Acute Paediatrics — MCQs
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A 10-year-old boy presents with a 24-hour history of fever (38.9°C), headache, and vomiting. He is photophobic and has mild neck stiffness. There is no rash. He is alert and oriented. Observations show heart rate 110/min, blood pressure 105/65 mmHg, capillary refill time 2 seconds. Blood glucose is 5.2 mmol/L. What is the most appropriate immediate management?
An 8-month-old infant born at 32 weeks gestation presents with a 2-day history of cough, nasal congestion, and reduced feeding. The infant has chronic lung disease of prematurity requiring home oxygen 0.1 L/min. On examination, temperature is 37.6°C, respiratory rate 68/min, heart rate 155/min, and oxygen saturation 88% on usual home oxygen. There are bilateral crackles and expiratory wheeze. The infant appears tired. What is the most appropriate management strategy?
A 7-year-old girl with known asthma presents to the emergency department with an acute exacerbation. She is unable to complete sentences, has a respiratory rate of 32/min, heart rate 128/min, and oxygen saturation 93% in air. She has received three back-to-back salbutamol and ipratropium nebulisers with oxygen, and oral prednisolone 30mg, but continues to have severe respiratory distress with widespread wheeze. What is the most appropriate next step in management?
A 3-year-old boy presents with acute onset respiratory distress. He was playing with small toys when he suddenly started coughing violently, became distressed, and developed stridor. On examination, he is sitting forward, drooling, has audible inspiratory stridor, and appears frightened. Oxygen saturation is 92% in air. His temperature is 37.1°C. He has had no preceding illness. What is the most appropriate immediate management?
A 15-month-old boy presents with a 4-day history of fever (maximum 39.8°C). He has been irritable and off his food. His mother has noticed his eyes look red. Examination shows bilateral bulbar conjunctival injection without discharge, an erythematous pharynx, dry cracked lips, and a faint maculopapular rash on the trunk. There is no palpable lymphadenopathy. Urine dipstick shows leucocytes 2+ but no nitrites. Blood tests show WCC 16 x 10⁹/L, CRP 78 mg/L, platelets 398 x 10⁹/L. What is the most appropriate next investigation?
A 9-month-old infant with bronchiolitis has been admitted for 24 hours. He is in 28% headbox oxygen maintaining saturations of 93-94%. He is taking 60% of normal oral feeds. Respiratory rate is 58/min with mild subcostal recession. Parents are asking when their baby can go home. According to current UK guidelines, which single factor would be the most important criterion that must be met before safe discharge?
A 5-year-old girl with asthma usually controlled on beclometasone 200 micrograms twice daily presents with an acute exacerbation. She has a respiratory rate of 28/min, heart rate 118/min, oxygen saturation 96% in air, and can speak in full sentences. There is bilateral wheeze on auscultation. Peak expiratory flow is 65% of her best. She has received one salbutamol nebuliser. What defines the severity of this asthma exacerbation?
A 2-year-old previously healthy child presents with fever of 40°C for 12 hours. On examination, the child appears lethargic, has a capillary refill time of 4 seconds peripherally, heart rate 165/min, respiratory rate 45/min, and a non-blanching purpuric rash on the trunk and legs. Blood pressure is 75/40 mmHg. What is the single most important immediate intervention?
An 18-month-old child presents with fever of 39.5°C for 6 hours. The parents report one brief episode of rhythmic jerking of all limbs lasting approximately 2 minutes, with loss of consciousness and post-ictal drowsiness. The child is now alert and playing. Examination reveals an inflamed right tympanic membrane but is otherwise normal. There is no rash. Developmental history is normal and there is no family history of epilepsy. What is the most appropriate management?
A 4-year-old boy with known asthma presents with acute severe breathlessness. He is unable to complete sentences, has a respiratory rate of 42/min, heart rate 140/min, and oxygen saturation 90% in air. He has widespread wheeze and is using accessory muscles. He has received salbutamol 10 puffs via spacer at home without improvement. What is the most appropriate immediate management in the emergency department?
Acute Paediatrics UK Medical PG Practice Questions and MCQs
Question 141: A 10-year-old boy presents with a 24-hour history of fever (38.9°C), headache, and vomiting. He is photophobic and has mild neck stiffness. There is no rash. He is alert and oriented. Observations show heart rate 110/min, blood pressure 105/65 mmHg, capillary refill time 2 seconds. Blood glucose is 5.2 mmol/L. What is the most appropriate immediate management?
