Pediatric Critical Care Practice Questions

Q: A 3-year-old child weighing 15 kg in the pediatric ICU has developed ventricular fibrillation (VF) and is undergoing cardiopulmonary resuscitation (CPR). As the physician on call, you decide to attempt defibrillation to restore normal rhythm. What is the recommended initial energy dose for defibrillation in this scenario?

60 J. **Explanation:** The management of pediatric cardiac arrest with a shockable rhythm (Ventricular Fibrillation or Pulseless Ventricular Tachycardia) follows the **PALS (Pediatric Advanced Life Support)** guidelines. **1. Why 60 J is correct:** The recommended initial energy dose for manual defibrillation in children is **2 J/kg**. * **Calculation:** 15 kg (child’s weight) × 2 J/kg = **30 J**. * However, if the initial shock is unsuccessful, the subsequent dose is increased to **4 J/kg**. * *Note on the Question:* In many clinical scenarios and standardized exams, if the initial 2 J/kg dose is not provided as an option or if the question implies a second attempt/escalation, the 4 J/kg dose is sought. For a 15 kg child, 4 J/kg equals **60 J**. (According to PALS, the sequence is 2 J/kg for the first shock, 4 J/kg for the second, and ≥4 J/kg for subsequent shocks, up to a maximum of 10 J/kg or the adult dose). **2. Why the incorrect options are wrong:** * **Options B, C, and D (280 J, 250 J, 320 J):** These doses are significantly higher than the pediatric safety limit. The maximum dose for pediatric defibrillation should not exceed **10 J/kg** or the standard adult dose (usually 200 J for biphasic or 360 J for monophonic). Using these doses on a 15 kg child would cause significant myocardial damage. **High-Yield Clinical Pearls for NEET-PG:** * **Defibrillation Doses:** 1st shock: 2 J/kg; 2nd shock: 4 J/kg; Subsequent: ≥4 J/kg (Max 10 J/kg). * **Synchronized Cardioversion:** Used for SVT or VT with pulses; dose is **0.5–1 J/kg** (initial) to **2 J/kg**. * **Paddle Size:** Use large paddles (>8 cm) for children >10 kg and small paddles (4.5 cm) for infants <10 kg. * **Epinephrine:** Administer 0.01 mg/kg (0.1 mL/kg of 1:10,000 concentration) every 3–5 minutes during CPR.

Q: What is the recommended endotracheal concentration of adrenaline during CPR in pediatric patients?

1:1,000. **Explanation:** In pediatric resuscitation, the preferred routes for adrenaline administration are intravenous (IV) or intraosseous (IO). However, if vascular access cannot be established, the **endotracheal (ET) route** is used. **1. Why 1:1,000 is Correct:** The standard IV/IO dose of adrenaline is **0.01 mg/kg** using the **1:10,000** concentration. However, drug absorption via the ET route is unpredictable and significantly less efficient than the IV route. To achieve comparable plasma levels, the **PALS (Pediatric Advanced Life Support) guidelines** recommend a much higher ET dose: **0.1 mg/kg**. To avoid delivering an excessive volume of fluid into the lungs, this higher dose is administered using the concentrated **1:1,000 (1 mg/ml)** preparation. **2. Why Incorrect Options are Wrong:** * **Option C (1:10,000):** This is the standard concentration used for **IV/IO** administration. Using this for the ET route would require 10 times the volume, potentially causing surfactant washout or interfering with gas exchange. * **Options A & B (1:10 lakhs / 1:1 lakh):** These are highly dilute concentrations (often used in local anesthesia with lidocaine) and are insufficient for cardiac arrest resuscitation. **High-Yield Clinical Pearls for NEET-PG:** * **ET Dose Rule of Thumb:** The ET dose of adrenaline is **10 times** the IV dose (0.1 mg/kg vs. 0.01 mg/kg). * **Administration:** After ET instillation, follow with several positive-pressure breaths to ensure peripheral distribution. * **Drugs via ET Tube (LEAN/NAVEL):** Remember the mnemonic **LEAN** (Lidocaine, Epinephrine, Atropine, Naloxone) or **NAVEL** (+ Vasopressin) for drugs that can be given endotracheally. * **Preferred Route:** Always prioritize IO access over ET if IV access fails, as IO pharmacokinetics are identical to IV.

