PALS Precourse Self Assessment Answers

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Sinus bradycardia
Sinus bradycardia
 
Sinus bradycardia - version 2
Sinus bradycardia – version 2
 
Normal sinus rhythm
Normal sinus rhythm
 
Asystole
Asystole
 
Wide complex tachycardia
Wide complex tachycardia
 
SVT converting to sinus rhythm after adenosine administration
SVT converting to sinus rhythm after adenosine administration
 
Wide complex tachycardia - version 2
Wide complex tachycardia – version 2
 
Torsades de pointes
Torsades de pointes
 
Supraventricular tachycardia
Supraventricular tachycardia
 
VF with successful defib and resumption of organized rhythm
VF with successful defib and resumption of organized rhythm
 
Pulseless electrical activity
Pulseless electrical activity
 
Ventricular fibrillation
Ventricular fibrillation
 
Sinus tachycardia
Sinus tachycardia
 
 
A previously healthy infant with a history of vomiting and diarrhea is brought to the emergency department by her parents. During your assessment, you find that the infant responds only to painful stimulation. The infant’s respiratory rate is 40 breaths per minute, and central pulses are rapid and weak. The infant has good bilateral breath sounds, cool extremities, and a capillary refill time of more than 5 seconds. The infant’s blood pressure is 85/65 mmHg, and glucose is 30 mg/dL (1.65 mmol/L). You administer 100% oxygen via face mask and start an IV. Which treatment is most appropriate for this infant?
Administer a bolus of isotonic crystalloid 20 ml/kg over 5-20 minutes, and also give D25W 2-4 ml/kg IV
 
A 9yo boy is agitated and leaning forward on the bed in obvious respiratory distress. The patient is speaking in short phrases and tells you that he has asthma but does not carry an inhaler. He has nasal flaring, severe suprasternal and intercostal retractions, and decreased air movement with prolonged expiratory time and wheezing. You administer 100% oxygen by a nonrebreathing mask. His spO2 is 92%. Which med do you prepare to give to this patient?
Albuterol (duh)
 
Paramedics are called to the home of a 1yo child. Their initial assessment reveals a child who responds only to painful stimuli and has irregular breathing, faint central pulses, bruises over the abdomen, abdominal distention, and cyanosis. Bag-mask ventilation with 100% oxygen is initiated. The child’s heart rate is 36/min. Peripheral pulses cannot be palpated, and central pulses are barely palpable. The cardiac monitor shows sinus bradycardia. Two-rescuer CPR is started. Upon arrival to the emergency department, the child is intubated and ventilated with 100% oxygen, and IV access is established. The heart rate is now 150/min with weak central pulses but no distal pulses. Systolic blood pressure is 74 mmHg. Which intervention should be provided next?
Rapid bolus of 20ml/kg of isotonic crystalloid
 
You are called to help treat an infant with severe symptomatic bradycardia (heart rate 66/min) associated with respiratory distress. The bradycardia persists despite establishment of an effective airway, oxygenation, and ventilation. There is no heart block present. Which is the first drug you should administer?
Epinephrine
 
Which statement is correct about the use of calcium chloride in pediatric patients?
Routine administration is not indicated during cardiac arrest
 
Which statement is correct about endotracheal drug administration during resuscitative efforts for pediatric patients?
It is the least desirable route of administration
 
Initial impression of a 2yo girl shows her to be alert with mild breathing difficulty during inspiration and pale skin color. On primary assessment, she makes high-pitched inspiratory sounds (mild stridor) when agitated; otherwise, her breathing is quiet. Her spO2 is 92% on room air, and she has mild inspiratory intercostal retractions. Lung auscultation reveals transmitted upper airway sounds with adequate distal breath sounds bilaterally. Which is the most appropriate initial intervention for this child?
Humidified oxygen as tolerated
 
You are part of a team attempting to resuscitate a child with ventricular fibrillation cardiac arrest. You delivered 2 unsynchronized shocks. A team member established IO access, so you give a dose of epinephrine, 0.01 mg/kg IO. At the next rhythm check, persistent ventricular fibrillation is present. You administer a 4 J/kg shock and resume CPR. Which drug and dose should be administered next?
Amiodarone 5 mg/kg IO
 
Which oxygen delivery system most reliably delivers a high (90% or greater) concentration of inspired oxygen to a 7yo child?
Nonrebreathing face mask
 
Which statement is correct about the effects of epinephrine during attempted resuscitation?
Epinephrine stimulates spontaneous contractions when asystole is present
 
A 10mo infant boy is brought to the emergency department. Your initial assessment reveals a lethargic, pale infant with slow respirations and slow, weak central pulses. One team member begins ventilation with a bag-mask device with 100% oxygen. A second team member attaches the monitor/defibrillator and obtains vital signs while a third team member attempts to establish IV/IO access. The patient’s heart rate is 38/min with the rhythm shown here. The infant’s blood pressure is 58/38 mmHg, and capillary refill is 4 seconds. His central pulses remain weak, and distal pulses cannot be palpated. Chest compressions are started and IO access is obtained. Which medication do you anticipate will be given next?
Epinephrine 0.01 mg/kg IV/IO
 
