Pediatric Critical Care Practice Questions

Q: What is the capillary refill time in a child with shock?

Greater than 3 seconds. **Explanation:** Capillary Refill Time (CRT) is a rapid clinical assessment tool used to evaluate peripheral perfusion. In a healthy child, CRT is typically less than 2 seconds. In the setting of **shock**, the body initiates a compensatory sympathetic response, leading to peripheral vasoconstriction to divert blood flow to vital organs (heart and brain). This reduced cutaneous perfusion results in a delayed CRT. * **Why Option C is Correct:** According to the **PALS (Pediatric Advanced Life Support)** and **WHO** guidelines, a CRT of **greater than 3 seconds** is considered a clinical sign of impaired systemic perfusion and is a hallmark of shock in children. It indicates significant peripheral vasoconstriction or decreased cardiac output. * **Why Options A & B are Incorrect:** A CRT of 1 or 2 seconds is considered within the **normal physiological range** for a child in a neutral thermal environment. These values do not indicate the circulatory compromise required to diagnose shock. * **Why Option D is Incorrect:** While a CRT >4 seconds certainly indicates shock, it is a late or more severe finding. The standard diagnostic threshold for identifying the onset of clinical shock is >3 seconds. **High-Yield Clinical Pearls for NEET-PG:** * **Technique:** CRT should be measured by applying firm pressure for 5 seconds to a blanchable skin surface (ideally the fingernail bed or chest) at the level of the heart. * **False Positives:** Cold ambient temperature can prolong CRT even in the absence of shock. * **Septic Shock Paradox:** In "Warm Shock" (early distributive shock), the CRT may actually be **brisk ( 3 seconds is also a key predictor of >5% dehydration in children with gastroenteritis.

Q: An infant presents to the emergency department unresponsive, with bradycardia and shallow breathing. What is the next step in management?

Cardiopulmonary resuscitation. **Explanation:** The correct answer is **Cardiopulmonary Resuscitation (CPR)**. This question follows the **PALS (Pediatric Advanced Life Support)** guidelines for managing a pediatric patient in cardiopulmonary arrest or pre-arrest. **Why CPR is the correct step:** In pediatrics, the primary cause of cardiac arrest is usually respiratory failure leading to hypoxia. This infant is unresponsive with shallow breathing (respiratory failure) and bradycardia. According to PALS guidelines, if a child/infant is unresponsive, not breathing (or only gasping), and has a **heart rate < 60 bpm with signs of poor perfusion** despite adequate oxygenation/ventilation, chest compressions must be started immediately. CPR in infants ensures coronary and cerebral perfusion while addressing the underlying hypoxia. **Why other options are incorrect:** * **A & B (Epinephrine/Atropine):** Pharmacological interventions are secondary to establishing high-quality CPR and airway management. Epinephrine is given only after CPR has commenced and rhythm is assessed. Atropine is not the first-line drug for bradycardia unless it is caused by increased vagal tone or primary AV block. * **C (Stabilize airway and assist breathing):** While airway management is crucial, the presence of bradycardia (<60 bpm) in an unresponsive infant indicates that cardiac output is insufficient to sustain life. One should not delay compressions to only focus on the airway. **Clinical Pearls for NEET-PG:** * **Compression Depth:** At least 1/3rd the AP diameter of the chest (approx. 4 cm in infants). * **Technique:** Two-finger technique (single rescuer) or Two thumb-encircling hands technique (two rescuers). * **Ratio:** 30:2 (single rescuer) or 15:2 (two rescuers). * **Pulse Check:** Brachial artery in infants; Carotid or Femoral in children.

Q: What is the amount of fluid to be given to a 2-year-old child weighing 12 kg with severe dehydration in the first half an hour of IV rehydration?

360 ml. ### Explanation The management of severe dehydration in children follows the **WHO Plan C** protocol. For a child over 1 year of age, the total intravenous fluid requirement is **100 ml/kg**, administered over 3 hours. **The Calculation:** * **Total Fluid:** 100 ml/kg × 12 kg = 1200 ml. * **First Phase (First 30 minutes):** 30 ml/kg. * 30 ml × 12 kg = **360 ml**. * **Second Phase (Next 2.5 hours):** 70 ml/kg. * 70 ml × 12 kg = 840 ml. Therefore, **360 ml** is the correct volume to be administered in the first 30 minutes. **Analysis of Incorrect Options:** * **Option A (120 ml):** This represents 10 ml/kg, which is insufficient for initial resuscitation in severe dehydration. * **Option B (240 ml):** This represents 20 ml/kg. While 20 ml/kg is the standard bolus for **hypovolemic shock**, the WHO Plan C specifically mandates 30 ml/kg for severe dehydration in the first phase. * **Option D (840 ml):** This is the volume for the **second phase** (remaining 2.5 hours) of the rehydration process. **High-Yield Clinical Pearls for NEET-PG:** 1. **Fluid of Choice:** Ringer’s Lactate (RL) is preferred. If RL is unavailable, Normal Saline (NS) can be used. 2. **Age Differentiation:** * ** 1 year:** 30 ml/kg in 30 mins, then 70 ml/kg in 2.5 hours (Total 3 hours). 3. **Assessment:** Reassess the child every 15–30 minutes. If the radial pulse is still weak, repeat the first 30 ml/kg bolus.

