1. The child has relapsed acute lymphoblastic leukemia (ALL) and underwent reinduction chemotherapy. 2. Following the first cycle of reinduction therapy, laboratory tests show: a white blood cell count of 21,900, uric acid level of 9, and LDH level elevated. 3. These laboratory abnormalities indicate tumor lysis syndrome, a potential complication of effective chemotherapy in patients with high tumor burden. Urgent intervention is needed to prevent renal failure and other complications.

1. Pediatric Emergencies - OSCE
PICU B.J.Wadia Hospital for Children
Dr Parmanand Andankar
Dr Hiren Mehta
Dr Bhushan katira

2. OSCE 1
• 3 month female child is admitted with history
of recurrent episodes of respiratory distress
• O/E: Resp rate- 70/min, suprasternal and
subcostal retractions, b/l reduced air entry,
subcostal retractions, b/l reduced air entry,
inspiratory and expiratory rhonchi
• CXR- b/l hyperinflation

4. 1. Give your clinical diagnosis
2. What is the CT Scan suggestive of?
3. Enumerate initial steps of management
4. Definitive treatment
4. Definitive treatment

5. • ANSWERS:
1. Intrathoracic upper airway obstruction
2. CT – vascular sling around the trachea
causing extrinsic compression
causing extrinsic compression
3. Position, sedation, oxygen, intubation under
anaesthesia with the smallest ET available
4. Definitive cardiovascular surgery to remove
the sling.

6. OSCE 2
Identify the numbers

7. Supratentorial
herniation
1. Uncal
2. Central (transtentorial)
3. Cingulate (subfalcine)
4. Transcalvarial
Infratentorial herniation
Infratentorial herniation
5. Upward (upward
cerebellar or upward
transtentorial)
6. Tonsillar (downward
cerebellar)

8. OSCE 3
• A 3 years old male child is admitted in PICU with status
epilepticus. He is on ventilator and on midazolam infusion at
10 mcg/kg/min since last 3 days. He is seizure free and
maintaining good blood pressures but is still very obtunded.
• ABG shows a Po2 120 mm Hg, Pco2 18 mm Hg, and pH 7.1.
• ABG shows a Po2 120 mm Hg, Pco2 18 mm Hg, and pH 7.1.
• Laboratory tests reveal the following: Na-138 mEq/L, K- 4.0
mEq/L, CL- 96 mEq/L, HCO3- 10 mEq/L, glucose 80 mg/dL (4.4
mmol/L), and BUN- 4 mg/dL (1.1 mmol/L).
• Serum osmolality is 346 mOsm/kg.

9. • Questions:
1. What do you think is the metabolic disorder
in this child?
2. What is the cause of this metabolic disorder?
2. What is the cause of this metabolic disorder?
3. What is the supporting evidence for the
diagnosis
4. Mention other causes of similar metabolic
disorder?

10. • Answers
1. Metabolic disorder- High anion gap metabolic
acidosis
2. Propylene Glycol – used as the vehicle for
midazolam..
2. Propylene Glycol – used as the vehicle for
midazolam..
3. High osmolal gap (346 – 282 = 64)
4. Other differentials – methanol, ethylene glycol,
salicylate toxicity, other drugs which contain
Propylene Glycol – phenytoin, melphalan

11. • State which of the following situations would be
expected to lower a patient's arterial pO2. There
may be none, one, or more than one correct
answer.
a) Anemia
a) Anemia
b) Carbon monoxide poisoning
c) An abnormal hemoglobin that holds oxygen with
half the affinity of normal hemoglobin
d) An abnormal hemoglobin that holds oxygen with
twice the affinity of normal hemoglobin
e) Lung disease with intra-pulmonary shunting.

12. • Only e) lung disease. . .
• a) affects only content, not oxygen saturation
or PO2.
• b) through d) affect only oxygen saturation
• b) through d) affect only oxygen saturation
and content, not PO2.

13. Which patient is more hypoxemic, and
why?
• Patient A:
pH 7.48
PaCO2 34 mm Hg
PaO2 85 mm Hg
• Patient B:
pH 7.32
PaCO2 74 mm Hg
PaO255 mm Hg
PaO2 85 mm Hg
SaO2 95%
Hemoglobin 7 gm%
PaO255 mm Hg
SaO2 85%
Hemoglobin 15 gm%

14. • The body needs oxygen molecules, so oxygen
content takes precedence over partial
pressure in determining degree of hypoxemia.
In this problem the amount of oxygen
In this problem the amount of oxygen
molecules contributed by the dissolved
fraction is negligible and will not affect the
answer. Also, the PaCO2 and pH are not
needed to answer the question.

