NREMT P-medic: Pedi

Which of the following age groups BEST defines a toddler?

1 to 3 years. A toddler is defined as a child who is between the ages of 1 and 3 years. It is at this point where they are upwardly mobile and frequently get into things that they shouldn't, hence the advent of the child cabinet locks and outlet plug covers. An infant is from age 1 month to 1 year. A preschooler is from 3 to 5 years of age. A child is older than age 5 years.

A 7-year-old boy was struck by a car while riding his bicycle. His BP is 60/40 mm Hg, pulse is 160 beats/min, and respirations are 34 breaths/min. How much IV fluid should you administer per bolus?

440 mL. You should first estimate the child's weight based on his age: (age [in years] × 2) + 8 = weight in kilograms. On the basis of this formula, a typical 7-year-old child would weigh 22 kg. Fluid boluses for children are at 20 mL/kg; therefore, this child should receive 440 mL of crystalloid fluid per bolus.

Which of the following medications and doses would you MOST likely administer to an average 4-year-old child prior to endotracheal intubation?

Atropine, 0.3 mg. Based on the formula (age [in years] × 2) + 8, an average 4-year-old child weighs 16 kg (35.2 lbs). Prior to endotracheal intubation, atropine is commonly administered to children in order to prevent a vagal-induced bradycardia; the dose is 0.02 mg/kg. Therefore, 0.32 (0.3 mg) of atropine would be appropriate for this child (0.02 × 16 = 0.32 [0.3]). In some cases, lidocaine may be given prior to intubation, especially if a head injury is present; however, the correct pediatric dose is 1 mg/kg (16 mg for this child). Although the cited doses of amiodarone and epinephrine are correct for a 16-kg child, these drugs are not given prior to intubation.

You are providing blow-by oxygen at 5 L/min to a newborn with central cyanosis. After 30 seconds, you reassess the newborn and determine that the cyanosis has not resolved. You should:

Begin positive-pressure ventilations and determine if intubation is necessary. Initial treatment for a newborn with central cyanosis—that is, cyanosis to the face and trunk—involves administering blow-by oxygen with the flowmeter set at 5 L/min. If central cyanosis persists despite the delivery of blow-by oxygen, you should begin positive-pressure ventilations (PPV). Endotracheal intubation can be considered at any point during resuscitation of the newborn; however, it should not precede adequately performed PPV. High oxygen flow rates (> 5 L/min) when delivering blow-by oxygen may cause drying of the mucosa of the newborn's eyes and should be avoided. Crystalloid fluid boluses are indicated if signs of hypovolemia are present (ie, pallor, weak or absent peripheral pulses). The need to perform chest compressions on the newborn is relatively uncommon; most cases of bradycardia can be resolved with adequately performed PPV.

You are assisting in the delivery of a baby. As soon as the head delivers, you should:

Check for the presence of a nuchal cord. As soon as the baby's head has delivered, you should quickly check to see if the umbilical cord is wrapped around the baby's neck (nuchal cord). The next step is to suction the baby's mouth and nose. It is extremely important to clear the baby's airway of fetal lung fluid prior to it taking its first breath. Once the baby has completely delivered, suctioning of the mouth and nose is repeated. Dry the baby off and keep him or her warm. Tactile stimulation (ie, flicking the soles of the feet, briskly rubbing the lateral thorax) may be needed if the baby's initial respiratory effort is poor.

A woman who is 38 weeks pregnant is in active labor. She tells you that this is her third pregnancy. Which of the following terms BEST describes her obstetric history?

Multigravida. Gravida refers to the number of times a woman has been pregnant, regardless of the length or outcome of the pregnancy. Para refers to the number of pregnancies carried beyond 28 weeks, regardless of whether the baby was born alive or dead. Primigravida describes a woman who is pregnant for the first time. Multigravida describes a woman who has been pregnant more than two times. Nulligravida describes a woman who has never been pregnant. Multipara describes a woman who has carried more than one baby beyond 28 weeks, regardless of whether the baby was born alive or dead. It cannot be said with certainty that the woman in this scenario is multiparous because it is not stated that her other two pregnancies were carried beyond 28 weeks.

A 26-year-old woman has had abdominal pain since the end of her menstrual period approximately 10 days ago. She reports that the pain is in both lower quadrants, and she has a temperature of 100.5°F. What is the MOST likely cause of her symptoms?

Pelvic inflammatory disease. Pelvic inflammatory disease (PID) typically presents within 7 to 10 days after the end of the menstrual cycle and is characterized by bilateral lower abdominal quadrant pain, low-grade fever, painful intercourse (dyspareunia), and vaginal discharge. PID is frequently the result of a sexually transmitted disease such as chlamydia or gonorrhea. Ruptured ovarian cysts and ectopic pregnancy are typically not associated with fever. The patient's clinical presentation is not consistent with acute cystitis, symptoms of which include dysuria and urinary frequency.

After delivering a baby, you clear the airway and take measures to prevent hypothermia. As you assess the newborn, you note the presence of central cyanosis and a pulse rate of 90 beats/min. Treatment should include:

Positive pressure ventilations. Central cyanosis (cyanosis of the trunk, neck, and head) and a pulse rate of less than 100 beats/min are both indicators of hypoxia in the newborn and should be treated with immediate positive-pressure ventilation (PPV). If the heart rate falls below 60 beats/min despite adequate PPV for 30 seconds, chest compressions should be started. Tactile stimulation (ie, flicking the soles of the feet, briskly rubbing the lateral thorax) is indicated if the newborn's initial respiratory effort is poor. Tracheal suctioning is indicated if there is thick, particulate meconium in the amniotic fluid and the newborn is not vigorous (eg, central cyanosis, poor muscle tone, bradycardia).

Compared to adults, children can maintain their blood pressure longer following an injury because they have a:

Proportionally larger blood volume. Compared to adults, children have a proportionally larger blood volume; however, their absolute blood volume is smaller (approximately 70 mL/kg). Because a child's circulating blood volume is large compared to an adult, injured children can maintain their blood pressure for longer periods than adults, even though they are still in shock. Compared to adults, a proportionally larger volume of blood loss must occur in the child before hypotension develops. This makes blood pressure an even less reliable indicator of perfusion in children than it is in adults. It is important to note that a child's condition will deteriorate rapidly and severely when he or she does decompensate.

A 39-year-old female, who is 35 weeks pregnant, presents with acute abdominal pain, irregular contractions, and vaginal bleeding. She is confused, her blood pressure is 70/48 mm Hg, pulse is 120 beats/min and weak, and respirations are 24 breaths/min and shallow. Her abdomen is tender to palpation and her uterus feels rigid. She is MOST likely experiencing:

Abruptio placenta. Abruptio placenta is the partial or complete detachment of the placenta beyond the twentieth week of gestation. Risk factors include multiparity, maternal trauma, maternal cocaine use, and maternal hypertension. It commonly presents with acute onset vaginal bleeding and abdominal pain in the third trimester. Bleeding may be disproportionate to the degree of shock because the placenta often falls over the cervical opening after detachment, containing much of the blood in the uterus. Other signs include abdominal pain and uterine rigidity. Placenta previa is the partial or complete implantation of the placenta over the cervical opening. Placenta previa typically presents with painless vaginal bleeding, although pain may be present in some cases. Uterine rupture typically presents with acute, tearing abdominal pain, active labor, and shock; abdominal palpation often reveals rigidity and pain, and in some cases, fetal parts. Previous cesarean sections or abdominal trauma are risk factors for uterine rupture. A spontaneous abortion is the spontaneous termination of pregnancy before the 20th week of pregnancy; this patient is 35 weeks pregnant.

A 25-year-old female who is 38 weeks pregnant tells you that her bag of waters ruptured 2 hours ago, and that she is now experiencing contractions every 6 minutes. Based on your assessment, you determine that delivery is not imminent. During transport, you should tell your partner to stop the ambulance and assist you with the patient if:

She tells you that she needs to move her bowels. Never attempt to delivery a baby in the back of a moving ambulance! While transporting a woman in labor, you must closely monitor her for signs of imminent delivery and be prepared to advise your partner to stop the ambulance and assist you with the patient. Signs of imminent delivery include regular contractions that are less than 2 minutes apart, the mother's urge to move her bowels (indicates that the baby's head is in the vagina and pressing against the rectum), and the presence of crowning (the baby's head is visible at the vaginal opening). If the mother becomes nauseated and begins to vomit, place her in a position that will prevent aspiration and provide her with an emesis basin; there is generally no need to stop the ambulance.