Q: What is the initial fluid of choice for the treatment of hypernatremic dehydration?

Normal saline (0.9% NaCl). **Explanation:** The management of hypernatremic dehydration (Serum $Na^+ > 150$ mEq/L) follows a two-step priority: **restoration of intravascular volume** followed by a **slow correction** of the free water deficit. **1. Why Normal Saline (0.9% NaCl) is the Correct Choice:** Regardless of the serum sodium level, the immediate priority in any dehydrated patient with signs of circulatory compromise is to restore hemodynamic stability. **Normal Saline (0.9% NaCl)** is an isotonic crystalloid that remains in the extracellular space, effectively expanding the intravascular volume and improving tissue perfusion. Even though the patient is hypernatremic, 0.9% NaCl is "hypotonic" relative to the patient's hyperosmolar plasma, making it safe for initial resuscitation. **2. Why the Other Options are Incorrect:** * **B & C (Half/Quarter Normal Saline):** These are hypotonic fluids. Using them during the initial phase can cause a rapid drop in serum osmolality, leading to a shift of water into brain cells, resulting in **cerebral edema** and seizures. * **D (Dextrose 5%):** D5W is functionally free water once the glucose is metabolized. It is contraindicated in acute resuscitation as it does not stay in the vascular compartment and poses the highest risk for rapid osmotic shifts. **Clinical Pearls for NEET-PG:** * **Rate of Correction:** In hypernatremia, the serum sodium should not be lowered faster than **0.5 mEq/L/hour** (or <10–12 mEq/L in 24 hours) to prevent cerebral edema. * **Maintenance Phase:** After initial boluses with NS, the fluid of choice for the deficit replacement phase is typically **0.45% Saline**. * **Breastfeeding Malnutrition:** A classic NEET-PG scenario for hypernatremic dehydration is a neonate with poor breastfeeding technique and significant weight loss.

Q: A 15-month-old girl has a history of poor oral fluid intake, occasional vomiting, rapid breathing, and decreased urine output. Physical examination reveals a pulse of 150/min, BP of 120/80, and a respiratory rate of 60/min. There are bibasilar rales, and the liver is palpable. Which of the following procedures might be helpful in evaluating the oliguria, EXCEPT?

Giving a fluid challenge with isotonic saline, 20 ml/kg. **Explanation:** The clinical presentation of this 15-month-old girl—tachycardia (150/min), tachypnea (60/min), bibasilar rales, and a palpable liver—is diagnostic of **Congestive Heart Failure (CHF)**. In this context, the oliguria is likely due to decreased cardiac output and renal perfusion. **1. Why Option A is the correct answer (The "Except"):** In a patient with signs of fluid overload or heart failure (rales and hepatomegaly), giving a **fluid challenge (20 ml/kg of isotonic saline)** is contraindicated. It can acutely worsen pulmonary edema and lead to respiratory failure. While fluid boluses are the standard treatment for hypovolemic shock, they are dangerous in cardiogenic shock or CHF. **2. Analysis of Incorrect Options:** * **Option B (Urine Sodium):** This helps differentiate between pre-renal azotemia (where urine sodium is typically 40 mEq/L), aiding the evaluation of oliguria. * **Option C (BUN and Creatinine):** These are essential baseline markers to assess the degree of renal impairment and the BUN/Creatinine ratio. * **Option D (IV Furosemide):** In the setting of CHF and fluid overload, a diuretic challenge can help determine if the kidneys are responsive and simultaneously treat the underlying pulmonary congestion. **Clinical Pearls for NEET-PG:** * **Hepatomegaly + Respiratory Distress:** In a pediatric patient, this combination should immediately raise suspicion of **Heart Failure**, not just primary lung disease. * **Fluid Management:** Always auscultate the lungs and palpate the liver before giving a fluid bolus. If rales or gallop rhythm are present, avoid aggressive fluid resuscitation. * **Normal BP in Shock:** Note that the BP (120/80) is actually high for a 15-month-old (compensated state); do not wait for hypotension to diagnose critical illness.

