Pediatric Critical Care — MCQs
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What is the immediate treatment for a 10 kg infant presenting with tetany?
A 3-year-old child ingested multiple tablets of metoprolol and presented with which of the following conditions?
A 2-year-old boy presents with fever for 3 days which responded to paracetamol. Three days later, he developed acute renal failure, marked acidosis, and encephalopathy. His urine showed plenty of oxalate crystals. The blood anion gap and osmolal gap were increased. Which of the following is the most likely diagnosis?
A child presents with seizures, and on examination, has a respiratory rate of 5 per minute, a pulse of 54 per minute, and cyanosis. What is the immediate next step in management?
What is the primary treatment for a dehydrated child?
You are the physician on call for the extracorporeal membrane oxygenation (ECMO) service. There are 5 calls today, but only one machine and one technologist available. Which of the following patients is the most appropriate recipient of this service?
Criteria for diagnosing Systemic Inflammatory Response Syndrome (SIRS) include all of the following EXCEPT:
A five-year-old boy develops sudden aphonia and respiratory distress while having dinner. Which of the following is the next recommended step in the management of this patient?
In a child weighing 15 kg, what is the approximate daily fluid maintenance requirement?
Which type of dehydration is considered the most dangerous?
Pediatric Critical Care Indian Medical PG Practice Questions and MCQs
Question 21: What is the immediate treatment for a 10 kg infant presenting with tetany?
- A. Intravenous Diazepam
- B. Intravenous calcium gluconate with cardiac monitoring (Correct Answer)
- C. Intravenous slow phenobarbital
- D. Observe and wait
Explanation: **Explanation:** **1. Why Option B is Correct:** Tetany is a clinical manifestation of severe hypocalcemia, characterized by increased neuromuscular excitability. The immediate priority is to stabilize the neuronal membranes and prevent life-threatening complications like laryngospasm or seizures. **Intravenous Calcium Gluconate (10%)** is the treatment of choice. In an infant, the standard dose is **1–2 ml/kg (100–200 mg/kg)** given as a slow infusion over 10–20 minutes. **Cardiac monitoring** is mandatory during administration because rapid infusion can cause bradycardia, arrhythmias, or even cardiac arrest. **2. Why Other Options are Incorrect:** * **Option A & C (Diazepam/Phenobarbital):** While tetany can mimic seizure-like activity, these are anticonvulsants. They do not address the underlying biochemical deficiency (low ionized calcium). Using sedatives without correcting the calcium deficit will not stop the tetanic spasms and may delay definitive treatment. * **Option D (Observe and wait):** Tetany is a medical emergency. Untreated hypocalcemia can lead to laryngospasm, tetanic seizures, or prolonged QT interval leading to fatal arrhythmias. **3. NEET-PG High-Yield Pearls:** * **Chvostek sign:** Tapping the facial nerve leads to twitching of the facial muscles (indicative of hypocalcemia). * **Trousseau sign:** Carpopedal spasm induced by inflating a BP cuff above systolic pressure for 3 minutes (more specific than Chvostek). * **ECG Finding:** The classic sign of hypocalcemia is **prolonged QTc interval**. * **Administration Tip:** Always dilute calcium gluconate and ensure a patent IV line, as extravasation can cause severe tissue necrosis and sloughing. * **Refractory Hypocalcemia:** If calcium levels do not improve despite therapy, check **Magnesium levels**, as hypomagnesemia can cause resistance to PTH.
Question 22: A 3-year-old child ingested multiple tablets of metoprolol and presented with which of the following conditions?