Which of the following signs would you expect to encounter in a 10-month-old infant with a fever?

Tachycardia. Tachycardia is a common response of the child to many factors, both intrinsic and extrinsic. It is very common to see both tachycardia and tachypnea in response to fever. Flushing (redness) of the skin is also common. Infants and small children cannot readily shiver as older children and adults can; this puts them at higher risk for hypothermia. Mottling indicates poor perfusion; it is not commonly observed in infants and children with a fever. It may, however, be observed in infants and children who are in septic shock.

During transport of a woman in labor, she tells you that she feels the urge to push. You visualize the perineum and see that the baby's head is visible at the vaginal opening. You should:

Tell your partner to stop the ambulance immediately. If en route to the hospital the mother begins to deliver the baby, as evidenced by crowning, you should first tell the driver to stop the ambulance immediately and assist you in the back with the delivery. Do NOT attempt to deliver a baby in the back of a moving ambulance; it is extremely unsafe.

Which of the following is MOST consistent with a foreign body upper airway obstruction in a child?

Acute dyspnea without a fever. You should suspect a foreign body obstruction of the upper airway in any infant or child who presents with an acute onset of dyspnea in the absence of fever. Respiratory distress in the presence of fever suggests obstruction of the upper or lower airway secondary to infection. Stridor is a high-pitched sound heard during inhalation. Stridor indicates swelling and partial obstruction of the upper airway, and in the presence of a fever, an underlying infection (ie, croup, epiglottitis). Labored breathing, drooling, and a high fever are classic signs of epiglottitis, which is now relatively uncommon in children. Rales (crackles) indicate fluid in the smaller airways in the lungs. In the presence of fever, rales suggests pneumonia; in the absence of fever, it may indicate pulmonary edema secondary to a primary cardiac problem (ie, CHF).

You are transporting a mother and her newborn baby to the hospital. As you are calling your radio report to the hospital, the mother suddenly becomes dyspneic and complains of a sharp pain to the right side of her chest. She is tachypneic, tachycardic, has a blood pressure of 98/68 mm Hg, and is developing cyanosis. She is MOST likely experiencing:

An acute pulmonary embolism. Your patient has signs of acute pulmonary embolism. An embolism may arise from a number of sources, but a blood clot in the pelvic circulation is a common cause. Leakage of amniotic fluid into the maternal circulation (amniotic embolism) and a clot arising from a DVT (pregnancy-related venous thromboembolism) are other examples of embolic processes. If a woman experiences acute dyspnea, pleuritic (sharp) chest pain, tachycardia, or hypotension in the postpartum state, suspect acute pulmonary embolism. A hallmark of acute pulmonary embolism is cyanosis that does not resolve with high-flow oxygen. Supine hypotensive syndrome is not causing this patient's problem; it is a condition that occurs before delivery and is caused by compression of the inferior vena cava by the gravid uterus when the mother is lying supine. Acute dyspnea, tachycardia, and pleuritic chest pain are common clinical findings in patients with a spontaneous pneumothorax; however, cyanosis and hypotension are not. Acute pulmonary edema is unlikely; pleuritic chest pain is not common in acute pulmonary edema, and she does not have hemoptysis (coughing up blood or blood-tinged sputum), which is common in acute pulmonary edema.

Which of the following conditions would a woman MOST likely develop if she does not take prenatal vitamins throughout her pregnancy?

Anemia. As blood volume increases during pregnancy, so does the number of red blood cells (RBCs), which increase by as much as 35%. This increase in RBCs increases the pregnant woman's need for iron; this is why most pregnant women take prenatal vitamins, which contain iron supplements. If a woman does not take iron supplements, the fetus will rob maternal stores for its needs, resulting in maternal iron-deficiency anemia. Potential complications associated with pregnancy-related anemia include preterm labor and spontaneous abortion. A woman's white blood cell count normally increases with pregnancy; however, leukopenia—a low white blood cell (leukocyte) count—is not associated with failure to take prenatal vitamins. There is no correlation between a woman's failure to take prenatal vitamins and thrombocytopenia—a low platelet count; clotting factors increase during pregnancy.

You receive a call for a 2-year-old child who is not breathing. After determining that the child is unresponsive and apneic, you should:

Assess for a carotid pulse. After determining that any patient is unresponsive and apneic, your next action should be to check for a pulse for at least 5 seconds but no more than 10 seconds. In children older than 1 year of age, assess the carotid or femoral pulse (brachial pulse in infants younger than 1 year of age). If a pulse is present, begin rescue breathing and reassess the pulse every few minutes. If a pulse is absent, begin chest compressions. It is critical to avoid any delays in starting chest compressions. If the patient is in cardiac arrest, start chest compressions first and then deliver rescue breaths. Intubation is not an immediate priority during cardiac arrest.

A 3-year-old girl is experiencing respiratory distress following an upper respiratory infection. Assessment reveals that she is listless and pale, and she has a pulse rate of 70 beats/min. You should:

Assist her ventilations with a bag-mask device. Keeping in mind that the leading cause of nontraumatic cardiac arrest in infants and children is respiratory failure, your most immediate priority in a child with signs of respiratory failure (eg, altered level of consciousness, pallor, bradycardia) should be to assist the child's ventilations with a bag-mask device attached to high-flow oxygen. After ensuring adequate ventilation and oxygenation, you should assess the child's cardiac rhythm. Atropine is rarely needed for children because bradycardia in this age group is almost always the result of hypoxia, not increased vagal tone. Monitor the child's heart rate; if it falls below 60 beats/min despite adequate ventilation and oxygenation, begin chest compressions. Auscultate the child's lung sounds; if wheezing is heard, administer a bronchodilator drug (ie, albuterol) in-line with the bag-mask device.

An 8-year-old child remains in ventricular fibrillation despite two shocks and high-quality CPR. Vascular access has been obtained, one dose of epinephrine has been given, and an advanced airway device has been placed. If the child remains in ventricular fibrillation following the third shock, you should continue CPR and then:

Give 120 mg of amiodarone. If ventricular fibrillation (V-Fib) or pulseless ventricular tachycardia (V-Tach) is refractory to defibrillation, high-quality CPR, and epinephrine, you should consider administering an antiarrhythmic—amiodarone or lidocaine (but not both). The pediatric dose for amiodarone is 5 mg/kg and 1 mg/kg for lidocaine. Using the formula (age [in years] × 2) + 8 to estimate the child's weight in kilograms (kg), an average 8-year-old child weighs 24 kg; thus he should receive 120 mg of amiodarone (24 × 5 = 120), which can be repeated twice at the same dose. Use a length-based resuscitation tape measure, if available. In pediatric patients, the maximum dose of amiodarone is 15 mg/kg/day. After an advanced airway device is placed during CPR, all patients (except for newborns) should be ventilated at a rate of 8 to 10 breaths/min (one breath every 6 to 8 seconds). If hypovolemia is suspected, a 20-mL/kg crystalloid bolus should be given (480 mL in a 24-kg child). Currently, there is no evidence to support the use of vasopressin in pediatric cardiac arrest.

A patient who is in her third trimester of pregnancy has vaginal bleeding. She is conscious and alert. Her BP is 108/68 mm Hg, her pulse is 90 beats/min and strong, and her respirations are 20 breaths/min and unlabored. You should:

Give oxygen as needed, cover her vagina with a sterile dressing, and establish IV access. The patient in this scenario is not exhibiting signs of shock. Therefore, the appropriate treatment for her includes oxygen as needed, covering her vagina with a sterile dressing, establishing IV access, and transporting her to the hospital. Set the IV at a keep-vein-open (KVO) rate, but be prepared to give fluid boluses if her condition deteriorates. Position her on her left side in order to prevent supine hypotensive syndrome. She does not require assisted ventilation at this time because her breathing is adequate (20 breaths/min and unlabored). Never pack any dressings into the vagina; doing so will not control the bleeding and increases the risk for infection. Uterine massage is indicated for postpartum bleeding; DO NOT perform uterine massage on a woman who is still pregnant.

A 2-year-old child fell from a second-story window. Based of the mechanism of injury and the anatomic differences between children and adults, you should expect that the primary impact occurred to the:

Head. Because a child's head is proportionately larger in comparison to an adult, small children tend to land head-first when they fall from a significant height as a result of gravity. This explains why falls with associated head trauma is the leading cause of traumatic death in infants and children. Adults attempt to land on their feet when they fall from a significant height.

