A 4-year-old girl presents with a 3-day history of fever to 39.8°C, lethargy, and reduced oral intake. She has no cough, rash, or diarrhoea. On examination, she is pale and lethargic but rousable. Temperature is 39.2°C, heart rate 156/min, respiratory rate 28/min, blood pressure 95/55 mmHg, capillary refill time 4 seconds centrally. Chest is clear, abdomen is soft with no organomegaly. There is no neck stiffness or photophobia, and no rash. Urine dipstick shows leukocytes ++, nitrites +, blood +. Blood tests show: Hb 108 g/L, WCC 18.2 × 10⁹/L (neutrophils 15.1), platelets 456 × 10⁹/L, CRP 142 mg/L. What is the most appropriate immediate management?
Q82
A 6-month-old infant is brought to the emergency department with a 6-hour history of fever to 38.6°C and increased work of breathing. The infant was born at term with no complications and is fully immunized. On examination, respiratory rate is 64/min, heart rate 168/min, temperature 38.4°C, oxygen saturation 91% in air. There is nasal flaring, subcostal and intercostal recession, and bilateral fine inspiratory crackles. The infant appears lethargic with reduced feeding. Capillary refill time is 3 seconds. What is the most appropriate immediate management priority?
Q83
A 2-year-old boy is brought to the emergency department following a generalized tonic-clonic seizure lasting 8 minutes at home. He has had a fever of 39.7°C for 12 hours. On arrival, the seizure has stopped and he is drowsy but responsive to voice. Capillary blood glucose is 5.2 mmol/L. Temperature is 39.1°C, heart rate 152/min, respiratory rate 36/min, oxygen saturation 97% in air. He has mildly inflamed tonsils and clear chest. There is no rash, photophobia, or neck stiffness. He has no previous history of seizures. Which of the following features makes this a complex febrile seizure?
Q84
A 15-month-old child presents with a 48-hour history of fever to 39.4°C and irritability. On examination, the tympanic membranes appear red and bulging bilaterally. The child is alert and interactive with no signs of serious illness. Throat appears normal with no exudate. There is no rash or neck stiffness. Heart rate is 140/min, respiratory rate 32/min, and oxygen saturation 98% in air. What is the most appropriate initial management?
Q85
A 9-year-old boy with known asthma attends clinic for review. He uses his salbutamol inhaler 2-3 times per week for symptom relief and wakes once per week with cough. He is on beclometasone 200 micrograms twice daily via a metered-dose inhaler. Examination reveals normal chest sounds and good technique with his inhaler. What is the most appropriate next step in his asthma management according to current UK guidelines?
Q86
A 3-year-old boy with recurrent wheeze is prescribed a salbutamol inhaler with a spacer device for symptom relief. His parents ask about the correct technique for administering inhaled medication via spacer. Which of the following represents the recommended number of breaths the child should take from the spacer after each actuation?
Q87
An 8-month-old infant presents to the emergency department with a 12-hour history of fever of 38.9°C and parental concern about reduced responsiveness. On examination, the infant is lethargic but rousable, has a non-blanching petechial rash on the trunk (4 lesions, each <2mm), temperature 38.7°C, heart rate 165 bpm, respiratory rate 48/min, capillary refill time 3 seconds centrally. Blood glucose is 4.2 mmol/L. What is the single most appropriate immediate management?
Q88
A 3-year-old boy with recurrent viral-induced wheeze presents to the emergency department with acute breathlessness and wheeze. His mother reports this is his fourth episode in the past year. He has been started on salbutamol inhaler via spacer with 8 puffs given, and symptoms have partially improved. Observations now show: respiratory rate 32/min, heart rate 118 bpm, oxygen saturation 96% in air. He can speak in full sentences. What is the most appropriate next step regarding his ongoing management plan?
Q89
A 4-year-old girl presents with a 4-day history of high fever up to 39.8°C, sore throat, and difficulty swallowing. She is drooling and sitting leaning forward. On examination, she appears toxic, has inspiratory stridor, temperature 39.5°C, respiratory rate 38/min, heart rate 148 bpm, oxygen saturation 96% in air. There is no rash. She is fully immunised including Haemophilus influenzae type b vaccine. What is the most appropriate immediate action?
