Shock — MCQs

10 questions

Best solution to be used in hypovolemic shock is:

How is catecholamine resistant shock managed in children?

Haemorrhagic shock due to acute blood loss includes: 1. Increasing pallor 2. Restlessness 3. Air hunger 4. Water-hammer pulse

In hypovolemic shock there is -

Which of the following statements about shock in children is correct?

What is the main goal of fluid resuscitation in a child with septic shock?

Which of the following statements about the ABCDE approach in pediatric Advanced Life Support (PALS) is incorrect?

A six year old child is admitted to the Paediatric ICU for seizures. He has been on treatment with Tacrolimus and Prednisolone. On investigations his blood urea is 68 mg/dL, Serum Sodium is 136 mEq/L likely cause of his seizures-

A 4-year-old admitted in ward with pneumonia. He develops sudden onset of breathlessness. What is the next step in management?

Q10Easy

What is the capillary refill time in a child with shock?

Shock Indian Medical PG Practice Questions and MCQs

Question 1: Best solution to be used in hypovolemic shock is:

A. Ringer's Lactate solution. (Correct Answer)
B. Darrow's solution.
C. 5% dextrose.
D. 0.9% Nacl.

Explanation: ***Ringer's Lactate solution*** - This **isotonic crystalloid solution** is commonly used in hypovolemic shock because its electrolyte composition is similar to that of human plasma. [2] - The **lactate** component is metabolized by the liver to bicarbonate, which helps to buffer acidosis often associated with shock. [2] *Darrow's solution* - Darrow's solution is a **hypertonic solution** containing high concentrations of potassium, primarily used for severe dehydration and significant potassium deficits, not initial fluid resuscitation in hypovolemic shock. - Its high potassium content can be dangerous in patients with **renal impairment** or who are already hyperkalemic. *5% dextrose* - **5% dextrose in water (D5W)** is an initially isotonic solution, but the dextrose is quickly metabolized, making it effectively a hypotonic solution. [2] - It is primarily used to provide **free water** and is not effective for volume expansion in hypovolemic shock as it does not stay in the intravascular space. [2] *0.9% Nacl* - **0.9% normal saline** is an isotonic crystalloid often used for volume resuscitation but has a higher chloride content than plasma, which can lead to **hyperchloremic metabolic acidosis** with large volumes. [1], [2] - While it expands the intravascular space, Ringer's Lactate is often preferred in situations of significant blood loss or acidosis due to its more balanced electrolyte profile and buffering capacity. [2]

Question 2: How is catecholamine resistant shock managed in children?

A. Hydrocortisone (Correct Answer)
B. Nor-adrenaline
C. Activated protein-C
D. Vasopressin

Explanation: ***Hydrocortisone*** - **Hydrocortisone** is the primary treatment for catecholamine-resistant shock in children by addressing the underlying mechanism of receptor unresponsiveness. - It works by **upregulating adrenergic receptors** on vascular smooth muscle, restoring sensitivity to endogenous and exogenous catecholamines. - Additionally provides anti-inflammatory effects and treats relative adrenal insufficiency, which is common in prolonged shock states. - **Standard dosing:** 50-100 mg/m² or 1-2 mg/kg every 6 hours in pediatric shock. *Nor-adrenaline* - **Nor-adrenaline** is a potent catecholamine (alpha and beta agonist) already used in shock management. - In catecholamine-resistant shock, adrenergic receptors are **desensitized or downregulated**, making additional catecholamines less effective. - This is part of the existing therapy that has failed, not the solution to resistance. *Activated protein-C* - **Activated protein-C** (drotrecogin alfa) was used in severe sepsis but has been **withdrawn from the market** due to lack of efficacy and increased bleeding risk. - Not recommended in current pediatric shock guidelines. - Does not address catecholamine receptor unresponsiveness. *Vasopressin* - **Vasopressin** is an important adjunctive agent for catecholamine-resistant shock, acting through **V1 receptors** (non-adrenergic pathway). - Provides vasoconstriction when adrenergic receptors are unresponsive, making it useful in refractory cases. - However, it does not restore catecholamine receptor sensitivity—it bypasses the problem rather than correcting it. - **Hydrocortisone** is preferred as the primary intervention because it addresses the underlying receptor dysfunction, while vasopressin serves as an alternative vasopressor pathway.

