Module 9 - Neonatal & Pediatric Emergencies Flashcards
1
Q
- Pediatric dose for Epinephrine is
A. 0.1 mg/kg IV
B. 0.01 mg/kg ETT
C. 1 mg IV
D. 0.01 mg/kg IV
A
- D: Epinephrine (adrenaline) is a hormone and neurotransmitter. It increases heart rate (beta 1 and inotropic effect), contracts blood vessels (alpha property), dilates air passages (beta-2 property), and participates in the fight-or-flight response of the sympathetic nervous system. A pediatric dosage of 0.01 mg/kg (intravenous or intraosseous route) is recommended every 3-5 minutes as needed. Endotracheal tube route dosage is 0.1 mg/kg body weight (0.1 mL of a 1:1,000 solution). Adrenaline is used as a drug to treat cardiac arrest and other cardiac dysrhythmias resulting in diminished or absent cardiac output. Its primary action initially is to increase peripheral resistance via alpha receptor-dependent vasoconstriction and secondly is to increase cardiac output via its binding to beta-receptors.
2
Q
- The pediatric patient may be pretreated with which medication prior to administering Anectine for the purpose of preventing bradycardia?
A. Etomidate
B. Atropine
C. Oxygen
D. Vecuronium
A
- B: Bradydysrhythmia is a complication that frequently is associated with succinylcholine (Anectine) use, especially in the pediatric patient, but may also occur in adults. Pretreatment with atropine (0.02 mg/kg) is advised in children to prevent bradycardia, and pretreatment with lidocaine (1.5 mg/kg) in patients with suspected or known head injury has been shown to attenuate the rise in ICP associated with endotracheal initubation. Atropine is a tropane alkaloid extracted from deadly nightshade (Atropa belladonna), jimsonweed (Datura stramonium), mandrake (Mandragora officinarum), and other plants of the family Solanaceae. Atropine increases firing of the sinoatrial (SA) node and conduction through the atrioventricular (AV) node of the heart, opposes the actions of the vagus nerve, blocks acetylcholine receptor sites, and decreases bronchial secretions. It is classified as a parasympatholytic (lytic—blocks). It is usually not effective in second-degree heart block (Mobitz type 2) and in third-degree heart block with a low Purkinje or ventricular escape rhythm. Atropine is contraindicated in ischemia-induced conduction block (widened QRS), because the drug increases oxygen demand of the AV nodal tissue, thereby aggravating ischemia and the resulting heart block.
3
Q
- You are transporting a thirty-two-week premature neonate with respiratory distress. Which drug may be administered in preparation for transport?
A. Antibiotics
B. Surfactant
C. D10
D. Prostaglandin
A
- B: The most common cause of respiratory distress in the preterm infant (born before 28-32 weeks of gestation) is respiratory distress syndrome (RDS), formerly known as hyaline membrane disease (HMD). This condition is primarily caused by a deficiency of surfactant. Surfactant decreases the surface tension in the alveolus during expiration, allowing the alveolus to maintain a functional residual capacity. The absence of surfactant results in poor lung compliance and atelectasis. Goal treatment for the use of exogenous surfactant is to increase pulmonary compliance, to prevent atelectasis at the end of expiration, and to facilitate recruitment of collapsed airways. The cornerstone of treatment of RDS is supplemental oxygen to maintain a PaO2 of 60-70 mmHg and an arterial saturation of 92-95%.
4
Q
- A neonate who is experiencing repetitive motions of a bicycling type action with lip smacking is presenting with what type of seizure?
A. Subtle
B. Tonic
C. Clonic
D. Myoclonic
A
- A: Subtle seizures are a type of seizure that is frequently overlooked by health-care providers. It may consist of repetitive mouth or tongue movement, bicycling movements, eye deviations, repetitive blinking, staring, or apnea. To treat neonatal seizures, it is important to attempt to identify the cause. The glucose level should be checked immediately, and if hypoglycemia is present (serum glucose
5
Q
- Your patient is PDA dependent. This would indicate likely require the administration of which of the following drugs?
A. Indomethacin
B. Progesterone
C. Prostaglandin
D. Synthetic surfactant
A
- C: Prostaglandins are normally used during transport when the patient’s condition is deteriorating, as indicated by the presence of metabolic acidosis, or when deterioration is anticipated before the completion of the transport. Prostaglandin E1 (PGE 1) is indicated for those heart defects that may be dependent on ductal patency for pulmonary blood flow. These heart defects include transposition without ventricular septal defect (VSD), pulmonary or tricuspid atresia, and critical pulmonary stenosis, including tetralogy of Fallot (TOF). Coarctation of the aorta and hypoplastic left heart syndrome may also require the use of PGE 1 for stabilization for transport. Keeping the patent ductus arteriosus (PDA) open using this medication allows stabilization of the newborn until more definitive treatment, usually surgical, can be carried out.
6
Q
- Which of the following would calculate an appropriate ETT size for a pediatric patient?
A. (age + 12)/4
B. Age + (16/4)
C. (Age + 16)/4
D. Age/4+4
A
- C: The proper endotracheal tube (ETT) size can be determined in several ways. It can be approximated by the size of the child’s little finger or nares.
