The Sick Child Flashcards
(401 cards)
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
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
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
4
Q
What is the most common reason for acute illness in kids
A
Sepsis
Overwhelming infection
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
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
7
Q
List potential causes of stridor
A
Anything that causes upper airway obstruction Bacterial tracheitis Croup Epiglottitis Inhaled foreign body
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)
9
Q
What CNS disease can kids present with
A
Meningitis: bacterial and viral
- varied symptoms
Encephalitis: commonly viral (coxsackie)
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
11
Q
What type of meningitis causes the classic rash
A
Meningococcus meningitis
Rash is purpuric and doesn’t blanche
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
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
14
Q
List common GI and urogenital presentations in kids
A
Viral gastroenteritis GI obstruction - pyloric stenosis, volvulus, intussusception Appendicitis UTI Testicular torsion
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
16
Q
What heart conditions might you see in young children
A
Congenital heart disease
Arrhythmias - SVT’s
Cardiac issues very rare in kids
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
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
19
Q
What has a better prognosis - respiratory or cardiac arrest
A
Respiratory
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
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
22
Q
Why might young children make a grunting noise
A
Cold
Hypoglycemia
Breathing problems - basically giving themselves CPAP by closing glottis
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
24
Q
Where do you perform cap refill on a child
A
Centrally by pressing on the sternum
25
If a child is in shock, how do you treat them
Fluids - based on body weight
Saline is best
Give blood if it is a trauma case
26
List the key signs of dehydration
```
Dry mucous membranes, eyes or fontanelle
Decreased skin turgor
Low urine output
Shock
Lethargy
Altered conscious level - severe
```
27
What is posturing
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
28
How do you treat pyloric stenosis
Surgery
| Pyloromyotomy - cut out the thickened muscle in the wall to reduce obstruction
29
What is intussusception
Part of the bowel folds in on itself like a telescope
30
List symptoms of intussusception
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
31
How does intussusception appear on US
When 'face on' it looks like a target or tree rings
| From the side it looks like a kidney - pseudokidney
32
How do you treat intussusception
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
33
How will appendicitis in a child appear on US
Usually just being able to see the appendix on US in a child means that it is inflamed
34
What is the jump test for appendicitis
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
35
If a baby is vomiting up green stuff, what diagnosis must be excluded
Malrotation with midgut volvulus
| It is a surgical emergency and if not caught in time then the gut and baby can die
36
Describe the normal fixed position of the gut
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
37
What can cause a malformation with midgut volvulus
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
38
List causes of acute scrotum problems
Testicular torsion - surgical emergency
Inflammation of the epididymis
Torsion of the hydatid - small area of necrosis on top of testicle (most common)
39
What is BXO
Abnormality of the penis
White scarring on the head around the urethral opening
Requires circumcision
40
Urological system is a common site of congenital malformation - true or false
TRUE
41
What is hypospadias
Abnormal opening in penis - e.g. urethra comes out below penis
42
What do you do if a testicle is stuck in the groin
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
43
How do you treat an absent testicle
You don't
| There is no need to move anything as nothing there to cause cancer risk
44
How do you move a testicle from the groin to scrotum
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
45
In an ABCDE situation, what differences must be done in Airway in a child
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
46
In an ABCDE situation, if a child is not breathing what do you do (only breathing tasks)
Give 5 rescue breaths
| Check for chest rising with each breath
47
In an ABCDE situation, if a child is not breathing and the rescue breaths are ineffective - what do you do
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
48
How do you treat a choking child (older)
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
49
How do you treat a choking child (infant)
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
50
Why cant you do the Heimlich manoeuvre on infants
High risk of rupturing abdominal organs
51
What is the WETFLAG procedure for a child in arrest situation
```
Weight - allows you to work out doses
Energy
Tube
Fluids
Lorazepam
Adrenaline
Glucose
```
52
List common signs of hypoglycemia in children
```
Tiredness
Feeling shaky
Lips tingling
Feeling tearful or irritable
Blurry vision
Lack of concentration
Going pale
Sweating
Headache
Feeling hungry
```
53
Children who are decompensating often appear well - true or false
True
Children are very good at compensating for illness
They are often severely unwell by the time they present as such
54
List the steps in the 3 minute exam for children
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
55
How can you determine if a child has an unprotected airway
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
56
At what stage of hypoxia does cyanosis present
Roughly below 85%
57
Why might a sats probe give artificially low readings in children
If the child is moving and you don't get good contact with the probe
58
Where do you place the sats probe on a small child
O2 sats taken from foot or whole hand on a baby as their fingers are too small
59
What is the target O2 sats for a child
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
60
Auscultation is less useful in children than in adults - true or false
True
