Fast Lane
A 4-year-old boy is seen at a community emergency department for abdominal pain and nonbloody, nonbilious vomiting for 1 day. He has a 1-week history of increased thirst and frequent urination, and he has been wetting his bed off and on as well. He had weight loss during the last few weeks and now weighs 12 kg (decreased from 15 kg 3 months ago).
His temperature is 37.1°C, heart rate is 180 beats/min, respiratory rate is 14 breaths/min, blood pressure is 82/54 mm Hg, and his oxygen saturation is 98% in room air.He appears to be taking deep breaths, the capillary refill is 5 seconds, and he has skin tenting. A diagnosis of diabetic ketoacidosis and severe dehydration is made on the basis of the initial blood glucose level (682 mg/dL [37.85 mmol/L]) and acidosis (venous pH 7.08; serum bicarbonate, <5 mEq/L [<5 mmol/L]; ꞵ-hydroxybutyrate 52.06 mg/dL [5 mmol/L]. Blood urea nitrogen is 68 mg/dL [24.28 mmol/L] and creatinine is 1.4 mg/dL [123.76 µmol/L]).
He is given two 20-mL/kg Intravenous 0.9% saline boluses over 60 minutes, 1.2 U of insulin as an intravenous push followed by intravenous insulin infusion at 1.2 U/h, 24 mEq of sodium bicarbonate intravenously, and 0.45% saline of 1.5 times the maintenance rate. On arrival to the pediatric intensive care unit 2 hours later, his point-of-care blood glucose is 246 mg/dL (13.65 mmol/L). He has another episode of vomiting, experiences a severe headache, and has become increasingly confused during the next hour. His pupils are now 5-mm dilated and sluggish, the Glasgow Coma Scale score has decreased from 14 to 9, and he becomes incontinent of urine. An urgent non contrast computed tomography of the brain is performed, and therapy with 3% saline is started for the suspected complication.
Of the following, the factor MOST likely associated with this patient’s complication is
A. administration of insulin as a bolus
B. administration of sodium bicarbonate
C. rate of fluid administration
D. sodium content in rehydration fluids
B. administration of sodium bicarbonate
A 4-year-old boy with status asthmaticus is intubated in an OSH ED for respiratory failure. The transport team arrives and notes that the patient is mechanically ventilated with PIP 34 cm H2O and PEEP 5 cm H2O. He has poor chest rise and minimal breath sounds. He is intubated with a 4.5-mm uncuffed endotracheal tube. His FiO2 is 1.0 and saturations are 85%. The results from an ABG are shown: PH: 8.19, PaCO2 74, PaO2 83
Of the following, the BEST treatment option to improve ventilation in this patient is to
A.change the endotracheal tube to a 4.5-mm cuffed tube
B.change the endotracheal tube to a 6.5-mm uncuffed tube
C.increase end-expiratory pressure to 8 cm H2O
D.increase peak inspiratory pressure to 40 cm H2O
A.change the endotracheal tube to a 4.5-mm cuffed tube
A 9-month-old female infant with lethargy, poor feeding, and diarrhea is transferred from ED to PICU. Her symptoms began 3 days ago, and she has produced 1 wet diaper in the past 24 hours. A peripheral intravenous catheter was placed, and she received 40 mL/kg of NS IV before being transferred. On admission to PICU, the infant is lethargic but arousable, with sunken eyes and anterior fontanelle as well as dry mucous membranes. The patient demonstrates no hepatomegaly. Her vital signs are a temperature of 36.4°C, a heart rate of 190, BP 65/36 mm Hg, RR 24, and an SpO2 97% in RA. Her capillary refill time is 4 sec.
Of the following, the BEST next step in the care of this patient is to
A.deliver another 20 mL/kg bolus of 0.9% saline intravenously
B.initiate intravenous fluids containing dextrose, saline, and potassium at maintenance rate
C.place a nasogastric tube and start oral rehydration therapy
D.start an infusion of norepinephrine
A.deliver another 20 mL/kg bolus of 0.9% saline intravenously
A 12y boy was admitted to the PICU with tachypnea, increased work of breathing, abdominal pain, and severe acidosis. The results of ABG were as follows: PH 6.97, PCO2 19, PO2 100, On further workup, he was found to have new-onset type I diabetes, as well as DKA. He was treated with intravenous fluids and an insulin infusion; as a result, his symptoms resolved and his anion gap and pH improved. He has been recovering well and was transitioned to self-administered insulin injections via an insulin pen and is now planned for transfer to the general pediatric floor today for further management and continued diabetes education. The physician is called to his room emergently because his 10-year-old brother, who has been visiting him unsupervised, developed generalized tonic-clonic seizure activity. His mother denies any significant medical history, prior seizure activity, recent ingestions, or trauma.
