emergency paeds

Question 1

paeds resp rates
infant (upto 1 year)
toddler (1-3)
preschooler (3-6)
school-age (6-12)
adolescent (12-18)

Answer 1

Infant (birth–1 year) 
30–60/m 
Toddler (1–3 years) 
24–40/m 
Preschooler (3–6 years) 
22–34/m
School-age (6–12 years) 
18–25/m 
Adolescent (12–18 yrs) 
12–16/m

Question 2

paeds HR
Infant (birth–1 year) 
Toddler (1–3 years) 
Preschooler (3–6 years) 
School-age (6–12 years) 
Adolescent (12–18 years)

Answer 2

Infant (birth–1 year) 
100-160/m 
Toddler (1–3 years) 
90 -150 /m 
Preschooler (3–6 years) 
80 -140/m 
School-age (6–12 years) 
70 -120/m 
Adolescent (12–18 years) 
60 -100/m

Question 3

immunisation history

Answer 3

Birth – BCG for at risk infants

2 months – DTaP, IPV, HIB, Hep B
PCV
Men B
Rotavirus

3 months – DTaP, IPV, HIB, Hep B
Rotavirus

4 months – DTP, IPV, HIB, Hep B
Men B
PCV booster

12 months – HIB/ Men C
PCV booster
Men B booster
MMR

3/4 years – DPT Polio
MMR

14 (School yr 9) Td/IPV
Men ACWY

Question 4

when does a kid
smile
sit unaided
walk
talk
handedness

Answer 4

Smile – 6 weeks
Sit unaided – 6 months
Walk – 12 months
Talk – 12 months
Handedness

Question 5

clinical Sx
mechanism
Mx

of paracetamol

Answer 5

Early:
• abdominal pain, vomiting
Later (12 h to 24 h):
• liver failure

Mechanism
initial gastric irritation
Toxic metabolite (NAPQI) produced by saturation of liver metabolism

Mx
Risk assessed by measuring plasma paracetamol concentration
Treat with intravenous acetylcysteine if concentration is high or liver function abnormal

Question 6

clinical Sx
mechanism
Mx

of button batteries

Answer 6

Abdominal pain
Gut perforation and stricture formation

mechanism
Leakage: corrosion of gut wall due to electrical circuit production

Mx
X-ray of chest and abdomen to confirm ingestion and identify position
Endoscopic removal is recommended if in the oesophagus, the object fails to pass, or symptoms are present (e.g. abdominal pain or melaena)

Question 7

clinical Sx
mechanism
Mx

of CO

Answer 7

Early:
• headache, nausea
Later:
• confusion, drowsiness leading to coma

mechanism
Binds to haemoglobin causing tissue hypoxia

Mx
High-flow oxygen to hasten dissociation of carbon monoxide
The role of hyperbaric oxygen therapy is unclear

Question 8

clinical Sx
mechanism
Mx

of salicyclates

Answer 8

Early:
• vomiting, tinnitus
Later:
• respiratory alkalosis followed by metabolic acidosis

Mechanism
Direct stimulation of respiratory centre
Uncouples oxidative phosphorylation leading to metabolic acidosis and hypoglycaemia

Mx
Plasma salicylate concentration 2–4 h after ingestion helps to estimate toxicity

Alkalinization of urine increases excretion of salicylates.

Haemodialysis also effectively removes salicylate

Question 9

clinical Sx
mechanism
Mx

of TCAs

Answer 9

Early:
• tachycardia, drowsiness, dry mouth
Later:
• arrhythmias, seizures

mechanism
Anti-cholinergic effects, interference with cardiac conduction pathways\

Mx
Treatment of arrhythmias with sodium bicarbonate
Support ventilation

Question 10

clinical Sx
mehcanism
Mx of

ethylene glycol

Answer 10

Early:
• intoxication
Later:
• tachycardia, metabolic acidosis leading to renal failure

mechanism
Production of toxic metabolites that interfere with intracellular energy production

Mx
Fomepizole inhibits the production of toxic metabolites; alcohol may also be used but has more adverse effects
Haemodialysis to remove toxic metabolites in severe cases