- A. Perform lumbar puncture immediately before starting antibiotics to confirm diagnosis
- B. Administer intravenous ceftriaxone immediately and perform lumbar puncture when safe to do so (Correct Answer)
- C. Obtain blood cultures, start intravenous ceftriaxone, and perform CT head before lumbar puncture
- D. Give intravenous dexamethasone before antibiotics to reduce inflammation
- E. Administer intravenous aciclovir and ceftriaxone together before lumbar puncture
Explanation: ***Administer intravenous ceftriaxone immediately and perform lumbar puncture when safe to do so*** - In a suspected case of **bacterial meningitis**, the immediate administration of **empirical intravenous antibiotics** like ceftriaxone is the highest priority to improve outcomes and prevent serious complications. - A **lumbar puncture** should not delay antibiotic treatment; it can be performed immediately after the first antibiotic dose or when the patient's condition permits, provided there are no contraindications such as signs of significantly raised intracranial pressure. *Perform lumbar puncture immediately before starting antibiotics to confirm diagnosis* - Delaying **life-saving antibiotics** to perform a lumbar puncture increases the risk of **neurological sequelae** and mortality, even if it might yield a more 'pristine' CSF sample for diagnosis. - In patients with suspected **meningitis**, clinical suspicion warrants urgent treatment, not diagnostic confirmation first. *Obtain blood cultures, start intravenous ceftriaxone, and perform CT head before lumbar puncture* - A **CT head** is generally not required before a **lumbar puncture** in a patient who is alert, oriented, and without focal neurological deficits, signs of **papilledema**, or other indicators of **raised intracranial pressure**. - Performing an unnecessary CT scan would delay the critical **lumbar puncture** and definitive diagnosis. *Give intravenous dexamethasone before antibiotics to reduce inflammation* - **Dexamethasone** is beneficial in reducing complications like **hearing loss** in bacterial meningitis and should be given just before or with the first dose of antibiotics. - However, it is an adjunctive therapy and should **never delay** the primary treatment with **antibiotics**, which targets the infection itself. *Administer intravenous aciclovir and ceftriaxone together before lumbar puncture* - While **aciclovir** is used for suspected **viral encephalitis**, this patient's presentation of fever, headache, photophobia, and neck stiffness, without altered consciousness or focal neurology, is more typical for **bacterial meningitis** requiring urgent specific treatment. - Although empiric antiviral therapy may sometimes be considered, the most immediate and critical intervention is effective **antibiotic coverage** for bacterial meningitis given its rapid progression and high morbidity.
Question 142: An 8-month-old infant born at 32 weeks gestation presents with a 2-day history of cough, nasal congestion, and reduced feeding. The infant has chronic lung disease of prematurity requiring home oxygen 0.1 L/min. On examination, temperature is 37.6°C, respiratory rate 68/min, heart rate 155/min, and oxygen saturation 88% on usual home oxygen. There are bilateral crackles and expiratory wheeze. The infant appears tired. What is the most appropriate management strategy?
- A. Start oral antibiotics for bacterial chest infection and continue home oxygen
- B. Admit for trial of nebulised hypertonic saline and chest physiotherapy
- C. Admit for increased oxygen therapy, nasogastric feeding support, and close monitoring (Correct Answer)
- D. Prescribe salbutamol inhaler via spacer and arrange paediatric respiratory clinic review in 48 hours
- E. Commence palivizumab prophylaxis and arrange home oxygen increase
Explanation: ***Admit for increased oxygen therapy, nasogastric feeding support, and close monitoring*** - The infant displays **bronchiolitis** with significant risk factors, including **prematurity (32 weeks)** and **chronic lung disease**, necessitating admission for supportive care. - Admission is indicated due to **hypoxia (88% on baseline oxygen)**, tachypnea, and signs of exhaustion which require **nasogastric feeding** and potential respiratory escalation. *Start oral antibiotics for bacterial chest infection and continue home oxygen* - **Bronchiolitis** is primarily a **viral infection** (typically RSV), and antibiotics do not improve outcomes unless there is clear evidence of secondary bacterial pneumonia. - Home management is unsafe here because the infant is already **hypoxic** despite their usual oxygen therapy and shows signs of clinical fatigue. *Admit for trial of nebulised hypertonic saline and chest physiotherapy* - National guidelines (such as **NICE**) do not recommend the routine use of **nebulised hypertonic saline** as it has not been shown to reduce hospital stay length. - **Chest physiotherapy** is not indicated in bronchiolitis and may increase distress in a tired infant with significant respiratory work. *Prescribe salbutamol inhaler via spacer and arrange paediatric respiratory clinic review in 48 hours* - **Salbutamol** is ineffective in bronchiolitis because the underlying pathology is **airway edema** and mucus plugging rather than smooth muscle bronchospasm. - Delaying care for 48 hours is dangerous; this infant is **acutely unwell** and at high risk for rapid respiratory failure. *Commence palivizumab prophylaxis and arrange home oxygen increase* - **Palivizumab** is a monoclonal antibody used for **prophylaxis** to prevent RSV; it is not an effective treatment once an infection is established. - Increasing oxygen at home is insufficient as it fails to address the infant's **reduced feeding**, increased work of breathing, and the need for **clinical monitoring**.
