A two-week-old baby is brought to your general ICU in extremis pending transfer to a paediatric centre. Born at term, she had been discharged well on day 5 of life. For three days she has had progressive tachypnoea, lethargy and failure to feed, and has now presented after a seizure. She has been intubated in the Emergency Department.
Blood tests taken on air prior to intubation show:
- a) List, in broad terms, the key differential diagnoses for this presentation. (20% marks)
- b) Outline your approach to differentiating between these diagnoses. (30% marks)
- c) Outline principles of early management pending transfer. (50% marks)
Answer and interpretation
a) List, in broad terms, the key differential diagnoses for this presentation. (20% marks)
- Inborn error of metabolism
- Sepsis (viral likely)
- Cardiac disease- especially duct dependent disease
- Trauma (NAI)
- Drugs / Toxins
b) Outline your approach to differentiating between these diagnoses. (30% marks)
- Exposure to ill persons including siblings and parents.
- “Colds”, chicken pox and maternal herpes should be specifically solicited.
- Maternal Group B Strep swab should be reviewed
- Cyanotic spells
- Family history including infant deaths, inborn errors of metabolism (IEMs), cardiac disease, degree of consanguinity
- General exam – trauma, rash Liver edge (failure, hepatitis) Murmurs Femoral pulses
- Urine amino and organic acids (if can’t be processed, take while acidotic and store)
- Cultures if not done
- CMV, HSV PCR
- Consider skeletal survey if any suggestion of injury Cranial ultrasound (widely available)
- Echo if available
c) Outline principles of early management pending transfer. (50% marks)
- Ongoing liaison with receiving centre.
- Restore then maintain BSL using 10% Glucose (2.5-5ml/kg 10% glucose bolus then 6mg/kg/min infusion.)
- Restore intravascular volume (even post FEAST fluid bolus reasonable)
- Direct therapy if specific pathology found- e.g. alprostadil infusion if evidence of duct dependent cardiac disease
- Empiric antibiotics
- Empiric antiviral given results above (acyclovir or ganciclovir)
- Nil protein intake till initial metabolic results in- maintain on glucose as above
- Lung protective ventilation
- General ICU housekeeping.
- Pass rate: 34%
- Highest mark: 7.0