A 7-year-old boy with known asthma is brought to the emergency department with acute breathlessness. He is unable to complete sentences, has a respiratory rate of 42 breaths per minute, heart rate of 145 beats per minute, and oxygen saturation of 89% on room air. He has widespread wheeze with poor air entry bilaterally. Peak expiratory flow rate is 40% of his best. He is started on high-flow oxygen, back-to-back nebulised salbutamol with ipratropium bromide, and oral prednisolone. After 1 hour there is minimal improvement. What is the most appropriate next step in management?
Q62
A 5-year-old boy with poorly controlled asthma is reviewed following his third admission for acute exacerbation in 6 months. He is currently on beclometasone 200 micrograms twice daily via spacer, but his mother reports he uses his salbutamol inhaler most days and wakes 2-3 times per week with cough and wheeze. Inhaler technique is checked and is good. What is the most appropriate next step in his management according to current guidelines?
Q63
A 4-year-old girl presents with a 5-day history of fever up to 40.2°C. She has been seen twice by her GP and prescribed oral antibiotics for suspected tonsillitis, but fever persists. On examination, she is miserable with temperature 39.8°C, bilateral non-purulent conjunctivitis, dry cracked lips with some bleeding, strawberry tongue, and erythematous palms and soles. There is a faint maculopapular rash on the trunk and a single palpable cervical lymph node measuring 1.8cm. Blood tests show: Hb 105 g/L, WBC 16.5 × 10⁹/L, platelets 445 × 10⁹/L, CRP 125 mg/L, ESR 68 mm/hr, albumin 28 g/L. What is the most critical time-sensitive intervention?
Q64
A 6-year-old girl with asthma on beclometasone 400 micrograms twice daily and salbutamol as needed presents with an acute exacerbation. She has received optimal bronchodilator therapy including back-to-back nebulisers, ipratropium, oral prednisolone, and intravenous magnesium sulphate. Despite this, she remains critically unwell with oxygen saturation 88% on high-flow oxygen, exhaustion, and reduced respiratory effort. Senior anaesthetic and PICU teams are present. What additional pharmacological therapy should be considered before intubation?
Q65
A 3-year-old boy with recurrent viral-induced wheeze is brought to the emergency department with increased work of breathing and wheeze. This is his third episode requiring hospital attendance this year. His parents report he is well between episodes and has no interval symptoms. What is the most appropriate long-term management strategy to discuss with the parents before discharge?
Q66
A 6-month-old infant presents with a 24-hour history of fever to 38.9°C and decreased feeding. The infant was born at term with no significant medical history. On examination, the infant is irritable, temperature 38.7°C, heart rate 155/min, respiratory rate 42/min, and capillary refill time 2 seconds. There is no rash, the fontanelle is not bulging, and systemic examination is unremarkable. Blood tests show: WBC 18.2 × 10⁹/L, CRP 65 mg/L. Urine dipstick is negative. What is the most appropriate next step in management?
Q67
A 5-year-old boy with known asthma on beclometasone 200 micrograms twice daily presents with wheeze and breathlessness after playing outside. In the emergency department, he receives salbutamol via spacer (10 puffs) and his symptoms improve. He is speaking in full sentences, oxygen saturation is 97% on air, respiratory rate 22/min, and peak flow is now 80% of predicted. He has mild scattered wheeze. The emergency department doctor is considering discharge. What is the most important additional treatment before discharge?
Q68
What is the recommended first-line inhaler device for delivering salbutamol to a 3-year-old child with acute wheeze in the emergency department who does not require hospital admission?
Q69
An 11-month-old infant is brought to the emergency department with a 6-hour history of fever to 40.1°C and increasing lethargy. On examination, the infant is drowsy with cool peripheries, mottled skin, capillary refill time of 4 seconds centrally, heart rate 170/min, respiratory rate 50/min, and blood pressure 65/40 mmHg. There are several non-blanching purpuric lesions on the trunk and limbs. What is the most appropriate immediate management?
Q70
A 2-year-old child presents with a 72-hour history of fever ranging from 38.5-39.9°C. The parents report the child has been irritable and refusing food but is drinking adequately. On examination, the child is alert but irritable, with a temperature of 39.2°C, heart rate 140/min, respiratory rate 28/min, and capillary refill time less than 2 seconds. There is bilateral conjunctival injection, erythematous cracked lips, a polymorphous rash on the trunk, and cervical lymphadenopathy with one node measuring 2cm. What is the most likely diagnosis?
