Pediatric Critical Care Practice Questions

Q: An 8-year-old boy presents with petechiae, azotemic oliguria and altered sensorium, in casualty. There is a history of diarrhoea for the past 5 days. The clinical diagnosis is –

H.U.S.. **H.U.S.** * The constellation of **petechiae** (indicating **thrombocytopenia**), **azotemic oliguria** (suggesting **acute kidney injury**), and **altered sensorium** (neurological involvement) following recent **diarrhea** is highly characteristic of **Hemolytic Uremic Syndrome (HUS)**, specifically **Shiga toxin-producing E. coli (STEC)-HUS**. * HUS is defined by the triad of **microangiopathic hemolytic anemia**, **thrombocytopenia**, and **acute kidney injury**, often precipitated by a gastrointestinal infection. *Acute prophyria* * **Acute porphyrias** are metabolic disorders affecting heme synthesis, presenting with acute neurovisceral attacks. * While they can cause neurological symptoms, they are not typically associated with **petechiae**, **thrombocytopenia**, or **renal failure** following diarrhea. *H.S. purpura* * **Henoch-Schönlein (IgA vasculitis) purpura** is characterized by palpable purpura, arthritis, abdominal pain, and renal involvement (hematuria/proteinuria). * While it can cause **purpuric rash** and **renal disease**, it typically presents with **palpable purpura** (due to vasculitis), not petechiae from thrombocytopenia, and is less commonly associated with severe oliguric acute kidney injury or profound altered mental status in this context. *Idiopathic thrombocytopenic purpura* * **Idiopathic Thrombocytopenic Purpura (ITP)** is characterized by **isolated thrombocytopenia** leading to bleeding manifestations like **petechiae** and purpura. * ITP does not typically cause **azotemic oliguria** or **altered sensorium**, as it primarily affects platelet count without involvement of other organ systems like the kidneys or central nervous system.

Q: A five-year-old girl presents with fever and conjunctivitis. Physical examination is significant for oral erythema and fissuring along with a generalized maculopapular rash and cervical lymphadenopathy. What is the most likely diagnosis?

Kawasaki disease. ***Kawasaki disease*** - This constellation of symptoms, including prolonged **fever**, **conjunctivitis**, **oral erythema** and **fissuring**, a generalized **rash**, and **cervical lymphadenopathy**, is highly characteristic of incomplete or classic Kawasaki disease. - It is a **vasculitis** primarily affecting **medium-sized arteries**, and early diagnosis and treatment are crucial to prevent **coronary artery aneurysms**. *Henoch-Schönlein purpura* - Characterized by **palpable purpura**, **arthralgia**, **abdominal pain**, and **renal involvement**, often after an upper respiratory infection. - While a rash is present, the specific features of oral changes and generalized erythema are not typical. *Takayasu arteritis* - A rare, large-vessel vasculitis primarily affecting the **aorta** and its major branches, leading to **claudication**, **pulse deficits**, and **hypertension**. - It most commonly affects **young women** and does not present with the acute mucocutaneous and lymph node findings seen in this child. *Polyarteritis nodosa* - A **necrotizing vasculitis** of **medium-sized arteries**, typically presenting with non-specific symptoms such as fever, weight loss, and myalgia, along with organ involvement (e.g., kidney, gastrointestinal, peripheral nerve). - It primarily affects adults and does not usually present with the specific mucocutaneous and lymphatic features seen in this pediatric case.

Q: A 9 year old girl was admitted for dialysis. On laboratory examination her potassium levels were 7.8 mEq/L. Which of the following would quickly lower her increased potassium levels -

IV Glucose and insulin. ***IV Glucose and insulin*** - **IV glucose and insulin** rapidly shifts potassium from the extracellular to the intracellular compartment by stimulating the Na-K-ATPase pump, making it the **most effective immediate treatment** for severe hyperkalemia. - This therapy acts **within 15-30 minutes** to lower serum potassium levels by 0.5-1.5 mEq/L, which is crucial in emergency situations with life-threatening hyperkalemia. - **Onset: 15-30 minutes** | **Duration: 4-6 hours** *IV calcium gluconate* - **IV calcium gluconate** does not lower serum potassium levels but rather **stabilizes the cardiac membrane** by antagonizing the arrhythmogenic effects of hyperkalemia. - It is an important **first-line treatment** when cardiac toxicity (peaked T waves, widened QRS) is present or imminent, providing immediate cardioprotection **within 1-3 minutes**. - However, it **does not reduce** the total body potassium load and must be followed by definitive treatments. *IV NaHCO3* - **IV sodium bicarbonate** can help shift potassium intracellularly, particularly in cases of hyperkalemia associated with **metabolic acidosis**, but its effect is **slower and less predictable** than insulin and glucose. - Its primary role is to correct acidosis, which secondarily contributes to potassium shift. - **Onset: 30-60 minutes**, making it **not the fastest** option for direct potassium reduction. *Oral kayexalate in sorbitol* - **Kayexalate** (sodium polystyrene sulfonate) is a **cation-exchange resin** that exchanges potassium ions for sodium ions in the gastrointestinal tract, leading to potassium excretion. - This method is **slow-acting** (requires **hours to take effect**) and is therefore not suitable for immediate management of critically high potassium levels like 7.8 mEq/L. - It removes potassium from the body permanently but is not an emergency treatment.

