STRS Quiz No 3

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STRS Quiz No 3
Welcome 10 Question Quiz
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STRS Quiz No 3
Question 1
A 3 year old girl presents with severe wheeze.
She responds poorly to nebulised salbutamol and
atrovent. A salbutamol infusion is commenced at 1
mcg/kg/min. She is intubated for hypoxia and
exhaustion. She is known to have episodes of
wheeze, usually responsive to salbutamol.
Comment on her CXR?
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STRS Quiz No 3
Answer Complete white out right lung due to
collapse and hyperinflation of left lung with
diffuse shadowing
This child has severe asthma with mucus plugging
causing both hyperinflation and collapse. She
was extremely hypoxic after intubation (sats
50-70 in 100 oxygen) but responded to urgent
physiotherapy (and the mucolytic rhDNase) which
partially inflated the right lung. This is a life
threatening situation which is recognised by the
lack of response to bronchodilators and
increasing hypoxia (due to V/Q mismatch.)
CXR post physio and rhDNase therapy on PICU
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STRS Quiz No 3
Question 2
A 1 week old baby is referred with cardiovascular
collapse. She was born at term after a difficult
labour. She responded to resuscitation via bag
and mask and was admitted to the NICU. Her
condition improved. Four days later she
developed respiratory distress initially managed
on CPAP. Today she has acutely deteriorated with
increasing respiratory distress, tachycardia,
poor perfusion and enlarged liver 6 cm. She is
intubated and ventilated. On arrival of the team
she looks clinically better. Saturations 100 in
air, HR 160, good peripheral pulses (including
femoral) BP 138/95, liver is 3 cm. Her CXR shows
a slightly enlarged heart and plethoric lung
fields. What is the most striking clinical
finding? What is the most likely cause?
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STRS Quiz No 3
Answer Severe hypertension (renal artery
thrombosis)
Neonatal hypertension is a rare cause of
cardiovascular collapse in a neonate . Often, it
is not until after resuscitation (in this case
ventilation) that the high blood pressure is
recognised. The most common cause is renovascular
disease, most usually due to renal artery or
aortic thrombosis. There is a strong association
with the use of umbilical catheters (this baby
had both UAC and UVC for 24 hours after birth.)
A CT angiogram showed clot in her abdominal aorta
extending into the ostia of both renal arteries
and extensive venous thrombosis. Systemic
thrombolysis successfully dissolved the renal
clots and renal function improved.
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STRS Quiz No 3
Question 3
A 5 month old boy is admitted with a diagnosis of
infective collitis. He has been seen twice in AE
over the last 2 days with vomiting. His mum
brought him back when she noticed blood in his
nappy (no diarrhoea). He is admitted for iv
antibiotics. Comment on his XRAY? What is the
most likely diagnosis?
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STRS Quiz No 3
Answer Dilated loops of small bowel, no distal
gas suggesting obstruction. Very likely
intussusception
This baby required resuscitation and an urgent
laparotomy. An ileo-ileal intussusception was
found and a small section of bowel
resected. Vomiting and abdominal distension
without diarrhoea requires careful consideration
of a surgical cause, especially in the context of
rectal bleeding.
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STRS Quiz No 3
Question 4
An 11 year old girl presents unconscious to her
local hospital. She has been unwell for 2 days
complaining of heavy, aching legs. On arrival,
she has a respiratory arrest and is immediately
intubated and ventilated. She had been admitted 2
years previously with a low blood sugar,
hyponatraemia and vomiting and improved with
fluid. What is the diagnosis? What clinical sign
would you look for?
Blood results Na 113 K 7.9 Glucoselt 1 mmol/l
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STRS Quiz No 3
Answer Addisons disease. Hyperpigmentation
It was December, yet she had a good tan including
palmer creases. Since the episode 2 years ago,
she had become increasingly less active and saw
the GP 4 weeks. A blood test showed a sodium of
125 mmol/l. Addisons disease is the commonest
cause of primary adrenal failure at this age.
Onset is slow and it is often not until adrenal
hormone production disappears completely, causing
the triad of low sodium, high potassium and low
blood sugar that the diagnosis is made. She
responded well to fluid resuscitation, dextrose
and hydrocortisone acutely. On admission PICU
she was found to have evidence of rhabdomyolysis
(elevated creatinine kinase with myoglobinuria)
which may occur in an acute Addisonian crisis and
explains her aching legs.
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STRS Quiz No 3
Question 5
A 10 month old boy is referred to PICU with
bronchiolitis. He had been admitted the day
before with cough and respiratory distress. He
has received atrovent, adrenaline and budesonide
nebulisers for wheeze and stridor. At times he
looks very distressed with severe recession,
inspiratory stridor, wheeze and cyanosis. Other
times he looks settled with minimal
recession. Comment on the childs clinical
state? What specific questions would you ask his
parents?
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STRS Quiz No 3
Answer Biphasic airway noises suggesting
tracheal obstruction. Ask about a history of
previous noisy breathing or intubation
Bronchiolitis does not cause stridor. Of concern
also is the episode of cyanosis. After intubation
he was extremely difficult to ventilate. He had
never been intubated previously and although had
evidence of chronic sternal recession his parents
had been reassured this was normal. Investigation
revealed the cause to be congenital tracheal
stenosis and an anomalous left pulmonary artery
(ring-sling anomaly).
CT scan (above) showing a left pulmonary artery
sling.
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STRS Quiz No 3
Question 6
A 4 week old baby is referred with a possible
chest infection. The baby was born at 35 weeks
gestation with an antenatal diagnosis if severe
aortic stenosis. This was treated with balloon
dilatation on day 2 of life and the baby was
discharged well 2 days later. His local team are
happy this is not cardiac. The baby is
grunting, recessing and has a heart rate of 180.
