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
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 statement is correct about the effects of epinephrine during attempted resuscitation?
Epinephrine stimulates spontaneous contractions when asystole is present
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.
Administer a bolus of isotonic crystalloid 20 ml/kg over 5-20 minutes, and also give D25W 2-4 ml/kg IV
Which statement is correct about endotracheal drug administration during resuscitative efforts for pediatric patients?
It is the least desirable route of administration
Which statement is correct about the use of calcium chloride in pediatric patients?
Routine administration is not indicated during cardiac arrest
A 9yo boy is agitated and leaning forward on the bed in obvious respiratory distress.
Albuterol
Which oxygen delivery system most reliably delivers a high (90% or greater) concentration of inspired oxygen to a 7yo child?
Nonrebreathing face mask
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
Rapid bolus of 20ml/kg of isotonic crystalloid
A 7yo boy is found unresponsive, apneic, and pulseless. CPR is ongoing
Identify and treat reversible causes
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
What compression-to-ventilation ratio should be used for 2-rescuer infant CPR?
15 compressions to 2 breaths
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
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 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
Administer a bolus of 20 ml/kg isotonic crystalloid
You are evaluating an irritable 6yo girl with mottled skin color.
Compensated shock associated with tachycardia and inadequate tissue perfusion
You assisted with the elective endotracheal intubation of a child with respiratory failure and a perfusing rhythm
Adequate bilateral breath sounds and chest expansion plus detection of ETCO2 with waveform capnography
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.”
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.
Epinephrine 0.01 mg/kg IV/IO
A 1yo boy is brought to the emergency department for evaluation of poor feeding, irritability, and sweating
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
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.
Perform needle decompression of the right chest
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
Atropine 0.02 mg/kg IV
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
A child becomes unresponsive in the emergency department and is not breathing. You are uncertain if a faint pulse is present
Start high-quality CPR
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 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
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 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 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)
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
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.”
Why is allowing complete chest recoil important when performing high-quality CPR?
The heart will refill with blood between compressions
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
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
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
A 12-year-old child being evaluated in the pediatric intensive care unit displays the following ECG waveform. The team interprets this as which arrhythmia?
second degree
Laboratory tests are ordered for a child who has been vomiting for 3 days and is diaphoretic, tachypneic, lethargic and pale. Which test would the provider use to determine the adequacy of oxygen delivery?
Lactate
A 9-year-old patient is presenting with decreased breath sounds, bradycardia, slowed respiratory rate and a low O2 saturation level. The provider interprets these findings as indicating which condition?
Respiratory failure
A 4-year-old child is brought to the emergency department by the parents. Assessment reveals that the child has only gasping respirations and the pulse rate is 65 beats per minute. Which action would the provider initiate first?
Deliver 1 BVM ventilation every 3 to 5 seconds.
A 15-year-old patient is being evaluated during a follow-up visit after being diagnosed with Lyme disease 2 months ago. A rhythm strip is obtained as shown below. The provider interprets this rhythm as indicating which arrhythmia?
First-degree atrioventricular (AV) block
A child in cardiac arrest experiences return of spontaneous circulation but is exhibiting signs of post–cardiac arrest syndrome (PCAS). The PALS resuscitation team determines that the child is experiencing a systemic response to ischemia/reperfusion. The team bases this determination on which finding(s)?
Hypotension
Fever
Hyperglycemia
A 2-year-old child arrives at the emergency department with the parents. The child is unresponsive, is not breathing and has no pulse. Two emergency department providers begin high-quality CPR. Which action(s) by the providers demonstrates high-quality CPR?
Allowing the chest to recoil fully after each compression
Providing ventilations that last about 1 second each
Compressing the chest about 2 inches
Giving 2 ventilations to every 15 compressions
A PALS resuscitation team is preparing to defibrillate a child experiencing cardiac arrest. For which rhythm(s) would this action be appropriate?
VF and pVT are shockable cardiac arrest rhythms.
A provider is assessing a child with suspected shock. Which statement correctly describes hypotension and shock?
Hypotension is not a consistent feature of shock;
A provider is caring for a 4-year-old child in the urgent care clinic. Primary assessment reveals difficulty breathing and an oxygen saturation of 91%. The provider administers oxygen by nasal cannula with the goal of improving the child’s oxygen saturation above what percentage?
Supplemental oxygen should be administered as needed to maintain an oxygen saturation above 94%.
An 11-year-old soccer player is brought to the emergency department. After a quick assessment, the team realizes this patient is experiencing a severe asthma exacerbation. Which medication would the team administer first?