15. • Patient A: Arterial oxygen content = .95 x 7 x
1.34 = 8.9 ml O2/dl
• Patient B: Arterial oxygen content = .85 x 15 x
1.34 = 17.1 ml O /dl
1.34 = 17.1 ml O2/dl
• Patient A, with the higher PaO2 but the lower
hemoglobin content, is more hypoxemic

16. OSCE 4
• 5 years old male child known case of Down
syndrome presents with fever, cough and
breathlessness
• He has severe tachypnoea, raised JVP and
• He has severe tachypnoea, raised JVP and
muffled heart sounds

17. 1) Identify the chest xray
2) What is the acute emergency therapy? Mention the
technique
3) Give the indications for the same?

18. • Answers :
1. Chest xray s/o massive pericardial effusion with
right mid zone consolidation
2. Acute emergency therapy – pericardiocentesis
2. Acute emergency therapy – pericardiocentesis
3. Procedure
4. Indications for pericardiocentesis
a) clinical features of cardiac tamponade or
obstructive cardiogenic shock.
b) 2 D echo s/o diastolic buckling of RA or RV

19. PROCEDURE
• SITE
ANTERIOR-fifth ICS outside apex but inside
outer edge of dullness
EPIGASTRIC(PREFERRED) – between
EPIGASTRIC(PREFERRED) – between
ensiform cartilage and left costal margin
POSTERIOR- near inferior angle of scapula
STERNAL-fourth left ICS lateral to sternum

22. OSCE 5
1) Identify the rhythm
2) Mention the ECG characteristics of this condition
3) Write causes of this condition
4) Briefly discuss the treatment

23. • Answers :
1. Ventricular tachycardia
2. ECG characteristics: a) ventricular rate - >120/min and regular
b) QRS Complex – Wide (>0.08 seconds)
c) P waves – not identifiable, if present not related to QRS (AV
Dissociation)
d) T waves – opposite in polarity from QRS
3. Causes – congenital heart disease, post cardiac surgery,
3. Causes – congenital heart disease, post cardiac surgery,
myocarditis/cardiomyopathy, long QT syndrome, electrolyte
disturbances (hypocalcemia, hyperkalemia, hypomagnesemia),
drug toxicity
4. Treatment – with pulses: synchronized cardioversion, adenosine,
amiodarone or procainamide
- pulseless: defibrillation and CPR.
treat possible contributing factors 6Hs and 5Ts.

24. OSCE 6
• 12 year old female presents
after head injury, GCS 6, HR
60/MIN, Irregular
respiration, normotensive
with CT scan shown –
• Identify the CT scan
• Identify the CT scan
• Immediate management
• Further management
• What is the most common
electrolyte disturbance
associated with above
patient

25. • Answers :
1. CT scan s/o – left subdural hematoma with
midline shift
2. Take care of ABC, intubation and
hyperventilation
3. Neurosurgical evacuation of the subdural
hematoma is the definitive therapy. Maintain
hematoma is the definitive therapy. Maintain
mean arterial pressure to maintain cerebral
perfusion pressure (CPP = MAP – ICP).
Decongestive measures such as mannitol or 3%
NaCl.
4. Hyponatremia

26. OSCE 7
• 6 year old female child comes with history of
progressive weight loss over the last several months,
polydipsia and oral thrush. Now she has complaints
of severe breathlessness, abdominal pain and
vomiting.
vomiting.
• O/E – dehydrated, acidotic, urine sugar and ketones
are 4+

27. • Questions
1. What is your diagnosis?
2. What is the therapy in the first hour
3. After 8 hours of treatment her k+ report
comes as 2.8. What actions will you take
4. What are her risk factors for developing
4. What are her risk factors for developing
cerebral edema
5. What are the mortality predictors in this
condition

