# Pediatric Critical Care Review Hasan Pappas

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 Click here for answer 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 Click here for answer 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. Click here for answer 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 Click here for answer 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 Click here for answer 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 Click here for answer 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 Click here for answer 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 Click here for answer 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 Click here for answer 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% Click here for answer 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 Click here for answer 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 Click here for answer 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 Click here for answer 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 Click here for answer 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 Click here for answer 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 Click here for answer 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)