- A. Widened QRS complexes
- B. Feeble pulse
- C. Tachycardia (Correct Answer)
- D. Prolonged AV conduction times
Explanation: ### Explanation **Correct Option: C (Tachycardia)** While beta-blockers like metoprolol typically cause bradycardia in adults, **paradoxical tachycardia** is a recognized clinical feature in pediatric beta-blocker toxicity, especially in the early stages. This occurs due to a compensatory sympathetic surge triggered by initial hypotension or a reflex response to peripheral vasodilation. In children, the heart rate is the primary determinant of cardiac output; therefore, the body may attempt to compensate for decreased myocardial contractility by increasing the heart rate initially. **Analysis of Incorrect Options:** * **A & D (Widened QRS & Prolonged AV conduction):** These are classic features of **Propranolol** toxicity. Propranolol has "membrane-stabilizing activity" (sodium channel blockade), which leads to QRS widening and heart block. Metoprolol is a cardioselective beta-1 blocker and lacks significant membrane-stabilizing effects at standard toxic doses, making these findings less likely than in propranolol overdose. * **B (Feeble pulse):** While hypotension can occur, a "feeble pulse" is a non-specific sign of shock. In the context of this specific NEET-PG pattern question, the focus is on the paradoxical heart rate response unique to pediatric presentations. **Clinical Pearls for NEET-PG:** * **Antidote of Choice:** **Glucagon** is the first-line antidote for beta-blocker toxicity (it bypasses beta-receptors to increase cAMP). * **Propranolol vs. Metoprolol:** Propranolol is lipid-soluble, crosses the BBB (causing seizures), and causes QRS widening. Metoprolol is cardioselective and less likely to cause CNS or ECG conduction delays. * **Hypoglycemia:** Always monitor blood glucose in pediatric beta-blocker ingestion, as it inhibits glycogenolysis.
Question 23: A 2-year-old boy presents with fever for 3 days which responded to paracetamol. Three days later, he developed acute renal failure, marked acidosis, and encephalopathy. His urine showed plenty of oxalate crystals. The blood anion gap and osmolal gap were increased. Which of the following is the most likely diagnosis?
- A. Paracetamol poisoning
- B. Diethylene glycol poisoning (Correct Answer)
- C. Severe malaria
- D. Hantavirus infection
Explanation: ### Explanation The clinical presentation of a child with a preceding febrile illness (likely treated with contaminated cough syrup), followed by the triad of **acute renal failure (ARF)**, **metabolic acidosis with a high anion gap (HAGMA)**, and **encephalopathy**, is classic for **Diethylene Glycol (DEG) poisoning**. **1. Why Diethylene Glycol (DEG) is correct:** DEG is a nephrotoxic and neurotoxic solvent sometimes used as an illegal, cheaper substitute for glycerin in pharmaceutical syrups (e.g., paracetamol or cough syrups). * **Oxalate Crystals:** DEG is metabolized into toxic acids. While ethylene glycol classically causes calcium oxalate crystals, DEG poisoning also presents with similar urinary findings and profound renal tubular damage. * **Gaps:** It causes a **High Anion Gap Metabolic Acidosis** (due to acidic metabolites) and an **Increased Osmolal Gap** (due to the parent compound). * **Triad:** The progression typically involves GI symptoms, followed by ARF, and finally neurological complications (cranial nerve palsies, encephalopathy). **2. Why the other options are incorrect:** * **Paracetamol poisoning:** Primarily causes acute liver failure (centrilobular necrosis). While ARF can occur, it is not the dominant feature, and it does not produce oxalate crystals. * **Severe malaria:** Can cause ARF (Blackwater fever) and encephalopathy (Cerebral Malaria), but it would not explain the increased osmolal gap or the presence of oxalate crystals. * **Hantavirus infection:** Causes Hemorrhagic Fever with Renal Syndrome (HFRS). While it causes ARF, the specific metabolic profile (osmolal gap) and oxalate crystals point specifically to toxic alcohol ingestion. **Clinical Pearls for NEET-PG:** * **Antidote:** Fomepizole (preferred) or Ethanol (competitively inhibits alcohol dehydrogenase). * **Key differentiator:** Ethylene glycol and DEG both cause high anion/osmolal gaps and renal failure, but DEG is historically linked to **mass poisoning outbreaks** via contaminated medicinal syrups. * **Renal Pathology:** DEG causes acute tubular necrosis (ATN) and cortical necrosis.
