Sedation in Pediatric Imaging — MCQs
The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) for rating postoperative pain in children under one year excludes all of the following, EXCEPT:
Which of the following intravenous anesthetic agents is contraindicated in epileptic patients posted for general anaesthesia
What does a pulse oximeter primarily measure?
Which drug is most commonly used for anxiolysis in pre-anaesthetic medication?
A child presented with blunt abdominal trauma, the first investigation to be done is -
An 11 year old female patient has come for a routine dental examination. She gives a history of epileptic episodes. General examination also reveals lack of eye contact, poor co-ordination, non-communicative, poor muscle tone, drooling, hyperactive knee jerk and strabismus. Which of the following techniques is contraindicated in the management of this child ?
You are in the operating room and notice the tracing in yellow colour on this device. What does it indicate?
Investigation of choice for the diagnosis of congenital hypertrophic pyloric stenosis is:
A 28-year-old male patient presents with colicky abdominal pain along with vomiting. X-ray abdomen shows:
The "triangular cord sign" on ultrasonography is indicative of which condition in a neonate?
Sedation in Pediatric Imaging Indian Medical PG Practice Questions and MCQs
Question 1: The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) for rating postoperative pain in children under one year excludes all of the following, EXCEPT:
- A. Oxygen saturation
- B. Torso
- C. Verbal response (Correct Answer)
- D. Cry
Explanation: ***Verbal response*** - The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) is designed for children **under one year of age**, who are typically pre-verbal. - While verbal complaints are not assessed, a child's **verbal response** (e.g., moaning, crying, or not making sounds at all) in relation to pain is a component of the scale, contributing to the interpretation of their comfort level. *Oxygen saturation* - **Physiological parameters** like oxygen saturation are typically not part of behavioral pain scales like CHEOPS, which focus on observable behaviors. - While low oxygen saturation can indicate distress, it is not a direct measure of pain for this scale. *Torso* - The CHEOPS scale assesses **pain-related behaviors** of extremities (e.g., legs, arms) and facial expressions, but does not specifically include observations of the "torso" as a separate category. - Behaviors like stiffening or arching of the torso might be implicitly considered under overall body tension, but it’s not a distinct domain. *Cry* - The **quality and intensity of crying** is a primary behavioral indicator of pain in pre-verbal infants and is a significant component of many pediatric pain scales, including CHEOPS. - A child's cry, along with other behaviors, helps differentiate between various levels of discomfort or pain.
Question 2: Which of the following intravenous anesthetic agents is contraindicated in epileptic patients posted for general anaesthesia
- A. Thiopentone
- B. Midazolam
- C. Ketamine (Correct Answer)
- D. Propofol
Explanation: ***Ketamine*** - Ketamine is known to have **proconvulsant effects**, particularly at higher doses, and can exacerbate seizures in epileptic patients. - It causes **dissociative anesthesia** and can increase intracranial pressure, which is generally undesirable in patients with seizure disorders. *Thiopentone* - Thiopentone is a **barbiturate** that acts as an anticonvulsant and is often used to treat seizures or status epilepticus, making it safe in epileptic patients. - It **decreases cerebral metabolic rate** and intracranial pressure, which are beneficial for patients with neurologic conditions. *Midazolam* - Midazolam is a **benzodiazepine** with strong anticonvulsant properties, frequently used to terminate seizures. - It enhances GABAergic inhibition, making it a **safe and effective sedative** for epileptic patients. *Propofol* - Propofol has **anticonvulsant properties** and is often used in the management of refractory status epilepticus. - It **decreases cerebral blood flow** and metabolic rate, making it a favorable choice in patients with epilepsy.
Question 3: What does a pulse oximeter primarily measure?