28. • Answers:
1. Diabetic ketoacidosis
2. First hour- Normal saline bolus 10 ml/kg
3. Add KCL in the IV fluids to 60 mEq/L, reduce
insulin to 0.5 to 0.8 u/Kg/hour
4. Younger age(<3 years), new onset, and longer
duration of symptoms, lower PCO2, severe
duration of symptoms, lower PCO2, severe
acidosis (pH<7.1), increased BUN, use of
bicarbonate, greater volumes of rehydration
fluids (in excess of 4 L/m2/24 hrs) and failure of
serum Na to rise with treatment
5. Cerebral edema and hypokalemia

29. OSCE 8
• 2 year old brought to the ED by her mother
that child is irritable and vomiting . She has
ingested 2/3 bottle of Calpol drops
• Denies other medication use
• The ingestion occurred 4 hours before arrival
• The ingestion occurred 4 hours before arrival
in ED
• During examination she is anxious,
diaphoretic, and has one more vomiting
• Physical examination results are unremarkable
except for a mildly tender abdomen

30. • Questions:
1. What are the stages of acetaminophen
toxicity?
2. What is the immediate treatment of this
patient?
3. What is the specific antidote? Mention its
dosage schedule
dosage schedule
4. Her serum acetaminophen levels were
250mcg/ml at 4 hours. What does this
signify?
5. Which nomogram is used in this condition?

31. • Answers:
• Stage 1: Early (4-12 hours), malaise,
nausea, vomiting
• Stage 2: Quiescent asymptomatic (24-72
• Stage 2: Quiescent asymptomatic (24-72
hours), liver enzymes become elevated
• Stage 3: Liver failure (48-96 hours),
elevated PT; death possible
• Stage 4: Hepatic abnormalities resolve (7-
8 days)

32. 2. Activated charcoal administration is the immediate
treatment in this child
3. N-Acetyl cysteine is the specific antidote. Proved to
be 100% effective when administered within 8 to 16
hours of exposure.
Dose - Load with 140 mg/kg orally then 17 doses of
70 mg/kg every 4 hours
70 mg/kg every 4 hours
4. The level indicate probable risk of hepatotoxicity.
Serum levels greater than 200, 100, 50 mcg/ml at 4,
8, 12 hours indicate a potential risk of
hepatotoxicity.
5. Rumack-Mathew nomogram

33. Rumack-Mathew nomogram

34. OSCE 9
Identify the CXR and give the
diagnostic criteria for this condition

35. Acute onset
Bilateral pulmonary infiltrates on chest
radiography
Pulmonary artery occlusion pressure <18 mm Hg
ARDS
Pulmonary artery occlusion pressure <18 mm Hg
or No clinical evidence of left atrial hypertension
PaO2:FIO2 ratio <300 = ALI
PaO2:FIO2 ratio <200 = ARDS
.
The American-European Consensus Conference on ARDS.1994.

36. OSCE 10
• 6 yr old female child is getting ventilated for ARDS
on PEEP of 15 with Ppeak of 36 and is on 60%
FiO2. early in the morning during sedation
holiday hours she has a bout of cough and she
suddenly desaturates.
• Considering that ET is properly placed and not
• Considering that ET is properly placed and not
obstructed and there is no equipment failure
what is the most likely possibility of this
deterioration
• What do you need to confirm the diagnosis
• Mention steps of needle thoracentesis

37. • Tension pneumothorax
• Needle thoracentesis
• Scalp vein needle in 2nd intercostal space with
the under water seal.
the under water seal.

38. Questions:
1) Identify the diagram
2) What does the X axis and Y axis stand for?
3) What does the numbers denote?

39. LV Pressure - Volume loop

40. What Is the is the loading dose required for
drug A if;
• Target concentration is 10 mg/L
• VD is 0.75 L/kg
• VD is 0.75 L/kg
• Patients weight is 75 kg

41. Loading Dose
Dose = Cp(Target) x VD
Dose = Cp(Target) x VD

42. Answer: Loading Dose of Drug A
• Dose = Target Concentration x VD
• VD = 0.75 L/kg x 75 kg = 56.25 L
• VD = 0.75 L/kg x 75 kg = 56.25 L
• Target Conc. = 10 mg/L
• Dose = 10 mg/L x 56.25 L
• = 565 mg

43. OSCE 13
1. What does the graph suggest
2. Define zero order and first order kinetics
3. Give example of drug following both type kinetics in
dose dependent manner