7
Q
- Some pediatric endotracheal tubes are cuffless, which prevents
A. Gastric insufflation
B. Right mainstem intubation
C. Aspiration
D. Subglottic stenosis and ulcerations
A
- D: Pediatric tubes that are cuffless prevent subglottic stenosis and ulceration, and they range in size from 2.5-6.5 mm. Cuffless tubes are recommended in children younger than eight years of age because the cricoid cartilage is the narrowest portion of the trachea, and if the tube used is of proper size, it serves as a physiologic cuff. A tube that is too large will not pass through the cricoid cartilage. A tube that is too small will not provide total airway protection.
8
Q
- Persistent Pulmonary Hypertension (PPHN) is a syndrome characterized by persistent elevated pulmonary vascular resistance resulting in
A. Right-to-left shunt
B. Left-to-right shunt
C. Apnea
D. Systemic hypotension
A
- A: Persistent pulmonary hypertension of the newborn (PPHN) results in a right-to-left shunt at the ductus arteriosus or the foramen ovale, leading to hypoxemia in the presence of a structurally normal heart. Demonstration of right-to-left shunting at the ductus using preductal and postductal simultaneous arterial blood gas (ABG) levels is helpful in the diagnosis.
9
Q
- The most common side effect, complicating transport of a newborn with the use of Prostaglandin E1 is
A. Hypoglycemia
B. Apnea, hypoventilation
C. Hypotension
D. Diarrhea
A
- B: Apnea and hypoventilation are the most common side effects complicating transport with the use of PGE 1. The length of transport and the difficulty of placing an ETT during transport must be considered in the decision of whether to place an ETT before transport when prostaglandins are begun. Other side effects can include fever, vasodilation with flushing, and diarrhea. Uncommonly, the vasodilation may result in systemic hypotension requiring intervention.
10
Q
- A medication utilized in the neonate that accelerates closure of the PDA is
A. Ibuprofen, Indomethacin
B. Dobutamine
C. PGE1
D. Oxytocin
A
- A: In newborns, a medication such as indomethacin or ibuprofen can be given to accelerate closure of the PDA. These medications are given in the stomach and can constrict the muscle in the wall of the PDA and promote closure. These drugs do have side effects, however, such as kidney injury or bleeding, so not all infants can receive them. Because of the potential side effects, the infant must have lab values checked before medications can be given. If the lab values are not normal or if the medications do not work, surgery can be performed and the PDA tied off (ligated).
11
Q
- A pediatric patient presents to the ED in acute respiratory distress, with increased work of breathing and reduced oxygen saturation. The patient is treated with multiple rounds of nebulized albuterol, ipratropium, oxygen supplementation, and parental steroids, with none to minimal improvement in clinical and objective evidence of respiratory distress. Which of the following medications is recommended for sedation prior to intubation because of the bronchodilatory effect it possesses?
A. Etomidate
B. Ketamine
C. Versed
D. Fentanyl
A
- B: Children experiencing severe asthma exacerbations may deteriorate to respiratory failure requiring endotracheal intubation and mechanical ventilation. Mechanical ventilation is often life saving in this setting, but also exposes the asthmatic child to substantial iatrogenic risk. Ketamine does have proven bronchodilation effects and is the anesthesia of choice for patients in respiratory distress. Ketamine does appear to have a beneficial role in reducing the length of intubation or hospital admission and level of respiratory distress in pediatric asthma patients already intubated or admitted to the ICU using multiple standard and nonstandard treatment modalities.
12
Q
- You are transporting a nine-year-old man weighing 40 kg with diagnosis of status asthmaticus on a ventilator. EtCO2 is 60. Ventilator settings are at Vt 250, FIO2 1.0, Rate 16, I:E 1:3, PEEP 5, PIP 48. How will you manage this patient?
A. Increase tidal volume
B. Increase I:E ratio
C. Increase PEEP
D. Increase respiratory rate
A
- B: The primary goal of asthma management is reversal of hypoxemia as well as control of contributing inflammatory responses. Too much oxygen or mechanical force may result in lung injury. Insufficient oxygen or mechanical force will result in hypoxia and hypoventilation. The starting respiratory rate (RR) is in part age determined, commonly 30-50 in neonates, 25-30 in infants, 20 in children, and 10-15 in teenagers. The rate is also dependent on the disease process. For example, patients who have air trapping or hyperinflation disorders (such as asthma) need a longer expiratory phase and therefore, a slower rate. The inspiratory time (IT or I-time) is also age and rate dependent and will also need to be altered depending on the child’s disease. A guideline is 0.4-0.7 seconds for infants and 0.5-1 seconds for children and adults. Longer I-times increase mean airway pressure (MAP) (by prolonging the inspiratory cycle) and therefore usually improve oxygenation. In choosing a tidal volume (TV) or PIP, the most important tenant to remember is, in general, to use a volume or pressure that causes good visible chest rise and air entry on auscultation. For TV ventilation, the starting range is usually about 5-8 mL/kg. Adjusting the FIO2 will only affect the pO2 and oxygen saturation. Increasing the ventilator rate will increase the minute ventilation, so this decreases the pCO2 (and hence increases the pH). These are the two most basic changes that occur in ventilator management. One could also increase the minute ventilation (which would decrease the pCO2) by increasing the TV (on a volume ventilator) or the PIP (on a pressure ventilator). Also realize that any parameter change which increases the MAP will also increase the pO2. One could increase the MAP by increasing the positive end-expiratory pressure (PEEP), the IT, or the PIP. Increasing the TV on a volume ventilator, in essence, increases the PIP, so this also increases the MAP. In nonventilated patients, the glottis opens and closes during spontaneous respirations. Partial closure of the glottis provides a physiologic “PEEP” of 3-4 mmHg by preventing complete emptying of the airway. In patients with good oxygenation and little pulmonary disease, a PEEP of 3-5 mmHg is adequate. Higher PEEPs are necessary for the patient with pulmonary edema, pneumonia, or atelectasis. High PEEP may also be useful for the postoperative heart patient with surgical bleeding. Be aware that increasing PEEP increases MAP. Patients with high MAPs may require volume infusions to maintain venous return and cardiac output. Inotropic support may also be needed in patients requiring very high PEEP of > 10 mmHg.