Acute Paediatrics UK Medical PG Practice Questions and MCQs
Question 61: A 7-year-old boy with known asthma is brought to the emergency department with acute breathlessness. He is unable to complete sentences, has a respiratory rate of 42 breaths per minute, heart rate of 145 beats per minute, and oxygen saturation of 89% on room air. He has widespread wheeze with poor air entry bilaterally. Peak expiratory flow rate is 40% of his best. He is started on high-flow oxygen, back-to-back nebulised salbutamol with ipratropium bromide, and oral prednisolone. After 1 hour there is minimal improvement. What is the most appropriate next step in management?
A. Arrange urgent admission to paediatric intensive care unit
B. Administer intravenous magnesium sulphate (Correct Answer)
C. Administer intravenous salbutamol infusion
D. Administer intravenous aminophylline
E. Continue nebulised bronchodilators and reassess in 30 minutes
Explanation: ***Administer intravenous magnesium sulphate***- This patient exhibits features of **severe acute asthma**, including inability to complete sentences, poor air entry, SpO2 89%, and PEFR 40% despite initial maximal nebulized bronchodilators (salbutamol and ipratropium bromide) and oral steroids. - **Intravenous magnesium sulphate** is recommended as the next step in the management of children with acute severe asthma that is refractory to initial bronchodilator therapy, acting as a bronchodilator through smooth muscle relaxation.*Arrange urgent admission to paediatric intensive care unit*- While urgent **PICU consultation** and readiness for admission are crucial for a patient with life-threatening asthma, it is not the immediate drug-based next step before trying other proven intravenous therapies.- **PICU admission** is typically indicated for patients with impending respiratory failure requiring ventilation, a **silent chest**, or those who have failed all available pharmacological interventions.*Administer intravenous salbutamol infusion*- **Intravenous salbutamol** is an advanced therapy for severe asthma, generally considered *after* intravenous magnesium sulphate if the patient remains unresponsive.- This option carries a higher risk of systemic side effects such as **tachycardia** and **hypokalaemia** compared to magnesium sulphate, requiring careful monitoring.*Administer intravenous aminophylline*- **Aminophylline** is a methylxanthine that acts as a bronchodilator, but its use is typically reserved for later stages in the escalation of severe asthma management due to its **narrow therapeutic index**.- It requires close monitoring of **serum levels** to prevent toxicity, which includes arrhythmias, seizures, and gastrointestinal disturbances.*Continue nebulised bronchodilators and reassess in 30 minutes*- This approach is inappropriate as the patient has already shown **minimal improvement** after one hour of maximal nebulised bronchodilator therapy, indicating a refractory and severe exacerbation.- Delaying the escalation to **intravenous therapies** in a child with such severe and unresponsive asthma can lead to further clinical deterioration and **respiratory arrest**.
Question 62: A 5-year-old boy with poorly controlled asthma is reviewed following his third admission for acute exacerbation in 6 months. He is currently on beclometasone 200 micrograms twice daily via spacer, but his mother reports he uses his salbutamol inhaler most days and wakes 2-3 times per week with cough and wheeze. Inhaler technique is checked and is good. What is the most appropriate next step in his management according to current guidelines?
