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Child Health > The Sick Child > Flashcards

The Sick Child Flashcards

1
Q

Describe the trends in HR, RR and BP of children

A

HR and RR start off much higher than adult values and get lower with age
BP starts off low and gets higher

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2
Q

What are the main anatomical differences in children

A

Large head and prominent occiput
High anterior larynx and floppy epiglottis - important in CPR and intubation
Relatively large surface area to volume - significant in burns cases
Flexible ribs - ‘sucking’ sign when in resp distress
Lower blood volume - bleed out fast

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3
Q

What are some of the most common illnesses that children present with

A 
Bronchiolitis 
URTI 
Croup 
Gastroenteritis 
Seizures 
Pneumonia/ LRTI
Asthma 
Viruses 
Head injury 
Abdominal pain 
UTI
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4
Q

What is the most common reason for acute illness in kids

A

Sepsis

Overwhelming infection

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5
Q

Describe the presentation of bronchiolitis

A

Starts with coryzal symptoms - cough (wet sounding), wheeze, runny nose, sometimes a temperature
Congestion causes breathing difficulty
Kids will struggle with feeding due to breathing difficulty - leads to dehydration
Widespread fine crackles in all areas
May cause apnoea’s

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6
Q

Describe the presentation of croup

A

Most common in toddlers - will be miserable and have a temp
Get stridor due to narrowing of upper airway
Hoarseness and barking cough
Increased WOB
Will get worse when they are upset and crying - keep calm

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7
Q

List potential causes of stridor

A 
Anything that causes upper airway obstruction
Bacterial tracheitis 
Croup 
Epiglottitis 
Inhaled foreign body
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8
Q

Describe asthma presentation and treatment in young kids

A

Not every kid who wheezes has asthma
Prolonged expiration is also a sign of asthma in children
Young kids cannot do peak flow
Treat with O2, bronchodilators and steroids (not in under 2s)

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9
Q

What CNS disease can kids present with

A

Meningitis: bacterial and viral
- varied symptoms

Encephalitis: commonly viral (coxsackie)

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10
Q

What would make you suspect meningitis and what would you do

A

Obvious signs like rash - not always there
Headache and photophobia not common complaints until about age 6
May have an unusual cry
Vomiting and fits
Generalised symptoms such as high temp and ‘not themselves’
Children are often irritable, hard to console

Treat as if they have meningitis - lumbar puncture, bloods and antibiotics

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11
Q

What type of meningitis causes the classic rash

A

Meningococcus meningitis

Rash is purpuric and doesn’t blanche

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12
Q

What can cause fits in children

A

Febrile seizures - reaction to temp
Vasovagal episode - fainting
Reflex anoxic seizure - stop breathing when they get a fright
Breath holding attack
Behavioural - looks like they’re blacking out but may just not be listening
Epilepsy
Arrhythmia

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13
Q

List signs of non-accidental injury

A

Broken ribs - kids have flexible ribs so have to really be damaged to break
Bruising in odd places
Retinal haemorrhages - sign of shaking

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14
Q

List common GI and urogenital presentations in kids

A 
Viral gastroenteritis
GI obstruction  - pyloric stenosis, volvulus, intussusception 
Appendicitis 
UTI 
Testicular torsion
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15
Q

Describe pyloric stenosis

A

Presents at around 4-6 weeks -purely a paediatric problem
Kids will be skinny, undernourished and get dehydrated quickly
They omit every time they try and eat – projectile, milky
Caused by thickened stomach wall at the pylorus which causes obstruction

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16
Q

What heart conditions might you see in young children

A

Congenital heart disease
Arrhythmias - SVT’s
Cardiac issues very rare in kids

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17
Q

What are some of the most common but vague symptoms that kids present with

A 
Difficulty breathing
Poor feeding
Fever
Rash
Lethargy / depressed conscious level
dehydration
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18
Q

What is the most common cause of arrest in children

A

Respiratory failure leading to respiratory arrest

Cardiac arrest may occur secondary to resp but rarely primary in children

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19
Q

What has a better prognosis - respiratory or cardiac arrest

A

Respiratory

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20
Q

Why cant you do a full head tilt, chin lift in a young child

A

Kids have a high anterior larynx so tilting their head back like in adult BEC you can compress their airway

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21
Q

List signs of breathing difficulty in young children

A

Grunting - baby basically giving themselves CPAP
Nasal flaring
Use of accessory muscles - head will bob, abdominal breathing
Recession - chest moves inwards
You get sternal. subcostal and intercostal
Tracheal tug

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22
Q

Why might young children make a grunting noise

A

Cold
Hypoglycemia
Breathing problems - basically giving themselves CPAP by closing glottis

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23
Q

Is low blood pressure normal in a child?

A

NO
Children are really good at maintaining their BP so if it drops they are very unwell
This is because they have really good peripheral vasoconstriction to compensate
Pre-terminal sign

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24
Q

Where do you perform cap refill on a child

A

Centrally by pressing on the sternum

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25
Q

If a child is in shock, how do you treat them

A

Fluids - based on body weight
Saline is best
Give blood if it is a trauma case

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26
Q

List the key signs of dehydration

A 
Dry mucous membranes, eyes or fontanelle 
Decreased skin turgor 
Low urine output 
Shock 
Lethargy
Altered conscious level - severe
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27
Q

What is posturing

A

It describes abnormal movements made in fits
It means there is something wrong with the brain stem
Decorticate - hands pulled up to chest
Decerebrate - arms by sides, palm rotated to ground - more severe

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28
Q

How do you treat pyloric stenosis

A

Surgery

Pyloromyotomy - cut out the thickened muscle in the wall to reduce obstruction

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29
Q

What is intussusception

A

Part of the bowel folds in on itself like a telescope

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30
Q

List symptoms of intussusception

A

Blood in nappy - red currant jelly sign
Vomiting - comes in waves
Colicky pain - child will settle in between bouts
Floppy baby
Sausage like mass in abdomen - often right side

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31
Q

How does intussusception appear on US

A

When ‘face on’ it looks like a target or tree rings

From the side it looks like a kidney - pseudokidney

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32
Q

How do you treat intussusception

A

Place a tube into the bowel via back passage and blow air up it to try and push it back into place – works in 70-80%
If this doesn’t work, it will require surgery

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33
Q

How will appendicitis in a child appear on US

A

Usually just being able to see the appendix on US in a child means that it is inflamed

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34
Q

What is the jump test for appendicitis

A

If they get up and are more than happy to jump around then they probably don’t have peritonitis
If they are too sore, they do and will need surgery

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35
Q

If a baby is vomiting up green stuff, what diagnosis must be excluded

A

Malrotation with midgut volvulus

It is a surgical emergency and if not caught in time then the gut and baby can die

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36
Q

Describe the normal fixed position of the gut

A

There are 2 fixed points in the normal abdomen
Distance between these is the longest distance in the abdomen
Blood supply in the middle of this is the superior mesenteric artery

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37
Q

What can cause a malformation with midgut volvulus

A

Congenital malformation where the fixed points of the gut are not in the correct place
Distance is shorter, as is blood supply so gut is more unstable and likely to twist

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38
Q

List causes of acute scrotum problems

A

Testicular torsion - surgical emergency
Inflammation of the epididymis
Torsion of the hydatid - small area of necrosis on top of testicle (most common)

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39
Q

What is BXO

A

Abnormality of the penis
White scarring on the head around the urethral opening
Requires circumcision

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40
Q

Urological system is a common site of congenital malformation - true or false

A

TRUE

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41
Q

What is hypospadias

A

Abnormal opening in penis - e.g. urethra comes out below penis

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42
Q

What do you do if a testicle is stuck in the groin

A

Must be located and moved down to the scrotum

This puts it in a place where it can be examined which is important for cancer risk in later life

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43
Q

How do you treat an absent testicle

A

You don’t

There is no need to move anything as nothing there to cause cancer risk

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44
Q

How do you move a testicle from the groin to scrotum

A

2 phase operation
Cut the testicular artery to free the testicle
Leave to let heal and aim for the blood supply from below to take over
If blood supply is successful then push the testicle through the deep ring into the scrotum

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45
Q

In an ABCDE situation, what differences must be done in Airway in a child

A

DO NOT do a full head tilt chin lift
Just tilt head slightly so that head is parallel to the surface it is on
This is because children have floppier airways and a high anterior larynx that make it easy to occlude the child’s airway by tilting back too far

