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Questions & Answers (Grade A+)
A 3-year-old boy who has a history of prematurity and subglottic stenosis is admitted to the PICU after placement of a tracheostomy tube in the operating room. He has had multiple previous intubations for upper respiratory tract obstruction. During this hospital admission, he again required tracheal intubation for upper airway obstruction, and a tracheostomy was performed on the fourth day after intubation. Three days after the procedure, he develops increased tracheal secretions and a fever. A chest radiograph reveals a focal consolidation of his left lower lobe. Of the following, the action that would have been MOST likely to reduce the occurrence of ventilator-associated pneumonia in this patient, based on recommendations from the Centers for Disease Control and Prevention, is A. elevation of the head of the bed to 30 to 45 degrees B. use of intermittent versus continuous feedings C. use of - correct answer ✅A
Questions & Answers (Grade A+)
The child described in the vignette has ventilator- associated pneumonia (VAP), defined by the Centers for Disease Control and Prevention (CDC) as pneumonia in a patient who has a device to assist or control ventilation through a tracheostomy or endotracheal tube for at least 48 hours before the onset of infection. VAP is associated with increased length of stay in the ICU, increased hospital length of stay, and increased ventilator-days. Whether VAP also is associated with increased mortality rates is debatable. The CDC has developed guidelines for prevention of VAP. As of August 2009, they recommend:
- Educate and involve staff in infection prevention
- Conduct surveillance for bacterial pneumonia in high-risk patients to determine trends and identify outbreaks
- Avoid routine changing of breathing circuits unless visibly soiled
- Drain and discard condensate in tubing away from patient
- Use sterile water for humidification
- Use sterile water for nebulization
Questions & Answers (Grade A+)
April 2010 - Question 2 A 6-month-old male infant is brought to the emergency department following the acute onset of an irregular heart beat and poor feeding. He is afebrile, and his parents report that he was well until today. On physical examination, the alert and fussy child has a heart rate of 225 beats/min, a respiratory rate of 60 breaths/minute, and a blood pressure of 87/60 mmHg. Other than tachycardia, results of his cardiovascular examination are normal, and other findings on his physical examination are unremarkable. Chest radiography reveals a normal- size cardiac silhouette. Electrocardiography documents a narrow-complex tachycardia with inverted P waves, a regular R-R interval, no variation with respiration, and a ventricular rate of 225 (Figure). Three consecutive escalating doses of adenosine fail to resolve the tachycardia. Echocardiography reveals a structurally normal heart with only mildly reduce - correct answer ✅B
Questions & Answers (Grade A+)
The infant described in the vignette most likely has atrial ectopic tachycardia (AET), a type of supraventricular tachycardia caused by an automatic focus within the myocardium. The automatic focus in cases of AET often is in an abnormal location in the atria, away from the sinus node. Sometimes it is associated with the atrial appendage. AET frequently can be resistant to medical therapy, and patients often present with secondary cardiomyopathy induced by prolonged tachycardia. Therefore, early rate control should be one of the priorities of treatment. Of the drugs listed, an infusion of esmolol offers the best chance of early and rapid control of the patient's tachycardia with the fewest adverse effects. Esmolol is an ultrashort half-life beta blocker that is delivered by continuous intravenous infusion, sometimes after an intravenous loading dose. Beta blockade can occur in as few as 2 to 10 minutes, and the drug's
Questions & Answers (Grade A+)
April 2010 - Question 3 A 12-year-old, 40-kg girl who has idiopathic scoliosis, but is otherwise well, is admitted to the PICU following anteroposterior spinal fusion. She is sedated, intubated, and mechanically ventilated. The resident chose initial ventilator settings of a rate of 24, tidal volume of 8 mL/kg, peak inspiratory pressure of 34 cm H2O, positive end-expiratory pressure of 5 cm H2O, and Fio2 of 0.4. A respiratory therapist brings the following results of arterial blood gas analysis (ABG) to you: pH of 7.22, Paco2 of 49 mm Hg, Pao2 of 132 mm Hg, and base excess of -6 mEq/L. However, there is no name on the laboratory sheet, and you are not sure that this ABG applies to this patient. Your physical examination confirms adequate chest rise and appropriate function of the ventilator. You order the ABG to be repeated. Of the following, the patient in the PICU who is MOST likely to have these results is A. a 1 - correct answer ✅B Acid production in the body occurs mostly as carbon dioxide (CO2) production during
