Neurogenic shock is a devastating consequence of spinal cord injury (SCI), also known as vasogenic shock. Injury to the spinal cord results in sudden loss of sympathetic tone, which leads to the autonomic instability that is manifested in hypotension, bradyarrhythmia, and temperature dysregulation. Spinal cord injury is not to be confused with spinal shock, which is a reversible reduction in sensory and motor function following spinal cord injury. Neurogenic shock is associated with cervical and high thoracic spine injury. Early identification and aggressive management are vital in neurogenic shock to prevent secondary spinal injury.

Low oxygen delivery in hypotension, hypoxia, oedema, intracranial hypertension or changes in cerebral blood flow should all be prevented to avoid secondary brain injury. There is no evidence to suggest that hypothermia prevents secondary brain injuries.

Internal abdominal bleeding is most probably the cause of the child’s shock, especially unresponsive to fluid boluses.

Excessive weight loss is generally indicative of suboptimal feeding, and infants with excessive weight loss are potentially dehydrated or at risk of dehydration.Jaundice associated with suboptimal breastfeeding– this is classically associated with weight loss >10% and a vicious cycle of sleepiness that in turn leads to further poor feeding. In the absence of clinical signs of dehydration, no evidence suggests that overhydration is helpful. If the infant is dehydrated, hydration should be given as clinically indicated. However, if the infant can tolerate oral feeding, oral hydration with a breast milk substitute is likely to be superior to intravenous hydration because it reduces enterohepatic circulation of bilirubin and helps wash bilirubin out of the bowel.

This clinical case is most probably due to intussusception complicated by sepsis. Regardless of the cause, the baby is sick and in a critical condition. The first thing to do is to preserve the vital signs and resuscitate with IV fluids. As sepsis is suspected, you should also start on triple antibiotics.

In an acute and severe asthma attack the child cannot complete sentences in one breath because they are too breathless. The O2 saturation is less than 92% and PEF is between 33-50% best or predicted. In children that are 2-5 years old, HR is more than 140 bpm and more than 125 bpm in those older than 5 years old. The RR in children between 2-5 years old is more than 40/min, and more than 30/min in those older than 5 years old.

Intussusception is one of the common causes of intestinal obstruction in children, resulting from the invagination or telescoping of one segment of the bowel into the other distal segment. It may induce bowel ischemia and necrosis, as well. It can occur as a complication of Meckel’s diverticulum. It usually occurs proximal to the ileocecal valve, and the most common presentation is ileocecal. Early signs and symptoms include cramping abdominal pain, nausea, vomiting, and pulling legs up to chest area. First line treatment includes resuscitation with IV fluids and nasogastric tube. It responds well to air-enema, which is also diagnostic.

Answer: Oculogyric crisisOculogyric crisis is an acute dystonic reaction of the ocular muscles characterized by bilateral dystonic elevation of visual gaze lasting from seconds to hours. This reaction is most commonly explained as an adverse reaction to drugs such as antiemetics, antipsychotics, antidepressants, antiepileptics, and antimalarials. Metoclopramide is a benzamide selective dopamine D2 receptor antagonist that is used as an antiemetic, with side effects that are seen frequently in children.1 The most common and most important side effects of metoclopramide are acute extrapyramidal symptoms, which require immediate treatment. Acute dystonic reactions occur as contractions of the muscles, opisthotonos, torticollis, dysarthria, trismus, and oculogyric crisis.

An epidural hematoma occurs when there is bleeding between the dura mater (a tough fibrous layer of tissue between the brain and skull) and the skull bone. These occur when arteries are torn as a result of a blow to the head, and injury in the temple area is a common cause. Although the pattern of a lucid interval followed by later neurological symptoms is characteristic, only a minority of patients display this pattern of symptoms. Reported death rates from epidural hematoma vary widely, ranging from 5% to over 40%. Middle meningeal artery is frequently involved in such incidents.

Any 2-month-old child presenting with any of the above signs, should be assessed and have a history taken and physical examination made before discharge. As these may all be signs and symptoms for a condition requiring hospitalisation.

The patient is suffering from an anaphylactic reaction to the cashew nut he consumed.Anaphylaxis:Anaphylaxis is an acute, rapidly progressing, potentially life-threatening IgE mediated Type I hypersensitivity reaction.It involves the release of mediators from mast cells, basophils and inflammatory cells. It is characterised by oedematous swelling of the airway mucosa giving rise to dyspnoea and respiratory distress.The most common cause of anaphylaxis in children is a food allergy.Risk factors for death in patients with anaphylaxis include asthma, age 11+, peanut allergy, and delay in adrenaline administration.Management of anaphylaxis includes:- Resuscitation – ABCD- Remove the allergen- IM adrenaline is given at ten microgram/kg or Nebulised adrenaline 5ml 1:1,000- IV Hydrocortisone is given at 4mg/kg- pro re nata IV fluid support. – Followed by observation.

