ACLS/PALS/NRP

Question 1

You are 4 minutes in to an unwitnessed, asystolic cardiac arrest, you have obtained IO access, and administered 1mg epinephrine, as per ACLS, what should you consider next?
A. Consider treatable causes (H’s and T’s)
B. Amiodarone administration
C. Fluid administration
D. endotracheal intubation

Answer 1

A. Consider treatable causes (H’s and T’s)

Question 2

1 minute after delivering a term baby they remain apneic and cyanotic with a HR of 50. You begin PPV for 15 seconds with no improvement in HR or colour. What should your next step be?
a. Attach the cardiac monitor while continuing PPV
b. Begin chest compressions with PPV at a 3:1 ratio
c. Ensure that the BVM is attached to a 100% O2 source
d. Adjust the mask seal and reposition the baby’s head and neck

Answer 2

d. adjust the mask seal and reposition

If PPV does not immediately correct bradycardia/apnea, proceed via MRSOPA. Attaching the cardiac monitor is not considered essential until corrective ventilatory steps have begun. Term babies should be ventilated at an FiO2 of 21% (room air)

p. 1512, NRP 8th

Question 3

Which of the following is NOT considered standard equipment when preparing for neonatal resuscitation?
a. A size 4.5 ETT
b. Oxygen source with flow meter
c. Clean towels/linens
d. Epinephrine 1:10,000

Answer 3

a. A size 4.5 ETT
typically, the largest size ETT used in NRP is 3.5

p. 1508

Question 4

What are recommended doses for the following medications in pediatric populations when managing cardiac emegencies (i.e. PALS doses)?
* epinephrine
* amiodarone
* lidocaine
* atropine
* adenosine

Answer 4

• epinephrine: 0.01mg/kg IV/IO or 0.1mg/kg ETT q.3-5m for cardiac arrest OR bradycardia
• amiodarone: 5mg/kg IV/IO up to 3 total doses
• lidocaine: 1mg/kg
• atropine: 0.02mg/kg (minimum 0.1mg, maximum 0.5mg)
• adenosine: 0.1mg/kg, followed by 0.2mg/kg (max: 6mg, 12mg)

Question 5

When should a compression/breathing ratio of 15:2 be used for pediatric CPR?
a. when an advanced airway is placed
b. when a second rescuer is available
c. when providing CPR as a single responder
d. should be used for all pediatric CPR

Answer 5

b. when a second rescuer is available

Question 6

You have delivered a neonate who remained apneic, bradycardic (HR=70) and cyanotic despite efforts to warm and stimulate them. Following initiation of PPV with an effective seal, you note that the neonate has a HR of 100bpm. What should you do next?
a. Re-evaluate the mask seal and positioning of the airway
b. Discontinue PPV and provide post-resuscitation care
c. Increase the oxygen flow rate and continue PPV
d. Attach the cardiac monitor and prepare equipment for intubation

Answer 6

b. Discontinue PPV and provide post-resuscitation care
PPV should only be continued if the HR is less than 100. Any HR that is greater than or equal to 100 should result in discontinuation of PPV

Question 7

You have delivered a neonate who remained apneic and cyanotic despite efforts to warm and stimulate them. Following PPV and corrective measures the neonate remains apneic with a HR of 58bpm. What should you do NEXT?
a. insert an SGA or perform endotracheal intubation
b. begin CPR with ventilations at a 3:1 ratio
c. administer 0.02mg/kg epinephrine via IO
d. attach the cardiac monitor and perform a pulse check and rhythm analysis

Answer 7

a. insert an SGA or perform endotracheal intubation
per NRP, “Insertion of an endotracheal tube is strongly recommended before starting chest compressions. If intubation is not successful or feasible, and the baby weighs more than approximately 2 kg, a laryngeal mask may be used.”