He is intubated and ventilated. Comment on the
CXR?
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STRS Quiz No 3
Answer Enlarged heart, mild hyperinflation,
plethoric lung fields.
Although this baby may well have a respiratory
infection, the possibility of cardiac failure is
high. The baby had a mixed respiratory,
metabolic acidosis with a lactate of 7 which,
together with the chest x-ray, would implicate
cardiac decompensation as part of the picture.
For this reason the baby was transferred to a
cardiac centre and on review had severe aortic
regurgitation and poor left ventricular function.
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STRS Quiz No 3
Question 7
An 18 month old boy presents shocked to AE. He
has been seen by the GP with intermittent
bile-stained vomiting over last 4 weeks. He is
resuscitated with fluid, inotropes and
ventilation. Comment on his CXR and possible
diagnosis?
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STRS Quiz No 3
Answer Diaphragmatic hernia (left hemithorax)
The CXR shows diffuse opacification on left with
air filled pockets, mediastinal shift to right
and abnormal position of the nasogastric tube.
This childs previous history suggests bowel
obstruction (bile-stained vomiting). His
abdominal x-ray was featureless with a paucity of
bowel gas. Unusually, for a child of this age,
the chest x-ray changes represent bowel in the
chest secondary to a congenital diaphragmatic
hernia. After resuscitation the child required
removal of a significant amount of dead
bowel. Bile stained vomiting is a very important
clinical indicator requiring urgent investigation
of a surgical cause.
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STRS Quiz No 3
Question 8
A 14 year old girl with cerebral palsy has a
sudden respiratory arrest whilst in the shower at
home. Her mother performed mouth to mouth
ventilation and she was bagged to AE by the
paramedics. Currently, saturations are 100 in
face mask oxygen, respiratory rate is 12 with
poor effort, heart rate 110, BP 101/95. GCS is 9,
pupils not assessed. Arterial pCO2 is 10. She is
blind and has severe scoliosis but a good level
of communication. What intervention is
required? What important history point must you
establish urgently?
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STRS Quiz No 3
Answer Intubation and ventilation for
hypoventilation. Does the child have a VP shunt
(this may be blocked)?
The cause of the sudden loss of consciousness and
hypoventilation is not clear. Ventriculoperitonea
l shunts are common in children with cerebral
palsy, in whom early signs of complications can
be difficult to detect. Differential diagnosis
for the acute neurological event in this case
would include a seizure, an acute cerebrovascular
event or a blocked VP shunt. An urgent CT scan is
required after the child has been intubated and
ventilated. She did indeed have a VP shunt and CT
showed gross hydrocephalous. She was transferred
urgently to a neurosurgical centre for
intervention. Making the diagnosis of a possible
neurosurgical problem as soon as possible is
important so the child can be taken to the most
appropriate institution as quickly as possible.
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STRS Quiz No 3
Question 9
A 3 year old has a generalized seizure at home
which terminated spontaneously on arrival of the
paramedic. Temperature and blood sugar were
normal at the scene. She is breathing with
saturations of 100 in face mask oxygen. You can
feel a femoral pulse but BP is unrecordable. GCS
is 3 and her pupils are dilated but
reactive. What does the ECG strip show and
what actions must be taken? What is a possible
explanation?
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STRS Quiz No 3
Answer Broad complex ventricular tachycardia
(VT). Requires intubation and ventilation and
cardioversion. Exclude possible drug Ingestion
as cause.
The combination of acute neurological symptoms
and arrhythmia immediately raises the possibility
of drug ingestion, likely accidental in a
toddler. This child is in VT and is shocked which
mandates urgent cardioversion (1 J/kg, then 2
J/kg if this fails) She had taken her mothers
amitryptilline. Sodium bicarbonate infusion may
be necessary in serious tricyclic overdose, as in
this case, aiming to achieve a slightly alkaline
pH.
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STRS Quiz No 3
Question 10
An arterial blood gas and chemistry reveal pH
7.0 pCO2 1.5 pO2 11 HCO3 2 BE -25 Na 125 K
4.5 urea 12 creat 65 Cl 95
A 9 year old boy with sickle cell disease is
admitted to AE with a possible painful crisis.
He has been vomiting for 2 days. He is lethargic
but talking to you and obviously breathless. His
respiratory rate is 30 and there is no recession.
Saturations are 100 in air and his chest is
clear on auscultation. What is the likely
diagnosis and how would you confirm it? Why is
the sodium so low? What is the anion gap?
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STRS Quiz No 3
Answer Diabetic ketoacidosis (DKA). Anion gap is
32.5 mmol/l. Hyponatreamia due to osmotic effect
of hyperglycaemia
Acidotic breathing is characteristic but can be
misdiagnosed. Severe metabolic acidosis with a
high anion gap is most usually the result of DKA.
Treatment requires SLOW rehydration (this has not
happened overnight) and insulin therapy (shuts
down ketone production). The aim is to maintain
plasma osmolality in the first 24 hours when the
risk of cerebral oedema is highest. As the plasma
glucose falls the plasma sodium should rise (the
corrected sodium should stay about the same). As
the ketone concentration falls in the blood the
anion gap should return to normal, usually in the
first 24 hours, although the acidosis will not
clear completely as hyperchloraemia is common
(resolves with time). Anion gap (normal 8-16)
(NaK) (HCO3Cl) Corrected sodium measured Na
(0.4 x (glucose-5.5))
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STRS Quiz No 3
End of quiz