Download - SCHHS Emergency Department

Question 8
Concerned parents present to the ED with their 5-day-old baby. The neonate is
feeding poorly, lethargic and jaundiced.
List 5 further bits of history you would like
List further Examination you would perform
What is your DDx
List 5 further bits of history you would like
- Antenatal history – TORCH, GBS status, fever during and post delivery,
cold sores, HSV, prematurity, term weight, LOS in hospital, resuscitation
at birth
- Feeding history
- Was baby born jaundice or has it just developed (onset after 3 days of age
more likely to be pathological)
- Birth trauma – breakdown of heme
- Maternal history – blood group, viral serology
- Family history of haemolytic disease (ABO, G6PD, spherocytosis)
- Dark urine or pale stools
- Urine output/wet nappies
- Antenatal USS
- Ill contacts
List further Examination you would perform
- General appearance – is the child unwell (sepsis and GIT obstruction can
cause jaundice)
- Vitals
- WOB
- Dehydration or poor weight gain – both exacerbate jaundice
- Syndromic appearance
- Fontanelles
- Signs of dehydration
- Murmurs
- CRT
DDx
-
-
Unconjugated Hyperbilirubinaemia
o Physiological - should resolve within 2 weeks
o Sepsis – Group B strep, TORCH infections, HSV, chlamydia – rarely
presents with jaundice alone
o Excessive, non haemolytic red cell destruction (polycythaemia,
bruising)
o GIT obstruction or ileus (pyloric stenosis)
o Prematurity
o Hypothyroidism
o Haemolysis from blood group incompatibility and red cell defects
Conjugated hyperbilirubinaemia
o Biliary atresia
o Choledochal cyst
o Neonatal hepatitis – congenital infection, alpha-1 antitrypsin
deficiency
o Metabolic – galactosaemia, fructose
o Complications of TPN
6. A 6 year old child with no significant past history presents with diabetic
ketoacidosis.
a) List the biochemical parameters required for the diagnosis of DKA (3 marks)
Metabolic acidosis with pH<7.3 or serum bicarbonate<15 mmol/L
Presence of ketones in blood or urine
Blood glucose>11 mmol/L or known diabetic
b) Outline 2 key steps in your initial management of DKA (5 marks)
Insulin: 50 units of Novorapid in 50mL N/Saline at 0.05-0.1units/kg/hr
IV fluids: Judicious use. N/Saline 10mL/kg bolus up to 20mL/kg if severe
hypoperfusion; then commence infusion of maintenance + correction of deficit over
24h.
c) List 2 electrolyte disturbances that may be anticipated in DKA treatment and
outline the management for each (4 marks)
Consequence
Management
Hypoglycaemia
Add dextrose to N/Saline when BSL
<15mmol
Total body hypokalaemia
Add 40mmol KCl to maintenance fluids
when K <5.0mmol
VAQ 5
An 8 year old boy has been brought to the emergency department with a fever of
38 degrees Celsius and a painful right ear.
a) List your differential diagnoses (3 marks)
Mastoiditis, cellulitis, perichondritis
b) Outline your management (3 marks)
Analgesia
IV antibiotics ENT referral
First time parents bring their distressed and crying six week old boy to the
emergency department. They report that their child has been repeatedly
vomiting all day.
1: List 4 historical features and 4 examination features you would elicit to
assess the severity of his illness
2: Fill in the table below listing a DDX and 2 supportive features each on
history and examination.
3: List investigations you may perform on this child – for each give indications
for testing.
1:
Hx
Behaviour / LOC at home
-consolable vs irritable vs lethargic obtunded
Tolerating feeds?
Number of wet nappies (< 4/ 24 hours indicative of dehydration)
Fevers
Nature of vomiting (small post feed spits vs large volume or bilious)
Antenatal /past hxhx (eg: premature at higher risk of serious disease, known
congenital metabolic / cardiac issue)
Ex:
General appearance (alert / interactive vs irritated vs obtunded)
Abnormal Vitals esp cap refil > 2 sec (expect HR100-160, RR 30-40 )
Wt loss/ failure to gain expected weight.
Fever – Mandates septic work up
Signs of dehydration: Skin turgor, mucous membranes, sunken eyes etc.
(Meningism, bulging fontanelle, petechial rash, tense distended abdomen)
Sepsis
(eg SBI, UTI, meningitis,)
Intestinal obstruction
(Volvulus,
intususseption,
incarcerated hernia
hirschprung’s)
Pyloric Stenosis
Metabolic disorder
(EG: congenital adrenal
hyperplasia, other
congenital metabolic
derangement, DKA)
CNS disorder
(, Tumor , hydrocephalus
Trauma (eg: Concealed
NAI, ICH)
ALOC, Fever, focal
symptoms
Billious vomiting, change
in bowel habit (note wide
normal variation daily 
weekly)
Episodic agitation / red
current stools with
intussuseption
Projectile non bilious
vomits
Hungry and feeds +++
Neonatal screening
FH
Fever, ALOC, focal signs
(meningism, rash, creps,)
Distended tense
abdomen
Signs of sepsis / shoc
with perforated viscous
Abnormal growth charts
(head circumference)
ALOC
Tense fontanelle
Large head
circumference,
Focal neurological ssigns
(pupillary asymmetry,
Social disadvantage
Past hx abuse / neglect
Provided history
inconsistent with
presentation
Retinal haemorrhages
Buises
Poor weight gain
Palpable olive
Visable peristalsis
Wt loss
Tachypnoea with DKA
Shock, ambiguous
genitalia with CAH
GORD
Small volume vomits
after meals only (milk
only not bilious)
Well / consolable
otherwise
Appropriate weight gain
Normal LOC
Normal vital signs
Others: Toxins, envenomation,
Ref:
http://lifeinthefastlane.com/pediatric-perplexity-006/ (Info from rosens)
+ RCH guidelines
An 11YO female with down syndrome is intubated for respiratory following a 3
day illness of rhinhorrhea, fever and cough.
1-List 4 important features of the CXR
2-Give 2 important differential diagnoses.
3-List 10 infectious agents that may cause this presentation
1:
-ETT in position
-Diffuse patchy opacification throughout both lung fields
-Loss of R heart border (? More confluent opacification in RMZ)
-Heart size appears normal.
(No PTX, no boney abnormality)
2: Pneumonia (CAP vs HAP based on history)
APO (eg underlying structural heart disease –more common in DS
decompensation with infective illness
3:
CAP organisms:
-typical
Strep pnemoniae
Staph Aureus
Haemophilus Influenzae
Gram neg bacilli (pseudomonas / klebsiella pneumonia)
Moroxella Caterhallis
Atypical
Legionella
Mycoplasma pneumonia
Chlamidia pnuemoniae
Viral:
Influenza
Parainfluenza
Adenovirus
RSV
Immunosuppressed
TB
PCP
Fungal
Tropical
Mellioidosis (B.Pseudomallei)
2010.1 VAQ 5 Peds
Scenario
A 4 year old boy presents to the emergency department following a choking episode
at home 30 minutes previously.
Q1) Describe the positive and negative findings in this xray ?
CXR showing a round opaque foreign body. The position is in the distal esophagus
because, it has past the carina. It is aligned along the coronal plane. Most likely it is a
coin due to lack of peripheral rim – but button battery cannot be rule out. No free air
seen in the mediastinum or under the diaphragms.
Q2) What factors will determine ongoing management of this patient
Ongoing signs and symptoms will determine the next step .
Next step removal by upper GI endoscopy under general anesthetic.
2010.1 SAQ 7 Pediatrics 017
An 8 week old infant is brought to the emergency department by his mother. The
mother states that the baby has been crying ‘all the time’ over the last week. The
baby looks physically well and has normal vital signs.
Q1) Describe the actions you would take to deal with this situation
Crying baby -Well looking 8 week old crying baby-Describe 7 steps in the
management of this infant
1) Detailed history of presenting complaint
a) Pattern of cry-Recurrent/Feeding/
b) Duration
c) Aggravating & mitigating factors
2) Directed history of feeding-Breast milk/Cows milk
a) Social history-Support for mother-Respite/Single mother/other
kids/unplanned pregnancy
3) Consider- Non-accidental history/Neglect
4) Consider -Possibility of post natal depression/failure to cope
5) Detailed Examination-Milestones/Height, weight, Head circumference,
signs of abuse, signs of neglect
6) Mental state examination of mother
7) Low threshold for admission
Original Answer and Interpretation http://lifeinthefastlane.com/saq-paediatrics017/
SAQ 1.
A 3 month old girl, born at term with no perinatal complications, presents with 2
days of breathing difficulty and poor feeding. Clinically, you suspect she has
bronchiolitis.
She is fully immunised.
On arrival her obs are:
HR 130, BP 90/50, RR 50, O2 sats 92% RA, Temp (rectal) 37.5
a. List other possible differentials for this child’s presentation? (4 marks)
 Pneumonia
 Sepsis
 Heart failure
 Severe gastroenteritis
 NAI
b. List investigations you may perform for this patient and briefly justify? (4
marks)
 BSL mandatory – poor feeding
 Routine investigations are not mandatory with bronchiolitis, but
may be used to rule out other diagnoses/detect complications
 VBG – Electrolytes for poor feeding, pH/CO2/lactate for sepsis,
respiratory status (alkalosis/acidosis)
 NPA – respiratory viruses, causative organism
 Septic work up – BC, urine, FBC, ELFTs, CRP, +/- LP