Question 11

clinical Sx
mechanism
Mx

alcohol

Answer 11

Hypoglycaemia
Coma
Respiratory failure

Direct inhibitory effect on glycolysis in the liver and neurotransmission in the brain

Monitor blood glucose and correct if necessary. Support ventilation if required
Blood alcohol levels may help to predict severity

Question 12

clinical sx
mechanism
mx

of iron

Answer 12

Initial: vomiting, diarrhoea, haematemesis, melaena, acute gastric ulceration
Latent period of improvement
6–12 h later: drowsiness, coma, shock, liver failure with hypoglycaemia, and convulsions
Long term: gut strictures

mechanism
Local corrosive effect on gut mucosa
Disruption of oxidative phosphorylation in mitochondria leads to free radical production, lipid peroxidation, and metabolic acidosis

Mx
Serious toxicity if >75 mg/kg elemental iron ingested

Serum iron level 4 h after ingestion is the best laboratory measure of severity

Intravenous desferoxamine chelates iron and should be administered in cases of moderate-to-severe toxicity

Question 13

clinical Sx
mechanism
Mx of

hydrocarbons ie. paraffin, kerosene

Answer 13

Pneumonitis
Coma

mechanism
Low viscosity and high volatility makes aspiration easy, resulting in direct lung toxicity
Direct inhibitory effect on neurotransmission in the brain

Mx
No specific antidote – supportive treatment only

Question 14

clinical sx
mechanism
Mx of

organophosphorus pesticides

Answer 14

Cholinergic effects:
• salivation, lacrimation, urination, diarrhoea and vomiting, muscle weakness, cramps and paralysis, bradycardia. and hypotension
Central nervous system effects:
• seizures and coma

Inhibition of acetylcholinesterase resulting in accumulation of acetylcholine throughout the nervous system

Supportive care
Atropine (often in large doses) as an anticholinergic agent
Pralidoxime to reactivate acetylcholinesterase

Question 15

factors increased risk of recurrence for self harm

Answer 15

lack of regret, evidence of planning, e.g. leaving a note, and a lack of protective social factors

Question 16

surgical cuases of abdominal pain

Answer 16

acute appendicitis

Question 17

other causes if abdo pain that are not abdo originated

Answer 17

• lower lobe pneumonia may cause pain referred to the abdomen
• primary peritonitis is seen in patients with ascites from nephrotic syndrome or liver disease
• diabetic ketoacidosis may cause severe abdominal pain
• urinary tract infection, including acute pyelonephritis,
- pancreatitis -> acute abdo pain, serum amylase

Question 18

Sx of acute appendicitis

Answer 18

– Anorexia
– Vomiting
– Abdominal pain, initially central and colicky (appendicular midgut colic), but then localizing to the right iliac fossa (from localized peritoneal inflammation)

Question 19

signs of acute appendicitis

Answer 19

– Fever
– Abdominal pain aggravated by movement, e.g. on walking, coughing, jumping, bumps on the road during a car journey
– Persistent tenderness with guarding in the right iliac fossa (McBurney’s point). However, with a retrocaecal appendix, localized guarding may be absent, and in a pelvic appendix there may be few abdominal signs.

Question 20

Mx of appendicitis

Answer 20

appendicectomy - uncomplicated

generalised guarding consistent w perforation -> fluid resuscitation and intravenous antibiotics are given prior to laparotomy

Question 21

define non-specific abdominal pain

Answer 21

• abdominal pain which resolves in 24–48 hours.

- accompanied by an upper respiratory tract infection with cervical lymphadenopathy

Question 22

what is intussusception

Answer 22

invagination of proximal bowel into a distal segment. It most commonly involves ileum passing into the caecum through the ileocaecal valve

most common cause of intestinal obstruction

3 m-2yrs

Question 23

most serious complication of intussusception

Answer 23

stretching and constriction of the mesentery resulting in venous obstruction, causing engorgement and bleeding from the bowel mucosa, fluid loss, and subsequently bowel perforation, peritonitis and gut necrosis

Question 24

presentation of intussusception

Answer 24

• Paroxysmal, severe colicky pain with pallor – during episodes of pain, the child becomes pale, especially around the mouth, and draws up the legs. There is recovery between the painful episodes but subsequently the child may become increasingly lethargic.
• May refuse feeds, may vomit, which may become bile stained depending on the site of the intussusception.
• A sausage-shaped mass – often palpable in the abdomen

Passage of a characteristic redcurrant jelly stool comprising blood-stained mucus – this is a characteristic sign but tends to occur later in the illness and may be first seen after a rectal examination.