Foreign body aspiration (FBA) commonly occurs in children aged 1–3 years. FBA typically presents with sudden onset of coughing and choking, followed by stridor and dyspnoea. Obstruction of the larynx or trachea is a potentially life-threatening situation that causes severe respiratory distress, cyanosis, and suffocation. Most commonly, the foreign body (FB) becomes lodged in the main and intermediate bronchi| approx. 60% of FB are located in the right main bronchus due to the more vertical orientation compared to the left main bronchus. Reduced breath sounds on the one side only would not be explained by a tracheal obstruction as it would cause reduced breath sounds bilaterally and a more severe clinical picture.

Intussusception is the invagination of one segment of the intestine within a more distal segment. It presents with vomiting, abdominal pain, and a palpable abdominal mass.Intussusception usually affects infants between 6-18 months old. Boys are affected twice as often as girls

A periosteal reaction can result from a large number of causes, including injury and chronic irritation due to a medical condition such as hypertrophic osteopathy, bone healing in response to fracture, chronic stress injuries, subperiosteal hematomas, osteomyelitis, and cancer of the bone. This history is consistent with a toddler’s fracture. Here a minor, usually twisting, injury results in a spiral fracture of the tibia. An initial X-ray may appear normal as the periosteum holds the bone together preventing displacement. Ten days later a repeat X-ray will show callous formation and confirm the diagnosis.

This clinical presentation is highly suggestive of choking. According to the BLS algorithm, the next step in managing a case of choking in a conscious child with an ineffective cough is five back blows.Other options:- Adrenaline intramuscularly: The history is similar to anaphylaxis, but the absence of a rash or oedema and the acute onset make choking more likely in this situation. Thus, adrenaline will not be of use in this patient.- CPR at a ratio of 15:2: Since the child is conscious, it is not advised. If the child were unconscious, you would commence basic life support.- Five abdominal thrusts: In the given scenario, the child is an infant. Abdominal thrusts are avoided in infants due to the risk of intra-abdominal injury.

NICE guidelines suggest that when a child’s single risk factor is 2 vomits, the child should be observed for 4 hours from the time of the injury, instead of having a CT.

Based on the findings presented, the sign elicited is Rovsing’s sign.Rovsing’s sign:It is a sign suggestive of appendicitis. A positive sign is determined when palpation in the left lower quadrant of a patient’s abdomen causes pain in the right lower quadrant.Other options:- Murphy’s sign is positive in gallbladder inflammation. With the upper border of the examiner’s hand in the right upper quadrant of the abdomen under the rib cage, the patient is asked to inhale. Inhalation causes the gallbladder to descend, which catches on the fingers, causing pain.- Cullen’s sign is suggestive of ectopic pregnancy or acute pancreatitis and describes the bruising around the umbilicus.- Tinel’s sign is positive in those with carpal tunnel syndrome. The examiner’s fingers tap the median nerve over the flexor retinaculum, which causes paraesthesia over the distribution of the median nerve.- Battles’ sign describes bruising behind the ear, suggesting a basal skull fracture of the posterior cranial fossa.

Bowel sounds in the chest and curved NG tube are suggestive of a diaphragm rupture, which has caused herniation of bowel into the thoracic cavity through the defect in the diaphragm.

Possible complications include:- Hearing loss (which may be partial or total)- problems with memory and concentration- problems with coordination and balance- learning difficulties (which may be temporary or permanent)- epilepsy (Seizures)- cerebral palsy- speech problems- vision loss (which may be partial or total)As hearing loss is the most common complication of meningitis people recovering from the condition are usually given a hearing test to assess their hearing.

The symptoms of excessive salivation and diarrhoea, along with hypotension, bradycardia, and bronchoconstriction, indicates excess parasympathetic nervous system activity. The patient is showing features of acetylcholine toxicity. Pesticides typically contain organophosphates that are potent inhibitors of acetylcholinesterase. This enzyme is responsible for the metabolism of acetylcholine. Acetylcholine is the neurotransmitter used in the neuromuscular junction, as well as at select points in the autonomic nervous system. The autonomic acetylcholine receptors can be nicotinic (more sensitive to nicotine) or muscarinic (more sensitive to muscarine). The most relevant receptors in this scenario are the muscarinic receptors as the majority are located in the parasympathetic nervous system smooth muscle, exocrine glands, and cardiac conduction system.Other options:- Accordingly, to cause the symptoms described, there must be an abundance of acetylcholine which stimulates the muscarinic receptors to enhance the parasympathetic effects. Therefore the reduction in the formation of acetylcholine option must be incorrect as this would produce the opposite effect. – Noradrenaline is the primary neurotransmitter in the sympathetic nervous system, and both answer options relating to noradrenaline would increase the neurotransmitter and potentiate the sympathetic nervous system effects, making them incorrect.Features can predict the accumulation of acetylcholine (mnemonic = SLUD):- Salivation- Lacrimation- Urination- Defecation/diarrhoeaCardiovascular symptoms include hypotension and bradycardia. The patient can show associated small pupils and muscle fasciculationManagement:- Atropine- The role of pralidoxime is still unclear – meta-analyses to date have failed to show any clear benefit.