1. South Thames Retrieval Service STRS Quiz No 1 Welcome 10 Question Quiz www.strs.nhs.uk

2. South Thames Retrieval Service STRS Quiz No 1 Question 1 This child was diagnosed with acute asthma and intubated for hypoxia in his local hospital. What urgent interventions must occur?

3. South Thames Retrieval Service STRS Quiz No 1 Answer: Bilateral chest drains for pneumothorax Complications post intubation include air leaks. Under positive pressure ventilation even the smallest pneumothorax may increase in size and tamponade. Therefore these require urgent drainage prior to transfer. Must differentiate from extreme hyperinflation before intervention

4. South Thames Retrieval Service STRS Quiz No 1 Question 2 This 6 month old baby with Down’s syndrome was admitted with bronchiolitis. Describe the two most striking abnormalities?

5. South Thames Retrieval Service STRS Quiz No 1 Answer: Cardiomegaly and hyperinflation This child had an atrioventricular septal defect (AVSD) causing a large left to right shunt and symptoms of heart failure. This child’s hyperinflation is significant and is most commonly due to bronchiolitis. Bronchoscopy however, showed marked compression of both bronchi from massive pulmonary arteries as a consequence of the AVSD. This improved after surgical closure of the AVSD

6. South Thames Retrieval Service STRS Quiz No 1 Question 3 This 6 week old baby presented with respiratory distress requiring intubation. These x-rays were taken 1 hour apart. What is the likely cause of the obvious abnormality on the1st x-ray?

7. South Thames Retrieval Service STRS Quiz No 1 Answer: Bowel in the chest (diaphragmatic hernia) Each winter a number of patients are admitted to the PICU with bronchiolitis and/or another important diagnosis. Cardiovascular abnormalities are most commonly discovered but also neuromuscular and airway abnormalities. This baby has a congenital diaphragmatic hernia. Increased positive pressure ventilation pushed the bowel down between x-rays, causing confusion over the diagnosis.

8. South Thames Retrieval Service STRS Quiz No 1 Question 4 This 10 year old was pulled from a swimming pool and recovered consciousness at the scene. In your hospital he is 94% saturated in 4 l/minute face mask oxygen. This x-ray was taken at 4 hours post submersion. What do you do?

9. South Thames Retrieval Service STRS Quiz No 1 Answer: Intubation and ventilation This child has a significant oxygen requirement and the x-ray shows gross pulmonary oedema. His respiratory distress and hypoxia is likely to get worse over the next 12-24 hours.

10. South Thames Retrieval Service STRS Quiz No 1 Question 5 This 2 year old with cyanotic heart disease presented with extremely unwell at her local hospital with fluid refractory shock. Two days later her abdomen became grossly dilated. What is the diagnosis?

11. South Thames Retrieval Service STRS Quiz No 1 Answer: necrotising enterocolitis Despite intensive resuscitation the bowel has suffered a severe hypoxic ischaemic injury. The bowel is dilated with thickened walls and obvious extensive intramural gas. Perforation is very likely to ensue which will require surgery

12. South Thames Retrieval Service STRS Quiz No 1 Question 6 This term baby age 6 days presented blue and shocked to her local hospital. Ventilation was extremely difficult and the child was referred fro ECMO. What cardiac diagnosis must be excluded?

13. South Thames Retrieval Service STRS Quiz No 1 Answer: Obstructed total anomalous venous pulmonary venous drainage (TAPVD) TAPVD is uncommon and rarely diagnosed antenatally. It may present very early if the venous drainage is obstructed and may appear clinically like an obstructed left sided lesion or severe sepsis. Echo diagnosis can be difficult and therefore must be done by a paediatric cardiologist. The x-ray shown is classic of obstructed TAPVD with a small heart and pulmonary oedema

14. South Thames Retrieval Service STRS Quiz No 1 Question 7 This 6 week old baby had increasing respiratory distress 2 weeks after confirmed RSV infection requiring intubation and ventilation. Describe two major abnormalities?

15. South Thames Retrieval Service STRS Quiz No 1 Answer: Hyperinflation and right sided aortic arch It is unusually for bronchiolitis to run such a protracted course unless something else is going on. The x-ray show gross hyperinflation and no evidence of secondary infection On questioning the mother, this baby had biphasic stridor from birth which strongly suggests a structural airway abnormality Bronchoscopy confirmed tracheal compression and CT chest confirmed a vascular ring secondary to a double aortic arch-hence the right sided aortic arch

16. South Thames Retrieval Service STRS Quiz No 1 Question 8 A 2 year old girl presents with a persistent cough for 3 weeks. There is no history of respiratory tract symptoms. She does have eczema and a strong family history of asthma. What is the most striking feature of her x-ray and possible diagnosis?

17. South Thames Retrieval Service STRS Quiz No 1 Answer: Right sided hyperinflation (suspected foreign body aspiration) This child had a unilateral wheeze. On further investigation with rigid bronchoscopy, a piece of bath sponge was found in her right main bronchus. Tracheal foreign bodies commonly wedge in the right main bronchus compared to the left side due to its less acute angle at the carinal bifurcation.

18. South Thames Retrieval Service STRS Quiz No 1 Question 9 This baby has acute abdominal distension. What concerning abnormality appears the abdominal x-ray?

19. South Thames Retrieval Service STRS Quiz No 1 Answer: Free gas below the diaphragm extending around the liver This baby has bowel perforation and needs urgent surgical review. A right sided up lateral decubitus film would show the free gas better.

20. South Thames Retrieval Service STRS Quiz No 1 Question 10 A 3 year old girl presents with a focal seizure. She is slow to regain full consciousness. What is the probable cause of her seizure given the CT head findings?

21. South Thames Retrieval Service STRS Quiz No 1 Answer: Right middle cerebral artery infarct Intracerebral vascular events are not common. A focal seizure must prompt some form of imaging, initially to rule out space occupying lesions of any kind. An infarct such as this could be primarily thrombotic or embolic and would need expert input from paediatric neurologists to determine the best course of management. Swelling around the infarct may cause mass effect and require surgical intervention.

22. South Thames Retrieval Service STRS Quiz No 1 End of quiz