• Abdominal distension and shock.

Question 25

how to confirm diagnosis of intusussception

Answer 25

US and also monitor treatment TARGET SIGN Unless there are signs of peritonitis, reduction of the intussusception by rectal air insufflation is usually attempted by a radiologist

Question 26

what is the compression ventialtion ratio

Answer 26

compression:ventilation ratio: lay rescuers should use a ratio of 30:2. If there are two or more rescuers with a duty to respond then a ratio of 15:2 should be used

Question 27

DDx for a red swollen eye

Answer 27

``` - pre-septal cellulitis • Orbital or Post-septal cellulitis. • Allergicconjunctivitis. • Bacterial conjunctivitis. • Trauma. - sub-periostal/orbital abscess - cavernous sinus thrombosis ```

Question 28

Features of pre-septal cellulitis

Answer 28

- redness and discharge from one eye - affected eye 'stuck shut' in the morninh - colour/consistency depends on cause - caused by bacteria (staph aureus, H strep, H.influenzae) chlamydia, viruses

Question 29

Definition of preseptal cellulitis

Answer 29

inflammatory disease of the orbit limited to the tissues anterior to the orbital septum.

Question 30

definition of orbital cellulitis

Answer 30

inflammatory disease of the superficial and deep structures of the orbit.

Question 31

aetiology of preseptal | cellulitis

Answer 31

* Commonly follows URTI and sinusitis (ethmoid commonest). * Respiratory pathogens (Streptococcus, Haemophilus) commonest. • Other sources: spread from skin, lachrymal ducts, middle ear etc.

Question 32

Mx of cellulitis

Answer 32

``` - Admit. • IV access. • FBC/CRP, cultures. • Nose swab. • IV Ceftriaxone. • ± IV Metronidazole • (if sinuses involved) • Prompt ENT and ophthalmology review - 4h obs - Consider CT scan ```

Question 33

Sx of meningitis

Answer 33

* Fever * Irritability * Lethargy / Drowsiness * High pitched cry * Loss of consciousness * Seizures * Poor feeding * Vomiting * Photophobia

Question 34

DDx of fever headache and neck stiffness

Answer 34

* Bacterial meningitis. * Viral meningitis. * Viral encephalitis. * Tuberculous meningitis. * Cerebral abscess. * Hydrocephalus. * Non-accidental injury

Question 35

acute Mx of bacterial meningitis

Answer 35

Call for senior help Airway: apply 15L/min facial O2 Breathing: support as necessary Circulation: IV or IO cannula Bloods: Gas (HCO3, BE, lactate), glucose. FBC, CRP, clotting, U&E check circulation (CRT, HR, BP) - Rx PRN IV 20ml/kg 0.9% NaCl fluid bolus Disability: assess: level of consciousness (GCS) Neurology - cranial nerves, focal. Raised ICP. Exposure - temperature rashes

Question 36

LP contraindications

Answer 36

- cardiorespiratory instability - signs of raised ICP: coma, low HR, high BP, papilloedema -> needs CT - coagulation abnormalities , thrombocytopenia - after seizures - until stabilised - focal neurological deficits - sogns of infection at the LP site - concerns about menigococcal septicaemia

Question 37

what is normal CSF

Answer 37

clear <5 lymphocytes 0.14-0.4g/L >50% BG

Question 38

bacterial menigititis CSF ``` Appearance white cells protein glucose organisms ```

Answer 38

turbid 100-10000 neutrophils increased protein decreased glucose S. pneumoniae - 14 days H. influenzae - 10 days N. Meningitis - 7 days neonates strep group B Ecoli Listeria

Question 39

``` viral meningitis Appearance white cells protein glucose organisms ```

Answer 39

clear <1000 lymphoctyes normal protein usually normal ``` Enteroviruses Echo, coxsackie Parechovirus Herpesviridae Herpesvirus 1 & 2 Varicella zoster CMV, EBV Herpesvirus 6 & 7 adenovirus influenza RSV measles mumps ```

Question 40