Question 8

You are responding to a cardiac arrest for a 45YO, 80kg patient with a known hypersensitivity to potassium-channel blockers. The patient is intially found in pulseless ventricular tachycardia which does not respond to initial defibrillation. What should your next step be?:
a. Provide epinephrine, 0.01mg/kg 1:10,000 IV/IO q. 3-5 minutes
b. Provide lidocaine, 120mg IV/IO
c. Provide amiodarone, 300mg IV push
d. Provide lidocaine, 40mg IV push

Answer 8

b. Provide lidocaine, 120mg IV/IO
initial dose is 1.0-1.5mg/kg, following dose is 1/2 the original dose. Amiodarone is contradindicated

Question 9

You are attending an adult cardiac arrest and have intubated your patient. You confirm tube placement via breath sounds, tube misting, visualization through cords, and EtCO2 waveform. You note that the EtCO2 reading is 8mmHg. What should your NEXT step be:
a. re-assess the positioning of the endotracheal tube
b. check inflation of the ETT cuff
c. ensure that the EtCO2 filter line is intact and unkinked
d. re-assess the effectiveness of chest compressions

Answer 9

d. re-assess the effectiveness of chest compressions

Question 10

You respond to a 6YO with GCS=3 and HR=24 in a sinus bradycardia. Despite attempts to ventilate and oxygenate the child, they remain bradycardic and you initiate CPR. You proceed to intubate the child and provide 0.01mg/kg epinephrine IO with no effect. What should your NEXT step be?
a. Prepare for transport to a pediatric receiving facility and initiate urgent extrication with CPR in progress
b. Provide additional doses of epinephrine at 0.01mg/kg IV/IO. Contact medical direction for further guidance
c. Administer atropine IO; 0.02mg/kg to a maximum of 0.5mg (minimum of 0.1mg).
d. Begin transcutaneous pacing at 60-80bpm, targeting amperage to mechanical capture of pulses.

Answer 10

a. Prepare for transport to a pediatric receiving facility and initiate urgent extrication with CPR in progress
keep in mind, this is bradycardia with a pulse, not cardiac arrest. Transcutaneous pacing is NOT indicated in children. Atropine may be useful if signs of high vagal tone or AV block are present (note that this is somewhat reversed from adults). Urgent transport is warranted

Question 11

1 minute after delivering a newborn you note that they continue to have poor tone, labored breathing, and persistent cyanosis. Their HR is auscultated at 140bpm. What should your NEXT step be?
a. Continue to dry and stimulate the baby
b. Begin PPV using a neonatal BVM at a rate of 40-60 bpm
c. Suction the nares and mouth, then apply oxygen
d. Position the airway, suction if needed, provide oxygen if targets are not met, consider CPAP

Answer 11

d. Position the airway, suction if needed, provide oxygen if targets are not met, consider CPAP
routine suctioning and oxygen administration is not best practice. Attempt to reposition the airway and assess for causes of hypoxia. PPV is not indicated if the HR is greater than 100bpm

Question 12

A baby is born with blue extremities and HR of 80. They appear irritated but do not cry when stimulated and they are limp in the provier’s hands. They are not crying at all. What is their APGAR score?

Answer 12

A1P1G1A0R0=3

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Question 13

You are attending a pediatric cardiac arrest. Your patient is a 7YO weighing 23kg, who presents in ventricular fibrillation which has been refractory to one round of defibrillation. What is the correct lidocaine dosage for this patient.
a. 46mg
b. 23mg
c. 2.3mg
d. 0.23mg

Answer 13

b. 23mg IV/IO
1mg/kg

Question 14

What three questions indicate the need to initiate the NRP algorithm? (four questions according to caroline’s)

Answer 14

• Term? (is the baby full term)
• Tone? (good muscle tone)
• Crying? (or breathing normally)
• Color? (of the amniotic fluid) (this is in caroline’s but not NRP)

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Question 15

What is the recommended technique for providing chest compressions in children?
a. Use either a one-handed or two-handed technique based on patient and rescuer anatomy, as well as rescuer comfort level
b. Use a one-handed technique to minimize thoracic trauma for pediatric patients
c. Use a two-handed technique to optimize compression depth and rate, and minimize rescuer fatigue
d. Use a two-hands-encircling technique with thumbs on the sternum to optimize compression depth and recoil

Answer 15

a. Use either a one-handed or two-handed technique based on patient and rescuer anatomy, as well as rescuer comfort level
There is no definitive evidence on outcomes for either method. Use whichever method seems appropriate for the rescuer and for the child’s anatomy

Question 16

Which of the following ACLS interventions is NOT indicated in pediatric patients?
a. Amiodarone
b. Atropine
c. Transcutaneous pacing
d. Lidocaine