| Children have much smaller chests so the noises will transmit across the whole chest - harder to localise
61
What is mottling a sign of
Poor perfusion
62
What affect can crying have on the obs
A distressed child will have an increased HR
63
What conditions can lead to poor perfusion
Sepsis
| Dehydration
64
Why is central cap refill more reliable than peripheral
It is not affected by environmental temperature
65
List signs of poor perfusion in children
Poor cap refill - peripheral affected first, then central
Mottled skin
Cold hands and feet
66
What does asymmetrical pupils suggest
SOL in the brain
| This includes haemorrhage
67
What condition can lead to sluggish pupils
Fits
| Drug overdose
68
Changing pupil size is suggestive of what
May suggest an ongoing fit even if there is no tonic clonic movements
69
What is true irritability and what does it suggest
When a baby truly cannot be consoled or distracted
| It is suggestive of raised ICP or meningitis
70
Why do boys with abdominal pain need a testicular exam
To exclude testicular torsion - emergency
| Should also look in groin for hernias
71
Persistant drowsiness is a red flag sign - true or false
True
| Often seen after fits or in fever
72
What type of thermometer is used on a young baby
Axillary thermometers are used in babies if ear too small for tympanic
73
List common causes of breathlessness in children
Asthma
Bronchiolitis
Pneumonia
Croup
74
Most severe resp infections usually occur in the first 3 years of life - true or false
True
| Includes strep pneumo, Hib, pertussis
75
A prolonged expiration phase is seen in which conditions
Asthma
| Bronchiolitis
76
B-agonists less effective for the treatment of asthma in children under 1 - true or false
True
| This is because asthma in this age group is usually atypical
77
How do you treat croup
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
78
How do you treat bronchiolitis
Supportive treatment only as it is viral
| May need O2 and feeding support if severe
79
What caused croup
It is typically caused by parainfluenza
| It is technically laryngotracheobronchitis
80
What causes bronchiolitis
Typically RSV
| Leads to acute inflammatory injury of the bronchioles - LRTI
81
How does pneumonia present in kids
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
-
82
Children may have persistent wheeze following pneumonia - true or false
True
Common for a few months after illness
Should grow out of it by age 2
83
List risk factors for respiratory illness in children
Prematurity
Required neonatal care
Exisiting cardio or resp disease
84
Respiratory distress can lead to dehydration in children - true or false
True
| The breathing difficulty makes it hard for them to feed properly leading to dehydration
85
Kids become more distressed as they decompensate - true or false
False
| They become less distressed as they become very tired/drowsy
86
Wheeze is an upper airway noise - true or false
False it is a lower airway noise
| Heard in asthma and bronchiolitis
87
Stridor is an upper airway noise - true or false
True
| Occurs on inspiration
88
Stridor is heard in which conditions
Heard in croup, foreign body aspiration, epiglottis etc.
89
Chest recessions are more common in younger children - true or false
True
They have softer smaller chests so less effort needed to indraw
Older kids with recessions are very sick
90
Intercostal and subcostal recession usually occur together - true or false
True
| They have the same clinical significance
91
Which type of chest indrawing most indicates severe respiratory distress and why
Sternal indrawing
| Lot of effort is needed to move such a large bone
92
Why do children in respiratory distress bob their heads
Head bob caused by pulling on sternocleidomastoid - they are using their accessory muscles
93
At which O2 saturation should you give a child supplemental oxygen
Give O2 if sats are below 92% - should get up to 100% quickly on high flow
94
Where might you hear bronchial breathing in a child
Heard just over an area of consolidation - harsh breathing noise
95
How would a child present if they have swallowed an foreign object
They will be very uncomfortable
| Will be drooling due to swallowing difficulty
96
Which is more common, children swallowing foreign bodies or inhaling them
Swallowing is more common
97
List the potential outcomes of an inhaled foreign body
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
98
A foreign body causing discomfort is most likely where - oesophagus or trachea
Oesophagus
99
How may children appear during an apnoea
May go floppy and cyanosed
100
In young infants (1-4 months old) apnoeas are a sign of what
Usually due to another underlying illness
Not necessarily respiratory in origin
Must be sent to hospital
101
Describe the difference in whooping cough presentation between older and younger kids
Older kids present with the classic whooping cough
| Younger kids may present with apnoeas
102
Tachycardia can be an indicator for respiratory distress - true or false
True
103
How do you manage status asthmaticus
Requires intubation and ventilation to take over breathing
| Can lead to respiratory failure without it
104
If a child has a silent chest, what must you do
You must call for intensive care
| It is a sign of severe respiratory distress
105
What is the most common cause of fever in children
Most are caused by mild viral illnesses which get better on their own
106
Why are infants more vulnerable to infection
They still have an immature immune system
| Takes around 2 years for the immune system to mature = thymus and spleen developing
107
The younger the child, the higher the risk of a local infection becoming sepsis - true or false
True
| This is due to their immature immune system
108
Children are more likely to present with non-specific infection symptoms than adults - true or false
True
109
Why is CRP not a useful blood test in the acute setting
It takes time for levels to rise so doesn't provide an accurate picture in the acute setting
110
What causes the purpuric rash seen in meningitis
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
111
Which blood tests should you perform on a child with suspected sepsis
Venous blood gas
WCC
Can also check lactate - significant if >3
112
The degree of the fever is a great predictor of illness severity - true or false
False
It is a poor predictor
Still important to ask about the degree and duration of the fever