A. Add montelukast 5mg once daily at night while continuing current inhaled corticosteroid dose (Correct Answer)
B. Increase beclometasone to 400 micrograms twice daily
C. Add salmeterol 50 micrograms twice daily to current treatment
D. Switch to fluticasone 125 micrograms twice daily
E. Refer to specialist paediatric respiratory team before making any changes
Explanation: ***Add montelukast 5mg once daily at night while continuing current inhaled corticosteroid dose***- For children aged **5-16 years** who are uncontrolled on low-dose **inhaled corticosteroids (ICS)**, current guidelines (e.g., BTS/SIGN) recommend adding a **Leukotriene Receptor Antagonist (LTRA)** as the first-line add-on therapy.- This patient meets the criteria for Step 3 management due to frequent **salbutamol** use, nocturnal symptoms, and multiple recent hospital admissions, indicating inadequate control despite good inhaler technique.*Increase beclometasone to 400 micrograms twice daily*- Increasing the dose of **ICS** to a moderate dose is generally recommended only if asthma remains uncontrolled after an adequate trial of an **LTRA**.- Escalating ICS dose as the immediate next step without first trying an LTRA can increase the risk of **systemic side effects** without following the preferred stepwise approach.*Add salmeterol 50 micrograms twice daily to current treatment*- While **Long-Acting Beta Agonists (LABA)** are first-line add-ons in adults, in pediatric patients under 16, **LTRA therapy** is prioritized before introducing a LABA at this stage.- If the child fails to respond to an LTRA, a **LABA** would then be considered as an alternative or additional Step 3 therapy.*Switch to fluticasone 125 micrograms twice daily*- Switching between different types of **ICS** at equivalent doses (beclometasone 200mcg BID is broadly comparable to fluticasone 125mcg BID) is not an evidence-based strategy to improve control when a patient is failing a specific step.- Management should focus on escalating to the next **pharmacological step** (e.g., adding an LTRA) rather than horizontal switching of medication classes.*Refer to specialist paediatric respiratory team before making any changes*- Referral to a **specialist pediatric respiratory team** is typically indicated at **Step 4** (uncontrolled on moderate-dose ICS and add-on) or if there is diagnostic uncertainty.- Management at Step 3 can and should be initiated in the **primary care** or general pediatric setting following standardized guidelines.
Question 63: A 4-year-old girl presents with a 5-day history of fever up to 40.2°C. She has been seen twice by her GP and prescribed oral antibiotics for suspected tonsillitis, but fever persists. On examination, she is miserable with temperature 39.8°C, bilateral non-purulent conjunctivitis, dry cracked lips with some bleeding, strawberry tongue, and erythematous palms and soles. There is a faint maculopapular rash on the trunk and a single palpable cervical lymph node measuring 1.8cm. Blood tests show: Hb 105 g/L, WBC 16.5 × 10⁹/L, platelets 445 × 10⁹/L, CRP 125 mg/L, ESR 68 mm/hr, albumin 28 g/L. What is the most critical time-sensitive intervention?
A. Start high-dose aspirin 80mg/kg/day in divided doses
B. Arrange urgent cardiology review and echocardiography
C. Administer intravenous immunoglobulin 2g/kg over 12 hours (Correct Answer)
D. Change antibiotics to intravenous ceftriaxone for possible bacterial infection
E. Perform blood cultures and start broad-spectrum antibiotics
Explanation: ***Administer intravenous immunoglobulin 2g/kg over 12 hours***
- The patient's clinical presentation, including persistent fever for over 5 days with **bilateral non-purulent conjunctivitis**, **dry cracked lips**, **strawberry tongue**, **erythematous palms and soles**, **maculopapular rash**, and **cervical lymphadenopathy**, meets the diagnostic criteria for **Kawasaki Disease**. Administering **IVIG** is the most critical time-sensitive intervention to prevent **coronary artery aneurysms**.
- Early administration of **IVIG**, ideally within the first 10 days of illness, significantly reduces the risk of serious cardiac complications from **vasculitis**.
*Start high-dose aspirin 80mg/kg/day in divided doses*
- While **aspirin** is an important component of Kawasaki disease treatment due to its **anti-inflammatory** and **anti-platelet** effects, it is typically given in conjunction with **IVIG** and is not the primary intervention for preventing **coronary artery abnormalities**.
- Prioritizing or delaying **IVIG** administration for aspirin alone would miss the critical window for definitive cardiac protection.
*Arrange urgent cardiology review and echocardiography*
- An **echocardiogram** is crucial for establishing a baseline and monitoring for **coronary artery aneurysms**, but starting **IVIG** should not be delayed by waiting for this review in a clinically clear case of Kawasaki disease.
- Delaying treatment while awaiting imaging increases the risk of progression of **coronary artery vasculitis**.
*Change antibiotics to intravenous ceftriaxone for possible bacterial infection*
- The distinctive constellation of signs like **strawberry tongue**, **conjunctivitis**, and **palm erythema** is characteristic of **Kawasaki disease**, not typically responsive to antibiotics, especially given the persistence of fever despite prior oral antibiotics.
- Pursuing further antibiotic regimens for bacterial infection at this point would delay the appropriate and time-sensitive treatment for **Kawasaki disease**.
*Perform blood cultures and start broad-spectrum antibiotics*
- Although blood cultures are part of a febrile workup, the specific clinical picture and laboratory findings (**elevated ESR/CRP**, **thrombocytosis** in later phases, **hypoalbuminemia**) strongly suggest an **inflammatory vasculitis** like Kawasaki disease, rather than an undifferentiated bacterial infection.