CXR – often non specific in bronchiolitis, but can rule out
pneumonia/heart failure.
c. List five factors to be considered when discharging this baby? (5 marks)
 Oxygenation
 Respiratory distress/Respiratory rate, WOB, fatigue, apnoea
 Feeding/dehydration
 Disease likely to worsen over the next 24-48 hours, thus close
observation required
 Very young child, likely to deteriorate quickly, so low threshold for
ongoing observation
 Degree of suspicion of alternative diagnoses –
sepsis/pneumonia/CCF
 Social/parental situation, understanding
SAQ 3
A two year old boy has been brought into your tertiary level ED after
falling off the top level of a bunk bed three hours ago. He hit his head on
wooden floorboards. He is presently alert, but wanting to sleep on his
mother’s lap.
a. What features on further history would make you consider scanning
this child’s head rather than just observing them? (3 marks, ½ mark
per answer, must have bold answers)
 LOC > 5mins
 Abnormal drowsiness
 3 or more vomits following head injury
 Suspicion of NAI
 Seizure after head injury in a non epileptic patient
 Amnesia (retrograde/anterograde) > 5mins duration (but a 2
year old might not be able to convey amnesia!)
 Mechanism – fall from over 3m is the Chalice rule, but this is
still potentially almost a 2m fall
b. What features on examination would make you consider scanning
their head? (2 marks)
 GCCS <14
 Suspicion of penetrating injury – unlikely from falling onto
floor
 Suspicion of depressed skull fracture eg boggy
haematoma– possible with fall from this height
 Signs of BOS fracture
 Any focal neurological deficit/abnormality

