1.
Motor vehicle accidents are the factor contributing most to childhood
trauma. All of the following statements are true except:
A.
Multi-system trauma accounts for 50% of deaths occurring in children >
1year of age
B.
Barorecptors in the carotoid sinus and aortic arch inhibit sympathetic
events to the heart and blood vessels via the vagus and glossopharyngeal nerves
C.
Tissue injury and local ischemia stimulate the nociceptive receptors,
which in turn can cause profound systemic effects
D.
Following hemorrhage in humans, the rise in osmolality is directly
related to the intravascular influx of sodium
E.
Sympathetic activity favors pre-capillary vasoconstriction
Click here for answer
2.
The “Flight or Fight” catecholamine response occurs in traumatic
events. Which of the following statements are true:
A.
Catecholamines produce hypoglycemia and hypokalemia
B.
a-stimulation
increases insulin and glucagon secretion
C.
b-stimulation
increases insulin and glucagon secretion
D.
The overall effect of catecholamines on the islet cells is to increase
glycogen and insulin secretion
E.
Cortisol increases the peripheral utilization of glucose
Click here for answer
3.
Select whether the following statements regarding endocrine physiology
are true or false:
____ Insulin is produced in the b-cell
of the pancreas
____ Glycogen is produced in the a-cell
of the pancreas
____ Diuresis is stimulated by a-adrenergic
receptors
____ Angiotension II is week vasoconstrictor
____ Aldosterone decreases Na+ reabsorption
____ Angiotension may cause ischemic renal tubular necrosis
____ b-endorphin
potentiates release of GH, ADH, and ACTH
Click here for answer
4.
All of the following statements regarding trauma are true except:
A.
Sodium citrate raises gastric pH, thereby reducing the consequences of
aspiration
B.
Denitrogenation or pre-oxygenation is one of the primary steps of rapid
sequence intubation
C.
Open operative cricothyroidotomy is an acceptable method for airway
maintenance when conventional intubation fails
D.
Reversal of non-deporlarizing muscle relaxants can be achieved with
anticholinesterases and antimuscarinics
E.
Children < 6 years of age do not fasciculate when given
succinylcholine
Click here for answer
5.
Match the following most commonly used fluid replacement with its most
descriptive choice:
A.
6% hydroxyethyl starch
B.
5% albumin
C.
Lactated Ringers
_____ 1.
Intravascular half-life = 24 hours
_____ 2.
Elimination half-time = 17 days
_____ 3.
Chloride similar to plasma chloride
Click here for answer
6.
Hemorrhage sustained as a result of severe trauma may require a large
volume of blood products. All of the following statements are true except:
A.
Blood must be administered to trauma patients who comprise ATLS Class III
and IV
B.
Type O, Rh-negative blood may be used when type specific blood is
unavailable
C.
Most coagulation factors in banked blood are unstable
D.
Specific consideration of FFP administration must at least begin when
200% of the calculated circulating blood volume has been replaced with
crystalloid and red cell concentrates
E.
Consideration of platelet administration begins when 100-150% of
calculated circulating blood volume has been replaced with crystalloid and red
cell concentrates
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7.
A 10-year-old boy is struck by a car while riding his bike. He is dragged
approximately 30 feet and suffers a significant blood loss and multiple
fractures. Which of the following statements is true regarding this situation:
A.
Weil’s “5-2” or “ 7-3” rule is based on changes in pulmonary capillary
wedge pressure and central venous pressure, respectively, from fluid boluses
B.
With compartment pressure of 20 cm H2O in muscle compartment
syndrome, immediate fasciotomy is indicated
C.
In flail chest, the nearer the defect to the diaphragm, the more serious
is the effect on ventilation
D.
Cardiac tamponade may present with “paradoxical pulse” and
hypertension
E.
Pulmonary hematoma takes 3-4 weeks to resolve
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8.
Select whether the following statements regarding childhood trauma are
true or false:
____ Rupture of
the diaphragm is more common on the right side
____ Aortic
rupture most frequently occurs near the attachment of the ligamentum arteriosum
____ Traumatic
asphyxia results from sudden intense compression of the chest wall with the
glottis closed
____ Urgent
thoracotomy may be necessary when blood loss > 100 ml/hr occurs via chest
tube drainage
____ Pulmonary
compliance increases with adult respiratory distress syndrome
____ The spleen
and liver are the most commonly injured solid organs in pediatric blunt trauma
____ An intravenous
pyelogram is contraindicated in a trauma victim experiencing gross hematuria
with physical evidence of renal injury
____ Peritoneal
lavage can irritate the peritoneum for 24-48 hours and obscure subsequent
abdominal evaluations
____ Abuse is the
most common cause of head injury in children < 1 year.
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9.
All of the following are criteria for skull films after head trauma except:
A.
Age < 1 year
B.
Loss of consciousness of 2 minutes
C.
Palpable scalp hematoma
D.
Cerebrospinal fluid drainage from the nose or ear
E.
Battle’s sign
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10.
Head and spinal cord injuries are the most severe result of childhood
trauma. All of the following statements are true except:
A.
“Late post-traumatic epilepsy” occurs at least one week after head
injury
B.
The overall incidence of post-traumatic seizures is approximately 7-10%
C.
Following traumatic impact of the spinal cord, small flame hemorrhages
are observed on the gray matter and pia arachnoid
D.
The release of lysosomal enzymes following spinal cord injury may
predispose patients to traumatic paralysis
E.
Increased perfusion following spinal cord trauma produces tissue necrosis
and ischemia
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11.
Select whether the following statements regarding spinal cord injury are
true or false:
____ Succinylcholine
induced hyperkalemia begins 3 days after injury and may persist for as long as 1
year following injury
____ Urolithiasis
may occur secondary to immobility after spinal cord injury
____ Urinary tract
infection is one of the major causes of mortality in patients with spinal cord
injury
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12.
All of the following statements regarding child abuse are true except:
A.
Incidence is approximately 6-10:1,000 population
B.