- Continuing with empiric broad-spectrum antibiotics for suspected bacterial infection would delay the critical **IVIG** intervention, which is essential to prevent severe cardiac sequelae.
Question 64: A 6-year-old girl with asthma on beclometasone 400 micrograms twice daily and salbutamol as needed presents with an acute exacerbation. She has received optimal bronchodilator therapy including back-to-back nebulisers, ipratropium, oral prednisolone, and intravenous magnesium sulphate. Despite this, she remains critically unwell with oxygen saturation 88% on high-flow oxygen, exhaustion, and reduced respiratory effort. Senior anaesthetic and PICU teams are present. What additional pharmacological therapy should be considered before intubation?
A. Intravenous hydrocortisone 100mg stat dose
B. Nebulised adrenaline 1:1000
C. Intravenous aminophylline loading dose then infusion (Correct Answer)
D. Inhaled sevoflurane anaesthetic agent
E. Subcutaneous adrenaline 1:1000
Explanation: ***Intravenous aminophylline loading dose then infusion***- In children with **life-threatening asthma** unresponsive to maximal therapy including **IV magnesium sulphate**, **IV aminophylline** is the next step according to **BTS/SIGN guidelines**.- It acts as a **phosphodiesterase inhibitor** to provide additional bronchodilation but requires **ECG monitoring** due to risks of arrhythmias and toxicity.*Intravenous hydrocortisone 100mg stat dose*- Since the patient has already received **oral prednisolone**, adding IV steroids provides no immediate additional benefit as they have a **slow onset of action**.- Steroids are crucial for reducing **airway inflammation** over hours, but they cannot reverse **acute respiratory failure** or exhaustion immediately.*Nebulised adrenaline 1:1000*- This treatment is primarily indicated for **croup (laryngotracheobronchitis)** to reduce upper airway mucosal edema.- It has no proven role in the management of **lower airway bronchospasm** associated with acute asthma exacerbations.*Inhaled sevoflurane anaesthetic agent*- **Sevoflurane** is a potent bronchodilator but is typically reserved for the **induction of anesthesia** or used within a PICU setting during mechanical ventilation.- It cannot be safely administered to a spontaneously breathing patient in this clinical state **before intubation** has been initiated by the senior team.*Subcutaneous adrenaline 1:1000*- **Subcutaneous adrenaline** is the first-line treatment for **anaphylaxis**, which presents with different clinical features like urticaria or angioedema.- While it can be used for bronchospasm in extreme cases where IV access is impossible, it is not part of the standard escalation for **refractory asthma** in a hospital setting.
Question 65: A 3-year-old boy with recurrent viral-induced wheeze is brought to the emergency department with increased work of breathing and wheeze. This is his third episode requiring hospital attendance this year. His parents report he is well between episodes and has no interval symptoms. What is the most appropriate long-term management strategy to discuss with the parents before discharge?
A. Regular daily inhaled corticosteroids to prevent future episodes
B. Parent-initiated oral montelukast at the onset of coryzal symptoms (Correct Answer)
C. Daily low-dose oral prednisolone during winter months
D. Regular daily long-acting beta-agonist (salmeterol) with salbutamol as needed
E. Salbutamol as needed only, with no preventive therapy
Explanation: ***Parent-initiated oral montelukast at the onset of coryzal symptoms***- This child presents with **episodic viral wheeze**, characterized by symptoms only during viral infections with **no interval symptoms** between episodes.- For recurrent, problematic viral-induced wheeze, **intermittent leukotriene receptor antagonists (LTRA)** like montelukast started at the first sign of a cold can reduce the severity and duration of the episode.*Regular daily inhaled corticosteroids to prevent future episodes*- **Daily inhaled corticosteroids (ICS)** are the mainstay for **multi-trigger wheeze** or asthma but are generally less effective for purely viral-induced wheeze.- ICS may be considered if intermittent montelukast fails, but it is not the first-line choice when there are no interval symptoms.*Daily low-dose oral prednisolone during winter months*- **Daily oral corticosteroids** are avoided in children due to significant **systemic side effects**, including growth suppression and adrenal suppression.- Management of wheeze focuses on **inhaled therapies** or targeted intermittent oral treatments rather than long-term systemic steroids.*Regular daily long-acting beta-agonist (salmeterol) with salbutamol as needed*- **Long-acting beta-agonists (LABA)** must never be used as monotherapy; they must always be prescribed alongside an **inhaled corticosteroid**.- LABAs are not indicated for the management of **episodic viral wheeze** in a 3-year-old child.*Salbutamol as needed only, with no preventive therapy*- While salbutamol is used for **acute symptom relief**, this child has had **three hospital attendances** in one year, indicating that "as needed" therapy alone is insufficient.- Clinical guidelines recommend initiating **preventative strategies** (like intermittent LTRA) when episodes are frequent or severe enough to require hospital visits.