Answer 16

c. Transcutaneous pacing

Question 17

You respond to a local pool for a 9YO drowning. Upon arrival, the PCP crew informs you that the child has a GCS of 3 and a HR of 35. They have placed a properly-sized supraglottic airway and have been providing rescue breaths at a rate of 2-3 BPM for the past 60 seconds, with no change in patient presentation. What should your NEXT step be?
a. Attach the cardiac monitor and perform a rhythm analysis
b. Instruct the responding crew to begin chest compressions and ventilations at a 15:2 ratio
c. Instruct the responding crew to begin continuous chest compressions and ventilations every 2-3 seconds
d. Obtain IV/IO access and administer 0.01mg/kg epinephrine 1:10,000

Answer 17

c. Instruct the responding crew to begin continuous chest compressions and ventilations every 2-3 seconds
Per PALS, pediatric patients in cardiac arrest or with ventilation/oxygen-refractory bradycardia should receive continuous compressions and ventilations at 2-3BPM if an advanced airway is in place. This includes SGAs.

Question 18

You respond to a 45 year old patient presenting in cardiac arrest, after two minutes of high quality CPR, the monitor is already attached, and the patient is receiving BVM-Ventilations, what are the next steps for the paramedic to take?

A. 1:10,000 epi 1MG
B. IO/IV/EJ
C. Endotracheal intubation
D. Pulse check, rhythm interpretation

Answer 18

Pulse check, Interpret rhythm.

Question 19

You respond to a crew request for pediatric tachycardia. On arrival, you find the following:
A 10YO patient presents with ALOC, signs of shock, and tachycardia. The responding crew reports a GCS of E2V2M4, BP = 78/58, HR = 164 with what appears to be a narrow QRS complex, SpO2 = 98% on NRB at 15LPM. The patient’s airway is patent and there are no signs of bleeding.
While receiving handover, your partner has started an IV catheter in the patient’s hand. A 12-lead ECG reveals monomorphic QRS complexes that are 0.086s in duration
What should your NEXT step be?
a. Search for, and treat, causes of shock. The tachycardia is likely the result and not the cause of the child’s pahtology
b. Administer adenosine, 0.1mg/kg IV to a maximum of 6mg to adress the patient’s likely supraventricular tachycardia
c. Re-assess the airway and provide bag-mask ventilation at a rate of 3-5BPM on 100% oxygen
d. Provide synchronized cardioversion at 0.5-1J/Kg to adress the patient’s unstable tachycardia with signs of cardiopulmonary compromise

Answer 19

a. Search for, and treat, causes of shock. The tachycardia is likely the result and not the cause of the child’s pahtology
Narrow-complex tachycardia at a rate of less than 180 in a child (or 220 in an infant) is likely a COMPENSATORY tachycardia. Search for the underlying cause of the child’s shock

Question 20

Select all of the following which are NOT part of the H’s and T’s of treatable causes of cardiac arrest
* Hypovolemia
* Hypoglycemia
* Hypothermia
* Acidosis
* Trauma
* Toxins
* Pulmonary thrombosis
* Hypokalemia
* Tension pneumothorax

Answer 20

Hypoglycemia and Trauma
hypokalemia is considered a treatable cause AS IS hyperkalemia. Hypoglycemia is no longer considered a treatable cause. The H’s and T’s are:
* Hypovolemia
* Hypoxia
* Hydrogen Ion excess (acidosis)
* Hypo/hyperkalemia
* Hypothermia
* Tension Pneumothorax
* Tamponade, cardiac
* Toxins
* Thrombosis, pulmonary
* Thrombosis, coronary

Question 21

Which of the following are NOT considered to be risk factors for requiring neonatal resuscitation?
1. Multiple Gestation
2. Maternal age of 18y
3. Pre-eclampsia
4. Polyhydramnios or oligohydramnios
5. Inadequate prenatal care
6. PROM (premature rupture of membranes)
7. MSAF (meconium-stained amniotic fluid)
8. Maternal multiparity
9. Maternal fever
10. Use of narcotics within 4 hrs. of delivery

Answer 21

Maternal age of 18y and Maternal multiparity
Maternal age is not considered a risk factor unless under 16y or over 35y
Multiparity is not considered a risk factor for the neonate, although previous C-sections increase the risk for uterine rupture

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Question 22

Which of the following is NOT an AHA recommendation when providing pediatric cardiac arrest management?
a. Switch compressors every 2 minutes to minimize rescuer fatigue
b. Compress to a depth of 5-6cm with full chest recoil for each compression
c. Provide continuous compressions with ventilations every 2-3 seconds if a SGA is in place
d. Compress to a depth of greater than or equal to 1/3 the anterior-posterior dimension of the chest