Which of the following statements regarding the length-based resuscitation tape measure is correct?

It is used in children up to 34 kg to estimate their weight based on their height. Most drugs are administered to infants and children based on their weight. There are a number of techniques and formulae for estimating a child's weight. For example, you can estimate a child's weight in kilograms based on his or her age using the formula: (age [in years] × 2) + 8. However, most clinicians agree that height rather than age is a more precise—and thus, more reliable—estimator of weight. Use of a length-based resuscitation tape measure is considered to be the most reliable way to estimate a child's weight; it will enable you to use the most appropriate-sized equipment (eg, oral airways, ET tubes, nasogastric tubes), as well as the most appropriate drug dosages. To measure the child using the length-based tape measure, place the red end of the tape at the top (crown) of the head, covering the red box at the end of the tape. Next, stretch the tape out the full length of the child, stopping at the heel. Note the color or letter block at the heel, and select the appropriate equipment by matching the color or letter on the tape to the color or letter on the equipment. If the child is longer than the tape, use the appropriate adult technique. The length-based resuscitation tape measure is reliable in children who weigh up to 34 kg (75 lb).

A 1-year-old child presents with a decreased level of alertness, bradypnea, cyanosis, and a heart rate of 50 beats/min. You should:

Provide bag-mask ventilations. The child is in cardiopulmonary failure, as noted by his decreased level of alertness, bradypnea (slow respirations), cyanosis, and bradycardia. You must immediately restore adequate oxygenation and ventilation with a bag-mask device. Bradycardia in children is usually due to hypoxia. If not treated, respiratory arrest, followed by cardiac arrest, will occur. Bradycardia in children requires aggressive treatment if the heart rate is less than 60 beats/min with signs of poor perfusion (eg, cyanosis, decreased mentation, poor muscle tone). Cardiac monitoring is indicated; however, your initial priority is oxygenation and ventilation. If the child remains bradycardic and poorly perfused despite adequate ventilation, begin chest compressions and establish vascular access (IV or IO). Give epinephrine if bradycardia and poor perfusion persist despite ventilations and chest compressions; the dose is 0.01 mg/kg (0.1 mL/kg) 1:10,000 IV or IO. Drugs given via the ET tube have an unpredictable onset of action; the IV or IO routes are clearly preferred. However, if intubation is necessary and vascular access cannot be established, give epinephrine via the ET tube (0.1 mg/kg [0.1 mL/kg] 1:1,000). Do not give epinephrine to a bradycardic child before establishing adequate ventilation and oxygenation!

Which of the following is the MOST appropriate action to take when you suspect child abuse?

Provide thorough objective documentation. Thorough objective documentation of the scene and your physical examination findings is vital in cases of suspected abuse. By law, you must report any and all cases of suspected abuse to the proper authority, which is the physician at the receiving hospital, who in turn has a legal obligation to notify child protective services (CPS). You should never confront or accuse the parents or caregivers of abuse because this could result in slander on your part if you are wrong. In addition, you must obtain consent from at least one parent prior to transporting the child, otherwise you may be held liable for kidnapping.

Initial management of a 5-year-old child in status epilepticus should focus on:

Providing adequate ventilatory support. Seizure deaths are hypoxic deaths; therefore, your initial focus on a child who is actively seizing, especially one in status epilepticus, is to provide adequate ventilatory support. Be sure to protect the seizing patient from injury. Once this has been addressed, measures aimed at stopping the seizure, which may include rectally-administered diazepam (Valium), would be your next priority. Obtain a blood glucose reading on any patient with an altered level of consciousness, including those experiencing seizures, and administer dextrose as needed. Apply the cardiac monitor and assess the child's cardiac rhythm after ensuring adequate ventilation and oxygenation.

Management of a woman who has been sexually assaulted should include:

Recognizing the patient as a crime scene. A patient that has been sexually assaulted (male or female) should be considered a walking crime scene. Of course, management of any life-threatening problems has priority, and you should not wait for law enforcement to arrive before performing any treatment (especially life-saving treatment). The patient should be discouraged (not forbade) from changing clothes, bathing, or douching. Wounds should not be cleaned as potential evidence may be destroyed. It is preferable to have an EMT or paramedic of the same sex assess the patient when possible.

Which of the following statements regarding isoimmunization (Rh disease) is correct?

Rh disease is most prominent with subsequent pregnancies and occurs when an Rh-negative mother becomes pregnant by a man with Rh-positive blood. Rh factor is a protein found on the red blood cells (RBCs) of most people. When this factor is absent, the person is said to be Rh negative. When a woman who is Rh negative becomes pregnant by a man who has the factor (Rh positive) and the fetus inherits this factor, the fetal blood can pass into the mother's circulation and produce maternal antibodies (isoimmunization) to the factor. Rh disease is normally not a problem in first pregnancies; however, in subsequent pregnancies, the antibody will aggressively cross the placental barrier to attack the fetal RBCs, which the mother's body identifies as foreign proteins. This attack can result in death of the fetus or cause hemolytic disease (erythroblastosis fetalis) in a newborn. Newborns with hemolytic disease may present with jaundice, anemia, and hepatomegaly (an enlarged liver). RhoGAM (Rho[D] immune globulin) contains IgG anti-D (anti-RhD) antibodies, which bind and destroy fetal Rh D-positive RBCs that have passed through the placenta from the fetus to the maternal circulation. RhoGAM, an intramuscular (IM) injection, is given to Rh-negative women who become pregnant by Rh-positive men; it prevents the woman's body from attacking subsequent Rh-positive pregnancies.

Emergency care for a child with suspected anemia should include:

Supplemental oxygen and transport. Anemia, a decreased red blood cell count, cannot be treated definitively in the prehospital setting. Therefore, your focus should be to provide supportive care (ie, maintaining the ABCs, administering oxygen) and transporting the patient to the hospital where identification and correction of the underlying cause can be provided.

Which of the following statements regarding fetal circulation in utero is correct?

The ductus arteriosus and foramen ovale divert blood flow away from the fetus's lungs. In utero, the fetus's lungs are full of fluid; therefore, its blood must be oxygenated by the mother via the umbilical cord and placenta. The foramen ovale shunts oxygenated blood from the fetus's right atrium directly into the left atrium, thus diverting blood flow away from the lungs. The ductus arteriosus connects the pulmonary artery and the aorta; it also diverts blood flow away from the lungs. Following delivery, the foramen ovale and ductus arteriosus constrict, which, in combination with an increase in fetal pulmonary circulation and clearance of fluid from the fetus's alveoli, allows the newborn to oxygenate its own blood. The ductus venosus transports oxygenated blood from the placenta to the fetus; it empties directly into the fetus's vena cava. The two umbilical arteries return deoxygenated blood and other wastes from the fetus to the placenta, where it is subsequently eliminated by the maternal circulation.

You are assessing an injured 4-year-old child and suspect that his injury was intentionally inflicted. Which of the following findings should increase your suspicion of this?

the injury occurred several hours before EMS was called. Your index of suspicion for child abuse should increase when there is an unreasonable delay in seeking care for the child; several hours is clearly an unreasonable delay. When a child is injured, a prudent parent summons help immediately. You should also be alert to the possibility of abuse if the child is withdrawn or avoids contact with his or her caregiver(s), if there are inconsistencies between caregivers regarding how the injury occurred, or if the mechanism of injury is beyond the developmental abilities of the child. Bruises to the tibias are a common injury pattern in small children, usually from bumping into furniture. Hematomas to the forehead and lacerations to the chin are also common injury patterns. Remember, you do not need proof that abuse occurred before you report your findings, only suspicion.

You are performing CPR on a 3-month-old infant in asystole and have established intraosseous access. The correct dose and concentration of epinephrine for this infant is:

0.01 mg/kg 1:10,000. The pediatric dose of epinephrine when administered via the IV or IO route is 0.01 mg/kg (0.1 mL/kg) of a 1:10,000 solution. If vascular access is not available, epinephrine can be given via the endotracheal tube; the dose is 0.1 mg/kg (0.1 mL/kg) of a 1:1,000 solution.

Which of the following is the appropriate intraosseous dose and concentration of epinephrine for a 5-year-old, 40-pound child in cardiac arrest?