Children are usually > 2 years of age
C.
A large head and weak neck muscles contribute to “shaking” injuries
of the infant brain
D.
Child risk factors include chronically ill children
E.
Parental risk factors include poor self esteem
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13.
All the following regarding the pathophysiology of thermal injury are
true except:
A.
Edema is maximal at 24 hours and gradually resolves over 3-5 days
B.
The osmotic pressure in burned tissue is increased
C.
Low cardiac output is secondary to decreased circulating blood volume
D.
Hypertension occurs in up to 60% of pediatric patients
E.
The mechanism of hypertension appears not to be secondary to hypervolemia
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14.
Which of the following is/are true regarding pulmonary dysfunction in
patients with major burns:
A.
Extravascular lung water is unrelated to plasma colloid osmotic pressure,
to pulmonary artery pressure wedge gradient, despite weight gain and peripheral
edema
B.
Thermal injury does not cause an increase in pulmonary capillary
permeability
C.
Inhalation injury does not appear to cause significant interstitial edema
directly
D.
Sepsis induced pulmonary capillary membrane injury is the principle cause
of pulmonary edema after thermal injury
E.
All of the above
Click here for answer
15.
Select whether the following statements are true or false regarding
thermal injury:
____ Renal blood
flow is decreased immediately following thermal injury
____ Glomerular
filtration rate is increased with the onset of the post-burn hypermetabolic
state
____ Hepatic
dysfunction occurs in < 5% of patients
____ Thromboscytosis
occurs in the first several days followed by thrombocytopenia
____ Factors V and
VIII increase with fibrinogen levels
____ Septic bone
marrow suppression is likely with generalized bleeding and thrombocytopenia
____ RBC mass
increases
____ Hypoxia is
the most common cause of encephalopathy in the first 48 hours
____ Acalculous
cholecystitis is manifested by fever, abdominal distention and jaundice
____ An immunocompromised condition is associated with severe
burn injury
____ Refractory anemia is present until the wound is closed.
Click here for answer
16.
Match the following type of burn with its clinical characteristics:
A.
1st degree
B.
2nd degree
C.
3rd degree
D.
4th degree
____ 1.
Extends to the hypodermic fat
____ 2.
Deep injury to bone, joint or muscle
____ 3.
Restricted to epithelial cells
____ 4.
Usually occurs secondary to high voltage electrical injury
____ 5.
“Full thickness injury”
____ 6.
Surgical closure is indicated
____ 7.
Erythema and pain – mild blistering
____ 8.
Viable dermal papillae separated by intervals < 1 mm are seen within a
few days
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17.
A child suffers a severe burn, which includes his entire left arm, right
leg, and back. What percentage of body surface area has been affected based on
the “Rule of 9’s”:
A.
52%
B.
45%
C.
12%
D.
23%
E.
92%
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18.
Match the following term with its appropriate definition:
A.
Minor burn
B.
Moderate burn
C.
Severe burn
____ 1.
Involves 5-15% of body surface area
____ 2.
Presence of smoke inhalation
____ 3.
No significant involvement of hands, feet or perineum
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19.
All of the following statements are true regarding burns and inhalation
injury except:
A.
More house fire mortality occurs from smoke inhalation than tissue damage
from flames
B.
Sites of chemical burns should be flushed with copious amounts of
isopropyl alcohol
C.
Any patient whose immunization series is uncertain should receive
age-appropriate toxoid and IM tetanus immune globulin
D.
The home is the most common place of pediatric burn accidents
E.
Scalding is the most common type of burn in the pediatric population
Click here for answer
20.
Which of the following would require referral to a burn center by the
American Burn Association guidelines?
A.
Electrical burns
B.
3rd degree burns > 5% of body surface area in any age
patient
C.
Partial thickness and 3rd degree burns involving face, eyes,
ears, hands, feet, genitalia, perineum, and major joints
D.
Partial thickness and 3rd degree burns involving more than 10%
of body surface area in patients < 10 years of age
E.
All of the above
Click here for answer
21.
Select whether the following statements are true or false regarding
thermal injury:
____ Massive
catecholamine release results in normotension despite hypovolemia
____ Children with
burns < 5% of body surface area always require intravenous resuscitation
____ Muscle
relaxants or sedation is contraindicated prior to tracheal intubation in
children displaying upper airway obstruction
____ Succinylcholine
is contraindicated 7 days after injury
____ The wound
initially is colonized by airborne gram-positive bacteria followed by endogenous
gram positive flora
Click here for answer
22.
Match the following drug with its associated effect:
A.
Silver sulfadiazine
B.
Mafenide
C.
Aqueous Na nitrate
D.
Iodophors
E.
Topical bacitracin cream
____ Rapid eschar
penetration
____ Contraindicated
in pregnancy
____ Rapid
resistance
____ Painful
____ Carbonic
anhydrase inhibitor
Click here for answer
23.
Which of the following is/ are true regarding the Parkland formula?
A.
First 24 hours: 4 ml/kg/
body surface area burned percent + maintenance fluid of lactated Ringers to
maintain urine output > 0.5 ml/kg/hr
B.
First 24 hours: 4
ml/kg/ body surface area + ½ maintenance lactated Ringers to maintain urine
output > 0.5 ml/kg/ hr
C.
Second 24 hours: maintenance
fluid of glucose-containing hypotonic fluid; colloid to maintain urine output
and albumin to treat hypoalbuminemia
D.
A and C only
E.
B and C only
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24.
Select whether the following statements are true or false regarding
burns:
____ E. cloacae
and S. aureus are commonly resistant to silver sulfadiazine
____ Silver
nitrate may induce methemoglobinemia
____ Ten
organisms/gram of tissue constitutes burn wound sepsis
____ Surgical
excision and closure should be performed > 1 month after presentation
____ The principal
form of wound coverage is autografting
Click here for answer
25.
Which of the following statement(s) is/are true regarding nutrition in
pediatric burn victims?
