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.

Diazepam given rectally may be helpful in treating prolonged convulsions outside and within hospital when intravenous injection is not possible. A rectal dose of 0.5 mg/kg (maximum 10 mg) of injectable diazepam, undiluted or diluted with a 50% propylene glycol solution, can stop seizures in up to 80% of children. There are few adverse reactions. Seizures in children usually cease spontaneously within 5-10 minutes and are rarely associated with significant sequelae. The chance of a seizure stopping spontaneously decreases significantly after 10-15 minutes. Similarly, the efficacy of anticonvulsant medication decreases after 10-15 minutes of fitting and the risk of adverse effects increases. Convulsive seizures lasting longer than 30 minutes constitute status epilepticus and may be complicated by cardio respiratory depression and brain injury. Diazepam or clonazepam, given intravenously, is generally the drug of choice for the emergency treatment of convulsive status epilepticus. Intravenous diazepam may be difficult to administer to the young convulsing child and, because of the need for intravenous access, is not ideal for rapid treatment in the community by non-medical carers.

Adrenaline (epinephrine) narrows blood vessels and opens airways in the lungs. These effects can reverse severe low blood pressure, wheezing, severe skin itching, hives, and other symptoms of an allergic reaction.

McBurney’s point is found 2/3rds of the way along an imaginary line that runs from the umbilicus to the anterior superior iliac spine on the right-hand side. On examination, features of generalised peritonitis can be observed if the appendix has perforated.Retrocecal appendicitis may have relatively fewer signs.Digital rectal examination may reveal boggy sensation if a pelvic abscess is present.Diagnosis is typically based on raised inflammatory markers coupled with compatible history, and examination findings.Ultrasound is useful in females where pelvic organ pathology can be a close differential diagnosis. Although it is not always possible to visualise the appendix on ultrasound, the presence of free fluid (always pathological in males) should raise suspicion. Ultrasound examination can also show evidence of luminal obstruction and thickening of the appendix.Management: Definitive management of appendicitis and appendicular perforation is appendicectomy which can be performed via either an open or laparoscopic approach.Simultaneous administration of metronidazole reduces wound infection rates. Patients with perforated appendicitis require copious abdominal lavage. Patients without peritonitis who have an appendix mass should receive broad-spectrum antibiotics and consideration given to performing an interval appendicectomy.

Age (years) Respiratory rate (per minute) Heart rate (per minute) Systolic blood pressure<1 30-40 110-160 70-901-2 25-35 100-150 80-952-5 25-30 95-140 80-1005-12 20-25 80-120 90-110>12 15-20 60-100 100-120Adapted from Advanced Paediatric Life Support Manual

Findings described are suggestive of Waterhouse-Friderichsen syndrome which develops secondary to meningococcaemia. The reported incidence of Addison’s disease is 4 in 100,000. It affects both sexes equally and is seen in all age groups. It tends to show clinical symptoms at the time of metabolic stress or trauma. The symptoms are precipitated by acute infections, trauma, surgery or sodium loss due to excessive perspiration.

Among the options provided, bradycardia is a feature of raised intracranial pressure.The features of raised intracranial pressure include relative bradycardia and hypertension, altered consciousness, focal neurology and seizures.All other options are signs of shock but not raised intracranial pressure.

Cushing reflex is a physiological nervous system response to increased intracranial pressure (ICP) that results in Cushing’s triad of increased blood pressure, irregular breathing, and bradycardia. It is usually seen in the terminal stages of acute head injury and may indicate imminent brain herniation. It can also be seen after the intravenous administration of epinephrine and similar drugs.

In children, food-induced anaphylaxis is the most common trigger and accounts for 37 %–85 % of cases, whereas insect bites/stings account for 5 %–13 % and medications account for 5 %–12 % Despite differences between studies, food allergy is clearly the most common cause of anaphylaxis in children