``` TB meningitis Appearance white cells protein glucose organisms ```

Answer 40

turbid clear/viscous 10-500 lymphocytes increased protein decreased glucose Mycobacterium TB

Question 41

``` viral encephalitis Appearance white cells protein glucose organisms ```

Answer 41

clear usually <1000 lymphocytes normal protein normal same as viral menigitis

Question 42

acute Mx of meningitis

Answer 42

<28 days: 3o cephalosporin + Amoxicillin + Gentamicin 1-3 mo: 3o cephalosporin + Amoxicillin IV amoxicillin + IV cefotaxime >3 mo: > 3m: IV cefotaxime (or ceftriaxone) 3o cephalosporin ± Amoxicillin (? Listeria) + Acyclovir (all age groups – until microbiology seen) 2. Steroids NICE advise against giving corticosteroids in children younger than 3 months dexamethsone should be considered if the lumbar puncture reveals any of the following: frankly purulent CSF CSF white blood cell count greater than 1000/microlitre raised CSF white blood cell count with protein concentration greater than 1 g/litre bacteria on Gram stain 3. Fluids treat any shock, e.g. with colloid 4. Cerebral monitoring mechanical ventilation if respiratory impairment 5. Public health notification and antibiotic prophylaxis of contacts oral ciprofloxacin is now preferred over rifampicin

Question 43

``` N. meningitidis H. influenzae Strep pneum Group B strep E.coli Listeria ```

Answer 43

``` N. meningitidis - 7 H. influenzae - 10 Strep pneum - 14 Group B strep - 14 E.coli - 21 cefotaxime/ceftriaxone ``` Listeria - 21

Question 44

other Mx of meningitis

Answer 44

steroids: only in childre older than 3m. <12h since 1st AB dose + purulent CSF IV fluids: normal maintenance. 2/3 if SIADH: low serum Na/osmolality high urine Na/osmolality CT scan: other intracranial pathologies Hearing test: in all within 6 weeks of presentation

Question 45

acute complications of meningitis

Answer 45

``` hearing impairment local vasculitis - CN palsies - focal neuro signs - septic shock ``` - DIC: due to sepsis and coagulopathy raised IC pressure: due to cerebral oedema increased BP decreaesd pulse/GCS SIADH: fluid retention and reduced serum Na hydrocephalus: obstructed by oedema/infection cerebral abscess/subdural empyema

Question 46

long term complications of meningitis

Answer 46

hearing loss - commonest complication, damage to cochlear hair cells local vasculitis: focal neuro lesions local cerebral infarction: cause seizures, can lead to epilepsy subdural effusion - more common in infants-> bulging fontanelle, enlarging head size and/or seizures; may be asymptomatic learning difficulties; developmental deficits

Question 47

Hx and examination of barking cough and noisy breathing

Answer 47

``` preceding Sx - runny nose, fever other Sx- toxicity (very high, To) choking episode/trigger drooling voice changes/hoarseness cyanotic episodes ``` VACCIANTION STATUS abnormal respiratory sounds/stridor respiratory status - RR, WOB

Question 48

DDx for barking cough and noisy breathing

Answer 48

viral croup (laryngeotracheoronchitis) Acute infections - epiglottitis - bacterial tracheitis - diphtheria - peritonsilar abscess - reteropharyngeal abscess other non infection - foreign body - anaphylaxis - burns - UA trauma - angioedema - VC dysfunction

Question 49

what is croup Sx typical age aetiology

Answer 49

``` triad - hoarse voice - barking cough - stridor +/- fever ``` 6m and 6yr aetiology parainfluenza virus (commonest) influenza virus, RSV, adenovirus, measles

Question 50

what is stridor

Answer 50

- High-pitched, high-energy usually inspiratory sound. • Caused by turbulent airflow over the upper airway. • Expiratory with severe UA or tracheal narrowing

Question 51

what is stretor

Answer 51

* Low-pitched, high-energy snoring sound. | * Caused by nasal obstruction, tonsil ± adenoid hypertrophy and neuromuscular weakness

Question 52

what is wheeze

Answer 52

- High-pitched whistling usually expiratory sound. | • Suggests narrowing of lower airways.