Question 66: A 6-month-old infant presents with a 24-hour history of fever to 38.9°C and decreased feeding. The infant was born at term with no significant medical history. On examination, the infant is irritable, temperature 38.7°C, heart rate 155/min, respiratory rate 42/min, and capillary refill time 2 seconds. There is no rash, the fontanelle is not bulging, and systemic examination is unremarkable. Blood tests show: WBC 18.2 × 10⁹/L, CRP 65 mg/L. Urine dipstick is negative. What is the most appropriate next step in management?
A. Discharge with safety-netting advice and arrange GP review in 24 hours
B. Perform lumbar puncture, blood culture, and start intravenous antibiotics (Correct Answer)
C. Prescribe oral antibiotics and arrange paediatric review in 48 hours
D. Observe in hospital for 4 hours and repeat observations before deciding on discharge
E. Arrange chest X-ray and start oral antibiotics if pneumonia is confirmed
Explanation: ***Perform lumbar puncture, blood culture, and start intravenous antibiotics*** - Infants aged **under 3 months** with a fever of **38°C or higher** or those aged **3–6 months** with **elevated inflammatory markers** (CRP >60 mg/L or WBC >15 x 10⁹/L) are at high risk for **serious bacterial infection (SBI)**. - Appropriate management includes a full **septic screen** (blood cultures, urine culture, and lumbar puncture) and immediate administration of **intravenous antibiotics** to cover potential meningitis or bacteremia. *Discharge with safety-netting advice and arrange GP review in 24 hours* - This approach is unsafe given the significantly **elevated CRP (65 mg/L)** and **WBC (18.2 × 10⁹/L)**, which indicate a high risk of occult infection. - Discharge is only considered for infants at **low risk** using validated clinical tools (like the NICE traffic light system) and with normal investigation findings. *Prescribe oral antibiotics and arrange paediatric review in 48 hours* - **Oral antibiotics** are inappropriate for an irritable infant with high inflammatory markers, as **intravenous therapy** is required to ensure adequate systemic coverage. - Delaying review for 48 hours is dangerous in this age group as **sepsis** or **meningitis** can progress rapidly without aggressive inpatient management. *Observe in hospital for 4 hours and repeat observations before deciding on discharge* - Observation alone is insufficient when **inflammatory markers** exceed the threshold for high risk; medical intervention should not be delayed by simple monitoring. - While observations are important, they cannot rule out **occult bacteremia** or **early meningitis** in an irritable infant with a fever. *Arrange chest X-ray and start oral antibiotics if pneumonia is confirmed* - There is no clinical indication for a chest X-ray as the **respiratory rate (42/min)** is within normal limits for a 6-month-old and there are no **respiratory distress** signs. - Pneumonia is an unlikely source here, and the focus must remain on ruling out **life-threatening infections** through a septic screen first.
Question 67: A 5-year-old boy with known asthma on beclometasone 200 micrograms twice daily presents with wheeze and breathlessness after playing outside. In the emergency department, he receives salbutamol via spacer (10 puffs) and his symptoms improve. He is speaking in full sentences, oxygen saturation is 97% on air, respiratory rate 22/min, and peak flow is now 80% of predicted. He has mild scattered wheeze. The emergency department doctor is considering discharge. What is the most important additional treatment before discharge?
A. Increase his regular beclometasone to 400 micrograms twice daily
B. Add montelukast 4mg once daily for 7 days
C. Prescribe oral prednisolone 20mg once daily for 3 days (Correct Answer)
D. Add ipratropium bromide inhaler to use four times daily
E. Prescribe a 7-day course of oral antibiotics
Explanation: ***Prescribe oral prednisolone 20mg once daily for 3 days***
- This child experienced an **acute asthma exacerbation** requiring ED treatment, necessitating a short course of **oral corticosteroids** to reduce inflammation and prevent relapse.