- A. Oxygen content of blood
- B. Oxygen saturation (Correct Answer)
- C. Partial pressure of oxygen
- D. Carbon dioxide levels
Explanation: ***Oxygen saturation*** - A pulse oximeter primarily measures the **percentage of hemoglobin** in arterial blood that is saturated with oxygen. - This is often reported as **SpO2** (peripheral oxygen saturation), an estimate of SaO2 (arterial oxygen saturation). *Oxygen content of blood* - The **total amount of oxygen** in the blood includes dissolved oxygen and oxygen bound to hemoglobin. - Pulse oximeters only measure the proportion of hemoglobin bound to oxygen, not the absolute amount of oxygen. *Partial pressure of oxygen* - This refers to the **amount of oxygen dissolved in the plasma** and is denoted as PaO2. - Measurement of PaO2 requires an **arterial blood gas (ABG)** analysis, which is an invasive procedure. *Carbon dioxide levels* - Pulse oximeters do **not measure CO2**; they use light absorption at specific wavelengths to differentiate oxyhemoglobin from deoxyhemoglobin. - Measurement of carbon dioxide requires **capnography** or arterial blood gas analysis.
Question 4: Which drug is most commonly used for anxiolysis in pre-anaesthetic medication?
- A. Morphine
- B. Atropine
- C. Scopolamine
- D. Diazepam (Correct Answer)
Explanation: **Diazepam** * **Diazepam**, a **benzodiazepine**, is widely used for **pre-anaesthetic anxiolysis** due to its potent **sedative**, **anxiolytic**, and **amnesic** properties. * It helps reduce patient anxiety and psychological stress before surgery, improving the overall perioperative experience. *Morphine* * **Morphine** is a powerful **opioid analgesic** primarily used for **pain relief**, not anxiolysis. * While it has some sedative effects, its main role in **pre-anaesthetic medication** is to reduce **intraoperative and postoperative pain**. *Atropine* * **Atropine** is an **anticholinergic drug** used to reduce **salivary and bronchial secretions** and to prevent **bradycardia** during intubation or surgery. * It does **not possess anxiolytic properties** and is not used to relieve pre-operative anxiety. *Scopolamine* * **Scopolamine** is another **anticholinergic drug** that can cause **sedation** and **amnesia**, making it useful for preventing **postoperative nausea and vomiting**. * However, its primary role is not anxiolysis, and its sedative effects are often accompanied by other undesirable anticholinergic side effects.
Question 5: A child presented with blunt abdominal trauma, the first investigation to be done is -
- A. USG (Correct Answer)
- B. CT Scan
- C. Complete Hemogram
- D. Abdominal X-ray
Explanation: ***USG*** - An **ultrasound (USG)** is the **first-line imaging investigation** for blunt abdominal trauma in children due to its **non-invasive nature**, lack of radiation exposure, and rapid bedside availability. - **FAST (Focused Assessment with Sonography for Trauma)** effectively identifies the presence of **free fluid** (indicating internal bleeding/hemoperitoneum) and can assess solid organ injuries, particularly the **spleen and liver**. - It is the **preferred initial investigation in hemodynamically stable pediatric patients**. *CT Scan* - A **CT scan** is more sensitive and provides detailed anatomical information but involves significant **radiation exposure**, which is a major concern in children. - It is usually reserved for cases where USG is inconclusive, there is a **high clinical suspicion of severe injury**, or when determining the need for surgical intervention in hemodynamically stable patients. *Complete Hemogram* - A **complete hemogram** assesses blood components like hemoglobin and hematocrit, which are crucial for evaluating blood loss, but it is a **laboratory test, not an imaging investigation**. - While important for initial assessment and serial monitoring, it doesn't provide immediate information about the **location, type, or extent of internal abdominal injuries**. *Abdominal X-ray* - An **abdominal X-ray** has limited utility in blunt abdominal trauma as it is primarily useful for detecting **hollow viscus perforation (free air)** or bony fractures. - It does not effectively visualize soft tissue injuries, fluid collections, or solid organ damage, making it unsuitable as the primary diagnostic tool in blunt abdominal trauma.
