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1

The paediatric team is resuscitating a 3-month-old boy who is in Pulseless Electrical Activity (PEA). He was discovered to be blue and lifeless when his parents went to wake him in the morning. The airway has been secured and despite ventilation the child remains blue. An intra-osseous needle has been inserted and two boluses of normal saline have been given. The nurse reports that the temperature of the child is 35°C. You listen to the chest and can hear bilateral breath sounds.

Where is the most appropriate position on the chest to do cardiac compressions?

Midline between the nipples
1 finger breadth above the line between the nipples
1 finger breadth below the line between the nipples
None of the above

1 finger breadth below the line between the nipples

In an infant the heart is lower in relation to the external landmarks than in older children or adults. The area of compression over the sternum should be one fingerbreadth below an imaginary line between the nipples.

2

You are in the acute assessment unit and see David, a 15-month-old boy who has a fever of 38.5°C. He has had a runny nose, cough and a fever for 3 days. Since this morning he has slept and has been difficult to wake. His heart rate is raised. He has a rash scattered over his legs which does not disappear with pressure.

Which of the following is the most likely diagnosis?

NAI
HSP
ITP
ALL
Septicaemia

Septicaemia

He has a purpuric rash, with lesions of variable size. In a febrile child, meningococcal septicaemia is most likely. This may be accompanied by meningitis.

Henoch–Schönlein purpura although localized to the legs, is associated with abdominal pain and joint pain but not with fever.

With Idiopathic thrombocytopenia the children are usually well.

This is a relatively short history of the child being unwell. In acute lymphoblastic leukaemia you would expect a longer history.

3

A 3-year-old boy who is unconscious arrives in Accident and Emergency. You manage his Airway, Breathing and Circulation. His blood glucose is normal. On examination you note that he has bilateral pinpoint pupils. His temperature and other vital signs are otherwise normal.

What is the most likely cause?

3rd nerve lesion
Severe hypoxia
Hypothermia
Tentorial herniation
Opiate poisoning

Opiate poisoning

Bilateral, pin-point pupils with coma can be caused by a pontine lesion or opiate poisoning. Opiate poisoning may occur in homes with illicit substance abusers or adults on methadone.

Third nerve lesions and tentorial herniation would cause a unilaterally dilated pupil.

Severe hypoxia would cause dilated pupils.

With hypothermia the child’s temperature would be low and causes dilated pupils.

4

You are called to see a 3-year-old boy with a high fever. The nurse is worried that he is very sleepy. As you walk into the resuscitation room he makes no spontaneous response. You try calling his name but he makes no response. On stimulation, his eyes open, he moans and he raises his hand and pushes your hand away.

What is this child’s Glasgow Coma Score?

8
9
10
11
12

9

Eyes: React to pain - 2
Verbal: Moans to pain - 2
Motor: Localises pain - 5

5

Ryan, aged 10 months, is rushed to the Accident and Emergency department after being found submerged in the bath. His mother runs screaming into the department saying ‘help my baby, please’.

Which is the next most appropriate step?

Commence bag and mask ventilation
In managing his airway, his head should be in the neutral position
Commence chest compressions in a ratio of 15:2
Assess patient, call for help
Remove wet clothing/towels

Assess patient, call for help

All resuscitation algorithms ensure that patient is assessed in a sequential manner, first initial assessment and then management in an A,B,C approach. Calling for help early on in these situations is paramount as you need many people for resuscitation. This baby is going to need his airway managing in the neutral position, with bag and mask ventilation and cardiac compressions in a ratio of 15:2; the wet clothing will also need removing.

6

Mohammed, aged 8 months, has been vomiting and off his feeds for two days. Initially he had episodes of crying uncontrollably, drawing his legs up into his abdomen as if in pain, and appeared fractious. His mother gave him some oral rehydration solution, but his vomiting continued and he has become lethargic. On admission to hospital he is in shock.

What is the most likely diagnosis?

Gastroenteritis
Malrotation
Strangulated hernia
Intussusception
Meckel diverticulum

Intussusception

Intussusception is the most likely cause of the pain and shock. Although this could be a strangulated hernia, this should be evident on clinical examination.

7

Mohammed, aged 8 months, has been vomiting and off his feeds for two days. Initially he had episodes of crying uncontrollably, drawing his legs up into his abdomen as if in pain, and appeared fractious. His mother gave him some oral rehydration solution, but his vomiting continued and he has become lethargic. On admission to hospital he is in shock. Intussusception is suspected.

Mohammed is 8 months old and weighs 8 kg. He needs a bolus of normal saline 0.9% to treat his shock.