- **National guidelines** recommend oral prednisolone (20mg for 5-11 years) for 3 days post-exacerbation, providing essential systemic **anti-inflammatory** effect.
*Increase his regular beclometasone to 400 micrograms twice daily*
- Adjusting **maintenance inhaled corticosteroid (ICS)** dose is a long-term management strategy, not the primary intervention for discharge after an acute exacerbation.
- While important for control, increased ICS alone does not provide the same rapid and systemic anti-inflammatory benefit as a short course of **oral steroids** to prevent acute relapse.
*Add montelukast 4mg once daily for 7 days*
- **Montelukast** is a **leukotriene receptor antagonist** for **long-term asthma control** or exercise-induced asthma, not for acute exacerbation management or preventing immediate relapse.
- A short 7-day course of montelukast is not a substitute for **oral corticosteroids** in providing prompt anti-inflammatory effects after an acute attack.
*Add ipratropium bromide inhaler to use four times daily*
- **Ipratropium bromide** is an **anticholinergic bronchodilator** typically used in **severe acute asthma exacerbations** within the emergency setting.
- It is not indicated for routine home discharge plans for a child who has responded well to **salbutamol** and has mild residual symptoms.
*Prescribe a 7-day course of oral antibiotics*
- **Asthma exacerbations** are predominantly triggered by **viral infections**, allergens, or irritants, making **antibiotics** generally ineffective and inappropriate.
- There are no clinical signs (e.g., fever, purulent sputum) in this patient to suggest a **bacterial infection** requiring antibiotic treatment.
Question 68: What is the recommended first-line inhaler device for delivering salbutamol to a 3-year-old child with acute wheeze in the emergency department who does not require hospital admission?
A. Nebuliser with face mask
B. Metered-dose inhaler with large volume spacer (Correct Answer)
C. Dry powder inhaler
D. Metered-dose inhaler alone without spacer
E. Breath-actuated metered-dose inhaler
Explanation: ***Metered-dose inhaler with large volume spacer***
- For children under 5 years, **BTS/SIGN guidelines** recommend a metered-dose inhaler (MDI) with a **spacer and mask** as the first-line delivery method for mild to moderate acute wheeze.
- This method is as effective as **nebulisation** for bronchodilator delivery, carries a lower risk of side effects like **tachycardia**, and is more cost-effective.
*Nebuliser with face mask*
- **Nebulisers** are generally reserved for patients with **severe or life-threatening asthma** who may require high concentrations of **oxygen** during treatment or are unable to cooperate with a spacer.
- They are no more effective than an **MDI plus spacer** for mild to moderate episodes and are more time-consuming to set up, making them less ideal for first-line use in non-severe cases.
*Dry powder inhaler*
- These devices require a strong, deep **inspiratory flow rate** to aerosolize the medication effectively, which is typically not achievable by a **3-year-old** child.
- They are generally only suitable for older children (usually over **5–7 years**) who can follow specific breathing instructions and generate sufficient inspiratory force.
*Metered-dose inhaler alone without spacer*
- Using an MDI alone requires precise **hand-breath coordination**, which is impossible for a toddler and leads to poor **lung deposition** of the medication.
- Without a spacer, most of the medication impacts the **oropharynx** due to high velocity, rather than reaching the lower airways.
*Breath-actuated metered-dose inhaler*
- While triggered by inhalation, these devices require a specific **minimum inspiratory flow** that small children cannot consistently generate, similar to dry powder inhalers.
- They are not recommended for children under **5 years old** or for the management of acute respiratory distress where breathing is shallow and inconsistent.
Question 69: An 11-month-old infant is brought to the emergency department with a 6-hour history of fever to 40.1°C and increasing lethargy. On examination, the infant is drowsy with cool peripheries, mottled skin, capillary refill time of 4 seconds centrally, heart rate 170/min, respiratory rate 50/min, and blood pressure 65/40 mmHg. There are several non-blanching purpuric lesions on the trunk and limbs. What is the most appropriate immediate management?