A.
Dietary lipid content should be > 25% of total dietary Kcals
B.
Parenteral feeds appear to have a benefit over enteral feeds
C.
Very early (4 hours after injury) institution of enteral nutrition may
lead to early achievement of positive nitrogen balance
D.
Patients with burns > 10% BSA, are recommended to receive 20% total
Kcals provided from protein, non-protein Kcal/nitrogen ratio 100:1, or 2.5
g/kg/day of amino acids
E.
C and D
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26.
All of the following statements are true regarding smoke inhalation
injury except:
A.
Thermal injury from smoke inhalation is usually limited to the
supraglottic airway
B.
Carbon monoxide accounts for approximately ½ of all fatal poisonings in
the United States
C.
The largest source of carbon monoxide is generated from incomplete
combustion of carbon-containing compounds
D.
When examination of the mouth and pharynx reveals erythema or blistering,
tracheal intubation is recommended
E.
Inhalation injury accounts for a small (10-15%) mortality associated with
major burns
Click here for answer
27.
All of the following statements are true regarding carbon monoxide
poisoning except:
A.
The P50 is
0.10 mm Hg
B.
Leftward shift of the oxyhemoglobin dissociation curve occurs
C.
There is an effect on the cytochrome-oxidase system
D.
A carbon monoxide Hb value within normal limits rules out recent carbon
monoxide poisoning
E.
The PO2 is
frequently normal
Click here for answer
28.
Which if the following is/are true regarding organ responses to carbon
monoxide:
A.
Heart rate and coronary blood flow increase
B.
Pulmonary edema occurs in 10-30% of cases
C.
Cerebral blood flow increases
D.
Cherry-red skin color is commonly encountered
E.
A, B, and C
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29.
Select whether the following statements are true or false regarding
carbon monoxide poisoning:
____ Renal failure
may occur secondary to myoglobinuria
____ Hypoamylasemia
occurs commonly
____ Mild acidosis
should be corrected if present
____ The half-life
when breathing room air is 5-6 hours
____ The half-life
when breathing 100% is 1 ½ hours
____ The half-life
when breathing 100% at 2.5 atmosphere is one ½ hour
____ Level of
consciousness at admission and the development of neuropsychiatric sequelae are
directly related
____ Hyperbaric
oxygen treatment is recommended for CO Hb > 25%
Click here for answer
30.
Match the following carbon monoxide concentration with its symptom:
A.
0.007 (carbon monoxide Hb – 10%)
B.
0.022 (carbon monoxide Hb – 30%)
D.
0.195 (carbon monixide Hb –80%)
____ 1.
Rapidly fatal
____ 2.
Shortness of breath with vigorous exercise
____ 3.
Disturbed judgment
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31.
Which of the following statement(s) is/are true regarding smoke injury
victims:
A.
Cyanide poisoning from smoke commonly occurs in the absence of carbon
monoxide toxicity
B.
The treatment of smoke inhalation respiratory injury in supportive
C.
Arterial blood gases may be normal for the first 12-24 hours in pulmonary
inhalation injury
D.
Smoke injury increases ciliary functions
E.
B and C
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32.
All of the following statements are true regarding electrical injury except:
A.
Joule’s law, P=1²R (where P = power (heat), I= amperage, and R =
resistance)
B.
Explains why tissue damage is greatest in high-resistant tissues (e.g.,
bone and fat)
C.
Surface burns result from ignition of clothing
D.
Arc burns may reach 3,000 degrees C.
E.
At low voltage, direct current is more dangerous than alternating current
F.
Ohm’s law states V=I x R (where I=flow, V=voltage, and R= resistance)
Click here for answer
33.
Select whether the following statements are true or false regarding
electrical burns:
____ Water content
and a thinner stratum corneum raise skin resistance in children compared to
adults
____ Tissue injury
is directly proportional to current intensity
____ V-fib can be
caused by current passing through the chest at approximately 100 mA
____ Tetanic spasm
of respiratory muscles occur at 10mA
____ Nearly 2/3 of
people struck by lightening die
____ Transient
arrhythmias occur in approximately 30% of patients
Click here for answer
34.
Regarding the pathophysiology of head injury, all of the following are
true except:
A.
Blood pressure auto-regulation is maintained better than CO2
auto-regulation
B.
CO2
auto-regulation has prognostic value in that outcome is better in patients with
intact CO2
vaso-responsivity
C.
Low cerebral blood flow in the frontoparietal cortex suggest the
likelihood of poor neurologic outcome
D.
Cerebral O2 consumption (CMRO2) is directly related to the cerebral O2
content difference
E.
Brain stem evoked potentials persist even during profound barbiturate
coma
Click here for answer
35.
Regarding blood transfusion in trauma patients, all of the following
statements are true except:
A.
To eliminate serious hemolytic reactions, it is best obtain at least an
ABO-Rh type and partial cross-match when using uncross-matched blood
B.
ABO-Rh type specific and cross-matched blood is preferable to Type O, Rh
negative cross-matched blood
C.
Type O, Rh negative, cross-matched, packed red blood cells should be used
in preference to Type O, Rh negative, whole blood
D.
The immediate phase cross-match (partial cross-match) will fail to detect
a major portion of clinically significant antibodies
E.
With packed red blood cells, one gains double the hemoglobin per unit of
blood as is found in a whole unit of blood
Click here for answer
36.
Which of the following regarding clinical management of hemostatic
defects in patients with trauma is inaccurate:
A.
A rapid drop in platelet count to 50,000/mm3 is more relevant than a slow drop to 10,000/mm3 in a patient
with leukemia
B.
Dilutional coagulopathy is easily and rapidly correctable if perfusion is
satisfactory
C.
Fresh frozen plasma administration is appropriate when a volume of fluid
equivalent to twice the blood volume of the patient has been administered
D.
Platelet administration should be considered when 150% of the circulatory
blood volume has been replaced with crystalloid solutions
E.