Question 1

All of the following is true about Basic Life Support (BLS) in a child except:

Accepted Answer

The most common cause of cardiac arrest is ventricular fibrillation.

Answer

Compression to ventilation ratio is 15:2 when more than one rescuer is present in an infant.

Answer

Brachial pulse check in an infant.

Answer

Adrenaline is the drug of choice.

Question 2

A 5-year-old child presents with high-grade fever and features of sepsis. On examination, the blood pressure is 90/60 mmHg and the pulse rate is 146 beats/min. What is the initial fluid of choice?

Accepted Answer

20 mL/kg of 0.9% normal saline

Answer

10 mL/kg of 0.45% normal saline

Answer

10 mL/kg of 10% dextrose

Answer

20 mL/kg of 0.45% normal saline

Question 3

A 9-month-old boy is brought to the emergency room in a limp and unresponsive state. Initial examination shows a pulse rate of 35/min and occasional irregular breaths. After initiation of CPR, including tracheal intubation and delivery of oxygen positive-pressure breaths and chest compressions, multiple attempts to insert an IV line fail. What is the most appropriate next step in management?

Accepted Answer

Place an intraosseous needle and administer fluids and inotropic agents

Answer

Obtain an arterial blood gas sample

Answer

Obtain a head CT study to evaluate reasons for unresponsiveness

Answer

Place a transthoracic cardiac pacemaker

Question 4

A 3-year-old child weighing 15 kg in the pediatric ICU has developed ventricular fibrillation (VF) and is undergoing cardiopulmonary resuscitation (CPR). As the physician on call, you decide to attempt defibrillation to restore normal rhythm. What is the recommended initial energy dose for defibrillation in this scenario?

Accepted Answer

60 J

Answer

280 J

Answer

250 J

Answer

320 J

Question 5

A 5-year-old child is brought to the emergency department after an electrocution incident. The child is apneic and is being ventilated with a bag and mask. There are burns on each hand. What is the next step in management?

Accepted Answer

Check pulses

Answer

Start chest compressions

Answer

Intubate

Answer

Check oxygen saturation

Question 6

What is the recommended endotracheal concentration of adrenaline during CPR in pediatric patients?

Accepted Answer

1:1,000

Answer

1:10 lakhs

Answer

1:1 lakh

Answer

1:10,000

Question 7

A 4-year-old child presents with shock and circulatory collapse. Intravenous access is not possible. What is the next best step?

Accepted Answer

Intraosseous cannulation

Answer

Intracardiac infusion

Answer

Thoracotomy

Answer

Cardiopulmonary resuscitation (CPR)

Question 8

What is the initial fluid of choice for the treatment of hypernatremic dehydration?

Accepted Answer

Normal saline (0.9% NaCl)

Answer

Half normal saline (0.45% NaCl)

Answer

Quarter normal saline (0.225% NaCl)

Answer

Dextrose 5% in water (D5W)

Question 9

A 3-year-old boy with a history of bronchial asthma presents with progressive shortness of breath for 1 day. On examination, the child is cyanotic, gasping, and unresponsive. What is your immediate priority?

Accepted Answer

Administer 100% oxygen by mask

Answer

Intubate

Answer

Ventilate with a bag-valve-mask device

Answer

Administer nebulised salbutamol

Question 10

A 15-month-old girl has a history of poor oral fluid intake, occasional vomiting, rapid breathing, and decreased urine output. Physical examination reveals a pulse of 150/min, BP of 120/80, and a respiratory rate of 60/min. There are bibasilar rales, and the liver is palpable. Which of the following procedures might be helpful in evaluating the oliguria, EXCEPT?

Accepted Answer

Giving a fluid challenge with isotonic saline, 20 ml/kg

Answer

Determining the urine sodium concentration

Answer

Determining the BUN and serum creatinine levels

Answer

Giving a dose of intravenous furosemide

Pediatric Critical Care — MCQs

Pediatric Critical Care — MCQs

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