A. Obtain blood cultures, perform lumbar puncture, then administer intravenous ceftriaxone
B. Administer intramuscular benzylpenicillin immediately and arrange urgent transfer
C. Establish intravenous access, give 20ml/kg bolus of 0.9% sodium chloride, and administer intravenous ceftriaxone (Correct Answer)
D. Administer oxygen, obtain blood cultures, and start broad-spectrum antibiotics after lumbar puncture
E. Give intravenous aciclovir and ceftriaxone after obtaining cerebrospinal fluid sample
Explanation: ***Establish intravenous access, give 20ml/kg bolus of 0.9% sodium chloride, and administer intravenous ceftriaxone***
- The infant presents with features of **septic shock** (hypotension, mottled skin, prolonged capillary refill time) and strongly suspected **meningococcal septicaemia** due to the non-blanching purpuric lesions; immediate **fluid resuscitation** and broad-spectrum antibiotics are critical and life-saving.
- **Intravenous ceftriaxone** is the first-line empirical antibiotic for suspected meningococcal disease in a hospital setting, offering broad coverage and excellent **CNS penetration**.
*Obtain blood cultures, perform lumbar puncture, then administer intravenous ceftriaxone*
- A **lumbar puncture** is **contraindicated** in a patient exhibiting signs of hemodynamic instability (shock) or potential raised intracranial pressure, as it carries a high risk of cerebral herniation.
- **Antibiotics** should be administered **immediately** in severe sepsis and septic shock, ideally after blood cultures but never delayed by diagnostic procedures like blood cultures or lumbar puncture.
*Administer intramuscular benzylpenicillin immediately and arrange urgent transfer*
- **Intramuscular benzylpenicillin** is primarily recommended as a **pre-hospital** emergency intervention for suspected meningococcal disease to minimize delay to initial antibiotics before hospital arrival.
- Since the infant is already in the **Emergency Department** with signs of severe shock, establishing intravenous access for rapid fluid resuscitation and comprehensive IV antibiotic delivery is the immediate priority.
*Administer oxygen, obtain blood cultures, and start broad-spectrum antibiotics after lumbar puncture*
- Performing a **lumbar puncture** in a critically unstable infant with signs of shock (BP 65/40 mmHg) is highly dangerous and can precipitate **cerebral herniation** or further cardiorespiratory compromise.
- While oxygen is important, the core immediate management for **septic shock** involves aggressive fluid resuscitation and rapid administration of antibiotics, not delaying antibiotics for an LP.
*Give intravenous aciclovir and ceftriaxone after obtaining cerebrospinal fluid sample*
- **Aciclovir** is an antiviral agent used for herpes simplex encephalitis/meningitis, which presents differently, typically with seizures or focal neurological deficits, not primarily with **purpuric rash** and profound shock.
- Delaying critical treatments like **antibiotics** and fluid resuscitation to obtain a **cerebrospinal fluid (CSF) sample** is unacceptable and significantly increases mortality risk in an infant with suspected bacterial sepsis and shock.
Question 70: A 2-year-old child presents with a 72-hour history of fever ranging from 38.5-39.9°C. The parents report the child has been irritable and refusing food but is drinking adequately. On examination, the child is alert but irritable, with a temperature of 39.2°C, heart rate 140/min, respiratory rate 28/min, and capillary refill time less than 2 seconds. There is bilateral conjunctival injection, erythematous cracked lips, a polymorphous rash on the trunk, and cervical lymphadenopathy with one node measuring 2cm. What is the most likely diagnosis?
A. Scarlet fever
B. Kawasaki disease (Correct Answer)
C. Measles
D. Infectious mononucleosis
E. Staphylococcal toxic shock syndrome
Explanation: ***Kawasaki disease***
- This diagnosis is strongly supported by the prolonged fever (72 hours) coupled with the characteristic findings of **bilateral conjunctival injection**, **erythematous cracked lips**, a **polymorphous rash on the trunk**, and **cervical lymphadenopathy** (node >1.5 cm), which meet several diagnostic criteria for the disease.
- Early recognition is crucial as **Kawasaki disease** is a **vasculitis** that can lead to serious complications like **coronary artery aneurysms** if not treated promptly with **intravenous immunoglobulin (IVIG)** and **aspirin**.
*Scarlet fever*
- While scarlet fever presents with fever and a rash, the rash is typically a fine, **sandpaper-like exanthem**, and it often includes a **strawberry tongue** with a significant sore throat.
- This condition does not typically cause **non-purulent conjunctivitis** or the distinct **cracked lips** seen in this patient.
*Measles*
- Measles is characterized by a prodrome of **cough, coryza, and conjunctivitis** (the
