b. List your treatment priorities in sequential order. (4 marks)
Airway/breathing – airway manouveurs and oxygen – improve saturations, if persistent hypoxia will likely require RSI
Treat shock – IV access, IO if unable and IV fluid – 10-20ml/kg bolus (smaller bolus in case of CHD), reassess and repeat
Seek/treat hypoglycaemia 2ml/kg 10% dextrose
Source control – Assume sepsis and empirically treatment with antibiotics – cefotaxime 100mg/kg and amoxicillin 50mg/kg
If CHD strongly suspected – prostaglandin
c. You decide to intubate this baby. What 2 sizes of ETT will you prepare?
3 + 3.5mm
51. A 4 year old boy presents to the ED with cough, stridor and fever.
a. List 4 causes of stridor in this patient. (4 marks)
Low pitched stridor
c. In a patient with suspect epiglottitis, what are your management priorities? (2 marks)
Keep child as calm as possible, avoid unnecessary interventions
Secure airway – ideally in theatre with gas induction
Source control – 3rd generation cephalosporin (cover HiB + others)
52. A 12 month old child presents to ED with a widespread red rash and difficulty breathing shortly after eating peanut butter for the first time.
Her vital signs are
HR 150 /min
Sat 88 %A with wheeze, no stridor
RR 50 /min
BP 60/30 mmHg
a. What is the initial dose and route of administration of adrenaline (1:1000) in millilitres for this patient? Show your working. (3 marks)
Expected weight for a 1 year old = (1 + 4)x2 = 10kg
Dose of adrenaline = 0.01 ml/kg of 1:1000 = 0.1ml IM
b. List 4 other treatments (with doses) that you would consider giving as adjuncts to IM adrenaline. (4 marks)
20ml/kg (200ml) 0.9% NaCl bolus
Salbutamol nebuliser 5mg
Adrenaline nebuliser 5mg
Hydrocortisone 4mg/kg (40mg) IV or prednisolone 2mg/kg = 20mg
Antihistamine – Cetirizine 2.5mg or chlorpheniramine 2mg
Oxygen at 6L per minute/to maintain sats >92%
Not promethazine – contraindicated in <2
c. After a period of observation you decide to discharge the child with a prescription for an EpiPen. List 3 important pieces of discharge advice. (3 marks)
Educate how and when to use EpiPen (action plan)
Warn about biphasic reaction. Watch for return of symptoms – administer epipen and return immediately to ED – call 111
Avoid all foods with peanuts (read labels/ask when eating out) +/- tree nuts
See GP in 24-48h for review
53. A 3 month old girl is brought in to ED with pallor and lethargy for the past hour. She has had fevers and URTI symptoms for the past 3 days.
Her observations are as follows:
GCS 15/15 but floppy/lethargic
HR 250 /min
BP 75/45 mmHg
CRT 2 seconds
Sat 95 %A
Temp 38.2 °C
This is her ECG.
a. What is the most likely diagnosis? (1 mark)
b. What are 2 features of the ECG that support this diagnosis? (2 marks)
Rate is extremely fast – too fast for sinus tachycardia
No P waves seen
c. List 3 treatment options in the order of escalation that you would perform them. (3 marks)
Vagal manouveurs – dunk head in ice water or cold face cloth dropped on face
Adenosine IV 100mcg/kg (can double dose Q2min up to 400mcg)
d. List 4 investigations you would perform in the ED and their justification. (4 marks)
BSL/glucose – prolonged tachycardia could cause hypoglycaemia, hypoglycaemia as cause of floppiness
FBC – anaemia leading to circulatory collapse, inc or dec WCC (sepsis)
Electrolytes/renal function – potassium/calcium/magnesium – deficiencies leading to arrhythmia
CXR – look for cardiomegaly/signs of CHD/myocarditis, signs of LVF, focal infection
Septic screen (blood culture, urine, consider LP) – sepsis as cause of SVT
Urine toxicology screen – as cause of arrhythmia
54. A 32 year old woman presents to your tertiary ED from her GP.
She has been referred with a letter stating:
“Thank you for reviewing this 32 year old who has recently returned from a trip to the UK, she has pleuritic chest pain and I am concerned about a possible PE.”
a. Name 3 risk stratification tools that you use to guide your assessment. (3 marks)
b. You calculate a Wells score of 3. What is the patient’s risk of PE? (1 mark)
c. A D dimer is 1100 and you need to discuss imaging with the patient. List 3 benefits and 3 negatives of CTPA. (3 marks)
Benefits (any of) – effective gold standard test, sensitive compared to VQ, evaluates clot burden may give alternative diagnosis, available to ED, relatively rapid, minimally invasive (cc angiogram)
Negatives (any of) – radiation, contrast allergy, contrast nephrotoxicity, difficult IV access difficult, expensive, can miss small sub-segmental (particularly if older gen CT).