Chalice also includes tense fontanelle, but this child is too old
for that to be a feature
VAQ 3
A 2 year old boy is brought to your ED by his grandparents, having been
found unresponsive at their home. He has no significant past medical
history.
On examination he is very drowsy with a GCS of 7 (E2, V1, M4) and has
the following observations:
HR 140
BP 80/50
RR 18
O2 Sats 100%
Temp 36.5oC
His initial blood results are:
VBG
pH 7.1
pO2 50
pCO2 37
HCO3 11
Lactate 8.8
Na 143
K 3.8
Cl 110
Glucose 1.8
a. List four abnormalities from the VBG
 Raised anion gap metabolic acidosis
 Lactic acidosis
 Concurrent respiratory acidosis
 Severe hypoglycaemia.
b. List four differential diagnoses
 Sepsis
 Toxic ingestion
 Seizures
 NAI
 Hypoperfusion
 Metabolic disorder - hypoglycaemia
VAQ 4
A 4 year old boy presents to the ED with a history of fever, sore throat and
an unwillingness to move his neck. There is no history of trauma.
Obs:
HR 120
RR 25
O2 Sats 98%
Temp 39 oC
A Xray of his neck is performed
a. List four salient features in the above xray and state your initial
interpretation
 Increased prevertebral space upper cervical/retropharyngeal
soft tissue swelling
 Pseudosubluxation C2-3/retrolisthesis C3
 Airway patent
 No foreign body
 No gas/collection
 Tracheal outline clear
 Interpretation – retropharyngeal abscess. DDx could also be
meningitis
b. List 5 important aspects of management in this patient





