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 Table of Contents  
CRITICAL THINKING
Year : 2020  |  Volume : 7  |  Issue : 4  |  Page : 221-225

PICU quiz


Department of Pediatric Critical Care and Pulmonology, Sri Balaji Action Medical Institute, New Delhi, India

Date of Submission27-May-2020
Date of Acceptance18-Jun-2020
Date of Web Publication13-Jul-2020

Correspondence Address:
Dr. Pradeep Kumar Sharma
Department of Pediatric Critical Care and Pulmonology, Sri Balaji Action Medical Institute, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JPCC.JPCC_92_20

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How to cite this article:
Sharma PK. PICU quiz. J Pediatr Crit Care 2020;7:221-5

How to cite this URL:
Sharma PK. PICU quiz. J Pediatr Crit Care [serial online] 2020 [cited 2020 Aug 9];7:221-5. Available from: http://www.jpcc.org.in/text.asp?2020/7/4/221/289533



Q1. A 7-year-old child was brought to the emergency room (ER) after fall from the third floor. He was resuscitated and intubated. Noncontrast computed tomography (CT) head revealed bilateral cerebral contusion and bilateral collapsed ventricles, with loss gray-white matter differentiation. His neurological examination before intubation revealed decerebrate posturing, midposition unreactive pupils, absent oculocephalic and oculovestibular reflexes, and hyperventilation. What type/stage of herniation this child presented with?

  1. Central herniation–diencephalic stage
  2. Uncal herniation
  3. Central herniation–midbrain–upper pons stage
  4. Tonsillar herniation
  5. No evidence of any herniation.


Q2. In the same child, intracranial pressure (ICP) monitoring was started and below is waveform.



What is the interpretation?

  1. Normal ICP
  2. Raised ICP with compliant brain
  3. Insufficient data
  4. Raised ICP with poorly compliant brain
  5. ICP catheter displaced with artifact readings.


Q3. Cerebral perfusion pressure target for this child is:

  1. Below 20 mmHg
  2. Between 40 and 50 mmHg
  3. At least 70 mmHg
  4. Between 30 and 40 mmHg
  5. Not well defined.


Q4. Further, in this case in the pediatric intensive care unit, the child is adequately sedated, paralyzed, and hemodynamically stable on vasopressor. No evidence of clinical or electrical seizures was noted. The serum Na + is 161 mEq/L and serum osmolarity is 330 mOsm/L. Repeat CT brain is showing diffuse cerebral edema. ICPs are showing readings of 25 mmHg for the last 3 h. What is the appropriate next step in management?

  1. Mannitol bolus at 0.25 mg/kg
  2. Hyperventilation to PCO2–25 mmHg
  3. Decompressive craniectomy (DC)
  4. Barbiturate coma
  5. This ICP reading is acceptable.


Q5. Your child underwent bilateral DC. At present, he is hemodynamically stable and off vasopressors. His electrolytes and metabolic profile are normal. He is off all sedation and paralysis for the past 4 days. His phenytoin levels are 10 μg/mL. He is unresponsive with no motor activity, with fully dilated, nonreactive pupils, absent gag, and apnea. You have planned for brain death testing. Which is not true for brain death?

  1. Present child does not satisfy the criteria for brain death test
  2. Two neurological examination with apnea test 12 h apart needs to be done
  3. Apnea testing requires documentation of an arterial PaCO220 mmHg above the baseline and 60 mmHg with no respiratory effort during the testing period
  4. Ancillary studies (electroencephalogram and radionuclide cerebral blood flow) are not required to establish brain death
  5. Assessment of neurologic function following cardiopulmonary resuscitation or other severe acute brain injuries should be deferred for 24 h or longer.


Q6. In context of control of raised ICP with hypertonic saline (HTS), which fact is not true?

  1. Bolus HTS (3%) is recommended and can be given through the peripheral line
  2. The bolus (3%) dose is between 2 and 5 mL/kg
  3. Bolus of 23.4% HTS may be considered for refractory ICP
  4. The reflection coefficient of HTS is nearly 1
  5. Dose of continuous infusion of 3% saline range between 0.1 and 1.0 mL/kg of body weight per 24 h.


Q7. Which of the following agents is NOT known to exacerbate neuromuscular weakness?

  1. Methyl prednisone
  2. Rocuronium
  3. Aminoglycosides
  4. Cephalosporin
  5. Magnesium.


Q8. Your patient with status epilepticus (SE) has just been transferred up from the ER. The ER physician says that after one of the antiepileptic drugs was given as bolus, the patient developed significant edema and discoloration of the hand where the medication was infused. Which is the medication that was most likely given?

  1. Lorazepam
  2. Phenytoin
  3. Phenobarbital
  4. Propofol
  5. Levetiracetam.


Q9. SE – all are true except

  1. SE is continuous or intermittent seizure that lasts ≥5 min without recovery of consciousness
  2. SE (either convulsive or nonconvulsive) lasting >30–60 min is sufficient to cause neuronal injury
  3. Seizure that fails to remit after treatment with two agents is considered refractory SE
  4. SE lasting than 30 min does not have any effect on response to anticonvulsants
  5. Lorazepam is the preferred first-line anticonvulsant for pediatric SE, except neonates.


Q10. A 12-year-old girl, resident of Gorakhpur, Uttar Pradesh, presented with fever for 5 days, altered sensorium, and seizures. She was started on ceftriaxone, acyclovir, levetiracetam, 3% normal saline infusion. Cerebrospinal fluid revealed 10 cells, all lymphocytes, sugar 76 mg/dL, and protein 64 mg/dL. Magnetic resonance imaging (MRI) brain revealed microhemorrhages in the corpus callosum and subcortical white matter in the bilateral centrum semiovale with meningeal enhancement. Her clinical condition worsened with the development of septic shock, acute kidney injury, and disseminated intravascular coagulation. She was mechanically ventilated and started on vasopressor, hemodynamic monitoring, and hemodialysis. All cultures were negative. Antibiotics were upgraded to meropenem. What should be the next step in management?

  1. Antifungal should be started
  2. Injection colistin should be added empirically
  3. Injection doxycycline should be started
  4. Continue with same treatment
  5. Repeat MRI brain to be done before any change.




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Financial support and sponsorship

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Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kochanek PM, Tasker RC, Carney N, Totten AM, Adelson PD, Selden NR, et al. Guidelines for the management of pediatric severe traumatic brain injury, third edition: Update of the brain trauma foundation guidelines. Pediatr Crit Care Med 2019;20:S1-82.  Back to cited text no. 1
    
2.
Nakagawa TA, Ashwal S, Mathur M, Mysore MR, Bruce D, Conway EE Jr., et al. Guidelines for the determination of brain death in infants and children: An update of the 1987 Task Force recommendations. Crit Care Med 2011;39:2139-55.  Back to cited text no. 2
    
3.
Murhekar MV, Mittal M, Prakash JA, Pillai VM, Mittal M, Girish Kumar CP, et al. Acute encephalitis syndrome in Gorakhpur, Uttar Pradesh, India-Role of scrub typhus. J Infect 2016;73:623-6.  Back to cited text no. 3
    




 

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