13
Q
- Recommended urinary output when caring for a pediatric patient should be
A. 100 mL/hr
B. 30-50 mL/hr
C. 1-2 cc/kg/hr
D. >200 mL/hr
A
- C: End-organ perfusion will decrease with fluid or blood loss and will be reflected by oliguria or anuria. Maintenance of 1-2 mL/kg of urine output is the goal of circulatory support in the pediatric patient. Urinary output varies with age. After fluid resuscitation, maintenance fluids must be provided on a kilogram body weight basis. Prevention of hypothermia as a result of fluid resuscitation is imperative.
14
Q
- You are transporting a three-year-old boy who was struck by a vehicle two hours prior to your arrival in the ER department. Your assessment reveals BP 60/38, HR 54, RR 36, SaO2 92%, skin condition is cool, with a delayed capillary refill. He is awake but is restless and irritable. Which of the following should always be recognized as ominous signs and should be treated aggressively in the pediatric patient?
A. Tachypnea and bradycardia
B. Delayed capillary refill and cool skin
C. Decreased level of consciousness and hypotension
D. Hypotension and bradycardia
A
- D: The initial compensatory mechanism that the transport team should look for during the early stages of hemorrhagic shock is tachycardia. The other compensatory mechanism that occurs to maintain normal perfusion and blood pressure is an increase in the systemic vascular resistance, which is manifested clinically by mottled or cool extremities, weak or thready distal pulses, delayed capillary refill time, and a narrowed pulse pressure. Hypotension and bradycardia should always be recognized as ominous signs and aggressively treated in the pediatric patient. After ventilation and oxygenation has been addressed, fluid resuscitation should quickly follow. Resuscitation begins with a 20 mL/kg bolus of warmed Ringer’s lactate or normal saline. Because only approximately one-third of crystalloid infusions remain in the intravascular space, this bolus may need to repeated twice or thrice. If more than 40-60 mL/kg of crystalloid solution is required to restore adequate perfusion, blood replacement must then be considered. The administration of 10 mL/kg of type specific or O negative packed red blood cells (PRBCs) should be considered in the pediatric patient presenting with hypovolemic shock.
15
Q
- You are transporting a 20-kg patient presenting with second- and third-degree burns to his entire face, anterior torso, and complete left arm. How much fluid should the patient receive in the first eight hours using the Parkland formula?
A. 2,880 mL
B. 1,960 mL
C. 1,440 mL
D. 3,650 mL
A
- C: The objective assessment of the burn injury itself includes estimating the burn size and depth, associated inhalation injuries, and calculation of fluid resuscitation needs. The size of the burn wound is most frequently estimated by using the rule of nines method, which divides the body into multiples of 9%. A fairly accurate approximation can be made using the patient’s entire palm size to represent 1% of the total BSA and visualizing that palm over the burned area. BSA calculated: 9% entire face; 18% anterior torso; 9% complete left arm. Answer: 4 × 20 = 80; 80 × 36 = 2,880; ½ administered in the first 8 hours = 1,440 mL. Refer table to review the rule of nines.
16
Q
- You are transporting a newborn who was delivered vaginally in a small ER about six hours prior to your arrival with a history of bilious vomiting, abdominal distention, feeding intolerance, and lack of stools for the last twenty-four hours. Initial management would include
A. Endotracheal intubation and ventilation
B. Needle decompression to correct underlying pulmonary leak
C. Decompression of the bowel with intermittent large-bore gastric suction
D. Request contrast studies for further evaluation prior to transport
A
- C: Common initial symptoms for intestinal obstruction include bilious vomiting, abdominal distention, feeding intolerance, large quantities of gastric contents at delivery, absence of an anal opening, and lack of stooling in the first twenty-four hours. Presence of tenderness, metabolic acidosis, or decreasing platelets may indicate a bowel necrosis or peritonitis and should be treated as an urgent problem. Management includes decompression of the bowel with intermittent large-bore gastric suction, IV fluids, antibiotic therapy as indicated, and respiratory support. Severe abdominal distention may compromise respiratory status.
17
Q
- You are managing a four-year-old boy presenting lethargic with nystagmus. You note he has depressed DTRs and has a profound anion-gap. The patient should be managed with which of the following?