Questions & Answers (Grade A+)
oxidative metabolism of carbohydrates, fats, and amino acids. CO2 subsequently is hydrated by carbonic anhydrase to form carbonic acid that, in turn, dissociates into hydrogen ion and bicarbonate: H+ + HCO
- <-> H2CO3 <-> CO2 + H2O. Acid production also occurs by generation of nonvolatile metabolic acids that are the byproducts of a variety of metabolic processes, such as incomplete catabolism of fat and carbohydrates or oxidation of sulfur-containing amino acids. An increase in H+ (or decrease in pH) shifts the previously noted equation to the right, and increased minute ventilation, which occurs within minutes, promotes elimination of the CO2 and return of pH toward normal. The respiratory response to altered pH or PaCO2 occurs nearly instantaneously as a result of central nervous system and peripheral chemoreceptors. The renal contribution to acid-base balance is complex. The kidneys must reabsorb filtered
Questions & Answers (Grade A+)
April 2010 - Question 4 A 17-year-old boy is brought to the emergency department from a party by friends following the acute onset of altered mental status and agitation. The friends admit that they were drinking alcohol at the party and that some partygoers were smoking illicit drugs. Physical examination reveals diaphoresis, a Glasgow Coma Scale Score of 10 (E2, V3, M5), heart rate of 180 beats/min, blood pressure of 150/92 mm Hg, respiratory rate of 20 breaths/min, and temperature of 40.0°C. Abnormal laboratory values include a slightly elevated creatine kinase of 260 U/L and a serum bicarbonate of 16 mEq/L (16 mmol/L). Urine toxicology is negative for amphetamines, narcotics, and benzodiazepines. Of the following, the MOST likely explanation for this boy's findings is A. blockade of alpha-1 receptors B. blockade of beta-1 receptors C. blockade of catecholamine reuptake D. increased monoamine oxidase enzyme activi - correct answer ✅C
Questions & Answers (Grade A+)
The boy described in the vignette exhibits the classic signs and symptoms of sympathomimetic toxicity via hyperactivity of the adrenergic sympathetic system: tachycardia, hypertension, fever, and sweating. He also has altered mental status and elevated creatine kinase and low serum bicarbonate values. These findings suggest that he has ingested cocaine. Sympathomimetic toxicity may result from direct release of norepinephrine (NE) stores from storage vesicles with drugs such as amphetamines and tyramine or from inhibition of the reuptake of NE that already has been released, as seen in cocaine intoxication Cocaine stimulates alpha- 1-, beta-1-, and beta-2-adrenergic receptors through increased concentrations of NE and, to a lesser extent, epinephrine. Cocaine produces preferential alpha-receptor activity on the cardiac and peripheral vasculature and additional cardiac effects through betaadrenergic
Questions & Answers (Grade A+)
April 2010 - Question 5 A 12-year-old girl presents with nausea, vomiting, oliguria, and facial rash that has a malar distribution. Laboratory analysis reveals anemia, thrombocytopenia, and renal failure. Complement values are low, and an antinuclear antibody panel is pending to confirm the diagnosis of suspected lupus erythematosus (SLE). After placing a femoral dialysis catheter to assist in acute management, the patient's nurse asks you what causes SLE. Of the following, a TRUE statement about the pathogenesis of SLE is that A. a family history of autoimmune disease is not associated with the risk of developing SLE B. complement deficiency is strongly associated with disease severity C. high cytokine concentrations bear little relation to disease activity D. interferon activates dendritic cells to differentiate into T cells E. plasma cell precursors are transiently elevated - correct answer ✅B
Questions & Answers (Grade A+)
Homozygous deficiency of any of the early components of the complement pathway (C1q, C1r, C1s, C4, and C2) predisposes to the development of SLE. Such deficiencies represent the strongest SLE susceptibility factors identified in humans. Further, a hierarchy of association appears to exist between disease severity, prevalence, and the missing protein. The strongest prevalence (>80%) and the most severe disease is noted in patients who are deficient in one of the C1 complex or C4 molecules. Deficiency of the C complement is associated with less severe disease. Siblings of patients who have SLE display a 10- to 20- fold increased risk of developing the disease. Monozygous twins have a 24% concordance rate; heterozygous twins have a concordance rate of 2%. A familial history of autoimmune disease is a significant risk factor for SLE. The risk of developing SLE increases with the number of first-degree relatives who have autoimmune diseases from an odds ratio of 4.1 (one relative) to 11.3 (two or more relatives).
