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CRITICAL THINKING
Year : 2020  |  Volume : 7  |  Issue : 6  |  Page : 366-369

PICU quiz


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

Date of Submission25-Sep-2020
Date of Acceptance03-Oct-2020
Date of Web Publication11-Nov-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_152_20

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How to cite this article:
Sharma PK. PICU quiz. J Pediatr Crit Care 2020;7:366-9

How to cite this URL:
Sharma PK. PICU quiz. J Pediatr Crit Care [serial online] 2020 [cited 2020 Nov 30];7:366-9. Available from: http://www.jpcc.org.in/text.asp?2020/7/6/366/300584



  1. A previously healthy 3-year-old boy presents with a fever of 104°F, neck rigidity, and headache. A lumbar puncture reveals cerebrospinal fluid (CSF) white blood cell count 850/cumm. The child treated with ceftriaxone, vancomycin, and acyclovir and admitted to the pediatric intensive care unit (PICU). CSF culture grows Streptococcus pneumoniae which is sensitive to ceftriaxone. The fever resolves over the next 72 h with improvement in his clinical examination. On the 6th day of admission, he complains of headache in the morning and vomits. In the afternoon, he becomes unresponsive with a fixed and dilated left pupil. Emergency head computed tomography (CT) shows nonobstructive hydrocephalus with enlargement of the lateral ventricles and effacement of the cerebral sulci. Which option best explains the pathophysiology of his hydrocephalus?


    1. Decreased CSF absorption due to blockage of the aqueduct of Sylvius with bacterial and cellular debris
    2. Decreased CSF absorption due to blockage of arachnoid granulations with bacterial and cellular debris
    3. Increase in CSF production due to inflammation
    4. Low-pressure hydrocephalus due to loss of cerebral cortical volume


  2. During the CT scan, the boy develops hypertension (blood pressure, 180/110 mm Hg) and bradycardia (heart rate - 40 beats/min), absent pupillary reflex in his left eye, and develops gasping type of respirations. His symptoms are most consistent with compression of which brain structure?


    1. Cerebellum
    2. Cortex
    3. Optic nerves
    4. Pons


  3. The patient is treated with 3% saline to reverse his herniation and is endotracheally intubated. An external ventricular drain put by neurosurgery team. An electroencephalogram reveals status epilepticus, which is refractory to midazolam but controlled by Phenobarbital. His condition gradually improves and subsequently discharged. Why the seizure is controlled by pentobarbital but not by midazolam?


    1. Pentobarbital acts on glycine receptors, whereas midazolam acts on GABA receptors.
    2. Pentobarbital penetrates the blood-brain barrier better than does midazolam.
    3. Pentobarbital depresses respiratory activity, allowing for better control of pCO2.
    4. Pentobarbital at high doses becomes a direct GABA agonist, leading to suppression of neuronal activity.


  4. Intracranial pressure (ICP) monitoring is most useful in directing therapy in which of the following situations in children?


    1. Hypoxic-ischemic encephalopathy
    2. Diabetic ketoacidosis with cerebral edema
    3. Stroke
    4. Traumatic brain injury (TBI)


  5. Which of the following statements is correct regarding cranial nerve examination?


    1. Absence of all eye movement with intact pupil light reflex suggests insult to the pons.
    2. Cold caloric stimulation that produces nystagmus with the rapid phase to the same side ear that has been stimulated indicates intact functioning of the cerebral cortex.
    3. Failure to move only the mouth with preservation of upper face movements indicates seventh nerve palsy.
    4. Wandering eye movements are more common with metabolic disorders.


  6. An 8-month-old boy is admitted to the PICU with a focal seizure followed by status epilepticus requiring treatment with two 1 mg/kg doses of lorazepam and a single dose of 20 mg/kg phenytoin, after which he intubated for airway protection. A physical examination shows signs of inflicted trauma with retinal hemorrhages and bruises of different ages. 24 h later, the child had normal vitals, bilateral reacting pupils, and withdrawal to painful stimuli. CT head was normal. Which is the best monitoring modality in this case?


    1. Continuous electroencephalography (EEG) for 12–24 h.
    2. Lumbar puncture.
    3. Repeat CT scan of the head.
    4. Magnetic resonance (MR) imaging with MR spectroscopy and diffusion-weighted imaging.


  7. A child presented with a head injury due to RTA. He was difficult responsive to painful stimulation. There was eyelid swelling which could only be retracted with difficulty. The radiologic evaluation revealed multiple right orbital fractures, with a small subarachnoid bleed in the left parietal area. On physical examination after 24 h, the patient is following commands, but not moving his right arm. Which statement best describes the extent of the patient's injury?


    1. Brain stem injury is likely because the patient is awake and has a focal neurologic finding.
    2. Central herniation is less likely because the patient was not able to be aroused on presentation and had an eye injury.
    3. Diencephalic and brain stem injury are less likely because the patient has awakened and is following commands.
    4. Medullary and corticospinal tract injury are likely because the patient does not move his right arm.


  8. The right eye of the patient from the previous scenario appears less swollen after 36 h, but the pupil was unequal and right pupil is not reacting to light. Ptosis is present. Which of the following can best describe the abnormality?


    1. Afferent disorder
    2. Horner syndrome
    3. Sympathetic abnormality
    4. Third nerve palsy


  9. Which of the following is a manifestation of midbrain lesion?


    1.  Cheyne-Stokes respiration More Details
    2. Fixed, pinpoint pupils
    3. Inferior and lateral gaze deviation
    4. Ipsilateral hemiplegia


  10. ICP is being monitored in a child following a closed head injury. Which of the following observations related to ICP values is true?


    1. ICP waves directly related to changes in arterial blood pressure and hyperemic events indicate refractory intracranial hypertension.
    2. In the 30-degree elevated position, a normal IC P value in a healthy child is negative with a range of around–5 mm Hg but not exceeding–10 mm Hg.
    3. In the standing upright position, a normal IC P value in healthy children is positive with a range from 5 to 10 mm Hg.
    4. In the horizontal position, a normal IC P value in healthy children is 15–20 mm Hg.




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