1.8 mL of a 1:10,000 solution. A 40-pound child weighs 18.18 (18) kg. When given via the intravenous (IV) or intraosseous (IO) route, you should use a 1:10,000 solution of epinephrine and give 0.01 mg/kg (0.1 mL/kg). Therefore, an 18-kg child should receive 0.18 mg (1.8 mL) of epinephrine 1:10,000, followed by a 5 mL saline flush, every 3 to 5 minutes. A 1:1,000 solution (0.1 mg/kg [0.1 mL/kg]) should be used if epinephrine is given via the ET tube in infants and children.

Assessment of a 9-month-old infant reveals decreased interactiveness, poor skin turgor, dry mucous membranes, delayed capillary refill, and a heart rate of 190 beats/min. Which of the following is the MOST appropriate rate for fluid rehydration?

20 mL/kg. According to the American Academy of Pediatrics (APP) children older than 1 month of age should receive 20 mL/kg fluid boluses, followed by a reassessment, if they have severe dehydration and signs of shock. Neonates (birth to 1 month of age) should receive 10 mL/kg fluid boluses.

In a 6-year-old child, the low normal systolic blood pressure is ____ mm Hg, the high normal systolic blood pressure is ____ mm Hg, and the average systolic blood pressure is ____ mm Hg.

82, 102, 92. For children between 1 and 10 years of age, the low normal systolic blood pressure (SBP) is estimated by using the following formula: low normal SBP = (age [in years] × 2) + 70. Therefore, the low normal SBP for a 6-year-old child is 82 mm Hg (12 [6 × 2] + 70 = 82). In this same age group, the high normal SBP is estimated by using the following formula: high normal SBP = (age [in years] × 2) + 90. Therefore, the high normal SBP for a 6-year-old child is 102 mm Hg (12 [6 × 2] + 90 = 102). Thus, the average SBP for a 6-year-old child is 92 mm Hg (82 [low normal] + 102 [high normal] = 184 ÷ 2 = 92). It is important to note that these are general parameters, not exact numbers. Other hemodynamic parameters (eg, peripheral pulses, skin condition, mental status) must be assessed.

A 4-year-old child remains in supraventricular tachycardia following an initial dose of adenosine. The appropriate second dose of adenosine for this child is:

3.2 mg. The initial dose of adenosine (Adenocard) for an infant or child is 0.1 mg/kg rapid IV/IO push. Although a parent or caregiver will often be present to tell you how much the child weighs, you must still be able to estimate his or her weight in kilograms (kg). For example, if a babysitter is taking care of the child, he or she will likely not know how much the child weighs. To estimate a child's weight in kilograms, use a length-based resuscitation tape measure (for children up to 34 kg [75 lb]) or this formula: (age [in years] × 2) + 8. On the basis of this formula, an average 4-year-old child weighs 16 kg (8 [4 × 2] + 8 = 16). Therefore, the appropriate initial dose of adenosine for this child is 1.6 mg (16 × 0.1 = 1.6). Do not exceed 6 mg for the initial dose. If needed, repeat adenosine at a dose of 0.2 mg/kg. For a 16-kg child, the second dose of adenosine is 3.2 mg (16 × 0.2 = 3.2). Do not exceed 12 mg for the second dose.

A 4-year-old child has partial-thickness burns to the entire face and head, anterior torso, and both anterior upper extremities. What percentage of the total body surface area does this represent?

42%. The Rule of Nines is modified accordingly for infants and children. For infants (less than 1 year of age), the head and face (front and back) represents 18% of the total body surface area (TBSA), the torso represents 36% (front and back), each upper extremity represents 9% (front and back), the groin represents 1%, and each lower extremity represents 13.5% (front and back). For each year over 1 year of age, subtract 1% from the head and add 0.5% to each lower extremity; use this formula until adult Rule of Nine values are reached. Based on this age modification, a 4-year-old child's head and face represents 15% (3% is subtracted from the head based on his age), the anterior torso represents 18%, and both anterior upper extremities represent 9%. Cumulatively, this represents 42% of the TBSA.

Evaluation of a newborn reveals that it has a pink body, but blue hands and feet; a strong cry; a pulse rate of 110 beats/min; and some spontaneous flexion of the extremities. It pulls its leg away when stimulated. You should assign an APGAR score of:

8. According to the APGAR scoring system, the newborn receives 1 point for appearance (pink body, blue hands and feet), 2 points for pulse rate (greater than 100 beats/min), 2 points for grimace/irritability (cries or pulls away when stimulated), 1 point for activity/muscle tone (some flexion of the extremities), and 2 points for respiratory effort (strong cry). Therefore, an APGAR score of 8 should be assigned.

A 7-year-old, 45-pound child is in cardiac arrest. The ECG shows ventricular fibrillation. If the first defibrillation is unsuccessful, you should defibrillate with:

80 joules. A 45-pound child weighs 20.45 (20) kg. The initial defibrillation energy setting for infants and children is 2 j/kg. Therefore, the first shock should be at 40 joules. If this is unsuccessful, the second shock should be delivered at 4 j/kg (after 2 minutes of CPR), which in a 20-kg child, is 80 joules. Subsequent shocks should be greater than or equal to 4 j/kg, with a maximum energy setting of 10 j/kg or the adult dose.

You are assessing a 7-year-old boy who has signs of shock. What is the low normal systolic blood pressure for a child of this age?

80 to 85 mm Hg. When estimating the low normal systolic blood pressure for a child between 1 and 10 years of age, use this formula: (age [in years] × 2) + 70. Therefore, the low normal systolic blood pressure for a 7-year-old child would be 80 to 85 mm Hg (7 [age in years] × 2 = 14 + 70 = 84). When estimating the high normal systolic blood pressure for a child between 1 and 10 years of age, use this formula: (age [in years] × 2) + 90.

Which of the following represents the low normal systolic blood pressure for a 6-year-old child?

82 mm Hg. In children between 1 and 10 years of age, the low normal systolic blood pressure (SBP) is calculated as follows: (age [in years] × 2) + 70. Therefore, the low normal SBP for a 6-year-old child is 82 mm Hg (6 [age in years] × 2) = 12 + 70 = 82. The high normal SBP in this same age group is calculated as follows: (age [in years] × 2) + 90.

If a small child accidentially pulled a pot of boiling water off of the stovetop, you would MOST likely encounter:

A downward splash pattern of superficial and partial-thickness burns to the anterior aspect of the body.

Following delivery, a newborn has a thick dark green substance around its mouth. The newborn has a strong cry, peripheral cyanosis, and a pulse rate of 120 beats/min. You should:

Administer blow-by oxygen and continue your assessment. According to the American Academy of Pediatrics, if a newborn is born with meconium in the amniotic fluid, further treatment will depend on whether or not the newborn is vigorous. A vigorous newborn has adequate breathing, as evidenced by a strong cry; a heart rate greater than 100 beats/min; and good muscle tone. The newborn in this scenario is vigorous; therefore, appropriate treatment should include administering blow-by oxygen and continuing your assessment. If the newborn with meconium is not vigorous (eg, poor breathing effort, poor muscle tone, bradycardia, central cyanosis), you should visualize the vocal cords and suction the trachea with a meconium aspirator attached to an endotracheal tube.

A newborn's mouth and nose are initially suctioned:

As soon as the head delivers, but before the next contraction. As soon as the newborn's head has delivered, perform a quick assessment to ensure that the amniotic sac has ruptured and is not encasing the newborn's face, and that a nuchal cord (umbilical cord wrapped around the neck) is not present. After this quick assessment—and any intervention needed—suction the newborn's mouth and nose. It is important to do this before the next contraction occurs, during which the shoulders and chest will deliver. Most newborns take their first breath following delivery of the shoulders and chest. Pressure in the birth canal inhibits chest expansion (and breathing), thereby decreasing the possibility of aspiration if the first breath occurs before the mouth and nose can be suctioned. After thoroughly suctioning the mouth and nose, deliver the rest of its body, immediately dry it off and keep it warm, and place it in a supine position with its head in a sniffing position. You may also place the newborn on its side, which will facilitate drainage of fetal lung fluid. After the newborn has been properly dried, warmed, and positioned, resuction its mouth and nose to ensure further clearance of fetal lung fluid from its airway. Suction the mouth and nose before assessing the newborn's respiratory effort; the airway must be clear before breathing can be assessed.

