Self Assessment MCQ
1- Which of the following statements about poisoning and overdose in the
paediatric population is true?
a) whenever a poison or toxin is ingested, you should induce vomiting to eliminate it
from the body
b) poisoning and overdose cause a significant number of deaths in the 15-to 24-
year-old age group
c) poisoning and overdose do not occur in the paediatric population
d) the first priority of management for the child with poisoning or a drug overdose is
to "get the antidote"
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Toxicologic causes (poisoning and overdose) are an important cause of death in the 15- to 24-year-old age group.
Answer a is incorrect for two main reasons. First and most important, vomiting should not be induced unless recommended by a local poison control center. No human clinical trials have shown that induction of vomiting changes outcome. Second, vomiting introduces the risk of aspiration, so it should not be induced in patients with limited airway protective reflexes, those who have ingested caustic material or hydrocarbons, or those who have ingested drugs that may rapidly depress mental status (eg, tricyclic antidepressants).
Answer c is incorrect. Although poisoning and ingestion of toxic substances do not cause a large number of deaths in young children, they are responsible for a large number of ED visits and hospitalizations.
Answer d is incorrect because the first priority of management for an infant or child with poisoning or drug overdose is to support airway, breathing, and circulation. Administration of an antidote may be unnecessary, or there may be no known antidote to the poison. If an antidote is needed, it should be administered only after you have assessed and supported airway, breathing, and circulation.
2- A 3-year-old unresponsive, apnoeicchild is brought to the Emergency Department. Ambulance staff transporting the child tell you the child became pulseless as they pulled up to the hospital. The child is receiving CPR, including positive-pressure ventilation with bag and mask and 100% oxygen and chest compressions. You confirm that apnoea is present and that ventilation is producing bilateral breath sounds and chest expansion while a colleague confirms absence of spontaneous central pulses and other signs of circulation. A third colleague attaches the ECG monitor and reports that ventricular fibrillation is present. Which of the following therapies is most appropriate for this child at this time?
a) establish IV/IO access and administer amiodarone 5 mg/kg
b) establish IV/IO access and administe rmagnesium 25-50mg/kg
c) attempt defibrillation at 4J/kg
d) establish IV/IO access and administer adrenaline 0.01 mg/kg
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The first therapy you should provide for ventricular fibrillation or pulseless ventricular tachycardia is an immediate attempt at defibrillation, and the first "dose" for infants and children is 2 J/kg. If that dose is ineffective, you should attempt defibrillation with a dose of 4 J/kg.
Answer a and b are incorrect because you should not delay the defibrillation attempt. Although vascular access should be established quickly, you can wait until the first 3 shocks are delivered if needed. Administration of amiodarone or magnesium is not recommended unless or until the VF/pulseless VT persists despite 3 shocks, a dose of adrenaline, and a fourth shock.
Answer d is incorrect because you should not delay the defibrillation attempt. You can wait to establish vascular access until after the delivery of the first 3 shocks if needed. Give adrenaline if VF/pulseless VT persists after 3 shocks.
3- You are attempting resuscitation of an infant or child with severe symptomatic bradycardia and no evidence of vagal etiology. The bradycardia persists despite establishment of an effective airway, oxygenation, and ventilation.
Which of the following is thefirst drug you should administer?
a) atropine
b) dopamine
c) adenosine
d) adrenaline
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Adrenaline is the first drug recommended for the treatment of severe symptomatic bradycardia that is unresponsive to establishment of airway, oxygenation, and ventilation.
Answer a is incorrect because atropine should be administered after adrenaline unless you suspect that the bradycardia is vagally induced.
Answer b is incorrect because dopamine is not included in the treatment algorithm for severe symptomatic bradycardia. Dopamine provides only indirect release of catecholamines that can stimulate heart rate. Adrenaline, a catecholamine with direct effects, should be administered for severe symptomatic bradycardia unresponsive to establishment and support of airway, oxygenation, and ventilation.
Answer c is incorrect because adenosine blocks AV conduction. Adenosine is used to treat supraventricular tachycardia. It is not recommended for the treatment of severe symptomatic bradycardia.
When the pads of a manual defibrillator is attached to a collapsed pulseless 7 years child the following rhythm is noted:
4- The patient has received the initial two shocks at 4J / kg.
What medication would you consider at this time?
a) Atropine 0.5 mg IV
b) Adrenaline 10 mcg/kg
c) Amiodarone300mgIV
d) Adenosine 6 mg IV
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5- What is the correct ratio of compressions to ventilations for this non-intubated
patient?
a) 5 compressions to 1 breath
b) 30 compressions to 2 breaths
c) 3 compressions to 1 breath
d) 15 compressions to 2 breaths
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The following 4 questions relate to the scenario below.
A 7 year old female child has been admitted to the emergency department stating she has palpitations, and feels a bit light headed. Her BP is 90/60. The monitor shows:
6- Which of the following is indicated first?
a) Adenosine 0.1 mg/kg rapid IV push followed by flush.
b) Perform Vagal manoeuvres
c) Give Verapamil 2.5mg IV
d) Sedation and immediate synchronised cardioversion
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7- Your initial intervention has been ineffective in terminating this arrhythmia. What drug should be administered IV?
a) Adenosine 0.1mg/kg
b) Amiodarone 5mg/kg over 10 min
c) Adrenaline infusion 2-10 micrograms/min
d) Adenosine 6 mg
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8- The drug administered above has also been ineffective in terminating this
arrhythmia. What is the next drug that should be administered IV?
a) Adenosine 6mg
b) Amiodarone 150 mg over 10 min
c) Adrenaline infusion 2-10 micrograms/min
d) Adenosine 0.2mg/kg
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9- The patient now states she is more short of breath and thinks she is going to faint. Her BP is 55/0. Your next intervention will be:
a) Adenosine 6mg IV
b) Amiodarone 150 mg over 10 min
c) Give Verapamil 2.5mg IV
d) Sedation and immediate synchronised cardioversion
The following 2 questions relate to the scenario below.
