Emergencies

Question 1

Vital signs Infants

Answer 1

RR 30-40
HR 110-160
BP 80-90

Question 2

Vital signs Young Children

Answer 2

RR25-35
HR 95-150
BP 85-100

Question 3

Vital signs Older Children

Answer 3

RR 20-25
HR 80-120
BP 90-110

Question 4

Causes of shock

Answer 4

Hypovolaemia .e.g. sepsis, dehydration, DKA, blood loss
Maldisription.e.g. sepsis, anaphylaxis
Cardiogenis .e.g. arrythmia, heart failure
Neurogenic .e.g. spinal cord injury

Question 5

Causes of Respiratory distress: Upper airway (stridor)

Answer 5

Croup
Epiglottits
Foreign Body
Congenita Malformation
Trauma

Question 6

Causes of Respiratory distress: Lower airway (wheeze)

Answer 6

Asthma
Bronchiolitis
Pneumonia
Pneumothorax

Question 7

Causes of unsconsciousness

Answer 7

Post-ictal
Status epilepticus
Infection .e.g. meningitis
Metabolic .e.g. DKA< hypoglycaemia, electolyte disturbance, inborn error of metabolism
Head Injury .e.g. trauma, NAI
Drug/Poison Ingestion
Intracranial Haemorrhage

Question 8

Surgical emergency

Answer 8

Acute abdomen .e.g. appendicitis, peritonitis

Intestinal obstruction .e.g. intussusception, malrotation, bowel atresia/stenosis

Question 9

Indicators of respiratory distress (Moderate)

Answer 9

Tachycardia
RR >50
Nasal flaring
Use of Accessory muscles
Inter/subcostal recession
Head retraction
Unable to feed

Question 10

Indicators of respiratory distress (Severe)

Answer 10

Cyanosis
Tiring
Reduced GCS
Saturation <92% despite oxygen
Rising pCO2

Question 11

Indications for intubation

Answer 11

Severe respiratory distress
Tiring due to work of breathing
Progressive hypoxaemia
Reduced consciousness level
Progressive muscle weakness

Question 12

Supportive therapy in respiratory failure

Answer 12

Oxygen SpO2 <92% (Max conc 0.60)
Noninvasive ventilation (CPAP and BPAP)
Invasive ventilatory support

Question 13

Airway positioning

Answer 13

Infants: neutral position, avoid overextension
Children: sniffing position + jaw thrust

Question 14

Chest compression positioning

Answer 14

Infant: 2 thumbs on lower sternum, hands round thorax
Small child: heel of hand, lower half of sternum
Large child: hands lower half of sternum

Question 15

Endotracheal tube sizing

Answer 15

Internal diameter(mm) = (age/4) + 4
Length oral tube (cm) = (age/2) + 12
Length nasal tube (cm) = (age/2) + 15

Question 16

Placement of intraosseous access

Answer 16

18 gauge trochlar with needle
Anterior surface
2-3cm below tibial tuberosity

Question 17

Reversible causes of cardiac arrest

Answer 17

Hypoxia
Hypovolaemia
Hypo/hyperkalaemia
Hypothermia
Tension pneumothorax
Thrombosis
Cardiac tamponade
Toxic/therapeutic disturbance

Question 18

Factors in childhood dehydration

Answer 18

Unable to take oral fluids
Additional losses .e.g. diarrhoea, fever, tachypnoea
Loss of retaining mechanism .e.g. burns, urinary

Question 19

Presentation shock (Early)

Answer 19

Tachypneoa
Tachycardia
Decreased skin turgor
Sunken eyes and fontanelle
Delayed cap refil >2s
Mottled, pale and cold skin
Cold-peripheral temp gap >4'c
Decreased urinary output

Question 20

Presentation Shock (Late)

Answer 20

Acidotic (Kussmal breathing)
Bradycardia
Confusion
Depressed cerebral state
Blue peripheries
Absent urine output
Hypotension