Airway currently patent but at risk of deterioration. Intubation if
starts to deteriorate, close observation. Have difficult airway
trolley present, gas induction/fibreoptic induction.
Analgesia
IV Access, IV Abs – eg cefotaxime 50mg/kg
Early ENT review, Anaesthetics/OT aware of patient in case
abscess needs drainage
CT scan if airway secure and can lie flat
SAQ 5: A three year old boy presents with his mother who is concerned that he is
limping .
Q1: List your DDx. (3 marks)
-Trauma (# especially toddlers # / Soft tissue injury)
--Need to consider NAI
-Septic arthritis
-Osteomyelitis
-Dysplastic hip
-Perthe’s (usually > 4)
-Transient synovitis
-Rheumatological disorder (eg RA)
-Neoplasia (ALL, bone tumors)
-Non- limb conditions (eg testicular torsion / appendicitis / diskitis)
-Functional
Q2: For your leading 3 differential diagnoses list 2 features each of history and
examination that may be supportive.
-Septic arthtitis:
Hx: -Fevers, acute onset (hours to days)
Ex: Toxic appearance (fevers, lethargy / unwell), Localised erythema warmth /
effusion /Severely reduced ROM.
-Trauma
Hx: Hx of trauma (may be absent), past history of injury / abuse / neglect
Ex: Localised evidence of trauma (contusions, boney tenderness)
Evidence of injury at other sites (bruises of varying age / NAI)
Transient Synovitis
-Hx: Systemically well child, Recent URTI
-Ex: Mild limitation in Hip ROM, Afebrile non toxic child.
3: Outline your approach to investigation of this child.
-Guided by hx and exam, well child with minimal symptoms for a short duration
may not need immediate investigation.
f febrile / systemically unwell / suspicion SA / OM  Bloods (FBC, ESR /
CRP / blood culture) ? inflammatory / infective process
lain films if trauma / perthe’s / malignancy suspected. May need Xray
pelvis and entire lower limbs if cannot clearly localise pain on clinical
examination.
SS may reveal hip effusion (SA / transient synovitis)
(Ref = RCH guidelines limping child / Exam feedback)
A 30 YO male is bought in after a polypharmacy OD that included
venlafaxine. He has been intubated and received 500mls NS prior to
arrival. His ECG is shown.
Vitals Are:
BP =80/40,
Sats 100% FiO2 =1
T =38.5
1: Describe and justify 4 important features of this ECG. (2 marks)
I
P
U
2: Provide and justify a differential diagnosis for his presentation. List 4.
(2marks)
4 List your management priorities within the first hour (4 marks)
1:
-Broad complex regular tachycardia with rate =174
-Rhythm – VT vs SVT / ST with abherent conduction (esp: Na+ blockade)
-Extremely broad QRS (200ms) ( VT more likely)
-NW axis (VT more likely)
-No obvious AV dissociation . fusion / capture beats  VT less likely
2:
1: Co-ingestion with a Na + blocking drug (eg TCA)
2: Massive venlafaxine OD (only extreme doses cause cardiac
arrhythmias)
3: Serotonin syndrome (likely co-ingestion with venlafaxine with another
serotonergic drug eg SSRI)  hyperthermia / rhabdomyolysis 
hyperkalaemia + arrhythmia
4: VT in setting of non toxicological /septic illness (would be less likely
than tox causes in this patient)
3:
A-Check +position of ETT (clinical , radiological)
B- Hyperventilation (TV 500, RR 24 + titrate (Aim pH =7.5 7.55). Ensure
adequate oxygenation, titrate Fi02 keeps sats >94 , p02 100.
C-Address hypotension + dysrhythmia
(N/S bolus 1L + reassess = repeat PRN)
-NaHC03 100mmol bolus + repeat to –narrow QRS, HD stable, pH =7.55)
-If persistant hypertension after 2 L start ionotropes (NAD 0.05
mcg/kg/min + titrate (obtain central access and IABP)
Check K+ and treat if hyperkalaemic.
HD endponts – MAP 65, cap refil < 2 sec, U/) > 1ml /kg / hr
D: exclude hypoglycaemia, sedate + with midaz 5 mg / hr once HD stable
Control seizures midaz
E: Address hyperthermia (monitor core temp, expose if T > 39.5
aggressively cool (cooled fluids, fan + mist, deep sedation, NM paralysis)
Post intubation cares (Maintenance fluids, NGT, IDC, analgesia / sedation)
Decontaminate with activated charcoal down NGT once position
confirmed.
Question 7
A 3 year old boy presents to your ED with a week of increasing lethargy and
malaise. Other than a recent bout of gastroenteritis from which he seemed
to be recovering he has no significant past medical history.
His observations are:
GCS 15
HR 120 /min
BP 100/60 mmHg
O2 Saturation 95 % on room air
Temperature 36.5 oC
His biochemistry is as follows:
Electrolytes
Na+
K+
ClHCO3Glucose
Urea
Creatinine
Hb
WCC
Plt
131
6.3
95
14
4.8
29.1
430
92
12.1
323
mmol/L
mmol/L
mmol/L
mmol/L
mmol/L
mmol/L
umol/L
g/l
x109/L
x109/L
(132-143)
(3.5-5.0)
(101-112)
(17-30)
(3.0-5.5)
(1.1-5.7)
(23-37)
(115-135)
(6.1-11.0)
(150-450)
List 4 important features of these investigations. 2 marks. Quantify the severity
of each:
Provide 4 differential diagnoses for his renal impairment. Provide supportive
evidence from the history and investigations of each. Include any features that go
against each diagnosis. ( 4 marks)
1: Severe acute renal impairment.
2: Moderate HAGMA likely although pH not given (HC03, AG = 22, Delta gap =
10/10 = 1  Likely pure HAGMA (Consistent with uremia)
3: Moderate Hyperkalaemia
4: Moderate anaemia (Hb =92)
2:
1: Pre renal causes
(Eg: Hypovolaemia / Shock / Sepsis during recent gastro illness – Now no signs
of shock, Normal Ur/ Cr ratio so insult must have resolved)
(HUS) post diarrhoeal illness and age group consistent, anaemia could be 2ndary
to haemolysis BUT would expect low platelets
2: Intrinsic renal disease
(Eg: Glomerulonephritis  Nephritic syndrome)
-Age group supportive but not hypertensive, no hx haematuria
(Toxins) eg: ethylene glycol  HAGMA + renal failure
No ALOC, No documented hx ingestion
3: Post renal causes
-Obstructive uropathy unlikely in theis age group but consider congenital reflux
uropathy
. A 3 year old girl with a rash is referred to the Emergency Department by her GP.
The GP had phoned the Emergency Department prior to the child arriving with
concerns about the child's general wellbeing.
a) What collateral information you could ask to address the GP’s concerns about
her general wellbeing? (4 marks)
Family situation
Evidence of failure to thrive or neglect i.e. underweight/not meeting milestones
Previous unexplained injury or illness
Previous mandatory reporting or known to DOCS
b) List 4 causes of skin lesions in a child (2 marks)
Serious bacterial infection i.e. Meningococcal
Viral exanthem
Urticaria
Bruising
Skin infection e.g. scabies or ringworm
c) What features might you find on examination to indicate a concerning cause of
rash? (3 marks)
Purpuric rash
Lesions concerning for bruising
Fever
Listless child
5) A 9 year old boy presents to ED after stepping on a sharp object at the local
beach. There is a small puncture wound on the plantar surface of his right foot.
X-ray shows a 15x5 mm metal foreign body 5 mm beneath the skin surface.
You decide to remove the object in ED under procedural sedation.
a) What factors would you consider in deciding whether to use procedural
sedation? List 2 specific examples of each.
Factors
Department
Examples
Patient load, time of day, availability of
appropriate space
Staff
Adequate numbers, experience
Patient
Fasting, consent
b) The child is fully recovered and the foreign body removed. What discharge
advice would you give?
Analgesia
Follow up plan
Wound care
Recognition of any problem requiring return to ED/or attendance to GP
VAQ 1
A 6 month old girl is brought to your ED with a rash which has been present for a
week but has become much worse in the last two days.
Observations:
Temp 37.8oC
Pulse 100/min
RR 20/min
SaO2 98% RA
Her photo is shown.
a) Describe the rash (2 marks)
Crusting, erythematous, involving the face, sparing of arms
b) List 4 differential diagnoses (4 marks)
Dermatitis/eczema, secondary infection, herpetic, SJS/TEN, Staph scalded skin,
impetigo
c) List 4 factors to help determine disposition (4 marks)
Any of:
Clinical factors: toxic vs. well, intake and output, DDx requiring inpatient care, comorbidities, other concerns with examination and Hx
Parents: Social, geographical/transport issues for both acute Mx and planned
review, time of day/night, not coping vs. highly motivated, NAI/ neglect of this
issue, previous issues, etc.
Planned Mx and R/v: DDx or DDx preferred Mx — e.g. IV antibiotics preferred vs.
oral, access to dermatological or paeds review if simplified by admission, simple vs
complex Mx regime (e.g. frequent creams/ointments, multiple medications,
bandaging, frequent bathing)
VAQ 4
A previously well 2 year old boy is brought to your ED by his parents when he
suddenly started to feel unwell and looked pale. His symptoms began an hour
prior to presentation.
On examination he is anxious and alert with a normal capillary refill time.
Observations:
BP 85/40 mmHg
Temp 36oC
SaO2 97 % 2L/min O2 via nasal prongs
An ECG is taken.
a) List 3 differential diagnoses (3 marks)