An 8 year old male child had been admitted to the paediatrics ward with a chest infection. His mother has rung the bell. When you came in, he was poorly responsive. He does have a weak carotid pulse. His BP is 58/40. He has oxygen and an IV line in place. The defibrillator has been attached, using the pads. The rhythm shown is:
10- The next treatment you will initiate is:
a) Dopamine infusion 10-20 microgram/kg/min and titrate to effect
b) Adrenaline 10mcg/kg IV and prepare for TCP
c) Atropine 0.5mg IV up to a total dose of 3mg
d) Isoprenaline 2-10micrograms/min infusion titrated to effect
11- In preparing for TCP, you will need to:
a) Synchronise the manual defibrillator
b) Place the defibrillator in AED mode
c) Attach the 3-lead cable to obtain a a feedback tracing
d) Attach bedside monitor in addition to the manual defibrillator
The next 7 questions relate to the following scenario.
A 55-year old man presents to a GP clinic complaining of chest tightness and shortness of
breath. He appears pale and states he feels “dizzy”. His blood pressure is 110/70mmHg.
His ECG is below.
12- You are preparing to use a manual external defibrillator and external pads in
the paediatric setting. When would it be most appropriate to use the smaller
"paediatric-sized” pads for delivery of energy?
a) the smaller pads should be used for synchronized cardioversion but not for
defibrillation
b) the smaller pads should be used when the patient weighs less than
approximately 25 kg or is less than 8 years old
c) the smaller pads should be used when the patient weighs less than
approximately 10 kg or is less than 1 year old
d) thesmaller pads should be used whenever you can compress the victim's chest
using only the heel of one hand
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13- A 7-year-old boy is found unresponsive, apnoeic, and pulseless. CPR is provided, and tracheal intubation and vascular access are achieved. The ECG monitor reveals pulseless electrical activity (PEA). An initial IV dose of adrenaline has been administered, and effective ventilations and compressions continue for 2 minutes. Which of the following therapies should you perform next ?
a) attempt to identify and treat reversible causes (using the H's andT's as a memory
aid)
b) attempt defibrillation at 4 J/kg
c) administer escalating doses of adrenaline
d) administer synchronized cardioversion
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Whenever a child does not respond to support of airway, oxygenation, and ventilation plus one dose of IV adrenaline, you should attempt to identify and treat potentially reversible causes of the cardiopulmonary arrest, especially when PEA is present. These potentially reversible conditions can be recalled by the use of 4 H's (hypoxemia; hypovolemia; hypothermia or hyperthermia; and hypokalemia, hyperkalemia, and other metabolic disorders) and the 4 T's (tamponade; tension pneumothorax; toxins, poisons, and drugs; and thromboembolism).
Answer b is incorrect because defibrillation is not recommended for treatment of PEA. Defibrillation is the treatment of choice for ventricular fibrillation/pulseless ventricular tachycardia.
Answer c is incorrect because escalating doses of adrenaline are not recommended for the treatment of pulseless arrest of any cause. High-dose adrenaline may be considered for special resuscitation situations such as sepsis or anaphylaxis.
Answer d is incorrect because synchronized cardioversion is not the treatment choice for PEA. Synchronized cardioversion is used to treat symptomatic tachycardias.
14- Which of the following statements about the effects of adrenaline during
attempted resuscitation is true?
a) adrenaline decreases peripheral vascular resistance and reduces myocardial
afterload so that ventricular contractions are more effective
b) adrenaline can improve coronary artery perfusion pressure and can stimulate
spontaneous contractions when asystole is present.
c) adrenaline is not useful in ventricular fibrillation because it will increase myocardial
irritability
d) adrenaline decreases myocardial oxygen consumption
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Adrenaline improves coronary artery perfusion pressure and myocardial oxygen delivery during CPR by increasing peripheral vascular resistance and aortic diastolic pressure. Adrenaline may also stimulate spontaneous cardiac contractions, so it may restore cardiac activity when asystole is present.
Answer a is incorrect because adrenaline increases peripheral vascular resistance, ventricular afterload, and oxygen demand.
Answer c is incorrect because adrenaline is useful in the treatment of ventricular fibrillation. It can increase the coarseness of ventricular fibrillation, enhancing the potential for termination of ventricular fibrillation by attempted defibrillation.
Answer d is incorrect because adrenaline increases myocardial oxygen consumption. Although adrenaline-induced elevation of coronary artery perfusion pressure during chest compressions enhances delivery of oxygen to the heart, oxygen consumption is increased, not decreased.
15- You are participating in the elective intubation of a 4-year-old child with
respiratory failure. You must select the appropriate size of uncuffed tracheal
tube. Which of the following sizes is most appropriate for an average 4-year-
old?
a) 3-mm tube
b) 4-mm tube
c) 5-mm tube
d) 6-mm tube
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To estimate the size of uncuffed tracheal tube from age for children 1 to 10 years old, use either of the following two formulas (they will yield the same answer):
Tracheal Tube Size (inner diameter, in mm)=(Age in years ÷ 4) + 4
OR
=(Age in years + 16) ÷ 4
Both formulas yield an estimated tracheal tube size of 5 mm. In the first formula, 4 ÷ 4 = 1 and 1 + 4 = 5 mm. In the second formula, 4 + 16 = 20 and 20 ÷ 4 = 5 mm.