A 7yo boy is found unresponsive, apneic, and pulseless. CPR is ongoing. The child is intubated, and vascular access is established. The ECG monitor shows an organized rhythm with a heart rate of 45/min, but a pulse check reveals no palpable pulses. High quality CPR is resumed, and an initial IV dose of epinephrine is administered. Which intervention should you perform next?
Identify and treat reversible causes
 
You find a 10yo boy to be unresponsive. You shout for help, and after finding that he is not breathing and has no pulse, you and a colleague begin CPR. Another colleague activates the emergency response system, brings the emergency equipment, and places the child on a cardiac monitor/defibrillator, which reveals the rhythm shown here. You attempt defibrillation at 2 J/kg and give 2 minutes of CPR. The rhythm persists at the second rhythm check, at which point you attempt defibrillation with 4 J/kg. A fourth colleague arrives, starts an IV, and administers 1 dose of epinephrine 0.01 mg/kg. If ventricular fibrillation or pulseless ventricular tachycardia persists after 2 minutes of CPR, you will administer another shock. Which drug and dose should be administered next?
Lidocaine 1 mg/kg IV
 
A 3yo boy presents with multiple-system trauma. The child was an unrestrained passenger in a high-speed MVC. On primary assessment, he is unresponsive to voice or painful stimulation. His respiratory rate is 5/min, heart rate and pulses are 170/min, systolic BP is 60 mmHg, capillary refill is 5 seconds, and spO2 is 75% on room air. Which action should you take first?
While a colleague provides spinal motion restriction, open the airway with a jaw thrust and provide bag-mask ventilation
 
You are alone and witness a child suddenly collapse. There is no suspected head or neck injury. A colleague responded to your shout for help and is activating the emergency response system and is retrieving the resuscitation equipment, including a defibrillator. After delivering 30 compressions, what would be your next action?
Open the airway with a head tilt-chin lift maneuver and give 2 breaths
 
You and another rescuer begin CPR. Your colleague begins compressions, and you notice that the compression rate is too slow. What should you say to offer constructive feedback?
“You need to compress at a rate of 100-120 per minute.”
 
You are caring for a 6yo patient who is receiving positive-pressure mechanical ventilation via an endotracheal tube. The child begins to move his head and suddenly becomes cyanotic, and his heart rate decreases. His spO2 is 65%. You remove the child from the mechanical ventilator and begin to provide manual ventilation with a bag via the endotracheal tube. During manual ventilation with 100% oxygen, the child’s color and heart rate improve slightly and his BP remains adequate. Breath sounds and chest expansion are present and adequate on the right side and are present but consistently diminished on the left side. The trachea is not deviated, and the neck veins are not distended. a suction catheter passes easily beyond the tip of the endotracheal tube. Which of hte following is the most likely cause of this child’s acute deterioration?
Tracheal tube displacement into the right main bronchus
 
You are giving chest compressions for a child in cardiac arrest? What is the proper depth of compressions for a child?
Compress the chest at least one third the depth of the chest, about 2 inches (5 cm)
 
You are supervising a student who is inserting an IO needle into an infant’s tibia. The student asks you what she should look for to know that she successfully inserted the needle into the bone marrow cavity. What do you tell her?
“Fluids can be administered freely without local soft tissue swelling.”
 
A pale and very sleepy but arousable 3yo child with a hx of diarrhea is brought to the hospital. Primary assessment reveals a respiratory rate of 45/min with good breath sounds bilaterally. Heart rate is 150/min, BP is 90/64 mmHg, and spO2 is 92% on room air. Capillary refill is 5 seconds, and peripheral pulses are weak. After placing the child on a nonrebreathing face mask (10L/min flow) with 100% oxygen and obtaining vascular access, which is the most appropriate immediate treatment for this child?
Administer a bolus of 20 ml/kg isotonic crystalloid
 
Why is allowing complete chest recoil important when performing high-quality CPR?
The heart will refill with blood between compressions
 
An 8yo child was struck by a car. He arrives in the ED alert, anxious, and in respiratory distress. His cervical spine is immobilized, and he is receiving a 10L/min flow of 100% oxygen by nonrebreathing face mask. His respiratory rate is 60/min, HR 150/min, systolic BP 70 mmHg, and spO2 84%. Breath sounds are absent over the right chest but present over the left chest, and the trachea is deviated to the left. He has weak central pulses and absent distal pulses. Which intervention should be performed next?
Perform needle decompression of the right chest
 
You assisted with the elective endotracheal intubation of a child with respiratory failure and a perfusing rhythm. Which provides a reliable, prompt assessment of correct endotracheal tube placement in this child?
Adequate bilateral breath sounds and chest expansion plus detection of ETCO2 with waveform capnography
 
Which ratio of compressions to breaths should be used for 1-rescuer child CPR
30 compressions to 2 breaths
 
You are caring for a 3yo with vomiting and diarrhea. You have established IV access. The child’s pulses are palpable but faint, and the child is now lethargic. The heart rate is variable (range, 44/min to 62/min). You begin bag-mask ventilation with 100% oxygen. When the heart rate does not improve, you begin chest compressions. The rhythm shown here is seen on the cardiac monitor. Which would be the most appropriate therapy to consider next?
Atropine 0.02 mg/kg IV
 