What volume of fluid would you give initially?

40ml
160ml
320ml
680ml
800ml

160ml

This is 20 ml/kg initially, repeated as necessary.

8

Mohammed, aged 8 months, has been vomiting and off his feeds for two days. Initially he had episodes of crying uncontrollably, drawing his legs up into his abdomen as if in pain, and appeared fractious. His mother gave him some oral rehydration solution, but his vomiting continued and he has become lethargic. On admission to hospital he is in shock. Intussusception is suspected.

Mohammed has received the fluid bolus of normal saline 0.9% which has improved his condition. From his presentation you suspect he is 10% dehydrated. You receive his laboratory results which reveal a plasma sodium of 138 mmol/L (within the normal range). His continuing fluid loss from vomiting is small and can be ignored. (The maintenance intravenous fluid requirement for a child of this age is 100 ml/kg/24 h.)

What is Mohammed’s total fluid requirement for the initial 24 hours? He weighs 8 kg.

160ml
320ml
800ml
880ml
1600ml

1600ml

Mohammed’s fluid requirement is calculated by adding:
• Deficit: 10% of 8 kg = 800 ml
• Maintenance: 100 ml/kg/24 h = 800 ml
• Continuing losses: 0 ml
Total = 1600 ml

9

You are called to the resuscitation room where there is a 6-year-old child who has arrived by ambulance. He is a known to have epilepsy and is on anti-epileptic treatment. The child has been having a generalised seizure for 15 minutes. The ambulance crew gave a dose of buccal midazolam 5 minutes ago. The emergency doctor has maintained the airway and has applied oxygen with a non-rebreathe mask. His capillary refill time is less than 2 seconds and his heart rate 120 beats/minute.

What is the next most appropriate management step?

Administer further anti-convulsant
Gain iv access
Check blood glucose level
Check pupils
Check conscious level

Check blood glucose level

This is the most appropriate next step as, if the patient is hypoglycaemic, the only treatment to stop the fit would be to administer glucose.

10

Seb, a 2-year-old boy, was at his cousin’s birthday party. His mother noticed that he has suddenly developed a widespread urticarial rash and has also become flushed in the face. His vital signs are normal and he has no respiratory compromise.

Which medication would you give?

im adrenaline
Oral corticosteroid
iv hydrocortisone
oral antihistamine
im antihistamine

Oral antihistamine

In children, the most common causes of acute food allergy are ingestion or contact with nuts, egg, milk or seafood. Urticaria and facial swelling are mild reactions. Immediate management is with an oral antihistamine (e.g. chlorpheniramine) and observed over 2 hours for possible

11

Jenny, a 3-year-old girl, was at a village fete. She suddenly developed swollen cheeks and lips and a widespread urticarial rash. She is rushed to the nearby general practice surgery, where it is noted that her breathing is very noisy. She is distressed and frightened. On auscultation she has widespread wheeze.

Which medication would you give first?

im adrenaline
Oral corticosteroid
iv hydrocortisone
oral antihistamine
im antihistamine

IM adrenaline

This child has anaphylaxis, which is life-threatening as she has upper airway obstruction and bronchoconstriction. Priority is to manage the airway and give oxygen via a non-rebreathe mask. The first medication to give would be intramuscular adrenaline.iv hydrocortisone should only be given after immediate treatment of the upper airway obstruction with intramuscular adrenaline. Also, her upper airway obstruction may be further compromised by the distress of establishing an intravenous cannula. It takes about 6 hours to have optimal effect.

This child is unlikely to be able to take oral medications and the antihistamine alone will not treat the upper airway obstruction and oral steroids would take too long to work.

im antihistamine would make the situation worse, as it is painful and will not directly treat the upper airway obstruction.

12

There has been a dramatic decline in the incidence of sudden infant death syndrome in the UK.

Which of the following is the single most important factor responsible for this decline?

Feet to foot of cot
Supine sleeping
Keeping baby in parent's room until 6 months
Keeping room cool
Parents should not smoke in same room as infant

Supine sleeping

All the answers have helped reduce the risk of cot death, but the single most important factor is putting babies to sleep on their backs.

13

What is the most common cause of death in children aged 1–14 years in the UK?

Accidents
Congenital heart disease
Infectious diseases
Malignant disease
Respiratory disease

Accidents

This is now the commonest cause of death, followed by malignant disease.