Abdominal pain, vaginal bleeding, and amenorrhea in a 25-year-old female should make the paramedic MOST suspicious for:

An ectopic pregnancy. Abdominal pain, with or without vaginal bleeding, in a female of childbearing age is an ectopic pregnancy until ruled out by a physician. An ectopic pregnancy occurs when the fertilized egg implants outside of the uterus, usually in a fallopian tube (tubal pregnancy). In rare cases, the egg may implant elsewhere in the abdominal cavity. Because the fallopian tubes are extremely narrow, even the slightest growth of the egg will cause symptoms; thus, ectopic pregnancy is an early (within the first 6 to 8 weeks) first trimester emergency. Patients with an ectopic pregnancy present with lower abdominal pain (typically unilateral), which may radiate to the back. In some cases, vaginal bleeding is absent; in other cases, vaginal bleeding is the only presenting sign. The patient often reports amenorrhea (absence of a menstrual period). Excessive bleeding associated with rupture can lead to shock. Risk factors for ectopic pregnancy include abdominal adhesions from surgery, history of pelvic inflammatory disease (PID), tubal ligation, and intrauterine device (IUD) use. A ruptured ovarian cyst also causes abdominal pain; however, most ruptures occur about a week before the patient's menstrual period is expected to begin, thus, a history of amenorrhea is usually absent. Women who experience a spontaneous abortion, delivery of the fetus and placenta before 20 weeks' gestation, know they are pregnant; women with an ectopic pregnancy do not. Pelvic inflammatory disease typically presents with a foul-smelling vaginal discharge, abdominal pain, and fever; vaginal bleeding and amenorrhea are uncommon.

A 4-year-old boy has a high fever and deep, rapid respirations. The child's mother states that she thinks her child got into the medicine cabinet. Which of the following medications has the child MOST likely ingested?

Aspirin. Aspirin (acetylsalicylic acid [ASA]) toxicity produces a high fever (hyperpyrexia) and metabolic acidosis. As the respiratory system attempts to rid the body of the excess acid and hydrogen ions, the patient's respirations become deep and rapid. Acetaminophen (APAP) toxicity result in liver damage or failure. Codeine is a narcotic and will depress the central nervous system, causing hypoventilation, bradycardia, and hypotension. Ibuprofen toxicity typically result in gastrointestinal damage.

You receive a call for an 18-month-old female who is not breathing. When you arrive at the scene, emergency medical responders are providing effective two-rescuer CPR. According to the child's father, she had a cough and runny nose for the past several days, but when he tried to wake her up from her nap, she was unresponsive. When you apply the cardiac monitor, you will MOST likely see:

Asystole. Primary ventricular dysrhythmias (ie, V-Fib, pulseless V-Tach) are uncommon in infants and children, although research has indicated that at some point during cardiopulmonary arrest, some children are in a "shockable" rhythm. Since most cases of cardiopulmonary arrest in the pediatric population are the result of respiratory failure, you would most likely encounter asystole or bradycardic PEA—signs of prolonged hypoxia—during the initial cardiac rhythm analysis. The child's prearrest history (ie, cough, runny nose) suggests respiratory failure as the precursor to her cardiopulmonary arrest.

You respond to a daycare center for a 2-year-old female who is having a seizure. Upon arrival, you find the child lying in a bed. She is no longer seizing, but her level of alertness is decreased. Her skin is hot to the touch and she is tachypneic and tachycardic. According to a daycare center employee, she picked up the child after the seizure stopped, but the child began crying uncontrollably. You should suspect that this child has:

Bacterial meningitis. Your initial impression of this child may be that she experienced a febrile seizure. However, there are some key clinical signs that point to bacterial meningitis. Following a febrile seizure, the postictal state—if there is one—is generally short-lived, and the child's mental status has often returned to baseline by the time you arrive at the scene. Furthermore, most children who are sick or injured are consoled after being picked up. However, a child who begins to cry—or cries worse—upon being picked up is likely in severe pain due to traction being pulled on the inflamed meninges of the spinal cord; this is called paradoxical irritability. The presence of "hot" skin indicates a high fever, which is more common with bacterial infections. There is no evidence that a toxic ingestion occurred, although you should inquire about the possibility. Febrile seizures occur when a child's body temperature acutely rises; they are typically benign and do not cause neurologic damage. Bacterial meningitis, however, is a life-threatening infection of the central nervous system that can result in severe sepsis, permanent neurologic damage, or death. Febrile seizures and seizures with a fever are NOT the same thing.

Which of the following cardiac rhythms would you MOST likely encounter in a 6-month-old infant with lethargy, profound respiratory distress, and an oxygen saturation of 79%?

Bradycardia with or without AV block. Bradycardia is an ominous sign in infants and children with a respiratory problem; it indicates severe hypoxia, decompensation, and impending respiratory or cardiac arrest. Idioventricular rhythms are generally not associated with a pulse, which this infant obviously has. Tachycardia in infants and children, as with adults, is often the result of conditions such as fear, fever, pain, or hypovolemia. However, when an infant or child is in the early (compensated) stages of respiratory distress, tachycardia is commonly observed. Supraventricular tachycardia (SVT), which, in the infant, is characterized by a ventricular rate greater than 220 beats/min (greater than 180 beats/min in children) and no beat-to-beat variability with movement (eg, the ventricular rate remains fixed despite patient movement), may indicate a primary cardiac problem that is not related to hypoxemia. Ventricular abberancy (ie, bundle branch block) is not commonly observed in infants and children.

A child with respiratory failure would MOST likely present with:

Bradypnea. Respiratory failure occurs when pulmonary respiration—that is, the exchange of O2 and CO2 in the lungs—is severely impaired. This causes a decrease in the PaO2 and an increase in the PaCO2, resulting in respiratory acidosis. Clinical manifestations of respiratory failure in a child include lethargy, bradypnea (slow respirations), bradycardia, and central cyanosis. Tachycardia, head bobbing, and marked irritability are signs of respiratory distress. Left untreated, respiratory failure will progress to respiratory arrest, which in children, is the most common cause of cardiopulmonary arrest.

A 9-month-old infant presents with respiratory distress. On appearance, the infant is active and has moderate retractions. Your assessment reveals diffuse wheezing; pink, warm, dry skin; and an oxygen saturation of 92%. This infant is MOST likely experiencing:

Bronchiolitis. Bronchiolitis—inflammation of the bronchioles—is caused by a viral infection and most commonly affects children less than 2 years of age. The most common source of this disease is respiratory syncytial virus (RSV), although a new virus, metapneumovirus, has also been found to cause bronchiolitis. The clinical presentation of bronchiolitis is similar to that of asthma—wheezing, respiratory distress, and hypoxemia. However, asthma is rare in children less than 12 months of age. Furthermore, asthma is typically not associated with a fever, whereas bronchiolitis may present with a low-grade fever. Croup is a viral infection of the upper airway; it most commonly affects children between 6 months and 6 years of age. Classically, croup is associated with a barky cough and low-grade fever; increased work of breathing and stridor are often noted in more severe cases. Because croup affects the upper airway, wheezing is generally not noted. Pneumonia typically presents with fever and coarse crackles on auscultation of one or more lobes of the lungs; in severe cases, signs of sepsis may be present.

The purpose of the transition phase of pediatric assessment is to:

Build trust by allowing the child to become familiar with you, your partner, and your equipment. The transition phase of pediatric assessment facilitates the building of trust and the reduction of anxiety by familiarizing the child with you, your partner and other crew members, and your medical equipment (eg, stethoscope, BP cuff, penlight, etc). To an older child or adult, a stethoscope is a harmless piece of equipment; to a small child, however, it is a torture device! It is important to note that the transition phase is only appropriate for children who are clinically stable. A clinically unstable child needs immediate treatment and transport—not a tour of your ambulance. The transition phase should continue during subsequent assessment of the child, provided that the he or she remains clinically stable.

Treatment for an unresponsive 18-month-old child with a severe foreign body airway obstruction includes:

CPR, followed by attempts to visualize and remove the obstruction under direct laryngoscopy. In a severe (complete) foreign body airway obstruction, no air exchange is occurring. All unresponsive patients with a severe airway obstruction should receive CPR. In the infant or child, perform 30 chest compressions (15 compressions if two rescuers are present), open the airway and visualize the mouth (remove the obstruction with a finger sweep only if you can see it), and attempt to ventilate. Repeat this procedure several times. If this is unsuccessful, continue chest compressions, visualize the airway with a laryngoscope (direct laryngoscopy), and attempt to remove the obstruction with Magill forceps if you can see it. Back slaps and chest thrusts are appropriate for a responsive infant with a severe airway obstruction, and abdominal thrusts are appropriate for responsive children and adults with a severe airway obstruction. The narrowest portion of a child's airway is at the cricoid ring; therefore, many airway obstructions occur at this level. As a result, a cricothyrotomy may not be successful because the cricothyroid membrane is above the level of the cricoid ring. Direct laryngoscopy is less invasive and should be attempted first. Supraglottic and perilaryngeal airway devices are of no benefit to patients with a severe airway obstruction because their function relies upon an unobstructed trachea.