Q90
A 9-month-old infant with a 3-day history of coryzal symptoms and cough is brought to the emergency department with increased work of breathing. On examination, respiratory rate is 65/min, heart rate 155 bpm, temperature 37.9°C, oxygen saturation 91% in air. There is subcostal and intercostal recession, nasal flaring, and bilateral fine inspiratory crackles with scattered wheeze throughout both lung fields. The infant is feeding approximately 50% of normal volume. What is the most appropriate initial management?
Acute Paediatrics UK Medical PG Practice Questions and MCQs
Question 81: A 4-year-old girl presents with a 3-day history of fever to 39.8°C, lethargy, and reduced oral intake. She has no cough, rash, or diarrhoea. On examination, she is pale and lethargic but rousable. Temperature is 39.2°C, heart rate 156/min, respiratory rate 28/min, blood pressure 95/55 mmHg, capillary refill time 4 seconds centrally. Chest is clear, abdomen is soft with no organomegaly. There is no neck stiffness or photophobia, and no rash. Urine dipstick shows leukocytes ++, nitrites +, blood +. Blood tests show: Hb 108 g/L, WCC 18.2 × 10⁹/L (neutrophils 15.1), platelets 456 × 10⁹/L, CRP 142 mg/L. What is the most appropriate immediate management?
A. Oral trimethoprim for 3 days and discharge with outpatient follow-up
B. Intravenous ceftriaxone after blood and urine cultures, with admission for monitoring (Correct Answer)
C. Oral amoxicillin for 7 days with outpatient review in 48 hours
D. Arrange urgent renal ultrasound before commencing antibiotics
E. Lumbar puncture followed by intravenous ceftriaxone
Explanation: ***Intravenous ceftriaxone after blood and urine cultures, with admission for monitoring***
- The patient exhibits features of **pyelonephritis** (high fever, high CRP, positive nitrites/leukocytes) alongside signs of **systemic compromise** such as lethargy, tachycardia, and a **capillary refill time of 4 seconds**.
- This presentation necessitates urgent management with **intravenous antibiotics** (like ceftriaxone) after obtaining cultures, and **hospital admission** for close monitoring due to potential sepsis.
*Oral trimethoprim for 3 days and discharge with outpatient follow-up*
- **Oral trimethoprim** is inadequate for a child presenting with signs of **systemic infection** and potential sepsis, as it would not achieve sufficient blood levels quickly enough.
- Discharging a lethargic child with **prolonged capillary refill time** and high fever is dangerous, as they require inpatient monitoring and supportive care.
*Oral amoxicillin for 7 days with outpatient review in 48 hours*
- **Oral amoxicillin** is insufficient for severe infections like pyelonephritis with systemic compromise, as intravenous therapy ensures rapid and effective drug delivery.
- An **outpatient review in 48 hours** is an unacceptable delay for a child with signs of evolving sepsis, where clinical deterioration can be rapid.
*Arrange urgent renal ultrasound before commencing antibiotics*
- Delaying antibiotic administration for imaging in a child with suspected **urosepsis** or severe infection is inappropriate and can worsen outcomes.
- While a **renal ultrasound** may be indicated to investigate underlying abnormalities, it should be performed after initiating definitive antibiotic treatment and stabilizing the patient.
*Lumbar puncture followed by intravenous ceftriaxone*
- There are no clinical signs of **meningitis** (such as neck stiffness or photophobia), and the strong evidence for a urinary tract infection makes a lumbar puncture unnecessary as an immediate step.
- The priority is to treat the identified source of infection (UTI) with appropriate antibiotics, rather than pursuing investigations for a less likely diagnosis at this stage.
Question 82: A 6-month-old infant is brought to the emergency department with a 6-hour history of fever to 38.6°C and increased work of breathing. The infant was born at term with no complications and is fully immunized. On examination, respiratory rate is 64/min, heart rate 168/min, temperature 38.4°C, oxygen saturation 91% in air. There is nasal flaring, subcostal and intercostal recession, and bilateral fine inspiratory crackles. The infant appears lethargic with reduced feeding. Capillary refill time is 3 seconds. What is the most appropriate immediate management priority?