44. 1.Graph suggests progression of drug
metabolism from first order kinetics to zero
order kinetics with increasing circulating drug
levels
2.First order kinetics – where a fixed proportion
of circulating drug gets metabolised
of circulating drug gets metabolised
• Zero order kinetics – fixed amount of drug
irrespective of the circulating drug level gets
metabolised
3.Phenytoin

45. OSCE 12
• Definition of fulminant hepatic failure
• Stages of hepatic encephalopathy
• Newer modalities of treatment

46. 1. The currently accepted definition in children
includes:
(1) biochemical evidence of acute liver injury (usually
<8 wk duration);
(2) no evidence of chronic liver disease; and
(3) hepatic-based coagulopathy defined as a PT >15
(3) hepatic-based coagulopathy defined as a PT >15
sec or INR >1.5 not corrected by vitamin K in the
presence of clinical hepatic encephalopathy, or a PT
>20 sec or INR >2 regardless of the presence of
clinical hepatic encephalopathy.

47. STAGES
I II III IV
Symptoms Periods of
lethargy,
euphoria;
reversal of day-
night sleeping;
may be alert
Drowsiness,
inappropriate
behavior,
agitation, wide
mood swings,
disorientation
Stupor but
arousable,
confused,
incoherent
speech
Coma
IVa responds to
noxious stimuli
IVb no response
Signs Trouble drawing Asterixis, fetor Asterixis, Areflexia, no
Signs Trouble drawing
figures,
performing
mental tasks
Asterixis, fetor
hepaticus,
incontinence
Asterixis,
hyperreflexia,
extensor
reflexes, rigidity
Areflexia, no
asterixis,
flaccidity
Electroencephal
ogram
Normal Generalized
slowing, θ waves
Markedly
abnormal,
triphasic waves
Markedly
abnormal
bilateral slowing,
δ waves, electric-
cortical silence

48. Newer modalities of therapy
• Single albumin pass dialysis
• Plasmapheresis
• MARS
• Bio-hepatic-filters
• Bio-hepatic-filters
• Orthotropic liver transplantation

49. OSCE 14
• A 4.5 yr old child on therapy for ALL has relapsed and had very
high WBC counts (58000).
• Following first cycle of reinduction child has following
parameters WBC – 21900, Uric acid – 9, LDH – 2600, Ca - 7.6,
PO4 – 8, and acidosis with K+ of 6.8.
• What is the diagnosis?
• Mention the doses of Fluid, HCO3 and Allopurinol.
• What will you monitor?
• What is the choice of dialysis?
• Mention newer modality of treatment with its mechanism

50. 1. Tumour lysis syndrome
2. Fluid - 3000ml/m2
3. Allopurinol 10mg/kg/day
4. HCO3 – 50 – 80 meq/L (Role controversial)
5. Monitor signs of fluid overload, urine output
5. Monitor signs of fluid overload, urine output
and urinary pH
6. Choice of dialysis - hemodialysis

51. Rasburicase (Recombinant Urate oxidase)

52. OSCE 15

53. • 5 yr old female apparently alright so far
presents with sudden onset of palpitation and
the above ECG. She had good peripheral
circulation. She did not respond to adenosine
2 doses.
• Identify the ECG
• Identify the ECG
• Mention the next drug of choice
• Mention its initial intravenous dose
• Where else is it a drug of choice?
• Mention the significant side effect

54. • Answers:
1. Supraventricular tachcardia
2. Inj. Amiodarone
3. 5mg/kg i.v.
4. Ventricular Tachycardia
5. Significant side effect- Hypotension with
5. Significant side effect- Hypotension with
rapid i.v. administration,

55. OSCE 16
• 6 years old male child while playing in the field
was found suddenly unconscious and limp.
• He showed b/l ptosis, hypotonia, areflexia and
preserved DTR and pupillary reflexes
preserved DTR and pupillary reflexes
• He developed respiratory paralysis

56. • Questions:
1. What is the likely diagnosis
2. What is the antidote of choice? Mention the
initial dose
3. How will you revert the respiratory paralysis
4. What other systems would you screen for
4. What other systems would you screen for
5. What is ophitoxemia

57. • Answers:
1. Snake bite
2. Anti snake venom (ASV) is the antidote of choice.
Initial dose – mild cases (only local manifestations )
– 5 vials
moderate cases (coagulation abnormalities,
bradycardia, mild systemic features) – 10 vials
bradycardia, mild systemic features) – 10 vials
severe cases – 15 vials
3. Respiratory paralysis – Neostigmine
4. Other systems – coagulation, cardiac, renal, hepatic
5. Ophitoxemia – symptomatology of snake bite