A. IV ethanol drip
B. Calcium
C. Potassium supplement
D. Sodium bicarbonate
A
- A: Ethylene glycol poisoning is caused by the ingestion of ethylene glycol (the primary ingredient in both automotive antifreeze and hydraulic brake fluid). It is a toxic, colorless, odorless, and almost nonvolatile liquid with a sweet taste and is occasionally consumed by children for its sweetness. Following ingestion, the symptoms of poisoning follow a three-step progression starting with intoxication and vomiting, before causing metabolic acidosis, cardiovascular dysfunction, and finally acute kidney failure. Treatment consists of initially stabilizing the patient followed by the use of antidotes. The antidotes used are either ethanol or fomepizole (Antizol) administered by intravenous infusion. The antidotes work by blocking the enzyme responsible for metabolizing ethylene glycol and therefore halt the progression of poisoning. Hemodialysis is also used to help remove ethylene glycol and its metabolites from the blood.
18
Q
- The fetus was delivered with obvious meconium staining. His one-minute APGAR is 8. Endotracheal suctioning
A. Should be performed via nose, then mouth
B. Should be performed via mouth, then nose
C. Should be performed endotracheally, then mouth, then nose
D. Should not be performed
A
- D: Meconium is normally stored in the infant’s intestines until after birth, but sometimes (often in response to fetal distress) it is expelled into the amniotic fluid prior to birth, or during labor. If the baby then inhales the contaminated fluid, respiratory problems may occur. The most obvious sign that meconium has been passed during or before labor is the greenish or yellowish appearance of the amniotic fluid. After birth, rapid or labored breathing, cyanosis, slow heartbeat, a barrel-shaped chest or low APGAR score are all signs of the syndrome. Inhalation can be confirmed by one or more tests such as using a stethoscope to listen for abnormal lung sounds (diffuse crackles and rhonchi), performing blood gas tests to confirm a severe loss of lung function, and using chest x-rays to look for patchy or streaked areas on the lungs. Infants who have inhaled meconium may develop RDS often requiring ventilatory support. Complications of meconium aspiration include pneumothorax and PPHN. When meconium staining of the amniotic fluid is present and the baby is born depressed, it is recommended by the newborn resuscitation guidelines that an individual trained in neonatal intubation use a laryngoscope and ETT to suction meconium from below the vocal cords. The APGAR score is determined by evaluating the newborn baby on five simple criteria on a scale from zero to two, then summing up the five values thus obtained. The resulting APGAR score ranges from zero to ten. The five criteria (Appearance, Pulse, Grimace, Activity, Respiration) are used as a mnemonic learning aid. The test is generally done at one and five minutes after birth, and may be repeated later if the score is and remains low. Scores 3 and below are generally regarded as critically low, 4 to 6 fairly low, and 7 to 10 generally normal.
19
Q
- Which of the following lab test is used to diagnose Reye’s syndrome?
A. Liver function tests
B. Ammonia
C. BUN
D. Potassium
A
- B: Reye’s syndrome is a potentially fatal disease that causes numerous detrimental effects to many organs, especially the brain and liver, as well as causing hypoglycemia. The exact cause is unknown, and while it has been associated with aspirin consumption by children with viral illness, it also occurs in the absence of aspirin use. The disease causes fatty liver with minimal inflammation and severe encephalopathy (with swelling of the brain). The liver may become slightly enlarged and firm, and there is a change in the appearance of the kidneys. Jaundice is not usually present. Early diagnosis is vital; while most children recover with supportive therapy, severe brain injury or death are potential complications. The ammonia test is primarily used to help investigate the cause of changes in behavior and consciousness. It may be ordered, along with other tests such as glucose, electrolytes, and kidney and liver function tests, to help diagnose the cause of a coma of unknown origin or to help support the diagnosis of Reye’s syndrome or hepatic encephalopathy caused by various liver diseases.
20
Q
- During transport, management of a thirty-seven week newborn diagnosed with persistent pulmonary hypertension (PPHN) may include which of the following to prevent right-to-left shunting?
A. Maintaining a pCO2 > 45 mmHg
B. Continuous monitoring of the blood pressure; support blood pressure with fluid volume replacement, and a vasopressor as needed
C. Continuous monitoring of the serum glucose
D. Administration of surfactant
A
- B: Treatment is aimed at maintaining adequate oxygenation, maintaining the infant in an alkalemic state through hyperventilation and the use of blood buffers, sedation or neuromuscular blockade, fluid boluses, and cardiotonic drugs. Maintenance of the systemic blood pressure discourages right-to-left shunting.
21
Q
- Pediatric airway anatomy differs from adult anatomy in the following ways, except
A. Airway diameter in children is smaller than adults
B. The larynx is located more anterior in infants and children
C. The epiglottis is long and narrow and angled away from the trachea
D. In children, younger than six years of age, the narrowest portion of the trachea is at the cricoid process.
A
- D: In children younger than 10 years of age, the narrowest portion of the trachea is at the cricoid process. The vocal cords are attached lower anteriorly and the tongue (especially in infants) is proportionately larger.
