OH $#!T!
A child in the PICU suddenly becomes unresponsive and pulseless. What is the first thing you do?
Start high-quality CPR and activate the code/emergency response.
HAVE YOUR PALS CARD!
This commonly used PICU sedative is an α₂-adrenergic agonist that provides sedation with minimal respiratory depression. What is it, and what are two important adverse effects?
Dexmedetomidine (Precedex).
Bradycardia and hypotension.
What is the most reliable bedside method for confirming that an ETT is in the trachea immediately after intubation?
Continuous waveform capnography/ETCO₂
VBG: pH 7.20 / PCO₂ 25 / HCO₃ 10. What's the primary acid-base disorder?
Metabolic acidosis
A child with septic shock has already received significant fluid resuscitation and remains hypotensive with hepatomegaly and new crackles. The resident wants “one more 20 mL/kg bolus.” What should happen instead?
Stop blindly giving fluid, reassess hemodynamics/fluid responsiveness, and escalate vasoactive support as appropriate.
A child suddenly becomes unresponsive and pulseless. The monitor shows ventricular fibrillation. Is this a shockable rhythm, and what other pediatric cardiac arrest rhythm is also shockable?
Yes.
The 2 shockable rhythms are:
Ventricular fibrillation (VF)
Pulseless ventricular tachycardia (pVT)
A 3-year-old is brought to the ED with altered mental status, pinpoint pupils, and respiratory depression after a possible ingestion. What medication should you give, and what is its mechanism of action?
Naloxone (Narcan)
MOA: Competitive opioid receptor antagonist
A child has a chest tube for a pneumothorax. You notice continuous bubbling in the water-seal chamber. What should you suspect?
Air leak
A DKA patient's glucose falls from 500 to 120. The bicarbonate is 11 and the anion gap is 21. What should you do? (Dr. Acevedo is in the shower and is not answering her phone)
Add/increase dextrose and continue the insulin until ketoacidosis resolves.
A previously healthy 5-year-old presents with suspected bacterial meningitis. What empiric antibiotics should you start?
Vancomycin + ceftriaxone (or cefotaxime)
A child develops urticaria, wheezing, vomiting, and hypotension minutes after receiving an antibiotic. What medication and route do you give first?
IM epinephrine 0.01 mg/kg of 1 mg/mL
Which commonly used PICU sedative provides sedation and analgesia, generally preserves spontaneous respirations, and can cause increased secretions?
Ketamine
Chest tube: A chest tube is accidentally pulled completely out of the patient's chest. What's your immediate action?
Cover the site with a sterile occlusive dressing, assess ABCs/respiratory status, call for immediate help, and prepare for replacement if needed.
A child has a glucose of 450 mg/dL, bicarbonate 6 mEq/L, pH 7.1, and positive serum ketones. What diagnosis do these labs suggest?
Diabetic Ketoacidosis
A child has potassium 7.1 mEq/L with peaked T waves and QRS widening. What medication should be given immediately, and what does it actually do to the potassium?
IV calcium (calcium gluconate or calcium chloride).
**Calcium does NOT lower the serum potassium. It stabilizes the cardiac membrane and reduces the immediate risk of malignant arrhythmias.
An intubated child suddenly desaturates. What mnemonic gives you four immediate causes to consider?
DOPE — Displacement, Obstruction, Pneumothorax, Equipment failure.
A 6 month old is in SVT with a heart rate of 230 bpm and is hemodynamically stable. Name 2 ECG features that support SVT. What medication can terminate it?
Narrow-complex tachycardia and P waves often absent/hidden in the QRS or retrograde.
Adenosine
HFNC: Besides providing oxygen, what are two ways high-flow nasal cannula can improve respiratory status?
Reduces work of breathing/dead-space rebreathing and can provide some distending airway pressure.
A child has Na 140, Cl 105, and HCO₃ 10. What is the anion gap?
AG = Na − (Cl + HCO₃) = 25meq/L
A child has been seizing for 15 minutes. They have already received two appropriate doses of a benzodiazepine but continue to seize. What is the next step in treatment? Name two medications you could use.
Give a second-line antiseizure medication.
A child with TBI suddenly develops hypertension, bradycardia, and irregular respirations. Name the triad and what it indicates.
Cushing triad → severely increased ICP/impending herniation
A patient receiving prolonged/high-dose propofol develops metabolic acidosis, rhabdomyolysis, hyperkalemia, and cardiovascular collapse. What syndrome is this?
Propofol infusion syndrome (PRIS).
You're ventilating a child with status asthmaticus who has severe air trapping. Do you primarily want a higher or lower respiratory rate, and why?
Lower RR → longer expiratory time → less dynamic hyperinflation/auto-PEEP
A child receiving continuous albuterol has lactate 6 mmol/L but is warm, well perfused, normotensive, and improving respiratory status. What's a likely explanation?
β₂-agonist–associated type B hyperlactatemia/lactic acidosis
A child with increased intracranial pressure has a MAP of 70 mmHg and an ICP of 25 mmHg. What is the cerebral perfusion pressure, and what happens to cerebral perfusion if ICP continues to rise while MAP stays the same?
CPP = MAP − ICP
70 − 25 = 45 mmHg
As ICP rises → CPP falls → cerebral blood flow becomes threatened, potentially leading to cerebral ischemia.