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46
Q

In an ABCDE situation, if a child is not breathing what do you do (only breathing tasks)

A

Give 5 rescue breaths

Check for chest rising with each breath

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47
Q

In an ABCDE situation, if a child is not breathing and the rescue breaths are ineffective - what do you do

A

If no signs of life give 15 chest compressions
Feel for brachial pulse
Anything below 100bpm is abnormal
Start CPR at a rate of 15:2

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48
Q

How do you treat a choking child (older)

A

Encourage them to cough
Give 5 back blows - check for object removal after each
Then go onto Heimlich manoeuvre
Repeat until it clears or until they fall unconscious

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49
Q

How do you treat a choking child (infant)

A

5 back blows with them pointing downwards - check for object removal after each
Then do 5 strong chest compressions
Repeat until it clears or until they fall unconscious

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50
Q

Why cant you do the Heimlich manoeuvre on infants

A

High risk of rupturing abdominal organs

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51
Q

What is the WETFLAG procedure for a child in arrest situation

A 
Weight - allows you to work out doses 
Energy 
Tube 
Fluids 
Lorazepam 
Adrenaline 
Glucose
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52
Q

List common signs of hypoglycemia in children

A 
Tiredness 
Feeling shaky 
Lips tingling 
Feeling tearful or irritable 
Blurry vision 
Lack of concentration 
Going pale 
Sweating 
Headache 
Feeling hungry
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53
Q

Children who are decompensating often appear well - true or false

A

True
Children are very good at compensating for illness
They are often severely unwell by the time they present as such

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54
Q

List the steps in the 3 minute exam for children

A

ABCDETT
Airway - secretions, stridor, foreign body
Breathing - RR, WOB, O2 sats, auscultation
Circulation - colour, HR, cap refill, temp of hands and feet
Disability - pupils, limb tone and movement, AVPU, glucose if very unwell or drowsy
ENT exam - look in ears and throat
Temperature
Tummy - soft, distended, tender, bowel sounds etc

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55
Q

How can you determine if a child has an unprotected airway

A

Test their gag reflex
Try and place an artificial airway and see how they react = they should cough and not tolerate
If they tolerate it then they are at risk of unprotected airway - maintain a jaw thrust and call anaesthetist

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56
Q

At what stage of hypoxia does cyanosis present

A

Roughly below 85%

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57
Q

Why might a sats probe give artificially low readings in children

A

If the child is moving and you don’t get good contact with the probe

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58
Q

Where do you place the sats probe on a small child

A

O2 sats taken from foot or whole hand on a baby as their fingers are too small

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59
Q

What is the target O2 sats for a child

A

Should have sats of 98% or more
94% or less is hypoxia
Once sats get down to 90% there is a more rapid deterioration - best to catch early

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60
Q

Auscultation is less useful in children than in adults - true or false

A

True

Children have much smaller chests so the noises will transmit across the whole chest - harder to localise

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61
Q

What is mottling a sign of

A

Poor perfusion

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62
Q

What affect can crying have on the obs

A

A distressed child will have an increased HR

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63
Q

What conditions can lead to poor perfusion

A

Sepsis

Dehydration

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64
Q

Why is central cap refill more reliable than peripheral

A

It is not affected by environmental temperature

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65
Q

List signs of poor perfusion in children

A

Poor cap refill - peripheral affected first, then central
Mottled skin
Cold hands and feet

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66
Q

What does asymmetrical pupils suggest

A

SOL in the brain

This includes haemorrhage

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67
Q

What condition can lead to sluggish pupils

A

Fits

Drug overdose

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68
Q

Changing pupil size is suggestive of what

A

May suggest an ongoing fit even if there is no tonic clonic movements

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69
Q

What is true irritability and what does it suggest

A

When a baby truly cannot be consoled or distracted

It is suggestive of raised ICP or meningitis

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70
Q

Why do boys with abdominal pain need a testicular exam

A

To exclude testicular torsion - emergency

Should also look in groin for hernias

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71
Q

Persistant drowsiness is a red flag sign - true or false

A

True

Often seen after fits or in fever

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72
Q

What type of thermometer is used on a young baby

A

Axillary thermometers are used in babies if ear too small for tympanic

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73
Q

List common causes of breathlessness in children

A

Asthma
Bronchiolitis
Pneumonia
Croup

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74
Q

Most severe resp infections usually occur in the first 3 years of life - true or false

A

True

Includes strep pneumo, Hib, pertussis

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75
Q

A prolonged expiration phase is seen in which conditions

A

Asthma

Bronchiolitis

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76
Q

B-agonists less effective for the treatment of asthma in children under 1 - true or false

A

True

This is because asthma in this age group is usually atypical

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77
Q

How do you treat croup

A

Responds really well to steroids - oral or inhaled
Usually a single dose of dexamethasone
In severe cases, nebulised adrenaline is used alongside O2 for immediate relief

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78
Q

How do you treat bronchiolitis

A

Supportive treatment only as it is viral

May need O2 and feeding support if severe

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79
Q

What caused croup

A

It is typically caused by parainfluenza

It is technically laryngotracheobronchitis

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80
Q

What causes bronchiolitis

A

Typically RSV

Leads to acute inflammatory injury of the bronchioles - LRTI

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81
Q

How does pneumonia present in kids

A

Present with non-specific symptoms compared to adults
Diagnosis is often based on general signs of infection as this is what kids present with - tachycardia, fever, lethargy, low O2 sats , resp distress
Will be more lethargic with a higher temp than with viruses
They often refuse food/drink
Cough is a less reliable symptom in kids, may be absent
-

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82
Q

Children may have persistent wheeze following pneumonia - true or false

A

True
Common for a few months after illness
Should grow out of it by age 2

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83
Q

List risk factors for respiratory illness in children

A

Prematurity
Required neonatal care
Exisiting cardio or resp disease

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84
Q

Respiratory distress can lead to dehydration in children - true or false

A

True

The breathing difficulty makes it hard for them to feed properly leading to dehydration

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85
Q

Kids become more distressed as they decompensate - true or false

A

False

They become less distressed as they become very tired/drowsy

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86
Q

Wheeze is an upper airway noise - true or false

A

False it is a lower airway noise

Heard in asthma and bronchiolitis

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87
Q

Stridor is an upper airway noise - true or false

A

True

Occurs on inspiration

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88
Q

Stridor is heard in which conditions

A

Heard in croup, foreign body aspiration, epiglottis etc.

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89
Q

Chest recessions are more common in younger children - true or false

A

True
They have softer smaller chests so less effort needed to indraw
Older kids with recessions are very sick

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90
Q

Intercostal and subcostal recession usually occur together - true or false

A

True

They have the same clinical significance

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91
Q

Which type of chest indrawing most indicates severe respiratory distress and why

A

Sternal indrawing

Lot of effort is needed to move such a large bone

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92
Q

Why do children in respiratory distress bob their heads

A

Head bob caused by pulling on sternocleidomastoid - they are using their accessory muscles

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93
Q

At which O2 saturation should you give a child supplemental oxygen

A

Give O2 if sats are below 92% - should get up to 100% quickly on high flow

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94
Q

Where might you hear bronchial breathing in a child

A

Heard just over an area of consolidation - harsh breathing noise

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95
Q

How would a child present if they have swallowed an foreign object

A

They will be very uncomfortable

Will be drooling due to swallowing difficulty

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96
Q

Which is more common, children swallowing foreign bodies or inhaling them

A

Swallowing is more common

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97
Q

List the potential outcomes of an inhaled foreign body

A

Coughed up
Brought up by Heimlich
Can go down into the bronchi = will present with wheeze
Life threatening choking cases are rare - hypoxic and LOC

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98
Q

A foreign body causing discomfort is most likely where - oesophagus or trachea

A

Oesophagus

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99
Q

How may children appear during an apnoea

A

May go floppy and cyanosed

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100
Q

In young infants (1-4 months old) apnoeas are a sign of what

A

Usually due to another underlying illness
Not necessarily respiratory in origin
Must be sent to hospital

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101
Q

Describe the difference in whooping cough presentation between older and younger kids