22
Q
- Primary cause of bradycardia in the neonate and pediatric patient is
A. Hypoglycemia
B. Hypoxia
C. Hypovolemia
D. Hemorrhage
A
- B: Hypoxia is a major cause of bradycardia in the pediatric patient, so bradycardia during any airway procedure should be treated promptly with assuring that the airway is open, oxygenation and ventilation. Placing the child in a “sniffing position,” with the midface placed superiorly and anteriorly, is the optimal alignment for airway protection. With traumatic injuries, care must be taken to maintain a neutral position of the cervical spine while opening the airway. Padding of the backboard under a child’s shoulders and posterior thorax will also aid in neutral alignment of the cervical spine.
23
Q
- Drug of choice for profound hypotension in septic shock is
A. Isotonic crystalloid solution
B. Levophed
C. Nipride
D. Dobutamine
A
- B: Sepsis is by far the most common cause of distributive shock. Goals of early resuscitation in patients with sepsis include restoration of tissue perfusion, reversal of oxygen supply dependency, and normalization of cellular metabolism. When appropriate fluid administration fails to restore adequate tissue perfusion and arterial pressure, vasopressors are usually necessary to increase mean systemic pressure, cardiac output, and oxygen delivery. Norepinephrine (Levophed) improves systemic blood pressure and does not substantially worsen end-organ ischemia in most studies of crystalloid-resuscitated septic shock patients. Norepinephrine may be preferential to other catecholamine pressors as first-line therapy for septic shock. Dosing of norepinephrine in shock patients is normally in the range of 0.01-5 µg/kg/minute and titrated to improvements in blood pressure and tissue perfusion. If sepsis is suspected, antibiotic therapy should be anticipated and discussed with both the referring and receiving physician.
24
Q
- You are managing a four-year-old boy who is requiring intubation. The appropriate size ET tube for this patient would be
A. 3.5
B. 4.0
C. 4.5
D. 5.0
A
- D: Using the formula 16 + age in years divided by 4 equals an ET tube size of 5.0.
25
Q
- What finding would you expect to see on a chest x-ray for a patient presenting with laryngotracheobronchitis?
A. Macdonald’s sign
B. Angel wing sign
C. Steeple sign
D. Thumb print sign
A
- C: The steeple sign is a sign on a frontal radiograph of tracheal narrowing and suggestive of the diagnosis of croup (laryngotracheobronchitis). Croup is the common term for a viral infection that affects the larynx but may extend into the trachea and bronchi. Patients generally present with a history of fever and coryza (acute inflammation of the mucous membrane of the nose, with discharge of mucus; a head cold). As the illness progresses inspiratory stridor may be present, as well as a characteristic “barking” cough. If the inflammation extends to the bronchi, rhonchi and wheezing may also be present. Care must be taken to rule out epiglottitis and retropharyngeal abscess because the presentations can be similar. Treatment is supportive and centers on treating dehydration and respiratory distress. Medications can include racemic epinephrine aerosols, dexamethasone, and prednisolone.
26
Q
- Vt is calculated at
A. 3-5 mL/kg
B. 5-8 mL/kg
C. 6-10 mL/kg
D. 10-15 mL/kg
A
- B: Tidal volume (Vt) is calculated in milliliters per kilogram. Traditionally 10-15 mL/kg was used but has been shown to cause barotrauma, or injury to the lung by overextension, so 6-8 mL/kg is now common practice in ICU for adults and older children. For infants and younger children without existing lung disease—a TV of 4-8 mL/kg to be delivered at a rate of 30-35 breaths/minute.
27
Q
- A scaphoid abdomen, unequeal breath sounds, dyspnea, and a shift in the PMI are a classic presentation of which of the following in the neonate patient?
A. Tension pneumothorax
B. Diaphragmatic hernia
C. Aspiration pneumonia
D. RDS, formerly known as hyaline membrane disease
A
- B: Diaphragmatic hernia is caused early in gestation when the pleuroperitoneal cavity fails to close. Abdominal contents migrate into the thoracic cavity, compressing developing lungs and causing pulmonary hyoplasia. Classic presentation by these infants includes early onset of respiratory distress with deterioration between the 1 and 5 minute APGAR scores in the delivery room. Clinical signs include dyspnea, unequal breath sounds, a shift in the PMI, and potentially scaphoid abdomen. The initial treatment efforts of preoperative stabilization are aimed at optimizing oxygenation, maintaining an adequate systemic blood pressure, and reducing the associated pulmonary hypertension. Because any distention of the bowel further compromises respiratory function, the transport team should insert a large-bore (10 Fr) orogastric tube and initiate suction. Positive-pressure ventilation with a face mask should be avoided. When ventilation is required, immediate endotracheal intubation should be performed.
28
Q
- Hypoglycemia in the neonate can be treated with
A. D 25% 2-4 mL/kg
B. D 10% 2-4 mL/kg
C. D 10% 5-10 mL/kg
D. D 5% 2-4 mg/kg
A
- B: Newborns are susceptible to hypoglycemia because of immature glucose control mechanisms, decreased glucose stores, or both. A serum glucose of < 40 mg/dL represents hypoglycemia in the newborn. Hypoglycemia may be treated with a slow intravenous bolus of 2-4 mL/kg of 10% dextrose followed by a maintenance infusion drip of 10% dextrose in water at a rate of 80 mL/kg/24 hour. Serum glucose levels should be checked every thirty minutes to one hour until it has been demonstrated that the amount of glucose provided is adequate to maintain normal serum glucose levels. The newborn weighing less than 1,000 g should receive 5% dextrose in water because of their intolerance of the higher glucose loads resulting in hyperglycemia. Hyperglycemia, blood glucose levels greater than 125 mg/dL, is most commonly seen in the newborn weighing less than 1,000 g or in newborns whose hypoglycemia as been overcorrected.