Q: What is the fluid of choice for a child with a burn sustained less than 24 hours ago?

Ringer lactate. **Explanation:** The management of pediatric burns in the first 24 hours focuses on aggressive volume resuscitation to counteract "burn shock," which is characterized by increased capillary permeability and massive fluid shifts from the intravascular to the interstitial space. **Why Ringer Lactate (RL) is the Correct Choice:** RL is the preferred crystalloid because its electrolyte composition closely resembles human plasma (isotonic). Unlike Normal Saline, RL contains sodium lactate, which is metabolized into bicarbonate, helping to buffer the metabolic acidosis commonly seen in burn patients. It prevents the development of hyperchloremic metabolic acidosis, which can occur with large volumes of 0.9% NaCl. **Analysis of Incorrect Options:** * **Fresh Frozen Plasma (FFP):** While burns cause protein loss, colloids like FFP are generally avoided in the first 8–12 hours because increased capillary permeability allows these large molecules to leak into the interstitium, worsening edema. * **Isolyte-P:** This is a hypotonic maintenance fluid. Using hypotonic solutions for initial resuscitation can lead to dangerous hyponatremia and cerebral edema. * **Platelet Transfusion:** This is not a resuscitation fluid; it is only indicated if there is documented thrombocytopenia or active coagulopathy. **High-Yield Clinical Pearls for NEET-PG:** * **Parkland Formula:** $4 \text{ mL} \times \text{Body Weight (kg)} \times \text{TBSA (\%)} = \text{Total fluid in 24 hours}$. Give half in the first 8 hours and the remainder over the next 16 hours. * **Pediatric Specifics:** Children <20 kg have limited glycogen stores; therefore, **Maintenance Fluid (containing 5% Dextrose)** must be added to the Parkland requirement to prevent hypoglycemia. * **Monitoring:** The most reliable indicator of adequate resuscitation is **Urine Output** (Target: $1 \text{ mL/kg/hr}$ in children; $0.5 \text{ mL/kg/hr}$ in adults).

Q: What is the proper rate of rescue breathing in children?

20 times per minute. **Explanation:** The correct rate of rescue breathing in children (infants and children up to the onset of puberty) is **20 times per minute**, which translates to **one breath every 2–3 seconds**. This guideline is based on the **2020 AHA (American Heart Association) Update for PALS**, which increased the recommended rate from the previous 12–20 bpm to a fixed, higher frequency to better match the physiological demands of a critically ill child. **Analysis of Options:** * **Option B (20 bpm):** This is the current standard for pediatric rescue breathing when a pulse is present but spontaneous breathing is absent or inadequate. * **Option A (12 bpm):** This was the lower end of the previous recommendation (12–20 bpm) and is now considered too slow for pediatric resuscitation. * **Option C (8 bpm):** This is significantly below the physiological requirement for any pediatric age group and would lead to hypercapnia and hypoxia. * **Option D (24 bpm):** While closer to the physiological respiratory rate of an infant, it exceeds the standardized BLS/PALS rescue breathing protocol of 20 bpm. **High-Yield Clinical Pearls for NEET-PG:** 1. **Rescue Breathing vs. Advanced Airway:** If an advanced airway (ET tube) is in place during CPR, the ventilation rate is also **one breath every 2–3 seconds (20–30 bpm)**, regardless of age. 2. **Pulse Check:** In pediatric BLS, if the heart rate is **<60 bpm** with signs of poor perfusion despite oxygenation/ventilation, start chest compressions even if a pulse is palpable. 3. **Adult Rate:** For adults, the rescue breathing rate remains **10–12 times per minute** (one breath every 5–6 seconds).

Q: In children, intraosseous lines are typically placed in which bone?

Tibia. **Explanation:** Intraosseous (IO) access is a life-saving procedure in pediatric resuscitation when peripheral intravenous access cannot be established within 90 seconds or three attempts. The **proximal tibia** is the most common and preferred site in children due to its thin cortex, easily identifiable landmarks (it is subcutaneous), and large marrow cavity which acts as a "non-collapsible vein." * **Tibia (Correct):** The preferred site is the **proximal tibia**, specifically 1–3 cm distal to the tibial tuberosity on the anteromedial surface. In older children, the **distal tibia** (proximal to the medial malleolus) is an alternative. * **Femur (Incorrect):** While the distal femur can be used in infants and young children, it is technically more difficult due to the thick layer of overlying fat and muscle, making landmarks harder to palpate compared to the tibia. * **ASIS/Iliac Crest (Incorrect):** These sites are rarely used for IO access in children. While the iliac crest is a common site for bone marrow aspiration/biopsy, it is not a primary site for emergency fluid resuscitation due to positioning difficulties during CPR. **Clinical Pearls for NEET-PG:** * **Indication:** Any emergency (shock, cardiac arrest) where IV access is delayed. * **Contraindications:** Fracture of the target bone, overlying skin infection (cellulitis), or previous IO attempt in the same bone. * **Flow Rates:** Fluids, blood products, and all ACLS medications can be given via IO. Pressure bags are often required to achieve adequate flow. * **Complication:** Osteomyelitis is the most serious (though rare) complication; others include compartment syndrome and growth plate injury.