Question 3: Haemorrhagic shock due to acute blood loss includes: 1. Increasing pallor 2. Restlessness 3. Air hunger 4. Water-hammer pulse

A. 1 & 2
B. 1, 2 & 3 (Correct Answer)
C. 2, 3 & 4
D. 1 & 4

Explanation: ***1, 2 & 3*** - **Increasing pallor** occurs due to reduced blood flow to the skin as the body shunts blood to vital organs in response to hypovolemia. - **Restlessness** and **air hunger** are signs of cerebral hypoxia and metabolic acidosis, respectively, as the circulatory system fails to deliver sufficient oxygen to tissues and clear CO2. *1 & 2* - This option is partially correct as **increasing pallor** and **restlessness** are indeed seen in hemorrhagic shock. - However, it incorrectly excludes **air hunger**, which is a significant clinical sign of severe hemorrhage and ensuing metabolic acidosis. *2, 3 & 4* - This option correctly identifies **restlessness** and **air hunger** as features of hemorrhagic shock. - However, **water-hammer pulse** is characteristic of conditions leading to a wide pulse pressure, such as aortic regurgitation, not the narrow pulse pressure seen in hypovolemic shock [1]. *1 & 4* - This option correctly identifies **increasing pallor** as a feature of hemorrhagic shock. - It incorrectly includes **water-hammer pulse**, which is not a sign of hypovolemic shock; rather, a weak, thready pulse is expected due to reduced stroke volume [1].

Question 4: In hypovolemic shock there is -

A. Efferent arteriolar constriction
B. Increased blood flow to kidney
C. Decreased cardiac output (Correct Answer)
D. Afferent arteriolar constriction

Explanation: ***Decreased cardiac output*** - **Hypovolemic shock** is fundamentally defined by **decreased circulating blood volume**, which leads to **decreased venous return** to the heart. - According to the **Frank-Starling mechanism**, decreased venous return leads to **decreased preload**, which results in **decreased stroke volume** and consequently **decreased cardiac output**. - This is the **primary hemodynamic characteristic** of hypovolemic shock and is present in ALL cases. - Decreased cardiac output triggers all the compensatory mechanisms seen in hypovolemic shock, including sympathetic activation and RAAS activation. *Afferent arteriolar constriction* - While afferent arteriolar constriction does occur in hypovolemic shock due to **sympathetic activation**, it is a **compensatory response** rather than the primary feature. - The predominant effect at the kidney level is actually a combination of both afferent and efferent arteriolar changes. - This occurs secondary to the decreased cardiac output. *Efferent arteriolar constriction* - **Efferent arteriolar constriction** is mediated primarily by **angiotensin II** and is actually MORE prominent than afferent constriction. - This helps **maintain glomerular filtration rate (GFR)** despite reduced renal blood flow by increasing glomerular hydrostatic pressure. - However, this is also a compensatory response, not the primary feature of hypovolemic shock. *Increased blood flow to kidney* - This is incorrect as hypovolemic shock causes **decreased renal blood flow**. - Blood is redistributed away from the kidneys to vital organs like the heart and brain through compensatory vasoconstriction.

Question 5: Which of the following statements about shock in children is correct?

A. Tachycardia is a sensitive indicator of shock in children. (Correct Answer)
B. Mottling of extremities is an early sign of shock.
C. Confusion and stupor are early signs of shock.
D. Respiratory rate is a more sensitive indicator of shock than heart rate.

Explanation: ***Tachycardia is a sensitive indicator of shock in children.*** - **Tachycardia** is often the first and most reliable sign of **compensated shock** in children, as their cardiovascular system initially maintains cardiac output by increasing heart rate. - Children have a remarkable ability to compensate for significant fluid loss, and an elevated heart rate helps maintain **perfusion** before blood pressure drops. *Mottling of extremities is an early sign of shock.* - **Mottling** of extremities is typically a sign of **decompensated shock** and indicates significant vasoconstriction and poor tissue perfusion. - It is a **late sign** that suggests the child's compensatory mechanisms are failing. *Confusion and stupor are early signs of shock.* - **Altered mental status**, such as confusion or stupor, usually indicates **severe shock** and reduced cerebral perfusion. - These are generally **late signs** of shock, appearing after initial compensatory mechanisms have failed. *Respiratory rate is a more sensitive indicator of shock than heart rate.* - While **tachypnea** can be present in shock due to metabolic acidosis or compensatory mechanisms, **tachycardia** is a more consistently sensitive and earlier indicator of circulatory compromise. - Respiratory changes can also be influenced by other factors like pain, fever, or respiratory illness, making heart rate a more specific initial marker for shock.