What compression-to-ventilation ratio should be used for 2-rescuer infant CPR?
15 compressions to 2 breaths
 
You are assisting in the elective intubation of an average-sized 4yo child with respiratory failure. A colleague is retrieving the color-coded length-based tape from the resuscitation cart. Which of the following is likely to be the estimated size of the uncuffed endotracheal tube for this child?
5mm tube
 
A 4yo boy is in pulseless arrest in the PICU. High-quality CPR is in progress. You quickly review his chart and find that his baseline-corrected QT interval on a 12-lead ECG is prolonged. The monitor shows recurrent episodes of the rhythm shown here. The patient has received 1 dose of epinephrine 0.01 mg/kg, but the rhythm shown here continues. If this rhythm persists at the next rhythm check, which medication would be most appropriate to administer at that time?
Magnesium sulfate 25-50 mg/kg IV
 
You are preparing to use a manual defibrillator in the pediatric setting. Which best describes when it is appropriate to use the smaller, pediatric-sized paddles?
If the child weighs less than 10kg or is less than 1 year old
 
An 18mo child has a 1 week hx of cough and runny nose. The child has diffuse cyanosis and is responsive only to painful stimulation with slow respirations and rapid central pulses. The child’s respiratory rate has decreased from 65/min to 10/min, severe inspiratory intercostal retractions are present, heart rate is 160/min, spO2 is 65% on room air, and capillary refill is less than 2 seconds. Which are the most immediate interventions for this toddler?
Open the airway and provide positive-pressure ventilation using 100% oxygen and a bag-mask device
 
A child becomes unresponsive in the emergency department and is not breathing. You are uncertain if a faint pulse is present. You shout for help and provide ventilation with 100% oxygen. The rhythm shown here is seen on the cardiac monitor. What is your next action?
Start high-quality CPR
 
You need to provide rescue breaths to a child victim with a pulse. What is the appropriate rate for delivering breaths?
1 breath every 3-5 seconds
 
How can rescuers ensure that they are providing effective breaths when using a bag-mask device?
By observing the chest rise with each breath
 
You are evaluating an irritable 6yo girl with mottled skin color. The patient is febrile (temperature 40C [104F]), and her extremities are cold with capillary refill of 5 seconds. Distal pulses are absent and central pulses are weak. Heart rate is 180/min, respiratory rate is 45/min, and blood pressure is 98/56 mmHg. How would you categorize this child’s condition?
Compensated shock associated with tachycardia and inadequate tissue perfusion
 
An 8mo infant is brought to the emergency department for evaluation of severe diarrhea and dehydration. On arrival to the emergency department, the infant becomes unresponsive, apneic, and pulseless. You shout for help and start CPR. Another provider arrives, at which point you switch to 2-rescuer CPR. The rhythm shown here is seen on the cardiac monitor. The infant is intubated and ventilated with with 100% oxygen. An IO line is established, and a dose of epinephrine is given. While continuing high-quality CPR, what do you do next?
Give normal saline 20 ml/kg IO rapidly
 
A 1yo boy is brought to the emergency department for evaluation of poor feeding, irritability, and sweating. The child is lethargic but arousable. He has labored breathing, very rapid pulses, and a dusky color. His respiratory rate is 68/min, heart rate 300/min, and blood pressure 70/45 mmHg. He has weak brachial pulses and absent radial pulses, a capillary refill of 6 seconds, spO2 85% on room air, and good bilateral breath sounds. You administer high-flow oxygen and place the child on a cardiac monitor and see the rhythm shown here. The child has no history of congenital heart disease. IV access has been established. Which therapy is most appropriate for this child?
Administer adenosine 0.1 mg/kg IV rapid push
 
During bag-mask ventilation, how should you hold the mask to make an effective seal between the child’s face and the mask?
Position your fingers using the E-C clamp technique
 
A 3yo unresponsive, apneic child is brought to the emergency department. EMS personnel report that the child became unresponsive as they arrived at the hospital. The child is receiving CPR with bag-mask ventilation. The rhythm shown here is on the cardiac monitor. A biphasic manual defibrillator is present. You quickly use the length from head to of the child on a color-coded length-based resuscitation tape to estimate the approximate weight as 15kg. Which therapy is most appropriate for this child at this time?
Attempt defibrillation at 30 J, and then resume CPR, beginning with compressions
 
You find an infant who is unresponsive, is not breathing, and does not have a pulse. You shout for nearby help, but no one arrives. What action should you take next?
Provide CPR for about 2 minutes before leaving to activate the emergency response system
 
Parents of a 1-year-old female phoned EMS when they picked up their daughter from the babysitter. Paramedics perform an initial impression revealing an obtunded infant with irregular breathing, bruises over the abdomen, abdominal distension, and cyanosis. Assisted bag-mask ventilation with 100% oxygen is initiated. On primary assessment heart rate is 36/min, peripheral pulses cannot be palpated, and central pulses are barely palpable. Cardiac monitor shows sinus bradycardia. Chest compressions are started at 15:2. In the ED the infant is intubated and ventilated, and IV access is established. The heart rate is now up to 150/min, but there are weak central pulses and no distal pulses. Systolic BP is 74. Of the following, which would be most useful in management of this infant? A. Synchronized cardioversion B. Epinephrine 0.01 mg/kg (0.1 mL/kg of 1:10,000 dilution) IV C. Rapid bolus of 20 mL/kg of isotonic crystalloid D. Atropine 0.02 mg/kg IV
C
 