A. Commence supplemental oxygen to maintain oxygen saturation >92% (Correct Answer)
B. Administer intravenous antibiotics after blood cultures
C. Perform chest X-ray to confirm diagnosis
D. Commence nasogastric feeding to maintain hydration
E. Administer nebulised salbutamol
Explanation: ***Commence supplemental oxygen to maintain oxygen saturation >92%***
- The infant's oxygen saturation of **91%** indicates **hypoxia**, making supplemental oxygen the most immediate life-saving intervention to improve tissue oxygenation.
- Following the **ABC (Airway, Breathing, Circulation)** principles, addressing compromised breathing and oxygenation is the highest priority in a critically unwell child.
*Administer intravenous antibiotics after blood cultures*
- While **fever**, **lethargy**, and **elevated heart rate** suggest a possible infection, correcting life-threatening **hypoxia** takes immediate precedence over starting antibiotics.
- **Blood cultures** and **antibiotics** are crucial but are secondary steps after securing the patient's immediate respiratory stability.
*Perform chest X-ray to confirm diagnosis*
- A **chest X-ray** is a diagnostic tool and should not delay initiating urgent, **life-saving interventions** like oxygen therapy in an infant with significant respiratory distress.
- Clinical assessment often guides initial management, and an X-ray may not be immediately necessary, especially in typical cases of **bronchiolitis**.
*Commence nasogastric feeding to maintain hydration*
- While the infant has **reduced feeding** and signs of poor perfusion (prolonged capillary refill), commencing feeding in an infant with a **respiratory rate of 64/min** poses a high risk of **aspiration**.
- Respiratory stabilization must be achieved first to reduce the risk of aspiration and ensure the infant can safely tolerate feeding, with **intravenous fluids** being an alternative for hydration if necessary.
*Administer nebulised salbutamol*
- **Nebulised salbutamol** is generally not recommended for infants under 12 months with suspected **bronchiolitis** as evidence for its efficacy is poor and it can cause adverse effects like **tachycardia**.
- The clinical presentation with **fine inspiratory crackles** is more consistent with **bronchiolitis** or **pneumonia**, for which bronchodilators are not a primary treatment.
Question 83: A 2-year-old boy is brought to the emergency department following a generalized tonic-clonic seizure lasting 8 minutes at home. He has had a fever of 39.7°C for 12 hours. On arrival, the seizure has stopped and he is drowsy but responsive to voice. Capillary blood glucose is 5.2 mmol/L. Temperature is 39.1°C, heart rate 152/min, respiratory rate 36/min, oxygen saturation 97% in air. He has mildly inflamed tonsils and clear chest. There is no rash, photophobia, or neck stiffness. He has no previous history of seizures. Which of the following features makes this a complex febrile seizure?
A. Age less than 3 years
B. Duration of seizure greater than 5 minutes (Correct Answer)
C. Temperature greater than 39°C
D. Presence of tonsillitis as the febrile source
E. Post-ictal drowsiness
Explanation: ***Duration of seizure greater than 5 minutes***- A seizure duration of **8 minutes** exceeds the common 5-minute threshold often used to define a **prolonged febrile seizure**, which is a feature categorizing it as **complex** rather than simple.- While some classifications strictly define complex as >15 minutes, durations between **5 and 15 minutes** are frequently considered prolonged, necessitating closer evaluation and classifying the event as complex due to its extended nature.*Age less than 3 years*- The typical age range for **febrile seizures** is **6 months to 5 years**, making a 2-year-old child fall within the expected demographic.- **Age** within this range does not, by itself, classify a febrile seizure as complex; it merely indicates susceptibility.*Temperature greater than 39°C*- **High fever** (typically above 38°C or 39°C) is the defining trigger for all **febrile seizures**, whether simple or complex.- The **absolute height** of the temperature does not differentiate between simple and complex febrile seizures.*Presence of tonsillitis as the febrile source*- The presence of an identifiable **extracranial source of fever** (like tonsillitis) is a prerequisite for diagnosing a febrile seizure, ruling out **intracranial infection**.- The **source of fever** does not contribute to the classification of the febrile seizure as simple or complex.*Post-ictal drowsiness*- **Post-ictal drowsiness** is a common and **normal physiological response** following a generalized seizure as the brain recovers.- While **prolonged** or **focal post-ictal deficits** (e.g., Todd's paralysis) would indicate a complex seizure, simple drowsiness is an expected finding and not a criterion for complexity.