29
Q
- You are transporting a ten-year-old boy with a history of being struck by a vehicle while riding his bicycle. Your assessment reveals a deteriorating neurologic status, hypotension, and bradycardia. Your management of the this patient would include all of the following, except
A. Elevation of the backboard to 30 degrees
B. Fluid resuscitation
C. Serum glucose determination
D. Nasal intubation
A
- D: Nasal intubations should not be performed on children less than twelve years of age because the acute angle to the glottis makes this an extremely difficult procedure while maintaining neutral cervical spine position. Needle or surgical cricothyroidotomy (dependent on age) may be necessary for airway protection for patients who cannot be successfully intubated and who cannot be ventilated and oxygenated by any other means. Children with Glasgow coma scores (GCS) of 8 or less, children with ongoing seizure activity, or those with deteriorating neurologic status should be intubated so that adequate oxygenation and airway protection is assured. Hypoxia and hypotension are the leading causes of neurologic deterioration in the head-injured patient. Preservation of stable mean arterial pressure is important to provide adequate cerebral perfusion and oxygenation. Elevation of the backboard to thirty degrees unless precluded by other injuries may assist in decreasing intracranial pressure.
30
Q
- A full-term newborn weighing 2,800 grams should be intubated with what size endotracheal tube?
A. 2.5
B. 3.0
C. 3.5
D. 4.0
A
- C: Newborn (34-38 weeks) (2,000-3,000 g) should be intubated with a 3.5 ET tube with an estimated tube depth at approximately 9 cm at the gums.
31
Q
- An eight-year-old child was hit by a car. Your assessment reveals radiation of pain to the left shoulder, ecchymosis, and abrasions to the retroperitoneal area bilaterally and abdominal distention. What injury do you suspect?
A. Liver
B. Spleen
C. Pneumothorax
D. Kidney
A
- B: Blunt trauma is the cause of the majority of abdominal injuries in children. Abdominal examination can be extremely difficult in the pediatric population because fear from exam or pain from distracting injuries interferes with assessment. A high index of suspicion should always be maintained with patients suffering multisystem injury. The solid organs most commonly injured in the pediatric patient are the spleen and the liver. Disruption of the vascular supply to these organs can result in massive hemorrhage. Radiation of pain to the left shoulder (Kehr’s sign) can indicate splenic injuries.
32
Q
- What finding would you expect to see on the lateral neck x-ray to confirm suspicion of epiglottitis?
A. McDonald’s sign
B. Steeple sign
C. Angel wing sign
D. Thumb print sign
A
- D: The thumbprint sign is a finding on a lateral C-spine radiograph that suggests the diagnosis of epiglottitis. The sign is caused by a thickened free edge of the epiglottis, which causes it to appear more radiopaque than normal, resembling the distal thumb. Epiglottitis is a rare but life-threatening bacterial infection of the epiglottitis and surrounding airway structures. Epiglottitis is second only to croup as a cause for infectious stridor. Clinical presentation includes symptoms that often occur rapidly causing caretakers to seek medical attention in twenty-four hours of the onset of initial symptoms, fever, stridor, labored respirations, and because of supraglottic edema, often present with drooling. They are often anxious and present in a classic tripod position (sitting forward with their arms supporting them with their jaws thrusted forward), which increased air entry. Endotracheal intubation should only be undertaken by staff capable of securing the airway, surgically if necessary.
33
Q
- Fluid resuscitation in a neonate patient should be administered at
A. 5 mL/kg
B. 10 mL/kg
C. 15 mL/kg
D. 20 mL/kg
A
- B: If a transport team suspects hypovolemia, the treatment would include careful transfusion with 10 mL/kg of an isotonic crystalloid solution such as normal saline or Ringer’s lactate solution.
34
Q
- You are transporting a four-year-old boy trauma patient. You are preparing to administer a weight per kg based medication. How many kilograms does patient weigh approximately?
A. 10 kg
B. 12 kg
C. 15 kg
D. 20 kg
A
- C: Using the formula (age in years × 2) + 8 gives an approximate weight of 16 kg for a-year-old child.
35
Q
- Expected endotracheal tube centimeter depth for a neonate can best be determined by using which of the following formulas?
A. 6 + weight in kg
B. 16 + age in years divided by 4
C. 10 + weight in kg
D. 3 + weight in kg
A
- A: Preparation for endotracheal intubation is the most overlooked but often the most important part of the procedure. Being properly prepared for problems that may arise can often prevent life-threatening complications during intubation. Use of cuffed ET tubes is recommended for children over the age of eight years and adults. Use of uncuffed ET tubes is recommended for children under the age of eight years because the normal narrowing at the cricoid cartilage functions as the “natural cuff.” Alternative method is using the length-based Broselow tape. Remember that an intubated child is at risk for the displacement of the ETT, ETT plugging, pneumothorax, or an equipment failure (ventilator malfunction). Assume that any deterioration in the child’s status is an airway problem until that is ruled out as a cause. “DOPE” is a useful mnemonic to remember potential causes of airway or ventilation problems in intubated patients.