Question 6: What is the main goal of fluid resuscitation in a child with septic shock?

A. Increase urine output
B. Reduce heart rate
C. Decrease fever
D. Restore blood pressure (Correct Answer)

Explanation: ***Restore blood pressure*** - In septic shock, **vasodilation** and extravasation of fluids lead to decreased **effective circulating volume** and profound **hypotension**. - Aggressive fluid resuscitation is critical to restore adequate **mean arterial pressure** and improve **organ perfusion**. *Increase urine output* - While increased urine output is a positive sign of improved renal perfusion, it is a **consequence** of successful resuscitation rather than the primary goal. - The main focus is on addressing the circulatory dysfunction that leads to **oliguria** in the first place. *Reduce heart rate* - A **high heart rate** (tachycardia) in septic shock is a compensatory mechanism to maintain **cardiac output** in the face of reduced preload and systemic vascular resistance. - Reducing heart rate directly is not the primary goal of fluid resuscitation and may even be harmful if **cardiac output** is already compromised. *Decrease fever* - Fever is a systemic inflammatory response to infection and is typically managed with **antipyretics**, not primarily with fluid resuscitation. - While fluids can help prevent complications of hyperthermia like dehydration, the main goal in shock is **hemodynamic stabilization**.

Question 7: Which of the following statements about the ABCDE approach in pediatric Advanced Life Support (PALS) is incorrect?

A. Dehydration is a component of the ABCDE approach. (Correct Answer)
B. Airway management is essential in PALS.
C. Breathing assessment is part of the ABCDE approach.
D. Circulation is a critical component of the ABCDE approach.

Explanation: ***Dehydration is a component of the ABCDE approach.*** - The **ABCDE approach** in PALS focuses on **Airway, Breathing, Circulation, Disability, and Exposure**, which are immediate life threats. - While dehydration is a crucial clinical concern in children, it's a **diagnostic consideration** and management target, not a primary component of the initial rapid assessment categories (A, B, C, D, E) themselves. - Dehydration may affect circulation (C) but is not itself a separate component of the ABCDE framework. *Airway management is essential in PALS.* - **Airway** is the first step in the ABCDE approach, focusing on ensuring a **patent and protected airway** to allow for effective ventilation. - **Airway management** is critical in pediatric resuscitation to prevent respiratory arrest and optimize oxygen delivery. *Breathing assessment is part of the ABCDE approach.* - **Breathing** is the second step, involving the assessment of **respiratory rate, effort, breath sounds, and oxygen saturation**. - Effective breathing is vital for adequate **oxygenation and ventilation**, and addressing breathing problems is a key part of PALS. *Circulation is a critical component of the ABCDE approach.* - **Circulation** is the third step, involving the assessment of **heart rate, blood pressure, capillary refill time, and peripheral perfusion**. - **Circulatory assessment** helps identify shock or cardiac arrest, which require immediate intervention. - The complete ABCDE also includes **Disability** (neurological status assessment using AVPU or GCS) and **Exposure** (full examination while preventing hypothermia).

Question 8: A six year old child is admitted to the Paediatric ICU for seizures. He has been on treatment with Tacrolimus and Prednisolone. On investigations his blood urea is 68 mg/dL, Serum Sodium is 136 mEq/L likely cause of his seizures-

A. Hyponatremia
B. Uremia
C. Hypocalcemia
D. Tacrolimus Toxicity (Correct Answer)

Explanation: ***Tacrolimus Toxicity*** - **Tacrolimus** is an immunosuppressant known to cause neurotoxicity, including seizures, particularly at higher concentrations or in susceptible individuals. - The patient's history of **tacrolimus use** and the absence of clear electrolyte imbalances make toxicity a primary concern. *Hyponatremia* - **Hyponatremia** (low serum sodium) is a common cause of seizures. - However, the patient's serum sodium level of **136 meq/L** is within the normal range, ruling out hyponatremia as the cause. *Uremia* - **Uremia**, characterized by a high blood urea nitrogen (BUN) and creatinine, can cause seizures due to the accumulation of toxins. - While the patient's **blood urea of 68 mg/dL** is elevated, it is not severely high enough in isolation to confidently ascribe seizures to uremia without additional clinical context like significantly impaired renal function. *Hypocalcemia* - **Hypocalcemia** (low serum calcium) can lead to seizures and other neurological symptoms. - However, there is no information provided about the patient's calcium levels, and it is less likely given the patient's current medication profile compared to tacrolimus's known side effects.