Answer 22

b. Compress to a depth of 5-6cm with full chest recoil for each compression
*this is the ADULT recommendation. For children, compress to a depth of greater than or equal to 1/3 the anterior-posterior dimension of the chest *

Question 23

You respond to a crew request for pediatric tachycardia. On arrival, you find the following:
A 10YO patient presents with ALOC, signs of shock, and tachycardia. The responding crew reports a GCS of E2V2M4, BP = 78/58, HR = 164 with what appears to be a narrow QRS complex, SpO2 = 98% on NRB at 15LPM. The patient’s airway is patent and there are no signs of bleeding.
While receiving handover, your partner has started an IV catheter in the patient’s hand.
What should your NEXT step be?
a. Provide synchronized cardioversion at 0.5-1J/Kg to adress the patient’s unstable tachycardia with signs of cardiopulmonary compromise
b. Administer adenosine, 0.1mg/kg IV to a maximum of 6mg to adress the patient’s likely supraventricular tachycardia
c. Obtain a 12-lead ECG, so long as it does not interfere with or delay appropriate therapy
d. Provide sedation: ketamine 0.1-0.5 mg/kg slow IV push every 60 seconds to effect in anticipation of need for DC cardioversion

Answer 23

c. Obtain a 12-lead ECG, so long as it does not interfere with or delay appropriate therapy
Per PALS, this should be part of the initial steps of assessment and resuscitation prior to initiation of any ACLS-specific therapies, so long as it does not delay appropriate intervention

Question 24

You respond to a 90YO patient with feelings of general weakness/malaise. On assessment you find they are tachycardic at a rate of 170bpm with a QRS of 0.11s. The rhythm is regular and monomorphic. Physical findings are otherwise unremarkable and they have no other complaints. What should you do next?
a. Investigate for other causes of shock, since the tachycardia is likely compensatory
b. Attempt a vagal maneuver, or provide adenosine, 6mg IV
c. Provide sedation and perform synchronized cardioversion at 100J, as this is a wide-complex tachycardia
d. Provide amiodarone, 150mg IV infusion over 10 minutes

Answer 24

b. Attempt a vagal maneuver, or provide adenosine, 6mg IV
This is defined as a narrow-complex tahcycardia (QRS is less than 0.12s). There are no signs of instability, so treat with vagal maneuvers or adenosine.

Question 25

You respond to a crew request for pediatric tachycardia. On arrival, you find the following:
A 10YO patient presents with ALOC, signs of shock, and tachycardia. The responding crew reports a GCS of E2V2M4, BP = 78/58, HR = 164 with what appears to be a narrow QRS complex, SpO2 = 88% on NRB at 15LPM. The patient’s airway is patent and there are no signs of bleeding.
While receiving handover, your partner has started an IV catheter in the patient’s hand.
What should your NEXT step be?
b. Administer adenosine, 0.1mg/kg IV to a maximum of 6mg to adress the patient’s likely supraventricular tachycardia
c. Re-assess the airway and provide bag-mask ventilation at a rate of 2-3BPM on 100% oxygen
d. Provide sedation: ketamine 0.1-0.5 mg/kg slow IV push every 60 seconds to effect in anticipation of need for DC cardioversion

Answer 25

c. Re-assess the airway and provide bag-mask ventilation at a rate of 2-3BPM on 100% oxygen
ABCs come before the fancy stuff, especially for children!

Question 26

What are the five indicators of cardiopulmonary compromise in adults? (i.e. what are signs of instability in the context of arrythmia)

Answer 26

• Hypotension
• Acutely altered mental status
• Signs of Shock
• Ischemic chest pain
• Acute heart failure

Use HASIA. For pediatrics, only use the first 3; HAS.

