Question 28

College answer

Syllabus topic/section:

2.1.17    Paediatrics: L2

Discussion: 

Candidates who did well on this question were able to formulate a list of differentials, provide an assessment to help differentiate between the answers listed in part a), and then provide a general and specific plan of management. Some candidates were able to efficiently tabulate appropriate parts of their answer. Answers that included structure and a clear management plan of the listed abnormalities (e.g. hypoglycaemia) received more marks, as did those that referenced frequent liaison with a paediatric centre and specific treatments such as prostaglandin for potential duct dependent cardiac lesions.

Answers that did not attract as many marks omitted detail in part c) (50% of total marks for the question) Candidates should be aware of the marks allocated to different parts of each question and prioritise their timing accordingly for maximum time value. Some answers omitted important details such as omission of non- accidental injury (NAI) as a DDx in part a) and/or liaison with a paediatric centre. Some candidates also wrote detailed intubation specifics which did not attract marks as the stem outlined the intubation was already complete.
 

Discussion

This is almost identical to Question 10 from the first paper of 2015, except in 2015 it was still ok to instruct the exam candidates to "list, in broad terms", whereas these days we use more meaningful language. 

a) Systematically:

• There is acidaemia
• The CO2 is compensated well: the expected is (1.5 × 5 + 8) = 15.5; so the acidosis is mainly metabolic
• There is reasonable oxygenation, considering this is a room air gas
• The lactate is severely elevated
• The BSL is desperately low
• the LFTs are severely deranged

What could this mean?

• Septic shock (probably the most common)
• Non-accidental injury (trauma)
• Congenital cardiac disease
• Drugs, eg. paracetamol
• Congenital metabolic disorders

b) Assessment:

c) Management:

Approach to management, which is very generic:

1. Assess the need for intubation.
   - At this stage, senior assistance from somebody expert in paediatric critical care is required, as the intubation may be difficult.
2. Administer 100% oxygen.
3. Establish venous access.
   - Give a 20ml/kg bolus, FEAST be damned.
   - Inotropes and vasopressors if no longer fluid-responsive
   - Parameters guiding resuscitation (eg. lactate, haemodynamic variables, urine output) differ little from adult standards
4. Sedation and analgesia to support tolerance of invasive therapies
   (also decreases demands on the cardiac output)
5. Electrolyte correction
6. Maintenance fluid
   - A urinary catheter will also be required.
7. No protein in diet until metabolic screen is cleared
   - Maintain normoglycaemia with infusion of 10% dextrose of dextrose-rich maintenance fluid
8. Blood transfusion may not be warranted
9. Empiric antibiotics if sepsis is suspected, within 1 hour.
   - Cultures of blood and urine.
   - Consider antivirals if there is suspicion of viral meningitis or encephalitis