Question 84: A 15-month-old child presents with a 48-hour history of fever to 39.4°C and irritability. On examination, the tympanic membranes appear red and bulging bilaterally. The child is alert and interactive with no signs of serious illness. Throat appears normal with no exudate. There is no rash or neck stiffness. Heart rate is 140/min, respiratory rate 32/min, and oxygen saturation 98% in air. What is the most appropriate initial management?
A. Prescribe amoxicillin 40 mg/kg/day in three divided doses for 5 days
B. Arrange urgent blood cultures and commence IV ceftriaxone
C. Advise regular analgesia and review if symptoms persist beyond 72 hours (Correct Answer)
D. Prescribe azithromycin for 3 days
E. Refer urgently to ENT for myringotomy
Explanation: ***Advise regular analgesia and review if symptoms persist beyond 72 hours***
- For most children with **acute otitis media (AOM)** who are systemically well, a **watchful waiting** approach or a **delayed prescription** is recommended, as most cases resolve spontaneously.
- Current guidelines emphasize the use of **paracetamol** or **ibuprofen** for pain management while monitoring for deterioration over 2-3 days.
*Prescribe amoxicillin 40 mg/kg/day in three divided doses for 5 days*
- Immediate antibiotics are generally reserved for children under 2 years with **bilateral AOM**, those with **otorrhoea**, or those who are **systemically unwell**.
- Even when indicated, the standard high-dose regimen for amoxicillin in AOM is typically **80-90 mg/kg/day** to cover resistant Streptococcus pneumoniae.
*Arrange urgent blood cultures and commence IV ceftriaxone*
- This invasive management is for **sepsis** or bacterial meningitis, which is ruled out by the child's **alert and interactive** state and lack of neck stiffness.
- Hospital admission and **parenteral antibiotics** are only necessary if there are signs of **mastoiditis** or other serious complications.
*Prescribe azithromycin for 3 days*
- **Macrolides** like azithromycin are considered second-line therapy and are mostly reserved for patients with a **true penicillin allergy**.
- Like amoxicillin, immediate use is not indicated in this case as the child does not meet the criteria for urgent antibiotic treatment.
*Refer urgently to ENT for myringotomy*
- **Myringotomy** is a surgical procedure reserved for cases of **intractable pain**, treatment failure, or severe complications like facial nerve paralysis.
- It is not an initial management step for uncomplicated, **bilateral red and bulging membranes** in a stable child.
Question 85: A 9-year-old boy with known asthma attends clinic for review. He uses his salbutamol inhaler 2-3 times per week for symptom relief and wakes once per week with cough. He is on beclometasone 200 micrograms twice daily via a metered-dose inhaler. Examination reveals normal chest sounds and good technique with his inhaler. What is the most appropriate next step in his asthma management according to current UK guidelines?
A. Add montelukast as an additional controller therapy
B. Increase beclometasone to 400 micrograms twice daily
C. Add long-acting beta-agonist (LABA) therapy (Correct Answer)
D. Switch to combination ICS/LABA inhaler
E. Continue current management and review in 3 months
Explanation: ***Add long-acting beta-agonist (LABA) therapy***
- The patient's symptoms (salbutamol 2-3 times/week, nocturnal cough once/week) indicate **uncontrolled asthma** despite being on a moderate dose of **inhaled corticosteroid (ICS)** (beclometasone 200 micrograms twice daily).
- According to current UK guidelines (**BTS/SIGN**) for children aged 5-16, the most appropriate next step for poorly controlled asthma on a moderate dose ICS is to **add a long-acting beta-agonist (LABA)**.
*Add montelukast as an additional controller therapy*
- **Montelukast** (a **leukotriene receptor antagonist**) is typically considered if a **LABA** is not tolerated, is contraindicated, or if the patient continues to have uncontrolled symptoms after a trial of LABA.
- It is not usually the preferred first add-on therapy after an ICS in this specific stepwise management of pediatric asthma.
*Increase beclometasone to 400 micrograms twice daily*
- Increasing the **ICS dose** significantly before adding a **LABA** is not the recommended next step in the stepwise management of pediatric asthma.
- Escalating to a higher dose of ICS first carries an increased risk of **systemic side effects**, such as potential **growth suppression**, without necessarily providing optimal symptom control compared to adding a LABA.