Question 143: A 7-year-old girl with known asthma presents to the emergency department with an acute exacerbation. She is unable to complete sentences, has a respiratory rate of 32/min, heart rate 128/min, and oxygen saturation 93% in air. She has received three back-to-back salbutamol and ipratropium nebulisers with oxygen, and oral prednisolone 30mg, but continues to have severe respiratory distress with widespread wheeze. What is the most appropriate next step in management?
- A. Intravenous magnesium sulphate 40 mg/kg over 20 minutes (Correct Answer)
- B. Intravenous aminophylline loading dose 5 mg/kg over 20 minutes
- C. Commence continuous salbutamol nebulisers
- D. Intravenous salbutamol infusion 5 micrograms/kg/minute
- E. Proceed to intubation and mechanical ventilation
Explanation: ***Intravenous magnesium sulphate 40 mg/kg over 20 minutes***- The patient presents with **severe acute asthma exacerbation** (unable to complete sentences, high RR/HR, SpO2 93%) refractory to initial bronchodilator therapy (multiple nebulisers) and oral corticosteroids.- **Intravenous magnesium sulphate** is a potent **bronchodilator** that acts by relaxing bronchial smooth muscle and is indicated as a crucial next step in severe acute asthma in children who do not respond to initial management.*Intravenous aminophylline loading dose 5 mg/kg over 20 minutes*- **Aminophylline** is a **methylxanthine** that can be used for severe asthma, but it is typically considered a second-line intravenous agent after magnesium sulphate.- It has a **narrow therapeutic index** and requires careful monitoring of serum levels and cardiac function due to potential **toxicity** (arrhythmias, seizures), making it less preferred as an immediate next step compared to magnesium.*Commence continuous salbutamol nebulisers*- While **continuous nebulisation** with salbutamol is an option for moderate to severe asthma, this patient has already received three back-to-back doses and continues to have severe distress.- At this point of **refractory severe asthma**, systemic therapy like intravenous magnesium sulphate is indicated to achieve a more rapid and sustained bronchodilation.*Intravenous salbutamol infusion 5 micrograms/kg/minute*- **Intravenous salbutamol** is an alternative systemic bronchodilator, but it is generally reserved for patients who do not respond to both nebulised bronchodilators and **intravenous magnesium sulphate**.- It carries a higher risk of **side effects** such as tachycardia, arrhythmias, and hypokalemia, making magnesium sulphate a safer and often more effective initial intravenous choice.*Proceed to intubation and mechanical ventilation*- **Intubation and mechanical ventilation** are extreme measures for **life-threatening asthma**, reserved for patients with impending respiratory failure (e.g., exhaustion, silent chest, rising CO2, severe hypoxia despite maximal therapy).- This patient is severely distressed but has not yet failed all **pharmacological interventions**, and there are still medical options like IV magnesium sulphate to attempt before resorting to invasive ventilation.
Question 144: A 3-year-old boy presents with acute onset respiratory distress. He was playing with small toys when he suddenly started coughing violently, became distressed, and developed stridor. On examination, he is sitting forward, drooling, has audible inspiratory stridor, and appears frightened. Oxygen saturation is 92% in air. His temperature is 37.1°C. He has had no preceding illness. What is the most appropriate immediate management?
