SHOCK

Questions
Getting back to our Case Scenario 2: A 12-year-old girl (40 kg body weight) presents with the
chief complaint of respiratory distress and lethargy over the past 18 hours. Parents state that
this morning she didn’t feel well. Initial respiratory rate is 40 breaths per minute. Lung exam is
notable for tachypnea, slight subcostal retractions and nasal flaring. Aeration is good bilaterally
and with faint, fine crackles over the lung bases. No wheezing is appreciated. She is arousable
but difficult to maintain attention, poorly following commands, and not particularly bothered by
peripheral IV insertion. Cardiac exam is notable for significant tachycardia with a HR of 150, BP
75/35, mean arterial pressure (MAP) 48. Radial pulses are weak, femoral pulses palpable, fair.
Hands and feet feel cool to touch. CRT is 5 seconds in the fingers and toes, 4 seconds over the
sternum. Abdominal exam is without tenderness or distention. A liver edge is noted to be 5 cm
below the right costal margin. Neurologically, she appears to be moving all of her extremities
with mild grimacing, weak speech, and localized flexion withdrawal to pinching. Pupils are 4 mm
in diameter and are briskly reactive to light. Skin exam unremarkable for any rash.

Initial triage: Initial saturation of peripheral oxygen (SpO2) is 92% on room air. Despite lack of
appreciable wheezing, a trial of nebulized albuterol and ipratropium solution is given via
nebulizer face mask with the fraction of inspired oxygen (FiO2) of 1.0 with no effect. Oxygen face
mask is then changed to a non-rebreather mask at 10 L/min, FiO21.0 with SpO2 95%. Upon PIV
insertion, samples are obtained for laboratory evaluation while fluid is being prepared for
administration.

1. What type of fluid should initially be given?

a. 25% albumin over 30 to 60 min
b. 1-unit PRBC over 60 min
c. 0.45% NaCl solution (1/2 NS), 10 to 20 mL/kg rapid infusion
d. 0.9% NaCl solution (NS), 10 to 20 mL/kg rapid infusion
e. D5 NS, 10 to 20 mL/kg rapid infusion

After a few minutes into the infusion, the patient becomes more tachycardic and hypotensive
with worsening dyspnea and lethargy. SpO2 falls to 85% despite the non-rebreather mask.
Upon re-examination of the abdomen, the liver edge is noted to be 4 cm below the right costal
margin.

2. Your next immediate interventions are...

a. give an additional fluid bolus immediately following the first bolus and increase the
oxygen flow rate to 20 L/min
b. slow down the fluid infusion to be given over 60 min and prepare to intubate
c. stop the fluid bolus immediately and begin airway support with manual positive
pressure ventilation via bag-valve-mask while preparing to begin a vasoactive infusion
d. begin dopamine infusion immediately and prepare to intubate.
 e. start chest compressions and begin airway support with manual rescue breathing via
bag-valve-mask

Blood pressure improves to 80/50 after the start of the hemodynamic medication infusion. SpO2
remains at 87% despite manual ventilation on FiO2 of 1.0. Patient is then intubated. Copious
amounts of pink, frothy fluid erupts through the larynx upon direct laryngoscopy during
intubation. SpO2 is eventually improved to 92% after escalating mechanical ventilatory support
and remaining on FiO2 of 1.0. Lung auscultation reveals fair aeration bilaterally with equal
breath sounds, moderate diffuse crackles with slight end-expiratory wheeze. BP decreases to
60/40, HR 195. Distal pulses are thready with cool, pale extremities, central pulses are weak.
CRT peripherally is >5 seconds, centrally 5 seconds. Heart sounds are appreciated, but HR is
too fast to be able to appreciate any abnormal sounds.

3. The next appropriate hemodynamic intervention is...

a. begin an epinephrine continuous infusion
b. begin chest compressions
c. begin a vasopressin continuous infusion
d. give a stress-dose hydrocortisone bolus
e. begin a norepinephrine continuous infusion

Blood pressure improves to 75/55, HR 190. Extremities exam is relatively unchanged. Lactate
from the PIV insertion is 10 mmol/L (normal <2). An arterial catheter is emergently placed. The
arterial blood gas is pH 7.18, pCO2 35, pO2 65, base excess -14. Lactate from the arterial
sample is 9.5 mmol/L. iCa is 0.85 mmol/L (normal 1.20 to 1.32). A CVC is emergently placed.