Answer a is incorrect because a 3-mm tube is too small for a 4-year-old child and would likely result in a large air leak around the tracheal tube. A 3-mm tracheal tube would be appropriate for a newborn.
Answer b is incorrect because a 4-mm tube is too small for an average 4-year-old child. A
4-mm tube is the appropriate size for an infant approximately 6 to 12 months of age.
Answer d is incorrect because a 6-mm tube is much too large for an average 4-year-old child. A 6-mm tube is the appropriate size for a child approximately 8 years old.
16- You are evaluating a 7-month-old boy. The infant presented with a history of
poor feeding, fussiness, and sweating. He is alert and responsive, and he has a
respiratory rate of 48 breaths/min with good bilateral breath sounds. Heart rate
is 250 bpm with narrow (<0.08 seconds) QRS complexes, and the heart rate
does not vary with activity or cry. Pulses are readily palpable, and capillary
refill is 2 seconds. Which of the following therapies is most appropriate for this
infant?
The ECG as follows:
a) make an appointment with a paediatric cardiologist for later in the week
b) consider vagalmanoeuvers (eg, ice to the face) while IV access is attempted and
provide IV adenosine once access is established
c) perform immediate synchronized cardioversion without awaiting establishment of
IV access
d) establish IV access, administer a fluid bolus of 20 mL/kg of isotonic crystalloid, and administer antibiotics
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The infant has signs and symptoms of SVT with a heart rate greater than 220 bpm, narrow-complex QRS complexes, and no variability in heart rate. Because the infant is stable (alert with good pulses and normal capillary refill), vagal maneuvers may be performed. Administer IV adenosine if vagal maneuvers are unsuccessful.
Answer a is incorrect because even a stable child with SVT requires medical attention within a few hours. Consultation with a paediatric cardiologist is appropriate, but you should not delay medical treatment for a week.
Answer c is incorrect because immediate or urgent synchronized cardioversion is not indicated for the treatment of tachycardia with adequate perfusion. You should first attempt vagal maneuvers, establish IV access, administer adenosine, and consult a paediatric cardiologist.
Answer d is incorrect because these therapies will not treat the SVT. Heart rates greater than 220 bpm are unlikely to be sinus in origin; therefore they are unlikely to be caused by sepsis or hypovolemia.
17- You are evaluating a responsive 6-year-old girl. The child presented with fever, irritability, mottled colour, cool extremities, and a prolonged capillary refill time. Her heart rate is 160 bpm, respiratory rate is 45 breaths/min, and BP is 98/56 mm Hg. Which of the following most accurately describes this child's condition, using the terminology taught in the PALS course?
a) decompensated shock associated with inadequate tissue perfusion
b) decompensated shock associated with inadequate tissue perfusion and significant
hypotension
c) compensated shock requiring no intervention
d) compensated shock associated with inadequate tissue perfusion
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The child definitely is in shock. Compensated shock is present because her blood pressure is adequate (ie, hypotension is not present) but signs of inadequate tissue and organ perfusion (eg, irritability, mottled colour, cool extremities) are observed. To determine whether blood pressure is adequate in children aged 1 to 10 years, estimate the lower limit (fifth percentile) of adequate systolic blood pressure using the following formula: 70 mm Hg + (2 × age in years). A systolic blood pressure below the number yielded by this formula indicates hypotension. Using this formula, the lower limit of adequate systolic blood pressure for a 6-year-old child is 82 mm Hg. In this case the child’s SBP was 98 mm Hg, indicating adequate blood pressure and thus compensated shock.
Answers a and b are incorrect because decompensated shock is defined by the presence of hypotension. In this case decompensated shock would be present if the child’s systolic blood pressure fell below 82 mm Hg.
Answer c is incorrect because compensated shock should be treated promptly. Failure to treat compensated shock may result in deterioration to decompensated shock or cardiac arrest.
18- An 8-year-old child was struck by a car. He arrives in the Emergency Department alert, anxious, and in respiratory distress. His cervical spine is
immobilized, and he is receiving a 10 L/min flow of 100% oxygen by face mask. Respirations are 60 breaths/min, heart rate is 150 bpm, and systolic blood pressure is 60 mm Hg.
No breath sounds are heard over the right chest, and the trachea is clearly deviated to the left. Pulse oximetry reveals an oxyhaemoglobin saturation of 84%. Which of the following is the most appropriate immediate intervention for this child?
a) perform tracheal intubation and call for a STAT chest x-ray
b) obtain a chest x-ray and provide bag-mask ventilation until the x-ray is read
c) establish IV access and administer a 20 mL/kg bolusof normal saline
d) perform needle decompression of the right chest and assist ventilation with a bag
and mask if necessary
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This victim has a tension pneumothorax, indicated by tachypnea with respiratory distress, absence of breath sounds over the right chest, deviation of the trachea to the left, and oxyhaemoglobin saturation of 84%. The victim also has tachycardia and hypotension, which suggest that the tension pneumothorax may be interfering with cardiovascular function. You must evacuate the pneumothorax immediately and be prepared to assist ventilation with a bag-mask if needed.
Answer a is incorrect because needle decompression of the pneumothorax, not intubation, is the appropriate treatment for tension pneumothorax. This child's airway appears to be patent, but his respiratory function is compromised. This compromise in respiratory function is entirely explainable by the tension pneumothorax.