- A. Perform lateral neck radiograph to identify foreign body location before any intervention
- B. Nebulised adrenaline and dexamethasone while arranging emergency bronchoscopy
- C. Direct laryngoscopy in emergency department to visualise and remove foreign body
- D. Allow child to stay in position of comfort, give high-flow oxygen, and arrange urgent transfer to theatre with senior anaesthetist and ENT surgeon present (Correct Answer)
- E. Attempt back blows and chest thrusts immediately
Explanation: ***Allow child to stay in position of comfort, give high-flow oxygen, and arrange urgent transfer to theatre with senior anaesthetist and ENT surgeon present***- Sudden onset of **respiratory distress**, stridor, and **drooling** while playing with toys strongly suggests an **upper airway foreign body obstruction**.- Maintaining a **position of comfort** and avoiding agitation is critical to prevent a partial obstruction from becoming a **complete airway obstruction**; definitive removal requires a controlled **theatre environment** with expert personnel.*Perform lateral neck radiograph to identify foreign body location before any intervention*- Radiographs should never delay the management of a child in **acute respiratory distress** or with potential airway compromise.- Many foreign bodies are **radiolucent** (e.g., plastic toy parts or food), meaning a normal X-ray cannot rule out the diagnosis and may provide false reassurance.*Nebulised adrenaline and dexamethasone while arranging emergency bronchoscopy*- These treatments are indicated for **Croup (Laryngotracheobronchitis)**, which typically presents with a **prodromal illness**, fever, and a barking cough rather than sudden onset during play.- **Adrenaline** and **steroids** will not provide clinical benefit for a mechanical obstruction caused by a **foreign body** and will delay appropriate management.*Direct laryngoscopy in emergency department to visualise and remove foreign body*- Attempting **direct laryngoscopy** in an awake or inadequately anesthetized child can trigger **laryngospasm** or cause the object to lodge deeper in the airway, worsening the obstruction.- Airway visualization and foreign body removal must be performed by experts (ENT/Anaesthesia) using **rigid bronchoscopy** in a controlled surgical setting.*Attempt back blows and chest thrusts immediately*- Medical maneuvers like **back blows** and chest thrusts are only indicated for **complete airway obstruction** where the child has an ineffective cough and is becoming cyanotic or unconscious.- In a child who is still **breathing and coughing** (evidenced by stridor and being conscious), these maneuvers may worsen the situation by dislodging the object into a more dangerous position or causing complete obstruction.
Question 145: A 15-month-old boy presents with a 4-day history of fever (maximum 39.8°C). He has been irritable and off his food. His mother has noticed his eyes look red. Examination shows bilateral bulbar conjunctival injection without discharge, an erythematous pharynx, dry cracked lips, and a faint maculopapular rash on the trunk. There is no palpable lymphadenopathy. Urine dipstick shows leucocytes 2+ but no nitrites. Blood tests show WCC 16 x 10⁹/L, CRP 78 mg/L, platelets 398 x 10⁹/L. What is the most appropriate next investigation?
- A. Chest radiograph
- B. Echocardiogram (Correct Answer)
- C. Blood cultures
- D. Urine microscopy and culture
- E. Throat swab for bacterial culture
Explanation: ***Echocardiogram*** - The patient exhibits features of **Kawasaki disease**, including high fever, **bilateral bulbar conjunctival injection**, dry cracked lips, and a **maculopapular rash**. - An **echocardiogram** is the critical investigation to monitor for **coronary artery aneurysms**, which are the most serious complication of this vasculitis. *Chest radiograph* - This is commonly used to rule out pneumonia in a febrile child but is not diagnostic for **Kawasaki disease**. - It would not provide specific information regarding the **coronary arteries** or systemic inflammation required for this clinical picture. *Blood cultures* - While performed to exclude **sepsis** or bacterial infection in a febrile infant, they do not confirm a diagnosis of **Kawasaki disease**. - The constellation of clinical signs and elevated **CRP** makes an inflammatory vasculitis more likely than a simple bacteremia. *Urine microscopy and culture* - The presence of leucocytes without nitrites suggests **sterile pyuria**, a common finding in **Kawasaki disease** due to urethritis. - While helpful to rule out a **UTI**, it is less critical than evaluating for cardiac complications via echocardiography. *Throat swab for bacterial culture* - This might be used to check for **Group A Streptococcus** (Scarlet fever), which can mimic some Kawasaki symptoms like rash and pharyngitis. - However, **Kawasaki disease** symptoms like non-purulent conjunctivitis and the severe risk of **coronary involvement** make cardiac imaging a higher priority.