Question 53

what is the westley score include

Answer 53

CROUP level of consciousness -> normal 0, disorientated= 5 cyanosis - none=0, with agitation=4, at rest=5 stridor none=0, wiht agitation=1, at rest=2 air entry - normal=0, decreased=1, markedly decreased=2 retractions- none=0, mild=1, moderate=2, severe=3

Question 54

welsey score <4 severity description Mx

Answer 54

mild Occasional barky cough. No stridor. No/mild retractions Mx Oral dexamethasone (0.15mg/kg). Score 0 – no treatment needed. Score <2 – discharged home; otherwise observe for 1 hour.

Question 55

westley severity score 4-6

Answer 55

moderate Frequent barky cough. Stridor at rest. Mild to moderate retractions No/little distress or agitation ``` prompt senior review oral dexamethasone (0.15mg/kg). (or nebulised budesonide (2mg) is struggling with oral meds) oxygen if pO2 <92% observe respiratory status ```

Question 56

westley severity score | >6

Answer 56

Severe Frequent barky cough. Stridor at rest. Marked retractions Significant distress and agitation Mx prompt senior review nebulised adrenaline (0.4mg/kg) of 1:1000 solution (1ml=1mg)

Question 57

aetiology of epiglottitis

Answer 57

Acute inflammatory swelling of epiglottis and surrounding tissues. Life-threatening emergency because of high risk of airway obstruction. Most common between 1 and 6 yrs but occurs at any age. Most commonly caused by Haemophilus influenzae.

Question 58

clinical presentation of epiglottitis

Answer 58

onset over hours appearance-> toxic, very unwell, anxious, restless, irritable ``` temp - >38.5 severe sore throat cant drink drooling absent cough soft whispering stridor muffled, reluctant to speak ```

Question 59

Mx of epiglotittis

Answer 59

Regardless of apparent severity, deterioration can occur rapidly. • Prompt senior review. • Call ICU, anaesthesia and ENT. • Avoid distressing the child. • Secure airway in theatre.

Question 60

DDx for fever and rash

Answer 60

Measles. • Rubella (German measles). • Slapped cheek (Fifth disease)(Parvovirus). • Roseola infantum (Sixth disease)(Herpes 6/7). • Enterovirus (echo, coxsackie). • Scarlet fever (Group A Streptococcus) • Kawasaki disease • Systemic onset juvenile idiopathic arthritis

Question 61

what are measles

Answer 61

highly contagious caused by RNA paramyxovirus incubation period: 10 days to fever 14 days to rash rash koplik spots conjunctivitis and coryza cough

Question 62

complications of measles

Answer 62

Respiratory: OM, croup, tracheitis, pneumonia. Neurological: febrile seizures, encephalitis, SSPE Other: Diarrhoea, hepatitis, myocarditis.

Question 63

what is roseola infantum

Answer 63

* Usually in younger children (6mo-2yr). • 3-4 days of fever and malaise. * Widespread rash when fever subsides.

Question 64

what is rubella

Answer 64

Mild disease; incubation 15-20 days. • Prodrome mild (low grade fever) or none. • Widespread rash spreading from face. • Lymphadenopathy (sub-occipital and post- Temp oC auricular) prominent.

Question 65

slapped cheek syndrome what is it

Answer 65

Parovirus B19 • Fever, malaise, headache, myalgia. • Rash appears on face a week later. • Progress to maculopapular (‘lace-like’) rash on trunk and limbs

Question 66

what is scarlet fever

Answer 66

Diffuse erythematous eruption generally associated with pharyngitis (Strep A). Cough • Rash: Diffuse blanching erythema. raised papules-sand-paper feel starts in groin and axilla; spreads to trunk and extremities ass w strawberry tongue

Question 67

history septicaemia

Answer 67

Fever Poor feeding Miserable, irritable, lethargy History of focal infection, e.g. meningitis, osteomyelitis, gastroenteritis, cellulitis Predisposing conditions, e.g. sickle cell disease, immunodeficiency

Question 68

signs on examination of septicaemia

Answer 68

Fever Tachycardia, tachypnoea, low blood pressure Purpuric rash (meningococcal septicaemia) Shock Multiorgan failure

Question 69

aetiology of septicaemia

Answer 69

Carried in nasopharynx: rate low in infants/young children | Droplet spread; needs prolonged close contact.