4. The next medication to try now to improve cardiac output is...

a. Bicarbonate, NaHCO3
b. Hydrocortisone stress dose
c. Cosyntropin stimulation challenge to determine efficacy for stress-dose corticosteroids
d. Calcium, as calcium chloride
e. Calcium, as calcium carbonate

BP improves to 90/65, HR 170 after medication given.

5. The following evaluative interventions are reasonable at this time EXCEPT:

a. Echocardiography
b. eFAST exam
c. Chest radiograph
d. 12-lead electrocardiogram
e. Viral, bacterial and fungal samplings for analysis

6. Other reasonable interventions to consider include which of the following (select all that
apply):
a. Calcium continuous infusion
b. Milrinone continuous infusion
 c. Bronchoalveolar lavage
d. Continuous renal replacement therapy

DROWNING AND SUBMERSION

Questions
1. All of the following are considered risk factors for drowning except:
a. Head trauma
b. Alcohol use
c. Upper respiratory infection with wheezing
d. Seizure disorder
e. Illegal drug use

2. True/False: The AAP supports swimming classes for children over 1 year of age.

3. Which of the following factors is associated with a poor outcome in a drowning case?
a. Low blood sugar level
b. Submersion longer than 5 minutes
c. Drug or alcohol use
d. Return of spontaneous cardiac rhythm following CPR
e. CPR for less than 3 minutes

4. Which of the following interventions will improve the outcome in a drowning victim?
a. Early intubation
b. Transfer to a trauma center
c. Intravenous access
d. Early bystander CPR
e. Cervical spine precautions

5. All of the following are complications after a submersion injury except?

a. Acute respiratory distress syndrome (ARDS)
b. Arrhythmias
c. Renal dysfunction
d. Hypernatremia
e. Aspiration pneumonia
RESPIRATORY FAILURE

Questions

1. True/False: To diagnose respiratory failure one must obtain an ABG.

2. Etiologies of respiratory failure include:

. . . . .a. burns
. . . . .b. botulism
. . . . .c. asthma
. . . . .d. pneumonia
. . . . .e. c & d
. . . . .f. all of the above

3. Upper airway problems are generally manifest by:

. . . . .a. wheezing
. . . . .b. grunting respirations
. . . . .c. stridor
. . . . .d. tracheal deviation

4. A previously healthy child with acute onset of respiratory distress and unilateral wheezing should be
suspected of having:
. . . . .a. reactive airway disease
. . . . .b. croup
. . . . .c. foreign body
. . . . .d. epiglottitis

5. Children with a central nervous system depression resulting in respiratory failure often display:
. . . . .a. retractions
. . . . .b. rapid abdominal breathing
. . . . .c. head bobbing
. . . . .d. none of the above

6. Reactive airway disease is characterized by:

. . . . .a. distal airway swelling
. . . . .b. increased secretions
. . . . .c. airway constriction
. . . . .d. wheezing
. . . . .e. all of the above

7. True/False: Respiratory distress in a child with a tracheostomy should be considered a plugged or

misplaced tracheostomy tube, until proven otherwise.

8. ARDS is characterized by:

. . . . .a. large alveolar-arterial gradient
. . . . .b. reduced compliance
. . . . .c. mortality rate of 5% to 10%
. . . . .d. a & b
TOXICOLOGY

Questions

1. The majority of accidental ingestions in the pediatric population occur in which age group?
. . . . . a. 6 months to 1 year of age.
. . . . . b. 18 months to 3 years of age.
. . . . . c. 4 years to 6 years of age.
. . . . . d. 8 years to 12 years of age.

2. The most common route of toxic exposures is via:

. . . . . a. Inhalation.
. . . . . b. Dermal contact.
. . . . . c. Bites and stings.
. . . . . d. Ingestion.
. . . . . e. Ocular contact.