A

Older kids present with the classic whooping cough

Younger kids may present with apnoeas

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102
Q

Tachycardia can be an indicator for respiratory distress - true or false

A

True

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103
Q

How do you manage status asthmaticus

A

Requires intubation and ventilation to take over breathing

Can lead to respiratory failure without it

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104
Q

If a child has a silent chest, what must you do

A

You must call for intensive care

It is a sign of severe respiratory distress

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105
Q

What is the most common cause of fever in children

A

Most are caused by mild viral illnesses which get better on their own

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106
Q

Why are infants more vulnerable to infection

A

They still have an immature immune system

Takes around 2 years for the immune system to mature = thymus and spleen developing

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107
Q

The younger the child, the higher the risk of a local infection becoming sepsis - true or false

A

True

This is due to their immature immune system

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108
Q

Children are more likely to present with non-specific infection symptoms than adults - true or false

A

True

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109
Q

Why is CRP not a useful blood test in the acute setting

A

It takes time for levels to rise so doesn’t provide an accurate picture in the acute setting

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110
Q

What causes the purpuric rash seen in meningitis

A

It is caused by the release of endotoxin by the meningococcus bacteria
It makes the blood vessels leaky and blood escapes to the skin leading to the purple areas

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111
Q

Which blood tests should you perform on a child with suspected sepsis

A

Venous blood gas
WCC
Can also check lactate - significant if >3

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112
Q

The degree of the fever is a great predictor of illness severity - true or false

A

False
It is a poor predictor
Still important to ask about the degree and duration of the fever

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113
Q

At which point does a temperature becoming concerning in a child

A

Particularly concerning if temp is over 39.5C

Though in those under 3 months 38 is considered significant

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114
Q

Which children are at particularly high risk of infection

A

Cerebral palsy
Prematurity
Those on steroids
History of leukaemia

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115
Q

How does fever influence HR and RR

A

Fever itself can increase HR and RR
Rule is an increase of 10bpm for each degree of fever
They should both fall in response to anti-pyrectics

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116
Q

How should a fever respond to anti-pyrectics

A

Should fall into an up and down pattern - goes down after dose and then rises again
This is a reassuring sign

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117
Q

What does tachypnoea without signs of resp distress suggest

A

It is a sign of sepsis

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118
Q

Which examinations would you do to find an infection focus in a child

A

Typical ABCDE
Check all over for rash (include glass test)
Check fontanelles
Check for photophobia
ENT exam - look for runny nose
Abdominal exam
Check a urine sample if no obvious focus
Use the NICE traffic light system to determine next steps

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119
Q

What signs are required for a diagnosis of ear infection in children

A

Redness alone isn’t enough - can be a general/non-specific sign
Only diagnose if there’s a fluid level behind it, if it’s dull or non-reflective or if its different from the other ear

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120
Q

How can fever affect the findings on ENT exam

A

Temp can make the eardrums pink/flushed - does not mean it’s an ear infection
Same with the tonsils

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121
Q

How will the tonsils appear in true tonsillitis

A

They will be large with a whitish exudate

May be red - not enough on its own

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122
Q

Babies sometimes present with hypothermia in response to infection - true or false

A

True
Babies under 8 weeks old often present without a fever even with a severe infection - may drop their temp instead
Hypothermia is a red flag

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123
Q

Good fever control can prevent a febrile convulsion - true or false

A

False

There is no evidence of this

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124
Q

When would a child be sent for a chest X-ray

A

CXR done in those under 3 with signs of sepsis or a raised RR

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125
Q

How do you diagnose a UTI in children

A

Get a clean catch urine if not toilet trained

Parents given a pot and baby left without nappy to catch urine

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126
Q

When should you suspect a UTI in children

A

Should be considered if you have a fever of unknown source
Children often present without the classic symptoms - more non-specific
Can rapidly turn to sepsis in babies

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127
Q

List signs of bone or joint infection in children

A

Reluctance to use limb or limping (atraumatic limp)
Joint may be warm and red
General signs of infection
Consider osteomyelitis or septic arthritis

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128
Q

How does Kawasaki disease present

A

Child will be very irritable and unwell
High temp goes on for several days
Non-specific rash - usually maculopapular
Red eyes and sore mouths
Large lymph node on one side of neck
Rash fades then peeling of fingers and toes occurs

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129
Q

Kawasaki disease is a disease of childhood - true or false

A

True

Most common in the under 2’s

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130
Q

Kawasaki disease can lead to complications with which major organ

A

The heart

Can also affect the coronary arteries

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131
Q

Kawasaki disease can lead to complications with which major organ

A

The heart

Can also affect the coronary arteries

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132
Q

Kawasaki disease can lead to complications with which major organ

A

The heart

Can also affect the coronary arteries

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133
Q

How do children with influenza present

A

Headache, muscle ache, tiredness, fever, may have a cough

Babies have less specific symptoms - D&V and rash

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134
Q

Sepsis caused by meningitis is more fatal than meningitis alone - true or false

A

True

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135
Q

How do you treat a child with suspected bacterial meningitis (immediate treatment)

A

Give empirical penicillin or ceftriaxone to any older child with suspected meningitis

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136
Q

Viral meningitis can have a mild presentation - true or false

A

True
Can occur alongside viruses - mild and presents with headache
Its the bacterial one that’s severe

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137
Q

List possible causes of rash in children

A 
Allergies
Med reaction
Stings and insect bites
Chemical reactions
Infection
Systemic disease
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138
Q

A rash combined with a cough and sore throat is suggestive of what

A

Measles

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139
Q

A rash combined with sore/red eyes is suggestive of what

A

Kawasaki disease

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140
Q

A rash combined with abdominal pain is suggestive of what

A

HSP

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141
Q

A rash combined with a recent burn is suggestive of what

A

Toxic shock syndrome

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142
Q

A rash combined with a bleeding gums, bruising, joint pain and lethargy is suggestive of what

A

Leukemia

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143
Q

Meningitis will always present with a non-blanching rash - true or false

A

False

Can have a blanching erythematous rash to start with so don’t rule it out

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144
Q

What is erythema toxicum neonatorum

A

A transient rash seen in babies under the age of 1

Appears as raised, red, blotchy areas

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145
Q

Which common childhood rashes present as macules or papules

A

Mild viral rashes, measles, rubella and Kawasaki disease

Macular - splotchy but under skin so cant feel
Papular is the same but with raised area
May be combined as maculopapular

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146
Q

Which common childhood rashes appear as vesicles

A

Vesicles - small blisters

Chickenpox, herpes simplex, shingles

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147
Q

Which common childhood rashes appear as pustules

A

Pustules - pus filled blisters

Strep or staph infections

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148
Q

Which common childhood rashes appear as petichiae or purpura

A

HSP

Meningococcal sepsis

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149
Q

What is the difference between petichiae and purpura

A

Petechiae - 1mm or less in size and flat

Purpura - purple areas 2mm or larger

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150
Q

Which conditions can cause an urticariral rash in children

A
  • Allergy and anaphylaxis

- Can come up and down again

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151
Q

What is cradle cap

A

Seborrheic dermatitis on the head causing flaky scalp

Common in babies

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152
Q

List common sites for eczema in children

A

Necks, elbows, knees, armpits and face

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153
Q

How does eczema appear when there is a secondary bacterial infection in it

A

Will be weepy with scabs

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154
Q

How does Neisseria meningitidis spread

A

Neisseria meningitidis can be found in the nose of carriers
In some people it spreads to the bloodstream then the brain
Most common in children under 5

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155
Q

How does Stevens Johnsons syndrome present in children

A

Rash and blistering of mucous membrane
Rash is target lesions
Children tend to be miserable and need admission if they need fluids (wont want to drink due to blistering)

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156
Q

What causes toxic shock syndrome in children

A

Caused by toxin secreting bacteria like strep or staph

Can occur after minor burn

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157
Q

How do you treat toxic shock syndrome

A

Immediate antibiotic treatment

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158
Q

How does toxic shock present following a burn

A

Burn looks normal but kid has a fever, diarrhoea, erythematous rash and generally unwell
Can become critically unwell very fast

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159
Q

What is HSP

A

It is an immune disease causing bleeding into the skin

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160
Q

How does HSP present in children

A

Child is usually well - obs normal

Presents with the purpuric rash - worst on back of legs and bum

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161
Q

List some of the main complications of HSP

A

Can cause bleeding in intestinal wall which causes abdo pain, may lead to intussusception
Can lead to kidney disease so check BP and urinalysis
Can also cause bleeding into joints causing pain

162
Q

What is idiopathic thrombocytopenic purpura

A

Immune disease which affects platelets and therefore clotting - shows up on FBC
Child will be completely well but have a petechial rash

163
Q

How do you treat idiopathic thrombocytopenic purpura

A

May need steroid treatment

164
Q

Why should you do a FBC in kids with a petichial/purpura

A

Have to exclude cancer as leukaemia can present like this

Will be clinically anaemic

165
Q

What is the more common type of fit - generalised or focal

A

Generalised

166
Q

What is the most common cause of fits in children

A

Temperature - febrile convulsions in younger children

In older children it is more likely a non-febrile epileptic fit in someone with known epilepsy

167
Q

List potential causes of fits in children

A 
Fever - febrile seizures
Acute brain injury 
Epilepsy
NAI - if head injury included 
Encephalitis/meningitis
Metabolic causes (particularly high/low sodium, low calcium, low glucose)
Reflex anoxic seizure 
Drug and alcohol overdose/withdrawal
168
Q

What event happens with warning symptoms a fit or a faint

A

A faint
Will have symptoms like dizziness, feeling hot, hearing and visual changes

Fits happen without warning

169
Q

What should you include in a seizure history

A

Try and get a step by step eyewitness account of the fit itself
Any warning signs
Was there any preservation of consciousness
The appearance of the child during - movement, eyes, colour changes, incontinence
Duration of fit and recovery
Post event headache?