Question 70

RFs of meningococcal septicaemia

Answer 70

``` age season - winter smoking preceding influenza A infection living in 'closed/semiclosed' community ```

Question 71

Mx of pre-hospital (primary care) and emergency care

Answer 71

IM benzypenicillin high flow oxygen blue light ambulance ``` notify ICU and anaethesia pre-arrival appropriate senior staff present rapid ABCDE assessment high flow O2 IV/IO access: blood tests, IV ceftriaxone, Iv fluid bolus ``` early inotrope support early airway support

Question 72

DDx of acute antalfgic gait

Answer 72

- transient synovitis - septic arthritis - osteomyelitis - trauma NAI - Malignancy (leukaemia, neuroblastoma) - perthes disease - juvenile idiopathic arthritis

Question 73

define transient synovitis

Answer 73

irritable hip. It is caused by temporary (transient) irritation and inflammation in the synovial membrane of the joint (synovitis). It is the most common cause of hip pain in children aged 3 – 10 years. It is often associated with a recent viral upper respiratory tract infection.

Question 74

presentation of transient synovitis Ix

Answer 74

- Limp - Refusal to weight bear - Groin or hip pain internal rotation abduction - Mild low grade temperature Ix US -> fluid in joint

Question 75

Mx of transient synovitis

Answer 75

symptomatic simple analgesia 3-9 -> if limp s present for less than 48 hours and they are otherwise well NEED CLEAR SAFETY NET ADVICE - attend A&E if the Sx wosern or develop fever follow up at 48 hours and 1 week

Question 76

what is septic arthritis common bacteria presentation

Answer 76

infection inside a joint common under 4 years ``` staph aureus neisseria gonorrhoea - Group A streptococcus (Streptococcus pyogenes) - Haemophilus influenza - Escherichia coli (E. coli) ``` - Hot, red, swollen and painful joint - Refusing to weight bear - Stiffness and reduced range of motion - Systemic symptoms such as fever, lethargy and sepsis joint drainage and irrigation

Question 77

what is used to measure likelihood of SA (modified Kocher criteria)

Answer 77

Fever >38.5oC • WCC >12 x 109/L • CRP >20 • Inability to weight bear None <0.2%; 1: 3% 2: 40% 3: 93.1% 4: 99.6%

Question 78

acute Ix for bone/joint infection

Answer 78

FBC - useful to differentiate (TS/SA; leukaemia) CRP highly sensitive Blood culture - should always be obtained, low yield x-ray - always perform at baseline US - very sensitive to identify joint effusion in SA synovial fluid - always be obtained before ABx +ve gram stain helps ABx choice drainage of pus aids

Question 79

Mx of bone/joint infection

Answer 79

1. Ix: FBC, CRP, BC, Hip US 2. early surfical referral for pus drainage 3. do NOT delay empiric IV ABx ABx <3 months: IV cefotaxime or ceftriaxone >3 months: IV ceftriaxone switch to oral w improvement ABx duration: SA 2-4 weeks; OM 2-6 weeks

Question 80

DDx for traumatic limp | 1-4

Answer 80

- DDH - septic arthritis/osteomyelitis - Transient synovitis Toddlers fracture Non-accidental injury

Question 81

DDx for atraumatic limp child 5-9

Answer 81

transient synovitis Perthes disease Juvenile idiopathic arthritis

Question 82

DDx of adolescent >10

Answer 82

slipped capital femoral epiphysis | juvenile idiopathic arthritis

Question 83

DDx for suspected allergic reaction

Answer 83

``` allergic reaction anaphylaxis skin: acute urticaria GUT: food poisoning, gastroenteritis Respiratory: URTI, irritant rhinoconjunctivitis. choking, viral wheeze, acute asthma exacerbation CVS: vasovagal syncope, panic attack ```

Question 84

define anaphylaxis

Answer 84

Severe, life-threatening allergic reaction that is acute in onset and can cause death