Upon delivery of an infant's head, you note that its face is encased in the amniotic sac and a nuchal cord is present. You should:

Clear the membrane away from the infant's face and attempt to slip the cord from around the neck. If the amniotic sac is covering the infant's head as it delivers, simply rupture it by pinching it with your fingers to permit drainage of amniotic fluid and enable the infant to breathe. In most cases, a nuchal cord (umbilical cord wrapped around the neck) is loose and is not a significant problem. However as the infant descends down the birth canal, the cord can become compressed, resulting in fetal bradycardia and distress. Gently attempt to slip the cord from around the infant's neck and over its head. If this maneuver fails, place umbilical clamps 2" apart, cut the cord in between the clamps, suction the infant's mouth and nose, and continue with the delivery. As soon as the infant's head has delivered, ask the mother to stop pushing so you can assess for a nuchal cord as well as suction the infant's mouth and nose.

A slow onset of a low-grade fever and respiratory distress in a 3-year-old child is MOST characteristic of:

Croup. Croup, or laryngotracheobronchitis, is a viral upper respiratory infection that typically affects children between the ages of 6 months and 4 years. It is characterized by a slow onset of a low-grade fever and a classic "seal-bark" cough. In some cases, croup can progress to respiratory distress and failure. Epiglottitis, which is a bacterial infection, produces a rapid onset of high fever, difficulty breathing, and is accompanied by signs such as drooling, difficulty swallowing, and inspiratory stridor. Epiglottitis is not as common in children as it used to be, but when it occurs, it affects children between the ages of 3 to 7 years. Asthma is not an infectious process and does not present with fever; it is a lower airway disease characterized by wheezing and varying degrees of respiratory distress. Asthma is rare in children less than 1 year of age. Bronchitis is a lower airway infection characterized by a productive cough and fever. In some cases, bronchitis can lead to respiratory distress and failure, especially in younger children.

A 33-year-old female presents with a headache, extreme weakness, chills, and a high fever for the past 10 days. She denies vaginal discharge, urinary difficulty, or painful intercourse. Assessment of her abdomen reveals palpable tenderness to the left upper quadrant. Which of the following is the MOST likely cause of her symptoms?

Cytomegalovirus. Cytomegalovirus (CMV) is a member of the herpesvirus family. This very common viral infection has no known cure, and can remain dormant in the body for years. An estimated 80% of the US population has been exposed to CMV. In its active stages, signs and symptoms of CMV include prolonged high fever, chills, headache, malaise, extreme fatigue, and an enlarged spleen—called splenomegaly—which would explain the patient's left upper quadrant abdominal pain. Although chlamydia, gonorrhea, and trichomoniasis can all cause fever, these are unlikely in this patient for several reasons. Pain during intercourse (dyspareunia) is common in patients with chlamydia, gonorrhea, and trichomoniasis; patients with CMV infection do not experience this. Foul-smelling vaginal discharge and painful urination (dysuria), both of which the patient denies, are very common in women with gonorrhea and trichomoniasis. If present, abdominal pain associated with chlamydia is typically located in the lower abdominal quadrants (lower back pain may also be present); this patient has pain isolated to her left upper quadrant. Women with chlamydia often complain of bleeding between menstrual periods; this is not common in women with CMV infection.

A woman is in labor and you are trying to determine if delivery is imminent. Which of the following questions would be the MOST pertinent to ask the patient?

Do you feel the urge to push? With the exception of crowning, one of the most reliable indicators of imminent delivery is when the mother feels the urge to push. This indicates that the baby is in the birth canal and is resting on top of the rectum. Rupture of the amniotic sac indicates that delivery is near but not necessarily imminent. There is no correlation between the length of labor with her last child and imminent delivery with this child. Although the first stage of labor is generally shorter in multigravida women than it is in primigravida women, multigravida women can remain in the first stage of labor for many hours, and primigravida women can progress through all stages of labor in less than 2 hours.

You and your team are performing CPR on an 8-year-old female who is in cardiac arrest. You have reason to believe that the child ingested her mother's amitriptyline. Reassessment after 2 minutes of CPR reveals that the child is in ventricular fibrillation. You should:

Defibrillate and immediately resume CPR. Defibrillation is a critical intervention for any patient with ventricular fibrillation (V-Fib) or pulseless ventricular tachycardia (V-Tach)—regardless of the suspected underlying cause—and should be performed without delay. In the infant or child, defibrillate one time with 2 J/kg, followed immediately by CPR. After 2 minutes, reassess the child. If V-Fib or pulseless V-Tach persists, defibrillate one time with 4 J/kg followed immediately by CPR. Subsequent shocks should be delivered every 2 minutes, as needed, at a dose that is greater than or equal to 4 J/kg (up to 10 j/kg). Assessing for a pulse in an unresponsive patient—infant, child, or adult—when the cardiac monitor clearly displays ventricular fibrillation will only cause unnecessary delays in defibrillation and CPR. During the 2 minutes that you are performing CPR (in between shocks), secure the airway with an advanced device (if needed), establish vascular access, and administer epinephrine. Amitriptyline (Elavil) is a tricyclic antidepressant drug. If you suspect this as the cause of the patient's cardiac arrest, sodium bicarbonate should be considered. Sodium bicarbonate is used to alkalinize the blood and promote excretion of the drug. Consult medical control or follow your local protocols regarding the pediatric dose for sodium bicarbonate.

Which of the following is the earliest sign of shock in an 18-month-old child?

Delayed capillary refill. A delayed (> 2 seconds) capillary refill time is a reliable early sign of early shock in children younger than 6 years of age. Remember that factors such as cold temperatures can increase capillary refill time. A rapid, thready (weak) pulse is a later sign of shock in any patient. A slow, bounding pulse and bulging fontanelles are signs of increased intracranial pressure.

A 24-year-old woman presents with severe nausea and vomiting for the past 36 hours. She tells you that she is 12 weeks pregnant with her first child. She is tachycardic, lightheaded, and extremely weak. You administer oxygen, begin transport, establish vascular access, and give her IV fluid boluses en route. Which of the following medications would MOST likely control her nausea and vomiting?

Diphenhydramine. Your patient likely has hyperemesis gravidarum, a condition of persistent nausea and vomiting during pregnancy. Hyperemesis gravidarum is a serious condition that may cause dehydration and malnutrition, which can have negative effects on the fetus. The condition is most common in first-time pregnancies, multiple gestations, and in obese woman; it is most prevalent between the eighth and twelfth weeks of pregnancy. Women with hyperemesis gravidarum often experience 3 or 4 (or more) episodes of vomiting per day. Treatment includes fluid rehydration and an antiemetic, such as promethazine (Phenergan) or ondansetron (Zofran). Diphenhydramine (Benadryl), an antihistamine, can also be given; the dose is 10 to 50 mg by deep IM or IV injection (pregnancy category B). Although primarily used to treat allergic reactions, diphendydramine possesses antiemetic properties. Terbutaline (Brethine), magnesium sulfate, and calcium chloride have no antiemetic properties. Terbutaline is a beta-2 agonist used for bronchospasm. Magnesium sulfate is used to treat eclamptic seizures, among other conditions. Calcium chloride is used to treat calcium-channel blocker toxicity, hyperkalemia, and as an antidote to counter the CNS depressant effects of magnesium sulfate.

You respond to a call for a 4-year-old girl who has had a seizure. When you arrive, you find that the child is in her mother's arms and crying. Which of the following questions would be the MOST pertinent to ask the mother initially?

Does the child have a history of seizures? All of the options in this question are pertinent questions to ask when a child experiences a seizure. However, you should immediately establish if the child has a history of seizures. This information will allow you to adjust further questioning accordingly (ie, recent fever or head injury, stiff neck, etc).