113
At which point does a temperature becoming concerning in a child
Particularly concerning if temp is over 39.5C
| Though in those under 3 months 38 is considered significant
114
Which children are at particularly high risk of infection
Cerebral palsy
Prematurity
Those on steroids
History of leukaemia
115
How does fever influence HR and RR
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
116
How should a fever respond to anti-pyrectics
Should fall into an up and down pattern - goes down after dose and then rises again
This is a reassuring sign
117
What does tachypnoea without signs of resp distress suggest
It is a sign of sepsis
118
Which examinations would you do to find an infection focus in a child
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
119
What signs are required for a diagnosis of ear infection in children
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
120
How can fever affect the findings on ENT exam
Temp can make the eardrums pink/flushed - does not mean it's an ear infection
Same with the tonsils
121
How will the tonsils appear in true tonsillitis
They will be large with a whitish exudate
| May be red - not enough on its own
122
Babies sometimes present with hypothermia in response to infection - true or false
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
123
Good fever control can prevent a febrile convulsion - true or false
False
| There is no evidence of this
124
When would a child be sent for a chest X-ray
CXR done in those under 3 with signs of sepsis or a raised RR
125
How do you diagnose a UTI in children
Get a clean catch urine if not toilet trained
| Parents given a pot and baby left without nappy to catch urine
126
When should you suspect a UTI in children
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
127
List signs of bone or joint infection in children
Reluctance to use limb or limping (atraumatic limp)
Joint may be warm and red
General signs of infection
Consider osteomyelitis or septic arthritis
128
How does Kawasaki disease present
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
129
Kawasaki disease is a disease of childhood - true or false
True
| Most common in the under 2's
130
Kawasaki disease can lead to complications with which major organ
The heart
| Can also affect the coronary arteries
131
Kawasaki disease can lead to complications with which major organ
The heart
| Can also affect the coronary arteries
132
Kawasaki disease can lead to complications with which major organ
The heart
| Can also affect the coronary arteries
133
How do children with influenza present
Headache, muscle ache, tiredness, fever, may have a cough
| Babies have less specific symptoms - D&V and rash
134
Sepsis caused by meningitis is more fatal than meningitis alone - true or false
True
135
How do you treat a child with suspected bacterial meningitis (immediate treatment)
Give empirical penicillin or ceftriaxone to any older child with suspected meningitis
136
Viral meningitis can have a mild presentation - true or false
True
Can occur alongside viruses - mild and presents with headache
Its the bacterial one that's severe
137
List possible causes of rash in children
```
Allergies
Med reaction
Stings and insect bites
Chemical reactions
Infection
Systemic disease
```
138
A rash combined with a cough and sore throat is suggestive of what
Measles
139
A rash combined with sore/red eyes is suggestive of what
Kawasaki disease
140
A rash combined with abdominal pain is suggestive of what
HSP
141
A rash combined with a recent burn is suggestive of what
Toxic shock syndrome
142
A rash combined with a bleeding gums, bruising, joint pain and lethargy is suggestive of what
Leukemia
143
Meningitis will always present with a non-blanching rash - true or false
False
| Can have a blanching erythematous rash to start with so don't rule it out
144
What is erythema toxicum neonatorum
A transient rash seen in babies under the age of 1
| Appears as raised, red, blotchy areas
145
Which common childhood rashes present as macules or papules
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
146
Which common childhood rashes appear as vesicles
Vesicles - small blisters
| Chickenpox, herpes simplex, shingles
147
Which common childhood rashes appear as pustules
Pustules - pus filled blisters
| Strep or staph infections
148
Which common childhood rashes appear as petichiae or purpura
HSP
| Meningococcal sepsis
149
What is the difference between petichiae and purpura
Petechiae - 1mm or less in size and flat
| Purpura - purple areas 2mm or larger
150
Which conditions can cause an urticariral rash in children
- Allergy and anaphylaxis
| - Can come up and down again
151
What is cradle cap
Seborrheic dermatitis on the head causing flaky scalp
| Common in babies
152
List common sites for eczema in children
Necks, elbows, knees, armpits and face
153
How does eczema appear when there is a secondary bacterial infection in it
Will be weepy with scabs
154
How does Neisseria meningitidis spread
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
155
How does Stevens Johnsons syndrome present in children
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)
156
What causes toxic shock syndrome in children
Caused by toxin secreting bacteria like strep or staph
| Can occur after minor burn
157
How do you treat toxic shock syndrome
Immediate antibiotic treatment
158
How does toxic shock present following a burn
Burn looks normal but kid has a fever, diarrhoea, erythematous rash and generally unwell
Can become critically unwell very fast
159
What is HSP
It is an immune disease causing bleeding into the skin
160
How does HSP present in children
Child is usually well - obs normal
| Presents with the purpuric rash - worst on back of legs and bum
161
List some of the main complications of HSP
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
What is idiopathic thrombocytopenic purpura
Immune disease which affects platelets and therefore clotting - shows up on FBC
Child will be completely well but have a petechial rash
163
How do you treat idiopathic thrombocytopenic purpura
May need steroid treatment
164
Why should you do a FBC in kids with a petichial/purpura
Have to exclude cancer as leukaemia can present like this
| Will be clinically anaemic
165
What is the more common type of fit - generalised or focal
Generalised
166
What is the most common cause of fits in children