Supraventricular tachycardia (broad sense of the term) most likely due to AV nodal
re-entry (SVT)
Re-entry via an accessory pathway (e.g. WPW or LGL);
Atrial flutter and/or fibrillation;
Paroxysmal atrial tachycardia;
If Sinus Tachycardia is listed must comment on why this is not likely.
b) List 3 management options. For each describe how you would perform it and
list one advantage for each. (9 marks)
Management option
Process
Advantage
Vagal manoeuvre
Ice slurry applied to face
Non-invasive
Adenosine
0.1mg/kg through
Rapid onset
(relatively) large bore
cannula in ACF
Cardioversion
Synchronised at 1J/kg
Indicated if
haemodynamic instability
Question 2
A nurse presents you with the ECG of a 4-year-old girl who is currently asymptomatic.
Observations include:
BP 90/60 mmHg RR 20 /min Temperature 37 0C
-
A. List 4 findings on this ECG and what is your diagnosis
Sinus tachycardia
Rate 135-160
Normal Axis
TWI v1-V3 and lead III
ST depression V4-V6
Normal intervals
-
B. List 7 findings which are abnormal in an adult ECG but normal in a paediatric
ECG
RAD
TWI V1-V3
Faster
Increased sinus arrhythmia
Complexes narrower QRS <80, PR <120
Slightly longer QTC
Q waves in inferior and precordial leads
Dominant R wave in V1
SAQ 6
A 4-month-old infant presents with a reduced conscious state following a brief
generalised seizure at home. An initial blood sugar is 1.5mmol.
a)
-
List your differential diagnosis
Sepsis
Inborn errors of metabolism
Epilepsy
Malnutrition/NAI
NAI – Insulin overdose
Endocrine disorders
Trauma
b) List 5 key aspects of your history and why
- Pregnancy and peripartum history – prematurity, ABI, congenital
disorders
- Family history of inborn errors or endocrine disorders – increase chance
of child having this
- Recent illnesses - sepsis
- Feeding – Malnutrition/hypoglycaemia
- Wet Nappies - Dehydration
- Vaccination - Sepsis
- Recent trauma – SAH/SDH
c)
-
List 5 things you would look for on clinical examination
Vital signs – fever, cardiovascular stability, cyanosis, CRT
Dysmorphic features
Signs of infection – rash, meningism
Signs of trauma
Signs of neurological abnormalities
Hydration status – fontanelles, skin turgor, mucous membranes
d)
-
List 4 investigations you would perform
Confirm BSL
Infection – Blood cultures, Urine, +/- LP
Metabolic screens on first pass urine
Electrolytes – hyponatraemia
SAQ 7
The police bring a 13-year-old girl to your emergency department following an
argument with her mother. She is agitated, combative, crying and has selfinflicted lacerations to both arms. The mother is enroute to the emergency
department.
a)
-
What are your top 5 priorities
Patient safety and staff safety
Risk assessment – suicidality, disclosure, home situation
Recognition of situation involving a minor where mother is not present
Disposition – utilisation of available referral channels – adolescent mental
health, social work
Notification to family services
b) What are 3 possible techniques/chemical and doses for restraint
- Oral – Olanzapine 5mg if <40kg, 10mg if >40kg, Risperidone 2mg,
Diazepam 5mg
- IM sedation – Droperidol 5-10mg, Haloperidol 5-10mg+ midazolam 510mg. Olanzapine 5-10mg
- IV sedation – Midazolam 0.15mg/Kg, Haloperidol 0.1mg/Kg
a. List possible investigations (if the child was unwell without a focus) and
rationale in the table below
Investigation
Rationale
b. What would be your approach to this child (i.e. in the original stem)
7.
a.
This question was quite difficult to change into a new style
question so forgive my feeble attempt. I think it would have been easier if the
child was < 3 months as at age of 1 there is just so much variability and clinician
gestalt that it is difficult to set specific questions.
Investigation
FBC
Rationale
Raised WCC / Neutrophils may indicate bacterial
process though not sensitive or specific
Low WCC / neutrophilia concerning in context of
fever ? oncology patient, broad spectrum Abx
required and mandatory admission
Elevation 75% sensitive and specific for serious
bacterial infection (Dunn pg 804)
CRP
Blood cultures
Need at least 3ml of blood, preferably two sets
Difficult to perform
Significant time delay which may not alter
treatment
Necessary for detecting organism in septicaemia
Urine dipstick
Highly sensitive and specific if nitrites present
(>90%)
Significant pyuria with microscopic haematuria
may indicate UTI
Gold standard urine test for detection of UTI
Slow, taking at least 1 hour in major centers for
cell counts, organism will take days to identify
Useful when consolidation present for ruling in
pneumonia
May detect parapneumonic effusion / empyema
Necessary to diagnose / rule out meningitis
Used to direct therapy – both antibiotic and
duration
May be useful for predicting course if positive
Also used for epidemiological purposes
Urine MCS
CXR
LP
Nasal viral PCR
b.
Again, not sure if this is specifically discussed in detail somewhere
that I just haven’t found, but the standard texts seem a little sparse.
Here is my answer, let me know if you think I have misinterpreted
the question or have said lies and deceit:
The child is well with no localizing symptoms, also assuming no
significant medical co-morbidities and / or antenatal issues such
as extreme prematurity
Significant bacterial infection is a possibility but much less likely
than if the child was < 3 months
Therefore, an approach could be to treat the child’s symptoms
with simple analgesia / antipyretics (paracetamol / ibuprofen)
Perform ward test urine looking specifically for nitrites
Discussion with parents – ensure happy observing child feeding,
drinking, playing well
Ensure access to phone / car / ability to return or get help, time of
day
Advice to return to hospital if the child deteriorates – appears
unwell, lethargic, reduced wet nappies, poor intake, other
symptoms develop (vomiting, diarrhoea, rash)
Otherwise follow up with GP in 24-48 hours for review
a. What is the expected weight for an 8 month old and what would be his
normal pulse, blood pressure and respiratory rate?
b. Describe 5 key features of this XR
c. Describe 5 aspects of management
2.
a.
b.
c.
Weight = half age in months + 4 = 8kg
Pulse 70-150
SBP 90-100
RR = <35
distended bowel gas in left upper quadrant
air fluid level left upper quadrant
intussusceptum within bowel lumen in right lower quadrant
no NGT present
airspaces seen appear clear
replacement of fluid losses
insertion of NGT if vomiting
air enema will reduce the intussussecptum in 75% of cases
otherwise surgery
mortality 1-3% with treatment, 100% without
a. Describe the photograph
b. What is the provision diagnosis and pathogen(s)?
c. What is the treatment?
5.
a.
b.
c.
image of the lower limbs of a child
multiple discrete and contiguous erythematous ulcers and crusted
erosions worse over the feet and ankles
satellite lesions likely present proximally due to autoinoculation
impetigo caused by staphylococcus aureus or group A betahaemolytic streptococci
encourage hygiene in the form of regular bathing to wash off
crusts
topical mupirocin 2% ointment q8hrly
oral cephalexin 30mg/kg (max 500mg) q8hrly
isolate the children – treat sister too unless all lesions are covered
or antibiotics commenced
a. What medications (including doses/amounts) are you going to give
this boy?
b. What is your provisional diagnosis?
c. What will determine this child’s disposition?
5.
a.
b.
c.
estimated weight 10kg
adrenaline 10mcg/kg = 100mcg IMI
hydrocortisone 4mg/kg = 40mg IV
or prednisone 1mg/kg = 10mg PO
normal saline 10-20ml/kg = 100-200ml
anaphylaxis
continuation of normal vital signs
improvement in work of breathing and wheeze
resolution of rash
stable for period of observation – at least 4 hours
co-operation and understanding of parents to education re:
avoiding egg products and use of epipen
action plan construction
time of day for discharge
referral to allergy specialist – either directly or via GP
a. What is the child’s estimated weight?
b. List 4 medications that can kill a child if one or two tablets only are
consumed
c. Outline key aspects of managing this child
8.
a.
b.
c.
(3+4) x2 = 14kg
chloroquine, dextropropoxyphene, propranolol, amitriptyline
(TCAs), verapamil, diltiazem, theophylline, sulphonylureas,
recreational sympathomimetic drugs, opioids (methadone,
morphine, oxycodone)
recognize serious life threat – sulphonylurea and beta-blocker
poisoning – consider activated charcoal but will need airway
secured
seek toxicology advice
administer 5ml/kg of 10% dextrose
administer octreotide as antidote
consider glucagon, insulin for beta blocker OD but being wary of
co-ingestion of hypoglycaemic agent
manage airway and plan to escalate if deteriorates
fluid bolus, inopropes, CPR if HR <60
check IO and search for IV access
monitor blood sugar level and correct as appropriate
transfer to ICU
manage family
2009.1 SAQ 5
A 9 month old girl with a fever of 39 degrees Celsius attends your ED with her
mother.
1.




