PALS Medican Training
For a pediatric patient of any age, each breath during CPR should be given over: A. 1 second B. 3 seconds C. 5 seconds D. 10 seconds
A. 1 second Rationale: Regardless of patient age, a single ventilation should take place over one second. It is important to remember that pediatric patients require less overall air volume than adults to. Thus, a small air volume should be used but provided over one second.
The initial impression of the infant or child includes: A. A quick assessment of level of consciousness breathing, and color B. A focused physical exam C. Measurement of vital signs D. Review of the ECG
A. A quick assessment of level of consciousness breathing, and color Rationale: The initial impression in PALS is very brief, a quick impression of how severe the child's condition is. This step is sometimes described as how the child "looks from the door." The initial impression precedes all other steps in the process.
What is the first assessment in the Pediatric Advanced Life Support (PALS) Primary Assessment? A. Airway B. Breathing C. Circulation D. Disability
A. Airway Rationale: In adults, the approach is CAB or circulation, airway, breathing. In children, however, respiratory issues are usually the primary cause of problems. Thus, the traditional ABC is followed, which corresponds to airway, breathing, circulation.
During CPR, correct compression depth for an adolescent is: A. Between 2 and 2.4 inches B. 1 inch for females and 2 inches for males C. 1.5 inches D. At least 2 inches
A. Between 2 and 2.4 inches Rationale: The chest must be compressed to a sufficient depth, but not too deeply. The heart should be squeezed so that blood is propelled through the blood vessels. A depth between 2 and 2.4 inches (5 and 6 cm) is considered optimal for adolescents and adults.
In an infant, the easiest artery to check for presence of a pulse is in the: A. Brachial artery B. Carotid artery C. Femoral artery D. Radial artery
A. Brachial artery Rationale: The brachial artery is the recommended location to check for a pulse in an infant. The artery runs close enough to the surface of the skin and provides a large enough area for an adult hand to quickly check for the presence or absence of a pulse. In larger children, the femoral artery may be more appropriate. In adults, the carotid artery is the first choice.
You are treating a child with bradycardia at a rate of 52, weak peripheral pulses, and increasing lethargy. A patent airway is established and oxygen is already being administered. What should also be happening right now? A. Chest compressions B. Give a crystalloid fluid bolus over 10 minutes C. Administer epinephrine D. Monitor the patient for further deterioration
A. Chest compressions Rationale: A heart rate of 60 bpm or less is considered cardiac arrest in a child. Since the child in the question has bradycardia with a heart rate of 52 bpm, chest compressions should be started immediately.
The 14-year-old child is awake but drowsy. She is answering all of the questions from the team. Her pulse rate is 104 bmp, oxygen saturation is 96%, and systolic blood pressure is 100 mm Hg. Which of the following is most appropriate? A. Continue to monitor the child B. Increase the oxygen for the child C. Perform synchronized cardioversion D. Give a rapid fluid bolus
A. Continue to monitor the child Rationale: The girl's vital signs are normal for her age and there is no need for specific intervention at this time.
For a child in ventricular fibrillation, which of the following is the most appropriate immediate intervention? A. Defibrillate at 2 joules/kg B. Quickly insert an IO or IV access C. Administer epinephrine at 0.01mg/kg IV/IO D. Administer amiodarone at 5mg/kg IV/IO
A. Defibrillate at 2 joules/kg Rationale: Ventricular fibrillation requires unsynchronized cardioversion (also known as defibrillation or shock). The other interventions may be useful but are secondary to defibrillation.
If it can be performed competently and efficiently, evidence supports the use of pediatric extracorporeal cardiopulmonary resuscitation in what setting? A. In-hospital cardiac arrest for cardiac diagnoses B. Out-of-hospital cardiac arrest C. Patients with non cardiac disease experiencing in-hospital cardiac arrest refractory to conventional CPR D. During targeted temperature management only
A. In-hospital cardiac arrest for cardiac diagnoses Rationale: Extracorporeal CPR may be considered in pediatric in-hospital cardiac arrest for cardiac diagnoses if it can be implemented competently and efficiently. There is insufficient evidence to recommend for or against the use of extracorporeal CPR for pediatric patients experiencing out-of-hospital cardiac arrest or for pediatric patients with non cardiac disease experiencing in-hospital cardiac arrest refractory to conventional CPR.