d. The CTPA is positive for bilateral proximal PEs. The patient has a BP of 100/70 mmHg, HR 98 /min, SpO2 94% RA. How could you risk stratify her further with regards to possible treatment? (3 marks - need to only list 3 to score 2.5, 4 scores 3 marks)
Echo – signs of RV strain
Troponin and/or BNP elevation
Subjective distress or breathlessness
ECG changes of RVH
55. A 4 year old boy presents to your ED at 1830h with his mother. He has had a runny nose, cough and wheeze for 2 days. His past history includes asthma and eczema since 18 months of age. He has required several hospital admissions for asthma.
a. List 6 important clinical signs when assessing this child. (3 marks, 0.5 marks each)
Level of consciousness
Respiratory rate (<20 or > 40)
Work of breathing – use of accessory muscles
Chest auscultation – presence of wheeze / lack of b/s eg silent chest
PEFR – if able (likely to be too young)
Ability to speak – words vs short sentences vs long sentences
b. He does not have an oxygen requirement and is assessed as “mild”. List treatment in ED including doses. (1 mark, 0.5 marks each)
Salbutamol 100mcg per puff via MDI and spacer 6 puffs per dose (accept slight variation depending on region)
or Salbutamol via nebuliser 2.5mg – 5mg
Prednisolone 1mg/kg (accept alternative steroid if dose appropriate)
c. The child improves and you wish to educate his mother in spacer and MDI technique and in spacer care. List 6 points that you will cover. (3 marks, 0.5 marks each)
Shake the MDI vigorously
Prime the spacer with 10 puffs of salbutamol (accept 6-12 puffs)
Hold the spacer tightly against the child’s face (may require two operators)
Deliver 1 puff then wait for 6 breaths
Deliver a total of 6 puffs
Wash the spacer in warm soapy water
Do not rinse the spacer
Allow to drip dry
d. List discharge criteria and advice you would give his parents. (3 marks, 0.5 marks each)
Sustained improvement with no requirement for salbutamol for > 2 hours
Action plan for parents – return if requires > 4 hourly salbutamol (accept range 2-4 hourly)
56. A factory worker presents to your department with 3% body surface area burns to his hands and forearms from a 100% hydrofluoric acid solution.
a. What percentage of body surface area burns would be expected to be associated with systemic toxicity from this acid and how does it cause toxicity?
Fluoride ions bind to calcium’s & magnesium resulting in cell dysfunction and death.
Systemic toxicity and ventricular dysrhythmias occur secondary to hypocalcaemia, hypomagnesaemia and acidosis.
b. List 3 investigations that may be useful to help determine further management of this patient and describe the abnormality that may be detected.
ECG : low Ca -> QT prolongation
Serum/ionized Ca – at presentation & Q4 hrly – likely to be low Ca.
Serum Mg – may also be low.
VBG – to detect acidosis
BSL – low/high may be an alternative cause for altered LOC
c. Name the antidote used to treat hydrofluoric acid toxicity.
d. List 3 routes by which it may be administered and the dose typically used for each route.
Topically to the skin as a gluconate gel (2.5%) -this can be applied immediately to the skin after exposure until pain resolves.
Intradermally – difficult in the fingers to give adequate volume.
Usual dose = 0.5ml/cm2 of Ca Gluconate (avoid Ca CO3)
Regional IV infusion -eg. with Biers Block- Dilute 1g of Ca Gluconate in 40mls of N saline, infuse into the arm and leave the cuff inflated for 20 minutes.
Intra-arterial infusion - dilute 1 ampoule of Ca gluconate in 40 ml normal saline & infuse over 4 hrs. Can be repeated as necessary.
57. A 3 year old child is brought into ED with a history of having ingested ‘at least’ 20 of her mother’s iron tablets.
a. List 2 clinical features of significant iron toxicity that are likely to be seen within the first 6 hours after the ingestion.
2 of Vomiting, Diarrhoea + Abdominal pain.
b. List 2 investigations that may be helpful in confirming that a patient has ingested iron tablets and when the abnormality is likely to be detected.
2 of :
Abdo XR – iron tablets are radio opaque so will be visible in the stomach on AXR immediately after ingestion and for many hours (?until passed into SI).
Serum iron level - Levels peak in 4 - 6hrs post ingestion.
Levels > 90 micmol/L are thought to be predictive of systemic toxicity.
ABG - an increased AG metabolic acidosis occurs with systemic toxicity, but this won’t be evident until hours (??>6) after the ingestion.
c. List 2 methods of decontamination that may be useful in the management of iron toxicity and their indications for use.