170
Q

Jerking movements means that it is definitely a seizure - true or false

A

False

May see jerking movements or incontinence in faints too

171
Q

What are the main differences between a faint and a fit

A

Fits happen without warning whereas faints usually have warning signs
The main difference is a fast recovery - should be back to normal within minutes
Faints are more common in older children

172
Q

When does cardiac syncope typically occur

A

Due to an arrhythmia - may not feel it

Occurs out of the blue or during exercise

173
Q

How can breath holding attacks lead to convulsive episodes

A

Children sometimes hold their breath in response to to pain or emotion
Can occur after a bump to the head as well
They hold it for so long they can pass out
Severe attacks can lead to reflex anoxic seizures in response to an asystole - true seizure

174
Q

Febrile convulsions are usually which type of seizure

A

Febrile convulsions are usually generalised seizures

Most recover quickly

175
Q

First time febrile convulsions are rare in those over the age of 3 - true or false

A

True

176
Q

If a fever triggers a fit in a known epileptic is it considered a febrile seizure

A

Not a true one

177
Q

How do most children present after a true seizure

A

Children are typically sleepy for 10-30 mins after a fit, they then develop a headache and may become irritable
Headache is a good sign they have had a true fit

178
Q

How likely is it for a child to have another febrile seizure after their first presentation

A

50/50 chance of having another before they grow out of it

179
Q

How do you manage a seizure

A

Time seizures - call for help if longer than 5 mins
Give O2 immediately, can insert an NP airway to hold it open
Then give IV drugs if you get access - e.g lorazepam
If no access the buccal route can be used - medazolam
Parents of known epileptic often have this at home for emergencies

180
Q

How does a focal seizure present

A

Child will be awake and usually aware

The fit will affect a specific part of the body

181
Q

How does a general seizure present

A

Child will be unaware of their surrounding - LOC
Includes tonic clonic seizures (jaw and fists clench, eyes roll back, may make grunting noises)
Also absence seizures

182
Q

How do you manage a child in the post-ictal period

A

Give paracetamol after seizure to treat the headache
Then need to assess for fit complications and then the cause of it
Put in recovery position
Do a full neuro exam after they are awake
Check blood glucose to exclude that as a cause

183
Q

Fits in infants only a few months old often look atypical - true or false

A

True

May present with odd posturing of arms, stiffness etc whilst some just go floppy

184
Q

List signs of aspiration post-seizure

A

Signs include a drop in O2 sats, high RR or resp distress following a seizure event

185
Q

What is status epilepticus

A

A fit lasting over 30 mins or when there is incomplete recovery between fits
Usually in severe epilepsy or severe underlying cause

186
Q

Why would a small baby be jittery

A

Small babies become ‘jittery’ if they have low sugars - shaky but not a true fit

187
Q

What is the most common cause of dehydration in children

A

Gastroenteritis - most often viral
Usually has to be severe for it to lead to dehydration
Children with chronic diseases are more vulnerable

188
Q

How do you manage viral gastroenteritis in children

A

Oral rehydration sachets (e.g diorylite) are used for an oral fluid challenge
Oral fluid challenge can be observed - get parents to note down intake and output
IV fluids needed for more severe case such as DKA or if oral management not working

189
Q

Which children are more vulnerable to dehydration

A

Children with chronic diseases

190
Q

What typically comes first in viral gastroenteritis, diarrhoea or vomiting

A

Vomiting usually precedes diarrhoea

191
Q

Diarrhoea and vomiting in children can be a sign of almost any illness, not just GI conditions - true or false

A

True

Many children will have 1 or 2 episodes of D&V with any illness so should run through other symptoms

192
Q

How would a child with campylobacter infection typically present

A

Gastroenteritis with abdominal cramps

193
Q

Why might appendicitis present with diarrhoea in children

A

It increases bowel motility = diarrhoea

Same with bowel obstruction

194
Q

What can cause bloody stools in children

A

Salmonella or shigella infection

Can also be a sign of intussuception - red current jelly sign

195
Q

In terms of nappies, when would you be worried about dehydration in a child

A

If no wet nappies for 12 hours

196
Q

List signs of severe dehydration in children

A 
Sunken eyes or fontanelle (ask parents if abnormal for them)
Dry mucous membranes
Mottling
Cool peripheries
Poor cap refill (poor perfusion due to dehydration)
Poor skin tugor
Oliguria
Tachycardia
Hypotension
Persistent drowsiness
197
Q

What is hypernatreamic dehydration

A

A type of dehydration specific to babies
Caused by their immature kidneys
If they get dehydrated (e.g. due to poor feeding or D&V) the kidneys cannot compensate properly by retaining water
Leads to a high sodium (imbalance due to water loss)

198
Q

How does hypernatraemic dehydration present

A

Drowsiness - wont wake up to feed
Skin eyes and fontanelles NOT sunken
High HR and RR
Diagnose by blood test - high Na

199
Q

Which children are at risk of hypernatraemic dehydration

A

Seen in first weeks of life when breastfeeding hasn’t been established properly or in bottle fed babies if feeds not made up properly
Also seen in those with severe watery diarrhoea

200
Q

How does DKA present

A

High glucose and ketones cause dehydration
High RR caused by acidosis
Polyuria, excessive thirst and dehydration

201
Q

List common abdominal causes of abdominal pain in children

A

Colic, intussuception, mesenteric adenitis, constipation, IBS (usually Crohns), coeliac, bowel obstruction, appendicitis

202
Q

List common causes of abdominal pain in children that originate outwith the abdomen

A 
Migraines
DKA, 
Psych issues - stress 
UTI
Testicular torsion
Ovarian cysts or torsion 
Malignancy 
Infections elsewhere can cause abdominal pain
203
Q

Appendicitis is hard to diagnose in children under 5 - true or false

A

True

Common for appendix to rupture before diagnosis

204
Q

List common causes of chronic abdominal pain in children

A

Constipation
IBD
Malignancy

205
Q

List common causes of acute abdominal pain in children

A

UTI
DKA
Surgical issue (obstruction, appendicitis etc)

206
Q

Bilious vomiting is suggestive of what type of pathology

A

Bowel obstruction

Investigate by AXR, bloods and surgical opinion

207
Q

List common symptoms of surgical bowel issues such as obstruction or appendicitis

A

Not eating
Severe pain
Worse on movement
Vomiting (particularly bilious = obstruction)

208
Q

List some red flag features of abdominal pain in children

A

Faltering growth/failure to thrive is a sign of more serious pathology
So is being woken from sleep by the pain

209
Q

List red flags for cervical lymphadenopathy

A
  • Persistent fever (> 2 weeks)
  • Weight loss
  • Night sweats
  • Pruritis
  • Lymph nodes in the supraclavicular region
  • Hepatomegaly
  • Splenomegaly
  • Anaemia
  • Excessive bruising
  • Fatigue
  • Shortness of breath
  • Bone pain
210
Q

What is the most common cause of lymphadenopathy in children

A

Mostly due to benign self-limiting viral illness

Increased numbers of immune cells collect in the nodes, enlarging them

211
Q

What is the first line treatment for lymphadenitis in children

A

Oral co-amoxiclav

212
Q

List common signs and symptoms of lymphoma

A 
Painless, enlarged nodes 
May grow rapidly or wax and wane 
Intermittent fever and night sweats 
Weight loss
Difficulty in breathing (seen if there's a large mediastinal mass
213
Q

How do you stage lymphoma

A
  • LP
    • CT chest, abdo and pelvis
    • Bone marrow biopsy
214
Q

What is tumour lysis syndrome

A

A potentially life threatening complication of cancer
Especially common in the early stages of chemotherapy treatment.
The tumours release their intracellular contents
Cancers with high proliferation rates (such as haem) re at an increased risk due to high cell turnover

215
Q

Describe stage 1 lymphoma

A

One group of lymph nodes is affected, or there’s a single extranodal tumour.