Question 146: A 9-month-old infant with bronchiolitis has been admitted for 24 hours. He is in 28% headbox oxygen maintaining saturations of 93-94%. He is taking 60% of normal oral feeds. Respiratory rate is 58/min with mild subcostal recession. Parents are asking when their baby can go home. According to current UK guidelines, which single factor would be the most important criterion that must be met before safe discharge?
- A. Oxygen saturations consistently ≥92% in air for 4 hours including during sleep and feeding (Correct Answer)
- B. Respiratory rate consistently below 50 breaths per minute
- C. Taking at least 75% of normal feeding volumes orally
- D. Complete resolution of subcostal recession
- E. Apnoea-free for at least 24 hours
Explanation: ***Oxygen saturations consistently ≥92% in air for 4 hours including during sleep and feeding***- According to **NICE guidelines (NG9)**, maintaining **oxygen saturation (SpO2) ≥92%** in room air for at least **4 hours** is the primary safety criterion for discharge for infants with bronchiolitis.- It is essential that these levels are stable during challenging periods such as **sleep** and **feeding** to ensure the infant is no longer at significant risk of respiratory compromise.*Respiratory rate consistently below 50 breaths per minute*- While a high respiratory rate indicates distress, many infants can remain **tachypnoeic** during the recovery phase of bronchiolitis without needing continued hospital care, provided oxygenation is stable.- There is no specific **numerical cutoff** for respiratory rate that acts as the single most important mandatory discharge threshold if other criteria, especially oxygenation, are met.*Taking at least 75% of normal feeding volumes orally*- UK guidelines suggest infants should be able to take **50-75%** of their normal fluid intake to be considered for discharge, but **adequate hydration** is secondary to stable oxygenation as the most important factor.- If an infant is hydrated and stable on room air, an intake of **60%** (as seen in this patient) may be acceptable depending on overall clinical judgment and the ability to maintain hydration at home.*Complete resolution of subcostal recession*- **Mild work of breathing**, such as subcostal recession, can persist for many days or even weeks after acute bronchiolitis and does not always preclude safe discharge.- The priority is that the **work of breathing** has significantly improved compared to admission, rather than being completely absent, assuming oxygenation is stable.*Apnoea-free for at least 24 hours*- While the absence of **apnoea** is a crucial prerequisite for discharge, it is rarely the most important limiting factor in a **9-month-old** infant with bronchiolitis, unless it was a prominent feature of their admission.- Apnoea is a more common and critical concern for **younger infants** (under 6 weeks corrected gestational age) or those born prematurely.
Question 147: A 5-year-old girl with asthma usually controlled on beclometasone 200 micrograms twice daily presents with an acute exacerbation. She has a respiratory rate of 28/min, heart rate 118/min, oxygen saturation 96% in air, and can speak in full sentences. There is bilateral wheeze on auscultation. Peak expiratory flow is 65% of her best. She has received one salbutamol nebuliser. What defines the severity of this asthma exacerbation?
- A. Life-threatening asthma
- B. Acute severe asthma
- C. Moderate acute asthma (Correct Answer)
- D. Mild acute asthma
- E. Brittle asthma
Explanation: ***Moderate acute asthma*** - The patient's **peak expiratory flow (PEF) of 65%** of best, ability to **speak in full sentences**, and oxygen saturation of **96%** are all consistent with **moderate acute asthma** in a child over 5 years. - While the respiratory rate (28/min) and heart rate (118/min) are slightly elevated for her age, they do not meet the higher thresholds for severe asthma exacerbation (e.g., RR >30/min, HR >125/min for this age group). *Life-threatening asthma* - This category is indicated by critical signs such as **silent chest**, **cyanosis**, poor respiratory effort, exhaustion, or **altered consciousness**. - Objective criteria for life-threatening asthma include **SpO2 <92%**, **PEF <33% of best**, or a normal/rising PaCO2, none of which are present in this case. *Acute severe asthma* - **Acute severe asthma** is defined by the **inability to complete sentences** in one breath, a **PEF between 33-50%** of best, or marked clinical signs like accessory muscle use. - Furthermore, objective markers such as a **respiratory rate >30/min** or a **heart rate >125/min** for a child aged 5-11 years are not met by this patient. *Mild acute asthma* - **Mild acute asthma** typically presents with minimal symptoms, a **PEF >80%** of best, and the patient would likely not require immediate nebulised bronchodilators. - The patient's PEF of 65% and the need for a salbutamol nebuliser indicate a more significant exacerbation than mild. *Brittle asthma* - **Brittle asthma** is a term for a **chronic, severe subtype** of asthma characterized by wide and unpredictable fluctuations in peak flow or recurrent, severe, and life-threatening attacks. - It describes a long-term pattern of asthma control rather than the **acute severity** of a single exacerbation.