Question 6: An 11 year old female patient has come for a routine dental examination. She gives a history of epileptic episodes. General examination also reveals lack of eye contact, poor co-ordination, non-communicative, poor muscle tone, drooling, hyperactive knee jerk and strabismus. Which of the following techniques is contraindicated in the management of this child ?
- A. Conscious sedation
- B. Aversive conditioning (Correct Answer)
- C. Pedi-Wrap
- D. Papoose Board
Explanation: ***Aversive conditioning*** - Aversive conditioning involves using **unpleasant stimuli** to reduce undesirable behaviors. This technique is ethically questionable and generally **contraindicated in pediatric dentistry**, especially for a child with complex needs like epilepsy and developmental delays, as it can cause significant distress and fear. - Given the patient's **epileptic episodes** and other neurological signs, any technique that could induce stress or fear might **trigger seizures** or exacerbate behavioral issues. *Conscious sedation* - **Conscious sedation** can be a useful technique for managing patients with special needs, including those with epilepsy, by reducing anxiety and improving cooperation during dental procedures. - While careful anesthetic consideration is required due to her **epileptic history**, it is not inherently contraindicated and can be safely administered with proper monitoring. *Pedi-Wrap* - The **Pedi-Wrap** is a type of **physical restraint** used to ensure patient safety and cooperation during dental treatment by limiting movement. - For a child with **poor co-ordination** and **poor muscle tone**, physical restraints can be a necessary tool to prevent injury during procedures. *Papoose Board* - A **Papoose Board** is another form of **physical restraint** designed to stabilize a child during dental treatment, similar to a Pedi-Wrap. - This technique is often used for pediatric patients who cannot cooperate due to age, developmental challenges, or medical conditions, which aligns with the description of this patient.
Question 7: You are in the operating room and notice the tracing in yellow colour on this device. What does it indicate?
- A. O2 pressure in exhaled air
- B. Capnography (Correct Answer)
- C. O2 pressure in inhaled air
- D. Airway pressure
Explanation: ***Capnography*** - The yellow tracing displays a waveform that is characteristic of a **capnogram**, which measures the concentration of **carbon dioxide (CO2)** in the expired breath over time. - The rectangular shape with a sudden rise, plateau, and rapid fall is typical of the **CO2 waveform** during a respiratory cycle. *O2 pressure in exhaled air* - While oxygen levels can be monitored, the characteristic waveform shown with its distinct plateau phase is specific to **carbon dioxide** measurement. - Oxygen monitoring provides different types of waveforms or numerical values, such as **pulsus oximetry**, which shows oxygen saturation. *O2 pressure in inhaled air* - Monitoring devices typically display **inspired oxygen concentration (FiO2)** as a numerical value rather than a waveform. - The waveform shown is indicative of gas exchange dynamics during **exhalation**, not inhalation. *Airway pressure* - Airway pressure tracings typically show a waveform that correlates with the **inspiratory and expiratory phases** of breathing, indicating the pressure within the airway. - However, the specific shape and plateau of the waveform in yellow are distinct from typical **airway pressure** curves and are characteristic of CO2.
Question 8: Investigation of choice for the diagnosis of congenital hypertrophic pyloric stenosis is:
- A. USG (Correct Answer)
- B. Barium meal
- C. Barium meal follow through
- D. CT scan with contrast
Explanation: ***USG*** - **Ultrasound** is the preferred initial imaging modality due to its non-invasiveness, lack of radiation, and high accuracy in visualizing the thickened pyloric muscle. - The classic ultrasound findings include a **pyloric muscle thickness** of ≥ 4 mm and a **pyloric channel length** of ≥ 14 mm. *Barium meal* - While a barium meal can show findings like the "string sign" or "shoulder sign," it involves **radiation exposure** and is generally considered a second-line investigation. - Its diagnostic accuracy is good, but it is less convenient and riskier than ultrasound for this condition. *Barium meal follow through* - This procedure tracks barium through the entire gastrointestinal tract, which is **excessive and unnecessary** for diagnosing pyloric stenosis, which is a localized obstruction. - It also involves significant **radiation exposure** and a prolonged examination time. *CT scan with contrast* - A **CT scan** involves significant **radiation exposure** and is not typically used for diagnosing congenital hypertrophic pyloric stenosis. - It is also less sensitive than ultrasound for visualizing the specific soft tissue changes in the pyloric muscle.