You enter a room to perform an initial impression of a previously stable 10-year-old male and find him unresponsive and apneic. A code is called and bag-mask ventilation is performed with 100% oxygen. The cardiac monitor shows a wide-complex tachycardia. The boy has no detectable pulses so compressions and ventilations are provided. As soon as the defibrillator arrives you deliver an unsynchronized shock with 2 J/kg. The rhythm check after 2 minutes of CPR reveals VF. You then deliver a shock of 4 J/kg and resume immediate CPR beginning with compressions. A team member has established IO access, so you give a dose of epi, 0.01 mg/kg (0.1 mL/kg of 1:10,000 dilution) IO after second shock. At the next rhythm check, persistent VF is present. You administer another 4 J/kg shock and resume CPR. Based on the PALS Pulseless Arrest Algorithm, what is the next drug and dose to administer when CPR is restarted? A. Magnesium sulfate 25-50 mg/kg IO B. Atropine 0.02 mg/kg IO C. Epinephrine 0.1 mg/kg of 1:10,000 dilution IO D. Amiodarone 5 mg/kg IO
D
 
Which of the following statements about calcium is true? A. Calcium chloride 10% has the same bioavailability of elemental calcium as calcium gluconate in critically ill children B. The recommended dose is 1-2 mg/kg of calcium chloride. C. Indications for administration of calcium include hypercalcemia, hypokalemia, and hypomagnesemia. D. Routine administration of calcium is not indicated during cardiac arrest.
D
 
Initial impression of a 9-year-old male with increased work of breathing reveals the boy to be agitated and leaning forward on the bed with obvious respiratory distress. You administer 100% oxygen by nonrebreathing mask. The patient is speaking in short phrases and tells you that he has asthma but does not carry an inhaler. He has nasal flaring, severe suprasternal and intercostal retractions, and decreased air movement with prolonged expiratory time and wheezing. His SpO2 is 96% (on nonrebreathing mask). What is the next medical therapy to provide to this patient? A. Adenosine 0.1 mg/kg B. Amiodarone 5 mg/kg IV/IO C. Albuterol by nebulization D. Procainamide 15 mg/kg IV/IO
C
 
You are called to help resuscitate an infant with severe symptomatic bradycardia associated with respiratory distress. The bradycardia persists despite establishment of an effective airway, oxygenation, and ventilation. There is no heart block present. Which of the following is the first drug you should administer? A. Dopamine B. Adenosine C. Atropine D. Epinephrine
D
 
An infant with a history of vomiting and diarrhea arrives by ambulance. During your primary assessment the infant responds only to painful stimulation. The upper airway is patent, the repiratory rate is 40/min with good bilateral breath sounds, and 100% oxygen is being administered. The infant has cool extremities, weak pulses, and a cap refill of more than 5 seconds. The infant’s BP is 85/65 mm Hg and glucose concentration is 30 mg/dL (1.65 mmol/L). Which of the following is the most appropriate treatment to provide for this infant? A. Establish IV or IO access, administer 20 mL/kg isotonic crystalloid over 10 to 20 minutes, and simultaneously administer D25W 2 to 4 mL/kg in a separate infusion. B. Establish IV or IO access and administer 20 mL/kg D50 .45% sodium chloride bolus over 15 minutes. C. Establish IV or IO access and administer 20 mL/kg Lactated Ringer’s solution over 60 minutes. D. Perform endotracheal intubation and administer epinephrine 0.1 mg/kg 1:1,000 via the endotracheal tube.
A
 
Which of the following statements about endotracheal drug administration is true? A. Endotracheal doses of resuscitation drugs in children have been well established and are supported by evidence from clinical trials. B. Endotracheal drug administration is the least desirable route of administration because of this route results in unpredictable drug levels and effects. C. Endotracheal drug administration is the preferred route of drug administration dring resuscitation because is results in predictable drug levels and drug effects. D. Intravenous drug doses for resuscitation drugs should be used whther you give the drugs by the IV, IO, or the endotracheal route.
B
 
Which of the following statements most accurately reflects the PALS recommendations for the use of magnesium sulfate in the treatment of cardiac arrest? A. Routine use of magnesium sulfate is indicated for shock-refractory monomorphic VT. B. Magnesium sulfate is indicated for torsades de pointes and VF/ pulseless VT associated with suspected hypomagnesemia. C. Magnesium sulfate is indicated for VF refractory to repeated shocks and amiodarone or lidocaine. D. Magnesium sulfate is contraindicated in VT associated with an abnormal QT interval during the preceding sinus rhythm.
B
 
Initial impression of a 2-year-old female reveals her to be alert with mild breathing difficulty during inspiration and pale skin color. On primary assessment, she makes high-pitched inspiratory sounds (mild stridor) when agitated; otherwise, her breathing is quiet. Her SpO2 is 92% in room air, and she has mild inspiratory intercostal retractions. Lung auscultation reveals transmitted upper airway sounds with adequate distal breath sounds bilaterally. Which of the following is the most appropriate initial therapeutic intervention for this child? A. Administer an IV dose of dexamethasone B. Perform immediate endotracheal intubation C. Administer humidified supplementary oxygen as tolerated and continue evaluation D. Nebulize 2.5 mg of albuterol
C
 