Q: A child presents with hypovolemic shock, anuria, and respiratory acidosis. What is the appropriate initial treatment?

Ringer's Lactate. **Explanation:** The primary goal in the management of **hypovolemic shock** is the restoration of intravascular volume and organ perfusion. **Why Ringer’s Lactate (RL) is the Correct Choice:** In pediatric shock, the initial priority is the "ABC" (Airway, Breathing, and Circulation). For circulation, the standard of care is the rapid administration of an isotonic crystalloid bolus (20 ml/kg). **Ringer’s Lactate** is preferred over Normal Saline in many scenarios because its electrolyte composition is more physiological, reducing the risk of hyperchloremic metabolic acidosis. Restoring volume will improve renal perfusion (addressing anuria) and tissue oxygenation, which often corrects the underlying acid-base imbalance without further intervention. **Analysis of Incorrect Options:** * **Dopamine & Dobutamine (B & C):** These are inotropic/vasopressor agents. They are contraindicated as initial therapy in hypovolemic shock because they increase myocardial oxygen demand and cannot improve cardiac output if the "tank is empty" (preload is insufficient). They are only considered in fluid-refractory shock. * **Sodium Bicarbonate (D):** While the patient has respiratory acidosis, the definitive treatment is improving ventilation and perfusion. Bicarbonate is rarely indicated in initial resuscitation and can paradoxically worsen intracellular acidosis and cause a shift in the oxyhemoglobin dissociation curve. **NEET-PG High-Yield Pearls:** * **Initial Fluid Bolus:** 20 ml/kg of isotonic crystalloid (RL or NS) over 5–10 minutes. * **Goal of Therapy:** Improvement in heart rate, capillary refill time ( 1 ml/kg/hr). * **Acidosis in Shock:** Most metabolic acidosis in shock is "Lactic Acidosis" due to anaerobic metabolism; it corrects with volume expansion.

Question 1

What is the capillary refill time in a child with shock?

Accepted Answer

Greater than 3 seconds

Answer

Greater than 1 second

Answer

Greater than 2 seconds

Answer

Greater than 4 seconds

Question 2

An infant presents to the emergency department unresponsive, with bradycardia and shallow breathing. What is the next step in management?

Accepted Answer

Cardiopulmonary resuscitation

Answer

Intravenous epinephrine

Answer

Intravenous atropine

Answer

Stabilize the airway and assist breathing

Question 3

What is the drug of choice for anaphylactic shock in a 10-year-old child?

Accepted Answer

Intravenous adrenaline

Answer

Subcutaneous adrenaline

Answer

Antihistamine

Answer

Corticosteroids

Question 4

What is the amount of fluid to be given to a 2-year-old child weighing 12 kg with severe dehydration in the first half an hour of IV rehydration?

Accepted Answer

360 ml

Answer

120 ml

Answer

240 ml

Answer

840 ml

Question 5

What is the fluid of choice for a child with a burn sustained less than 24 hours ago?

Accepted Answer

Ringer lactate

Answer

Fresh frozen plasma

Answer

Isolyte-P

Answer

Platelet transfusion

Question 6

Management of raised intracranial pressure in a child with head injury admitted to the ICU includes all of the following except:

Accepted Answer

Minimal use of sedation and analgesia

Answer

Mannitol, if there is no intracranial hemorrhage

Answer

Controlled mechanical ventilation

Answer

Hypertonic saline may be used

Question 7

What is the proper rate of rescue breathing in children?

Accepted Answer

20 times per minute

Answer

12 times per minute

Answer

8 times per minute

Answer

24 times per minute

Question 8

In children, intraosseous lines are typically placed in which bone?

Accepted Answer

Tibia

Answer

Femur

Answer

ASIS

Answer

Iliac crest

Question 9

An infant weighing 4 kg presents with severe dehydration (10% dehydration). Calculate the total intravenous fluid requirement for the first 24 hours.

Accepted Answer

500 ml

Answer

800 ml

Answer

100 ml

Answer

1200 ml

Question 10

A child presents with hypovolemic shock, anuria, and respiratory acidosis. What is the appropriate initial treatment?

Accepted Answer

Ringer's Lactate

Answer

Dopamine

Answer

Dobutamine

Answer

Sodium Bicarbonate injection

Pediatric Critical Care — MCQs

Pediatric Critical Care — MCQs

On this page

Practice by Chapter

Want unlimited practice?