Question 85

criteria for anaphylaxis

Answer 85

acute onset of illness involving skin mucosa or both ie urticaria, angioedema and at least one of the following 1. resp compromise ie dyspnoea, wheeze, stridor, hypoxaemia, reduced PEF 2. reduced BP or end organ dysfunction ie. hypotonia (collapse), syncope, incontinence two or more of the following after exposure to likely allergen for that patient (mins to hours) 1. skin or mucous membrane involvement 2. resp compromise 3. cardio compromise 4. persistent GI Sx - crampy abdominal pain, vomiting reduced BP after exposure to known allergen for that pt (mins to several hrs) 1. infant child: low age specific systoli or >30% drop 2. adolescent <90 or >30% drop

Question 86

what is urticaria

Answer 86

- Also called hives, wheals or welts. - Common condition affecting up to 20% of population. Typically intensely pruritic erythematous plaque. May be associated with angioedema (swelling). Commonly categorized by chronicity: • Acute: <6 weeks; triggers allergy, URTI, idiopathic. • Chronic: >6 weeks; spontaneous or physical triggers

Question 87

Mx of urticaria

Answer 87

- History and examination to make diagnosis. - In new-onset acute urticaria where assessment does NOT suggest underlying cause, NO investigations; may consider FBC and CRP if worried about vasculitis. - High-dose non-sedating antihistamines - ± Oral glucocorticosteroids.

Question 88

Mx of paracetamol overdose

Answer 88

ingestion <1h and >150 mg/kg give oral charcoal and IV anti-emetic risk of liver toxicity based on paracetamol dose <150mg/kg - unlikely > 250mg/kg likely > 12g total - potentially fatal delay sampling to 4h after ingestion -Paracetamol level. • U&E – baseline renal status/risk of AKD. • LFT – monitor ALT levels for hepatotoxicity. • Glucose – hypoglycaemia common in liver necrosis. • Clotting screen – INR as PT best indicator of liver necrosis. • Venous gas –acidosis in 10% of acute liver failure.

Question 89

common causes of seizures in children

Answer 89

- febrile convulsions - Known epilepsy ± acute illness • Meningitis or encephalitis •Hypoglycaemia/hypocalcaemia • Metabolic/Poisoning - trauma - accidental/non accidental - drugs - raised ICP

Question 90

Hx of seizure complications

Answer 90

``` before fit - aura/temperature during fit - duration - shaking - tongue biting - limbs involved - incontinence ``` * Epilepsy?; medication, compliance, Rx change. * Fever, trauma, poisoning ingestion. Hypoxia, hyperthermia, DIC. • Resp: Airway obstruction; aspiration. Pulmonary oedema; drug depression. • CVS: Arrhythmia, Hypertension. Ix FBC, U&E, LFT, Clotting, Gas, Culture. • Metabolic screen, toxicology, drug levels ± CT

Question 91

features of a febrile convulsion How will you prevent further recurrences and reassure parent

Answer 91

6 months - 5 years - no previous neurology - generalised in nature - <15 mins duration - no IC infection/metabolic disturbance - simple or complex - not epilepsy - very common in children - due to high temp - give antipyretic to control temperature - prevent injury - has a very good prognosis as they tend to stop as the children grows - no increased risk of developing epilepsy

Question 92

features of infantile spasms

Answer 92

``` age of onset 3-12 months sudden violent flexor spasms of head, trunk and limbs followed by extension of arms. • Last 1-2 seconds; occur multiple/day. • Often with developmental regression. • EEG: hypsarrthymia; Rx ACTH, steroids. ```

Question 93

features of an absence epilepsy

Answer 93

``` age of onset 4-12 years; girls>boys - sudden onset; last few seconds (<30s) - ass w automatisms - flickering of eyes, purposeless movement of eyes/mouth EEG: 3 per second hx spike and eave -spontaneous remission in adolescence ```

Question 94

Mx of croup

Answer 94

oral dexamethasone no tolerated nebulised budesonide -> rapidly decreases laryngeal mucosal inflammation -> reducing the duration and severity of croup

Question 95

red flags sign of children at any age

Answer 95

``` >60 breaths/minute grunting reduced skin turgor non-blanching rash neck stiffness seizures bulging fontanelle. ```