Question 24: A child presents with seizures, and on examination, has a respiratory rate of 5 per minute, a pulse of 54 per minute, and cyanosis. What is the immediate next step in management?
- A. Administer diazepam for seizures, followed by adrenaline and chest compressions.
- B. Intubation followed by ventilation with oxygen and chest compressions. (Correct Answer)
- C. Administer oxygen, chest compressions, and adrenaline; insert a laryngeal mask airway (LMA).
- D. Administer intravenous midazolam stat, followed by insertion of a laryngeal mask airway (LMA).
Explanation: This question tests the application of the **Pediatric Advanced Life Support (PALS)** algorithm in a child with impending cardiopulmonary arrest. ### **Explanation of the Correct Answer (B)** The child presents with a **"pre-arrest"** state: severe bradypnea (RR 5/min), significant bradycardia (HR 54/min), and cyanosis. In pediatrics, the primary cause of cardiac arrest is usually respiratory failure. 1. **Airway & Breathing:** With a RR of 5 and cyanosis, the immediate priority is securing the airway and providing oxygenation. **Intubation** is the definitive method. 2. **Circulation:** According to PALS guidelines, if the heart rate is **<60 bpm with signs of poor perfusion** (cyanosis, altered sensorium) despite adequate oxygenation/ventilation, **chest compressions** must be initiated immediately. ### **Why Other Options are Incorrect** * **Option A:** While the child has seizures, they are likely secondary to hypoxia. Administering diazepam (a respiratory depressant) before securing the airway will worsen the respiratory failure. Adrenaline is secondary to high-quality CPR. * **Option C:** Oxygen and compressions are correct, but an LMA is generally a rescue device. In a critical arrest scenario with seizures (risk of aspiration), endotracheal intubation is preferred over LMA for definitive airway protection. * **Option D:** Midazolam will further depress the respiratory drive. Securing the airway takes precedence over pharmacological seizure control in a bradycardic, cyanotic child. ### **Clinical Pearls for NEET-PG** * **The "Rule of 60":** In pediatric resuscitation, start chest compressions if HR <60 bpm with poor perfusion, even if a pulse is palpable. * **Sequence:** Always follow **ABC** (Airway-Breathing-Circulation) in pediatric respiratory-led arrests, unlike the CAB sequence in adult primary cardiac arrests. * **Seizures in Distress:** Always consider **hypoxia or hypoglycemia** as the cause of new-onset seizures in a crashing child.
Question 25: What is the primary treatment for a dehydrated child?
- A. 0.9% normal saline
- B. 5% dextrose (Correct Answer)
- C. 10% dextrose
- D. 50% dextrose
Explanation: The primary goal in treating a dehydrated child is to restore intravascular volume and maintain blood glucose levels, as children have limited glycogen stores and are highly prone to hypoglycemia during stress. **Explanation of the Correct Answer:** **Option B (5% Dextrose)** is considered the standard component of maintenance fluids in pediatrics. While isotonic saline (0.9% NS) is used for initial bolus resuscitation in shock, the question refers to the general treatment of a dehydrated child. In pediatric practice, maintenance fluids must contain glucose (typically 5% Dextrose) to prevent catabolism, ketosis, and hypoglycemia. Modern guidelines often recommend **Isotonic Maintenance Fluids** (e.g., 0.9% NS + 5% Dextrose) to prevent hospital-acquired hyponatremia while providing necessary caloric support. **Analysis of Incorrect Options:** * **Option A (0.9% Normal Saline):** While used for "fluid resuscitation" (boluses) to correct hypovolemia, it lacks glucose. Using saline alone for maintenance can lead to hypoglycemia in pediatric patients. * **Option C & D (10% & 50% Dextrose):** These are hypertonic solutions. 10% Dextrose is typically reserved for neonates or specific hypoglycemic protocols, while 50% Dextrose is contraindicated in children due to the risk of rebound hypoglycemia and osmotic injury to veins; 25% is the maximum concentration usually used for pediatric boluses (diluted). **NEET-PG High-Yield Pearls:** * **Holiday-Segar Formula:** Used to calculate maintenance fluid requirements (100/50/20 rule). * **Fluid of Choice for Resuscitation:** 0.9% Normal Saline or Ringer’s Lactate (20 ml/kg bolus). * **Fluid of Choice for Maintenance:** Isotonic solutions (0.9% NS) with 5% Dextrose are now preferred over older hypotonic (0.18% or 0.45% NS) solutions to avoid hyponatremic encephalopathy. * **Deficit Calculation:** In children, mild dehydration is <5%, moderate is 5-10%, and severe is >10% weight loss.