Q: A child with moderate to severe head injury is admitted in PICU. First line treatments are all except:

IV mannitol. ***IV mannitol*** - While **intravenous mannitol** is used in the management of head injury to reduce **intracranial pressure (ICP)**, it is **not a first-line treatment**. - It is a **second-line therapy** reserved for documented or suspected elevated ICP despite initial supportive measures. - First-line management focuses on maintaining adequate oxygenation, ventilation, and cerebral perfusion, while mannitol is used for specific ICP management when needed. *Analgesia and sedation* - **Analgesia and sedation** are essential **first-line treatments** to reduce pain, anxiety, and agitation, which can increase **intracranial pressure (ICP)**. - These therapies ensure patient comfort, decrease metabolic demand, facilitate mechanical ventilation, and prevent secondary brain injury. *Hypothermia* - **Therapeutic hypothermia** is **NOT routinely recommended** as a first-line treatment in pediatric traumatic brain injury. - Current evidence (including the Cool Kids trial) has not demonstrated benefit, and it may be associated with adverse effects. - It is considered **investigational** and not part of standard first-line management protocols. - **Note**: While this is also not first-line, the question specifically tests knowledge that mannitol is second-line therapy for ICP management. *Controlled mechanical ventilation* - **Controlled mechanical ventilation** is a fundamental **first-line treatment** for severe head injury to secure the airway and ensure adequate oxygenation and ventilation. - Prevents secondary brain injury from **hypoxia** and **hypercapnia**, which can worsen outcomes. - Maintaining appropriate **PaCO2 levels** is critical to control cerebral blood flow and intracranial pressure.

Q: According to the Lund and Browder chart, what percentage of total body surface area (TBSA) does the head and face represent in a 1-year-old child?

19%. ***19%*** - The **Lund and Browder chart** accounts for age-related variations in body proportions, assigning a larger percentage of **total body surface area (TBSA)** to the head in infants and young children. - For a **1-year-old child**, the head and face are estimated to represent approximately **19% TBSA**, which decreases with age as the body proportions change. *16%* - While 16% is a value sometimes associated with the head, it is not the accurate percentage for a **1-year-old child** according to the **Lund and Browder chart**. - This percentage is typically closer to that of an **older child** or adult's head, as body proportions change over time. *10%* - **10% TBSA** is far too low for the head and face of a **1-year-old child** as per the Lund and Browder chart. - This value is usually associated with areas like the **arms** in children or the head of an **adult** in some simpler TBSA estimation methods. *13%* - **13% TBSA** is an underestimation for the head and face of a **1-year-old child** when using the **Lund and Browder chart**. - The large relative size of an infant's head means it contributes a significantly higher percentage to their **total body surface area**.

Q: In severe CNS infections in children with complications, treatment may include:

All of the options. ***All of the options*** - Treatment for **severe and complicated CNS infections** in children often requires a **multi-pronged approach** beyond antimicrobial therapy to manage severe neurological impairment, respiratory compromise, and immune-mediated complications. - Depending on the severity and specific infection, **IV Ig**, **ventilation**, and **plasmapheresis** may all be necessary adjunctive interventions to support the child and combat inflammation/autoimmune components. - **Note:** Primary treatment includes appropriate antimicrobials (antibiotics/antivirals), but this question focuses on adjunctive therapies for complicated cases. *IV Ig* - **Intravenous immunoglobulins (IV Ig)** are used in severe CNS infections with immune-mediated components, particularly **autoimmune encephalitis**, **post-infectious encephalomyelitis (ADEM)**, or severe viral encephalitis. - IV Ig modulates the immune response and may reduce neurological damage in specific scenarios. *Ventilation* - **Mechanical ventilation** is crucial for patients with severe CNS infections who develop respiratory compromise due to **brainstem dysfunction**, **refractory seizures**, **increased intracranial pressure** leading to hypoventilation, or **decreased consciousness** (GCS ≤8). - Essential for respiratory support and maintaining adequate oxygenation/ventilation in critically ill patients. *Plasmapheresis* - **Plasmapheresis** (plasma exchange) is used in specific CNS infections with **autoimmune or highly inflammatory components**, such as **autoimmune encephalitis**, **acute disseminated encephalomyelitis (ADEM)**, or **severe CNS vasculitis**. - Removes harmful autoantibodies and inflammatory mediators from circulation, particularly when IV Ig is insufficient.