The clinical scenario provided is highly suggestive of third-degree burns (or full-thickness burns) that may have invaded the deeper levels up to dermis, evident from the insensate nature of the lesion.Degrees of Burns:- First degree burns are superficial second-degree burns.- Second-degree burns are just deeper than that of first-degree burns but vary enormously in other properties.- Third-degree burns are full-thickness burns which are leathery in consistency, and insensate. These burns do not heal on their own. The sensory neurons present in the skin at the deeper levels are destroyed completely and hence provide a paradoxical lack of pain.- Fourth-degree burns involving the subcutaneous tissues, tendons, and bones are very difficult to manage.Assessment of the extent of the burns for the treatment employs specialized charts, such as Lund and Browder charts and Wallace rule of nines.The Lund and Browder chart is, however, considered the most accurate.Wallace’s Rule of Nines can be used for children >16 years: – Head + neck = 9%- Each arm = 9%- Each anterior part of leg = 9%- Each posterior part of leg = 9%- Anterior chest = 9%- Posterior chest = 9%- Anterior abdomen = 9%- Posterior abdomen = 9%

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

All of the presenting features of the child are suggestive raised intracranial pressure. Thus, urgent treatment with 20% Mannitol can improve the child’s condition. Mannitol is an osmotic diuretic that is used in the treatment of raised intracranial pressure. It should be avoided in hypovolaemia because of its diuretic effects. Other options:- Head up at 15°: Keeping the head up at 20° in the midline will aid venous drainage. – Maintain CO2 at 5 kPa: If there is an acute rise in intracranial pressure, then lowering the CO2 to 4–4.5 kPa as a temporary measure can be beneficial. However, this must be only short-lived since it causes vasoconstriction and can impair cerebral blood flow. – 10% glucose bolus: Maintaining normoglycemia in traumatic brain injury is important. – 0.9% saline infusion: Hypertonic saline infusion of 3% can reduce intracranial pressure. 0.9% saline as a bolus could be beneficial if there were hypotension.

Pupils are dilated in patients with amitriptyline overdose.Tricyclic antidepressants have a narrow therapeutic index, and thus, small doses can be fatal in children. Deaths from tricyclics are more common than other antidepressants. Bimodal incidence with toddlers (accidental) and teenagers (deliberate) most commonly affected.Symptoms: They occur within 6 hours of ingestion.- Nausea, vomiting, and headache- Elevated body temperature- Agitation, sleepiness, confusion, coma- Dry mouth, blurred vision, urinary retention (anticholinergic)- Dilated pupils- Seizures- Hypotension, tachycardia, conduction disorders, and cardiac arrest- Respiratory depressionManagement:Treatment focuses on supportive care. This includes airway protection, ventilation and oxygenation, intravenous fluids, and cardiac monitoring.Other measures include:- Activated charcoal within 2 hours- Hypotension is treated with IV fluids and adrenaline- Cardiac monitoring- Sodium bicarbonate in acidosis or if there are wide QRS complex (> 100 ms)- Convulsions may require diazepam or lorazepam.

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.

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.

Biliary atresia is a rare condition that causes obstructive jaundice. Without surgical treatment, e.g. Roux-en-Y, Kasai procedure or liver transplantation, death is likely by 2 years of age. The aetiology of biliary atresia is unknown. Theories suggest a multitude of etiological and causative factors that are both genetic and acquired.The other conditions do not cause a conjugated hyperbilirubinemia.

This is a case of an anaphylactic reaction that requires immediate intervention. IM adrenaline dose for 6-12 year old children is 300 micrograms IM.

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.

People aged 16 or over are entitled to consent to their own treatment. This can only be overruled in exceptional circumstances. Children under the age of 16 can consent to their own treatment if they’re believed to have enough intelligence, competence and understanding to fully appreciate what’s involved in their treatment. This is known as being Gillick competent.Otherwise, someone with parental responsibility can consent for them.This could be:the child’s mother or fatherthe child’s legally appointed guardiana person with a residence order concerning the childa local authority designated to care for the childa local authority or person with an emergency protection order for the child.Giving the blood transfusion is therefore both clinically and ethically the right course of action.Jehovah’s Witnesses frequently carry a signed and witnessed Advance Decision Document listing the blood products and autologous procedures that are, or are not, acceptable to them It is appropriate to have a frank, confidential discussion with the patient about the potential risks of their decision and the possible alternatives to transfusion, but the freely expressed wish of a competent adult must always be respected.

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.

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.

The boy has an increased BMI which implies he is overweight. Possible trauma to his pancreas might have led to a diabetes-like condition, induced by damage to the beta cells. Fasting blood glucose should be measured as a follow-up strategy to see if the damage is reversible or irreversible and to conclude if the glycosuria is related to his metabolic profile or to his accident.

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.