Questions & Answers (Grade A+)
You are evaluating a 1-month-old girl who was intubated and placed on mechanical ventilation for 2 weeks because of respiratory syncytial virus bronchiolitis. She has improved, and you wean her off mechanical ventilation and extubate her. Within 30 minutes of extubation, she develops significant stridor, retractions, bilateral decreased air entry, tachypnea, and tachycardia. Of the following, the therapeutic option MOST likely to have prevented this problem is A. helium-oxygen mixture B. inhaled budesonide C. intravenous dexamethasone D. nebulized epinephrine E. subcutaneous epinephrine - correct answer ✅C Dexamethasone is a glucocorticosteroid that has predominant anti-inflammatory and minimal mineralocorticoid activity. Its anti- inflammatory actions are related to the inhibition of leukocyte migration and lymphocytic immune responses. Glucocorticoids have been
Questions & Answers (Grade A+)
shown to inhibit the production of factors involved in inflammation, including vasoactive and chemoattractant factors, as well as the secretion of lipolytic and proteolytic enzymes and to decrease migration of leukocytes to areas of injury. In addition, glucocorticoids have significant inhibitory effects on factors affecting production of cytokines such as interferon-gamma, granulocyte/monocyte colony- stimulating factor, interleukins, and tumor necrosis factor-alpha. Two randomized, controlled trials in children have shown that the administration of dexamethasone prior to extubation significantly reduced postextubation stridor and the need for epinephrine. In addition, one of the studies showed that children who received dexamethasone prior to extubation had a significantly lower incidence of reintubation. The benefits of dexamethasone appear greater in infants than in older children and adults. Epinephrine provides alpha- and beta-agonist effects and acts on vascular smooth
Questions & Answers (Grade A+)
has made his mechanical ventilation a challenge. Surgeons have reattached his small bowel, but they want to avoid enteral nutrition for at least 1 more week. For this reason, intravenous nutrition was started 2 days ago that includes: Dextrose, 17.5% Amino acids, 1 g/kg per day Intravenous fat emulsion, 1 g/kg per day Sodium, 6 mEq/100 mL Potassium, 4 mEq/100 mL Acetate, 1 mEq/100 mL Trace element solution Multivitamins His fluid rate is 60 mL/hr, and he appears clinically euvolemic. Laboratory studies document:Sodium, 133 mEq/L (133 mmol/L) Potassium, 4.4 mEq/L (4.4 mmol/L) Chloride, 92 mEq/L (92 mmol/L) Bicarbonate, 28 mEq/L (mmol/L) Blood urea nitrogen, 17 mg/dL (6.1 mmol/L)
Questions & Answers (Grade A+)
Cre - correct answer ✅B The boy described in the vignette has hyperglycemia, hypertriglyceridemia, hypercarbia, and respiratory acidosis. Nutrition can have an impact on these conditions and the child's hospital course. Evidence suggests that significant hyperglycemia worsens both morbidity and mortality in critically ill patients. During the metabolic stress response that usually is seen with major trauma or sepsis, exogenous glucose does not shut down gluconeogenesis, so patients often cannot tolerate usual glucose infusion rates. Further, as a metabolic substrate, glucose has a respiratory quotient of 1.0, meaning that one mole of carbon dioxide is generated for every mole of oxygen consumed. Adequate nutrition using a substrate that generates less carbon dioxide is optimal when the patient has difficulty with ventilation. Excessive carbohydrate administration also leads to the