Which of the following statements about the effects of epinephrine during attempted resuscitation is true? A. Epinephrine decreases the peripheral vascular resistance and reduces myocardial afterload so that ventricular contractions are more effective B. Epinephrine is contraindicated in ventricular fibrillation because it increases myocardial irritability. C. Epinephrine improves coronary artery perfusion pressure and stimulates spontaneous contractions when asystole is present. D. Epinephrine decreases myocardial oxygen consumption.
C
 
Which of the following most reliably delivers a high (90% or greater) concentration of inspired oxygen in a toddler or older child? A. Face tent with 15 L/min oxygen flow B. Simple oxygen mask with 15 L/min oxygen flow C. Nasal cannula with 4 L/min oxygen flow D. Nonrebreathing face mask with 12 L/min oxygen flow
D
A 3-year-old unresponsive, apneic child is brought to the emergency department. The cardiac monitor shows V Fib. EMS personnel report that the child became unresponsive as they arrived at the hospital. The child is receiving CPR, including bag-mask ventilation with 100% O2 and chest compressions at a rate of at least 100/min. Compressions and ventilations are being coordinated at a ratio of 15:2. You conform that apnea is present and that ventilation is producing bilateral breath sounds and chest expansion while a colleague confirms absent pulses. Cardiac monitor shows the above rhythm. A biphasic manual defibrillator is present. You quickly use the crown-heel length of the child on a length based, color-coded resuscitation tape to estimate the approximate weight as 15kg. Which of the following therapies is most appropriate for this child at this time?  A. Establish IV/IO access and administer lidocaine 1 mg/kg IV/IO  B. Establish IV/IO access and administer epinephrine 0.01 mg/kg (0.1 mL/kg of 1:10,000 dilution) IV/IO  C. Attempt defibrillation at 30 J, then resume CPR beginning with compressions.  D. Establish IV/IO access and administer amiodarone 5 mg/kg IV/IO.
A 3-year-old unresponsive, apneic child is brought to the emergency department. The cardiac monitor shows V Fib. EMS personnel report that the child became unresponsive as they arrived at the hospital. The child is receiving CPR, including bag-mask ventilation with 100% O2 and chest compressions at a rate of at least 100/min. Compressions and ventilations are being coordinated at a ratio of 15:2. You conform that apnea is present and that ventilation is producing bilateral breath sounds and chest expansion while a colleague confirms absent pulses. Cardiac monitor shows the above rhythm. A biphasic manual defibrillator is present. You quickly use the crown-heel length of the child on a length based, color-coded resuscitation tape to estimate the approximate weight as 15kg. Which of the following therapies is most appropriate for this child at this time? A. Establish IV/IO access and administer lidocaine 1 mg/kg IV/IO B. Establish IV/IO access and administer epinephrine 0.01 mg/kg (0.1 mL/kg of 1:10,000 dilution) IV/IO C. Attempt defibrillation at 30 J, then resume CPR beginning with compressions. D. Establish IV/IO access and administer amiodarone 5 mg/kg IV/IO.
C
 