After ensuring that the airway is protected and applying a 100% fraction of inspired oxygen facemask, the MOST appropriate next step the clinician takes is likely to be
A.administering 2 mL/kg of 3% hypertonic saline solution
B.administering 0.25 mg/kg of intravenous labetalol
C.obtaining a noncontrast computed tomographic scan of the head
D.obtaining a point-of-care glucose test
D.obtaining a point-of-care glucose test
A previously healthy, 10-year-old boy is admitted to the general pediatric floor with 5 days of high fever, right ocular pain, and eyelid swelling. He was admitted to the hospital 2 days ago, at which time he was found to have an orbital cellulitis and a positive blood culture result for methicillin-resistant Staphylococcus aureus, sensitive to clindamycin. He remains in the hospital, receiving intravenous clindamycin, but continues to experience persistent, intermittent fever. He has developed progressively worsening confusion and altered mental status over the course of the day, and his mother noticed that he has been breathing fast since yesterday. On examination, he is moaning and demonstrating only minimal response to noxious stimuli.
His vital signs are shown: Temp:40°C; BP: 130/70,HR: 60, RR: 14, SpO2 95% on RA
Of the following, the MOST appropriate next intervention is to
A.administer hyperosmolar therapy
B.administer a rapid 20-mL/kg bolus of crystalloid
C.immediately arrange for a computed tomographic scan of the brain
D.start epinephrine infusion at 0.1 µg/kg/min
A.administer hyperosmolar therapy
A 3 yr old boy was intubated due to ARDS secondary to strep pneumonia. He continued to have worsening hypoxia and required escalation from IMV to HFOV. His SpO2 improved to low 90s after switched to HFOV and FiO2 was able to decrease from 1 to 0.6. 1 hour later, you obtained ABG, which showed PH 7.15, PaCO2 85, PaO2 70, Lactic acid 1.2. RT asked you if you would like to make changes for the HFOV settings, and which would be the best option to increase minute ventilation
A. Decrease in amplitude from 60 to 55
B. Decrease in Hertz from 9 to 7
C. Decrease mean airway pressure from 28 to 26
D. Decrease in the inspiratory time ration from 0.33 to 0.25
B. Decrease in Hertz from 9 to 7
A 14yr boy is admitted to the PICU from ED with status asthmaticus. He is currently receiving continuous nebulized albuterol and intravenous solumedrol every 6 hours, with some improvement. His RR is 25 breaths/min and his SpO2 is 95% on 0.5 FiO2 via facemask connected to a Venturi system. While in the intensive care unit, he reports having pain and tingling of his left arm since playing football yesterday. He is evaluated by the orthopedics team and found to have an anterior shoulder dislocation. The orthopedic resident is planning to do a bedside reduction of the dislocation via the Stimpson method and has asked for sedation and analgesia for the procedure.
Of the following agents, the MOST appropriate to use in this scenario is
A.ketamine
B.lorazepam
C.morphine
D.propofol
A.ketamine
A 4-year-old boy was admitted to the hospital with nausea, vomiting, lethargy, and signs of dehydration thought to be secondary to a viral gastroenteritis that had not resolved despite several days of over-the-counter medications. He has been treated with intravenous fluid hydration for approximately 24 hours with significant resolution of his symptoms; however, now he is complaining of mild pain in the right upper quadrant.