Fresh frozen plasma yields only 10% of the equivalent clotting factors of
a single unit of fresh whole blood
Click here for answer
37.
A constant finding in compartment syndrome is:
A.
Paresthesia
B.
Weakness
C.
Pain with passive motion
D.
Loss of distal pulses
E.
Loss of sensation and proprioceptive functions distally
Click here for answer
38.
In a patient with multiple trauma, which one of the following statements
would be least accurate:
A.
An oral gastric tube should be passed in all patients with abdominal
trauma
B.
If a pelvic fracture is suspected, a rectal examination should be done
C.
If a genitourinary injury is suspected, urinary catheterization should be
avoided
D.
With refractory hypotension and a presence of a normal peripheral
perfusion, spinal cord injury is highly suspect
E.
Pain on passive motion is a constant finding with compartment syndrome
Click here for answer
39.
Chest trauma in children is usually seen in a setting of multiple trauma
involving other organs. Characteristics
of chest trauma unique to children do not include which one of the following:
A.
Serious intrathoracic injury may be present in the absence of obvious
external chest wall injury
B.
There is a low incidence of great vessel and airway injury due to the
mobility of the mediastinum
C.
The excessive mediastinal shift contributes to the rapid development of
cardiovascular and ventilatory compromise
D.
Almost all deaths from thoracic trauma in children occur at the scene
E.
Penetrating trauma in children is very unusual
Click here for answer
40.
In children with multiple trauma, when cardiac arrest develops in the
setting of chest trauma, it usually results from:
A.
Hypovolemia
B.
Aortic rupture
C.
Aortic dissection
D.
Cardiac tamponade
E.
None of the above
Click here for answer
41.
In regard to flail chest in children, which of the following statements
is least accurate:
A.
Frequently associated lung contusion
B.
Thoracic radiograph frequently shows rib fractures
C.
It is rarely seen in children
D.
Initial therapy should include humidified oxygen and limitation of
crystalloid solutions
E.
Definitive therapy involves positive pressure ventilation, with positive
end expiratory pressure
Click here for answer
42.
The least common occult and potentially serious injury to the chest of a
child with multiple trauma is:
A.
Pulmonary contusion
B.
Pulmonary laceration
C.
Pulmonary hematoma
D.
Tracheobronchial tear
E.
Esophageal rupture
Click here for answer
43.
A 2-year old white male who was a victim of a motor vehicle accident with
multiple trauma, is noted to have diffuse opacification of the entire right
lower lobe of the lung, associated with blunting of the right costophrenic
angle. After endotracheal
intubation, blood is retrieved during suctioning of the endotracheal tube.
Which of the following statements would be considered inaccurate
regarding the diagnosis in this child:
A.
Persistent air leak at the chest tube insertion for pneumothorax is
consistent with parenchymal lung injury
B.
Radiographic changes of
opacification tend to disappear into 6th day
C.
Over-hydration, particularly with crystalloids may ameliorate some of the
respiratory symptoms in this child
D.
Empyema and lung abscess are recognized complications
E.
Acute respiratory distress syndrome is a recognized complication
Click here for answer
44.
Approximately 150,000 individuals die world-wide as a result of
submersion injuries, per year. All
of the following statements regarding submersion injuries in the US are true except:
A.
Overall incidence of drowning is approximately 6/100,000 population
B.
Twenty-five percent of deaths due to drowning are secondary to exhaustion
while swimming
C.
More than half of drowning cases are not resuscitated
D.
The majority of all drowning victims are males less than 20 years of age
E.
Eighty percent (80%) of drowning accidents occur in the spring
Click here for answer
45.
Which of the following statements regarding drowning and near-drowning is
true:
A.
The majority of accidental drownings occur in the North and Eastern
United States
B.
Sunday is the most common day of the week for drowning accidents
C.
Bathtubs are the most common site for submersion accidents in children
D.
Childhood drowning rates are highest in Caucasians
E.
Bathtub drownings occur most frequently in infants who are being
supervised by a sibling generally less than four years of age
Click here for answer
46.
Select whether the following statements pertinent to drowning and
near-drowning are true or false:
____ Drowning
refers to death from submersion within 24 hours of the occurrence
____ Most human
drowning victims aspirate greater than 25 ml/kg of fluid
____ Freshwater
causes wash-out and dilution of surfactant, while saltwater inactivates
surfactant
____ Pulmonary
function tests demonstrate hyper-reactive airways in children who have recovered
from near-drowning, but who did not require mechanical ventilatory support
Click here for answer
47.
The pathophysiology of submersion injury can include which of the
processes below:
A.
Asphyxia
B.
Fluid overload
C.
Pulmonary injury
D.
Hypothermia and the living reflex
E.
All of the above
Click here for answer
48.
Hypothermia can present as a complicating factor in a submersion injury.
Which of the following statements is true regarding hypothermia:
A.
Therapeutic hypothermia has been shown to improve outcome after
near-drowning
B.
Moderate hypothermia (32-35°)
causes cessation of shivering, with a decrease in heart rate, blood pressure and
oxygen consumption
C.
Resuscitation of a drowning victim should continue until the core
temperature is 28°
C. before the patient is declared dead
D.
Coagulopathies occur frequently with hypothermia
E.
Pupillary dilatation occurs at core temp>33°
C
Click here for answer
49.
Select whether the following statements are true or false regarding
drowning and near-drowning:
____ Positive
pressure ventilatory support is indicated when PaO2 is less than 100
mm Hg despite FiO2 of
.40
____ Chest
radiograph findings correlate well with clinical outcome
____ Cardiopulmonary
resuscitation in the emergency room, pH < 7.0, coma, and ventilatory support
when combined predict a high mortality in children with submersion injuries
____ Glasgow coma
scale < 6 predicts a high probability of mortality in submersion victims
____ PEEP is the
cornerstone of therapy
____ Steroids are
useful for treating cerebral edema following ischemic
or anoxic insults
____ Intracranial
pressure monitoring after submersion injury is highly recommended
____ Victims
swallow large amounts of water prior to loss of consciousness and before
aspiration occurs
Click here for answer
50.