Question 27

You respond to a crew request for pediatric tachycardia. On arrival, you find the following:
A 10YO patient presents with ALOC, signs of shock, and tachycardia. The responding crew reports a GCS of E2V2M4, BP = 68/38, HR = 210 with what appears to be a narrow QRS complex, SpO2 = 98% on NRB at 15LPM. The patient’s airway is patent and there are no signs of bleeding.
A 12-lead ECG reveals monomorphic QRS complexes that are 0.086s in duration.
Your partner states that they were unable to obtain IV access and will try again in the other arm.
What should your NEXT step be?
a. Attempt a vagal maneuver, since IV access is not yet available for adenosine administration
b. Wait for your partner to obtain IV access, then administer adenosine, 0.1mg/kg IV to a maximum of 6mg to adress the patient’s likely supraventricular tachycardia
c. Re-assess the airway and provide bag-mask ventilation at a rate of 3-5BPM on 100% oxygen
d. Provide synchronized cardioversion at 0.5-1J/Kg to adress the patient’s unstable tachycardia with signs of cardiopulmonary compromise

Answer 27

d. Provide synchronized cardioversion at 0.5-1J/Kg to adress the patient’s unstable tachycardia with signs of cardiopulmonary compromise
Although vagal maneuvers are often the first-line therapy for pediatric NCT, this child has frank findings of hemodynamic instability. All three criteria of cardiopulmonary comproise are met (AMS, shock, hypotension). The first-line treatment should be synchronized DC cardioversion

Question 28

You are attending a pediatric cardiac arrest. Your patient is a 7YO weighing 23kg, who presents in ventricular fibrillation which has been refractory to one round of defibrillation. What is the correct amiodarone dosage for this patient.
a. 115mg IV/IO
b. 300mg IV/IO
c. 150mg IV/IO
d. amiodarone is not indicated for pediatric cardiac arrest

Answer 28

a. 115mg IV/IO
5mg/kg

Question 29

5 minutes after being born, a baby is centrally and peripherally cyanotic and has a HR of 120. They cry out when stimulated and weakly flex their extremities. Their crying is slow and irregular. What is their APGAR score and what is the significance of this finding? What should your next step be?

Answer 29

A0P2G2A1R1=6
Any score less than 7 at 5 minutes is considered poor and requires further monitoring. You should intiate early transport and assign a new APGAR score every 5 minutes until 20 minutes after birth.

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Question 30

You respond to a 9YO child with tachycardia and signs of cardiopulmonary compromise. Your findings are as follows: GCS = E2V3M5, BP = 74/56, HR = 204 with a QRS duration of 0.10s. What should you do FIRST?
a. attach the precordial leads and obtain a 12-lead ECG
b. Attempt a vagal maneuver if it will not cause a delay, otherwise immediately administer 0.1mg/kg adenosine IV/IO
c. Provide synchronized cardioversion at 0.5-1J/Kg followed by a second attempt at 2J/Kg if unsuccessful
d. Administer amiodarone, 5mg/kg over 20-60 minutes

Answer 30

c. Provide synchronized cardioversion at 0.5-1J/Kg followed by a second attempt at 2J/Kg if unsuccessful
This meets the criteria of wide-complex tachycardia with cardiopulmonary compromise (QRS is greater than 0.09s). Immediate DC cardioversion is indicated

Question 31

What is the initial dose of epinephrine for a paediatric in cardiac arrest?

A. 0.01mg/kg
B. 0.001mg/kg
C. 1mg
D. 0.02mg/kg

Answer 31

A. 0.01mg/kg

Question 32

Describe pediatric epinephrine dosing in cardiac arrest

Answer 32

• IV/IO: 0.01mg/kg 1:10,000 q.3-5 minutes. Max. 1mg per bolus
• Endotracheal: 0.1mg/kg q.3-5 minutes.

Question 33

You respond to an 8YO child with “heart problems”. On arrival, family states they had a sudden onset of weakness/confusion and a “funny feeling in their chest”. On assessment you find them to be GCS = E3V4M6, HR=190 with a QRS of 0.09s, BP = 68/40. What is the MOST likely underlying rhythm?
a. Sinus tachycardia
b. Supraventricular tachycardia
c. Ventricular tachycardia
d. Sinus arrythmia

Answer 33

b. Supraventricular tachycardia
This meets criteria for “narrow-complex” because the QRS is less than or EQUAL to 0.09s. SVT tends to be sudden-onset and has a rate greater than 180 in children (greater than 220 in infants)

Question 34

You have delivered a baby at 31 weeks gestation. What should your first steps be?
a. Vigorously dry and stimulate the baby
b. Assess for breathing and pulse for 10s, start PPV if needed
c. Place the baby in a food-grade plastic bag, without drying
d. Start chest compressions if HR is less than 60 bpm.