*Switch to combination ICS/LABA inhaler*
- While the eventual goal might be a combination inhaler, the initial step in the guidelines is often to *add* a separate **LABA** to the existing ICS to assess the response to the new class of medication.
- A direct switch to a combination inhaler often comes later, for instance, if the individual LABA is effective and convenience is desired, or as part of a **MART (Maintenance and Reliever Therapy)** regimen which has specific criteria.
*Continue current management and review in 3 months*
- Continuing the current management is inappropriate as the patient exhibits clear signs of **uncontrolled asthma**, including frequent reliever use and nocturnal symptoms.
- Delaying treatment escalation would leave the child at continued risk of **asthma exacerbations**, **sleep disturbance**, and impaired quality of life due to persistent symptoms.
Question 86: A 3-year-old boy with recurrent wheeze is prescribed a salbutamol inhaler with a spacer device for symptom relief. His parents ask about the correct technique for administering inhaled medication via spacer. Which of the following represents the recommended number of breaths the child should take from the spacer after each actuation?
A. 10 breaths
B. 2 breaths
C. 3 breaths
D. 5 breaths (Correct Answer)
E. 7 breaths
Explanation: ***5 breaths***
- For young children, the recommended technique involves taking **five tidal breaths** after each single actuation to ensure effective delivery of the medication to the small airways.
- This method optimizes **drug deposition** in the lungs while being realistic and achievable for a 3-year-old child to perform during an acute episode.
*2 breaths*
- Taking only two breaths is generally **insufficient** for a young child using a spacer to inhale the full dose of the medication.
- This shorter duration increases the risk of **sub-optimal drug delivery**, potentially failing to resolve the wheeze effectively.
*3 breaths*
- While slightly closer to the goal, three breaths are still below the clinical standard required for **adequate ventilation** of the spacer chamber.
- Pediatric guidelines consistently recommend a minimum of **five breaths** to ensure the medication is not left suspended in the device.
*7 breaths*
- Recommending seven breaths is unnecessary as clinical evidence shows that **maximum medication extraction** is typically achieved within the first five breaths.
- Extending the process can lead to **poor compliance** or increased distress in a young child who is already experiencing respiratory difficulty.
*10 breaths*
- Although taking ten breaths is not harmful, it is **excessive** and does not provide additional therapeutic benefit over five breaths.
- For a toddler, maintaining a seal for ten breaths may be **physically challenging**, making the administration process unnecessarily long and difficult for parents.
Question 87: An 8-month-old infant presents to the emergency department with a 12-hour history of fever of 38.9°C and parental concern about reduced responsiveness. On examination, the infant is lethargic but rousable, has a non-blanching petechial rash on the trunk (4 lesions, each <2mm), temperature 38.7°C, heart rate 165 bpm, respiratory rate 48/min, capillary refill time 3 seconds centrally. Blood glucose is 4.2 mmol/L. What is the single most appropriate immediate management?
A. Obtain blood cultures, perform lumbar puncture, then administer IV ceftriaxone 80 mg/kg
B. Administer intramuscular benzylpenicillin 300 mg immediately then arrange urgent transfer
C. Commence fluid resuscitation with 20 ml/kg 0.9% sodium chloride then administer IV ceftriaxone
D. Administer IV ceftriaxone 80 mg/kg immediately, then perform investigations (Correct Answer)
E. Contact paediatric intensive care for retrieval and await their arrival before starting treatment
Explanation: ***Administer IV ceftriaxone 80 mg/kg immediately, then perform investigations***
- In an infant with **fever**, **lethargy**, and a **non-blanching petechial rash**, **meningococcal sepsis** is highly suspected, requiring immediate administration of **IV antibiotics**.
- Clinical guidelines emphasize that **antibiotic administration** must not be delayed for investigations like blood cultures or lumbar puncture when severe bacterial infection is suspected.
*Obtain blood cultures, perform lumbar puncture, then administer IV ceftriaxone 80 mg/kg*
- **Lumbar puncture** is contraindicated or should be deferred in a child with signs of **circulatory compromise** (prolonged CRT, tachycardia) due to the risk of herniation or clinical deterioration.
- Delaying **antibiotics** to obtain blood cultures is not acceptable in this emergency, as prompt treatment significantly impacts outcome.