List 4 essential features of history (4 marks)
Immunization status (essential) – 1 mark
Oral intake (essential) - 1 mark
Urine output (essential) - 1 mark
A mark can be obtained for any of the following
o Sick contacts/Recent travel
o Infective/Localizing symptoms (cough, swelling, erythema)
2.




List 4 essential features of examination to be sought (4 marks)
Vitals
Hydration status
LOC (AVPU)
Rash
3. List the most important ED investigation in undifferentiated fever
in this patient (1 mark)
 Urinalysis
4. The patient has a febrile convulsion in the department. What age
group does febrile seziures usually affect? (1/2 mark)
 6mo to 6 years
5. What percentage of children will have a febrile seizure (1/2 Mark)
 5%
Question 8
A 5 year old boy presents with an acute exacerbation of asthma. On examination
there is reduced air entry bilaterally with expiratory wheeze. He has tracheal tug,
sub-costal recession and is tachypnoeic. Initial pulse oximetry reveals oxygen
saturation of 85% on room air. He has had no treatment prior to arriving in the
emergency department.
a) Please outline your initial management of this child (5 marks)
b) After an hour in the ED the patient deteriorates and reduced level of
consciousness and significant respiratory fatigue is evident. You decide to
intubate the patient and it goes smoothly, please outline your ventilation
strategy for an asthmatic patient. (5 marks)
Question 8 Answers
c) Please outline your initial management of this child (5 marks)