Q: Anti Snake Venin (ASV) should be given in all these situations with further lab investigations in a child presenting at 4 am except :

Severe pain abdomen but no fang marks. ***Severe pain abdomen but no fang marks*** - This is the scenario where ASV should **NOT** be given without further lab investigations - **Abdominal pain** has numerous differential diagnoses (appendicitis, peritonitis, gastroenteritis, pancreatitis, etc.) - Without clear evidence of snakebite (no fang marks), **confirmation is crucial** before administering ASV - ASV carries risks including anaphylaxis and serum sickness, so it should only be given when snakebite is confirmed or highly likely *Incorrect: External ophthalmoplegia* - External ophthalmoplegia (cranial nerve involvement) is a **classic sign of neurotoxic envenomation** - This requires **immediate ASV administration** regardless of other investigations - Delay can lead to respiratory muscle paralysis and death *Incorrect: Ptosis with head flexed without bite marks* - **Ptosis** and **head flexor weakness** are pathognomonic signs of neurotoxic envenomation (typically from kraits/cobras) - These signs mandate **immediate ASV** even without visible bite marks - Absence of bite marks occurs in ~50% of genuine snakebites (dry bites, small fangs, thick clothing) *Incorrect: Local swelling with fang marks* - **Direct evidence of envenomation** with both local signs and bite marks - Requires **immediate ASV administration** to prevent progression of local and systemic effects - No lab investigations needed before starting ASV

Q: The best scale to measure pain in children of 5 years of age would be:

Faces Scale. ***Correct: Faces Scale*** - The **Faces Pain Scale-Revised (FPS-R)** is the **gold standard for pain assessment in children aged 4-12 years** who are capable of self-reporting pain. - At **5 years of age**, children have the cognitive ability to understand and use facial expressions to indicate their pain level, making this the **preferred tool** for this age group. - It uses simple cartoon faces ranging from "no pain" to "worst pain," which are easily understood by preschool and school-aged children. - **Self-report scales are preferred over behavioral scales** when children are developmentally capable of using them, as per WHO and pediatric pain management guidelines. *Incorrect: CHEOPS* - The **Children's Hospital of Eastern Ontario Pain Scale (CHEOPS)** is a **behavioral observation scale** designed for children aged 1-7 years. - While valid for 5-year-olds, it is primarily used for **post-operative pain assessment** or when children **cannot self-report** (e.g., sedated, developmentally delayed, or very young). - At age 5, when a child can self-report, behavioral scales are **less preferred** than self-report tools like the Faces Scale. - CHEOPS requires trained observers and assesses 6 behavioral categories: cry, facial expression, verbal responses, torso position, touch, and leg position. *Incorrect: VAS* - The **Visual Analog Scale (VAS)** is a continuous scale requiring abstract thinking about pain intensity, typically suitable for children **≥8 years** and adults. - A 5-year-old typically **lacks the cognitive maturity** to accurately conceptualize pain on an abstract linear scale without concrete visual anchors. *Incorrect: McGill Scale* - The **McGill Pain Questionnaire** is a complex, multidimensional tool designed for **adults and adolescents**. - It relies on sophisticated vocabulary to describe sensory, affective, and evaluative aspects of pain, making it **completely unsuitable** for a 5-year-old child.

Q: A pediatric patient presents with a 45-minute history of continuous convulsions. The senior resident (SR) recommends IV lorazepam, but the junior resident (JR) is unable to secure IV access. What is the next best step in management?