Answer b is incorrect because the diagnosis of a tension pneumothorax should be a clinical, not a radiographic, process. The tension pneumothorax should be evacuated as soon as the clinical diagnosis is made. Obtaining a chest x-ray will result in an unnecessary delay during which the hypoxia can worsen and progressive deterioration of cardiorespiratory function can develop.
Answer c is incorrect because establishment of IV access is not as high a priority as stabilization of the respiratory function. The cardiovascular compromise is probably secondary to the tension pneumothorax. Although fluid administration may be required, you should evaluate the child's systemic perfusion after the tension pneumothorax is evacuated and you ensure that airway and breathing are adequate.
19- A 2-year-old child presents with mild difficulty breathing of gradual onset. She
is alert, but she has a sore throat and is making coarse, high-pitched
inspiratory sounds (mild stridor). Her oxyhaemoglobin saturation is 94% in
room air, and her lung sounds are clear with adequate breath sounds
bilaterally. Which of the following is the most appropriate initial interventionfor
this child?
a) immediate tracheal intubation
b) immediate radiologic evaluation of the soft tissues of the neck
c) evaluation of oxyhaemoglobinsaturation with pulse oximetry and analysis of
arterial blood gases to determine if hypercarbia is present
d) administration of humidified supplemental oxygen as tolerated and continued
evaluation
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This child is not in acute distress, and she has no clinical evidence of respiratory failure. The most appropriate intervention is to provide humidified oxygen as tolerated and observe the child to see if she improves, deteriorates, or stays the same. It may be useful to begin pulse oximetry, but monitoring of oxyhaemoglobin saturation is not mandatory at this time.
Answer a is incorrect because this child does not meet the criteria for intubation. If you determine that the child has upper airway obstruction and cannot maintain an airway, or if the child demonstrates signs of fatigue or respiratory failure, then tracheal intubation is indicated.
Answer b is incorrect because radiologic evaluation should wait until you have determined that this child will be stable with administered oxygen.
Answer c is incorrect. Although it would be appropriate to begin pulse oximetry, it is not necessary to perform an arterial puncture for arterial blood gas analysis at this point because the child has only mild difficulty breathing. Such an invasive procedure would likely worsen the child's respiratory distress.
20- An 18-month-old child presents with a 1-week history of a cough and runny
nose. He is cyanotic and responds only to painful stimulation. His heart rate is
160bpm; respirations have dropped from 65 to 10 per minute with severe
intercostal retractions and a capillary refill time of less than 2 seconds. Which
of the following is the most appropriate immediate treatment for this toddler?
a) establish vascular access and administer a 20 mL/kg bolus of isotonic fluids
b) open the airway and provide positive-pressure ventilation using 100% oxygen and
a bag-mask device
c) administer 100% oxygen by face mask, establish vascular access, and obtain a
STAT chest x-ray
d) administer 100% oxygen by face mask, obtain blood for arterial blood gas
analysis, and establish vascular access
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This child has signs of overt respiratory failure with decreased responsiveness, severe intercostal retractions, and an acute drop in respiratory rate from 65 to 10 breaths/min. Immediate and aggressive support of ventilation is indicated.
Answer a is incorrect because the child has no signs of poor systemic perfusion (capillary refill time is 2 seconds). Although the child is tachycardic, the tachycardia is probably related to the respiratory distress, and the heart rate should normalize once the respiratory distress is treated. Establishment of vascular access does not address the airway problem.
Answers c and d are incorrect because the child requires support of respiratory rate in addition to supplemental oxygen. Without adequate respiratory effort, supplemental oxygen delivered by face mask will not be transported into the lungs and circulatory system.
21- You are supervising another healthcare provider in the insertion of an
intraosseous needle into an infant's tibia. Which of the followingsigns should
you tell the provider willbestindicate successful insertion of a needle into the
bone marrow cavity?
a) pulsatile blood flow will be present in the needle hub
b) fluids or drugs can be administered freely without local soft tissue swelling
c) resistance to insertion suddenly increases as the tip of the needle passes through
the bony cortex into the marrow
d) once inserted the shaft of the needle moves easily in all directions within the bone
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If fluids or drugs can be administered freely and no soft tissue swelling develops near the site of insertion, the needle is correctly placed in the intraosseous space.
Answer a is incorrect because an IO needle is inserted into the bone marrow into a non-collapsible venous plexus. This venous plexus does not have pulsatile blood flow.
Answer c is incorrect because resistance decreases with passage of the needle through the cortex and into the bone marrow.
Answer d is incorrect because the needle will not move easily after insertion if it is correctly placed. It will be held firmly in an upright position by the rigid tissue comprising bone.
22- An anxious but alert 7-year-old child is brought to the Emergency Department.
The child has a heart rate of 260 bpm with narrow QRS complexes and no
variability in heart rate with activity. Respirations are 30 breaths/min and
unlabored. Extremities are warm, and capillary refill time is less than 2
seconds. He is awake and alert, and he denies chest pain or shortness of
breath. Which of the following is the most appropriate initial treatment for this
child?
a) perform immediate synchronized cardioversion (0.5 to 1 J/kg)
b) establish vascular access and administer a 20 mL/kg bolus of normal saline
c) attempt vagal maneuvers (Valsalva), and establish vascular access for adenosine if needed.
d) begin immediate transcutaneous overdrive pacing
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The child is relatively stable with good perfusion, so urgent cardioversion is not indicated. Attempt to convert the tachycardia with vagal maneuvers (such as blowing through an obstructed straw), and establish vascular access to provide a route of administration for adenosine.
Answer a is incorrect because immediate synchronized cardioversion is appropriate for children with tachycardia and poor perfusion.
