

Show Answer

  • Full sepsis work-up
  • Discharge home with review in 12 hours if
    • No risk factors
    • Looks well
    • WCC 5-15, 000
    • Urine micro clear
    • CXR (if done) clear
    • CSF (if done) clear
  • If unwell or something found on Ix then admit observation +/- antibiotics

(4 marks)

 

c.) > 3 months

Show Answer

  • Child looks well
    • Urine
    • Discharge with review within 24 hours or sooner if deteriorates
  • Child looks miserable but alert, interactive and responsive
    • Urine
    • Symptomatic treatment
    • Observation then decide d/c or further work-up
  • Child looks unwell
    • Full sepsis work up
    • Admit for observation +/- antibiotics

(6 marks)

Author: J Haire

Ref: Cameron p.230-233 and RCH guidelines


 

Question 2.

A 3 year old boy presents with 6 days of fever. He has red eyes and a rash.

 

A.) What diagnosis needs to be ruled out?

Show Answer

  • Kawasaki’s Disease

(1 mark)

 

B.) What are the diagnostic criteria for this disease?

Show Answer

  • Fever for at least 5 days AND 4 of the following 5 other features:
  • Bilateral conjunctival injection
  • Enanthem – dry, cracked lips; oropharyngeal erythema; strawberry tongue
  • Exanthema – polymorphous
  • Peripheral changes – erythema (palms and soles), oedema (hands and feet), desquamation (2nd & 3rd week)
  • Cervical adenopathy
  • AND rule out other diseases that may cause the symptoms

(7 marks)

 

 C.) Do all children have to meet the criteria and if not which children need to be considered for this condition?

Show Answer

  • Incomplete Kawasaki’s
  • Lower threshold for infants < 6m
  • Consider in any child with unexplained fever for 5 days and 2 features of Kawaski disease

(3 marks)

 

 D.) What investigations should be performed for this condition?

Show Answer

  • Any needed to rule-out another cause
  • Echocardiography to look for coronary artery changes at 2 weeks, 6 weeks, 12 months
  • Platelet count (marked thrombocytosis in 2nd week)

(3 marks)

 

E.) What are the complications of this disease?

Show Answer

  • Coronary artery disease ? dilatation, aneurysm, thrombosis and occlusion leading to MI, sudden death
  • Myocarditis ? CCF, dysrhythmias
  • Pericarditis

(2 marks)

 

F.) How is the disease treated?

Show Answer

  • 2g of Iv immunoglobulin over 10 hours once in the first 10 days of the disease
  • Aspirin 3-5 mg/kg od for 6-8 weeks (can give high dose 80-100 mg/kg in 3-4 divided doses a day initially but no benefit if giving IVIG)
  • Can repeat IVIG if ongoing fevers
  • Have used pulses of corticosteroids in refractory cases

(2 marks)

Author: J Haire

Ref: Cameron p.112-114; RCH guidelines


 

Question 3.

A mother brings to your emergency department her 4 day old boy with a 24 hour history of poor feeding and rapid breathing. He also had 2 episodes where he appeared to stop breathing for a few seconds.

 

A.) What is your differential diagnosis?

Show Answer

  • Pneumonia
  • Aspiration
  • Bronchiolitis
  • Sepsis (UTI, meningitis, bacteraemia)
  • Abdominal causes (distention, gastroenteritis, volvulus)
  • Congenital heart disease
  • Metabolic acidosis (inherited metabolic disease, ductal-dependant congenital heart disease)
  • Congenital anomalies (cleft palate, laryngeal or tracheomalacia, vascular rings)
  • Delayed presentation of diaphragmatic hernia
  • Neuromuscular disease (botulism, congenital)

(5 marks)

 

B.) What is the definition of an Apparent Life-Threatening Event (ALTE)?

Show Answer

  • Episode frightening to caregiver
  • Involved some combination of apnoea, colour change (cyanosis, pallor, plethora), change in muscle tone (limp or stiff), choking or gaging

(2 marks)

 

C.) What are the common causes of ALTEs?

Show Answer

  • Respiratory tract infection
  • Seizure (febrile)
  • GORD
  • Misinterpretation of benign processes e.g. periodic breathing
  • Vomiting/choking episode

(3 marks)

 

D.) On further examination you find an irritable baby with a RR of 70 bpm, tracheal tug, nasal flaring, chest wall retraction, widespread creps on lung auscultation and O2 Sats of 92%. What is the diagnosis and how severe is it?

Show Answer

  • Bronchiolitis
  • Moderate

(2 marks)

 

E.) What investigations are required?

Show Answer

  • None

(1 mark)

 

F.) What is the management?

Show Answer

  • O2 to maintain sats > 92% in escalating fashion
    • Nasal prongs
    • High-flow nasal prongs
    • NIV – CPAP
    • Ventilation
  • Hydration depending on what can be tolerated
    • Breast/bottle feeds
    • NG feeds
    • IVF
  • Apnoea monitoring
  • PICU if frequent apnoea’s

(4 marks)

Author: J Haire

Ref: Tintinalli p.737; 746-7; 800; RCH guidelines bronchiolitis


 

Question 4.

A 7 year old girl is brought to your emergency department by ambulance following a moderate speed motor vehicle accident.  She complains of a sore neck and tingling in her hands.  She is currently lying on the stretcher crying, distressed and hyperventilating with no cervical immobilisation.  The girl’s uninjured mother has accompanied her in the ambulance.

 

A.) What are the problems here?

Show Answer

  • Distressed girl
  • No cervical immobilisation
  • Symptoms that may indicate significant lesion (or hyperventilation)

(3 marks)

 

B.) What techniques could be used to decrease her distress?