Severe exacerbation of asthma and likely to respond well to acute
therapy in the context of no pre-hospital treatment but need to
anticipate for further deterioration.
Supplemental oxygen to aim for saturation > 94%
Bronchodilator therapy
o Salbutamol 2.5mg nebulizer as burst of 3 initially 10-15
minutes apart
o Ipratropium 250mcg nebulizer as burst of 3 initially 10-15
minutes apart
o If rapid response then consider use of spacer (Superior
efficacy in those with sufficient airflow movement)
Steroids
o Prednisolone 1mg/kg up to 50 mg orally or if not able to
swallow then hydrocortisone at 4mg/kg IV.
Close observation and monitoring for response to treatment.
Prepare for deterioration: Place topical EMLA cream early on
arrival but no IVC unless no response to initial therapy.
Communication
o With parents (keep them close by!) and inform them of
progress
o Inpatient team if admission is required for further
stretching of bronchodilator therapy is beyond the means
of ED and short stay unit.
d) After an hour in the ED the patient deteriorates and reduced level of
consciousness and significant respiratory fatigue is evident. You decide to
intubate the patient and it goes smoothly, please outline your ventilation
strategy for an asthmatic patient. (5 marks)


Recognition that intubation is the last resort and only done in
extremis. It is a clinical decision and invasive ventilation in
asthmatics carries 10-20% mortality rate.
Lung protective ventilation strategy (ARDSnet)