After ROSC in a pediatric patient who has been treated for shock, the first intervention is to: A. Optimize ventilation and oxygenation B. Consider a vasopressor C. Administer epinephrine D. Administer dobutamine
A. Optimize ventilation and oxygenation Rationale: While vasopressors such as epinephrine and dobutamine may be useful in treating children who have recovered from cardiac arrest, the first intervention is to ensure adequate oxygenation and ventilation after return of spontaneous circulation (ROSC).
In the pediatric population, most cardiac arrests result from: A. Respiratory failure or shock B. Ventricular fibrillation C. Ventricular tachycardia D. None of the above
A. Respiratory failure or shock Rationale: In adults, cardiac arrest is usually a primary cardiac issue. In children, however, cardiac arrest is usually preceded by respiratory failure or some form of shock.
You are providing fluid resuscitation on a 15-year-old in shock. A sign his condition is improving is: A. Systolic blood pressure of 110 mm Hg B. Decreasing urine output C. Oxygen saturation at 90% D. Heart rate of 120 bpm
A. Systolic blood pressure of 110 mm Hg Rationale: Decreased urine output, oxygen saturation of 90%, and heart rate of 120 bmp are worrisome signs for continuing shock. However, a systolic blood pressure of 110 mm Hg is within normal limits for a 15-year-old boy.
When doing the Primary Assessment of the child, the rescuer knows that simple measures to maintain an open airway include all of the following except: A. Use of a laryngeal mask airway B. Place the child in a position of comfort C. Use the head tilt-chin lift maneuver to open the airway D. Attempt to relieve a foreign body obstruction if aspiration is suspected
A. Use of a laryngeal mask airway Rationale: A laryngeal mask airway may be necessary to support the child's airway, but it is considered an advanced airway, not a simple airway opening procedure.
For SVT in pediatric patients, the correct first IV or IO dose of adenosine is: A. 1 mg/kg to a maximum first dose of 6 mg B. 0.1 mg/kg to a maximum first dose of 6 mg C. 0.01 mg/kg to a maximum first dose of 6 mg D. Adenosine is contraindicated for pediatric patients
B. 0.1 mg/kg to a maximum first dose of 6 mg Rationale: This dosage should be committed to memory. The second adenosine dose is double (0.2mg/kg to a maximum dose of 12 mg).
A late sign of tissue hypoxia is: A. Tachycardia B. Cyanosis C. Tachypnea D. Nasal Flaring
B. Cyanosis Rationale: Cyanosis or a bluing of the skin usually indicates severe tissue hypoxia. Tachycardia and tachypnea would occur in early stages of hypoxia. Nasal flaring cannot be specifically used to determine the state of tissue hypoxia.
Which is an early sign of decreased perfusion? A. Increased intensity of peripheral pulses B. Diminished intensity of peripheral pulses C. Absent peripheral pulses D. Diminished central pulses
B. Diminished intensity of peripheral pulses Rationale: Absent peripheral pulses indicates cardiac arrest. One would expect peripheral pulses to diminish before central pulses since the arteries are farther away from the heart. Increased intensity of peripheral pulses would not occur in the condition of decreased perfusion.
Normal breath sounds are expected in which of the following respiratory problems? A. Lower airway obstruction B. Disordered control of breathing C. Upper airway obstruction D. Lung tissue disease
B. Disordered control of breathing Rationale: Disordered control of breathing is due to a neurological problem, not a problem with the lung tissue. Therefore, normal breath sounds may be heard in someone with disordered control of breathing. One would expect to hear abnormal breath sounds in the other three causes of respiratory issues.
Parents bring their child with a chief complaint of fever. On exam, you note that he is tachycardia and hypotensive. He has bounding peripheral pulses and normal capillary refill in his extremities. His temperature is 104 degrees F. You suspect the child is in: A. Hypovolemic shock B. Distributive shock C. Cardiogenic shock D. Obstructive shock
B. Distributive shock Rationale: Distributive shock is the inappropriate distribution of blood volume. Septic shock is a form of distributive shock. The presence of fever helps narrow the diagnosis. In distributive shock, peripheral pulses may be bounding or weak and capillary refill may be normal or diminished. This patient is likely in the early stages of shock (compensated shock).
The 2-year-old toddler is playing in the playroom in the hospital with a respiratory rate of 30 breaths per minute. Which action is appropriate? A. Know that this is an ominous sign that may signal impending arrest B. Do nothing; this is a normal finding C. Notify the resuscitation tea about the child's status D. Evaluate the child's airway to ensure that it is open
B. Do nothing; this is a normal finding Rationale: The normal range of respiratory rates in a two-year-old is 24 to 40 respirations per minute. Therefore, respiratory rate of 30 is completely normal.