Question 21

Initial fluid resuscitation

Answer 21

0.9% saline 20ml/Kg

Repeat twice if no response

Question 22

Maintenance Fluid Requirments

Answer 22

First 10Kg 100ml/kg/24h
Second 10Kg 50ml/Kg/24h
Subsequent Kg 20ml/Kg/24h

Question 23

Clinical features Sepsis

Answer 23

Fever
Poor feeding
Miserable, irritabilit, lethargic
History of focal infection
Tachycardia
Tachypnoea
Low BP
Pupuric rash
Shock
Multi-organ failure

Question 24

Common Organisms Spesis

Answer 24

Coagulase negative Staph
Gram negative N.meningitidis/E.coli
HiB, meningococcus and pneumococcus non-immunised
Neonates: Group B strep and E.coli

Question 25

Mx Sepsis

Answer 25

``` Antibiotics Fluids Circulatory support: ionotropic FFP , cryoprecipitate and platelet transfusion in DIC Transfer to ICU ```

Question 26

Mx anaphylaxis

Answer 26

``` ABCDE IM Adrenaline High flow Oxygen IV fluids Chlorpheniramine Hydrocortisone Salbutamol ```

Question 27

IM Adrenaline Doses (1:1000)

Answer 27

>12y 500mcg 6-12y 300mcg <6y 150mcg

Question 28

IV Chlorphenamine Dose

Answer 28

>12y 10mg 6-12y 5mg 6m-6y 2.5mg <6m 250mcg/Kg

Question 29

IV Hydrocortisone Dose

Answer 29

>12y 200mg 6-12y 100mg 6m-6y 50mg <6m 25mg

Question 30

Mx Status Epilepticus

Answer 30

ABCDE High flow O2 Blood Glucose 5m Lorazepam 15m Lorazepam 25m Anaesthetic help, rectal paraldehyde, phenytoin over 20m/phenobarbitone over 5m 45m rapid sequence induction anaesthesia with thiopental

Question 31

Neuroprtective strategies to prevent 2' brain injury

Answer 31

``` Midline head positioning Tilt head 20-30' Fluid restriction with isotonic fluids Intubation and ventilation GCS<9 Maintain normocapnia (4.5-5.3kPa) Osmotic diuretics .e.g. mannitol Maintain high/normal BP Maintain normothermia Avoid hypotension/hypoxaemia ```

Question 32

GCS Older children/Teens Eyes

Answer 32

4 opens spontaneously 3 sound 2 pressure 1 none

Question 33

GCS Older children/Teens Verbal

Answer 33

``` 5 Orientated 4 Confused 3 Words 2 Sounds 1 None ```

Question 34

GCS Older children/Teens Motor

Answer 34

``` 6 Obeys commands 5 Localising 4 Normal flexion 3 Abnormal flexion 2 Extension 1 None ```

Question 35

GCS Children <4 Eyes

Answer 35

4 opens spontaneously 3 sound 2 pressure 1 none

Question 36

GCS Children <4 Verbal

Answer 36

``` 5 Talks normall/interacts 4 Words 3 Vocal sounds 2 Cries 1 None ```

Question 37

GCS Children <4 Motor

Answer 37

6 Obeys commands 5 Localising 4 Normal flexion 3 Abnormal flexion (decorticate posturing) 2 Abnormal Extension (decerebrate posturing) 1 None

Question 38

Pupillary signs in coma

Answer 38

Pinpoint fixed: opiates, barbituates, pontine lesion Fixed, dilated: severe hypoxia, during/post-siezure, anticholinergics, hypothermia Unilateral dilated: expanded ipsilateral lesion, tentorial herniation, 3rd nerve lesion, seizures

Question 39

Features of apparent life threatening event

Answer 39

``` Cyanosis or pallor Absent, decreased or irregular breathing Change in tone No concerning features or detailed history Normal examination ```

Question 40

Mx Apparent life threatening event

Answer 40