Albuterol plus ipratropium bromid
A child in the pediatric step-down unit is exhibiting signs of respiratory distress. When assessing this child, which circulation finding might be present?
Pallor is a circulation finding that may be seen in patients with respiratory distress.
A healthcare provider is performing a primary assessment of a child in respiratory distress. The provider documents increased work of breathing when which findings are observed?
Nasal flaring, use of accessory muscles to breathe and intercostal, substernal or suprasternal retractions are all indicators of increased work or effort of breathing. Grunting and inspiratory stridor are abnormal breath sounds.
An 11-year-old child develops unstable wide-complex tachycardia. Assessment reveals signs of significant hemodynamic compromise, but the child has a pulse. The PALS team would prepare the child for which intervention?
First-line treatment for unstable wide-complex tachycardias consists of synchronized electrical cardioversion, particularly when signs of hemodynamic compromise are apparent.
A 4-month old infant is brought to the emergency department in cardiac arrest. Which condition would the team identify as the most common cause of cardiac arrest in an infant of this age?
Sudden infant death syndrome
A 9-year-old child is brought to the emergency department because the child suddenly collapsed at school. The child’s ECG reveals the following waveform, and primary assessment findings indicate that the child is hemodynamically unstable. Which primary assessment findings indicate this?
Difficulty breathing
Hypotension
Mottling
Decreased level of consciousnes
2-year-old child is brought to the pediatric urgent care clinic by the parent who says that the child has had a barking cough for two days. During the rapid assessment of the child, the provider hears audible inspiratory stridor. Which common cause of partial upper airway obstruction in children would the provider most likely suspect?
croup
A 6-year-old child is brought to the emergency department. The child has been experiencing extremely watery stools over the past several days. After completing the assessment, the healthcare provider suspects that the child may be experiencing shock. Which type of shock would the provider most likely suspect?
hypovolemic
While performing a rapid assessment and formulating an initial impression using the Pediatric Assessment Triangle (PAT), the provider assesses the child’s circulation. Which information would be important to consider?
When assessing the adequacy of circulation, consider skin color and visible mucous membranes for pallor (or gray/dusky color), cyanosis, mottling or flushing and evidence of any bleeding, including life-threatening bleeding.
Assessment of a 3-month-old infant admitted with respiratory distress reveals fever, grunting and a wet, “junky” cough. The infant’s parents said the child had a recent respiratory infection with a fever. A rapid respiratory syncytial virus (RSV) test is positive. Which condition would the provider most likely suspect as the cause?
bronchiolitis
PALS resuscitation team notes the following ECG waveform and the child does not have a pulse. The team prepares to intervene to address which arrhythmia?
torsades
The emergency response team is providing care to a preschooler who is experiencing shock. The primary goal, common to all types of shock, is to restore a favorable balance between tissue perfusion and metabolic demand with a focus on what?
The primary goal in shock, regardless of cause, is to restore a favorable balance between tissue perfusion and metabolic demand with a focus on oxygen delivery and oxygen demand.
The PALS resuscitation team is providing care to an intubated child in cardiac arrest. Which result best determines the adequacy of the team’s chest compressions?
End-tidal carbon dioxide level between 15 and 20 mmHg
The PALS team leader is conducting a debriefing session with the team. Which topic(s) would the team leader most likely address during the session?
Summary of the event, including what actions were taken, Discussion of the pros and cons of the interventions, Identification of ways to improve, Evaluation of the objective data gathered during the event
Assessment of a 7-year-old patient with septic shock reveals capillary refill of 3 seconds, diminished pulses, narrow pulse pressure and cool, mottled extremities. The emergency response team interprets these findings as indicating which type of septic shock?
Most children in septic shock present with cold shock (i.e., delayed capillary refill, diminished pulses, peripheral vasoconstriction, narrow pulse pressure, and cool, mottled extremities) instead of warm shock.
Primary assessment of a 10-year-old child reveals septic shock. As part of the secondary assessment, laboratory testing is completed to evaluate the child’s status. Which laboratory tests would be ordered for this child?
Laboratory testing for the child in septic shock may include CBC, blood cultures, blood gasses, coagulation panel, renal function tests, liver function panel and lactate level.
A 4-year-old patient presents with tachycardia, tachypnea, cold extremities and weak pulses. Assessment also reveals an enlarged liver and neck vein distension. The provider interprets these assessment findings as suggesting which type of shock?
cardio
A 10-year-old child has collapsed in the gym of the elementary school. The school nurse arrives and determines that the child is unresponsive. The school nurse then simultaneously checks for breathing and a central pulse, limiting this assessment to which time frame?