*Administer intramuscular benzylpenicillin 300 mg immediately then arrange urgent transfer*
- **Intramuscular benzylpenicillin** is appropriate for **pre-hospital** management of suspected meningococcal disease to minimize delay before hospital arrival.
- As the infant is already in the emergency department, **IV ceftriaxone** is the preferred and more effective immediate intervention.
*Commence fluid resuscitation with 20 ml/kg 0.9% sodium chloride then administer IV ceftriaxone*
- While the infant shows signs of **shock** (prolonged CRT), the **absolute priority** in suspected meningococcal sepsis is the immediate administration of **antibiotics**.
- **Fluid resuscitation** should be initiated concurrently with or immediately following the first dose of antibiotics, not as a preceding step that delays antimicrobial therapy.
*Contact paediatric intensive care for retrieval and await their arrival before starting treatment*
- Delaying life-saving **antibiotics** and initial stabilization while waiting for **PICU retrieval** is unacceptable and significantly increases morbidity and mortality risk.
- The initial emergency management, including **antibiotics**, must be initiated by the treating team without delay.
Question 88: A 3-year-old boy with recurrent viral-induced wheeze presents to the emergency department with acute breathlessness and wheeze. His mother reports this is his fourth episode in the past year. He has been started on salbutamol inhaler via spacer with 8 puffs given, and symptoms have partially improved. Observations now show: respiratory rate 32/min, heart rate 118 bpm, oxygen saturation 96% in air. He can speak in full sentences. What is the most appropriate next step regarding his ongoing management plan?
A. Start regular inhaled corticosteroid beclometasone 100 micrograms twice daily
B. Prescribe oral montelukast 4 mg once daily as preventer therapy (Correct Answer)
C. Continue salbutamol as required only and provide written asthma action plan
D. Start combination inhaled corticosteroid and long-acting beta-agonist therapy
E. Arrange skin prick allergy testing before deciding on preventer therapy
Explanation: ***Prescribe oral montelukast 4 mg once daily as preventer therapy***
- For preschool children (under 5) with frequent **viral-induced wheeze**, a leukotriene receptor antagonist (**LTRA**) like montelukast is the first-line preventer therapy according to **BTS/SIGN guidelines**.
- This patient warrants a 4-8 week trial of **montelukast** due to the frequency of symptoms (four episodes in one year) to reduce the inflammatory response triggered by viral infections.
*Start regular inhaled corticosteroid beclometasone 100 micrograms twice daily*
- **Inhaled corticosteroids (ICS)** are the first-line preventer for children with **multiple-trigger wheeze** or clinical features of asthma, rather than purely episodic viral wheeze.
- Evidence suggests that ICS are less effective than **LTRAs** for managing wheezing that occurs exclusively during **viral upper respiratory infections** in preschool children.
*Continue salbutamol as required only and provide written asthma action plan*
- While a written action plan is vital, management with **SABA** alone is insufficient for a child experiencing **recurrent episodes** (four per year) that impact clinical stability.
- Relying solely on **rescue medication** fails to address the underlying inflammatory pathway responsible for the frequency of these exacerbations.
*Start combination inhaled corticosteroid and long-acting beta-agonist therapy*
- **LABA** therapy is not recommended for preschool children under five and must never be prescribed without concurrent **inhaled corticosteroids**.
- Stepping up to combination therapy is reserved for older children with persistent **asthma symptoms** that are poorly controlled on standard dose steroids.
*Arrange skin prick allergy testing before deciding on preventer therapy*
- **Skin prick testing** identifies atopy but does not alter the immediate pharmacological management of **episodic viral wheeze** in a 3-year-old.
- Preventer therapy is initiated based on **clinical frequency** and severity of wheezing episodes rather than the presence of specific allergic sensitizations.
Question 89: A 4-year-old girl presents with a 4-day history of high fever up to 39.8°C, sore throat, and difficulty swallowing. She is drooling and sitting leaning forward. On examination, she appears toxic, has inspiratory stridor, temperature 39.5°C, respiratory rate 38/min, heart rate 148 bpm, oxygen saturation 96% in air. There is no rash. She is fully immunised including Haemophilus influenzae type b vaccine. What is the most appropriate immediate action?
