VAQ 3 Answer

VAQ 3 Answer
Paediatric pneumonia is a fairly common ED presentation, so knowing how to pick it and how to treat it is an essential FACEM skill.  This question throws a few curve-balls to increase the difficulty level, and make it a bit more interesting, so here we go…

a) Describe & Interpret the Xray
This is a fairly straightforward Xray, so you need to think a bit laterally about how you might make your answer stand out, or score an extra point or two, as everyone will pick that it’s pneumonia, but high level answers will have a better description, and relate the answer to the question.

With simple Xrays like this, it’s fine to use point form, but don’t forget to comment on the obvious:
Plain or contrast: Plain
Projection: AP
Position of patient: Erect
Part of body: Chest Xray
Then go for the money:
Right upper lobe dense alveolar opacification consistent with pneumonic consolidation. RUL collapse – elevation of horizontal fissure
? early alveolar changes right lower lobe/left lower lobe
No CCF/LVF
Cardiac silhouette normal
Bones/soft tissues normal

Do you find it hard to describe these sorts of changes on chest X-rays? Then have a look at our article on describing chest X-ray opacities.

Then put some relevant negatives:
Remember to relate them to the question:
Indiginous – at risk for MRSA/lung abscess/endocarditis, so:
No abscess/fluid levels
No effusion/empyema

Now you need to write a quick summary

Summary:
RUL pneumonia, possible early changes in RLL & LLL
(now relate this to question)
in clinically unwell indigenous child (this alters your DDx)
? Immunisations status
? TB Exposure
? Rheumatic heart disease/endocarditis risk
? Geographic location (see below)
DDx:
Now remember, common things are common
Viral pneumonia is still the commonest cause, so put this first, and mention some viruses:
eg Influenza A/B, H1N1 (especially as the child is sick) but go on to mention the bacterial causes in order of likelihood:
Bacterial:
Strept.pneumoniae – still the commonest bacterial cause
Atypical: Mycoplasma (Legionella/Chlamydia uncommon in kids)
Staph aureus/MRSA
TB – upper lobe involvement, indiginous
Melioid – cause of severe pneumonia in northern/tropical Australia in the wet season

b) Management = Treatment, Supportive Care, Disposition:
You must mention all 3 of these to answer the question properly, and you will lose marks if you run out of time and don’t mention disposition. So use them as subheadings.

Treatment:
Here is where you need to extrapolate from the clinical information and realize that this is a very sick child, with likely septic shock, respiratory distress, hypoxia and the potential to go downhill rapidly (with possible early multi-lobe changes on CxR). 

So an opening statement alluding to the fact that you recognize this helps show the examiners that you are “on to it”, and this child will be safe in your capable hands! Making the statement also helps you define what it is that you’re treating, and will give your answer more focus.

Knowing your paeds vital signs will help you categorise the severity in this case, and the vitals were put in specifically to test this knowledge.

Statements like…
“Lobar pneumonia in unwell child with hypoxia/septic shock”
Anticipate rapid deterioration
Urgent Paeds/ICU attendance required

…gives a nice synopsis, and direction to the rest of your answer.

NB always write “attendance” when talking about referrals.  You want them down in ED ASAP seeing the patient ASAP, right? Using words like “review” or “referral” implies a lesser sense of urgency, and sounds like you’re going to ask nicely “if they’d kindly come down and please see the patient sometime” vs “I need you down here now to see a very sick child”. Can you see the difference?

Manage in paeds resusc area:
Paeds resusc trolley to bedside
A/B:
High flow O2, aim sats > 94%

Now the high level answers will see that the child may need intubation, so a quick statement about specific gear you’ll need looks good:
2yo, so ETT tube size = (age/4) + 4 = 4.5mm
So write something like:

Potential intubation:
Get 4.5mm ETT out
Sux: 1-1.5mg/kg
Induction drug – we won’t go into this – you choose what you’d use, and write that drug with the mg/kg dose.
(Personally I’d use ketamine, but I don’t want to start any arguments…!). Caution with anything that will worsen the hypotentsion.

C:
this is tricky as without information about perfusion status, it’s hard to tell if the child is properly shocked. 
There is also current controversy about fluid boluses in septic children (see the excellent discussion of this over at EMPEM.org), but you still need to institute what you’d do in real life.  Don’t get bogged down in explanation, just say what you’d really do:

NB hypotensive tachycardic:
IV Access x 2, bloods/blood cultures x 2
N.Saline bolus 10-20ml/kg, x 2-3, then inotropes. Aim – normalize perfusion.

Antibiotics:
Again this depends on your presumptive diagnosis, but the Antibiotic Guidelines has a fairly detailed section on pneumonia in kids, we’ve done a quick summary of it here.

Anti-Pyretic:
Paracteamol: 15mg/kg 4-6/24
Ibuprofen: 10mg/kg 8/24

Supportive Care:
One way to think of this is: “Ongoing care of the critically unwell child”
OR
What will this child need to:
a) stay alive
b) be as comfortable as possible while in your ED?
c) Get out of your ED to a ward bed ASAP

Hi flow O2
Maintenance fluid
Seek & treat metabolic derangement: eg hypoglycaemia

AND:
For all paediatric questions, remember The “Fluffy Bunnies”: these are the “feel good” points that show you’re thinking about the whole situation. for example:

Involve parents
Child friendly environment
Indiginous Liason Officer/Social work referral

Another essential point is feedback to the GP.  This part of your answer can really define how you will work as a Consultant.  The arrogant approach would be to write something condescending, like “Inform GP of missed diagnosis of pneumonia”, which sounds critical and judgmental. If you wrote this, you need to go back and re-write this part of your answer.

Another approach would be to realize that the kid may have looked like a bronchiolitis with widespread creps (given the possible multi-lobe involvement on CxR), and may not have been as sick when in their rooms, and regardless of the eventual outcome, the GP absolutely did the right thing by sending the child in.

An even-handed answer might go something like: “Feedback to GP: Dx severe community acquired pneumonia, timely referral appreciated”. In one ED I work in now, every patient seen has a brief summary faxed to the GP on the day of attendance, and we are getting very positive feedback from the GP’s about this communication improvement.

Finally, Disposition:
Lets face it, this kid is sick, and too sick to go to a paediatric ward:
“Paeds ICU admission/transfer”
will suffice

So there you have it, a seemingly simple chest Xray, that you can actually say a helluva lot about.

TEACHING POINTS:
PAEDS VITAL SIGNS
You must know these to answer paediatric resuscitation questions accurately. Draw up a table, and post on your bathroom mirror, and read it every night while brushing your teeth, so you have it drilled in for the exam.

CxR INFILTRATES
See our article on interpreting chest x-ray opacities for more details on this often poorly done part of exam answers.

PAEDS FLUID RESUSC
This is a current area of debate in the literature and you need to know what the current controversies are. EMPEM.org have a great discussion of this, and you should read/listen to it.

PAEDS PNEUMONIA ANTIBIOTICS
Check out our summary of the Therapeutic Guidelines section on paeds pneumonia treatment.

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