Question 9: A 4-year-old admitted in ward with pneumonia. He develops sudden onset of breathlessness. What is the next step in management?

A. Intercostal drainage tube insertion
B. Emergency needle thoracostomy (Correct Answer)
C. Decrease mechanical ventilation setting
D. Increase mechanical ventilation setting

Explanation: ***Emergency needle thoracostomy*** - This patient, a 4-year-old with pneumonia and sudden breathlessness, likely has a **tension pneumothorax**, which is a life-threatening emergency requiring immediate decompression. The chest X-ray shows a collapsed right lung and a mediastinal shift, consistent with tension pneumothorax. - An **emergency needle thoracostomy** (needle decompression) is the immediate life-saving procedure to relieve the pressure in a tension pneumothorax before more definitive treatment can be initiated. - Performed by inserting a large-bore needle (14-16G) into the **2nd intercostal space, mid-clavicular line** on the affected side. *Intercostal drainage tube insertion* - While an intercostal drainage tube (chest tube) is the definitive treatment for pneumothorax, it takes more time to insert and is not the immediate first step for a **tension pneumothorax** in an unstable patient. - The delay in performing needle decompression could be fatal in a rapidly deteriorating patient with tension pneumothorax. *Decrease mechanical ventilation setting* - Decreasing mechanical ventilation settings would not address the underlying pathology of a tension pneumothorax, which is trapped air causing lung collapse and mediastinal shift. - This action could further compromise the patient's respiratory status if the pneumothorax is severe and the patient is already hypoxemic. *Increase mechanical ventilation setting* - Increasing mechanical ventilation settings would likely worsen a **tension pneumothorax** by forcing more air into the pleural space and increasing intrathoracic pressure. - This would further compromise venous return to the heart and reduce cardiac output, rapidly leading to **cardiovascular collapse**.

Question 10: What is the capillary refill time in a child with shock?

A. Greater than 1 second
B. Greater than 2 seconds
C. Greater than 3 seconds (Correct Answer)
D. Greater than 4 seconds

Explanation: **Explanation:** Capillary Refill Time (CRT) is a rapid clinical assessment tool used to evaluate peripheral perfusion. In a healthy child, CRT is typically less than 2 seconds. In the setting of **shock**, the body initiates a compensatory sympathetic response, leading to peripheral vasoconstriction to divert blood flow to vital organs (heart and brain). This reduced cutaneous perfusion results in a delayed CRT. * **Why Option C is Correct:** According to the **PALS (Pediatric Advanced Life Support)** and **WHO** guidelines, a CRT of **greater than 3 seconds** is considered a clinical sign of impaired systemic perfusion and is a hallmark of shock in children. It indicates significant peripheral vasoconstriction or decreased cardiac output. * **Why Options A & B are Incorrect:** A CRT of 1 or 2 seconds is considered within the **normal physiological range** for a child in a neutral thermal environment. These values do not indicate the circulatory compromise required to diagnose shock. * **Why Option D is Incorrect:** While a CRT >4 seconds certainly indicates shock, it is a late or more severe finding. The standard diagnostic threshold for identifying the onset of clinical shock is >3 seconds. **High-Yield Clinical Pearls for NEET-PG:** * **Technique:** CRT should be measured by applying firm pressure for 5 seconds to a blanchable skin surface (ideally the fingernail bed or chest) at the level of the heart. * **False Positives:** Cold ambient temperature can prolong CRT even in the absence of shock. * **Septic Shock Paradox:** In "Warm Shock" (early distributive shock), the CRT may actually be **brisk (<1 second)** due to peripheral vasodilation, though "Cold Shock" with delayed CRT is more common in pediatrics. * **Dehydration:** A CRT >3 seconds is also a key predictor of >5% dehydration in children with gastroenteritis.

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