Answer b is incorrect because there is no evidence that the child has hypovolemic shock. Capillary refill time is less than 2 seconds and extremities are warm. The child is awake and alert.
Answer d is incorrect because transcutaneous overdrive pacing may be considered if the child's perfusion is poor and urgent intervention is required. This child is not in acute distress.
23- A pale and obtunded 3-year-old child with a history of diarrhoea is brought to
the hospital. Respirations are 45 breaths/min with no distress and good breath
sounds bilaterally. Heart rate is 150 bpm, and BP is 88/64 mm Hg. Capillary refill
time is 5 seconds, and peripheral pulses are weak. After placing the child on a
10 L/min flow of 100% oxygen and obtaining vascular access, which of the
following is the most appropriate immediate treatment for this child?
a) obtain a chest x-ray
b) administer a maintenance crystalloid infusion
c) administer a 20 mL/kg bolus of IV or IO isotonic fluids
d) administer a dopamine infusion at a rate of 2 to 5Pg/kg per minute
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This child has signs of compensated shock, including prolonged capillary refill, weak peripheral pulses, and tachycardia with a blood pressure that is adequate for age. The shock is probably caused by hypovolemia secondary to diarrhoea, so administration of an isotonic crystalloid fluid bolus is needed.
Answer a is incorrect because a chest x-ray is not indicated during initial stabilization of the child. The child's respiratory rate is 45 breaths/min with clear breath sounds and no evidence of distress.
Answer b is incorrect. To correct hypovolemic shock, you must give fluid in bolus allotments (20 mL/kg). Maintenance fluids are inadequate to correct the shock that is present.
Answer d is incorrect because fluid resuscitation is needed. Vasopressors like dopamine may be unnecessary if fluid resuscitation is adequate.
24- An infant with a history of vomiting and diarrhea arrives by ambulance. The
infant responds only to painful stimulation. The upper airway is patent,
respiratory rate is 40 breaths/min with good bilateral breath sounds, and 100%
oxygen is being administered. She has cool extremities, weak pulses, and a
capillary refill time of more than 5 seconds. Blood pressure is 85/65 mm Hg,
and glucose concentration (measured by bedside test) is 8.2 mmol/l. Which of
the following is the most appropriate treatment for this infant?
a) establish IV or IO access and administer 20 mL/kg 5% dextrose and 0.45%
sodium chloride over 5 minutes
b) establish IV or IO access and administer 20 mL/kg lactated Ringer's solution over
60 minutes
c) perform tracheal intubation and administer 0.1 mg/kg adrenaline (0.1 mL/kg of
1:1000 solution) by tracheal tube
d) administer 20 mL/kg isotonic crystalloid over 10 to 20 minutes
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This infant is in shock with signs of poor perfusion (cool extremities, weak pulses, and prolonged capillary refill). Her history of vomiting and diarrhoea suggests hypovolemic shock. Immediate volume resuscitation is needed.
Answer a is incorrect because you should not routinely use glucose solutions during resuscitation. Administer glucose if the patient has documented hypoglycemia.
Answer b is incorrect because fluid resuscitation should be accomplished rapidly (administration of 20 mL/kg boluses over 20 minutes or less). Administration of fluids over 60 minutes is too slow to restore intravascular volume and improve systemic perfusion.
Answer c is incorrect. First, this infant's airway and breathing appear to be adequate at this time. The first priority for resuscitation is support of the circulation with volume administration. Volume administration should not be delayed to perform tracheal intubation. Second, there is no indication for adrenaline. This infant requires volume administration, which should be accomplished without delay.
25. Which basic airway skill is the most commonly used method for providing positive-pressure ventilation?
a) Mouth-to-mouth
b) Mouth-to-barrier device
c) Bag-mask ventilation
d) A time cycled ventilator
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26. A Rigid suction Catheter type is more effective than a Soft Catheter type for which of the following uses:
a) More effective suctioning of the oropharynx
b) Aspiration of thin secretions from the oropharynx and nasopharynx
c) Performing intratracheal suctioning
d) Suctioning through an in-place airway to access the back of the pharynx in a patient with clenched teeth
to view the answer to the question above27. In children One cycle of CPR consists of
a) 15 compressions then 2 breaths
b) 20 compressions then 2 breaths
c) 30 compressions then 3 breaths
d) 20 compressions then 3 breaths
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28- Which of the following devices will most reliably delivering a high (90% or greater) concentration of inspired oxygen?
a) a nasal cannula with oxygen flow of 4 L/min
b) a simple oxygen mask
c) a non-rebreathing face mask with an oxygen reservoir
d) a partial rebreathing mask
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With an oxygen flow of 10 to 12 L/min and a good seal between the patient's face and mask, a non-rebreathing face mask can provide an inspired oxygen concentration of 95%.
Answer a is incorrect because a nasal cannula cannot reliably provide a stable high concentration of inspired oxygen. The inspired oxygen concentration provided by a nasal cannula will vary on the basis of the patient’s respiratory rate, respiratory effort, and size. Although a nasal cannula will deliver higher inspired oxygen concentrations to infants than to children, an oxygen concentration greater than 90% will not be achieved.
Answer b is incorrect because a simple oxygen mask is a low-flow device. A simple oxygen mask delivers only 35% to 60% oxygen with a flow rate of 6 to 10 L/min.
Answer d is incorrect because a partial rebreathing mask reliably delivers an inspired oxygen concentration of only 50% to 60%.