If one person is performing bag-mask ventilation, the best way to provide effective ventilation is to use the: A. A-C clamp technique B. E-C clamp technique C. B-C clamp technique D. D-C clamp technique
B. E-C clamp technique Rationale: The E-C clamp technique gets its name from the shape that the fingers form around the mask and the patient's face. The thumb and index finger form a "C" while the other three fingers form an "E." This hand configuration allows for tight seal and good control of the bag mask.
Signs of cardiac arrest include all of the following except: A. Unresponsiveness B. Elevated diastolic blood pressure C. No breathing or gasping breaths D. No pulse
B. Elevated diastolic blood pressure Rationale: A person in cardiac arrest will not generate blood pressure, thus an elevated diastolic blood pressure cannot occur during cardiac arrest. The other signs listed are consistent with cardiac arrest.
The SAMPLE acronym can be used to obtain a focused history for a pediatric patient. The "E" in sample stands for: A. Exam B. Event C. Eyes D. Ecchymosis
B. Event Rationale: SAMPLE stands for signs and symptoms, allergies, medications, past medical and surgical history, last meal, and events. It is useful for remembering the secondary assessment in PALS.
In the post resuscitation period after cardiac arrest, fluids, inotropes and vasopressors should be used to maintain a systolic blood pressure above: A. 120 mm Hg B. Fifth percentile for age C. Third percentile for age D. Inotropes and vasopressors should never be used in children
B. Fifth percentile for age Rationale: This is a new recommendation in the most recent guidelines. Fluids, inotropes, and vasopressors should be used to maintain systolic blood pressure above the fifth percentile by age in children who have had a return of spontaneous circulation after cardiac arrest. In previous versions, there were no studies to support the use of these drugs.
To replace blood loss in hemorrhagic shock, the rule for fluid resuscitation is to: A. Give 1 mL of crystalloid for every 1 mL of estimated blood loss B. Give 3 mL of crystalloid for every 1 mL of estimated blood loss C. Give 5 mL of crystalloid for every 1 mL of estimated blood loss D. Give 10 mL of crystalloid for every 1 mL of estimated blood loss
B. Give 3 mL of crystalloid for every 1 mL of estimated blood loss Rationale: In hemorrhagic shock, a useful rule of thumb for fluid resuscitation is 3 milliliters of crystalloid for every one milliliter of suspected or estimated blood loss. If colloid is used, 1 mL should be used for every 1 mL of estimated blood loss.
Which of the following is true regarding the treatment of pulseless ventricular tachycardia or ventricular fibrillation that does not respond to shock? A. Amiodarone is superior to lidocaine B. Lidocaine is superior to amiodarone C. Amiodarone and lidocaine are equally effective D. Neither amiodarone nor lidocaine should be used
C. Amiodarone and lidocaine are equally effective Rationale: In 2010 PALS guidelines, amiodarone was given a place of prominence for shock-refractory ventricular fibrillation or pulseless ventricular tachycardia. Lidocaine was considered a substitute if amiodarone was not available. With the most recent guideline update, however, amiodarone and lidocaine are considered equally effective for these indications. Specifically, amiodarone or lidocaine may be used for ventricular fibrillation/pulseless ventricular tachycardia that does not respond to defibrillation.
The initial impression of a child in distress reveals that the child is breathing and responsive. Which intervention is performed next? A. Open the child's airway B. Activate the emergency response system C. Conduct the primary assessment D. Hyperventilate with a bag-mask device
C. Conduct the primary assessment Rationale: The initial impression includes an assessment of level of consciousness, breathing, and color. Next, the rescuer checks responsiveness and breathing. If the child is responsive and breathing then the rescuer should move to the primary assessment sequence. The rescuer would consider the other options listed if the child was not responsive or breathing effectively.
In a child, the most worrisome sound is: A. Rales or crackles B. Cooing C. Grunting D. Wheezing
C. Grunting Rationale: Grunting is a sign of severe respiratory distress and generally indicates imminent respiratory failure. Wheezing and rales can occur in many mild to moderate respiratory diseases and are not as worrisome as grunting. Cooing is the normal sound of a happy, healthy infant.
All of the following are included in the Evaluate step of the Evaluate-Identify-Intervene sequence except: A. Primary assessment B. Secondary assessment C. Placement of an airway D. Diagnostic tests
C. Placement of an airway Rationale: The placement of an airway is an intervention, not an evaluation. It is done after an evaluation or "Evaluate" step was used to "Identify" an issue that required an airway device.