Question 96

essential examination for hip pain in children and why

Answer 96

abdomen - appendicitis axillae anf groin - lymphadenopathy, hepatosplenomegaly and pallor points heamatological malignancy hip scrotum - testicular torsion

Question 97

features of perthes disease

Answer 97

5-10 uears avascular necrosis of the femoral head ``` features limp painful at times limb shortened stiffness and reduces range of movement x-ray: early changes include widening of joint space, later changes include decreased femoral head size/flattening ``` Diagnosis plain x-ray - femoral head Fragmentation (radiolucency) and re-ossification (radiodensity) technetium bone scan or magnetic resonance imaging if normal x-ray and symptoms persist AP + Lateral pelvic xray Complications osteoarthritis premature fusion of the growth plates To keep the femoral head within the acetabulum: cast, braces If less than 6 years: observation Older: surgical management with moderate results Operate on severe deformities

Question 98

Ix for slipped upper femoral epiphysis

Answer 98

x ray of the hip AP and lateral Klein’s line is drawn along the superior border of the femoral neck and should intersect with the growth plate. Failure to do so suggests early SUFE. Mx bed rest + minimum weight bearing surgical fixation if worsening

Question 99

Signs of meningitis

Answer 99

``` Fever • Irritable • Difficult to examine • Altered LOC • Neck stiffness* • Bulging fontanelle* anterior fontanelles closes at 18 months • Opisthotinos • +ve Brudzinski sign* • +ve Kernig sign* ```

Question 100

RFs of DDH

Answer 100

firstborn child, female sex, family history of DDH, breech presentation at birth, and oligohydramnios.

Question 101

what is juvenile idioptahic arthritis

Answer 101

<16 lasts for more than 6 weeks ``` features pyrexia salmon-pink rash lymphadenopathy arthritis uveitis anorexia and weight loss ``` Ix ANA positive RF - (-ve)

Question 102

Symptoms of osteomyelitis inital mx

Answer 102

- cause -> staph aureus, strep, haemophilus influenzae - severe pain high temp tenderness joint movements is not affected In young child/infant ``` Widespread limb pain difficult to localize on examination Pseudoparalysis Bone or limb swelling Erythema Refusal to bear weight or sit down Limping Older children tend to localize pain ``` Mx - analgesia - commence IV ABx better after 24-48hrs -> oral ABx for 6w FAILS - surgical drainage/debridement of osteomyelitis lead to pathological fracture

Question 103

Mx of Bone Joint infection complications

Answer 103

<3m IV cefotaxime/ceftriaxone > 3m IV flucoxacillin allergic - vancomycin 2–4 weeks for SA • 4–6 weeks for OM. oral ABx • 2–6 weeks for pyomyositis 1. Chronic infection 2. Relapse 3. Reinfection with different bacterial agent 4. Abscess or sequestrum 5. Residual pain and rigidity 6. Bone deformity 7. DVT

Question 104

Signs of raised ICP

Answer 104

``` papilloedema reduced consciousness neurological signs cushing reflex decerebrate posturing ```

Question 105

Ix for meningitis

Answer 105

bloods - FBC, U&E, CRP ABG blood culture LP if CT shows no ICP

Question 106

chicken pox virus name incubation features Mx

Answer 106

``` varicella zoster 10-21 days fever initially itchy, rash starting on head/trunk before spreading. Initially macular then papular then vesicular systemic upset is usually mild ``` Mx - calmine lotion skl -> until all the lesions are dry and have crusted over (usually about 5 days after the onset of the rash). complications - secondary bacterial infection of lesions - NAIDs, invasive group A streptococcal soft tissue infections may occur resulting in necrotizing fasciitis pneumonia encephalitis (cerebellar involvement may be seen) disseminated haemorrhagic chickenpox arthritis, nephritis and pancreatitis may very rarely be seen

Question 107

Ix of Bone Joint infection

Answer 107

- FBC + CRP - Blood cultures - synovial fluid before AB initiation - xray -> : Frequently normal at baseline. Repeat imaging 10-21 days from symptom onset shows appearance of osteolytic changes or periosteal elevation - US for joint effusion - MRI within 3-5 days of onset bone scan