5 seconds, but no more than 10.
A child being cared for in the pediatric telemetry unit suddenly displays the following ECG waveform. The provider prepares to intervene because the child is demonstrating which type of arrhythmia?
Supraventricular tachycardia
A 6-year-old patient is brought to the emergency department after a bicycle accident. Assessment reveals tracheal deviation to the left side, chest pain on inspiration and decreased breath sounds on the right side. The provider suspects obstructive shock caused by what condition?
tension pneumothorax
A child is experiencing stable supraventricular tachycardia (SVT) and is to receive treatment. Which initial treatment would the provider administer?
vagal
An unresponsive 7-year-old child with no pulse is brought to the pediatric urgent care center by his parents and CPR is initiated. The cardiac monitor reveals ventricular fibrillation. Which action would the PALS team take first?
initiate defibrillation with 2 J/kg.
A child who is stable and exhibiting a narrow-complex tachycardia is to receive adenosine. The provider would be alert for which result after administering this medication?
Patients may have a brief period of “asystole” following the administration of adenosine. This is normal and typically self-limited.
An 8-year-old child being treated in the emergency department has significant respiratory distress. The child also exhibits hives, wheezing, angioedema, tachycardia and dyspnea. The parents state that the child, who is allergic to peanuts, had eaten some popcorn that had peanuts in it. The team initiates care, preparing to administer which agent first?
epi
A 2-year-old child of unknown weight arrives at the emergency department in cardiac arrest. When preparing to administer medications, which action would be appropriate for the team to take?
tape
The PALS team is providing post–cardiac arrest care to an 8-year-old child in the pediatric intensive care unit. Which intervention would the team implement to achieve the primary goal of post–cardiac arrest care?
ensure MAP
A 12-year-old is being treated in the urgent care clinic. The mother reports that the child came home from school yesterday with a high fever, vomiting and multiple episodes of watery diarrhea. The healthcare provider obtains a rhythm strip and notes the following waveform. The provider interprets this as which type of arrhythmia?
sinus tahy
A child requires cardiac monitoring. A three-electrode system is being used. At which location would the provider place the red electrode?
On the lower left abdomen
An advanced airway was placed in a 5-year-old child. Which action(s) would be most appropriate for the team to take to confirm correct placement?
Auscultate over the lungs and epigastrium for air movement, Observe for bilateral chest rise, Evaluate results of capnography.
A 12-lead ECG is ordered for a child complaining of a “racing heart.” When placing the electrodes on the child, at which location would the lead for V4 be placed?
fifth intercostal space at the midclavicular line on the patient’s left side.
A 7-year-old child collapses on the playground at school. The school nurse is called to the scene and determines that the child is unresponsive and is not breathing and has no pulse. The nurse initiates CPR. At what rate and depth would the nurse deliver compressions to this child?
100 to 120 compressions per minute at a depth of about 2 inch
Which action would the PALS team initiate to manage increased intracranial pressure in a pediatric patient?
Maintain the head in midline position with 30-degree elevation
child is experiencing shock. The emergency response team prepares for imminent cardiac arrest when assessment reveals which finding(s)?
Hypotension, Bradycardia, Diminished central pulses
A 30-month old child has been diagnosed with moderate croup. Which medication(s) would the provider administer?
Corticosteroids, Racemic epinephrine
After ROSC, a child is experiencing post–cardiac arrest hemodynamic instability. The PALS resuscitation team would administer which element to restore intravascular volume and optimize preload?
Isotonic fluid boluses
A 5-year-old child with a history of a chronic neuromuscular disease is experiencing respiratory distress. The child is breathing spontaneously and receiving supplemental oxygen. Which additional intervention is a critical component of airway management for this patient?
Airway clearance
A provider is forming an initial impression of a child using the Pediatric Assessment Triangle (PAT). During which step of the PAT may the provider use the mnemonic TICLS to assess the patient?
appearance
A child in the pediatric intensive care unit displays the following ECG waveform. The child has no pulse. The resuscitation team interprets this as which arrhythmia
Monomorphic pulseless ventricular tachycardia
A child experiencing unstable bradycardia is receiving CPR. Despite efforts with CPR, including assuring oxygenation and ventilation, the child’s status remains unchanged. Which medication would the emergency response team expect to administer next?
epi
A 4-year-old child suddenly collapses in the playroom of the facility. A healthcare provider observes the event and hurries over to assess the child. The healthcare provider completes which assessment first?
rapid
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