Answer 34

c. put the baby in a bag
Do not vigorously dry babies who are less than 32wks gestation. Putting the baby in the bag happens prior to initiation of PPV or consideration of chest compressions

p. 1514

Question 35

When arriving first on scene you determine that the 8 year old child presented to you does not have a pulse and is not breathing, you should immediately start CPR. What is the appropriate compression rate prior to the insertion of an advanced airway?

A. 15:2
B. 30:2
C. 3:1
D. continuous compressions

Answer 35

A. 15:2

Question 36

Which of the following is NOT considered an indicator of ROSC per ACLS guidelines?
a. Palpable central pulses and measurable blood pressure
b. Abrupt, sustained increase in EtCO2 (usually greater than 40 mmHg)
c. Intentional movements of extremities or opening of eyes
d. Spontaneous arterial pressure waves with intra-arterial monitoring

Answer 36

c. Intentional movements of extremities or opening of eyes
This may be due to compression-induced consciousness. The end-tidal “spike” is recognized by ACLS

Question 37

You respond to an 8YO child with “heart problems”. On arrival, family states they had a sudden onset of weakness/confusion and a “funny feeling in their chest”. On assessment you find them to be GCS = E3V4M6, HR=190 with a QRS of 0.09s, BP = 68/40. Describe adenosine dosage for this patient population
a. 6mg, followed by 12mg IV/IO
b. 0.01mg/kg, followed by 0.02mg/kg IV/IO. Maximum doses of 0.6/1.2mg
c. 0.1mg/kg, followed by 0.2mg/kg IV/IO. Maximum doses of 6/12mg
d. adenosine is not indicated for pediatric administration

Answer 37

c. 0.1mg/kg, followed by 0.2mg/kg IV/IO. Maximum doses of 6/12mg

Question 38

Which of the following is NOT considered a sign of cardiopulmonary compromise in children?
a. Ischemic chest pain
b. Acutely altered mental status
c. Signs of shock
d. Hypotension

Answer 38

a. Ischemic chest pain
use “HAS” for children, “HASIA” for adults. Ischemic chest pain and acute heart failure are the other adult criteria

Question 39

A 7YO patient presents with decreased level of consciousness and hypotension at 74/46mmHg. Cardiac monitoring reveals a narrow-complex sinus bradycardia at 45bpm. What should your first step be?
a. provide transcutaneous pacing at 60-80bpm, utilizing increasing amperage until mechanical capture is noted.
b. administer atropine, 0.02mg/kg IV/IO
c. secure the airway and support ventilation and oxygenation
d. initiate chest compressions and attach the therapy electrodes

Answer 39

c. secure the airway and support ventilation and oxygenation
per PALS, pediatric patients with bradycardia at less than 60bpm and signs of hemodynamic compromise should first receive ventilatory/oxygenation support. If the HR remains under 60bpm following 30 seconds of adequate ventilation/oxygenation, start CPR. If there is no palpable pulse, treat as cardiac arrest

Question 40

Which of the following is NOT correct about IO insertion in a large child?
a. gently drill, immediately release the trigger when a “pop” or “give” is felt as the needle enters the medullary space
b. gently drill, advancing the needle set approximately 1-2 cm after entry into the medullary space (felt as a loss of resistance)
c. push the needle tip through the skin until the tip rests against the bone
d. at least one black line on the catheter must be visible above the skin for confirmation of adequate needle set length

Answer 40

a. gently drill, immediately rtelease the trigger when a “pop” or “give” is felt as the needle enters the medullary space
For infants and small children, only drill until “give” is felt. For adults or large children, you should continue to insert the needle 1-2cm into the medulalry cavity

Question 41

(6.2.a) After delivering a baby at 36wks (3000g), you found them to be persistently cyanotic, apneic and bradycardic. Despite PPV and corrective steps, including placement of a 3.5mm ETT, the HR remains below 60BPM. After starting chest compressions, what should your next step be?
1. Administer 0.01mg/kg 1:10,000 epinephrine via IO
2. Administer 3mL of 1:10,000 epinephrine via ETT
3. Administer 0.3mL 1:10,000 epinephrine via UVC
4. Adminiter 0.03mg of 1:10,000 epinephrine via ETT

Answer 41

.2. Administer 3mL of 1:10,000 epinephrine via ETT
Recommended dosing is 0.02mg/Kg IV/IO or 0.1mg/kg ETT. This translates to 0.2mL/kg or 1.0mL/kg of 1:10,000 epinephrine, respectively

NRP 8th

Question 42

While attempting to pass a nasogastric tube in a neonate, you notice that the tube coils in the posterior nasopharynx bilaterally. The baby has appeared distressed since birth, with increased respiratory effort and persistent cyanosis. What is the likely cause, and what treatment is available?