Signs of increased respiratory effort include all of the following except: A. Nasal flaring B. Chest retractions C. Respiratory rate of 48 in an infant D. Respiratory rate of 38 in a preschooler
C. Respiratory rate of 48 in an infant Rationale: The normal range of respiratory rates in an infant is 30 to 60 respirations per minute. A respiratory rate of 38 breaths per minute in a preschooler would be abnormally high since the normal range in this age is 22 to 34 breaths per minute.
The pediatric patient in ventricular tachycardia has a systolic blood pressure of 40 mm Hg and is beginning to show signs of shock. The child has a pulse but poor perfusion. The correct next intervention for this child is: A. Perform vagal maneuvers B. Administer amiodarone C. Synchronized cardioversion D. Defibrillation (unsynchronized)
C. Synchronized cardioversion Rationale: Since this is ventricular tachycardia, we know the QRS complex is wide. The hypotension, poor perfusion, and signs of shock indicate this is unstable tachycardia. Immediate synchronized cardioversion is required.
The ill child is breathing room air. Oxygenation is adequate if the oxygen saturation is at least: A. 65% B. 75% C. 85% D. 95%
D. 95% Rationale: A blood oxygenation level above 94% is considered normal. Levels below this amount usually require specific intervention.
Problems that may precipitate pediatric cardiac arrest include: A. Respiratory B. Circulatory C. Arrhythmias D. All of the above
D. All of the above Rationale: While respiratory issues are usually to blame for cardiac arrest in children, arrhythmias and circulatory problems may also be to blame.
Which of the following is an appropriate action for a team member during PALS? A. The team member should tell the team leader if he is unable to perform an assigned task B. The team member should maintain a professional tone C. The team member should share information when pertinent D. All of the above are good practices for a team member
D. All of the above are good practices for a team member Rationale: Team members have several responsibilities during a life-saving and support situation. The team member must realistically determine if he or she can perform an assigned task and let the team leader know as soon as possible if the assigned task cannot be performed. Professional communication should be maintained at all times and the team leader should be made aware of pertinent information as it becomes available.
Which piece of information does an arterial blood gas measurement provide? A. If the patient has hypoxemia B. If the patient has pH abnormalities C. If the patient is being inappropriately ventilated D. An arterial blood gas measurement can reveal all of these things
D. An arterial blood gas measurement can reveal all of these things Rationale: An arterial blood gas provides a direct measurement of oxygen, carbon dioxide, and pH of the blood. From these values, various metabolic and respiratory issues can be determined which can have set ventilation settings.
The rate for compressions in the pediatric patient is: A. 60-80 compressions per minute (normal adult heart rate) B. 80-100 compressions per minute C. At least 100 compressions per minute D. Between 100 and 120 compressions per minute
D. Between 100 and 120 compressions per minute Rationale: The former recommendation was at least 100 chest compressions per minute; however, studies showed that some rescuers were compressing too rapidly, not fully compressing the heart, not allowing full chest rebound, and not maintaining blood flow. For these reasons, the current recommendation is 100 to 120 high-quality compressions per minute. Not too slow, not too fast.
Which is not a typical cause of upper airway obstruction? A. Croup B. Anaphylaxis C. Foreign body inspiration D. Bronchiolitis
D. Bronchiolitis Rationale: Bronchiolitis is an inflammation in the bronchioles, which are small airways distal to bronchi. Bronchiolitis is a common cause of lower airway obstruction in children. The other etiologies listed are upper airway obstructions.
You are caring for a 7-year-old patient who is attached to a cardiac monitor. As you are talking and laughing with him, you look at the monitor and see a flat light. Your first intervention should be to: A. Defibrillate at 2 joules/kg B. Quickly insert an IO or IV access C. Administer epinephrine at 0.01mg/kg IV/IO D. Check the monitor leads to make sure they are attached
D. Check the monitor leads to make sure they are attached Rationale: Asystole is a form of cardiac arrest, which would cause a loss of consciousness. If the child is conscious, the most likely explanation for a "flat line" is that the leads are not properly connected.
All of the following are warning signs that compensatory mechanisms are failing except: A. Increasing heart rate above normal for the child's age and activity level B. Absent peripheral pulses C. Decreasing level of consciousness D. Increasing blood pressure
D. Increasing blood pressure Rationale: Decreased blood pressure would indicate that compensatory mechanisms are failing, as are absent peripheral pulses and decreased level of consciousness. Increased heart rate is an active compensatory mechanism.