Which of the following is/are true regarding brain death:
A.
In the premature infant, the electroencephalogram is not a reliable
diagnostic tool for brain death
B.
Contrast medium when used in cerebral angiography an cause reactive
hypotension
C.
Radionuclide flow studies have been noted to show cerebral blood-flow
despite clinical brain death and electrocerebral silence on the
electroencephalogram
D.
Analysis of evoked response potentials are not suppressed by sedative
anesthetic drugs
E.
All of the above
Click here for answer
51.
All of the following statements regarding the Report of the Task
Force for Determination of Brain Death in Children are true except:
A.
Brain death cannot be diagnosed in
infants less than 7 days of age
B.
Two examinations and an electroencephalogram separated by 48° are
necessary in brain death cases of children from 7 days to 2 months of age
C.
Two examinations and an electroencephalogram separated by 24° are
necessary in brain death cases of children 2 months to one year of age: but
repeat examination/electroencephalogram is not necessary if radionuclide brain
flow study demonstrates absent perfusion
D.
Two examinations 12° apart in a child less than one year of age with
irreversible brain damage requires corroborative testing
Click here for answer
52.
Stereotyped movements of the extremities and extensor posturing in
patients with brain death are called the:
A.
Lazarus sign
B.
Spinal sign
C.
Brainstern reflex
D.
Reflex sign
E.
Mertz sign
Click here for answer
53.
Brain death is a necessity in order for organ donation to occur.
Select whether the following statements are true or false regarding brain
death:
____ Hemodynamically,
there should not be a cardiac acceleration response to atropine in dead patients
____ A
hypertensive response to a surgical incision in brain dead organ donors in the
absence of vasopressor agents or volume administration has been described
____ Cerebral
blood flow may be depressed as much as 40 percent during barbiturate coma
____ It frequently
requires 1-2 days for family members to gather and absorb the reality of death
in another family member
Click here for answer
Answers
1.
D
Generally, following hemorrhage in humans, a rise in osmolality is
directly related to the glucose concentration in the plasma, not the result of
an influx of sodium. All of the other statements are true. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; pp
1467-1470)
2.
C
Catecholamines produce hyperglycemia, hyperlipidemia, increased oxygen
consumption, hyperkalemia, and a
stimulation, reduces insulin and glucagon secretion. The overall effect of catecholamines on the islet cells it to
not only increase glucagon, but also decrease insulin secretion.
Cortisol decreases the peripheral utilization of glucose but the increase
in plasma cortisol is designed to produce an increase in osmolality in response
to hemorrhage. (Rogers MC, et al. Textbook
of Pediatric Intensive Care, 3rd Edition; p 1470)
3.
T, T, T, F, F, T, T
Angiotensin II is a powerful vasoconstrictor.
Aldosterone works on the ascending loop of Henle and in the collecting
ducts of the kidney to increase sodium and water absorption. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; pp
1470-1472)
4.
C
An attempted open operative cricothyroidotomy may cause irreversible
damage to the larynx. All of the
other statements are true. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; pp
1474-1476)
5.
B, A, C
Hydroxyethyl starch, albumin, and lactated ringers are commonly used
fluid replacement solutions. Their
physical properties differ and may affect selection. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; pp
1481-1482, Table 43.5)
6.
C
Almost all plasma coagulation factors are stable in banked blood, with
the exception of Factor V and VIII. With massive transfusion, defined as greater
than 2 blood volumes in a child, hemostatic defects may occur as a result of
dilution or a decrease in the platelet and circulating protein coagulation
factors. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; pp
1482-1483)
7.
C
In Weil’s 5-2 or 7-3 rule, the 5-2 applies to the central venous
pressure (CVP) and the 7-3 rule applies to the pulmonary capillary wedge
pressure (PCWP). Volume boluses are
administered and the pressure response is measured.
When the central venous pressure is less than 8 or the PCWP is less than
12, 10-20 ml/kg of isotonic solution is infused over 10-15 minutes.
If the CVP increases by more than 5 or the PCWP increases by more than 7,
the infusion is stopped. Immediate
fasciotomy is indicated when a pressure greater than 60 cm H2O is
present. Cardiac tamponade presents
with paradoxical pulse and hypotension. A
pulmonary hematoma takes only a few days to resolve. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; pp
1485-1490)
8.
F, T, T, T, F, T, F, T, T
The rupture is more likely on the left because of the presence of the
liver on the right acting as a cushion to the diaphragm.
Pulmonary compliance decreases with adult respiratory distress syndrome. An intravenous pyelogram is indicated for gross hematuria
with clinical evidence of renal injury and unstable clinical course of blood
loss and a possible renal artery injury. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; pp
1491-1495)
9.
B
Loss of consciousness of 3 minutes or more is an indication for a skull
film. (Rogers MC, et al. Textbook
of Pediatric Intensive Care, 3rd Edition; p1495, Table 43.7)
10.
E
There is a decrease in the perfusion, which results in the initial
ischemic insult to the spinal cord following trauma. All of the other statements
are true (Rogers MC, et al. Textbook
of Pediatric Intensive Care, 3rd Edition; p 1496)
11.
T, T, T
(Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition;
p 65, Table 2.10 and p 1498)
12.
B
Child victims of abuse are usually < 2 years of age. (Rogers MC, et
al. Textbook of Pediatric Intensive
Care, 3rd Edition; p 1498, Table 43.8)
13.
E
Hypertension is a commonly described phenomenon associated with thermal
injury. The increase in plasma
renin activity and aldosterone increases intravascular volume and raises blood
pressure. (Rogers MC, et al. Textbook
of Pediatric Intensive Care, 3rd Edition; p 1522)
14.
E
Pulmonary dysfunction after thermal injury may be secondary to
inhalational injury, aspiration, shock, sepsis, congestive heart failure or
trauma. The presence of
inhalational injury increases mortality by 20% while pneumonia increases the
risk of mortality by 40% in burn patients.