216
Q

Describe stage 2 lymphoma

A

Two or more groups of nodes are affected
Or there is a single extranodal tumour that has spread to nearby lymph nodes
Or there are two single extranodal tumours, but only on one side of the diaphragm.

217
Q

Describe stage 3 lymphoma

A

There is lymphoma on both sides of the diaphragm (either in two or more groups of nodes)
Or there are two single extranodal tumours
Or the lymphoma is affecting the chest.

218
Q

Describe stage 4 lymphoma

A

The lymphoma has spread beyond the lymph nodes to other organs of the body such as the bone marrow or nervous system

219
Q

List the key features of tumour lysis syndrome

A

Hyperkalaemia - usually happens first)
Hyperphosphataemia which then causes the hypocalcaemia and hyperuricaemia.
AKI - happens for many reasons - hyperhydration before chemo, obstruction by uric acid and calcium phosphate

220
Q

What is screened for in the newborn heel prick test

A

Cystic Fibrosis, Congenital Hypothyroidism, Phenylketonuria, MCADD, Sickle Cell Disease, Maple Syrup Urine Disease, Homocystinuria, Glutaric Aciduria type 1 and Isovaleric Aciduria

221
Q

How is Cystic Fibrosis screened for in the UK

A

Part of the newborn heel prick test

222
Q

Describe the early management of CF

A

Monitor feeding and growth
Give pancreatic enzyme replacement to prevent malabsorption, particularly of fats
Fat soluble vitamin supplements required as not properly absorbed- ADEK

Also treated with regular physiotherapy and prophylactic antibiotics

223
Q

How is faecal elastase used in monitoring of CF

A

Faecal elastase is a marker of exocrine pancreatic function so CF kids may get it measured
This function is usually decreases in CF

224
Q

Why is pancreas function reduced in CF

A

The pancreatic ducts get obstructed by thickened secretions, reducing function
Both exocrine and endocrine functions are
Leads to malabsorption and diabetes

225
Q

How can CF present

A

Recurrent respiratory infections - can lead to bronchiectasis)
Failure to thrive
Pale/offensive stool - due to pancreatic insufficiency and malabsorption
Meconium ileus - bowel obstruction due to sticky stool

226
Q

What are the two main nutritional challenges seen in cystic fibrosis

A

Pancreatic dysfunction results in malabsorption of energy dense fats The chronic respiratory infection results in an increased calorie requirement

227
Q

How do you treat the nutritional deficiencies associated with CF

A

Counteracted with enzyme replacement and calorie dense diet

Sometimes overnight gastrostomy or NG feeds are used

228
Q

List some of the complications of CF

A

Bronchiectasis, diabetes, distal intestinal obstruction syndrome, cirrhotic liver disease and infertility

229
Q

A normal respiratory rate in a child with respiratory distress may be falsely reassuring - true or false

A

True

Can be a sign of a tiring child

230
Q

Why should you note if a child was distressed during an examination

A

Distress can make them tachycardic etc. so may be a false sign
Important to note down

231
Q

How do you correct for gestation on a growth chart

A

Should correct for gestation on growth chart if born before 37 weeks - measurements plotted at their actual age (i.e. as though born at 40 weeks) and then a line (with an arrow pointing left) should be drawn back the number of weeks the infant was premature

232
Q

Until what age do you correct for gestation on the growth chart

A

Until they are 1 year old

233
Q

What causes slapped cheek syndrome

A

Human Parvovirus B19 or Fifth Disease

234
Q

What is the risk of catching parvovirus/slapped cheek syndrome in pregnancy

A

Infection in pregnancy can lead to fetal anaemia, ‘hydrops fetalis’ and miscarriage

235
Q

What are the symptoms of slapped cheek syndrome

A

Fever
Headache
Runny nose
Followed by a rash on the arms and legs and middle of the body
The child may develop bright-red cheeks/”slapped-cheek” rash.

236
Q

Describe the rash seen in slapped cheek syndrome

A

Bright red cheeks
The rash is seen on the arms and legs and middle of the body
It fades from the centre outwards, so it looks lacy.
Usually lasts around 2 weeks

237
Q

Which children are at high risk if they catch slapped cheek syndrome

A

Children with sickle cell disease as can cause aplastic crisis

238
Q

What is involved in a septic screen in children

A

LP, urine culture (clean catch), CXR when resp signs

239
Q

When would you do a septic screen in a child

A

In all infants with fever under 6 weeks of age.
It is highly advisable in febrile infants between 6 weeks and 3 months, especially when the child is clinically unwell or the white cell count is abnormal

240
Q

List contraindications for LP in children

A

Coma
Signs of raised ICP
Cardio or resp compromise
Focal neuro signs or seizures
Recent seizure (within 30 mins or not returned to normal)
Coagulopathy/thrombocytopenia
Local infection (in the area where an LP would be performed)
The febrile child with purpura where meningococcal infection is suspected.

241
Q

List some potential complication of LP in children

A

Failure to obtain a specimen / need to repeat LP/ Traumatic tap (common)
Post-dural puncture headache - fairly common
Transient/persistent paresthesiae/numbness (very uncommon)
Respiratory arrest from positioning (rare)
Spinal haematoma or abscess (very rare)
Tonsillar herniation (extremely rare in the absence of contraindications above)

242
Q

How do you prescribe fluids in children

A

For the 1st 10kg prescribe 100ml/kg
For the 2nd 10kg prescribe 50ml/kg
For every kg above 20kg prescribe 20ml/kg

243
Q

Lower lobe pneumonias can present with abdominal pain in children - true or false

A

True

244
Q

What signs of constipation may be found on abdominal exam

A

Hard faeces may be felt in the left iliac fossa

245
Q

What is the most common cause of peritonitis in children

A

Perforated appendix

246
Q

How does peritonitis present

A

Leads to widespread tenderness and guarding

Will also cause pain on movement

247
Q

How can extra-abdominal infections lead to intussuception

A

Due to swelling of Peyer’s patches (lymph node collections) in the bowel wall in response to the infection
Bowel folds around this
May be seen with tonsillitis or ear infections

248
Q

List some potential causes of abdominal masses in children

A

Neuroblastoma and Wilms tumour
Appendix abscess
Constipation

249
Q

How might testicular torsion present

A

Swelling in scrotum
Tenderness or pain
Abdominal pain
Colour change

250
Q

Testicular torsion is common in which age group

A

Torsion is most common in boys over 12 but should be considered in all boys

251
Q

What is more common falling head injury in children - diffuse brain injury or haemorrhage

A

Diffuse brain injury - cerebral oedema

Usually occurs over the 24hrs after the injury

252
Q

List red flag symptoms that suggest a serious head injury in children

A

Persistent drowsiness - more than 2 hours
Persistent headache
Persistent vomiting

253
Q

What key factors should be covered in a head injury history

A 
Mechanism of injury 
Risk of NAI?
Behaviour at time of injury and since then 
Ages 
LOC (means injury was significant)
254
Q

What is considered a significant fall in a child

A

Anything from their height or above

255
Q

Which consequences of head injury can lead to true irritability in children

A

Cerebral oedema, contusions and haemorrhage

256
Q

Which consequences of head injury can lead to true irritability in children

A

Cerebral oedema, contusions and haemorrhage

257
Q

What are the indications for CT scan following head injury

A 
LOC for more than 1 min 
Head injury with seizure 
Persistent drowsiness - over 2 hours 
Headache
Vomiting
258
Q

Brain haemorrhage almost always causes a headache = true or false

A

True

259
Q

Following head injury behavioural changes usually occur after focal signs present - true or false

A

False

Behavior usually changes first

260
Q

Which type of head injuries are common signs of NAI

A

Skull fracture and subdural haemorrhage
Injuries around the eye and ear may also be suspicious
Facial bruising in a non-walking infant is suspicious of NAI