Laboratory tests were again performed this morning before his planned discharge. The results are notable for the following values: ALT: 1126, AST: 980, INR: 2.7, BUN 35, Of the following, the MOST appropriate next step in management is
A.administration of activated charcoal
B.administration of N-acetylcysteine
C.repeat laboratory tests of liver functions in 24 hours
D.treatment based on the Rumack-Matthew nomogram
B.administration of N-acetylcysteine
A 2yo, 12-kg boy was admitted to thePICU with respiratory failure secondary to necrotizing staphylococcal pneumonia. During his course, he developed severe ARDS and multisystem organ dysfunction requiring vasopressor support with norepinephrine, now running at 0.2 µg/kg/min. Current ventilator settings are as follows: RR: 20, Vt 72ml, Ti: 1sec, PEEP 10, FiO2 0.6, his PIP ranges from 25-30. The patient is sedated and receiving neuromuscular blockade. He is evaluated for acute desaturation and hypotension. His vital signs are as follows: BP: 62/39, HR: 180, SpO2 65%, and he is on 100% oxygen now. His central venous pressure is 18 mm Hg, and the peak inspiratory pressure is 42 cm H20. Physical examination findings are significant for severely diminished breath sounds on the left, jugular venous distention, tracheal deviation to the right, and poor peripheral pulses.
Of the following, the MOST definitive next step in management is to
A.administer 10 mL/kg intravenous bolus push of normal saline
B.order a chest radiograph to evaluate the position of the endotracheal tube
C.perform a left-sided needle thoracostomy
D.start an epinephrine infusion
C.perform a left-sided needle thoracostomy
A 10-year-old boy is admitted to the PICU for respiratory distress from a left lung empyema and small pneumothorax. He requires 2 L/min oxygen via nasal cannula to maintain SpO2 > 90%. The physical examination reveals mild tachypnea and decreased breath sounds on the left side. The patient’s BP, HR, and the remainder of physical examination findings are normal. Because of persistent fever, a thoracostomy tube is inserted for drainage of the empyema. The attending physician supervising the procedural sedation for the chest tube placement requests the respiratory therapist to have end-tidal monitoring during the sedation. Fentanyl and propofol are used to provide deep sedation. A medical student is
intrigued by the end-tidal waveform and the PETCO2 reading (currently 40). She asks about condition(s) that could lead to increases in the PETCO2 of this patient.
Of the following, the condition MOST likely to increase PETCO2 rapidly in this patient is
A.addition of dexmedetomidine
B.bolus of sodium bicarbonate
C.cardiac arrest
D.tension pneumothorax
B.bolus of sodium bicarbonate
A patient is started on a mechanical ventilator due to severe and persistent respiratory failure. Over the ensuing few days, it is noticed that his oxygenation is poor. The critical care physician decides to increase the PEEP from 7 to 20 mm H20. When the PEEP is increased, this may result in which of the following complication?
A.Increasing venous return
B.Decreasing intracranial pressure
C.Increasing CO2 excretion
D.Decreasing cardiac output
D.Decreasing cardiac output
A 4-year-old boy was admitted to the PICU with respiratory failure likely secondary to staphylococcal pneumonia that required intubation and mechanical ventilation. During his PICU course he developed ARDS that required increased ventilator support and multisystem organ dysfunction that required norepinephrine. He has been improving during the past week and has weaned to a PEEP of 5 cm H2O and FiO2 30%. He is no longer receiving vasopressor support and has improved multisystem organ dysfunction. He is now tentatively planned for extubation. Vital signs are normal for age. The patient has been receiving fentanyl, dexmedetomidine, and midazolam infusions while intubated. In preparation for extubation, the midazolam and fentanyl infusions are discontinued in the hour preceding extubation. Before extubation, he develops agitation. He is given a 2-μg/kg bolus of dexmedetomidine and continued on an intravenous infusion of the dexmedetomidine at 0.5 μg/kg/h. The patient then developed hypertension (blood pressure of 140/90 mm Hg) with a heart rate of 65 beats/min. The patient appears well sedated with no change in score when assessed using the State Behavioral Scale.
Of the following, the MOST likely cause of the patient’s hypertension is
A.allergic reaction to dexmedetomidine
B.bolus of dexmedetomidine
C.development of narcotic withdrawal
D.unintentional bolus of fentanyl
B.bolus of dexmedetomidine
An 18M boy is brought to the ED with acute onset of vomiting, diarrhea, and cough. The patient was apparently healthy when dropped off at daycare in the morning. The mother was called approximately an hour after lunch because he had started coughing a few hours earlier followed by vomiting and then diarrhea. The only thing he ate for lunch was a cupcake, which had been brought in for another child’s birthday. The mother noticed that during the car ride to the hospital he was itching all over, was licking his lips, and had hiccups. On arrival at the emergency department, he is afebrile. His heart rate is 162 beats/min, respiratory rate is 28 breaths/min, blood pressure is 78/28 mm Hg, and oxygen saturation is 92% in room air.