Temperature - febrile convulsions in younger children
In older children it is more likely a non-febrile epileptic fit in someone with known epilepsy
167
List potential causes of fits in children
```
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
What event happens with warning symptoms a fit or a faint
A faint
Will have symptoms like dizziness, feeling hot, hearing and visual changes
Fits happen without warning
169
What should you include in a seizure history
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
Jerking movements means that it is definitely a seizure - true or false
False
| May see jerking movements or incontinence in faints too
171
What are the main differences between a faint and a fit
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
When does cardiac syncope typically occur
Due to an arrhythmia - may not feel it
| Occurs out of the blue or during exercise
173
How can breath holding attacks lead to convulsive episodes
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
Febrile convulsions are usually which type of seizure
Febrile convulsions are usually generalised seizures
| Most recover quickly
175
First time febrile convulsions are rare in those over the age of 3 - true or false
True
176
If a fever triggers a fit in a known epileptic is it considered a febrile seizure
Not a true one
177
How do most children present after a true seizure
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
How likely is it for a child to have another febrile seizure after their first presentation
50/50 chance of having another before they grow out of it
179
How do you manage a seizure
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
How does a focal seizure present
Child will be awake and usually aware
| The fit will affect a specific part of the body
181
How does a general seizure present
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
How do you manage a child in the post-ictal period
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
Fits in infants only a few months old often look atypical - true or false
True
| May present with odd posturing of arms, stiffness etc whilst some just go floppy
184
List signs of aspiration post-seizure
Signs include a drop in O2 sats, high RR or resp distress following a seizure event
185
What is status epilepticus
A fit lasting over 30 mins or when there is incomplete recovery between fits
Usually in severe epilepsy or severe underlying cause
186
Why would a small baby be jittery
Small babies become 'jittery' if they have low sugars - shaky but not a true fit
187
What is the most common cause of dehydration in children
Gastroenteritis - most often viral
Usually has to be severe for it to lead to dehydration
Children with chronic diseases are more vulnerable
188
How do you manage viral gastroenteritis in children
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
Which children are more vulnerable to dehydration
Children with chronic diseases
190
What typically comes first in viral gastroenteritis, diarrhoea or vomiting
Vomiting usually precedes diarrhoea
191
Diarrhoea and vomiting in children can be a sign of almost any illness, not just GI conditions - true or false
True
| Many children will have 1 or 2 episodes of D&V with any illness so should run through other symptoms
192
How would a child with campylobacter infection typically present
Gastroenteritis with abdominal cramps
193
Why might appendicitis present with diarrhoea in children
It increases bowel motility = diarrhoea
| Same with bowel obstruction
194
What can cause bloody stools in children
Salmonella or shigella infection
Can also be a sign of intussuception - red current jelly sign
195
In terms of nappies, when would you be worried about dehydration in a child
If no wet nappies for 12 hours
196
List signs of severe dehydration in children
```
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
What is hypernatreamic dehydration
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
How does hypernatraemic dehydration present
Drowsiness - wont wake up to feed
Skin eyes and fontanelles NOT sunken
High HR and RR
Diagnose by blood test - high Na
199
Which children are at risk of hypernatraemic dehydration
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
How does DKA present
High glucose and ketones cause dehydration
High RR caused by acidosis
Polyuria, excessive thirst and dehydration
201
List common abdominal causes of abdominal pain in children
Colic, intussuception, mesenteric adenitis, constipation, IBS (usually Crohns), coeliac, bowel obstruction, appendicitis
202
List common causes of abdominal pain in children that originate outwith the abdomen
```
Migraines
DKA,
Psych issues - stress
UTI
Testicular torsion
Ovarian cysts or torsion
Malignancy
Infections elsewhere can cause abdominal pain
```
203
Appendicitis is hard to diagnose in children under 5 - true or false
True
| Common for appendix to rupture before diagnosis
204
List common causes of chronic abdominal pain in children
Constipation
IBD
Malignancy
205
List common causes of acute abdominal pain in children
UTI
DKA
Surgical issue (obstruction, appendicitis etc)
206
Bilious vomiting is suggestive of what type of pathology
Bowel obstruction
| Investigate by AXR, bloods and surgical opinion
207
List common symptoms of surgical bowel issues such as obstruction or appendicitis
Not eating
Severe pain
Worse on movement
Vomiting (particularly bilious = obstruction)
208
List some red flag features of abdominal pain in children
Faltering growth/failure to thrive is a sign of more serious pathology
So is being woken from sleep by the pain
209
List red flags for cervical lymphadenopathy
- 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
What is the most common cause of lymphadenopathy in children
Mostly due to benign self-limiting viral illness
| Increased numbers of immune cells collect in the nodes, enlarging them
211
What is the first line treatment for lymphadenitis in children
Oral co-amoxiclav
212
List common signs and symptoms of lymphoma
```
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
How do you stage lymphoma
- LP
- CT chest, abdo and pelvis
- Bone marrow biopsy
214
What is tumour lysis syndrome
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
Describe stage 1 lymphoma
One group of lymph nodes is affected, or there’s a single extranodal tumour.