261
Q

How does the AVPU scale correlate to GCS

A

P on AVPU is roughly GCS 8

262
Q

Which scalp signs suggest an underlying skull fracture

A

Soft, boggy or large swelling on scalp may suggest underlying fracture
Boggy haematoma

263
Q

Facial bone fractures are common in children - true or false

A

False

Only really happens with a direct blow or high power injury like unrestrained RTA

264
Q

What is mesenteric adenitis

A

Inflammation of the abdominal lymph nodes
Typically caused by viral infection
Causes abdominal pain in children

265
Q

How do you differentiate between reflux and GORD in children

A

All kids get reflux but GORD is when the reflux causes faltering growth or signficant distress

266
Q

Why should you not examine the throat in suspected croup

A

There is a risk of epiglottitis and if you irritate this it can lead to airway closure

267
Q

What symptoms may be caused by administration of salbutamol

A

Tachycardia

Tremor

268
Q

What is the minimum amount you want a child to be feeding per day

A

100ml per kg is the minimum you want

150ml per kg per day is normal feed

269
Q

How does HUS present

A

Bloody diarrhoea - acute
Common cause of AKI in children
Microangiopathic Haemolytic Anaemia
Red cell fragmentation on Blood Film

270
Q

What is HUS

A

Haemolytic uraemic syndrome

Consequnce of an e.coli 0157 infection

271
Q

How do you manage HUS

A

Send stool sample
If well discharged with worsening advice
If unwell admit and give IV fluids

272
Q

List signs of uncontrolled asthma

A

Symptoms every day
Symptoms disturbing sleep
Using reliever inhaler once a day or more
Symptoms triggered by simple exertion such as walking up stairs
Frequent absence from school due to asthma

273
Q

List signs of poorly controlled asthma

A

Any asthma symptoms three times a week or more
Waking in the night because of asthma, one night a week or more
Any limitation on activities - exercise, leisure activities, school attendance
Using reliever inhaler three times a week or more

274
Q

What is the main difference between the administration of aerosol and dry powder inhalers

A

Aerosol inhalers are inhaled slowly and deeply, but dry powder inhalers should be inhaled fast and forcefully

275
Q

Why do children have higher resp rates than adults

A

Smaller people have smaller tidal volumes

RR higher to keep minute ventilation

276
Q

Why do children have higher heart rates than adults

A

Smaller people have smaller stroke volumes

HR higher to maintain a sufficient cardiac output

277
Q

What signs suggest severe croup

A

Severe respiratory distress
Cyanosis
Exhaustion

278
Q

How do you manage GORD In children

A

Conservative measures
Thickening feed (eg. Gaviscon)
Reducing stomach acid (eg. PPI / H2 antagonist)
Emptying stomach faster (eg. Domperidone)
Early weaning can be useful

279
Q

How does transient synovitis present

A

Painful joint - usually hip
Child will be otherwise well and afebrile
Preceded by viral illness in approximately 50%

280
Q

How do you manage transient synovitis

A

Usually resolves by itself in 7-14 days

281
Q

What is Perthes disease

A

Avascular necrosis of the capital femoral epiphysis

Typically occurs in those aged 3-9

282
Q

How does Perthes disease present

A

Onset occurs over weeks
Child will be systemically well
No other joint involvement (just hip) and no signs of joint inflammation

283
Q

How does septic arthritis present in children

A

Most commonly affects lower limbs
Usually unwell with fever / malaise and evidence of joint inflammation
Pain is usually severe
Hold the affected limb flexed or completely stop using the limb

284
Q

How do you manage septic arthritis in children

A

Early involvement of orthopaedics as joint destruction can occur within 24 hours

285
Q

Which children are most affected by SUFE

A

Usually late childhood / adolescence
M>F 2:1
Often weight >90th centile

286
Q

How does SUFE present

A

Antalgic gait and apparent leg length discrepancy

287
Q

Severe eczema can impact on development - true or false

A

True
All time and energy goes into skin
Miss out on opportunities and education

288
Q

How can eczema lead to fluid loss

A

If severe you get leaking of serous fluid through broken skin - loss of fluid

289
Q

The vast majority of children have which type of diabetes

A

Type 2

Even with rising obesity, the rate of type 2 in children isn’t as high

290
Q

Good glycaemic control early on can reduce risk of complications further down the line - true or false

A

True

This is why paediatric diabetes is so important to control

291
Q

The level of response to insulin changes as the child ages - true or false

A

True
Honeymoon period when first started on treatment where they are really responsive
Become less responsive to insulin in puberty - though to be due to hormone change etc

292
Q

Why would a family history of thyroid problems be relevant to a child with suspected diabetes

A

Both are autoimmune conditions and can therefore be related/run in families

293
Q

How might DKA present in a child

A

History of polyuria, polydipsia and tiredness
Tummy pain
Breathing issues - Kussmaul’s breathing
Symptoms of dehydration

294
Q

How might DKA present in a child

A

History of polyuria, polydipsia and tiredness
Tummy pain
Breathing issues - Kussmaul’s breathing
Symptoms of dehydration

295
Q

How do you diagnose DKA

A 
Urinalysis
NPT – glucose and ketones
Bloods – FBC, U&E, Glucose, CRP, +/-Culture, HbA1c, Anti-GAD antibodies
Blood gas
Additional Ix on basis of presentation
296
Q

How do you diagnose DKA

A 
Urinalysis
NPT – glucose and ketones
Bloods – FBC, U&E, Glucose, CRP, +/-Culture, HbA1c, Anti-GAD antibodies
Blood gas
Additional Ix on basis of presentation
297
Q

How do you manage DKA

A

Treat shock - IV access and fluids
Switch off ketosis - rehydrate then commence replacement insulin
O2 if required (sats<94%)
Monitor Electrolyte shifts (Na, K, Cl & HCO3)
Convert to S/C insulin once ketosis reversed and patient feeling better.

298
Q

Describe how fluids are replaced in a patient with DKA

A

Initial bolus of 0.9% NaCl given to treat shock if present - 10ml/kg
After this you move to maintenance fluids which are given much slower - aiming to replace the fluid deficit
Subtract the initial bolus from the calculated deficit to get the dose of fluid needed

299
Q

Why would you need K+ replacement in a patient being treated for DKA

A

Administration of insulin will cause your K+ to drop so will need replaced – quite hard to replace so catch it early

300
Q

If a known diabetic patient presents with DKA you should stop their insulin - true or false

A

False

Long acting insulin should never be stopped – if they come in with DKA you should still give them it at night

301
Q

What can cause fluid loss in a child

A

Blood loss
Gastroenteritis - D&V
Burns

302
Q

What are the main reasons for requiring resuscitation in children

A

Respiratory Arrest = 85% of paediatric resus are hypoxia related
CARDIAC ARREST – 15% of paediatric resus are SHOCK related

Much more likely to survive respiratory arrest

303
Q

Which conditions can cause fluid maldistribution

A

Septic shock
Cardiac disease
Anaphylaxis

304
Q

How do you perform CPR in a child

A

Open airway - neutral head in infants, sniffing in children (not full head tilt)
Can lift chin or do jaw thrust if ineffective
If not breathing properly give 5 rescue breaths
Then move to 15 chest compression with 2 rescue breaths - 1/3 of chest depth
2 fingers or hand encircling in infants, one hand in young children

305
Q

What is the biggest cause of mortality in children worldwide

A

Neonatal death

Then diarrhoael diseases then pneumonia

306
Q

What is the most common thing for children to present with

A

Respiratory illness

307
Q

How do you recognise sepsis in a child

A

Any child with suspected or proven infection and at least 2 from:

  • Core temp <36C or >38C
  • Inappropriate tachycardia
  • Altered mental state (sleepiness, irritability, lethargy, floppiness)
  • Reduced peripheral perfusion
308
Q

Which children at at higher risk of sepsis and therefore have a lower threshold for treatment

A 
Infants below 3 months old
Immunosuppressed or comprimised 
Recent surgery 
Indwelling devices/lines 
Complex neurodisability or long term condition 
High index of clinical suspicion 
High parental concern
309
Q

What is the paediatric sepsis 6

A

Give high flow O2
Takes bloods - cultures, glucose, lactate
Give IV or IO antibiotics

If shocked:

