Anaphylaxis, Asthma & Diabetic Emergencies

A child has just eaten a biscuit containing peanuts. Which sign most strongly suggests anaphylaxis rather than a mild allergic reaction?

• AA single red patch around the mouth
• BSwelling of the tongue and a hoarse voice✓
• CA few small itchy spots on one forearm
• DSneezing with a slightly runny nose

Answer: Swelling of the tongue or throat, a hoarse voice, wheeze and breathing difficulty are the airway signs that mark out anaphylaxis, often within minutes of the trigger. A few localised itchy spots, sneezing or a red patch around the mouth can occur with a mild reaction and do not on their own indicate a life-threatening one, although the child must still be watched closely.

A child with a known nut allergy is wheezing, her face is swelling and she is going floppy after snack time. Her adrenaline auto-injector is in the room. What should be done first?

• ACall the parents to ask what they want done
• BGive her a drink of water to clear her throat
• CSit her outside in the fresh air to recover
• DUse the auto-injector in the outer thigh✓

Answer: Adrenaline is the treatment for anaphylaxis and is given without delay, followed by a 999 call saying the word anaphylaxis. Water cannot help a swelling airway and could choke her, phoning the parents wastes vital minutes, and fresh air does nothing to reverse the reaction.

Where and how should an adrenaline auto-injector be given to a child with anaphylaxis?

• AInto the front of the forearm, on bare skin
• BInto the upper arm muscle, after the sleeve has been removed
• CInto the buttock, through clothing if necessary
• DInto the outer thigh, through clothing if necessary✓

Answer: Auto-injectors are designed for the outer thigh and can be used through clothing, so there is no need to undress the child. The upper arm, buttock and forearm are not the recommended site, and delaying to remove clothing is unnecessary.

You are phoning 999 for a child whose throat is swelling after a wasp sting. Which word should you tell the call handler so the right response is sent?

• AHypoglycaemia
• BMeningitis
• CAnaphylaxis✓
• DConvulsion

Answer: Saying anaphylaxis tells the call handler this is a life-threatening allergic reaction needing an urgent ambulance. Hypoglycaemia describes low blood sugar, meningitis is an infection and a convulsion is a seizure, none of which describes what is happening to this child.

After giving the auto-injector and calling 999, a child with anaphylaxis is breathing without much difficulty. How should you position her while you wait?

• ALying down with her legs raised✓
• BKneeling forward over a cushion
• CSitting upright in a chair
• DWalking slowly around the room to keep calm

Answer: Lying down with the legs raised supports her blood pressure; only if breathing becomes difficult should she sit up slowly with her shoulders raised. Sitting upright in a chair is reserved for when breathing is hard, and walking or kneeling forward should never be allowed because standing or walking during anaphylaxis can cause collapse.

Five minutes after the auto-injector, a child with anaphylaxis is still wheezing and pale and the ambulance has not arrived. Another auto-injector is available. What should you do?

• AWait a further 15 minutes before considering another dose
• BGive the other injector into the thigh now✓
• CGive the other injector into the upper arm straight away
• DGive the other injector only if the child stops breathing

Answer: If there is no improvement 5 minutes after the initial dose, another auto-injector is used, again in the outer thigh. Waiting a further quarter of an hour or holding it back until breathing stops lets the reaction progress, and the upper arm is the wrong site.

A child who has just had adrenaline for anaphylaxis says she feels better and wants to walk to the first aid room. What should you do?

• ACarry her to the first aid room on your back
• BLet her walk slowly if an adult holds her hand
• CKeep her lying down and bring the equipment to her✓
• DLet her sit in a chair until the ambulance arrives

Answer: A child with anaphylaxis must not stand or walk, even if she seems to be improving, because it can cause a sudden collapse. Walking with a hand held, being carried upright or sitting up in a chair all involve getting her up, so everything is brought to her instead and the used injector is sent with her.

The EYFS says staff should be aware that allergies can develop at any time. Which stage does it single out as a particular risk?

• AWhen a child first starts sleeping at nursery
• BWhen solid foods are being introduced during weaning✓
• CWhen a child moves from the baby room to the toddler room
• DWhen a child has just finished a course of antibiotics

Answer: Weaning is when new foods are first tried, so it is the stage the EYFS highlights for new allergies appearing, and allergy action plans should follow the BSACI model with parents and health professionals. Moving rooms, starting naps or finishing antibiotics are not identified in the framework as allergy triggers.

A child is having an asthma attack at nursery. How should you position him while you get his reliever inhaler?

• ALying face down on a mat
• BLying flat on his back
• CSitting up straight✓
• DLying on his side

Answer: Sitting up straight opens the chest and makes breathing easier, and keeping him calm is part of the treatment. Lying flat, on his side or face down restricts the chest and makes it harder to breathe deeply.

How should a child's blue reliever inhaler be given during an asthma attack?

• AOne puff every 10 minutes, up to 3 puffs, through a spacer
• BOne puff every 30 to 60 seconds, up to 10 puffs, through a spacer✓
• CTwo puffs every 5 minutes, up to 4 puffs, without a spacer
• DTen puffs at once, then nothing more until the ambulance arrives

Answer: The NHS advises one puff every 30 to 60 seconds via a spacer, shaking the inhaler between puffs, to a maximum of 10 puffs. Spacing puffs minutes apart delivers too little too slowly, firing all ten at once wastes most of the dose, and a limit of 3 or 4 puffs stops far below the amount that may be needed.

A child has had the full 10 puffs of his reliever, is no better and 999 has been called. Ten minutes later the ambulance has not arrived. What should you do?

• ALie him flat and raise his legs
• BGive a glucose gel instead
• CRepeat the inhaler doses✓
• DWait for the paramedics to arrive

Answer: If there is no improvement after 10 minutes and the ambulance has not come, the reliever doses are repeated in the same way. Glucose gel treats low blood sugar and has no place here, lying flat makes breathing harder, and simply waiting leaves a deteriorating child untreated.

Below which blood glucose reading is a child with diabetes considered to be having a hypo?

• A4 mmol/L✓
• B10 mmol/L
• C2 mmol/L
• D7 mmol/L

Answer: Hypoglycaemia means a blood glucose below 4 mmol/L, which is the point at which fast-acting sugar is given. Waiting until the level falls to 2 would leave the child untreated for too long, while 7 and 10 are readings above the hypo threshold.

Before lunch, a child with type 1 diabetes becomes sweaty, shaky and irritable. She is fully conscious and can swallow. What should you give her?

• AA small glass of fruit juice✓
• BA diet cola to avoid extra sugar
• CA cheese sandwich and nothing else
• DA glass of cold water to cool her down

Answer: Sweating, shaking and irritability point to a hypo, so a conscious child gets fast-acting sugar such as fruit juice, a sugary drink, glucose tablets, glucose gel or jelly babies, with a recheck after 10 to 15 minutes and then a longer-acting carbohydrate. A diet drink has no sugar, water does nothing for blood glucose, and a sandwich on its own is too slow to act.

A child with diabetes is found unconscious on the toilet floor but is breathing normally. What should you do?

• ARub glucose gel inside her cheek and wait for her to wake up
• BLay her flat, raise her legs and give her jelly babies when she stirs
• CTurn her onto her side, give nothing by mouth and call 999✓
• DSit her up and pour a little sugary drink into her mouth

Answer: An unconscious child cannot protect her airway, so she goes into the recovery position, nothing is given by mouth and 999 is called; glucagon may be given by someone trained to use it. Gel, drinks or sweets in the mouth of an unconscious child can block the airway, and lying flat with legs raised is the position for shock, not for an unresponsive breathing child.