216
Describe stage 2 lymphoma
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
Describe stage 3 lymphoma
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
Describe stage 4 lymphoma
The lymphoma has spread beyond the lymph nodes to other organs of the body such as the bone marrow or nervous system
219
List the key features of tumour lysis syndrome
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
What is screened for in the newborn heel prick test
Cystic Fibrosis, Congenital Hypothyroidism, Phenylketonuria, MCADD, Sickle Cell Disease, Maple Syrup Urine Disease, Homocystinuria, Glutaric Aciduria type 1 and Isovaleric Aciduria
221
How is Cystic Fibrosis screened for in the UK
Part of the newborn heel prick test
222
Describe the early management of CF
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
How is faecal elastase used in monitoring of CF
Faecal elastase is a marker of exocrine pancreatic function so CF kids may get it measured
This function is usually decreases in CF
224
Why is pancreas function reduced in CF
The pancreatic ducts get obstructed by thickened secretions, reducing function
Both exocrine and endocrine functions are
Leads to malabsorption and diabetes
225
How can CF present
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
What are the two main nutritional challenges seen in cystic fibrosis
Pancreatic dysfunction results in malabsorption of energy dense fats The chronic respiratory infection results in an increased calorie requirement
227
How do you treat the nutritional deficiencies associated with CF
Counteracted with enzyme replacement and calorie dense diet
| Sometimes overnight gastrostomy or NG feeds are used
228
List some of the complications of CF
Bronchiectasis, diabetes, distal intestinal obstruction syndrome, cirrhotic liver disease and infertility
229
A normal respiratory rate in a child with respiratory distress may be falsely reassuring - true or false
True
| Can be a sign of a tiring child
230
Why should you note if a child was distressed during an examination
Distress can make them tachycardic etc. so may be a false sign
Important to note down
231
How do you correct for gestation on a growth chart
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
Until what age do you correct for gestation on the growth chart
Until they are 1 year old
233
What causes slapped cheek syndrome
Human Parvovirus B19 or Fifth Disease
234
What is the risk of catching parvovirus/slapped cheek syndrome in pregnancy
Infection in pregnancy can lead to fetal anaemia, ‘hydrops fetalis’ and miscarriage
235
What are the symptoms of slapped cheek syndrome
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
Describe the rash seen in slapped cheek syndrome
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
Which children are at high risk if they catch slapped cheek syndrome
Children with sickle cell disease as can cause aplastic crisis
238
What is involved in a septic screen in children
LP, urine culture (clean catch), CXR when resp signs
239
When would you do a septic screen in a child
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
List contraindications for LP in children
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
List some potential complication of LP in children
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
How do you prescribe fluids in children
For the 1st 10kg prescribe 100ml/kg
For the 2nd 10kg prescribe 50ml/kg
For every kg above 20kg prescribe 20ml/kg
243
Lower lobe pneumonias can present with abdominal pain in children - true or false
True
244
What signs of constipation may be found on abdominal exam
Hard faeces may be felt in the left iliac fossa
245
What is the most common cause of peritonitis in children
Perforated appendix
246
How does peritonitis present
Leads to widespread tenderness and guarding
| Will also cause pain on movement
247
How can extra-abdominal infections lead to intussuception
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
List some potential causes of abdominal masses in children
Neuroblastoma and Wilms tumour
Appendix abscess
Constipation
249
How might testicular torsion present
Swelling in scrotum
Tenderness or pain
Abdominal pain
Colour change
250
Testicular torsion is common in which age group
Torsion is most common in boys over 12 but should be considered in all boys
251
What is more common falling head injury in children - diffuse brain injury or haemorrhage
Diffuse brain injury - cerebral oedema
| Usually occurs over the 24hrs after the injury
252
List red flag symptoms that suggest a serious head injury in children
Persistent drowsiness - more than 2 hours
Persistent headache
Persistent vomiting
253
What key factors should be covered in a head injury history
```
Mechanism of injury
Risk of NAI?