``` Period of observation ECG Perinasal swab for pertussis Brief monitoring with continuous pulse oximetry Reassurance of parents Parental training in BLS ```

Question 41

Likely underlying disorder of apparent life threatening event

Answer 41

``` Age <60d Gestation at birth <32w Duration >1m Repeat event CPR given by trained medical professional Concerning feature of history Abnormality on examination ```

Question 42

Risk factors for SIDS

Answer 42

``` Age 1-6m (Peak 2-4m) Low birth weight and preterm Male Illness in last 24h Lying prone (Main risk factor) Co-sleeping Overheating Infant pillow use Infant swaddling Low family income No maternal education Poor/overcrowded housing Maternal age <21y High maternal parity Maternal smoking in pregnancy/post-natally Maternal alcohol or drug use ```

Question 43

Prevention of SIDs

Answer 43

Sleeping on back Avoiding heavy wrapping and high room temp Head uncovered Blanket height max to shoulders Feet to foot of cot No smoking Urgent medical advice for unwell infant Baby in bedroom for first 6m Avoiding baby in bed esp. with alcohol or drugs Breastfeeding Avoid sleeping with infant on sofa/armchair

Question 44

dDx Encephalopathy

Answer 44

``` Infection Status epilepticus Trauma Intracranial tumour/haemorrhage/infarct/abscess Diaetes mellitus Hypoglycaemia Inborn error of metabolism Hepatic Failure Acute renal failure Poisoning Shock Hypertension Respiratory failure ```

Question 45

Ix Meningitis

Answer 45

FBC Culture: blood, urine, infective sites, CSF Acute phase reactants Rapid bacterial antigen/PCR

Question 46

Features meningitis

Answer 46

``` Fever Irritability, lethargy, drowsiness Poor feeding/vomiting Rash Seizures Neck stiffness and pain Bulging fontanelle Overseas travel ```

Question 47

Features status epilepticus

Answer 47

``` Hx of seizures Neurocutanrous lesions on the skin Developmental delay Ongoing seizure activity Focal neurology ```

Question 48

Ix Status epileptics

Answer 48

``` Blood Glucose Electrolys: Na+, K+, Ca+, Mg+ Drug levels (esp. anticonvulsants) EEG CT scan ```

Question 49

Ix Trauma

Answer 49

Radiology | Consider NAI work up

Question 50

Features Trauma

Answer 50

``` Hx accident Bruising/haemorrhage Fractures .e.g. cervical spine Focal neurology Retinal haemorrhages ```

Question 51

Ix Intracranial lesion

Answer 51

Cranial CT/MRI | Coagulation screen

Question 52

Ix Diabetes Mellitus/Hypoglycaemia

Answer 52

Blood Glucose Plasma electrolytes Urine glucose and ketones Blood gas

Question 53

Ix Inborn error of metabolism

Answer 53

``` Blood Glucose Blood gas Blood amonia, lactate Urine amino and organic acids Plasma amino acids ```

Question 54

Features metabolism encephalitis

Answer 54

``` Hx loss of consciousness Sudden collapse Consanguinity Death/illness siblings Developmental delay Hepatomegaly ```

Question 55

Ix Hepatic falilure

Answer 55

Abnormal LFTs | Prolonged prothrombin

Question 56

Ix Acute Renal Failure

Answer 56

Abnormal creatinine

Question 57

Ix Posioning

Answer 57

Toxicology screen | Plasma level paracetamol and salicylates

Question 58

Ix Shock

Answer 58

``` FBC Cultures Urea Electrolytes Blood gas ```

Question 59

Ix Hypertension

Answer 59

Left ventricular hypertrophy on ECG or echo Creatinine and electrolytes Fundoscopy

Question 60

Ix Respiratory Failure

Answer 60

Chest Xray | Arterial blood gas- hypoxia, hypercarbia