Question 148: A 2-year-old previously healthy child presents with fever of 40°C for 12 hours. On examination, the child appears lethargic, has a capillary refill time of 4 seconds peripherally, heart rate 165/min, respiratory rate 45/min, and a non-blanching purpuric rash on the trunk and legs. Blood pressure is 75/40 mmHg. What is the single most important immediate intervention?
- A. Administer intravenous ceftriaxone 80mg/kg stat
- B. Give 20ml/kg intravenous fluid bolus of 0.9% sodium chloride (Correct Answer)
- C. Obtain blood cultures and perform lumbar puncture
- D. Administer intramuscular benzylpenicillin and arrange immediate transfer
- E. Commence inotropic support with dopamine infusion
Explanation: ***Give 20ml/kg intravenous fluid bolus of 0.9% sodium chloride*** - The child presents with signs of **septic shock** (lethargy, tachycardia, prolonged capillary refill, hypotension, purpuric rash), making **fluid resuscitation** the most important immediate step to restore **tissue perfusion**. - Rapid administration of an **isotonic crystalloid** bolus (20ml/kg) is critical in pediatric shock to address **hypovolemia** and stabilize hemodynamics. *Administer intravenous ceftriaxone 80mg/kg stat* - While **early antibiotics** are vital for suspected **sepsis** and **meningococcal disease**, correcting life-threatening **circulatory collapse** with fluids takes precedence in a patient actively in shock. - Antibiotics should be administered as soon as possible, ideally concurrently with or immediately after the initial **fluid bolus**, once resuscitation has begun. *Obtain blood cultures and perform lumbar puncture* - A **lumbar puncture** is **contraindicated** in a child with **hemodynamic instability**, signs of shock, or a rapidly evolving **purpuric rash** due to the risk of cerebral herniation. - Although important for diagnosis, **blood cultures** and other diagnostic tests should never delay the initiation of **emergency fluid resuscitation** and antibiotics in critical patients. *Administer intramuscular benzylpenicillin and arrange immediate transfer* - **Intramuscular benzylpenicillin** is primarily recommended as a **pre-hospital** or **community intervention** when intravenous access is unavailable for suspected meningococcal disease. - In a hospital setting where the child is already in **shock**, **intravenous fluid expansion** and **IV antibiotics** are the immediate standard of care. *Commence inotropic support with dopamine infusion* - **Inotropic support** with agents like **dopamine** is reserved for **fluid-refractory shock**, typically after a patient has received adequate fluid boluses (e.g., 40-60 ml/kg). - Initiating **vasopressors** or **inotropes** before addressing underlying **hypovolemia** can be detrimental and is not the primary immediate intervention for shock.
Question 149: An 18-month-old child presents with fever of 39.5°C for 6 hours. The parents report one brief episode of rhythmic jerking of all limbs lasting approximately 2 minutes, with loss of consciousness and post-ictal drowsiness. The child is now alert and playing. Examination reveals an inflamed right tympanic membrane but is otherwise normal. There is no rash. Developmental history is normal and there is no family history of epilepsy. What is the most appropriate management?