He has bilateral wheezing, moderate to severe tracheal tugging, moderate intercostal retractions, and subcostal retractions. He has facial swelling and appears to be diaphoretic with some drooling. He is quite irritable and clinging to his mother. An intravenous catheter is placed and supplemental oxygen is started via a high-flow nasal cannula. He received IM epinephrine, IV methylpred, famotidine and diphenhydramine. 20ml/kg NS bolus was also given. His BP improved and he was no longer in respiratory distress. 1 hour later, he started to become hypotensive again with BP 70/30mmHg, what is the medication indicated for this patient?
A.diphenhydramine
B.epinephrine
C.famotidine
D.methylprednisolone
B.epinephrine
A 15yr old girl was found unresponsive at home after ingesting an unknown substance.The patient is resuscitated and intubated in the field by EMS. On arrival to the ER, the patient’s temperature is 38.4°C, HR is 110, and BP is 130/78. Lung exam reveals crackles in the right lower chest without wheezes. A chest radiograph shows a dense infiltrate in the right lower lobe. The patient is placed on SIMV with tidal volume 450mL, RR 16, PEEP 5 cm H2O, and FiO2 0.40. On these settings, the patient’s RR is measured at 30. An arterial blood gas reveals: pH 7.45,PaCO2 34 mm Hg, PaO2 50 mm Hg, and SaO2 83%, her ETCO2 reading is 30. The FiO2 is increased to 1.0, and an ABG done 30 minutes later shows: pH 7.43, PaCO2 36 mm Hg, PaO2 55 mm Hg, and SaO2 89%, ETCO2 reading remains the same. The patient’s measured respiratory rate is unchanged.
The PRIMARY physiologic abnormality accounting for the hypoxemia is:
a) Excessive dead space ventilation
b) Low cardiac output
c) Intrapulmonary shunt
d) Hypoventilation
c) Intrapulmonary shunt
A 2yr girl with no significant PMH is admitted to PICU with 3 days of fever, decreased oral intake, lethargy, and increased WOB. The patient was given a presumed diagnosis of bronchiolitis in ED and placed on HFNC with minimal improvement. Her vital signs on arrival to the intensive care unit are as follows: HR 160, RR 42, SpO2 91% on FiO2 40%, BP 70/35, T 39. PE reveals: lethargy, bilateral crackles in lungs, no wheezing, tachycardic, no murmur, audible gallop, abd liver 3cm below right costal margin, cool extremities, cap refills 5 sec, weak pulses. ABG showed: pH, 7.10; PaCO2, 30; PaO2 55 mm Hg; and serum lactate level, 13 mmol/L.
Of the following, the next BEST step in management is likely
A.administration of 20 mL/kg of intravenous normal saline
B.initiation of β-blocker treatment
C.initiation of an epinephrine infusion
D.initiation of a norepinephrine infusion
C.initiation of an epinephrine infusion
A 12-year-old, 120-kg boy was admitted to the PICU 5 days ago after being thrown from the all-terrain vehicle that he was driving without a helmet. His injuries include multiple compression fractures of the lumbar and thoracic spine, ligamentous injury to the cervical spine, and diffuse axonal injury without extra-axial hemorrhage affecting the frontal, parietal, and occipital areas of the brain on magnetic resonance imaging (MRI). He is given fentanyl 100 μg/hour and dexmedetomidine 0.5 μg/kg/hour as infusions for 48 hours to facilitate mechanical ventilation. He undergoes successful extubation, but continues to undergo cervical spine immobilization with thoracic and lumbar bracing. Since extubation, he has been very agitated and intermittently confused. He is given clonidine for anxiolysis and risperidone for delirium. He has been responding to commands intermittently. His other medications include enoxaparin for deep vein thrombosis prophylaxis, levetiracetam for early posttraumatic seizure prophylaxis, and famotidine for gastrointestinal prophylaxis.