58. OSCE 17
• 15 year old male boy went for a late night
party
• Next day morning had high grade fever, chest
pain,altered sensorium, profuse sweating and
pain,altered sensorium, profuse sweating and
palpitations
• When seen in medical care facility he was
found to have HR-150/min, BP – 160/100 mm
Hg, pupils- constricted, extremities- flushed

59. 1. What is the toxidrome?
2. What is the probable agent?
3. What additional investigations would you ask
for
for
4. Treatment of acute chest syndrome

60. • Answers:
1. Sympathetic storm
2. Cocaine
3. ECG, liver function tests, coagulation studies
3. ECG, liver function tests, coagulation studies
and renal function tests
4. MONA – morphine, oxygen, nitroglycerine
and aspirin

61. Observed stations in pediatric
emergencies
emergencies
WADIA CME

62. A 6 year old boy was found unresponsive on a
playround. Perform Basic life support.
Observed station 1

63. Observed station 1: Key
• Stimulate and see for responsiveness
• Call for help
• Attach AED
• Open airway – head tilt chin lift and jaw thrust
• Look listen feel for breath
• Look listen feel for breath
• 2 rescue breaths
• Check carotids or brachials – 10 secs
• Chest compressions : 3:1 neonate, 15:2 two rescuer, 30:2
single rescuer
• Continue for five cycles
• Reassess breathing – 2 breaths
• Reassess circulation – 5 cycles of CPR

64. Observed station 2
• 10mths baby brought with severe dehydration
and iv access fails after 3 attempts.
• Establish intraosseus access
• Mention 2 complications
• Mention 2 complications
• How long can you keep it ?

65. • Introduces - ½
• Handwash – ½
• Selection of site – 1
• Cleaning of area – ½
• Checking instruments -1
Observed station 2: Key
• Checking instruments -1
• Technique – position -1, insertion-1, fixation-1
• Confirmation – 1
• Says thanks - ½
• 2 complications – 1
• How long can you keep it 1

66. Observed station 3
• 5 yr old child found choking after eating a
piece of meat in a restaurant
• What actions will you take?
• How is it done in infants?
• How is it done in infants?

67. • Checks for responsiveness
• Position
• Hand position
• Thrusts
Observed station 3: Key
• Thrusts
• Alternate methods

68. Demonstrate the use of
this instrument on this 7
year old child
Explain the mother about
its use
Explain about prevention
of asthma triggers

69. • Avoid the maneuver in patients with severe airway
obstruction, as it may worsen bronchospasm acutely.
• Do not attempt in a child less than 5 to 7 years of age
unless the child has previous experience before the
present ED visit.
• Review the procedure before the patient performs it.
• Be sure the patient has a tight seal on the mouthpiece,
• Be sure the patient has a tight seal on the mouthpiece,
the exhalation hole on the meter is not blocked, and
the meter measuring gauge is unimpeded by the
patient.
• Coach the patient with encouraging words during the
maneuver.

70. • Take the best of three measures for the current peak
flow.
• If done after use of a bronchodilator, wait 10 to 15
minutes to obtain an adequate response. A clinically
relevant bronchodilator response is an improvement in
PEFR of greater than 15%.
• Check the result against the standard for this child or
against the standard nomograms for the patient's size.
against the standard nomograms for the patient's size.
• Observe the technique for:
– Poor maximal inspiration
– Less than maximal effort
– Occlusion of the exhalation hole or gauge
– Premature cessation of the exhalation

71. • Enumerate the steps of Hand Washing?

73. Asthma Table
1) Identify the
instruments?
2) Administer MDI
inhalations to a 1 year
old child?
3) Advice about cleaning
of these instruments

74. • How to Use spacer with MDI?
Step 1
Assemble the Spacer and fit the Baby
Mask onto the Spacer mouthpiece.
Visually check that the assembled
Spacer with Baby Mask is clean.
• Step 2
Remove the protection cap from the
inhaler and check that the
mouthpiece is clean.
• Step 3
• Step 3
Shake the inhaler well.
• Step 4
Insert the inhaler into the opposite
end of the Spacer. The Spacer with
Baby Mask is now ready for use.
• How to clean the spacer and the
mask?