In the resuscitation phase of burn injury, lung injury results from
hypoxia and subsequent reoxygenation, carbon monoxide and cyanide toxicity,
airway edema, chest wall and pulmonary compliance problems.
Hypoproteinemia may contribute to edema formation in the
post-resuscitative phase. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; p 1522)
15.
T, T, F, F, T, T, F, T, T, T, T
Renal blood flow decreases immediately after injury.
Later, GFR increases coinciding with the onset of the postburn
hypermetabolic state. Hepatic
dysfunction is commonly encountered in thermal injury, and can generally be
found in more than 50% of patients. Thrombocytopenia
appears first, then is followed by thrombocytosis several days later.
Significant increases in fibrinogen, Factors V and VIII occur.
Red blood cell mass decreases. Hypoxia occurring in the first 48 hours
was the most common cause of encephalopathy and was related to smoke and carbon
monoxide inhalation sustained in enclosed fires. Acalculous cholecystitis is of
two types in the burn patient. The
first involves bacterial seeding in septic patients and the second arises in
patients with dehydration, ileus, or pancreatitis in whom the gallbladder is
distended with sterile fluid. Burn
injured patients are immunocompromised. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; pp
1522-1525)
16.
C, D, A, D, C, C, A, B
First-degree burns are superficial burns isolated to the epithelial cells
and characterized by erythema and mild blistering.
Second-degree burns involve a tissue depth into the dermis.
A superficial partial thickness burn is moist, red and tender.
It becomes pale, but dermal papillae can be visualized through the eschar
within a few days. Third degree burns extend through all layers of the skin and
invade the hypodermic fat. Fourth
degree burns involve deep injury to bone, joint or muscle. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; pp
1525-1526)
17.
B
With the Rule of 9’s the front and back are each assigned 18% of body
surface area; each arm is assigned 9%; each leg is assigned 18%.
Therefore, a burn that involves 9% (arm), plus 18% (leg), plus 18%
(back), equals 45% total body surface area burn. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; p 1526)
18.
B, C, A
A minor burn involves less than 5% of the body surface area and no
significant involvement of the hands, feet, face, or perineum.
A moderate sized burn involves between 5 and 15% of the body surface
area. Alternatively, any full thickness component also qualifies.
Involvement of the hands, face, feet, perineum, or the presence of a
complicating factor such as chemical or electrical injury also constitutes a
moderate burn. A severe burn is characterized by a > 15% total body
surface area burn or the presence of smoke inhalation or carbon monoxide
poisoning. (Rogers MC, et al. Textbook
of Pediatric Intensive Care, 3rd Edition; p 1526, Figure 45.2)
19.
B
House fires account for 84% of burn associated fatalities, the cause of
which is most frequently smoke inhalation rather than tissue damage from flames.
Chemical burns should be flushed with water for 20-30 minutes, not alcohol.
Tetanus prophylaxis must be addressed in all burn patients.
Scald burns are the most common type of pediatric burn and the home is
the most common location. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; p
1526-1527, Table 45.1)
20.
E
The criteria for transfer to a burn center include significant underlying
disease, associated inhalation injury, 10% body surface area (BSA) or more of
partial or 3rd degree burns in children < 10 years of age or >
20% in children > 10 years of age, 3rd degree burns > 5% in any
age group, electrical and chemical burns, and burns associated with major
trauma. (Rogers MC, et al. Textbook
of Pediatric Intensive Care, 3rd Edition; pp 1527-1428)
21.
T, F, T, T, T
Systemic blood pressure is usually maintained after thermal injury
despite hypovolemia, thereby making blood pressure an insensitive measure of
volume status. Generally, children with less than 5% of their BSA burned do not
require intravenous fluid therapy. Children with a burn exceeding 15% BSA will
require intravenous resuscitation. If
the burn size exceeds 30% BSA, placement of a central venous catheter is
recommended. Muscle relaxants and
sedation are contraindicated in the child who has signs of upper airway
obstruction up until the airway is secured. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; p 1528)
22.
B, A, E, B, B
Mafenide is an excellent antibacterial.
It inhibits carbonic anhydrase and may lead to acidosis.
It can be painful, but penetrates the eschar rapidly. It is applied twice daily.
Silver Sulfadiazene is a broad antibacterial agent that is painless.
It penetrates fairly well through the eschar.
It is contraindicated in pregnancy and has unknown absorptive properties
in the fetus. Bacitracin is limited
in its antibacterial action, has poor eschar penetration, but is easy to apply
and cosmetically acceptable. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; p 1530,
Table 45.2)
23.
D
The Parkland formula recommends lactated Ringer’s solution in the first
24 hours post-burn in the amount of 4 ml/kg/%BSA burn.
One half of this volume is given in the first 8 hours post-burn and the
remainder given over the remaining 16 hours.
The resuscitation should be adjusted to maintain a urine output of
0.5-1.0 ml/kg/hr. On the second
post-burn day, maintenance fluid of a glucose-containing hypotonic fluid may
begin. (Rogers MC, et al. Textbook
of Pediatric Intensive Care, 3rd Edition; p 1529)
24.
T, T, F, F, T
Resistance to silver sulfadiazene is common for E. cloacae, S. aureus,
and occasionally P. aeruginosa. All
three of these organisms are usually sensitive to Mafenide.
Silver nitrate can induce methemoglobinemia.
Ideally surgical excision and closure of the wound should take place as
soon as the child is stable enough for anesthesia.
More than 105 organisms per gram of tissue constitute burn wound sepsis.
Early surgical closure decreases significant blood loss. (Rogers MC, et
al. Textbook of Pediatric Intensive Care, 3rd Edition;
p 1530-1531, Table 45.2)
25.