3. A mother of a 2 year old boy calls you because she suspects that her son may have eaten a few of his
grandmother's "heart pills." She claims that her son seems fine and that the possible ingestion may have
occurred 30 minutes ago. What is the best action for you to take as the child's pediatrician?
. . . . . a. Have the mother induce vomiting immediately by sticking her finger in the child's mouth.
. . . . . b. Immediately give the child eight ounces of water or milk to dilute the concentration of pills in his
stomach.
. . . . . c. Have her administer ipecac syrup immediately in order to induce vomiting.
. . . . . d. Advise no interventions at the present time, but also advise her that if the child should begin to
develop any symptoms to go to the emergency department for further treatment.
. . . . . e. Call you local poison control center immediately for advice.

4. The gastrointestinal decontamination method of choice for a child who presents to the emergency
department with multiple episodes of vomiting two hours after ingesting a toxic amount of iron is:
. . . . . a. Syrup of ipecac.
. . . . . b. Orogastric lavage.
. . . . . c. Activated charcoal with sorbitol.
. . . . . d. Multiple doses of activated charcoal.
. . . . . e. Whole bowel irrigation.

5. A child with a suspected ingestion presents to the emergency department with delirium, tachycardia,
mydriasis, dry mucus membranes and warm/dry skin. This child exhibits signs and symptoms of which
toxidrome?
. . . . . a. Anticholinergic.
. . . . . b. Sympathomimetic.
. . . . . c. Cholinergic.
. . . . . d. Opioid.
. . . . . e. Sedative hypnotic.

6. A parent suspects that her 18 month old son may have accidentally ingested a few pellets of rat poison.
The mother should:
. . . . . a. Not panic and simply wait to see if her son develops any signs and symptoms of toxicity before
calling her pediatrician.
. . . . . b. Call 911 immediately since this may be a medical emergency.
. . . . . c. Call her local poison control center immediately for advice, rather than waiting to see if
her son will develop signs and symptoms of toxicity.
. . . . . d. Induce vomiting by giving her son a teaspoon of ipecac syrup.
. . . . . e. Rush her son to the nearest emergency department for immediate gastric lavage and activated
charcoal.

7. Activated charcoal would NOT be an effective method of gastrointestinal decontamination for which
one of the following ingestions?
. . . . . a. Albuterol.
. . . . . b. Ferrous sulfate.
. . . . . c. Amoxicillin.
. . . . . d. Carbamazepine.
. . . . . e. Phenobarbital.
PULMONARY RESUSCITATION

Questions

1. The most common cause of pulmocardiac arrest in children is:

. . . . . a. Acute myocardial infarction
. . . . . b. Hemorrhagic shock
. . . . . c. Nonaccidental trauma
. . . . . d. Ventricular fibrillation
. . . . . e. Hypoxia and respiratory failure

2. Endotracheal intubation is not indicated for which of the following:

. . . . . a. Control and protection of the airway.
. . . . . b. Prolonged mechanical ventilation.
. . . . . c. Tension pneumothorax.
. . . . . d. Hyperventilation of the patient with a head injury.
. . . . . e. Improved oxygen delivery and ventilation.

3. The drug/treatment of choice for asystole in children is:

. . . . . a. Atropine
. . . . . b. Calcium chloride
. . . . . c. Adenosine
. . . . . d. Defibrillation
. . . . . e. Epinephrine

4. A 12 year old child comes to the ED pulseless. ECG reveals a wide complex tachycardia. Initial
management should be:
. . . . . a. Immediate defibrillation.
. . . . . b. Immediate synchronized cardioversion.
. . . . . c. Adenosine
. . . . . d. Epinephrine

5. The most common cause of PEA in children is:

. . . . . a. Tension pneumothorax
. . . . . b. Metabolic acidosis
. . . . . c. Toxic ingestions
. . . . . d. Profound hypovolemia
. . . . . e. Hyperkalemia

6. The most common cause of bradycardia in children is:

. . . . . a. Hypokalemia
. . . . . b. Heart block
. . . . . c. Hypoxemia
. . . . . d. Toxic ingestions
. . . . . e. Myocarditis