ACE the ACEM PEM MCQ's - references and resources listed further below
The Febrile Child – see guidelines website - tpched.org (fever)
1. With regards to febrile illness in previously well children in a fully vaccinated population, which one of the following is the best option:
- Temperatures of 40 degrees are likely to cause neurological damage.
- Temperature should be controlled with Ibuprofen in order to prevent febrile seizures.
- Conjugate pneumococcal vaccination programs have significantly reduced the incidence of occult bacteraemia.
- In well appearing children over the age of 2 months, a WCC should be requested.
2. An immunized previously well child of 2 years age presents with a fever of 39.8 degrees and no obvious focus of infection. The child appears well. Which one of the following is the best option:
- A poor response to Ibuprofen requires a full sepsis workup.
- The WCC is a good screening test for excluding occult bacteraemia.
- A positive blood culture in this setting is highly specific and sensitive.
- The risk of occult bacteraemia is less than 1%.
3. With regard to petechial rash in children,which of the following is the best option:
- The risk of meningococcal infection is 20%.
- A well appearing child with petechiae on the thorax does not need further investigation.
- A toxic appearing child with petechiae in the SVC distribution who has been vomiting does not need investigation.
- A well appearing child with petechiae in the SVC distribution who has been coughing does not need further investigation.
4. A 2-month-old child presents with high fever and no focus of infection. The child appears well and has normal vital signs. Which of the following is the best option:
- The Yale Observation Scale is accurate is assessing toxicity in this age group.
- E. Coli, Listeria Monocytogenes and group B Streptococcus are possible bacterial pathogens in this group.
- Lumbar puncture is indicated in this group.
- A CXR is likely to be abnormal in this setting.
Fever guidelines - QCH - tpched.org
The Royal Children’s Hospital Melbourne, Clinical Practice Guidelines. Febrile Child under 3 yr. Available online:
Nathan W. Mick. CHAPTER 165 – Pediatric Fever. In: Marx: Rosen's Emergency Medicine, 7th ed.Copyright © 2009 Mosby, An Imprint of Elsevier.
NICE clinical guideline 47: Issue date: May 2007 Feverish illness in children Assessment and initial management in children younger than 5 years. NICE
Developed by the National Collaborating Centre for Women’s and Children’s Health
RENAL DISEASE / GUT
Urinary Tract Infection
5. With regards to UTI in children 3-36 months of age who are previously well, which one of the following is the best option:
- To exclude urinary tract infection, a suprapubic aspirate, a urethral catheter sample or a bag-urine sample are all equally sensitive.
- If the urine dipstick is positive for either leucocyte esterase or nitrites, the probability of the child having a UTI is 18%.
- If the urine microscopy is positive for bacteria, the post-test probability of UTI is 80%.
- If the child is febrile and systemically unwell, the current recommended empiric therapy is intravenous ciprofloxacin.
Urinary tract infection in children. NICE Guideline. Urinary tract infection in children: diagnosis, treatment and long-term management.
Williams GB et al. Diagnosis and Management of urinary tract infection in children. Journal of Paediatrics and Child Health 48 (2012) 296-30.
6. A 3yo boy presents to ED with 4 days of vomiting,frequent loose watery stools and clinical evidence of dehydration. He fails an attempt at oral and nasogastric rehydration therapy – IV access is obtained and an intravenous infusion of Normal saline is planned. His laboratory findings are as follows:
WCC 10 x10 9/L (4-11x10 9/L)
Neutrophils 4 x10 9/L (2.5-7.5x109/L)
Hb 70g/L (130-160g/L)
Platelets 20 x109 /L (150-400 x 109/L)
Urea 14 umol/L (1-6umol/L)
Creatinine 200 umol/L (30-75umol/L)
Which of the following is the best option:
- This patient will benefit from IV Gentamycin
- Encephalopathy is a possible complication
- IV 'pulse' Methylprednisolone should be administered
- Antimotility agents have been shown to improve outcome
Marx: Rosen's Emergency Medicine, 7th ed. Genitourinary and renal tract disorders
http://emedicine.medscape.com/article/201181-overview - Parmar MS. Haemolytic-Uremic Syndrome. Available at: http://emedicine.medscape.com/article/201181-overview Accessed: 5/11/2018
7. A previously well 3yo boy has had a viral illness for 3 days.He presents to ED with fatigue and poor feeding. He appears dehydrated, his capillary refill time is 3 seconds, heart rate is 122 and he has not passed urine for 6 hours.