- A. Admit for lumbar puncture and intravenous antibiotics pending culture results
- B. Prescribe antibiotics for otitis media, provide safety netting advice, and arrange GP follow-up (Correct Answer)
- C. Start prophylactic antiepileptic medication and refer to paediatric neurology
- D. Arrange urgent EEG and MRI brain as outpatient
- E. Admit for 24-hour observation and blood cultures
Explanation: ***Prescribe antibiotics for otitis media, provide safety netting advice, and arrange GP follow-up*** - The child presents with a **simple febrile seizure** (generalized, <15 minutes, single episode) triggered by **acute otitis media**; management focuses on treating the source and parental reassurance. - Since the child is now **alert**, clinically stable, and has no signs of **meningitis**, he can be safely managed in the community with appropriate **safety netting** instructions. *Admit for lumbar puncture and intravenous antibiotics pending culture results* - **Lumbar puncture** is only indicated if there are signs of **meningitis** (e.g., neck stiffness, non-blanching rash) or if the child is persistently lethargic. - This child is currently **alert and playing** with an identifiable focus of infection, making invasive investigations unnecessary. *Start prophylactic antiepileptic medication and refer to paediatric neurology* - **Simple febrile seizures** do not significantly increase the long-term risk of **epilepsy** and do not require long-term antiepileptic therapy. - Referral is usually reserved for **complex febrile seizures** or children with underlying **developmental delay** or neurological abnormalities. *Arrange urgent EEG and MRI brain as outpatient* - An **EEG** is not recommended after a simple febrile seizure as it does not predict the recurrence of seizures or future epilepsy. - **Neuroimaging** is generally unnecessary unless there are focal neurological deficits, signs of **raised intracranial pressure**, or features of a complex seizure. *Admit for 24-hour observation and blood cultures* - Routine admission is not required if the child has fully recovered, is **clinically well**, and there is a clear source of infection like **otitis media**. - **Blood cultures** are not indicated for a simple febrile seizure unless the child appears **septic** or there is no localized source of fever found on examination.
Question 150: A 4-year-old boy with known asthma presents with acute severe breathlessness. He is unable to complete sentences, has a respiratory rate of 42/min, heart rate 140/min, and oxygen saturation 90% in air. He has widespread wheeze and is using accessory muscles. He has received salbutamol 10 puffs via spacer at home without improvement. What is the most appropriate immediate management in the emergency department?
- A. High-flow humidified oxygen and intravenous hydrocortisone
- B. Salbutamol nebuliser with oxygen, ipratropium bromide nebuliser, and oral prednisolone (Correct Answer)
- C. Intravenous salbutamol infusion and intravenous hydrocortisone
- D. Salbutamol nebuliser with oxygen and intravenous magnesium sulphate
- E. Oxygen, intravenous aminophylline loading dose, and oral prednisolone
Explanation: ***Salbutamol nebuliser with oxygen, ipratropium bromide nebuliser, and oral prednisolone***- This patient presents with **acute severe asthma** (SpO2 90%, HR 140, RR 42, unable to complete sentences), requiring immediate **first-line therapy**.- Guidelines recommend **high-flow oxygen**, frequent **short-acting beta-agonists (SABA)**, **ipratropium bromide** for synergistic bronchodilation, and **corticosteroids** to reduce airway inflammation.*Intravenous salbutamol infusion and intravenous hydrocortisone*- **Intravenous bronchodilators** are reserved for patients with **life-threatening asthma** or those failing to respond to repeated nebulized therapy after initial aggressive management.- **Oral prednisolone** is generally preferred over IV hydrocortisone in children as it is equally effective and less invasive unless the child is vomiting or has very severe, life-threatening asthma.*Salbutamol nebuliser with oxygen and intravenous magnesium sulphate*- **Intravenous magnesium sulphate** is a second-line treatment used for **refractory severe asthma** or life-threatening cases that do not respond to initial nebulizers and corticosteroids.- This option lacks **ipratropium bromide** and **corticosteroids**, which are essential components of the initial comprehensive management bundle for severe exacerbations.*Oxygen, intravenous aminophylline loading dose, and oral prednisolone*- **Aminophylline** is typically used in a **Critical Care** or High Dependency setting for children who are not responding to maximal first- and second-line therapies (including inhaled bronchodilators, steroids, and magnesium).- It has a **narrow therapeutic index** and is not indicated as an immediate first-line management step in the emergency department for severe asthma.*High-flow humidified oxygen and intravenous hydrocortisone*- While oxygen and steroids are necessary, they are insufficient alone for managing **acute bronchospasm** without active **bronchodilators** like salbutamol.- **Humidified oxygen** is not routinely recommended for acute asthma management and should not delay the administration of nebulized medications.
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