Whole bowel irrigation –recommended for ingestions of > 60mg/kg confirmed on AXR.
Endoscopic removal - if potentially lethal ingestion where WBI fails or is impossible.
d. Name the antidote used to treat iron toxicity and list 2 indications for its use.
Indications for use are:
Iron levels > 90 micmol/L (500micg/dL) - as this predicts systemic toxicity.
Signs of systemic toxicity including -
Altered mental status
58. A 32 year old female with a history of bipolar disorder is brought in by ambulance after having taken her weeks worth of lithium. She is alert and orientated and complains of no systemic symptoms at this time.
a. List two early signs or symptoms that suggest a significant amount of Lithium has been ingested acutely and the earliest and most frequent sign of neurological toxicity associated with Lithium ingestion.
GI symptoms ie :
Abdominal pain – occur with significant acute ingestion
Tremor is the earliest sign of neuro toxicity.
b. List 2 tests that may have an influence on further management of a patient presenting after an acute overdose of lithium and explain why they may be relevant.
AXR – may show concretions of tablets in the stomach, indicating need for aggressive GI decontamination.
U + E’s - renal impairment may be an indicator of the need for dialysis. Hypokalaemia can be a complication.
BSL - excludes hypo/hyper-glycaemia as alternative cause for altered mental status.
Paracetamol level - incase polypharmacy ingestion, since paracetamol OD is initially asymptomatic, but can -> hepatic toxicity, and there is an available antidote if used within the first 8 hrs after ingestion.
Alcohol - since often a co-ingestant & may be an alternative cause for altered mental status.
c. List two treatments that may be considered for a patient suffering from acute Lithium toxicity and one possible indication for each.
Volume resuscitation with Normal saline (10-20ml/kg then reassess) – indicated for patients who are volume deplete after significant GI fluid loss & to maintain adequate urine output of > 1ml/kg/hr to ensure adequate Li elimination.
Haemodialysis - primarily useful in those with significant renal impairment +/or in those who present late with clinical features of lithium neurotoxicity.
59. A 20 year old female presents saying she has taken an overdose of aspirin.
a. List 4 features of acute salicylate intoxication and the dose expected to cause severe toxicity.
> 300mg/kg causes severe toxicity.
Symptoms include (Together known as salicylism):
Progressing to altered LOC / seizures / hyperthermia / metabolic acidosis /
pulmonary oedema (10%) and alveolar haemorroage
b. What method of decontamination may be useful in the management of salicylate toxicity and for up to how long after the ingestion?
Activated charcoal – for up to 8 hours post ingestion (as gastric emptying can be delayed after an OD). A repeat dose after 4 hours may also be useful.
c. Name 2 methods of enhancing the elimination of salicylates and list 1 possible indication for each.
Urinary alkalinisation – indicated in any patient who is symptomatic from toxicity.
Haemodialysis – rarely needed but may be considered when (1 of) :
-Urinary alkalinization isn’t feasible.
Serum salicylate levels > 9.4 mmol/L after an acute ingestion.
c. List 5 major complications of severe Plasmodium falciparum malaria.
any 5 of:
Cerebral malaria – delirium, coma, seizures
Non-cardiogenic pulmonary oedema
d. What are the two main choices for the urgent initial treatment of severe Plasmodium falciparum malaria?
1. Artesunate (2.4mg/kg IV) then oral
2. Quinine (20mg/kg IVI over 4 hours)
62. A two month old infant has been brought in following a brief seizure. She has had coryzal symptoms and high fevers for two days. She has no relevant past history and no allergies. On examination: HR 110 /min, BP 80/45 mmHg, Temp 39.7°C. There is no rash and no clear focus of infection but the child is ill-appearing and drowsy.
a. What investigations are required?
Other inflammatory markers – CRP etc
At 2 months most would consider too young to assess on purely clinical grounds.
Could comment that WCC/CRP do not confirm/exclude SBI
Sick child – possible abnormality of fluids in/out
Part of septic workup – especially as going to give antibiotics
Part of septic workup. While this could be a “simple febrile convulsion” with another source of sepsis LP is mandatory in this setting
A lumbar puncture is performed:
CSF white cell count
Neutrophils 120 (nil)
Lymphocytes 25 (<5)
CSF red cell count 200
CSF Protein 1.2 (< 0.4 g/L)
CSF glucose 0.4 (> 2.5 mmol/L)
b. Interpret these results.
Highly suggestive of bacterial meningitis. Likely a “traumatic tap” but ratio of RBC:WBC still indicates too many WBCs
c. List and justify the medications you would use to treat this child.
Could choose ceftriaxone though under 3 months usually cefotaxime (hepatic immaturity)