Which of the following statements about the use of atropine is correct? A. It should be routinely used prior to endotracheal intubation B. Very small infants receive a minimum dose of 0.1 mg IV C. It is the treatment of choice for supraventricular tachycardia D. It may be used for the treatment of symptomatic bradycardia
D. It may be used for the treatment of symptomatic bradycardia Rationale: Atropine is no longer recommended for routine use prior to endotracheal intubation. The minimum dose is 0.02 mg per kilogram intravenously. Atropine is not used to treat supraventricular tachycardia.
Which of the following drugs should be routinely given to every child before endotracheal intubation? A. Atropine B. Epinephrine C. Aspirin D. None of these drugs are routinely given to children before endotracheal intubation
D. None of these drugs are routinely given to children before endotracheal intubation Rationale: Older guidelines had recommended the use of low dose atropine prior to endotracheal intubation in children to prevent paradoxical bradycardia. However, new guidelines state that atropine should not be routinely used for this purpose. Neither aspirin nor epinephrine has any use in this context.
Which of the following most likely indicates upper airway obstruction? A. Decreased inspiratory effort B. Audible breath sounds in the lungs C. Even rhythmic breathing D. Retractions during inspiration
D. Retractions during inspiration Rationale: Retractions may be a sign of upper airway obstruction since they usually indicate respiratory effort against resistance or closure of the upper airway. Even rhythmic breathing is normal as are audible breath sounds. Decreased inspiratory effort is usually a sign of disordered control of breathing.
A 10-year-old child with sinus tachycardia has adequate tissue perfusion. The most appropriate thing to do in this case is to: A. Consider using vagal maneuvers B. Consider giving adenosine C. Consider giving amiodarone D. Search for a reversible cause of the tachycardia
D. Search for a reversible cause of the tachycardia Rationale: There may be an innocuous explanation for the sinus tachycardia (e.g., the child was playing vigorously or is frightened). Vagal maneuvers and adenosine are useful for supraventricular tachycardia, but would not be the first choice for sinus tachycardia. Amiodarone could be used for supraventricular tachycardia, ventricular tachycardia with or without pulses, or ventricular fibrillation.
An 8-year-old has a pulse and heart rate of 168 bpm. The monitor shows a regular rhythm with normal QRS complexes, regular P waves, and a regular R to R pattern. What is the rhythm? A. Ventricular tachycardia B. Normal sinus rhythm C. Supraventricular tachycardia D. Sinus tachycardia
D. Sinus tachycardia Rationale: Normal QRS complexes, regular P waves, and a regular R to R pattern is sinus rhythm. The upper limit of normal for heart rate in an 8-year-old is 110 bpm, which means this patient has tachycardia.
Drugs that can be safely administered via an ET tube include all of the following except: A. Atropine B. Epinephrine C. Lidocaine D. Sodium bicarbonate
D. Sodium bicarbonate Rationale: Sodium bicarbonate should not be given through an endotracheal tube (ETT). The drugs that can be administered through an ETT are remembered by the acronym NAVEL: naloxone, atropine, vasopressin, epinephrine, and lidocaine.
All of the following are true about the Evaluate-Identify-Intervene sequence except: A. The sequence should be repeated until the pediatric patient is stable B. The sequence should be done after each intervention C. The sequence should be done when the patient's condition changes D. The sequence should only be used if the pediatric patient is responsive
D. The sequence should only be used if the pediatric patient is responsive Rationale: The Evaluate-Identify-Intervene sequence should be repeated at regular intervals during a life-saving event. The patient's clinical condition will change from moment-to-moment requiring repeated evaluations and subsequent interventions. The sequence is applied whether or not the patient is responsive.
Intraosseous (IO) access for vascular access should be avoided if: A. The child has an ET tube in place B. CPR is being done C. Attempts to start an IV have failed D. Unsuccessful IO attempts have been tried in the same bone
D. Unsuccessful IO attempts have been tried in the same bone Rationale: Intraosseous access can be placed during CPR and if an ET tube is in place. The IO route may be useful if multiple IV attempts have failed. However, if IO access has failed in a bone, one should attempt to obtain access in a different bone.
You are on a team caring for an anxious child with tachypnea, stridor on inspiration, and a "barking" cough. You should suspect: A. Disordered control of breathing B. Lung tissue disease C. Lower airway obstruction D. Upper airway obstruction
D. Upper airway obstruction Rationale: A barking cough is the classic sign of croup, which is a common cause of upper airway obstruction in children. Stridor on inspiration and tachypnea support this diagnosis.
48 A. B. C. D.
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49 A. B. C. D.
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50 A. B. C. D.
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