  • Consider fluid resus
  • Inotrophic support early - adrenaline or dextrose
  • Involve seniors/specialists early
310
Q

How does tonsillitis present in children

A 
Fever
Poor oral intake
Drooling
Halitosis
Rash/perioral pallor
311
Q

How do you deal with a choking child

A

If they have an effective cough - encourage them to cough until they clear the obstruction or deteriorate

If ineffective cough but conscious - do 5 back blow followed by 5 thrusts (on chest for infant and abdomen for child over 1)

If ineffective cough but unconscious - open airway, give 5 breaths and then start CPR

312
Q

List the reversible causes of cardiac arrest

A

Hypoxia
Hypovolaemia
Hypo/hyperkaelameia (or other metabolic)
Hypothermia

Tension pneumothorax
Tamponade
Toxins
Thromboembolism

313
Q

What are the shockable rhythms

A

VF

Pulseless VT

314
Q

What are the non-shockable rhythms

A

Pulseless electrical activity

Asystole

315
Q

What is the resus protocol for a newborn

A

If all is normal - clear airway, keep warm and dry
If not crying - reposition and stimulate
If apneoic or HR< 100 bpm then give positive pressure ventilation
If HR<60 then ensure effective lung inflation and add chest compression
If this does not work consider adrenaline

316
Q

How do you get intraosseous access

A

Go in on the medial aspect of tibia, around 1-2 fingers below tibial tuberosity
Perpendicular to flat surface of bone
Push until gives

317
Q

Which type of fluid should be used for fluid resus in children

A

Use ISOTONIC solutions - 0.9% saline or 4.5% albumin
Hypotonic will cause cerebral oedema and may cause coning
DO NOT use dextrose as volume replacement

318
Q

What volume of fluid needs to be lost for signs of shock to present

A

Around 25% of circulating volumes

319
Q

How would you use a spacer with a pressurized metered dose inhaler

A

Long, slow breaths in and out of the spacer – 10 for young children (5 for older children)

320
Q

Which types of inhaler can be used with a spacer

A

Pressurised metered dose inhaler

321
Q

What is a PMDI

A

Pressurised metered dose inhaler
e.g. salbutamol or seretide evohaler
Classic blue ‘puffer’
Must breath in, press down inhaler and continue to inhaler - one action

322
Q

Why is it important to clean spacers

A

The build up of drug inside spacer makes it less effective

323
Q

What is a breath actuated inhaler

A

Inhaler where the delivery of drug is triggered by the patient breathing in
Convenient as easy to use but does not require a spacer

324
Q

What is a dry powder inhaler

A

Where drug is delivered as a powder - obviously

Need to breath in hard and fast - not pressurised so patient has to do the work

325
Q

PMDIs can be used by all age groups - true or false

A

True

Younger children will likely need a spacer

326
Q

List signs of a true seizure

A 
Tonic – stiffness 
Clonic – movements 
Eye rolling 
Loss of consciousness 
If they are a known epileptic 
Incontinence 
Heart rate increases 
Hypoxia 
Post-ictal period – takes some time to recover, drowsy
326
Q

Focal seizures can progress into a generalised ones - true or false

A

True

327
Q

If breathing regular/relaxed it’s unlikely to be a seizure - true or false

A

True

328
Q

Flashing lights is a common trigger of seizure in children - true or false

A

False it is rare

329
Q

Neonatal seizure are very rare - true or false

A

True

Can be very difficult to diagnose the cause

330
Q

List some potential causes of seizures in neonates

A

Myoclonus of infancy
Reflux - sandiffer syndrome, contort due to reflux discomfort
Normal baby movements
Jitters
Infantile spasms
West syndrome - causes seizures in small babies, associated with developmental regression, has a distinctive EEG

331
Q

Every child who comes in with a syncope/funny turn needs an ECG - true or false

A

True
May be due to an arrhythmia
Some kids make fitting movements when collapsed

332
Q

What is gratification

A

Unconscious movements which are done because they feel good

Can appear unresponsive or seizure like

333
Q

What can be done to avoid febrile seizures

A

Nothing

It just happens to some children in response to temperature (>38C)

334
Q

What must be excluded before a diagnosis of febrile seizure can be made

A

CNS infection

If the infection is meningitis then it is not a febrile convulsion, it is due to the brain infection itself

335
Q

Which types of epilepsy are specific to childhood

A

Childhood absence epilepsy
Benign epilepsy of childhood with centro-temporal spikes

Juvenile myoclonic epilepsy develops in adolescence

336
Q

EEGs can be used to diagnose epilepsy - true or false

A

False

It is not a diagnostic test but used with history to corroborate

337
Q

When would a MRI brain be requested for a child who had a seizure

A

If there was a focal onset

338
Q

When would genetic tests be carried out on a child presenting with seizure

A

Particularly if early onset < 3yo
Intractable
Strong family history

339
Q

When is epilepsy considered to have resolved

A

In those who had an age-dependent syndrome but are now past the applicable age
Those who have remained seizure free for the past 10 years with no seizure medication for the last 5

340
Q

What is the diagnostic criteria for epilepsy

A

At least 2 unprovoked seizures occurring more than 24hrs apart

Or one unprovoked seizure and a probability of another that is similar to the general recurrence risk after 2 unprovoked over the next 10 years

341
Q

Which signs are suggestive of an UMN lesion

A

Weakness accompanied by increased tone and hyper-reflexia

342
Q

Which signs are suggestive of a LMN lesion

A

Flaccid weakness with absent reflexes,
Look for bowel and bladder involvement or a sensory level to locate level of a spinal cord injury
May affect one limb (Nerve entrapment)
May be ascending as in Guillain Barre
Or intermittent, relapsing and “sounds unusual” as in periodic paralysis

343
Q

List the main indications for urgent brain imaging in children

A

Altered Conscious level (CT)
Focal seizures as discussed (CT)
Cranial nerves involvement or Focal neurology ( ? Brain, spine or both) (CT)
Raised ICP – bradycardia, hypertension, papilloedema (CT)
Spinal cord injury/ compression – ONLY INDICATION FOR AN out of hours MRI
Combination of signs

344
Q

Angular chelitis may be caused by which conditions

A 
IBD 
Infection 
Candida 
Drooling 
Atopic eczema 
Poor nutrition
345
Q

Mouth ulcers may be seen in which conditions

A

Often a sign of Crohn’s

Sometime seen in coeliac

346
Q

Pigmented or freckled lips are a sign of which condition

A

Peutz-Jegher’s syndrome

A cancer syndrome - GI, breast, ovaries, pancreas

347
Q

How far down can you visualise with an endoscope

A

Down to the 2nd part of the duodenum

348
Q

All endoscopies in children are carried out under GA - true or false

A

True

At least in the UK

349
Q

List symptoms of GORD in children

A

Retrosternal pain/heartburn
Vomiting
Back arching
Cough/aspiration pneumonia

If it leads to severe oesophagitis and erosion you may see melaena/anaemia

350
Q

How might eosinophilic oesophagitis present in children

A 
Difficulty swallowing (dysphagia)
Painful swallow
Food bolus obstruction
351
Q

Gastric ulcers rarely present in children under what age

A

Rare before the age of 2
Typically due to H/pylori infection
Presents with pain, vomiting and melaena

352
Q

Children have much higher calorie requirements per kg than adults - true or false

A

True
They have to consistently gain weight and grow
This is why bowel disorders can lead to failure to thrive/grow

353
Q

What is the most common cause of rectal bleeding in children

A

Constipation and passage of hard stools

This can lead to fissures as well

354
Q

Erythema nodusum is associated with which GI condition

A

Crohn’s
It is confined to arms and legs
Nodular and painful

355
Q

Pyoderma gangrenosum is assocated with which GI condition

A

Crohn’s and UC
Confined to arms and legs
Looks like an infected ulcers but doesn’t respond to antibiotics

356
Q

Dermatitis herpetiformis is associated with which GI condition

A

Coeliac disease
Rarer in children than adults
Can appear anywhere on the body and looks like eczema

357
Q

What are the most common causes of viral diarrhoea

A

Noravirus, adenovirus, (rotavirus in countries without rotavirus vaccine)

358
Q

What is the most common cause of diarrhoea in children, virus, bacteria or parasite

A

Viral

359
Q

what are the most common bacterial causes of diarrhoea in children

A

E-coli 0157 (associated with Haemolytic Uraemic Syndrome), clostridium difficile, campylobacter, salmonella, cryptosporidium