14

Hamim, a boy aged 3 years, fell 3 metres from a first-floor balcony on to a concrete path. He presents to the Accident and Emergency department with his parents who are concerned that he has vomited several times since the episode. After the fall he immediately cried out in pain, but appeared to be all right. His mother reports that he did not lose consciousness. On examination he is found to be fully conscious but has a large bruise over the left parietal region. There are neither focal neurological signs nor any other injuries. His heart rate is 110 beats/minute, his respiratory rate is 25 breaths/minute and his blood pressure is 90/50 mmHg.

Which of the following would be the most serious clinical sign?

Nasal discharge since his fall
Further enlargement of parietal bruise
A fractured nose
Laceration above the eye requiring suturing
A unilateral black eye

Nasal discharge since his fall

This child has had a significant head injury. His vital signs are normal. A nasal discharge post head trauma is a significant sign. It may be leakage of cerebrospinal fluid (CSF) that can indicate a basal skull fracture.

Parietal bruising, a fractured nose or facial laceration are all distressing, but do not suggest significant brain or skull injury.

Black eyes (periorbital ecchymosis) are a significant sign if bilateral, as this can indicate a basal skull fracture.

15

Hamim, a boy aged 3 years, fell 3 metres from a first-floor balcony on to a concrete path. He presents to the Accident and Emergency department with his parents who are concerned that he has vomited several times since the episode. After the fall he immediately cried out in pain, but appeared to be all right. His mother reports that he did not lose consciousness. On examination he is found to be fully conscious but has a large bruise over the left parietal region. There are neither focal neurological signs nor any other injuries. His heart rate is 110 beats/minute, his respiratory rate is 25 breaths/minute and his blood pressure is 90/50 mmHg.

Eight hours after admission, the nurses note a change in his level of consciousness. He is now responsive only to painful stimuli; his left pupil is dilated although still responsive to light. His airway, breathing and circulation are satisfactory. A CT scan shows that there is a haemorrhage and a skull fracture. He is stabilized in the resuscitation room.

Which of the following is the most appropriate next step in his management?

Clotting studies
EEG
Skeletal survey
Ophthalmology opinion
Neurosurgical referral

Neuro referral

This child has sustained a potentially serious head injury and now has reduced level of consciousness and focal neurological signs, which are indications to be assessed by a neurosurgical specialist. The priority for this child is to prevent further secondary brain injury.

16

Chelsea is a 2-year-old girl who presented 6 months ago with a fractured femur which was felt to be accidental. She presents to Accident and Emergency having slipped in the bath whilst briefly being left alone. On examination there is swelling and bruising over Chelsea’s anterior right chest wall. She has some older bruises on her right thigh. She has no other medical problems and is not on any medication. The chest X-ray reveals rib fractures.

Select the most appropriate next management:

Genetic counselling
Parental reassurance
Child protection case conference
Discharge home without follow up
Health visitor home assessment

Child protection case conference

Even if you do not see the fractures on this X-ray, there are some features in this history which are very concerning. The child is left unsupervised in the bath; she has had a previous femur fracture and has bruises on her thigh. A child protection conference needs to be undertaken to assess the safest and most appropriate outcome for this child.

17

You are a junior doctor working on the paediatric ward. You are asked to take some bloods from Chloe, an 11-year-old girl. Her parents do not wish to be present. When rolling up her sleeve to look for a suitable place for venepuncture you note numerous bruises from strap marks to her upper arm. You ask her how she got the bruising. She replies that her uncle did it as she had been misbehaving.

What should you do with the information?

Ignore it; she was being disciplined for misbehaviour
Just document what was said in the notes including sketches and photographs
Document what was said in the medical notes including sketches and photographs and inform the Consultant on call.
Inform the health visitor and request a home assessment
Inform her mother what she said and suggest she asks the uncle about it

Document what was said in the medical notes including sketches and photographs and inform the Consultant on call.

This is a safeguarding issue, as the girl has alleged physical abuse and this needs to be taken seriously. Other agencies e.g. social services and school need to be contacted to identify any concerns, and the patient needs a full medical examination by a paediatrician trained in child protection.

18

Louise, aged 4 years, was hit by a car in the local supermarket car park. She is brought to the Accident and Emergency department by the paramedical team.

An initial assessment shows:
• Airway —neck collar in place, talking to mother
• Breathing —receiving oxygen via a rebreathing circuit, oxygen saturation 99%
• Breathing —air entry satisfactory and equal bilaterally, respiratory rate 30/min
• Circulation —pulse 160/minute, blood pressure 90/50, capillary refill time 3 sec
• Disability —alert, but frightened and agitated, moving all four limbs.

She has abrasions to her left flank and pain in her left shoulder.

What is the next intervention needed?

Intubation and ventilation
IV access
CXR
Analgesia
Blood glucose

IV access

Louise has cardiovascular compromise and urgently needs fluid resuscitation. She therefore needs intravenous access.