E
An adverse effect on the immune function may occur if lipid content is
more than 15% of total diet Kcals particularly if it is high in the omega-6
fatty acids. Enteral feeds prevent hypermetabolism and catabolism in contrast to
parenteral feeds.Positive nitrogen balance may be achieved earlier with the
institution of enteral nutrition within the first 4 hours. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; pp
1531-1532)
26.
E
Thermal injury from smoke inhalation is usually limited to the supra-glottic
airway. Inhalation injury accounts for > 50% of the mortality associated with
major burns. Carbon monoxide poisoning accounts for approximately 50% of the
poisonings in the US per year. The
largest source of carbon monoxide is generated from the incomplete combustion of
carbon-containing compounds. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; p
1534-1536)
27.
D
The oxyhemoglobin dissociation curve is shifted to the left in carbon
monoxide poisoning, thereby enhancing oxygen affinity for hemoglobin and
impeding oxygen delivery from blood to tissue.
The toxic effects of carbon monoxide result from its direct action on the
cytochrome-oxidase system and not solely on the reduced oxygen carrying capacity
of the blood. If a significant
amount of time has passed since the exposure of carbon monoxide poisoning, an
abnormal level may not be discovered. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; pp
1534-1536, Figure 45.4)
28.
D
The heart rate and coronary blood flow increase in response to carbon
monoxide. Pulmonary edema occurs in
about 10-30% of cases, however, the mechanism for pulmonary edema remains
speculative. Cerebral blood flow
and edema also increase. The cherry-red skin color is not commonly seen clinically.
(Rogers MC, et al. Textbook of
Pediatric Intensive Care, 3rd Edition; pp 1534-1536, Table 45.4)
29.
T, F, F, T, T, T, T, T
Muscle necrosis leads to myoglobinuria and subsequent acute renal
failure. Salivary amylase is responsible for development of
hyperamylasemia. A mild acidosis
actually shifts the oxyhemoglobin dissociation curve to the right, increasing
release of oxygen to the tissues and so should not be treated. The half-life of
carbon monoxide is 5-6 hours in room air, 1.5 hours in 100% FiO2, and
less than 30 minutes in 100% FiO2 in 2.5 atmospheres.
Hyperbaric oxygen treatment should be instituted when a patient has a
COHb of > 25%, signs and symptoms of carbon monoxide poisoning, and a
hyperbaric oxygen facility available. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; pp
1534-1538, Table 45.5, 45.6, and 45.7)
30.
C, A, B
Carbon monoxide concentrations affect the presenting symptoms.
A COHb concentration of > 0.195 is rapidly fatal, a COHb of 0.022 is
associated with disturbed judgement, and a concentration of 0.007 is associated
with shortness of breath with vigorous exercise. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; p 1537,
Table 45.5)
31.
E
Cyanide poisoning from smoke commonly occurs and acts synergistically
with carbon monoxide toxicity. Smoke
injury decreases ciliary function. Patients
with pulmonary injury may be asymptomatic with a normal chest radiograph on
presentation. Arterial blood gases
may also be normal for the first 12-24 hours. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; p 1539)
32.
D
At low voltages, alternating current is more dangerous than direct
current because of its ability to freeze the extremity to the electrical source.
Joule’s law states that power equals amperage squared times resistance (P=I2R). Surface burns result from the ignition of clothing or from
the heat of the current traveling close to the skin. Arc burns are produced by a current that travels external to
the body as an electric arc forms between two object of opposite charge. (Rogers
MC, et al. Textbook of Pediatric
Intensive Care, 3rd Edition; p 1540)
33.
F, T, T, F, F, F, T
Water content and a thinner stratum corneum decreases skin resistance in
children. The conducting system of
the heart is particularly vulnerable and ventricular fibrillation can occur with
a current of 100 mA passing through the chest.
Transient arrythmias are present in 30% of patients. Tetanic spasms of
respiratory muscles occur at 30mA. Neurologic
findings are common. Loss of
consciousness, spinal cord lesions, deafness, seizures, and changes in mood
commonly occur after electrical injury. Nearly
2/3 of people struck by lightning live. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; p 1541)
34.
A
35.
D
When using uncrossmatched blood, it is best to obtain at least an ABO and
Rh type and partial crossmatch. This
is sometimes referred to as an incomplete or partial crossmatch.
The immediate phase crossmatch eliminates serious hemolytic reactions due
to errors in the ABO typing. It
will fail to detect only a few unexpected antibodies outside of the ABO system,
most of which are clinically insignificant.
If time does not permit even a preliminary screen, ABO and Rh
type-specific, uncrossmatched blood is still preferable (and more abundant).
Of patients never exposed to blood, fewer than one in 1000 will have an
unexpected antibody detected in the immediate phase crossmatch. (Rogers MC, et
al. Textbook of Pediatric Intensive
Care, 3rd Edition; pp 1482-1483)
36.
E
FFP provides the equivalent clotting factors of a single unit of fresh
whole blood. The administration of
FFP should be considered when 200% of the calculated circulating blood volume
has been replaced with crystalloids and red cell concentrates. A precipitous
fall in platelet count may not be tolerated as well as a slow decline in
thrombocytopenic patients. Platelet administration begins when 100 to 150% of the
calculated circulating blood volume has been replaced with crystalloid and red
cell concentrates. The dilutional
coagulopathy is rapidly corrected once perfusion is restored, but may be
exacerbated by the development or persistence of hypotension. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; p 1483)
37.
C
Bleeding and edema within an intact fascial compartment can lead to the
development of increased pressure, muscle ischemia and death.
While pulses may be intact distally with a compartment syndrome, one
constant finding is severe pain even with passive motion.
Muscle compartment pressures can be evaluated during the secondary survey
of the trauma patient using an 18-gauge needle and water manometer.
Compartment pressures of 40 cm H2O should cause concern while
pressures greater than 60 cm H2O require fasciotomy. (Rogers MC, et
al. Textbook of Pediatric Intensive
Care, 3rd Edition; p 1486)
38.
C
In addition to measuring urine output, the bladder catheter facilitates
the diagnosis of urinary tract injury and rhabdomyolysis.