29- Which one of the following is not a common cause of PEA?
a) Hypoxia
b) Thoracic damage
c) Toxins
d) Thrombosis
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30- Which of the following are the two most easily reversible causes of PEA?
a) Hypovolemia and PE
b) Thrombosis and chest Trauma
c) Hypoglycemia and Hypoxia
d) Tension pneumothorax and Hyperkalaemia
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31- Cardiac arrest rhythm associated with no discernible electrical activity on the ECG is
a) VF
b) Bradycardia
c) Pulseless Electric Activity
d) Asystole
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32- You are transporting a 6-year-old tracheally intubated patient who is receiving positive-pressure mechanical ventilation. The child begins to move his head and suddenly becomes cyanotic and bradycardic. You remove the child from the mechanical ventilator circuit and provide manual assisted ventilation with a bag via the tracheal tube. During manual ventilation with 100% oxygen, the child's colour and heart rate improve slightly and his blood pressure remains adequate. Breath sounds and chest expansion are present and adequate on the right side, but they are consistently diminished on the left side. The trachea is not deviated, and the neck veins are not distended. A suction catheter passes easily beyond the tip of the tracheal tube. Which of the following is the most likely cause of this child's acute deterioration?
a) tracheal tube displacement
b) tracheal tube obstruction
c) tension pneumothorax
d) equipment failure
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The child's movement has most likely displaced the tracheal tube into the right main bronchus. The child's symptoms of cyanosis, bradycardia, and decreased breath sounds on the left are most consistent with tracheal tube displacement. The "DOPE" mnemonic (Displacement of the tube from the trachea, Obstruction of the tube, Pneumothorax, and Equipment failure) is a convenient tool to recall the causes of sudden decompensation in patients who are tracheally intubated and mechanically ventilated.
Answer b is incorrect because tracheal tube obstruction would likely cause a bilateral decrease in breath sounds that would not improve with manual ventilation. In addition, the suction catheter passes easily beyond the tip of the tube, suggesting a lack of obstruction.
Answer c is incorrect because both the child's colour and heart rate improve marginally and do not deteriorate during manual assisted ventilation. In addition, breath sounds, although diminished on the left, are present on both sides. (Note, however, that diminished breath sounds on one side could indicate tension pneumothorax.) Also, neither midline shift nor neck vein distension is present, but these are late and uncommon signs of tension pneumothorax in children. Nonetheless these signs together make tube displacement much more likely than tension pneumothorax.
Answer d is incorrect because if equipment failure were the problem, the child would likely improve once he was removed from the mechanical ventilatory circuit and manual ventilation was provided.
33-An unresponsive 7-month-old infant presents with cold extremities and a capillary refill time of more than 5 seconds. His heart rate is 260 bpm with weak pulses and narrow QRS complexes. IV access is established with difficulty. The infant is receiving 100% oxygen by non-rebreathing face mask, and oxygenation and ventilation are adequate. Paediatric monitor/defibrillation/pacing electrode pads are in correct position on the infant's chest. You attempt to flush the IV line with normal saline and note that it is no longer patent. Which of the following is the most appropriateinitial treatment for this infant?
a) perform immediate tracheal intubation
b) reattempt vascular access to enable administration of IV adenosine
c) establish IO access and administer a 20 mL/kg bolus of isotonic crystalloid followed by adenosine
d) perform immediate synchronized cardioversion
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If vascular or intraosseous access is established or rapidly attainable, IV adenosine may be administered even if systemic perfusion is compromised. But in this infant vascular access was difficult to establish and the line is no longer functional. This infant is in shock and needs immediate synchronized cardioversion.
Answer a is incorrect because there is no immediate indication for tracheal intubation. Ventilation and oxygenation are adequate, and the shock appears to be due to SVT. The treatment for SVT is synchronized cardioversion. If hypoventilation is present, provide bag-mask ventilation with supplementary oxygen.
Answers b and c are incorrect because further delay of cardioversion to reattempt vascular access cannot be justified in an infant with poor perfusion. In addition, a fluid bolus is not the best choice in this situation because the infant's poor systemic perfusion is most likely due to the tachycardia itself. Delay of cardioversion to give a fluid bolus is inappropriate.
34- You are preparing to provide attempt synchronized cardioversion for a child with supraventricular tachycardia. What is the recommended initial energy dose for synchronized cardioversion for infants and children?
a) 0.05 to 0.1 J/kg
b) 0.5 to 1 J/kg
c) 2 to 4 J/kg
d) 6 to 10 J/kg
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A starting dose of 0.5 to 1 J/kg is recommended for attempted cardioversion. If the patient remains in a rhythm requiring cardioversion, the energy dose should be doubled to 1 to 2 J/kg.
Answer a is incorrect because a dose of 0.05 to 0.1 J/kg is too low for routine cardioversion. If a child is known to be receiving a drug such as digitalis, a low initial cardioversion dose may be used. But digitalis therapy is a special resuscitation circumstance, and the initial dose would still be higher than 0.05 to 0.1 J/kg.
Answer c is incorrect because an initial dose of 2 to 4 J/kg is too high for routine cardioversion. If ventricular fibrillation occurs, attempted defibrillation with an initial dose of 2 J/kg is recommended. The recommended dose for subsequent defibrillation attempts is 4 J/kg.
Answer d is incorrect because 6 to 10 J/kg is much higher than the dose recommended for attempted cardioversion in infants and children.