Show Answer

  • Reassurance
  • Talk so she can see you
  • Distraction with TV, IPad etc.
  • Explain situation to mother and employ her help
  • Analgesia
    • Oral paracetamol +/- codeine
    • IN fentanyl
    • NO

(4 marks)

 

C.) What techniques could be used to immobilise her neck?

Show Answer

  • Hard cervical collar
  • Philadelphia collar
  • Sandbags and tape

(3 marks)

 

D.) What else could be done to alleviate this situation?

Show Answer

  • Early assessment to decide if imaging needed
  • If imaging needed then expedite it i.e. ask radiology to do plain films asap and then assess when she is in radiology dept so can move onto CT quickly

(3 marks)

Author: J Haire

 


 

Question 5.

A 14 year old female presents to the emergency department via ambulance with agitation and drowsiness. An arterial blood gas is taken.

 

FIO2 0.21

pH 6.89 (7.35-7.45)

pCO2 72 mmHg (35-45)

pO2 60 mmHg (80-110)

HCO3- 10 mmol/L (23-32)

Base Excess – 20.5 (-2 / +2)

Sodium 136 mmol/L (135-145)

Potassium 4.0 mmol/L (3.5-5.5)

Chloride 90 mmol/L (90-115)

Urea 16 mmol/L (3.5-8.0)

Creatinine 0.14 mmol/L (0.06-0.12)

 

A.) Describe the acid base abnormalities in this blood gas

Show Answer

  • Severe acidosis
  • Metabolic (? HCO3) and respiratory (?pCO2) acidosis
  • Anion gap metabolic acidosis
    • AG = 136 – (90 + 10) = 36
  • Delta ratio = 24/15 = 1.7 = uncomplicated AGMA

(4 marks)

 

B.) Comment on the pO2

Show Answer

  • Low for FIO2 0.21
  • A-A gradient = 60 – (713 x 0.21 – 72/0.8) = 60-60 = 0

(2 marks)

 

C.) Comment on the rest of the blood gas

Show Answer

  • NA normal
  • K normal
  • Chloride decreased (vomiting, diarrhoea, DKA, respiratory depression)
  • Urea and creatinine raised – moderate renal failure

(3 marks)

 

D.) What are the likely causes of these abnormalities?

Show Answer

  • Respiratory acidosis
    • Likely due to depressed LOC
    • DDx respiratory disease (but normal Aa gradient); neuromuscular disease
  • AGMA and depressed LOC likely due to toxin, DKA or sepsis
  • Toxins
    • Toxic alcohols
    • Co, cyanide
    • Toluene
    • Metformin
    • Paracetamol
    • Fe
    • Isoniazid
    • Salicylates
  • Renal failure likely secondary to OD, sepsis or DKA

(4 marks)

 

Author: J Haire


 

Question 6.

A 15 month old girl is brought to your emergency department by her nanny with burns isolated to the area shown in this photograph. The history is that the toddler accidentally pulled a cup of hot coffee from the bench down on herself.

 Paedia 2 Pix 1 SA

 A.) Describe the injury

Show Answer

  • 5% burn
  • Left cheek + ear + neck predominately superficial with couple of small blisters indicating partial thickness – superficial (superficial dermal)
  • Burns over shoulder and lateral proximal arm mid dermal (partial thickness)
  • Over joint and face (special areas)

(4 marks)

 

B.) What is your management of the burn?

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
  • Clean
    • With NSaline and gauze
  • Debridement
    • Remove loose skin and non-viable skin
  • Shave 2 cm around wound edge
  • Dressings
    • Also discuss with burns unit
    • Likely low-adherent dressing e.g. Mepitel or Melolin

(8 marks)

Author: J Haire

Ref: RCH and Victorian burns management guidelines


 

Question 7.

A 7 year old child has had these lesions on his legs for seven days. His 4 year old sister has the same skin eruption.

Paedia 2 Pix 2 SA

A.) Describe the lesions

Show Answer

  • Multiple over posterior aspect of lower legs
  • Erythematous base
  • Crusty margins

(2 marks)

 

B.) What is the diagnosis?

Show Answer

  • Impetigo

(1 mark)

 

C.) What is the treatment?

Show Answer

  • Wash crusts off with NSaline
  • Then apply topical mupirocin 2% ointment q8hr
  • If systemic symptoms/not responding to topical treatment/extensive lesions then use oral antibiotic e.g. Flucloxacillin, cephalexin

(3 marks)

 

D.) What other precautions need to be taken?

Show Answer

  • Treat sibling too
  • Exclude from childcare/school until treatment started and sores completely covered with watertight dressings

(2 marks)

Author: J Haire


 

Question 8.

A 4 year old boy arrives at your urban district emergency department one hour after falling from a playground slide. He opens his eyes to speech, uses inappropriate words and obeys commands (GCS 12).

The nearest neurosurgical service is twenty minutes away by road ambulance.

An image from his head CT scan is shown.

 Paedia 2 Pix 3 SA

A.) Describe the abnormalities on this CT

Show Answer

  • Large elliptical collection of blood left temperoparietal region
  • Heterogeneous appearance – old and new blood
  • Mass effect
    • Midline pushed 1-2 cm to right
    • Effacement of lateral ventricles and sulci
  • Loss of gyri and sulci – raised ICP

(4 marks)

 

B.) What is this?

Show Answer

  • Large extradural haematoma
  • With mass effect

(2 marks)

 

C.) What are the pros and cons of intubating prior to transfer?

Show Answer

  • Pros
    • Will not lose airway en route as likely to deteriorate
    • Controlled environment in ED vs back of ambulance; less chance of catastrophe
    • Can hyperventilate to control ICP
    • Will need to be tubed prior to treatment anyway
  • Cons
    • Will take time – delay transfer
    • Could increase ICP
    • Risk of intubation

(4 marks)

Author: J Haire


 

 

 

 

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