While assisting in the delivery of a baby, you note that a loop of the umbilical cord is protruding from the vagina, just ahead of the presenting part of the fetus. As your partner applies high-flow oxygen to the mother, you should:

Elevate her hips, instruct her to pant with each contraction, and gently push the baby back up into the vagina. With a prolapsed umbilical cord, the cord emerges from the uterus ahead of the baby. With each uterine contraction, the cord is then compressed between the presenting part of the baby and the bony pelvis, shutting off the baby's supply of oxygenated blood from the placenta. Fetal asphyxia may ensue if circulation through the cord is not rapidly reestablished and maintained until delivery. Treatment for a prolapsed umbilical cord begins by administering high-flow oxygen and positioning the mother so that her hips are elevated. Hip elevation may allow the presenting part of the fetus to recede slightly back into the birth canal, thus relieving pressure off of the cord. Instruct the mother to pant with each contraction, which will prevent her from bearing down. Do not instruct her to push with each contraction; doing so will further compress the cord! With two fingers of your gloved hand, gently push the baby (not the cord) back up into the vagina until the presenting part no longer presses on the cord. While you maintain pressure on the presenting part, have your partner cover the exposed portion of the cord with sterile, moist dressings. You must maintain that position, with a gloved hand pushing the presenting part of the baby away from the cord, throughout transport to the hospital.

A 29-year-old female presents with lower abdominal pain and scant vaginal bleeding. She recently had a dilation and curettage (D&C) procedure following a spontaneous abortion. Her blood pressure is 108/68 mm Hg, pulse is 110 beats/min, and respirations are 20 breaths/min. Her temperature is 102.4°F. You should be MOST suspicious for:

Endometritis. Endometritis is an inflammation of the inner uterine lining (endometrium), usually due to infection. It may also occur following gynecologic surgery (ie, D&C), abortion, or intrauterine device use. Symptoms include malaise, fever, constipation, vaginal bleeding or discharge, and lower abdominal or pelvic pain. Endometritis may lead to septic shock if untreated. Endometriosis is a condition in which endometrial tissue grows outside the uterus, usually on the abdominal and pelvic organs. Symptoms include pain localized in the lower back, pelvis, and abdomen; painful bowel movements during menses, fatigue, escalating menstrual cramps, and heavy vaginal bleeding. Fever is usually absent. Pelvic inflammatory disease (PID) is an infection of the female reproductive organs; it occurs almost exclusively in sexually active women. In PID, disease-causing organisms enter the vagina during intercourse and invade the uterine cavity. The infection may spread to the fallopian tubes and ovaries. PID presents with severe abdominal pain and fever. An ovarian cyst is a fluid-filled sac that forms on or within an ovary. In a functional cyst, the ovaries form tiny sacs (cysts) during the menstrual cycle to hold the eggs. Once the egg matures, it is released from the sac, which subsequently dissolves. If the sac seals itself after release of the egg, fluid accumulates in it, the cyst begins to grow (corpus luteum cyst), and the patient experiences abdominal pain on the side of the cyst; fever is usually absent.

You are transporting a woman who is 35 weeks pregnant. The patient complains of abdominal cramping, but denies vaginal bleeding. An IV of normal saline has been established and she is receiving supplemental oxygen. As you are reassessing her, she tells you that she is extremely lightheaded. Her skin is diaphoretic and her pulse is rapid and weak. You should:

Ensure that she is positioned on her left side. From around the middle of the second trimester through the end of the pregnancy, the pregnant patient is at risk for supine hypotensive syndrome if she lies in a supine position. Supine hypotensive syndrome is a condition in which the gravid uterus compresses the inferior vena cava (IVC), resulting in a reduction in cardiac output by as much as 25%. If the patient experiences signs of reduced cardiac output (ie, lightheadedness, tachycardia, hypotension), you should immediately ensure that she is positioned on her left side. This simple intervention is often all that is needed to shift the uterus off of the IVC and improve cardiac output. If the patient's condition does not improve following positioning, infuse an isotonic crystalloid solution as needed until hemodynamic stability is achieved. If the patient's condition is refractory to positioning and IV fluid boluses, continue treatment as needed and notify the receiving facility of the patient's condition. Contact medical control if dictated by your local protocols.

Following delivery of a baby who was born at 38 weeks, you note the presence of thick particulate meconium in the amniotic fluid. The newborn has a strong cry, a heart rate of 120 beats/min, good muscle tone, and central cyanosis. You should:

Ensure the newborn is warm and dry, suction its mouth and nose, and administer blow-by oxygen. Meconium, a greenish-black tar-like substance, is the baby's first bowel movement, which usually occurs during the first 24 hours postpartum. If the fetus is distressed in utero, however, it may void the meconium into the amniotic fluid. Because meconium is thick, partial or complete airway blockage may occur. The fetus may also aspirate meconium into its lungs. Complications of meconium aspiration include atelectasis, persistent pulmonary hypertension, and pneumonitis. True meconium aspiration has a high fetal mortality rate. If meconium is present in the amniotic fluid at birth, determine if it is thin and green or thick and particulate. If the infant is vigorous (eg, strong cry, adequate breathing, good muscle tone, heart rate above 100 beats/min), tracheal suctioning is not indicated; perform standard interventions (eg, drying, warming, positioning, suctioning the mouth and nose). If the newborn is not vigorous, do not dry or stimulate him or her. Attach a meconium aspirator and suction tubing to the end of an ET tube, visualize the trachea, and suction in between the vocal cords while withdrawing the ET tube from the trachea. Repeat this until you have cleared as much meconium from the trachea as possible. The newborn in this scenario is vigorous, despite the presence of thick meconium; therefore, tracheal suctioning is not indicated. Dry and warm the newborn and suction its mouth and nose as usual. The presence of central cyanosis, however, necessitates blow-by oxygen, which can be delivered via oxygen tubing or mask, at a flow rate of 5 L/min.

CPR is in progress on a 3-year-old child with asystole. The airway is being properly managed and vascular access has been obtained. Which of the following drug-dose combinations is MOST appropriate to give via the IV or IO route?

Epinephrine, 1.4 mL 1:10,000. During cardiac arrest, epinephrine is given based on the child's weight in kilograms. In children 1 year of age and older, use the following formula to estimate the child's weight in kilograms: (age [in years] × 2) + 8. Thus, an average 3-year-old child would weigh 14 kg (3 [age in years] × 2) = 6 + 8 = 14. When given via the IV or IO route, the appropriate dose and concentration of epinephrine is 0.01 mg/kg (0.1 mL/kg) of a 1:10,000 solution. Therefore, a 3-year-old child should receive 1.4 mL (0.14 mg) of epinephrine (0.1 mL/kg × 14 kg = 1.4 mL). If given via the ET tube, the appropriate pediatric dose of epinephrine is 0.1 mg/kg (0.1 mL/kg) of a 1:1,000 solution; in a 14 kg child, this equals 1.4 mL (1.4 mg). Atropine is not indicated for infants and children with asystole or PEA. Amiodarone is indicated for refractory V-Fib or pulseless V-Tach; it is not indicated for patients with asystole. The pediatric dose of amiodarone is 5 mg/kg, up to a maximum dose of 15 mg/kg (2.2 g in adolescents) per 24 hours.

You are dispatched to a local school for a 9-year-old child who is ill. He is conscious and alert, and tells you that he is lightheaded and that his chest feels funny. He denies pain, shortness of breath, or any other symptoms. His breath sounds are clear and equal bilaterally, and his skin is pink, warm, and dry. The cardiac monitor reveals a regular narrow-complex tachycardia at a rate of 200 beats/min. His BP is 100/58 mm Hg and his respirations are 20 breaths/min. You ask him to bear down, but this has no effect on his heart rate. In addition to supplemental oxygen, you should:

Establish vascular access and give 2.5 mg of adenosine. The child in this scenario is hemodynamically stable, with supraventricular tachycardia (SVT) showing on the cardiac monitor. Treatment should include supplemental oxygen as needed, vagal maneuvers, and 0.1 mg/kg of adenosine (maximum of 6 mg) if vagal maneuvers are unsuccessful. You can estimate his weight (in kg) based on his age using the formula (age [in years] × 2) + 8. If the first dose of adenosine is unsuccessful, give a second dose at 0.2 mg/kg (maximum of 12 mg). If his clinical status deteriorates, perform synchronized cardioversion at 0.5 to 1 j/kg. His BP is consistent with his age and there are no signs of hypovolemia; therefore, a fluid bolus is not indicated. In some cases, amiodarone may be given for refractory SVT; however, this is highly dependent on your transport time and local protocols.