Overnight, he becomes increasingly agitated and removes his intravenous catheter as well as his cervical collar repeatedly. The PICU staff gives him 3 doses of haloperidol (2 mg intravenously) for these episodes. Six hours after the last dose of haloperidol he is poorly responsive with his head turned to the left and eyes deviated to the left. He will not follow commands and cannot participate in extraocular movement testing. Pupils are 4 mm and reactive. His nurse states that he is afebrile, mildly tachycardic, and hypertensive. He is maintaining his airway and has room air oxygen saturations of 99%. The nurse further notes that he is moving his left arm but keeping his right hand clenched in a fist, protruding his tongue, and intermittently moaning.
Of the following, the MOST appropriate next management step for this patient is to
A.administer diphenhydramine
B.administer lorazepam
C.initiate rapid cooling
D.perform repeat brain magnetic resonance imaging
A.administer diphenhydramine
A 10Y, 35-kg boy is struck by a vehicle traveling at 35 mph while riding his bike without a helmet. At the scene, he is unresponsive with agonal respirations. Vital signs: HR 130, RR 6, BP 154/82, SpO2 80%in RA. ABG: pH 7.11, Paco2 65 mm Hg, and Pao2 of 40 mm Hg. The patient is intubated before transfer to a level 1 trauma center (estimated transport time, 20 minutes) and En route, the paramedic places the patient on a transport ventilator with a fraction of inspired oxygen of 100% with the following settings: Vt, 200 mL; PEEP, 5 cm H2O; PS, 10 cm H2O; RR, 20 breaths/min. Five minutes after intubation, ABG pH 7.35, Paco2 of 40 mm Hg, and Pao2 of 150 mm Hg. Ten minutes before arrival to PICU, the ambulance oxygen source runs out and the patient receives ventilation with FiO2 21%. The ET CO2 remains stable at 38 mm Hg. SpO2 decreased from 95% to 75%.
Of the following, the cerebral blood flow in this patient is MOST likely
a.highest just before intubation
b.increased by 25% when oxygen saturation decreases to 75%
c.lowest 5 minutes after intubation
d.unaffected by oxygen saturation decreasing to 75%
a.highest just before intubation
Patient was on SIMV PC+PS, and started to improve gradually. The patient is changed to pressure support ventilation with inspiratory pressure of 12 cm H20 and PEEP of 5 cm H20.
Which ONE of the following is TRUE regarding the patient’s respiratory status on pressure support ventilation (PSV)?
a) Tidal volumes will be the same with each breath
b) Minute ventilation will be constant
c) Minute ventilation will vary according to her strength and effort
d) Inspiratory to expiratory (I:E) ratio is set by the physician
c) Minute ventilation will vary according to her strength and effort
A previously healthy 14-month-old male is admitted to the pediatric intensive care unit with lethargy, poor feeding, vomiting, and diarrhea. His symptoms began 48 hours ago, and he has produced 2 small wet diapers in the past 24 hours. On physical examination he has tachycardia with diminished capillary refill time, dry mucous membranes, and a weak cry. Laboratory data are shown: Na 159, K 4.6, Cl 121, HCO3 11, BUN 26 Cr 0.4, glucose 99
Of the following, the MOST likely finding in this patient would be
A.decreased urine specific gravity
B.fractional excretion of sodium less than 1%
C.fractional excretion of urea greater than 50%
D.increased glomerular filtration rate
B.fractional excretion of sodium less than 1%
A 12-year-old boy is admitted to the PICU late in the evening for evaluation of fever and weight loss over the past several weeks. no pertinent past medical history. His SpO2 is 100% in room air. He is hemodynamically stable.
Laboratory data are shown: WBC: 250, H/H: 10/40, Na 140, K 4.1, Cl: 95, HCO3 20, BUN 19, Cr 1.2, Uric acid 12.3, Heme/onc was called and recommended 1.5 MIVF and rasburicase for the elevated uric acid. Patient made NPO for bone marrow and LP in the morning. The intensivist was called to the bedside 6 hours after admission secondary to respiratory distress. The boy’s vital signs are shown: BP 130/85, HR 150, RR 30, SpO2 88%, His lung sounds are clear. A chest radiograph is without significant pathology. An arterial blood gas test via co-oximetry reveals the following: PH 7.3, PaCO2 30, PaO2 95, Oxygen saturation 95%, Lactate 8.
Of the following, the MOST important immediate treatment for this patient is
A.bicarbonate bolus
B.furosemide
C.methylene blue
D.supplemental oxygen
C.methylene blue