A 3-year-old boy presents with multiple system trauma. The child was an unrestrained passenger in a motor vehicle crash. On primary assessment he is unresponsive to voice or painful stimulation. His respiratory rate is less than 6/min, heart rate is 170/min, systolic blood pressure is 60 mm Hg, cap refill is 5 seconds, and SpO2 is 75% in room air. Which of the following most accurately summarizes the first interventions you should take to support this child? A. Establish immediate vascular access, administer 20 mL/kg isotonic crystalloid, and reassess the patient; if the child’s systemic perfusion does not improve, administer 10 to 20 mL/kg packed red blood cells. B. Provide 100% oxygen by simple mask and perform a head-to-toe survey to identify the extent of all injuries; begin an epinephrine infusion and titrate to maintain a systolic blood pressure of at least 76 mm Hg C. Open the airway (jaw-thrust technique) while stabilizing the cervical spine, administer positive-pressure ventilation with 100% oxygen, and establish immediate IV/IO access. D. Provide 100% oxygen by simple mask, stabilize the cervical spine, establish vascular access, and provide maintenance IV fluids.
C
Initial impression of a 10-month-old male in the emergency department reveals a lethargic pale infant with slow respirations. You begin assisted ventilation with a bag-mask device using 100% oxygen. On primary assessment heart rate is 38/min, central pulses are weak, but distal pulses cannot be palpated. Blood pressure is 60/40, and cap refill is 4 seconds. During your assessment, as colleague places the child on a cardiac monitor and you observe the rhythm above (sinus bradycardia, 40 bpm). The rhythm remains unchanged despite ventilation with 100% oxygen. What are your next management steps?  A. Administer adenosine 0.1 mg/kg rapid IV/IO and prepare for synchronized cardioversion.  B. Start chest compressions and give epinephrine 0.1 mg/kg (0.1 mg/kg of 1:1,000) IV/IO  C. Start chest compressions and give epinephrine 0.01 mg/kg (0.1 mL/kg of 1:10,000) IV/IO  D. Administer 20 mL/kg isotonic crystalloid and epinephrine 0.1 mg/kg (0.1 mL/kg of 1:10,000) IV/IO
Initial impression of a 10-month-old male in the emergency department reveals a lethargic pale infant with slow respirations. You begin assisted ventilation with a bag-mask device using 100% oxygen. On primary assessment heart rate is 38/min, central pulses are weak, but distal pulses cannot be palpated. Blood pressure is 60/40, and cap refill is 4 seconds. During your assessment, as colleague places the child on a cardiac monitor and you observe the rhythm above (sinus bradycardia, 40 bpm). The rhythm remains unchanged despite ventilation with 100% oxygen. What are your next management steps? A. Administer adenosine 0.1 mg/kg rapid IV/IO and prepare for synchronized cardioversion. B. Start chest compressions and give epinephrine 0.1 mg/kg (0.1 mg/kg of 1:1,000) IV/IO C. Start chest compressions and give epinephrine 0.01 mg/kg (0.1 mL/kg of 1:10,000) IV/IO D. Administer 20 mL/kg isotonic crystalloid and epinephrine 0.1 mg/kg (0.1 mL/kg of 1:10,000) IV/IO
C
A 1-year-old male is brought to the emergency department for evaluation of poor feeding, fussiness, and sweating. On initial impression he is lethargic but arousable and has labored breathing and a dusky color. Primary assessment reveals a respiratory rate of 68/min, heart rate 300/min that does not very with activity or sleep, blood pressure 70/45 mm Hg, weak brachial pulses and absent radial pulses, cap refill 6 seconds, SpO2 85% in room air, and good bilateral breath sounds. You administer high-flow oxygen and place the child on a cardiac monitor. You see the above rhythm (SVT) with little beat-to-beat variability of the heart rate. Secondary assessment reveals no history of congenital heart disease. IV access has been established. Which of the following therapies is most appropriate for this infant?  A. Adenosine 0.1 mg/kg IV rapidly; if adenosine is not immediately available, perform synchronized cardioversion.  B. Make an appointment with a pediatric cardiologist for later in the week.  C. Establish IV access and administer a flid bolus of 20 mL/kg isotonic crystalloid.  D. Perform immediate defibrillation without waiting for IV access
A 1-year-old male is brought to the emergency department for evaluation of poor feeding, fussiness, and sweating. On initial impression he is lethargic but arousable and has labored breathing and a dusky color. Primary assessment reveals a respiratory rate of 68/min, heart rate 300/min that does not very with activity or sleep, blood pressure 70/45 mm Hg, weak brachial pulses and absent radial pulses, cap refill 6 seconds, SpO2 85% in room air, and good bilateral breath sounds. You administer high-flow oxygen and place the child on a cardiac monitor. You see the above rhythm (SVT) with little beat-to-beat variability of the heart rate. Secondary assessment reveals no history of congenital heart disease. IV access has been established. Which of the following therapies is most appropriate for this infant? A. Adenosine 0.1 mg/kg IV rapidly; if adenosine is not immediately available, perform synchronized cardioversion. B. Make an appointment with a pediatric cardiologist for later in the week. C. Establish IV access and administer a flid bolus of 20 mL/kg isotonic crystalloid. D. Perform immediate defibrillation without waiting for IV access
A
 
You are preparing to use a manual defibrillator and paddles in the pediatric setting. When would it be most appropriate to use the smaller “pediatric” sized paddles for shock delivery? A. If the patient weighs less than approximately 10 kg or is less than 1 year of age. B. Whenever you can compress the victim’s chest using only the heel of one hand C. To attempt synchronized cardioversion but not defibrillation D. If the patient weighs less than approximately 25 kg, or is less than 8 years of age.
A
Initial impression of a 10-year-old male shows him to be unresponsive. You shout for help, check breathing or only gasping. After finding that he is pulseless, you begin CPR. A colleague arrives and places the child on a cardiac monitor, revealing the above rhythm (V Tach). The two of you attempt defibrillation at 2 J/kg and give 2 minutes of CPR. The rhythm persists at the second rhythm check, at which point you attempt defibrillation using 4 J/kg. A third colleague establishes IO access and administers one dose of epinephrine 0.01 mg/kg (0.1 mL/kg of 1:10,0000) during the compressions following the second shock. If VF or pulseless VT persists after 2 minutes of CPR, what is the next drug/dose to administer?  A. Adenosine 0.1 mg/kg IV  B. Amiodarone 5 mg/kg IV  C. Epinephrine 0.1 mg/kg (0.1 mL/kg of 1:1,000) IV  D. Atropine 0.02 mg/kg IV
Initial impression of a 10-year-old male shows him to be unresponsive. You shout for help, check breathing or only gasping. After finding that he is pulseless, you begin CPR. A colleague arrives and places the child on a cardiac monitor, revealing the above rhythm (V Tach). The two of you attempt defibrillation at 2 J/kg and give 2 minutes of CPR. The rhythm persists at the second rhythm check, at which point you attempt defibrillation using 4 J/kg. A third colleague establishes IO access and administers one dose of epinephrine 0.01 mg/kg (0.1 mL/kg of 1:10,0000) during the compressions following the second shock. If VF or pulseless VT persists after 2 minutes of CPR, what is the next drug/dose to administer? A. Adenosine 0.1 mg/kg IV B. Amiodarone 5 mg/kg IV C. Epinephrine 0.1 mg/kg (0.1 mL/kg of 1:1,000) IV D. Atropine 0.02 mg/kg IV
B
 