35- An 18-month-old submersion (near-drowning) victim is currently stable in a community hospital ED. A tracheal tube is in place with proper position confirmed. The toddler is receiving mechanical ventilation and a low-dose dopamine infusion to support blood pressure and perfusion. Which of the following options is most appropriate for transporting this child from the community hospital to a tertiary care center?
a) a helicopter team with no paediatric experience that is 20 minutes away
b) the local EMS service with a Basic ambulance staff
c) a paediatric critical care transport team from the receiving tertiary care center that is 30 minutes away
d) the local basic EMS service with a paediatric nurse along to help
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Triage and transport decisions must be based on local EMS and transport conditions and on communication between the medical control teams from the referring and receiving institutions. Because the specifics of the given EMS/transport locale are unknown in this case, the best answer is the paediatric critical care transport team from the receiving tertiary care center. Paediatric critical care transport teams provide optimal transport for critically ill children, and they should generally be used to transport the most critically ill children. This preference is true even if the paediatric critical care team takes somewhat longer to arrive or to stabilize the patient than a less-skilled team.
Answer a is incorrect because a team with paediatric critical care expertise is preferable to a helicopter team without paediatric experience, particularly since the paediatric team can theoretically arrive within a few minutes of the helicopter team.
Answer b is incorrect because local EMS teams often do not have the training, experience, or equipment for long-distance transport of a critically ill child. Basic ambulance staff cannot re-intubate the patient if the tracheal tube becomes displaced.
Answer d is incorrect because local basic EMS service personnel will likely have limited experience in prehospital management of critically ill children, and the paediatric nurse may find it difficult to provide ongoing care in a moving vehicle with limited equipment and unfamiliar surroundings. The personnel accompanying critically ill children should be skilled in the interventions that potentially will be needed during transport (eg, establishment of vascular access, tracheal intubation, and relief of pneumothorax).
36- Which of the following is not a symptom of unstable tachycardia?
a) Shortness of breath
b) severe headache
c) Altered mental status
d) Chest pain
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37- A 3-year-old boy presents with multiple system trauma. The child was an unrestrained passenger in a motor vehicle crash. He is unresponsive to voice or painful stimulation, and his right pupil is dilated and responds sluggishly to light. His respiratory rate is less than 6 breaths/min, heart rate is 170 bpm, systolic blood pressure is 60 mm Hg, and capillary refill time is 5 seconds. What are the first actions you should take to support this child?
a) provide 100% oxygen by simple mask, immobilize the cervical spine, establish vascular access, and provide maintenance IV fluidsb) provide 100% oxygen by simple mask and perform a head-to-toe survey to identify the extent of all injuries; begin an adrenaline infusion and titrate to maintain a systolic blood pressure of at least 76 mm Hg
c) establish immediate vascular access, administer 20 mL/kg of isotonic crystalloid, and reassess the patient; if the child's systemic perfusion does not improve, administer 10 to 20 mL/kg of packed red blood cells
d) open the airway (jaw thrust technique) while immobilizing the cervical spine, administer positive-pressure ventilation, and attempt immediate tracheal intubation
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Children with multiple system trauma often present with shock and head injury. The first steps in their care include opening and clearing the airway while maintaining cervical spine immobilization. Assess respiratory rate and effort and begin positive-pressure ventilation. Then assess the adequacy of oxygenation, ventilation, and circulation, and treat life-threat-ening injuries. You will need to rapidly establish vascular access to administer a 20 mL/kg bolus of isotonic crystalloid because the child has signs of decompensated shock (ie, systolic blood pressure is <70 mm Hg + [2 × age in years]). After fluid administration, you should reassess the ABCs and systemic perfusion.
Answer a is incorrect because the victim’s ventilation is inadequate (respiratory rate <6 breaths/min), requiring assisted ventilation. Although the role of fluid resuscitation in paediatric trauma victims continues to be debated, support of airway and breathing with cervical spine immobilization takes priority over establishment of vascular access. In addition, maintenance fluids are insufficient for resuscitation of a child with decompensated hypovolemic shock.
Answer b is incorrect because airway and breathing should be supported in the initial assessment before the head-to-toe survey is performed. Adrenaline infusion is not indicated until after adequate volume resuscitation is provided.
Answer c is incorrect because vascular access and volume resuscitation (with crystalloid and with blood products) are not the initial priorities. Although those actions will eventually be required, you must first open the airway and provide assisted ventilation with 100% oxygen while keeping the cervical spine immobilized.
38-You are caring for a 7-year-old boy. The child was a pedestrian struck by a car. He is breathing spontaneously
with oxygen supplementation, and he has good central pulses. He has an open mid-shaft fracture of the right femur;
his right thigh is swollen and bleeding heavily. The child arrives in your medical facility with adequate ventilation and
perfusion, and his spine is immobilized. Which of the following are the best initial steps for you to take to treat this
child's leg injury?
a) apply direct pressure to the wound and continue to evaluate and support systemic perfusion, including perfusion of the leg
b) call the orthopedic surgeon and do not touch the leg
c) attempt to align the fracture and apply a tourniquet above the wound
d) attempt to control bleeding with haemostatic clamps, apply a tourniquet, and then attempt to align the fracture
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a
Initial support of systemic perfusion requires control of external haemorrhage and then ongoing assessment and support of cardiovascular function and systemic perfusion. Direct pressure is the best initial method to stop external bleeding. Use thin sterile gauze dressings and wear gloves. Bulky dressings are not recommended because they may absorb large amounts of blood and dissipate the pressure applied to the wound. Continued evaluation includes assessment of the severity of bleeding and evaluation of distal leg pulses.
Answer b is incorrect because you must immediately control the external haemorrhage. Do not wait for a consultant to treat life-threatening emergencies. The haemorrhage can often be controlled by simple application of direct pressure.
