|CRITICAL THINKING-PICU QUIZ
|Year : 2020 | Volume
| Issue : 2 | Page : 99-101
Pradeep Kumar Sharma1, Praveen Khilnani2
1 Department of Pediatric Critical Care and Pulmonology, Sri Balaji Action Medical Institute, New Delhi, India
2 Department of Pediatric Critical Care and Pulmonology, Rainbow Children Hospital, New Delhi, India
|Date of Submission||26-Feb-2020|
|Date of Decision||04-Mar-2020|
|Date of Acceptance||10-Mar-2020|
|Date of Web Publication||10-Apr-2020|
Dr. Pradeep Kumar Sharma
Sri Balaji Action Medical Institute, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sharma PK, Khilnani P. PICU quiz. J Pediatr Crit Care 2020;7:99-101
1. A 5-year-old child with muscular dystrophy is scheduled to undergo muscle biopsy for diagnosis. Anesthesia is induced using sevoflurane and you start injecting succinylcholine in preparation for intubation. The child develops masseter spasm immediately and temperature rises to 41°C. After immediate discontinuation of inhaled anesthesia and succinylcholine, which one of the following steps is the most appropriate?
- Start normal saline bolus
- Intravenous (IV) injection of dantrolene
- Arrange bed in the pediatric intensive care unit (PICU)
- Start 100% oxygen with a high flow rate to wash out residual sevoflurane
- Paralyze and intubate the child with another agent.
2. An 18-month-old boy with Type I spinal muscular atrophy is in the PICU with respiratory syncytial virus bronchiolitis which presented as fever and copious secretions. He has a respiratory rate (RR) of 56 breaths/min with deep subcostal retractions and is started on noninvasive positive-pressure ventilation (PPV) with inspiratory pressure of 15 cm H2O and expiratory pressure of 5 cm H2O. After a while, his retractions are much improved, and RR is 30 breaths/min. However, saturations are only 92% on 40% oxygen, and the chest radiograph reveals basilar atelectasis. Which one of the following treatment plans will best recruit her collapsed lung?
- Increase expiratory pressures to 10 cm of H2O and inspiratory pressures to 20 cm H2O
- Just increase expiratory pressure to 10 cm of H2O
- Give glycopyrolate to decrease secretions
- Intubation and mechanical ventilation
- Chest physiotherapy with mechanical insufflation-exsufflation.
3. A 4-year-old boy is being treated for pneumococcal pneumonia and sepsis. You have noticed decreased breath sounds on the right side along with increased ventilatory settings. He has become more edematous, has decreased urine output, and has oozing around his central and arterial lines. His blood workup shows thrombocytopenia, elevated liver enzymes, coagulopathy, and worsening renal function. His chest radiograph shows a new right-sided pleural effusion. You decide to place a right-sided chest tube to evacuate the effusion. He is receiving a fentanyl drip and intermittent benzodiazepine for sedation. Which one of the following options would be the most appropriate next step in management of this patient?
- Use rocuronium for paralysis and start diuretics to help decrease pleural effusion
- Use cisatracurium for paralysis and insert the Intercostal drainage (ICD) in the fifth intercostal space (ICS) in the right mid axillary line
- Use cisatracurium for paralysis and insert the ICD in the second ICS in the right mid-clavicular line
- Use rocuronium for paralysis and insert the ICD in the fifth ICS in the right mid-axillary line
- Use rocuronium for paralysis and insert the ICD in the second ICS in the right mid-clavicular line.
4. A 2-month-old girl developed poor feeding and irritability early this morning. She was brought to the emergency department (ED) due to respiratory distress. On examination, she looks mottled and has weak pulses. Her rhythm strip in lead II showed the following rhythm. The emergency physician tried cardioversion with 0.5 J/kg, but rhythm on the monitor did not change.
Which one of the following options is the next most appropriate intervention?
- Synchronized cardioversion with 0.25 J/Kg
- 25 mg/kg of IV magnesium sulfate
- Defibrillation with 2 J/kg
- Synchronized cardioversion with 2 J/kg
- 0.1 mg/kg of IV adenosine.
5. A 2-year-old infant is brought to the ED after his mother found him drinking an unknown substance from a soda bottle in the family's pool house. You suspect that the substance was an acidic pool cleaner. Physical examination of the child's lips, tongue, and oropharynx reveals no abnormalities. Of the following, the MOST appropriate next step in management is:
- Emergent upper gastrointestinal radiographic series
- Initiation of oral antibiotic therapy
- Parental reassurance and patient discharge
- Placement of a nasogastric tube for lavage
- Referral for emergency esophagoscopy.
6. A 10-year-old girl was admitted in the PICU with a history of injury over the right ankle 1 week back. The child had features of sepsis with septic shock and was ventilated for a duration of 48 h. The diagnosis of Methicillin-resistant Staphylococcus aureus (MRSA) septicemia was made, and she had responded well to IV vancomycin. The child was extubated onto nasal prong oxygen and showed significant clinical improvement. After 10 h of extubation, you get a call from the intensive care unit that the child had sudden deterioration in the form of increased respiratory distress, tachycardia, and hypotension. What are the possibilities you consider and intervention?
- Tension pneumothorax and needs an emergency ICD insertion
- Seizure and needs IV midazolam
- Bronchospasm and needs IV steroid and nebulisations
- Cardiac tamponade secondary to pericardial effusion leading to obstructive shock and needs urgent echocardiography (ECHO) and drainage
- Septic shock and needs fluid bolus.
7. The child presents with elevated serum free calcium, but parathyroid hormone (PTH) is in the normal range. What is the best conclusion?
- PTH is normal; therefore, problem does not lie in parathyroid gland
- PTH should be low if the parathyroid is functioning normally; thus, the problem is in the parathyroid gland
- The child is excessively sensitive to PTH since normal levels are stimulating excessive calcium mobilization from bone
- You need a parathyroid scan to make a conclusion.
8. Which is/are correct statements regarding the inspiratory time (Ti)
- At the end-Ti, the expiration phase always starts
- If Ti is set by the inspiration-to-expiration ratio, the Ti is independent of ventilator frequency
- If Ti is directly set, the expiratory time decreases with increasing ventilator frequency
- Normal Ti is in the range of 3–4 s.
9. Causes of right ventricular failure include/s:
- Acute pulmonary embolus
- Acute respiratory distress syndrome (ARDS)
- Obstructive sleep apnea
- All of the above.
10. Regarding prone position ventilation which is correct:
- The PROSEVA study group showed no mortality benefit at 28 days in severe ARDS
- Alveolar recruitment is affected as drainage of secretions gets impaired
- A more homogeneous ventilation distribution is achieved due to favorable changes in thoraco-abdominal compliance
- Proning increases extravascular lung water
- The optimal duration of prone positioning is 24 h.
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