His biochemistry is as follows:
BSL 33 mmol/L
HCO3 10 mmol/L
K 5.9 mmol/L
Na 142 mmol/L
Which of the following is the correct option:
- A fluid bolus of 20ml/kg Normal Saline is indicated immediately
- Immediate commencement of an Insulin infusion is indicated.
- Potassium supplementation should commence after urine output is
- 0.45% Saline (Half Normal Saline) is an appropriate fluid for replacing
the deficit volume over 72 hours.
Australasian Paediatric Endocrine Group (2011). Clinical practice guidelines: Type 1 diabetes in children and adolescents.
RCH DKA guidelines
tpched.org guidelines - DKA
8. A 7-month-old child with no previous medical illness presents with a 3 day history of coryza and cough.
Vital signs include:
Saturations 94% and mild subcostal recession.
Examination reveals widespread inspiratory crepitations and expiratory wheeze with bilateral equal air entry. 2 other children in the family have ‘flu-like illness’. The child is breastfeeding comfortably in the mother’s arms. There is no family history of atopy or asthma.
Which of the following is the best option:
- An NPA is important in this clinical setting.
- Salbutamol is likely to be of benefit.
- A trial of hypertonic 3% saline may be beneficial.
- A period of observation is indicated.
tpched.org - bronchiolitis guidelines
Fitzgerald D A. Viral bronchiolitis for the clinician. Journal of Paediatrics & Child Health 2011;47(4):160-166.
Gadomski AM, Bhasale AL. Bronchodilators for bronchiolitis. Cochrane Database Syst. Rev. 2006; CD001266.
Seiden J A, Scarfone R J. Bronchiolitis: An Evidence-Based Approach to Management . Clin Ped Emerg Med 2009; 10:75-81.
9. An ex-premature (30week gestation) 4month-old boy has a 2-day history of cough and coryza with associated wheeze. He has had 3 previous episodes of bronchiolitis with documented minimal response to ventolin.
His vitals are:
saturations in R/A: 91%.
He has marked respiratory distress with recession and widespread inspiratory and expiratory wheeze and crepitations. Which of the following is the correct option:
- A trial of salbutamol is useful.
- A trial of hypertonic 3% saline may be useful.
- A trial of High flow nasal cannula humidified oxygen is indicated
- High Flow Humidified Nasal Cannula Oxygen provides a degree of positive end expiratory pressure approximating 15 cm of H2O.
10.With regard to asthma and wheeze in children, which of the following is the best option:
- In moderate cases of asthma, a CXR is useful for excluding pneumonia.
- An arterial blood gas is useful to assess fatigue in severe asthma.
- Preschool aged children with wheeze responsive to salbutamol do not benefit from oral steroids, unless they are moderate -to –severely unwell and require admission to hospital.
- Nebulised Magnesium Sulphate is not effective in the management of asthma.
tpched.org - asthma guidelines and wheeze guideline in children
Global Strategy for Asthma Management and Prevention in Children 5 Years and Younger 2018
GINA for children over 5
National Asthma Council of Australia Handbook website
Panickar J, Lakhanpaul M, Lambert PC, et al. Oral Prednisolone for Children with Virus-Triggered Wheezing. N Engl J Med 2009;36(4):329-338.
Cochrane Review: Magnesium sulfate for treating exacerbations of acute asthma in the emergency department. Rowe BH, Bretzlaff J, Bourdon C, Bota G, Blitz S, Camargo CA. Published Online: July 8, 2009
Cochrane Review: Inhaled magnesium sulfate in the treatment of acute asthma Blitz M, Blitz S, Beasely R, Diner B, Hughes R, Knopp JA, Rowe BH
Published Online: July 8, 2009