An oral gastric tube should be placed in all patients with abdominal
trauma. This procedure removes air
from the stomach and improves ventilation, empties liquid and particulate matter
and decreases the likelihood of aspiration, and provides diagnostic information
concerning the presence of blood in the upper gastrointestinal tract.
If a pelvic fracture is suspected or seen on a radiograph, a rectal
examination should be performed to evaluate the possibility of bone fragment
injury to pelvic structures. Pain on passive range of motion is a constant
finding in compartment syndrome. See response to question 37. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; pp
1485-1487)
39.
D
Almost all deaths from thoracic injury in children occur after the victim
reaches the resuscitation center and most children can be treated successfully
with prompt diagnosis and aggressive early management.
Penetrating injuries to the chest are unusual in children and usually
result from fractured ribs rather than from external missiles. The mediastinum
of the child is more mobile and this contributes to a low incidence of major
vessel and airway injury. However,
serious intrathoracic injury may be present in the absence of obvious chest wall
injury. (Rogers MC, et al. Textbook
of Pediatric Intensive Care, 3rd Edition; pp 1487-1488)
40.
A
Cardiac arrest from blunt chest trauma is nearly always associated with
multiple system injuries and results from hypovolemia either from external or
internal blood loss. (Rogers MC, et al. Textbook
of Pediatric Intensive Care, 3rd Edition; pp 1487-1488)
41.
D
Flail chest injuries are rarely seen in children because high-velocity
direct chest trauma is uncommon. Additionally,
rib fractures are less common in children than adults because children have very
pliable ribs that are resistant to fracture.
Contusions and/or penetrating injury of the lung parenchyma are
frequently involved. The initial
therapy should include humidified oxygen and a limitation of crystalloid
resuscitation, if the remainder of the injuries permit, so that there will be a
decrease in extravasation of fluid into the injured pulmonary parenchyma and a
limitation of the secondary acute pulmonary edema.
Definitive treatment of the flail chest takes place in the PICU by
controlled ventilation and positive end expiratory pressure. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; pp
1488-1489)
42.
E
The least common occult and potentially serious injury to the chest of a
child with multiple trauma is esophageal rupture.
From most to least common, the injuries are pulmonary contusion,
pulmonary laceration, pulmonary hematoma, tracheobronchial tear, myocardial
contusion, diaphragmatic rupture, partial aortic or great vessel disruption and
esophageal perforation. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; p 1489)
43.
C
In the setting of pulmonary contusion, overhydration should be avoided
because fluid will sequester in the damaged lung tissue and complicate the
clinical condition. Radiographic evidence of a pulmonary contusion includes early
consolidation of the lung parenchyma, which may be focal in nature, with
resolution over 2-6 days. Empyema or abscess formation may occur after pulmonary
contusion secondary to the extravasation of fluid and blood into the alveolar
and interstitial spaces. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition;
pp 1489-1490)
44.
E
Drowning is the third most common cause of death by unintentional injury
among persons of all ages in the US, and the second leading cause of injury
deaths in children less than 15 years old.
Males account for 78% of all deaths from drowning.
Approximately 50% of the drowning deaths occur occur in the summer.
(Rogers MC, et al. Textbook of
Pediatric Intensive Care, 3rd Edition; pp 875-877)
45.
E
The majority of drowning accidents occur in the southern and western US;
Saturday is the most common day of the week for drowning accidents; private
pools are the most common sites for submersion accidents involving children;
drowning rates are highest among the African-American population. (Rogers MC, et
al. Textbook of Pediatric Intensive Care, 3rd Edition;
pp 875-877)
46.
T, F, T, T
Drowning is death from asphyxia caused by submersion in water.
Death usually occurs at the time of submersion or within 24 hours.
Most human drowning victims aspirate less than 3-4ml/kg of fluid.
Fresh water causes surfactant to denature and become nonfunctional;
Seawater either dilutes surfactant concentrations or washes the surfactant out
of the alveolus entirely. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; pp 875-881)
47.
E
The pathophysiology of submersion injury can include the processes of
asphyxia, fluid overload, pulmonary injury, and hypothermia with the diving
reflex. (Rogers MC, et al. Textbook
of Pediatric Intensive Care, 3rd Edition; pp 878-883)
48.
D
Therapeutic hypothermia has not been shown to improve outcome; a body
temperature of less than 32°
C causes the cessation of shivering; resuscitation of drowning victims should
continue until the core temperature is at least 32°
C ; pupillary dilatation occurs at a core temperature of less than 30°
C. (Rogers MC, et al. Textbook of
Pediatric Intensive Care, 3rd Edition; pp 882-889)
49.
T, F, T, T, T, F, F, T
Chest radiographs do not correlate with clinical outcome.
Steroids have not been shown to be useful in improving outcome for
ischemic or anoxic insults. Intracranial
pressure monitoring has not been shown to improve outcome in submersion injury.
Peep is often useful in treating the pulmonary dysfunction that is associated
with a near-drowning episode, which is unresponsive to supplemental oxygen.
The drowning victim will often swallow a large amount of water, which may
induce emesis and subsequent aspiration. Consciousness
is then lost. (Rogers MC, et al. Textbook
of Pediatric Intensive Care, 3rd Edition; pp 878-889)
50.
E
The EEG may not be reliable in very young and particularly premature
infants, since there are reports of return of neuronal function and EEG activity
after the demonstration of electrocerebral silence. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; pp 896-899)
51.
D
No corroborative testing is required in the case described. (Rogers MC,
et al. Textbook of Pediatric
Intensive Care, 3rd Edition; pp 895-900)
52.
A
Stereotyped movement of the extremities and extensor posturing can be
seen in patient who are clearly brain dead; these have been termed the Lazarus
sign. Spinal and deep tendon reflexes are found on physical examination in at
least 50% of brain dead patients. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; p 902)
53.
T, T, T, T
All of these statements are true. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; pp 895-902)