Behaviour at time of injury and since then
Ages
LOC (means injury was significant)
```
254
What is considered a significant fall in a child
Anything from their height or above
255
Which consequences of head injury can lead to true irritability in children
Cerebral oedema, contusions and haemorrhage
256
Which consequences of head injury can lead to true irritability in children
Cerebral oedema, contusions and haemorrhage
257
What are the indications for CT scan following head injury
```
LOC for more than 1 min
Head injury with seizure
Persistent drowsiness - over 2 hours
Headache
Vomiting
```
258
Brain haemorrhage almost always causes a headache = true or false
True
259
Following head injury behavioural changes usually occur after focal signs present - true or false
False
| Behavior usually changes first
260
Which type of head injuries are common signs of NAI
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
How does the AVPU scale correlate to GCS
P on AVPU is roughly GCS 8
262
Which scalp signs suggest an underlying skull fracture
Soft, boggy or large swelling on scalp may suggest underlying fracture
Boggy haematoma
263
Facial bone fractures are common in children - true or false
False
| Only really happens with a direct blow or high power injury like unrestrained RTA
264
What is mesenteric adenitis
Inflammation of the abdominal lymph nodes
Typically caused by viral infection
Causes abdominal pain in children
265
How do you differentiate between reflux and GORD in children
All kids get reflux but GORD is when the reflux causes faltering growth or signficant distress
266
Why should you not examine the throat in suspected croup
There is a risk of epiglottitis and if you irritate this it can lead to airway closure
267
What symptoms may be caused by administration of salbutamol
Tachycardia
| Tremor
268
What is the minimum amount you want a child to be feeding per day
100ml per kg is the minimum you want
| 150ml per kg per day is normal feed
269
How does HUS present
Bloody diarrhoea - acute
Common cause of AKI in children
Microangiopathic Haemolytic Anaemia
Red cell fragmentation on Blood Film
270
What is HUS
Haemolytic uraemic syndrome
| Consequnce of an e.coli 0157 infection
271
How do you manage HUS
Send stool sample
If well discharged with worsening advice
If unwell admit and give IV fluids
272
List signs of uncontrolled asthma
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
List signs of poorly controlled asthma
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
What is the main difference between the administration of aerosol and dry powder inhalers
Aerosol inhalers are inhaled slowly and deeply, but dry powder inhalers should be inhaled fast and forcefully
275
Why do children have higher resp rates than adults
Smaller people have smaller tidal volumes
| RR higher to keep minute ventilation
276
Why do children have higher heart rates than adults
Smaller people have smaller stroke volumes
| HR higher to maintain a sufficient cardiac output
277
What signs suggest severe croup
Severe respiratory distress
Cyanosis
Exhaustion
278
How do you manage GORD In children
Conservative measures
Thickening feed (eg. Gaviscon)
Reducing stomach acid (eg. PPI / H2 antagonist)
Emptying stomach faster (eg. Domperidone)
Early weaning can be useful
279
How does transient synovitis present
Painful joint - usually hip
Child will be otherwise well and afebrile
Preceded by viral illness in approximately 50%
280
How do you manage transient synovitis
Usually resolves by itself in 7-14 days
281
What is Perthes disease
Avascular necrosis of the capital femoral epiphysis
| Typically occurs in those aged 3-9
282
How does Perthes disease present
Onset occurs over weeks
Child will be systemically well
No other joint involvement (just hip) and no signs of joint inflammation
283
How does septic arthritis present in children
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
How do you manage septic arthritis in children
Early involvement of orthopaedics as joint destruction can occur within 24 hours
285
Which children are most affected by SUFE
Usually late childhood / adolescence
M>F 2:1
Often weight >90th centile
286
How does SUFE present
Antalgic gait and apparent leg length discrepancy
287
Severe eczema can impact on development - true or false
True
All time and energy goes into skin
Miss out on opportunities and education
288
How can eczema lead to fluid loss
If severe you get leaking of serous fluid through broken skin - loss of fluid
289
The vast majority of children have which type of diabetes
Type 2
| Even with rising obesity, the rate of type 2 in children isn't as high
290
Good glycaemic control early on can reduce risk of complications further down the line - true or false
True
| This is why paediatric diabetes is so important to control
291
The level of response to insulin changes as the child ages - true or false
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
Why would a family history of thyroid problems be relevant to a child with suspected diabetes
Both are autoimmune conditions and can therefore be related/run in families
293
How might DKA present in a child
History of polyuria, polydipsia and tiredness
Tummy pain
Breathing issues - Kussmaul's breathing
Symptoms of dehydration
294
How might DKA present in a child
History of polyuria, polydipsia and tiredness
Tummy pain
Breathing issues - Kussmaul's breathing
Symptoms of dehydration
295
How do you diagnose DKA
```
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
How do you diagnose DKA
```
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
How do you manage DKA
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
Describe how fluids are replaced in a patient with DKA
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
Why would you need K+ replacement in a patient being treated for DKA
Administration of insulin will cause your K+ to drop so will need replaced – quite hard to replace so catch it early
300
If a known diabetic patient presents with DKA you should stop their insulin - true or false
False
| Long acting insulin should never be stopped – if they come in with DKA you should still give them it at night
301
What can cause fluid loss in a child