Initial ventilator settings
o Estimated weight = Agex2+8 = 18kg
o Slow respiratory rate 6-8 breaths per min
o Tidal volume 5-8 ml/kg
o Larger I:E ratio of 1:4 or 1:5
o Minimal PEEP of < 5 cmH2O (PEEP of 0 often used)
o Limit plateau pressure < 20 cm H2O
o FiO2 of 1.0
Permissive hypercapnoea: reduces risk of barotrauma
Reducing end expiratory pressure, may need to do this manually
by disconnecting patient from circuit and actively press on the
chest to ensure maximal exhalation. (Reductionof “Auto-PEEP”)
Continuation of maximal treatment for exacerbation of asthma
Monitor for complications and barotrauma
References
ACEM Examiners Report 2011.2
Dunn’s page 507 – Management of life threatening asthma
Question 2
A 3 month old girl is brought to your emergency department after 3 days of
diarrhea and vomiting. She appears very unwell and lethargic, with sunken eyes,
a sunken fontanelle and dry mucous membranes.
These are her blood results
a) What type of acid base disturbance is shown and what other salient
findings (4 mark)
b) Please list potential differential diagnoses for this acid base disturbance.
(4 marks)
Question 2 Answers
a) What type of acid base disturbance does this show? (4 mark)
Normal anion gap metabolic acidosis with appropriate respiratory
compensation
Hypernatraemia with no correction needed as BSL if normal
Relative hypokalaemia with correction made of acidaemia
Hyperlactataemia: Hypoperfusion
Elevated renal indices: Urea Creatinine ratio <100 likely pre-renal cause
Unable to comment on oxygenation as this is venous gas
b) Please list potential differential diagnoses. (4 marks)
Severe dehydration / Hypovolaemia leading to hypoperfusion
GIT causes: vomiting and diarrhea / uretero-enterostomies / Obstructed
ileal conduit
Renal causes: Renal tubular acidosis / Drugs (Carbonic Anhydrase
Inhibitors)
Others: Addison’s disease / Recovery from ketoacidosis
References
ACEM’s examiners report 2011-2
3. A baby is born in your resuscitation room after a precipitous birth from a 32 week
pregnant woman. The baby is not breathing and there is thick meconium stained liquor on
the bed. The delivery is otherwise uneventful and the mother requires no acute medical
treatment. There is no on-site neonatal or obstetric service.
a) List 8 key steps in resuscitation of the preterm newborn.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
keep infant warm (resuscitaire)
clear meconium from airway with suction
dry and stimulate infant to breathe post clearing meconium
provide PPV if infant not breathing and/or HR<100bpm
Endotracheal intubation considered early due to prematurity and meconium
aspiration
Circulation – provide ECC + PPV @ 3:1 if HR<60bpm
Adrenaline if HR<60bpm
Establish access (IV periph/umbi, or IO)
Estimated weight 2-3kg
Assigned person to support mother
b) List your differential diagnosis.
• N iNborn errors of metabolism
• E electrolyte abnormalities
• O overdose (toxin, poison)
• S seizures
• E enteric emergencies
• C cardiac abnormalities
• R recipe (formula, herbs, additives)
• E endocrine crisis
• T trauma
• S sepsis
(Dunn pg 145)
c) Outline your post-resuscitation care in this situation
-
Early consultation with neonatal retrieval services
Consideration of all causes in DDx, including initiation of any appropriate
medications:
o Glucose
-
o Antibiotics
o Anti-epileptics
o Naloxone
Observation and monitoring while awaiting transfer
Care of mother
Psychosocial care of parents and family
Transfer to tertiary centre with NICU/SCN
SAQ 5
A 2 year old presents to your mixed ED with a plastic bead into their right nostril.
She’s not distressed but her parents are concerned as they have tried to get the
bead out with no success. Part of the bead is visualized on brief nares inspection.
Question 1
Name 3 techniques of bead retrieval and list main advantages and disadvantages
for all 3
SAQ 5 Answers
Question 1
Name 3 techniques of bead retrieval and list main advantages and disadvantages
for all 3.





Obtain consent from parents
Patient positioning – wrap with 2 person hold.
Topical anaesthesia – lignocaine and phenylephidrine
Good light source. Nasal speculum
Consider Potential need for procedural sedation
Positive pressure
 Occluding the unaffected nostril the parent providing a forced expiration
in to the child’s mouth similar to mouth to mouth in CPR.
 Can also use Bag Valve mask for same purpose if parental technique
doesn’t work.
 Main disadvantage - Theoretical risk of barotrauma. Initial method
requires parental under standing and co operation.
Suction
 Apply narrow bore suction to bead
 Adv – atraumatic.
 Dis adv – need to have equipment and very narrow suction catheter.
Alligator forceps
 Grasp the bead with aligator forceps.
 Pro - Good for smaller objects near the anterior nares
 Con - May fail if round bead. Nasal trauma
Glue on a stick
 Acrocyanolate glue on the tip of a swab.
 Con - Very steady hand. May stick to mucosa and cause trauma.
Reference - Paediatric Camron, Second Ed, Page 344, Exam report
SAQ 7
A concerned father has brought his 2 year old to triage. The triage nurse call you
as the child is floppy and unresponsive. He has had vomiting and diarrhea for
three days. On you initial survey you realize that the child is not breathing and
doesn’t have a pulse.
Question 1.
In the space below describe the algorithm or the critical steps required in the
management of this child, including drug and dosages that you would use
Question 2
What are the important factors involved in the decision to cease resuscitation in
a paediatric arrest
SAQ 7 Answers
Question 1.
In the space below describe the algorithm or the critical steps required in the
management of this child, including drug and dosages that you would use.
Reference – ARC guidelines. Resus.org.au
Remember to include calculated weight.
Question 2
What are the important factors involved in the decision to cease resuscitation in
a paediatric arrest?



Total arrest time/duration or resus
Was the arrest witnessed
Was there bystander CPR


Clinical response to therapy
CO morbidities.

Information from colleagues regarding long term medical and also
parental wished

Presence of reversible factors – Hs and Ts

If > 2 doses of adrenaline required and no response, survival unlikely

More prolonged time is suggested if Vf/Vt, toxic, drug, significant rapid
onset hypothermia

? availability of ECMO
Reference - ARC guidelines, Resus.org.au