36
Q
- When identifying vessels on the umbilical stump, the umbilical vein, as compared to the umbilical arteries, is usually located at what position?
A. 10 o’clock
B. 4 o’clock
C. 12 o’clock
D. 8 o’clock
A
- C: The umbilical vein remains patent and viable for cannulation until approximately one week after birth. The transport team must be able to identify the two thick-walled, constricted arteries (four o’clock and eight o’clock position) and the thinner-walled larger vein (twelve o’clock position).
37
Q
- The circulating blood volume in a child is
A. 10-20 mL/kg
B. 20-40 mL/kg
C. 50-60 mL/kg
D. 70-80 mL/kg
A
- D: A pediatric patient has only 80 mL of circulating volume/kg, so small amounts of fluid or blood loss can cause serious physiologic effects. The goal in supporting cardiac output in shock is the replacement of lost circulating volume.
38
Q
- A surgical airway can be placed through the cricothyroid membrane on children over the age of
A. 8 years
B. 10 years
C. 11 years
D. 12 years
A
- C: A rare occurrence in the pediatric population is the necessity for control of the airway via surgical means. A surgical airway can be placed through the cricothyroid membrane on children older than eleven years, but it is recommended that needle cricothyroidotomy be performed on children younger than eleven years. Indications for needle cricothyroidotomy include complete airway obstruction, severe orofacial injuries, and laryngeal transaction where there is an inability to secure the airway and/or provide adequate ventilation and oxygenation by less-invasive means. Needle cricothyroidotomy does not protect the paitent’s airway from passive aspiration and is considered a temporary measure until ETT placement or removal of the obstruction can be achieved.
39
Q
- In an emergency situation, an umbilical vein catheter when placed correctly should only be inserted as far as necessary to obtain blood and should not go beyond which of the following?
A. Level of the right atrium
B. Liver
C. Kidneys
D. Ductus venonus
A
- B: The principal indication for umbilical vein catheterization is to gain vascular access during emergency resuscitation. Umbilical vein catheterization may be a life-saving procedure in neonates who require vascular access and resuscitation. A 3.5 F catheter is used for preterm newborns, and a 5 F catheter is used for full-term newborns. In an emergency, the catheter is best advanced only 1-2 cm beyond the point at which good blood return is obtained to avoid injecting hyperosmolar fluids into the portal vessels and causing liver necrosis. This is approximately 4-5 cm in a full-term neonate. Umbilical vein catheters may be placed in the inferior vena cava above the level of the ductus venosus and below the level of the right atrium (10-12 cm). This acts as central venous access, allowing central venous pressure (CVP) monitoring, medication infusions, and the administration of hyperalimentation solutions. The position of the catheter must be confirmed radiographically. After proper placement of the umbilical line, intravenous fluids and medication may be administered to critically ill neonates.
40
Q
- Noninitiation or discontinuation of newborn resuscitation as recommended by the International Guidelines for Neonatal Resuscitation include all of the following, except?
A. Birthweight
B. Confirmed trisomy 13 or 18
C. Gestational age
D. Severe fetal growth restriction or congenital hydrocephalus
A
- C: The International Guidelines for Neonatal Resuscitation include recommendations for noninitiation or discontinuation of resuscitation, which include birth weight
41
Q
- One of the most common causes of new-onset wheezing in children is
A. Croup
B. Bronchiolitis
C. Epiglottitis
D. Pneumonia
A
- B: Bronchiolitis is a lower respiratory tract infection (primarily viral), which is one of the more common causes of new-onset wheezing in children. Respiratory syncytial virus (RSV) is the causative agent in the majority of cases, but parainfluenza and Mycoplasma pneumoniae have also been isolated. Wheezing is the most common presenting complaint, often with an accompanying 2-5 days’ history of coryaz and cough. Most cases occur in the winter months, with the majority of infections in children below one year of age. Apnea in children younger than three months is also characteristic of RSV infections.
42
Q
- Which of the following is not indicated for the treatment of bronchiolitis?
A. Adequate hydration
B. Supplemental oxygen
C. Corticosteroids
D. Nebulized albuterol aerosols
A
- C: Oral albuterol solutions are not indicated for patients who do not respond to aerosol therapy. Corticosteroids are not indicated for the treatment of bronchiolitis. Patients in severe distress, who are unresponsive to therapy, may require intubation and mechanical ventilation.
43
Q
- You are transporting a five-year-old boy with a diagnosis of sepsis secondary, a localized necrotic skin area of unknown etiology. The “bull’s-eye” appearing necrotic area is noted to the left upper thigh area. Which of the following may be the most likely cause?
A. Black widow spider bite
B. Brown recluse spider bite
C. Snake bite
D. Scorpion sting
A
- B: Brown recluse spiders usually have a dark violin-shaped mark on their cephalothorax, just behind their eyes, resulting in the nicknames fiddleback spider, brown fiddler, or violin spider. Unlike most spiders, the brown recluse has six eyes arranged in three pairs, instead of the usual eight. The bite forms a necrotizing ulcer, “bull’s-eye” in appearance, that destroys soft tissue and may take months to heal, leaving deep scars. These bites usually become painful and itchy within 2-8 hours. Pain and other local effects worsen 12-36 hours after the bite, and the necrosis develops over the next few days. Over time, the wound may grow to as large as 25 cm (10 in.) in extreme cases. The damaged tissue becomes gangrenous and eventually sloughs away.