A. Examine the throat with tongue depressor and take throat swab
B. Contact senior paediatric and anaesthetic teams urgently and keep child calm (Correct Answer)
C. Administer nebulised adrenaline 5 ml of 1:1000
D. Lay the child flat and obtain intravenous access for blood tests
E. Administer intramuscular benzylpenicillin immediately
Explanation: ***Contact senior paediatric and anaesthetic teams urgently and keep child calm***- The clinical presentation of **high fever**, **drooling**, and **tripod positioning** is highly suggestive of **acute epiglottitis**, a life-threatening airway emergency.- Immediate involvement of **senior anaesthetic and paediatric teams** is critical to secure the airway in a controlled environment (e.g., operating theatre) before total obstruction occurs.*Examine the throat with tongue depressor and take throat swab*- Attempting to visualize the throat with a **tongue depressor** is strictly contraindicated as it can precipitate **reflex laryngospasm** and complete airway collapse.- Clinical examination should be deferred until the airway is stabilized by specialists equipped for **emergency intubation**.*Administer nebulised adrenaline 5 ml of 1:1000*- **Nebulised adrenaline** is the treatment for **croup** (laryngotracheobronchitis), not epiglottitis, and may be ineffective here.- Administering a nebuliser may **distress the child**, increasing the risk of sudden airway obstruction.*Lay the child flat and obtain intravenous access for blood tests*- **Lying the child flat** can lead to immediate airway occlusion in patients with epiglottitis; they must be allowed to remain in their **position of comfort**.- Painful procedures like **IV access** should be avoided until the airway is secured, as distress can trigger fatal **airway closure**.*Administer intramuscular benzylpenicillin immediately*- While antibiotics are necessary, they are secondary to **airway management** and should not delay the mobilization of the resuscitation team.- **Benzylpenicillin** is the empirical treatment for suspected meningococcal septicemia, but this patient's symptoms point toward **upper airway obstruction** rather than meningitis.
Question 90: A 9-month-old infant with a 3-day history of coryzal symptoms and cough is brought to the emergency department with increased work of breathing. On examination, respiratory rate is 65/min, heart rate 155 bpm, temperature 37.9°C, oxygen saturation 91% in air. There is subcostal and intercostal recession, nasal flaring, and bilateral fine inspiratory crackles with scattered wheeze throughout both lung fields. The infant is feeding approximately 50% of normal volume. What is the most appropriate initial management?
A. Commence oxygen therapy via nasal cannulae to maintain saturations ≥92% and observe feeding (Correct Answer)
B. Administer nebulised salbutamol and reassess response after 20 minutes
C. Administer nebulised hypertonic saline 3% and reassess in 30 minutes
D. Start oral prednisolone 1 mg/kg for 3 days
E. Commence intravenous fluids and nil by mouth
Explanation: ***Commence oxygen therapy via nasal cannulae to maintain saturations ≥92% and observe feeding***- The clinical presentation of a **9-month-old infant** with coryzal symptoms, crackles, and wheeze is diagnostic of **bronchiolitis**.- According to **NICE guidelines**, supplemental **oxygen therapy** is indicated as the first-line intervention when saturations are persistently **below 92%**.*Administer nebulised salbutamol and reassess response after 20 minutes*- **Bronchodilators** like salbutamol are not recommended in the management of bronchiolitis as the pathophysiology involves **airway edema** rather than smooth muscle bronchospasm.- Clinical trials have shown no significant improvement in **respiratory distress** or duration of hospital stay with the use of beta-2 agonists.*Administer nebulised hypertonic saline 3% and reassess in 30 minutes*- While **nebulised hypertonic saline** may be used in some inpatient protocols, it is not recommended for **initial emergency management** by current clinical guidelines.- Evidence regarding its efficacy in reducing **admission rates** or length of stay remains inconsistent and lower priority than oxygenation.*Start oral prednisolone 1 mg/kg for 3 days*- **Corticosteroids** (oral or inhaled) have no proven benefit in infants with bronchiolitis and are not recommended for routine use.- Unlike asthma, the inflammation in bronchiolitis does not respond effectively to **steroid therapy**.*Commence intravenous fluids and nil by mouth*- Infants should receive **nasogastric (NG) or intravenous fluids** only if they are unable to maintain adequate hydration (typically **<50% or 75%** of normal intake).- Since this infant is still feeding **50% of normal volume**, the clinical priority remains **oxygenation and close observation** before escalating to invasive fluid management.