Question 9: A 28-year-old male patient presents with colicky abdominal pain along with vomiting. X-ray abdomen shows:
- A. Pseudo-obstruction
- B. Cancer colon
- C. Small bowel obstruction (Correct Answer)
- D. Paralytic ileus
Explanation: ***Small bowel obstruction*** - The X-ray image shows multiple **dilated loops of small bowel** with **air-fluid levels** and prominent **valvulae conniventes** (herringbone pattern), which are classic signs of small bowel obstruction. - The clinical presentation of **colicky abdominal pain** and **vomiting** is highly consistent with a small bowel obstruction. *Pseudo-obstruction* - Pseudo-obstruction, or Ogilvie's syndrome, primarily affects the **large bowel**, leading to colonic dilation without a mechanical obstruction. - While it can cause abdominal pain and vomiting, the X-ray findings would typically show marked dilation of the colon rather than predominantly small bowel loops. *Cancer colon* - Colon cancer, if it causes obstruction, typically presents as a **large bowel obstruction**, with colonic dilation proximal to the tumor. - While severe cases could lead to cecal dilation and subsequent small bowel obstruction, the primary radiographic findings would focus on the colon. *Paralytic ileus* - Paralytic ileus, or adynamic ileus, involves generalized bowel dilation (both small and large bowel) due to **impaired peristalsis**, without mechanical obstruction. - Although it causes abdominal pain and vomiting, it usually presents with more continuous, less colicky pain, and the X-ray often shows gas in the colon, which is typically absent or minimal in a complete small bowel obstruction.
Question 10: The "triangular cord sign" on ultrasonography is indicative of which condition in a neonate?
- A. Galactosemia
- B. Biliary atresia (Correct Answer)
- C. Hepatitis
- D. None of the above
Explanation: **Explanation:** The **triangular cord sign** is a highly specific ultrasonographic finding for **Biliary Atresia (BA)**. It represents a cone-shaped or triangular fibrotic mass of the cranial part of the extrahepatic biliary tree. On ultrasound, it appears as an echogenic (hyperechoic) area located anterior to the bifurcation of the portal vein. A thickness of **>4 mm** is generally considered diagnostic. **Why Biliary Atresia is correct:** In BA, there is progressive fibro-obliterative destruction of the extrahepatic biliary system. The "triangular cord" is the sonographic visualization of this fibrous remnant at the porta hepatis. When combined with an absent or small, irregular gallbladder (ghost gallbladder sign), it is a pathognomonic finding. **Why other options are incorrect:** * **Galactosemia:** This is a metabolic disorder. While it can cause neonatal jaundice and hepatomegaly, it does not involve anatomical obliteration of the bile ducts; diagnosis is via enzyme assays and urine reducing sugars. * **Hepatitis (Neonatal):** This is the primary differential for BA. On ultrasound, neonatal hepatitis typically shows a patent biliary tree and a normal-sized gallbladder. It lacks the specific fibrous cord seen in BA. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Intraoperative Cholangiogram (IOCG). * **Best Initial Screening:** Ultrasound (looking for the triangular cord sign). * **Functional Imaging:** HIDA scan (shows uptake by the liver but **no excretion** into the bowel even after 24 hours). * **Surgical Management:** Kasai Procedure (Hepatoportoenterostomy), ideally performed before 60 days of life. * **Liver Biopsy:** Shows bile duct proliferation and portal fibrosis.
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