A chest X-ray is needed but this comes after ABC.

Analgesia and a blood sugar are important but not until she has some fluid.

19

Louise, a girl aged 4 years, was hit by a car in the local supermarket car park. She is brought to the Accident and Emergency department by the paramedical team.

An initial assessment shows:
• Airway —neck collar in place, talking to mother
• Breathing —receiving oxygen via a rebreathing circuit, oxygen saturation 99%
• Breathing —air entry satisfactory and equal bilaterally, respiratory rate 30/min
• Circulation —pulse 160/min, blood pressure 90/50, capillary refill time 3 sec
• Disability —alert, but frightened and agitated, moving all four limbs.

She has abrasions to her left flank and pain in her left shoulder.

Chest and abdominal X-rays show fractures of the 9th and 10th ribs on the left-hand side.

What is the most important investigation to perform to establish the cause of her condition?

Abdo US
CT head
Cervical spine X-ray
FBC
Blood creatinine, U&Es

Abdo US

The history and signs suggest hypovolaemic shock from splenic injury. She needs an urgent abdominal ultrasound scan (FAST scan, focused abdominal sonography in trauma).

20

Ronaldo is a 2½-year-old boy from Brazil. He pulled a chip pan off the cooker and has been extensively burnt. He is rushed to the nearest Accident and Emergency department. His airway, breathing and circulation are satisfactory. His burns are to his chest, abdomen and his right arm and hand. Most of the burnt area is now blistering and mottled in colour, with a few white areas. Intravenous analgesia is given.

What immediate management does Ronaldo require?

IV 0.9% saline
Place in cold water
Cover the burns with sterile dressings
Intubation and artificial ventilation
IV antibiotics

IV 0.9% saline

There will be significant fluid loss through the burnt areas, which needs replacing.

21

Jake is a 3-year-old boy. His brother spilt a pan of hot water over him and he has been extensively burnt. He is rushed to the nearest Accident and Emergency department. His airway and breathing are satisfactory. He is tachycardiac, his capillary refill time is 4 seconds and he has a low blood pressure. He has 20% burns involving his chest, abdomen and his right arm and hand.

What is the most important underlying cause for his tachycardia and a capillary refill of 4 seconds?

Shock secondary to his pain from his burns
Shock due to loss of blood plasma, because of damage to his blood vessel secondary to his burn
He has shock due to loss of red blood cells, because of damage to his blood vessels secondary to his burn
He has shock due to vasodilation of his blood vessels, secondary to his burn
He has shock due to vasodilation of his blood vessels, secondary to infection developing in his burn

Shock due to loss of blood plasma, because of damage to his blood vessel secondary to his burn

Jake has hypovolaemic shock secondary to the loss of blood plasma. This is secondary to loss of skin integrity.

22

Solomon, aged 3 years, has been found eating some of his pregnant mother’s iron tablets; up to 10 tablets are missing. Their general practitioner advised that he should be taken to hospital directly. On examination in the emergency department he is found to be talkative, with no obvious abnormalities. He has no other medical problems and is not normally on any medications.

What would be the first investigation you would perform?

Abdo Xray
FBC
Clotting
Serum iron
LFTs

Abdo Xray

An abdominal X-ray identifies if there is a significant number of tablets in his stomach.

The serum iron result will not be helpful at this stage as he will not have absorbed the medication.

23

Solomon, aged 3 years, has been found eating some of his pregnant mother’s iron tablets; up to 10 tablets are missing. Their general practitioner advised that he should be taken to hospital directly. On examination in the emergency department he is found to be talkative, with no obvious abnormalities. He has no other medical problems and is not normally on any medications.

Your investigation suggests a significant ingestion of iron.

Which of the following would you initiate?

IV acetylcusteine
IV naloxone
IV desferrioxamine
Forced alkaline diuresis
Intubate and hyperventilate

IV desferrioxamine

Intravenous desferrioxamine binds with iron in the blood excreting it in urine and faeces.

24

Pauline is a 6-year-old girl. Her teacher is concerned, as she has been rubbing herself ‘down below’ in the classroom and touching other girls. She later discloses to her teacher that her stepfather has hurt her with his ‘willy’. She is seen by the consultant paediatrician who notices some vulval soreness and so takes a swab which reveals gonococcus. She also notices that there is some bruising to the thighs. She plots her weight and finds it to be just above the 99th centile. She has no other medical problems.

Which of the following findings is the most suggestive of sexual abuse?