Blood loss
Gastroenteritis - D&V
Burns
302
What are the main reasons for requiring resuscitation in children
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
Which conditions can cause fluid maldistribution
Septic shock
Cardiac disease
Anaphylaxis
304
How do you perform CPR in a child
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
What is the biggest cause of mortality in children worldwide
Neonatal death
| Then diarrhoael diseases then pneumonia
306
What is the most common thing for children to present with
Respiratory illness
307
How do you recognise sepsis in a child
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
Which children at at higher risk of sepsis and therefore have a lower threshold for treatment
```
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
What is the paediatric sepsis 6
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
How does tonsillitis present in children
```
Fever
Poor oral intake
Drooling
Halitosis
Rash/perioral pallor
```
311
How do you deal with a choking child
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
List the reversible causes of cardiac arrest
Hypoxia
Hypovolaemia
Hypo/hyperkaelameia (or other metabolic)
Hypothermia
Tension pneumothorax
Tamponade
Toxins
Thromboembolism
313
What are the shockable rhythms
VF
| Pulseless VT
314
What are the non-shockable rhythms
Pulseless electrical activity
| Asystole
315
What is the resus protocol for a newborn
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
How do you get intraosseous access
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
Which type of fluid should be used for fluid resus in children
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
What volume of fluid needs to be lost for signs of shock to present
Around 25% of circulating volumes
319
How would you use a spacer with a pressurized metered dose inhaler
Long, slow breaths in and out of the spacer – 10 for young children (5 for older children)
320
Which types of inhaler can be used with a spacer
Pressurised metered dose inhaler
321
What is a PMDI
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
Why is it important to clean spacers
The build up of drug inside spacer makes it less effective
323
What is a breath actuated inhaler
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
What is a dry powder inhaler
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
PMDIs can be used by all age groups - true or false
True
| Younger children will likely need a spacer
326
List signs of a true seizure
```
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
Focal seizures can progress into a generalised ones - true or false
True
327
If breathing regular/relaxed it’s unlikely to be a seizure - true or false
True
328
Flashing lights is a common trigger of seizure in children - true or false
False it is rare
329
Neonatal seizure are very rare - true or false
True
| Can be very difficult to diagnose the cause
330
List some potential causes of seizures in neonates
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
Every child who comes in with a syncope/funny turn needs an ECG - true or false
True
May be due to an arrhythmia
Some kids make fitting movements when collapsed
332
What is gratification
Unconscious movements which are done because they feel good
| Can appear unresponsive or seizure like
333
What can be done to avoid febrile seizures
Nothing
| It just happens to some children in response to temperature (>38C)
334
What must be excluded before a diagnosis of febrile seizure can be made
CNS infection
| If the infection is meningitis then it is not a febrile convulsion, it is due to the brain infection itself
335
Which types of epilepsy are specific to childhood
Childhood absence epilepsy
Benign epilepsy of childhood with centro-temporal spikes
Juvenile myoclonic epilepsy develops in adolescence
336
EEGs can be used to diagnose epilepsy - true or false
False
| It is not a diagnostic test but used with history to corroborate
337
When would a MRI brain be requested for a child who had a seizure
If there was a focal onset
338
When would genetic tests be carried out on a child presenting with seizure
Particularly if early onset < 3yo
Intractable
Strong family history
339
When is epilepsy considered to have resolved
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
What is the diagnostic criteria for epilepsy
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
Which signs are suggestive of an UMN lesion
Weakness accompanied by increased tone and hyper-reflexia
342
Which signs are suggestive of a LMN lesion
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
List the main indications for urgent brain imaging in children
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
Angular chelitis may be caused by which conditions
```
IBD
Infection
Candida
Drooling
Atopic eczema
Poor nutrition
```
345
Mouth ulcers may be seen in which conditions
Often a sign of Crohn's
Sometime seen in coeliac
346
Pigmented or freckled lips are a sign of which condition
Peutz-Jegher's syndrome
| A cancer syndrome - GI, breast, ovaries, pancreas
347
How far down can you visualise with an endoscope
Down to the 2nd part of the duodenum
348
All endoscopies in children are carried out under GA - true or false
True
| At least in the UK
349
List symptoms of GORD in children
Retrosternal pain/heartburn
Vomiting
Back arching
Cough/aspiration pneumonia
If it leads to severe oesophagitis and erosion you may see melaena/anaemia
350
How might eosinophilic oesophagitis present in children
```
Difficulty swallowing (dysphagia)
Painful swallow
Food bolus obstruction
```
351
Gastric ulcers rarely present in children under what age
Rare before the age of 2
Typically due to H/pylori infection
Presents with pain, vomiting and melaena
352
Children have much higher calorie requirements per kg than adults - true or false
True
They have to consistently gain weight and grow
This is why bowel disorders can lead to failure to thrive/grow
353
What is the most common cause of rectal bleeding in children
Constipation and passage of hard stools
| This can lead to fissures as well
354
Erythema nodusum is associated with which GI condition
Crohn's