44
Q
- A ten-year-old boy presents to the emergency department with a history of feeling a “sharp” pinprick, dull numbing pain to the right foot, muscle cramping, with intense abdominal pain that started about thirty minutes prior. Which of the following may be the most likely cause
A. Black widow spider bite
B. Brown recluse spider bite
C. Snake bite
D. Scorpion sting
A
- A: The female black widow’s bite is particularly harmful to humans because of their unusually large venom glands (males almost never bite humans). The black widow spider produces a protein venom that affects the victim’s nervous system. This neurotoxic protein is one of the most potent venoms secreted by an animal. Some people are slightly affected by the venom, but others may have a severe response. The first symptom is acute pain at the site of the bite, although there may only be a minimal local reaction. Symptoms usually start within twenty minutes to one hour after the bite. Local pain may be followed by localized or generalized severe muscle cramps, abdominal pain, weakness, and tremor. The southern black widows, as well as the closely related western and northern species, which were previously considered the same species, have a prominent red hourglass figure on the underside of their abdomen. A person bitten by a black widow spider, who has pain severe enough to seek treatment at an emergency department, will require narcotic pain relief. Muscle relaxants given by injection may also be of value. Although calcium gluconate given through an IV has long been advocated, it does not seem to produce much relief of symptoms.
45
Q
- You have been called to the scene for a six-year-old girl with a history of snake bite to the left lower extremity while on a camping trip. Management of this patient would include all of the following, except
A. Immobilization of the affected extremity in neutral position
B. Measuring the leg girth every fifteen minutes and marking the line of demarcation
C. Administration of pain analgesia, antihistamines, and anti-inflammatory medications
D. Application of ice to the affected area
A
- D: The care of viper envenomation should include wound cleansing, immobilization of the affected part (decreases the circulation of venom throughout the body), no use of compression techniques (including ice), and transport. Included in the coagulation studies should be fibrin split products and fibrinogen levels. Treatment can include fluids, administration of steroids, medications to decrease risk of anaphylaxis, and snake antivenin. If the patient exhibits signs of severe envenomation, such as edema that has progressed 30 cm in 1 hour of the bite, shock, kidney failure, pulmonary edema, bleeding, or paralysis, administration of antivenin should be started.
46
Q
- A newborn who is hypoxic in room air but demonstrates a partial pressure of oxygen greater than 150 in 100% oxygen is more likely to have which of the following?
A. Heart disease
B. Pulmonary disease
C. Esophageal atresia
D. Necrotizing enterocolitis
A
- B: The infant who is hypoxic in room air but demonstrates a partial pressure of oxygen (pO2), greater than 150 in 100% oxygen is more likely to have pulmonary disease than heart disease with a fixed right-to-left shunt. Comparison of simultaneous ABGs demonstrating a PaO2 at least 10 mm higher from a preductal site versus a postductul site indicates right-to-left shunting of desaturated blood at the ductal level.
47
Q
- Gastroschisis in a newborn is best described as
A. Ischemia of the bowel
B. An arrest of the development of the abdominal wall, with the abdominal contents remaining externalized, which is covered by a membrane
C. Persistent elevated pulmonary vascular resistance resulting in a right-to-left shunt at the ductus arteriosus or the foramen ovale, leading to hypoxemia
D. A defect in the abdominal wall that has otherwise completed its development and allows protrusion of abdominal contents which is not covered by a membrane
A
- D: Gastrochisis is a defect in the abdominal wall that has completed its development. The defect allows for protrusion of abdominal contents and is not covered by a membrane. Because the defect is normally very close to the umbilicus, it is frequently mistaken for an omphalocele. An omphalocele is an arrest of development of the abdominal wall, with the abdominal contents remaining externalized. The defect remains covered by a membrane in utero, although the sac may be broken during delivery.
48
Q
- When transporting a neonate suspected of having esophageal atresia, you should immediately
A. Obtain vascular access and administer fluids
B. Elevate the head of the bed to prevent gastric reflux
C. Provide positive-pressure ventilation
D. Obtain a chest x-ray
A
- B: Findings related to identification of esophageal atresia include inability to pass an oral gastric tube to the stomach, excessive oral secretions, and feeding intolerance. Management of these infants during transport should include the following: intermittent suction of the upper esophageal pouch, elevation of the head of the bed to prevent gastric reflux, and intravenous fluid therapy for fluids and glucose.
82
Q
APGAR
A
88
Q
Steeple sign is
A
a frontal radiograph of tracheal narrowing and suggestive of the diagnosis of croup.
98
Q
What Clinical sign?
A
thumbprint sign
Epiglottitis is a rare but life-threatening bacterial infection of the epiglottitis and surrounding airway structures. Epiglottitis is second only to croup as a cause for infectious stridor.
- Clinical presentation includes symptoms that often occur rapidly causing caretakers to seek medical attention in twenty-four hours of the onset of initial symptoms, fever, stridor, labored respirations, and because of supraglottic edema, often present with drooling.
