Paeds SAQs · acute-care-resuscitation-and-toxicology
Altered conscious state in children — formative SAQs
Two MedVellum formative short-answer questions on the child with an altered conscious state: securing the airway and screening with AVPU and an age-adapted Glasgow Coma Scale, checking and correcting a dangerous low glucose immediately (DEFG), treating an ongoing convulsion at five minutes, recognising raised intracranial pressure, and keeping infection, toxin, metabolic and safeguarding causes open while escalating. The marks and timing support transparent self-assessment. They are not an official board format or pass standard.
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Target exams
SAQ 1 — A drowsy, feverish three-year-old
Question 1 — 10 formative marks; suggested time 15 minutes [2]
A three-year-old is brought in drowsy, responding to voice only, with a stiff neck, a purpuric rash and a temperature of 39.5 degrees. The heart rate is 140, the capillary refill is 3 seconds, and the blood pressure is low-normal. The team has been called. [10]
- State what you do in the first 60 seconds and why. (2 marks)
- Describe your disability assessment and the level of consciousness measure you record. (3 marks)
- State why you check the bedside glucose now and what a dangerous low would prompt. (2 marks)
- Describe the findings that would signal raised intracranial pressure or impending herniation, and your immediate response. (3 marks) [2]
Full-credit answer — SAQ 1
Reveal full-credit answer for SAQ 1
1. First 60 seconds
"This child is critically unwell with altered consciousness, shock and a purpuric rash. I call the senior paediatric and resuscitation teams now, name a leader, allocate roles, and bring age- and weight-appropriate equipment and monitoring. I secure the airway, give high-flow oxygen, support ventilation if ineffective, and treat shock while I begin the disability assessment. Stabilisation precedes diagnosis." [2]
2. Disability assessment
"I screen with AVPU: the child responds to Voice, which is below Alert, so I convert to an age-adapted Glasgow Coma Scale. I record best eye opening, best verbal response and best motor response separately, because the motor response and its trend are the most predictive components. I examine the pupils for size, equality and reactivity, assess posture and tone for lateralising signs, and time any seizure. I document the components and the total and reassess after each action." [1] [2]
3. Bedside glucose and DEFG
"I check a point-of-care glucose now because altered consciousness must always trigger DEFG: don't ever forget glucose. Hypoglycaemia can coexist with infection and is a reversible cause of brain injury. A dangerous low (around or below 3 mmol per litre in most children, using the local age-specific threshold) I correct immediately through the active age- and context-specific pathway, then recheck and investigate the cause. I confirm an unexpected result when feasible, but I never let confirmation delay treatment of a dangerous low." [4]
4. Raised intracranial pressure
"New pupillary asymmetry, dilation or unreactivity, abnormal decorticate or decerebrate posture, or a Cushing pattern of rising blood pressure with falling heart rate and irregular breathing signal raised intracranial pressure and impending herniation. My immediate response is to raise the head of the bed, keep the midline position, optimise oxygenation and control ventilation to avoid hypercapnia, because hypercapnia raises intracranial pressure, and arrange urgent neuroimaging and neurosurgical input. I do not perform a lumbar puncture until raised pressure is excluded and the child is stable." [9]
SAQ 2 — Convulsive status epilepticus in a school-age child
Question 2 — 10 formative marks; suggested time 15 minutes [6]
A six-year-old with known epilepsy has been convulsing continuously for eight minutes when the team arrives. Intravenous access is in place. After the seizure is controlled, the child remains obtunded and the glucose is normal. [6]
- State the definition that applies at five minutes and your first-line treatment principle. (2 marks)
- Outline second-line options, naming the trial evidence that informs the choice. (3 marks)
- State the bedside actions that must accompany drug treatment. (2 marks)
- The child has new-onset diabetes presenting in ketoacidosis and becomes increasingly obtunded. Explain the mechanism and the principle of management. (3 marks) [6]
Full-credit answer — SAQ 2
Reveal full-credit answer for SAQ 2
1. Status definition and first-line
"An ongoing convulsive seizure at five minutes is convulsive status epilepticus and activates first-line treatment; I do not wait for two doses to fail. My first-line is a benzodiazepine by the available route: intravenous lorazepam or diazepam, or buccal or intranasal midazolam when intravenous access is delayed. I reassess the airway and breathing between doses." [6]
2. Second-line and trial evidence
"If the seizure continues, I give a second-line agent per the local pathway. The ESETT trial found levetiracetam, fosphenytoin and valproate broadly comparable for established status across age groups, and the paediatric EcLiPSE trial favoured levetiracetam over phenytoin for safety. I therefore commonly use levetiracetam as second-line, with weight-appropriate doses from the local paediatric cognitive aid." [6] [7]
3. Bedside actions alongside drugs
"I protect and position the airway, give high-flow oxygen, and support ventilation if breathing is ineffective, because respiratory depression is the main risk of benzodiazepines. I check the bedside glucose now and correct a dangerous low immediately. I control carbon dioxide because hypercapnia raises intracranial pressure, and I prepare for a third-line pathway and critical-care input if the seizure continues." [4]
4. Cerebral oedema of diabetic ketoacidosis
"Increasing obtundness in diabetic ketoacidosis may signal cerebral oedema, a leading cause of death in children with the condition, in which rising intracranial pressure compresses the brain. The principle of management is prevention and cautious correction: a careful fluid and insulin strategy with close neurological monitoring, avoiding rapid biochemical correction. If pressure rises, I raise the head, control ventilation, arrange urgent neuroimaging, and treat the raised pressure through the neurocritical-care pathway." [9]
References
- [1]Hoffmann, Florian Comparison of the AVPU Scale and the Pediatric GCS in Prehospital Setting Prehospital emergency care, 2016.PMID 26954262
- [2]Kirschen, Michael P Inter-Rater Reliability Between Critical Care Nurses Performing a Pediatric Modification to the Glasgow Coma Scale Pediatric critical care medicine, 2019.PMID 30946292
- [4]Faustino, E Vent S Hypoglycemia in critically ill children Journal of diabetes science and technology, 2012.PMID 22401322
- [6]Chamberlain, James M Efficacy of levetiracetam, fosphenytoin, and valproate for established status epilepticus by age group (ESETT): a double-blind, responsive-adaptive, randomised controlled trial Lancet (London, England), 2020.PMID 32203691
- [7]Appleton, Richard E Levetiracetam as an alternative to phenytoin for second-line emergency treatment of children with convulsive status epilepticus: the EcLiPSE RCT Health technology assessment (Winchester, England), 2020.PMID 33190679
- [9]Dunger, David B Predicting cerebral edema during diabetic ketoacidosis The New England journal of medicine, 2001.PMID 11172161
- [10]Chávez-Bueno, Servio Bacterial meningitis in children Pediatric clinics of North America, 2005.PMID 15925663