Answer 42

Bilateral choanal atresia (bony or membranous coverings over the openings at the posterior nasopharynx). May be treated by placing an oral airway

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Question 43

You respond to a 90YO patient with feelings of general weakness/malaise. On assessment you find they are tachycardic at a rate of 170bpm with a QRS of 0.12s. The rhythm is regular and monomorphic. The patient’s skin is pale and clammy and their BP is 88/45. What should you do next?
a. Investigate for other causes of shock, since the tachycardia is likely compensatory
b. Attempt a vagal maneuver, or provide adenosine, 6mg IV
c. Consider sedation and perform synchronized cardioversion at 100J, as this is a wide-complex tachycardia
d. Provide amiodarone, 150mg IV infusion over 10 minutes

Answer 43

c. Consider sedation and perform synchronized cardioversion at 100J, as this is a wide-complex tachycardia
Considered wide because the QRS is greater than or equal to 0.12s. Signs of instability are present, so cardioversion is preferred over amiodarone administration

Question 44

You respond to a 90YO patient with feelings of general weakness/malaise. On assessment you find they are tachycardic at a rate of 170bpm with a QRS of 0.12s. The rhythm is regular with variation in QRS morphology. Physical findings are otherwise unremarkable and they have no other complaints. What should you do next?
a. Investigate for other causes of shock, since the tachycardia is likely compensatory
b. Attempt a vagal maneuver, or provide adenosine, 6mg IV
c. Provide sedation and perform synchronized cardioversion at 100J, as this is a wide-complex tachycardia
d. Provide amiodarone, 150mg IV infusion over 10 minutes

Answer 44

d. Provide amiodarone, 150mg IV infusion over 10 minutes
This is a wide-complex tachycardia (wide is defined as greater than or equal to 0.12s). There are no signs of instability so initial management is by amiodarone infusion. If there are signs of instability, proceed with synchronized cardioversion. Adenosine is not indicated because the rhythm is not monomorphic

Question 45

You are responding to a 8-month-old cardiac arrest. Describe proper landmarking of an intraosseous catheter for infants.
a. Landmark 3cm proximal to the lateral malleolus of the distal tibia.
b. Landmark 1cm medial to the tibial tuberosity (or 1cm medial to a point directly distal to the patella).
c. Landmark 2-3cm medial to the tibial tuberosity or approximately 3cm below the patella and 2cm medial to that point.
d. Landmark the midline of the distal femur at a point directly above the patella and insert the needle at a 45-degree angle, cephalad

Answer 45

b. Landmark 1cm medial to the tibial tuberosity (or 1cm medial to a point directly distal to the patella).
Proximal tibia placement follows the “1-and-1” rule for infants/neonates/small children, or the “3-and-2” rule for adults, adolescents, or large children. 1-and-1 refers to landmarking 1cm below the patella, and 1cm medial to that point on the tibial plateau

Question 46

You respond to an 8YO child with “heart problems”. On arrival, family states they had a sudden onset of weakness/confusion and a “funny feeling in their chest”. On assessment you find them to be GCS = E3V4M6, HR=190 with a QRS of 0.09s, BP = 68/40. Your partner has already placed an intravenous catheter. What should your next step be?
a. Attempt a vagal maneuver (modified valsalva if the child is able to comply, or cold compresses over the face/neck)
b.Provide synchronized cardioversion at 0.5-1J/kg, followed by a second attempt at 2J/kg if unsuccessful
c. Provide ABC support, initiate transport, and monitor the child for signs of further instability
d. Administer adenosine, 0.1mg/kg IV

Answer 46

d. Administer adenosine, 0.1mg/kg IV
Vagal maneuvers should only be attempted if they will not cause a delay in treatment. Since an IV catheter is already placed, the first priority should be treatment with adenosine

Question 47

You have defibrillated Ventricular fibrillation twice with no change in the underlying rhythm, after defibrillation, and epinephrine administration, which anti-arrythmics should the paramedic consider?

A. Calcium/bicarb
B. 150mg Amioderone
C. 1-1.5MG/KG lidocaine
D. 300mg Amiodarone or lidocaine

Answer 47

D. 300mg Amiodarone or lidocaine

Question 48

What is the appropriate dose for the initial defibrillation of a 2 year old child weighing 8kg?