More likely to present with blood in stool

360
Q

what are the most common parasitic causes of diarrhoea in children in the UK

A

Giardia

Most other causes found abroad

361
Q

How do you treat viral gastroenteritis in children

A

Trial of oral rehydration with oral rehydration solution (Dioralyte, Rehydrat)
Consider 1 dose ondansetron
Use syringe and give 5 ml every 2 minutes, consider NG tube if refusing to take solution
Intravenous fluids- admission with attention to fluid balance

362
Q

List potential causes of diarrhoea in children

A

Infection most common cause
Inflammatory bowel disease
Malabsorption/enteropathies

363
Q

Which conditions can cause malabsorption in children

A 
Coeliac Disease
Crohn’s disease
Cystic fibrosis 
Food allergies
Lactose intolerance
Other rarer causes
364
Q

What is Toddler’s diarrhoea

A

A benign condition thought to be caused by bowel immaturity
Typically self-limiting and improves by age 5-6
Can have up to 10 stools per day
No other abdominal symptoms, thriving child

365
Q

How do you manage Toddler’s diarrhoea

A

Rule out other causes - FBC, U&E, LFT, Coeliac screen
Reduce excessive fruit juice
Increase fat if on low fat diet
Keep fibre content normal
May rarely need Loperamide to help with toilet training

366
Q

GORD in children is typically benign and self-limiting - true or false

A

True

~ 98% resolved by 2 years

367
Q

How do you manage GORD in a child

A

Assess for overfeeding
Reassurance
Consider cow’s milk protein allergy and trial of hydrolysed formula
Carobel or Gaviscon added to feed as thickener
Consider use of PPI
Further investigate if loosing weight/red flag signs

368
Q

How does coeliacs disease present

A 
Diarrhoea 
Pale Stools 
Bloating
Growth failure 
Anaemia - asymptomatic
369
Q

How do you screen for coeliac disease

A 
tissue transglutaminase (TTG)
anti- endomesial antibodies (EMA)

Should also check FBC, U&Es, LFTs, CRP, Iron studies, Ferritin, stool cultures, consider faecal calprotectin

370
Q

What is the gold standard for coeliac diagnosis

A

endoscopy with duodenal biopsy

371
Q

Children can be diagnosed with coeliac based on blood tests alone - true or false

A

True
Although only if classical symptoms
AND
TTG > 10 x upper limit of normal (varies between labs)

372
Q

How does coeliac appear on histology

A

Crypt hyperplasia
Flattening of villi
Lymphocytic infiltration

373
Q

Coeliac disease can be associated with which other conditions

A

Diabetes Mellitus type1
Autoimmune thyroid disease
Juvenile Chronic Arthritis
Other autoimmune diseases

Down’s syndrome
Turner syndrome
Williams syndrome

374
Q

List some complications of coeliac disease

A 
Osteoporosis
Anaemia 
Short stature 
Delayed puberty 
Female infertility
Intestinal malignancies (t-cell lymphoma)
375
Q

How does Crohn’s present

A 
Diarrhoea (with blood in Crohn’s colitis)
Weight loss
Anaemia
Abdominal pain
Peri-oral or perianal lesions

extra-intestinal signs in liver, eyes and skin

376
Q

How does Crohn’s present on histology

A 
skip lesions
oedema,
Inflammation
Cryptitis
Abscesses
only 30% have granulomas
377
Q

How do you investigate suspected Crohn’s disease

A

FBC, U&Es, LFTs, CRP (ESR), ferritin, coeliac screen, plasma viscosity (if >10years)
Faecal Calprotectin
Stool cultures x 3 - including C.diff.
Upper and lower GI endoscopy
MRI small bowel study - barium study in younger children

378
Q

List potential complications of Crohn’s disease

A 
Perforation
Fistulae
Colon CA in colitis
Sclerosing cholangitis
Autoimmune hepatitis
Small increased risk of malignancies - increased by immunosuppressive meds
379
Q

How do you manage Crohn’s in children

A

Induce remission

  • Elemental diet for 6-8 weeks (for upper GI disease)
  • Steroids (Prednisolone)

Maintenance
initially azathioprine
step up to methotrexate +/- infliximab or adalimumab

Avoid surgery if possible

Nutrition
Diet rich in calories
Low in bulk to avoid obstruction

380
Q

What is the definition of constipation

A

Must include two from:
Less than three defecations per week
At least one episode per week of faecal incontinence (after the child has acquired toileting skills)
A history of excessive stool retention or retentive posturing
A history of painful or hard bowel movements
Presence of a large faecal mass in the rectum
A history of stools with large diameter that may obstruct the toilet

381
Q

Recurrent rectal prolapse in children can be an indicator for which condition

A

CF

382
Q

Explosive passing of stool following rectal examination suggests which condition

A

Hirschsprung’s disease

383
Q

What typically causes rectal/anal skin tags in children

A

Usually caused by healed fissures

These can be caused by Crohn’s or sexual assault

384
Q

List risk factors for constipation in children

A 
Low fibre intake 
Low fluid intake
Excessive dairy products
Lack of exercise
Obesity 
Problems with toilet training
385
Q

How can you treat constipation in children

A

Softeners - e.g. Magrocol such as Laxido, Movicol
May need Laxido clear out if faecal impaction +/- soiling

May need to add stimulant such as Docusate or Senna

Adjust dose to achieve bristol stool chart goal

386
Q

Long term use of laxatives will harm the bowel - true or false

A

False

Laxatives DO NOT make the bowel lazy- longstanding constipation harms the bowel

387
Q

Why do children with constipation sometimes soil themselves

A

Faecal impaction causes overflow diarrhoea

Patient often not aware of soiling or smell

388
Q

What is Infant Dyschezia

A

Problem in learning to defaecate with poor coordination of straining on stool and opening of the external anal sphincter
Babies appear in pain when trying to pass stool and settle when stool is passed
Stools are soft when passed-this is not constipation and laxatives will not help
Generally resolves after 2-4 weeks, no treatment is required

389
Q

How is UC graded

A

Mild
Distal colon only, <3 stools/day, little blood, no fever, no weight loss

Moderate
3-5 stools/day, bloody, abdo pain + cramps, low grade fever, mild anaemia, weight loss

Severe
>5 stools/day, frank blood, fever, anaemia, leukocytosis, hypoalbuminiaemia, pain, risk of toxic megacolon and perforation (requires admission and urgent assessment with endoscopy)

390
Q

Most children with UC present with which grade of disease

A

moderate to severe pancolitis

391
Q

How do you manage toxic megacolon

A

‘Drip and suck’
IV antibiotics
Early surgical review

392
Q

List some complications of UC

A

Long term risk of Colon Cancer

Extra intestinal manifestations
growth failure
arthropathy
episcleritis
skin (erythema nodosum/pyoderma gangraenosum)
auto-immune liver disease (more common in males, can progress to primary sclerosing cholangitis)

393
Q

How does UC appear on histology

A

polymorph nuclear leucocytes near base of crypts
crypt abscesses
NO granulomas

394
Q

How do you manage UC

A

Steroids to induce remission

Maintenance therapy
Mild - Mesalazine only
Moderate to severe - Mesalazine + Azathioprine,
Non responders - Mezalazine+ Azathioprine+ Infliximab or Adalimumab

CURE = Colectomy

395
Q

How do you manage UC

A

Steroids to induce remission

Maintenance therapy
Mild - Mesalazine only
Moderate to severe - Mesalazine + Azathioprine,
Non responders - Mezalazine+ Azathioprine+ Infliximab or Adalimumab

CURE = Colectomy

396
Q

What is eosinophilic oesophagitis

A

Immune condition characterised by eosinophilic infiltration of the oesophageal mucosa
2nd most common cause of oesophagitis after GORD

397
Q

How does eosinophilic oesophagitis present

A

Clinical presentation with difficulty swallowing or food bolus obstruction

398
Q

How does eosinophilic oesophagitis present

A

Clinical presentation with difficulty swallowing or food bolus obstruction

399
Q

How do you treat eosinophilic oesophagitis

A

1st line dietary management top 6 food elimination (seafood, nuts, dairy, eggs, wheat, soya, 80% successful)
2nd line topical viscous budesonide

400
Q

List potential causes of vomiting due to obstruction

A

Pyloric stenosis
Intestinal volvulus
Intussusception
Adhesions after previous surgery

Child Health (14 decks)

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