ICU AND YOU · Superquiz 63 — The school-age child

1A nine-year-old is admitted with asthma. Over an hour he becomes quieter, his wheeze diminishes and he stops resisting the mask. His oxygen saturation is unchanged. The most useful reading of this is that he is:

AImproving, since the wheeze is settling and he is tolerating treatment BTiring, and the loss of wheeze reflects falling air movement rather than resolution CAnxious, and the quiet phase is a normal response to being in hospital DAdequately treated, since the saturation has not fallen

Wheeze requires turbulent flow, and turbulent flow requires air moving. A chest that falls silent in a child who was audibly wheezing has usually lost air movement, not inflammation. The saturation is the least helpful number here — it is preserved by supplemental oxygen long after ventilation has begun to fail, and it is the carbon dioxide and the conscious state that move first. A child who stops fighting the mask has stopped being able to.

See Mind Map #34, second station, and Mnemonic #56 — C is for chest.

2A previously well nine-year-old with mycoplasma pneumonia has had a completely opacified left hemithorax for two days and has tolerated it. This afternoon the film is unchanged but he is drowsy and desaturating on a reservoir mask. The finding that best explains the change is:

AProgression of the pneumonia, which the film may lag behind BA pneumothorax on the opposite side CSomething unimaged — an occluded airway, an embolus, or both DSedation from his analgesia

When the deterioration outruns the radiograph, the radiograph is not the explanation. In the case this question is drawn from, the child had both a plastic bronchitis–like cast obstructing the left main bronchus and pulmonary emboli in the right pulmonary artery — so the one lung that was still ventilating was the one with clot in it. The same film on two days, with a very different child, is itself the finding.

The case is Journal Club #99; Kim et al, Archives of Pediatric Critical Care 2026. See also Mnemonic #56 — the first O.

3A ten-year-old is brought in with vomiting, lethargy and abdominal pain and is diagnosed with gastroenteritis. He looks mottled and tired. After a 20 mL/kg fluid bolus he is visibly worse, with increasing respiratory distress. The next step most likely to help is:

AA second fluid bolus, since he remains poorly perfused BAn antiemetic and reassessment in an hour CA bedside echocardiogram, chest film and troponin DBroad-spectrum antibiotics for presumed sepsis

Myocarditis at this age arrives dressed as gastroenteritis, and the fluid bolus that makes the child worse is the diagnostic moment rather than a treatment failure. Look for hepatomegaly, a gallop, a raised jugular venous pressure, a big heart on the film, and low voltages or ST change on the ECG. Antibiotics and antiemetics are not wrong in themselves; they are wrong as the next thing you do.

See Mind Map #34, the station headed “the one you cannot miss”, and Bare Bones #1, point nine.

4An eight-year-old boy is referred with six weeks of intermittent knee pain and a limp. His knee examination is entirely normal. The most important next step is to:

AArrange a knee MRI BExamine the hip CReassure and review in six weeks DCheck inflammatory markers for juvenile idiopathic arthritis

Referred pain is the trap of this age group. Perthes disease peaks between four and eight, and a slipped upper femoral epiphysis presents a little later — both classically as knee pain in a child who cannot localise reliably. A normal knee in a limping child should send your hands to the hip, and internal rotation is the movement most often lost first. Imaging the knee finds nothing and costs weeks.

PERTHES appears in Superpuzzle #51; see also Medical Students’ Place No. 4, tier two.

5A twelve-year-old presents after taking an unknown quantity of paracetamol four hours ago. She is well and her mother is with her throughout. The single most important thing to do that is easily missed is:

ATake the paracetamol concentration now, since four hours have passed BStart acetylcysteine empirically while awaiting the level CSpeak to her alone, and arrange a mental health assessment DGive activated charcoal

The level matters and four hours is the right time to take it, so that answer is not wrong — it is simply the thing nobody forgets. What gets missed is that a deliberate ingestion is a mental health presentation that happens to involve a drug. At twelve, one-on-one time is what the guidance recommends, and the account you get with a parent present is often not the whole one. Every deliberate ingestion needs an assessment, not just a concentration.

Doses and thresholds in Drugstore #2. On time alone, see Medical Students’ Place No. 4 — paediatric bodies recommend it from about eleven.

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