Bruising to the thighs
Disclosure of event to teacher
Gonococcus on swab
Sexualised behaviour
Vulval soreness

Gonococcus on swab

All of these could suggest sexual abuse but only the gonococcus on the swab can absolutely confirm it. Identifying a sexually transmitted infection in a child is highly suggestive of sexual abuse. It will not however inform you of whom the perpetrator is.

The disclosure is very useful and a police investigation would need to be undertaken. But only the gonococcus on the swab can absolutely confirm sexual abuse.

Bruising over the thighs is common in active children but it is more concerning if it is found in the inner thigh as this area is anatomically ‘protected’ and not often bruised accidentally. But only the gonococcus on the swab can absolutely confirm sexual abuse.

25

Mr and Mrs Walsh attend clinic with their new baby, Ophelia, who has Down syndrome. They are keen to have further children and want to know more about their future risk of having children with Down syndrome. What chromosomal abnormality is likely to have caused Ophelia to have Down syndrome?

Non-disjunction
Translocation
Mosaicism
Point mutation
Triplet repeat expansion

Non-disjunction

It is responsible for 94% of cases of Down syndrome. the pair of chromosome 21s fails to separate, so that one gamete has two chromosome 21s and one has none. related to maternal age.

Translocation (5%) - When the extra chromosome 21 is joined onto another chromosome (usually chromosome 14, but occasionally chromosome 15, 22 or 21), this is known as a Robertsonian translocation.

Mosaicism (1%) - In mosaicism, some of the cells are normal and some have trisomy 21. This usually arises after the formation of the chromosomally normal zygote by non-disjunction at mitosis but can arise by later mitotic non-disjunction in a trisomy 21 conception. The phenotype is sometimes milder in Down syndrome mosaicism.

26

Mr and Mrs David are seen by the geneticists as their baby, Sarah, has Down syndrome. Her chromosomes are examined. Three copies of chromosome 21 are seen, one of which is attached to chromosome 14. How would you describe this abnormality?

Non-disjunction
Balanced Robertsonian translocation
Unbalanced Robertsonian translocation
Mosaicism
Triplet repeat expansion

Unbalanced translocation.

This is important because there is an increased risk of recurrence as one of the parents is likely to have a balanced translocation whereby one of their copies of chromosome 21 is attached to chromosome 14.

27

Olive is a 10-day-old baby with Down syndrome. On examination, you hear a loud heart murmur. What is the most likely cause?

Patent ductus arteriosus
Aortic stenosis
Coarctation of the aorta
Innocent murmur
Atrioventricular septal defect

Atrioventricular septal defect.

This is the most common congenital cardiac anomaly in children with Down syndrome. 40% of children with Down syndrome have a congenital heart defect and therefore it is important that all children have an echocardiogram in the neonatal period.

28

Fiona is a well 4-year-old girl with Down syndrome. She attends her yearly follow-up appointment with her mother. There are no real problems other than constipation, for which her general practitioner has started treatment. When you plot Fiona on the Down syndrome growth chart, you notice that her height is starting to drift from the 75th to the 25th centile. Her weight, however, has gone from the 50th to the 75th centile.

Which of the following investigations would you perform?

FBC
TFT
Cytogenetic testing
Coeliac screen
U&Es

Thyroid function tests

Children with Down syndrome are at an increased risk of hypothyroidism. Growth failure and constipation are symptoms of hypothyroidism. Coeliac disease is more common in Down syndrome and it can cause short stature; however her weight would be falling.

29

Mary is an infant with Down syndrome. She was diagnosed soon after birth and this has been confirmed with a rapid karyotype. Her antenatal scans had been all normal and a routine echocardiogram on the neonatal unit shortly after birth was normal. She attends the community clinic for the first time at 4 weeks of age. She is now thriving and feeding well. Her parents have many questions about what is going to happen in the future. In particular, they have been reading that she is at increase risk of certain diseases because she has Down syndrome.

Out of the following, which is a higher risk to Mary, compared with the general population?

Duodenal atresia
Ischaemic heart disease
Pyloric stensosis
Congenital heart disease
Leukaemia

Leukaemia.

Children with Down syndrome are also at an increased risk of congenital heart disease and duodenal atresia. However Mary had a normal echocardiogram and duodenal atresia would have already presented with bile-stained vomiting within the first few days of life. Children with Down syndrome are not at an increase risk of ischaemic heart disease or pyloric stenosis.

30

Louise has Turner’s syndrome. What is her karyotype?

46, XO
46, XX
45, XO
45, XY
47, XXY

45, XO.

There are 22 pairs of autosomes, and only one sex chromosome, an X. This makes the total number of chromosomes 45.