Question 26: You are the physician on call for the extracorporeal membrane oxygenation (ECMO) service. There are 5 calls today, but only one machine and one technologist available. Which of the following patients is the most appropriate recipient of this service?
- A. A 1-day-old, full-term, anencephalic 4-kg boy suffering from meconium aspiration syndrome and hypoxia
- B. A 75-year-old man with Alzheimer disease, severe pneumonia, and elevated pulmonary arterial pressure
- C. A 5-year-old girl with rhabdomyosarcoma metastatic to the lungs
- D. A 3-day-old boy preoperative for a congenital diaphragmatic hernia (Correct Answer)
Explanation: ### Explanation The core principle of ECMO (Extracorporeal Membrane Oxygenation) selection is **reversibility**. ECMO is a temporary "bridge" to recovery, surgery, or transplant; it is not a destination therapy. It is indicated when a patient has a high risk of mortality (typically >80%) but possesses a potentially reversible condition and no lethal comorbidities. **Why Option D is Correct:** Congenital Diaphragmatic Hernia (CDH) is a classic indication for neonatal ECMO. These infants often suffer from severe pulmonary hypertension and respiratory failure. ECMO provides hemodynamic stability and allows for "lung rest," acting as a **preoperative bridge** to stabilize the infant before surgical repair or as a postoperative support mechanism. **Why the Other Options are Incorrect:** * **Option A:** While Meconium Aspiration Syndrome is a common indication for ECMO, **anencephaly** is a lethal congenital anomaly. ECMO is contraindicated in patients with a poor long-term prognosis or non-survivable conditions. * **Option B:** Advanced age (75 years) and progressive neurodegenerative disease (**Alzheimer’s**) are relative or absolute contraindications due to poor physiological reserve and limited quality of life post-procedure. * **Option C:** Metastatic malignancy (**rhabdomyosarcoma**) carries a very poor prognosis. ECMO is generally avoided in patients with terminal illnesses or severe immunosuppression where the underlying disease is not curable. ### Clinical Pearls for NEET-PG * **Primary Goal:** ECMO provides temporary support for the heart and/or lungs, allowing them to recover from an acute insult. * **Inclusion Criteria (Neonatal):** Gestational age >34 weeks, weight >2 kg (to allow cannulation), and reversible lung disease. * **Absolute Contraindications:** Lethal chromosomal abnormalities, irreversible brain damage, and major intracranial hemorrhage (Grade III or IV) due to the need for systemic anticoagulation (heparin) during ECMO. * **High-Yield Fact:** The most common neonatal indication for ECMO is **Meconium Aspiration Syndrome (MAS)**, but the presence of lethal anomalies always takes precedence in triage.
