CICM SAQ 2015.1 Q10

Question

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

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)

History:

  • 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
  • Injury
  • Cyanotic spells
  • Apnoeas
  • Family history including infant deaths, inborn errors of metabolism (IEMs), cardiac disease, degree of consanguinity

Examination:

  • General exam – trauma, rash Liver edge (failure, hepatitis) Murmurs
Femoral pulses

Investigations:

  • CXR
  • ECG
  • Ammonia
  • 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
Exams LITFL ACEM 700

Examination Library

CICM

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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