Answer c is incorrect because control of external haemorrhage and assessment and support of cardiovascular function are the priorities. Although an open long-bone fracture should be immobilized in an anatomic position, alignment is not the initial priority. Tourniquets should not be used except in cases of traumatic amputation associated with uncontrolled bleeding from a major vessel. You may need to reposition the leg if distal pulses are lost.
Answer d is incorrect because direct pressure to control the haemorrhage should be attempted first. Blind application of haemostatic clamps is not recommended.
39- You are alone when you see your neighbor's’ 13-year-old daughter floating face-down in their swimming pool. She is unresponsive, limp, and cyanotic when you pull her from the water. You did not witness her entry into the water.
Which of the following best summarizes the first steps you should take to maximize this adolescent's chances of survival?
a) shout for help, open her airway with a jaw thrust while keeping her cervical spine immobilized, check breathing, and provide 5 rescue breaths if she is not breathing adequately
b) carefully lay her on the ground,leave her to phone 111, and then return, open her airway, and continue the steps of CPR
c) immediately begin cycles of 30 chest compressions and 2 ventilations
d) shout for help and if no one arrives, open her airway with a head tilt–chin lift, check breathing, and provide 2 rescue breaths if she is not breathing adequately
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a
This victim is 13 years old. Although she falls within the age category for the "adult" sequence of BLS actions, which generally directs the lone rescuer to “phone first” before beginning the steps of CPR, submersion is a special resuscitation situation for victims of all ages. All submersion victims need immediate rescue breathing if they are not breathing when they are removed from the water. Whenever you rescue a submersion victim and the submersion was not witnessed, you should presume that head and neck injuries (eg, a diving injury) are present. You should immobilize the cervical spine and open the airway using a jaw thrust.
Answer b is incorrect because you should immediately check breathing and provide rescue breathing if the victim is not breathing adequately. You should not follow the typical "adult" sequence of resuscitation for submersion victims.
Answer c is incorrect. First, you should not begin chest compressions unless there are no signs of circulation after you have delivered 5 rescue breaths. Second, a 15:2 compression-to-ventilation ratio is recommended for children 1 to 8 years of age where there are 2 people with a duty to respond (such as health professionals, but a 30:2 ratio is recommended for single rescuers, as well as for children 8 years of age and older and for adults, particularly for prehospital BLS.
Answer d is incorrect because you should not use a head tilt–chin lift to open the airway. The victim may have a head or neck injury. You should treat all submersion victims as though they have a head or neck injury unless you witnessed the submersion.
40- You are assisting at field event, in a professional sports facility, You witness a young teenage girl collapse while running. She is unresponsive. when you arrive at her side. Other bystanders have called for an ambulance and are performing well-coordinated CPR. They report that the teen has no known health problems, is now apnoeic and pulseless. Which of the following actions would most likely improve this teen’s chance of survival?
a) take over mouth-to-mouth resuscitation
b) attach and operate an AED as soon as one can be is retrieved
c) provide crowd control
d) get a blanket to keep the patient warm
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b
Although primary cardiac events are an uncommon cause of cardiopulmonary arrest in the young, they do occur, and they are more common in adolescents than in infants and children. This scenario describes an adolescent with an apparent primary cardiac event during strenuous exertion. With sudden cardiac arrest, the most likely rhythm is ventricular fibrillation or pulseless ventricular tachycardia. The most effective treatment for VF/pulseless VT is defibrillation, so defibrillation should be attempted as soon as possible. Because this victim is older than 8, an AED can be used.
Answer a is incorrect because you should not interfere with well-coordinated CPR.
Answer b is incorrect because crowd control, although helpful, will not contribute to this girl's survival.
Answer d is incorrect because the therapies that will have the greatest impact on this girl's survival are prompt bystander CPR and early defibrillation.
41- What is not a typical sign of respiratory distress?
a) tachypnea
b) fever
c) nasal flaring
d) tachycardia
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42- What is the most common form of infectious pneumonia which often causes empyema?
a) streptococcus pneumoniae
b) mycoplasma pneumoniae
c) chlamydia pneumoniae
d) staphylococcus pneumoniae
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a
43- Children with increased ICP typically will present with all the following
except:
a) irregular breathing
b) bradycardia
c) tachycardia
d) hypertension
to view the answer to the question above44- Shock occurs with the following level of blood pressure:
a) decreased
b) increased
c) normal
d) all the above
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45- Myocordial dysfunction impairs cardiac output and stroke volume
which can typically lead to:
a) cardiogenic shock
b) septic shock
c) anaphylactic shock
d) neurogenic shock
a
46- Which is not a common assessment when determining the
effectiveness of fluid resuscitation?
a) temperature
b) heart rate
c) skin coloration
d) urine output
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a
47- For cardiogenic shock, you should deliver a fluid challenge (5 to 10
mL/kg bolus) over what length of time?
a) 1-5 minutes
b) 5-10 minutes
c) 10-20 minutes
d) under 3 minutes
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c
48- ______________ is described as an accumulation of pressurized air
in the pleural space.
a) tension pneumothorax
b) cardiac tamponade
c) massive pulmonary embolism
d) none of the above
a
49- What is the first sign of the body's defensive response when a child
or infant is in shock?
a) body temperature drop
b) body temperature rise
c) heart rate increase
d) heart rate decrease
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50- The first warning sign of respiratory distress is:
a) decrease of heart rate
b) increase in blood pressure
c )increase in respiratory rate
d) decrease in body temperature
51- What age period is croup most common to occur?
a) 3 - 5 years
b) months - 3 years
c) 4 - 7 years
d) 1 month - 12 months
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