Question 27: Criteria for diagnosing Systemic Inflammatory Response Syndrome (SIRS) include all of the following EXCEPT:
- A. Temperature > 38.5°C or < 36°C
- B. Respiratory rate > 2 standard deviations above normal for age
- C. Persistent tachycardia over 0.5 hour in children < 1 year old (Correct Answer)
- D. > 10% immature neutrophils
Explanation: To diagnose **Systemic Inflammatory Response Syndrome (SIRS)** in the pediatric population, at least two out of four criteria must be met, one of which **must** be abnormal temperature or leukocyte count. ### Why Option C is the Correct Answer (The Exception) The criteria for tachycardia in pediatric SIRS is defined as a mean heart rate **> 2 standard deviations (SD) above normal for age** in the absence of external stimuli (pain, drugs) OR a persistent elevation over a **0.5-to-4-hour period**. However, the specific age-related threshold for tachycardia in infants (<1 year) is typically defined as **>180 bpm**. The option is technically incorrect because the definition of SIRS relies on SD-based thresholds or specific bpm cut-offs rather than just the duration alone without the quantitative value. Furthermore, bradycardia (HR < 10th percentile) is also a criterion, but only for infants <1 year. ### Explanation of Incorrect Options (SIRS Criteria) * **Option A (Temperature):** Core temperature >38.5°C or <36°C is a mandatory primary criterion. * **Option B (Respiratory Rate):** Mean RR > 2 SD above normal for age or the need for mechanical ventilation for an acute process is a valid criterion. * **Option D (Leukocyte Count):** Elevated or depressed leukocyte count for age (not secondary to chemotherapy) or **>10% immature neutrophils (bands)** is a valid criterion. ### NEET-PG High-Yield Pearls * **Mandatory Rule:** Unlike adults, pediatric SIRS **must** include either abnormal temperature or abnormal WBC count. * **Sepsis Definition:** SIRS + suspected or proven infection. * **Severe Sepsis:** Sepsis + cardiovascular dysfunction OR ARDS OR ≥2 organ dysfunctions. * **Septic Shock:** Sepsis with cardiovascular dysfunction that persists despite ≥40 mL/kg of fluid resuscitation.
Question 28: A five-year-old boy develops sudden aphonia and respiratory distress while having dinner. Which of the following is the next recommended step in the management of this patient?
- A. Heimlich maneuver (Correct Answer)
- B. Chest thrust maneuver
- C. Finger sweep maneuver
- D. Cricothyroidotomy or tracheostomy
Explanation: ### Explanation **Correct Option: A. Heimlich maneuver** The clinical presentation of sudden aphonia (inability to speak) and respiratory distress while eating is a classic sign of **complete foreign body airway obstruction (FBAO)**. In a conscious child older than one year, the **Heimlich maneuver (subdiaphragmatic abdominal thrusts)** is the gold-standard emergency intervention. It works by increasing intrathoracic pressure to create an "artificial cough," which forcefully expels the foreign body from the larynx or trachea. **Why other options are incorrect:** * **B. Chest thrust maneuver:** This is the recommended technique for infants (**<1 year old**) instead of abdominal thrusts, as the latter can cause significant liver or splenic injury in infants due to their anatomy. * **C. Finger sweep maneuver:** This is strictly contraindicated in blind scenarios. Attempting a blind finger sweep can push the foreign body deeper into the airway, converting a partial obstruction into a complete one. It should only be performed if the object is clearly visible and easily reachable. * **D. Cricothyroidotomy or tracheostomy:** These are invasive surgical airways. While they may be necessary if non-invasive maneuvers fail and the patient becomes unconscious, they are never the *initial* step for a conscious patient with FBAO. **High-Yield Clinical Pearls for NEET-PG:** * **Age Cut-off:** Use **Back blows and Chest thrusts** for infants (<1 year); use **Heimlich maneuver** for children (>1 year) and adults. * **The "Universal Sign":** Clutching the throat with hands is the classic sign of choking. * **Sequence Change:** If the patient becomes **unconscious**, immediately transition to **CPR** (starting with chest compressions), regardless of whether a pulse is present. * **Definitive Diagnosis:** For stable patients with suspected foreign body aspiration, **Rigid Bronchoscopy** is both the diagnostic and therapeutic gold standard.
Question 29: In a child weighing 15 kg, what is the approximate daily fluid maintenance requirement?