You are supervising another healthcare provider who is inserting an intraosseous (IO) needle into an infant’s tibia. Which of the following signs should you tell the provider is the best indication of successful insertion of a needle into the bone marrow cavity? A. You are unable to aspirate any blood through the needle. B. Pulsatile blood flow will be present in the needle hub. C. Once inserted, the shaft of the needle moves easily in all directions within the bone. D. Fluids can be administered freely without local soft tissue swelling.
D
 
You are evaluating an irritable 6-year-old girl with mottled color. On primary assessment she is febrile ( temperature 104 F) and her extremities are cold (despite a warm ambient temperature in the room) with cap refill of 5 seconds. Distal pulses are absent and central pulses are weak. Heart rate is 180/min, respiratory rate is 45/min, and blood pressure is 98/56. Which of the following most accurately describes the categorization of this chil’s condition using the terminology taught in the PALS Provider Course? A. Hypotensive shock associated with inadequate tissue perfusion. B. Compensated shock associated with tachycardia and inadequate tissue perfusion. C. Hypotensive shock associated with inadequate tissue perfusion and significant hypotension. D. Compensated shock requiring no intervention.
B
You are caring for a 3-year-old with vomiting and diarrhea. You have established IV access. When you place an orogastric tube, the child begins gagging and continues to gag after the tube is placed. The child's color has deteriorated; pulses are palpable but faint and the child is now lethargic. The heart rate is variable (range 44/min to 62/min). You begin bag-mask ventilation with 100% oxygen. When the heart rate does not improve, you begin chest compressions. The cardiac monitor shows the above rhythm (Sinus Bradycardia at 50 bpm). Which of the following would be the most appropriate therapy to consider next.  A. Cardiology consult for transcutaneous pacing.  B. Epinephrine 0.1 mg/kg (0.1 mL/kg of 1:1,000) IV  C. Atropine 0.02 mg/kg IV  D. Attempt synchronized cardioversion at 0.5 J/kg
You are caring for a 3-year-old with vomiting and diarrhea. You have established IV access. When you place an orogastric tube, the child begins gagging and continues to gag after the tube is placed. The child’s color has deteriorated; pulses are palpable but faint and the child is now lethargic. The heart rate is variable (range 44/min to 62/min). You begin bag-mask ventilation with 100% oxygen. When the heart rate does not improve, you begin chest compressions. The cardiac monitor shows the above rhythm (Sinus Bradycardia at 50 bpm). Which of the following would be the most appropriate therapy to consider next. A. Cardiology consult for transcutaneous pacing. B. Epinephrine 0.1 mg/kg (0.1 mL/kg of 1:1,000) IV C. Atropine 0.02 mg/kg IV D. Attempt synchronized cardioversion at 0.5 J/kg
C
 
An 18-month-old child presents with a 1-week history of cough and runny nose. Your initial impression is a toddler responsive only to painful stimulation with slow respirations and diffuse cyanosis. You begin a primary assessment and find that the child’s respiratory rate has fallen from 65/min to 10/min, severe inspiratory intercostal retractions are present, heart rate is 160/min, SpO2 is 65% in room air, and cap refill is less than 2 seconds. Which of the following is the most appropriate immediate treatment for this toddler? A. Administer 100% oxygen by face mask, obtain an arterial blood gas, and establish vascular access. B. Administer 100% oxygen by face mask, establish vascular access, and obtain a STAT chest x-ray. C. Establish vascular access and administer a 20 mL/kg bolus of isotonic crystalloid. D. Open the airway and provide positive-pressure ventilation using 100% oxygen and a bag-mask device.
D
 
You are transporting a 6-year-old endotracheally intubated patient who is receiving positive-pressure mechanical ventilation. The child begins to move his head and suddenly becomes cyanotic and bradycardic. SpO2 is 65% with good pulse signal. You remove the child from the mechanical ventilator circuit and provide manual ventilation with a bag via the endotracheal tube. During manual ventilation with 100% oxygen, the child’s color and heart rate improve slightly and his blood pressure remains adequate. Breath sounds and chest expansion are present and adequate on the right side, but they are consistently diminished on the left side. The trachea is not deviated, and the neck veins are not distended. A suction catheter passes easily beyond the tip of the endotracheal tube. Which of the following is the most likely cause of this child’s acute deterioration? A. Tracheal tube displacement into the right main bronchus B. Tension pneumothorax on the right side C. Tracheal tube obstruction D. Equipment failure.
A
 
A child becomes unresponsive in the emergency department and is not breathing. You provide ventilation with 100% oxygen. You are uncertain if a faint pulse is present with the above rhythm (asystole). What is your next action? A. Order transcutaneous pacing. B. Start high quality CPR, beginning with compressions. C. Start an IV and give atropine 0.01 mg/kg IV D. Start an IV and give epinephrine 0.01 mg/kg IV (0.1 mL/kg of 1:10,000)
B
 