A. 16 J
B. 32 J
C. 100J
D. 30J

Answer 48

A. 2J/kg

Question 49

You’ve delivered a baby at 39wks gestation, the mother is an IV drug user and states she used fentanyl 2 hrs. prior to delivery. The baby has poor respiratory effort and tone. After 30s of drying and stimulation, they continue to have poor respirations and are globally cyanotic, what should you do next?

Answer 49

• Assess breathing and circulation
• If apneic or if HR is less than 100bpm, begin PPV
• If breathing and HR is greater than 100bpm, give supplemental O2
• DO NOT GIVE NALOXONE (SERIOUSLY! DON’T DO IT!)

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Question 50

You are responding to a 5YO child (20kg) who presents unresponsive with a pulse. BP = 65/30, HR =35bpm. Despite adequate ventilation and oxygenation, the child remains bradycardic and you initiate CPR. What should your next step be?
a. Secure the airway via ETT in order to optimize ventilation/oxygenation
b. Administer atropine, 0.6mg IV/IO to correct bradycardia
c. initiate transcutaneous pacing at a rate of 60-80bpm, targeting amperage to mechanical capture of pulses
d. Administer epinephrine 1:10,000, 0.20mg IV/IO to correct bradycardia

Answer 50

d. Administer epinephrine 1:10,000, 0.20mg IV/IO to correct bradycardia
Suggested pharmacotherapy is epinephrine 0.01mg/kg IV/IO or epinephrine 0.1mg/kg ETT or atropine 0.02mg/kg (MAX=0.5mg)

Question 51

Which of the following is considered routine care for the newly-delivered neonate?
a. Suction the oropharynx of any secretions
b. Dry the infant and wrap them in linens or place on mother’s bare skin
c. Obtain an APGAR score at 5 and 10 minutes
d. Apply oxygen to obtain an SpO2 of 100%

Answer 51

b. Dry the infant and wrap them in linens or place on mother’s bare skin
routine suctiononing is no longer recommended unless there is MSAF or airway obstruction. APGAR is obtained at 1 and 5 minutes. Oxygen should only be applied as part of NRP and should follow time-specific targets

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Question 52

In which of the following examples should adenosine be considered in cases of pediatric wide-complex tachycardia (QRS is greater than 0.09s)?
a. GCS = 15, BP = 92/50, HR = 204 in a regular, monomorphic rhythm
b. GCS = 13, BP = 98/46, HR = 198 in a regular, monomorphic rhythm
c. GCS = 15, BP = 102/60, HR = 224 in an irregular rhythm with two different QRS morphologies
d. GCS = 15, BP = 68/40, HR = 170 in a regular rhythm with multiple QRS morphologies

Answer 52

a. GCS = 15, BP = 92/50, HR = 204 in a regular, monomorphic rhythm
for pediatric WCT, adenosine should only be considered in cases where there is no cardiopulmonary compromise and the rhythm is regular and monomorphic

Question 53

You respond to a local pool for a 10YO drowning. Upon arrival, the PCP crew informs you that the child has a GCS of 3 and a HR of 35. They report poor seating of a properly-sized supraglottic airway and have reverted to BVM ventilation with an OPA with no change in patient presentation. After instructing first responders to initiate CPR at a 15:2 ratio, you elect to intubate the child using a cuffed ETT. Which of the following would be an appropriate tube size and depth for a child of this age?
a. 5.0 ETT, secured 15cm at the teeth
b. 4.0 ETT, secured 15cm at the teeth
c. 6.0 ETT, secured 18cm at the teeth
d. 6.5 ETT, secured 22cm at the teeth

Answer 53

c. 6.0 ETT, secured 18cm at the teeth
Tube size/depth may be estimated by using the following; size = age/4 + 4 for an uncuffed tube. Subtract 0.5 for a cuffed tube. Tube depth = 3 x the tube size

Question 54

How does the definition of a “wide” QRS vary between adult and pediatric populations?

Answer 54

for adults, a QRS is considered “wide” if it is greater than or equal to 0.12s in duration. For pediatrics, a QRS is considered “wide” if it is greater than 0.09s

Question 55

What is the appropriate rate of providing rescue breaths for pediatric patients?

Answer 55

once every 2-3 seconds