Rectal diazepam. ***Rectal diazepam*** - Rectal diazepam is an **effective first-line alternative** when IV access cannot be obtained in status epilepticus - It has a **rapid onset of action** (within 2-5 minutes) and can be easily administered in emergency settings - **Widely available** and part of established pediatric seizure protocols globally - Both rectal diazepam and IM midazolam are acceptable alternatives per current guidelines *Intramuscular midazolam* - IM midazolam is **equally effective** and increasingly preferred in many modern protocols when IV access is unavailable - The RAMPART trial demonstrated **faster seizure cessation** with IM midazolam compared to rectal diazepam in prehospital settings - **Both IM midazolam and rectal diazepam** are considered first-line alternatives per WHO and major pediatric emergency guidelines - Either option is appropriate depending on local protocols and availability *Intramuscular phenobarbital* - Phenobarbital has a **slower onset of action** when given intramuscularly (15-30 minutes) - Typically reserved for **refractory status epilepticus** or as a second-line agent after benzodiazepines have failed - Not preferred as an immediate alternative to IV lorazepam *IV phenytoin* - IV phenytoin **requires IV access**, which is specifically unavailable in this scenario - It is a second-line antiepileptic for status epilepticus, used after benzodiazepines - Requires **cardiac monitoring** due to risk of hypotension and arrhythmias

Q: Which of the following is a sign of severe dehydration in a child?

Sunken eyes. ***Sunken eyes*** - **Sunken eyes** are a classic sign of significant fluid loss, indicating a depletion of interstitial fluid around the eyes. - This finding is a strong indicator of **moderate to severe dehydration** in children, along with other signs like absent tears and dry mucous membranes. *Normal skin turgor* - **Normal skin turgor** means the skin returns quickly to its original position after being pinched, which is characteristic of adequate hydration. - In dehydration, skin turgor is usually **decreased**, meaning the skin will tent or recoil slowly. *Increased urine output* - **Increased urine output** is a sign of adequate hydration and proper kidney function, as the kidneys are able to excrete excess fluid. - In severe dehydration, the body conserves fluid, leading to significantly **decreased urine output** (oliguria) or no urine output (anuria). *Moist mucous membranes* - **Moist mucous membranes** (e.g., in the mouth or nose) indicate sufficient hydration, as the body can maintain secretions. - In dehydration, especially severe cases, mucous membranes become **dry and sticky** due to reduced fluid volume.

Question 1

An 8-year-old boy presents with petechiae, azotemic oliguria and altered sensorium, in casualty. There is a history of diarrhoea for the past 5 days. The clinical diagnosis is –

Accepted Answer

H.U.S.

Answer

H.S. purpura

Answer

Idiopathic thrombocytopenic purpura

Answer

Acute porphyria

Question 2

A five-year-old girl presents with fever and conjunctivitis. Physical examination is significant for oral erythema and fissuring along with a generalized maculopapular rash and cervical lymphadenopathy. What is the most likely diagnosis?

Accepted Answer

Kawasaki disease

Answer

Henoch-Schönlein purpura

Answer

Takayasu arteritis

Answer

Polyarteritis nodosa

Question 3

A 9 year old girl was admitted for dialysis. On laboratory examination her potassium levels were 7.8 mEq/L. Which of the following would quickly lower her increased potassium levels -

Accepted Answer

IV Glucose and insulin

Answer

IV NaHCO3

Answer

Oral kayexalate in sorbitol

Answer

IV calcium gluconate

Question 4

A child with moderate to severe head injury is admitted in PICU. First line treatments are all except:

Accepted Answer

IV mannitol

Answer

Analgesia and sedation

Answer

Hypothermia

Answer

Controlled mechanical ventilation

Question 5

According to the Lund and Browder chart, what percentage of total body surface area (TBSA) does the head and face represent in a 1-year-old child?

Accepted Answer

19%

Answer

16%

Answer

10%

Answer

13%

Question 6

In severe CNS infections in children with complications, treatment may include:

Accepted Answer

All of the options

Answer

IV Ig

Answer

Ventilation

Answer

Plasmapheresis

Question 7

Anti Snake Venin (ASV) should be given in all these situations with further lab investigations in a child presenting at 4 am except :

Accepted Answer

Severe pain abdomen but no fang marks

Answer

External ophthalmoplegia

Answer

Local swelling with fang marks

Answer

Ptosis with head flexed without bite marks

Question 8

The best scale to measure pain in children of 5 years of age would be:

Accepted Answer

Faces Scale

Answer

VAS

Answer

CHEOPS

Answer

McGill Scale

Question 9

A pediatric patient presents with a 45-minute history of continuous convulsions. The senior resident (SR) recommends IV lorazepam, but the junior resident (JR) is unable to secure IV access. What is the next best step in management?

Accepted Answer

Rectal diazepam

Answer

Intramuscular phenobarbital

Answer

Intramuscular midazolam

Answer

IV phenytoin

Question 10

Which of the following is a sign of severe dehydration in a child?

Accepted Answer

Sunken eyes

Answer

Normal skin turgor

Answer

Increased urine output

Answer

Moist mucous membranes

Pediatric Critical Care — MCQs

Pediatric Critical Care — MCQs

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