- A. 100 mL
- B. 1250 mL (Correct Answer)
- C. 1500 mL
- D. 1750 mL
Explanation: The calculation of daily maintenance fluid in pediatrics is based on the **Holliday-Segar Formula**, which estimates caloric expenditure and corresponding water needs based on body weight. ### **The Holliday-Segar Rule (100/50/20 Rule):** * **First 10 kg:** 100 mL/kg/day * **Next 10 kg (11–20 kg):** 50 mL/kg/day * **Each kg above 20 kg:** 20 mL/kg/day **Calculation for a 15 kg child:** 1. First 10 kg: $10 \times 100 \text{ mL} = 1000 \text{ mL}$ 2. Remaining 5 kg: $5 \times 50 \text{ mL} = 250 \text{ mL}$ 3. **Total:** $1000 + 250 = \mathbf{1250 \text{ mL/day}}$ ### **Analysis of Options:** * **A (100 mL):** This is the rate per kg for only the first 10 kg, not the total volume. * **C (1500 mL):** This would be the requirement for a 20 kg child ($1000 + 500$). * **D (1750 mL):** This would be the requirement for a child weighing approximately 32.5 kg. ### **High-Yield Clinical Pearls for NEET-PG:** * **Hourly Rate (4/2/1 Rule):** For quick calculations, use 4 mL/kg/hr for the first 10 kg, 2 mL/kg/hr for the next 10 kg, and 1 mL/kg/hr thereafter. For this child: $(10 \times 4) + (5 \times 2) = 50 \text{ mL/hr}$. * **Fluid Choice:** Isotonic solutions (e.g., 0.9% Normal Saline) are now preferred over hypotonic solutions (like 0.18% NS) for maintenance in hospitalized children to prevent **iatrogenic hyponatremia**. * **Exceptions:** Maintenance requirements increase with fever (12% for every 1°C rise) and decrease in conditions like SIADH, oliguric renal failure, or congestive heart failure.
Question 30: Which type of dehydration is considered the most dangerous?
- A. Hyponatremic dehydration
- B. Hypernatremic dehydration (Correct Answer)
- C. Isonatremic dehydration
- D. Dehydration from a non-diarrheal cause
Explanation: **Explanation:** **Hypernatremic dehydration (Serum Na+ >150 mEq/L)** is considered the most dangerous form of dehydration due to its profound impact on the central nervous system. **Why it is the most dangerous:** In hypernatremic states, the high extracellular osmolality causes water to move out of the brain cells into the extracellular space (osmotic shift). This leads to **cerebral shrinkage**, which can tear delicate bridging veins, resulting in **intracranial hemorrhage**, subdural hematomas, and permanent neurological damage or seizures. Furthermore, the clinical signs of dehydration (like skin turgor) are often masked because water is pulled from the cells into the vascular space, maintaining blood pressure until late stages. This often leads to a dangerous delay in diagnosis. **Analysis of Incorrect Options:** * **A. Hyponatremic dehydration (Na+ <130 mEq/L):** While it carries a risk of cerebral edema during rapid correction, the initial compensatory mechanisms are generally less catastrophic than the vascular tearing seen in hypernatremia. * **C. Isonatremic dehydration (Na+ 130–150 mEq/L):** This is the most common type (approx. 80% of cases). Electrolyte balance is maintained, making it the safest and easiest to manage. * **D. Non-diarrheal causes:** The etiology (e.g., vomiting or decreased intake) is less critical than the resulting serum tonicity in determining immediate mortality risk. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Sign:** "Doughy" or velvety skin texture is characteristic of hypernatremic dehydration. * **Management Rule:** Never correct hypernatremia faster than **0.5 mEq/L/hour** (or 10–12 mEq/L per 24 hours) to prevent **Cerebral Edema**. * **Most common type:** Isonatremic dehydration. * **Most common cause of Hypernatremic dehydration:** High solute intake (improperly mixed formula) or viral diarrhea with high insensible water loss.
Practice by Chapter
Respiratory Failure
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Shock
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Cardiopulmonary Resuscitation
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Acute Respiratory Distress Syndrome
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Mechanical Ventilation in Children
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Sedation and Analgesia
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Status Epilepticus
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Diabetic Ketoacidosis
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Pediatric Trauma
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Poisoning and Toxidromes
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Near-Drowning
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Multiple Organ Dysfunction Syndrome
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