You have just assisted with the elective endotracheal intubation of a child with respiratory failure and a perfusing rhythm. Which of the following provides the most reliable, prompt assessment of correct endotracheal tube placement in this child? A. Absence of audible breath sounds over the abdomen during positive-pressure ventilation. B. Auscultation of breath sounds over the lateral chest bilaterally plus presence of mist in the endotracheal tube. C. Clinical assessment of adequate bilateral breath sounds and chest expansion plus presence of exhaled CO2 in a colormetric detection device after delivery of 6 positive-pressure ventilations. D. Confirmation of appropriate oxygen and carbon dioxide tensions on arterial blood gas analysis.
C
 
An 8-year-old child was struck by a car. He arrives in the emergency department alert, anxious, and in respiratory distress. His cervical spine is immobilized, and he is receiving a 10 L/min flow of 100% oxygen by nonrebreathing face mask. PRimary assessment reveals respiratory rate 60/min, heart rate 150/min, systolic blood pressure 70, and SpO2 84% on supplementary oxygen. Breath sounds are absent over the right chest, and the trachea is deviated to the left. He has weak central pulses and absent distal pulses. Which of the following is the most appropriate immediate intervention for this child? A. Provide bag-mask ventilation and call for a STAT chest x-ray B. Perform needle decompression of the right chest and assist ventilation with a bag and mask if necessary. C. Establish IV access and administer a 20 mL/kg normal saline fluid bolus D. Perform endotracheal intubation and call for a STAT chest x-ray
B
 
A 7-year-old boy is found unresponsive, apneic, and pulseless. CPR is ongoing. The child is intubated and vascular access is established. The ECG monitor reveals an organized rhythm, but a pulse check reveals no palpable pulses. Effective ventilations and compressions are resumed, and an initial IV dose of epinephrine is administered. Which of the following therapies should you perform next? A. Administer synchronized cardioversion at 1 J/kg B. Administer epinephrine 0.1 mg/kg IV (0.1 mL/kg of 1:1,000) C. Attempt defibrillation at 4 J/kg D. Attempt to identify and treat reversible causes (using the H’s and T’s as a memory aid)
D
A 4-year-old male is in pulseless arrest in the pediatric intensive care unit. A code is in progress. As the on-call physician you quickly review his chart and find that his baseline corrected QT interval on a 12-lead ECG is prolonged. A glance at the monitor shows recurrect episodes of the above rhythm. The boy has received one dose of epi, but continues to demonstrate the rhythm illustrated above (Torsades de Pointes). If this rhythm persists at the next rhythm check, which medication would be the most appropriate to administer at this time?  A. Lidocaine 1 mg/kg IV  B. Adenosine 0.1 mg/kg IV  C. Epinephrine 0.1 mg/kg (1:1000)  D. Magnesium sulfate 25 to 50 mg/kg IV
A 4-year-old male is in pulseless arrest in the pediatric intensive care unit. A code is in progress. As the on-call physician you quickly review his chart and find that his baseline corrected QT interval on a 12-lead ECG is prolonged. A glance at the monitor shows recurrect episodes of the above rhythm. The boy has received one dose of epi, but continues to demonstrate the rhythm illustrated above (Torsades de Pointes). If this rhythm persists at the next rhythm check, which medication would be the most appropriate to administer at this time? A. Lidocaine 1 mg/kg IV B. Adenosine 0.1 mg/kg IV C. Epinephrine 0.1 mg/kg (1:1000) D. Magnesium sulfate 25 to 50 mg/kg IV
D
 
A pale and obtunded 3-year-old child with a history of diarrhea is brought to the hospital. Primary assessment reveals respiratory rate of 45/min with good breath sounds bilaterally. Heart rate is 150/min, blood pressure is 90/64, and SpO2 is 96% room air. Cap refill is 5 seconds and peripheral pulses are weak. After placing the child on a nonrebreathing face mask (10 L/min) with 100% O2 and obtaining vascular access, which of the following is the most appropriate immediate treatment for this child? A. Begin a maintenance crystalloid infusion B. Administer a bolus of 20 mL/kg isotonic crystalloid C. Obtain a chest x-ray D. Administer a dopamine infusion at 2 to 5 mcg/kg per minute.
B
 
An 8-month-old male is brought to the ED for evaluation of severe diarrhea and dehydration. In the ED the child becomes unresponsive and pulseless. You should for help and start CPR. Another provider arrives, and you begin a compression-to-ventilation ratio of 15:2. The cardiac monitor shows the above rhythm. The infant is intubated and ventilated with 100% O2. An IO line is rapidly established and a dose of epi is given. Of the following choices for management, which would be most appropriate to give next? A. Normal saline 20 mL/kg IV rapidly B. Amiodarone 5 mg/kg IO C. Defibrillation 2 J/kg D. High dose epinephrine 1:1,000, 0.1 mg/kg
A
 
You are participating in the elective intubation of a 4-year-old child with respiratory failure. You must select the appropriate sized uncuffed endotracheal tube. You do not have a Brazlow tape to use to estimate correct endotracheal tube size. Which of the following is the most appropriate uncuffed endotracheal tube for an average 4-year-old. A. 4-mm tube B. 6-mm tube C. 5-mm tube D. 3-mm tube
C

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