It is confined to arms and legs
Nodular and painful
355
Pyoderma gangrenosum is assocated with which GI condition
Crohn's and UC
Confined to arms and legs
Looks like an infected ulcers but doesn't respond to antibiotics
356
Dermatitis herpetiformis is associated with which GI condition
Coeliac disease
Rarer in children than adults
Can appear anywhere on the body and looks like eczema
357
What are the most common causes of viral diarrhoea
Noravirus, adenovirus, (rotavirus in countries without rotavirus vaccine)
358
What is the most common cause of diarrhoea in children, virus, bacteria or parasite
Viral
359
what are the most common bacterial causes of diarrhoea in children
E-coli 0157 (associated with Haemolytic Uraemic Syndrome), clostridium difficile, campylobacter, salmonella, cryptosporidium
More likely to present with blood in stool
360
what are the most common parasitic causes of diarrhoea in children in the UK
Giardia
| Most other causes found abroad
361
How do you treat viral gastroenteritis in children
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
List potential causes of diarrhoea in children
Infection most common cause
Inflammatory bowel disease
Malabsorption/enteropathies
363
Which conditions can cause malabsorption in children
```
Coeliac Disease
Crohn’s disease
Cystic fibrosis
Food allergies
Lactose intolerance
Other rarer causes
```
364
What is Toddler's diarrhoea
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
How do you manage Toddler's diarrhoea
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
GORD in children is typically benign and self-limiting - true or false
True
| ~ 98% resolved by 2 years
367
How do you manage GORD in a child
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
How does coeliacs disease present
```
Diarrhoea
Pale Stools
Bloating
Growth failure
Anaemia - asymptomatic
```
369
How do you screen for coeliac disease
```
tissue transglutaminase (TTG)
anti- endomesial antibodies (EMA)
```
Should also check FBC, U&Es, LFTs, CRP, Iron studies, Ferritin, stool cultures, consider faecal calprotectin
370
What is the gold standard for coeliac diagnosis
endoscopy with duodenal biopsy
371
Children can be diagnosed with coeliac based on blood tests alone - true or false
True
Although only if classical symptoms
AND
TTG > 10 x upper limit of normal (varies between labs)
372
How does coeliac appear on histology
Crypt hyperplasia
Flattening of villi
Lymphocytic infiltration
373
Coeliac disease can be associated with which other conditions
Diabetes Mellitus type1
Autoimmune thyroid disease
Juvenile Chronic Arthritis
Other autoimmune diseases
Down’s syndrome
Turner syndrome
Williams syndrome
374
List some complications of coeliac disease
```
Osteoporosis
Anaemia
Short stature
Delayed puberty
Female infertility
Intestinal malignancies (t-cell lymphoma)
```
375
How does Crohn's present
```
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
How does Crohn's present on histology
```
skip lesions
oedema,
Inflammation
Cryptitis
Abscesses
only 30% have granulomas
```
377
How do you investigate suspected Crohn's disease
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
List potential complications of Crohn's disease
```
Perforation
Fistulae
Colon CA in colitis
Sclerosing cholangitis
Autoimmune hepatitis
Small increased risk of malignancies - increased by immunosuppressive meds
```
379
How do you manage Crohn's in children
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
What is the definition of constipation
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
Recurrent rectal prolapse in children can be an indicator for which condition
CF
382
Explosive passing of stool following rectal examination suggests which condition
Hirschsprung’s disease
383
What typically causes rectal/anal skin tags in children
Usually caused by healed fissures
| These can be caused by Crohn's or sexual assault
384
List risk factors for constipation in children
```
Low fibre intake
Low fluid intake
Excessive dairy products
Lack of exercise
Obesity
Problems with toilet training
```
385
How can you treat constipation in children
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
Long term use of laxatives will harm the bowel - true or false
False
| Laxatives DO NOT make the bowel lazy- longstanding constipation harms the bowel
387
Why do children with constipation sometimes soil themselves
Faecal impaction causes overflow diarrhoea
| Patient often not aware of soiling or smell
388
What is Infant Dyschezia
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
How is UC graded
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
Most children with UC present with which grade of disease
moderate to severe pancolitis
391
How do you manage toxic megacolon
‘Drip and suck’
IV antibiotics
Early surgical review
392
List some complications of UC
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
How does UC appear on histology
polymorph nuclear leucocytes near base of crypts
crypt abscesses
NO granulomas
394
How do you manage UC
Steroids to induce remission
Maintenance therapy
Mild - Mesalazine only
Moderate to severe - Mesalazine + Azathioprine,
Non responders - Mezalazine+ Azathioprine+ Infliximab or Adalimumab
CURE = Colectomy
395
How do you manage UC
Steroids to induce remission
Maintenance therapy
Mild - Mesalazine only
Moderate to severe - Mesalazine + Azathioprine,
Non responders - Mezalazine+ Azathioprine+ Infliximab or Adalimumab
CURE = Colectomy
396
What is eosinophilic oesophagitis
Immune condition characterised by eosinophilic infiltration of the oesophageal mucosa
2nd most common cause of oesophagitis after GORD
397
How does eosinophilic oesophagitis present
Clinical presentation with difficulty swallowing or food bolus obstruction
398
How does eosinophilic oesophagitis present
Clinical presentation with difficulty swallowing or food bolus obstruction
399
How do you treat eosinophilic oesophagitis
1st line dietary management top 6 food elimination (seafood, nuts, dairy, eggs, wheat, soya, 80% successful)
2nd line topical viscous budesonide
400
List potential causes of vomiting due to obstruction
Pyloric stenosis
Intestinal volvulus
Intussusception
Adhesions after previous surgery