Immediately following delivery, your patient is experiencing heavy vaginal bleeding. In an attempt to control the bleeding, you should:

Firmly massage the fundus of her uterus. Postpartum bleeding can be controlled by one of two methods. The quickest is to firmly massage the fundus (top) of the uterus, which results in constriction of the uterine vasculature. The other is to allow the newborn to nurse as this will stimulate the mother's pituitary gland to secrete oxytocin, which also causes uterine vasoconstriction. Never pack any dressings into the vagina; this will not stop the bleeding and increases the risk for maternal infection. Positioning the mother on her left side may prevent supine hypotensive syndrome, a problem that may occur before delivery; however, it will not control vaginal bleeding. Elevation of the extremities may be considered (depending on local protocol) if the mother is in shock, although this will not control vaginal bleeding.

A 19-year-old woman, who is 28 weeks pregnant with her first baby, presents with a headache, edema to her ankles and hands, and a blood pressure of 144/88 mm Hg. She is conscious and alert. In addition to administering supplemental oxygen, you should:

Establish vascular access, transport her, and monitor her for seizure activity. Your patient has signs of preeclampsia, also called pregnancy-induced hypertension. Women younger than 20 years of age experiencing their first pregnancy are at highest risk for preeclampsia, followed by advanced maternal age, a history of multiple pregnancies, and risk factors of chronic hypertension, renal disease, and diabetes. Preeclampsia usually manifests after the 20th week of pregnancy. Signs include edema of the face, ankles, and hands; gradual onset of hypertension; and proteinuria. Headache, nausea and vomiting, agitation, weight gain, and visual disturbances are also common. Preeclampsia can lead to chronic hypertension, which may cause impaired fetal growth and development, impaired liver and renal function, and pulmonary edema. The most immediate concern for the preeclamptic mother is the development of a seizure, which marks the onset of eclampsia. Treatment for preeclampsia involves administering oxygen, establishing IV access, and transporting while monitoring for seizures en route. Use of lights and siren may precipitate seizures and should be avoided. Medical control may order a magnesium sulfate infusion for preeclamptic patients to prevent seizures. If a seizure occurs, give 2 to 4 g of magnesium sulfate via slow (over 3 minutes) IV push. Although your patient's BP is elevated, it does not warrant prehospital antihypertensive therapy (ie, labetalol [Normodyne]). Lowering a patient's BP in the field is dangerous; it should be performed in the controlled setting of a hospital.

The Apgar scoring system is used to:

Evaluate the adequacy of a newborn's vital functions following birth. The Apgar scoring system is a useful means of evaluating the adequacy of a newborn's vital functions following birth; such information will prove useful to those who are involved in the subsequent care of the baby. In this system, five parameters—heart rate, respiratory effort, muscle tone, reflex irritability, and color—are each given a score from 0 to 2. The first Apgar score is assigned 1 minute following birth; the second score is assigned 5 minutes following birth and every 5 minutes thereafter. The Apgar score is NOT used to determine the need for or extent of resuscitation. The determination of whether the newborn requires resuscitation, as well as the extent of resuscitation needed, is made immediately following birth; you would not wait 60 seconds before determining if the newborn requires any form of resuscitation. The need for and extent of resuscitation is based on three parameters—respiratory effort, heart rate, and color. According to the American Academy of Pediatrics, approximately 10% of newborns require resuscitation beyond the simple steps of drying, warming, positioning, and suctioning; only 1% require aggressive resuscitation (eg, chest compressions, intubation, medications).

Which of the following signs is MOST indicative of inadequate breathing in an infant?

Expiratory grunting. Expiratory grunting is an ominous finding in an infant or small child and suggests impending respiratory failure. It is the result of the child attempting to maintain oxygen reserve in the lungs. Because infants rely heavily on their diaphragm for breathing, they are often referred to as "belly breathers." Pink mucous membranes indicate adequate oxygenation and perfusion of the tissues. Tachycardia is an early sign of respiratory distress in infants and children; however, as their condition deteriorates, they often develop bradycardia.

A 6-month-old infant with bacterial meningitis would MOST likely present with:

Fever, paradoxical irritability, and poor feeding. Meningitis, inflammation or infection of the protective covering of the brain and spinal cord (meninges), is usually caused by a viral or bacterial infection. Viral meningitis is rarely life-threatening; however, bacterial meningitis is potentially fatal. In the early stages of the illness, it can be difficult to distinguish viral from bacterial meningitis, so always proceed as if the child has bacterial meningitis. The child's presentation varies depending on his or her age and the type of infection present. The younger the child, the more vague the symptoms. Infants often have a fever (usually high-grade), poor feeding, a bulging fontanelle, vomiting, and paradoxical irritability. A child with paradoxical irritability becomes more irritable or cries when picked up by a caregiver due to pain caused by aggravation of an already inflamed spinal cord. Unlike older children, infants and small children rarely present with nuchal rigidity (neck pain or stiffness), mainly because they don't have much of a neck. Pneumococcal and meningococcal meningitis account for most cases in children. Meningococcal meningitis may cause seizures, septic shock, and death, and is often accompanied by a petechial (small, pinpoint red spots) or purpuric (large purple or black spots) rash, in addition to other signs and symptoms of meningitis. Urticaria (hives) is associated with allergic reactions, not meningitis. Due to the hypermetabolic state that occurs when children are attempting to compensate for shock, they often deplete their glucose stores, resulting in hypoglycemia.

A 32-year-old woman is 36 weeks pregnant. She had one spontaneous abortion in the past and has two children at home. You should document her obstetric history as:

G4A1P2. Gravidity refers to the number of times a woman's been pregnant, regardless of the term or outcome of the pregnancy. Parity refers to the number of pregnancies carried beyond 28 weeks, regardless of whether the baby was born alive or dead. If the patient has had an abortion—spontaneous or induced—it should also be documented. Therefore, the patient's obstetric history should be documented as G4 (she's been pregnant four times, including her current pregnancy), A1 (she had one abortion), and P2 (she has two living children).

During the delivery of a newborn's head, you note the presence of a nuchal cord. You should:

Gently slip the cord over the newborn's head. Initial management for a nuchal cord (umbilical cord wrapped around the newborn's neck) is to gently attempt to slip the cord over the newborn's head. In most cases, the cord will easily slide over the newborn's head. However, if this is unsuccessful, the cord should be clamped and cut. Administer oxygen to the mother, continue the delivery, and transport as soon as the newborn has been delivered and assessed.

You are transporting an intubated 7-year-old child who experienced a traumatic brain injury. Full spinal precautions have been applied, you are ventilating the child at a rate of 20 breaths/min, and an intraosseous catheter has been placed in the child's proximal tibia. Reassessment of the child's blood pressure reveals a reading of 70/40 mm Hg. You should:

Give a 20 mL/kg crystalloid bolus and reassess blood pressure. According to the Brain Trauma Foundation (BTF), hypotension in a child between 6 and 12 years of age exists when the systolic BP falls below 80 mm Hg. In the brain-injured child—or any patient for that matter—a single episode of hypotension can be disastrous because it results in a decrease in cerebral perfusion pressure (CPP), which leads to cerebral ischemia and potential brain damage. If the systolic BP falls below 80 mm Hg in a brain-injured child between 6 and 12 years of age, you should administer a 20 mL/kg isotonic crystalloid bolus and then reassess the blood pressure; additional fluid boluses may be needed. Ventilations in the brain-injured child should be guided to an end-tidal CO2 (ETCO2) of between 32 and 35 mm Hg. Routine hyperventilation should be avoided in the brain-injured patient unless signs of brain herniation are present. Signs of brain herniation include unresponsiveness, asymmetric or bilaterally fixed and dilated pupils, and decerebrate (extensor) posturing or no motor response to painful stimuli. If these signs are observed in the brain-injured child, brief periods of mild hyperventilation (30 breaths/min) may be beneficial.

You have just delivered an infant born at 37 weeks' gestation. After drying and warming the infant, you assess him and note that his respirations are rapid and irregular, his pulse rate is 90 beats/min, and his face and trunk are cyanotic. You should:

Give positive-pressure ventilations for 30 seconds and then reassess the newborn. After drying, warming, and positioning a newborn following delivery, the need for further treatment is based on your assessment of respiratory effort, heart rate, and skin color. Rapid (40 to 60 breaths/min) and irregular respirations are normal for the newborn, provided that they are producing adequate tidal volume. Newborn bradycardia is defined as a heart rate less than 100 beats/min. Bradycardia in the newborn indicates hypoxemia and should be treated with positive-pressure ventilations (PPV). Provide PPV for 30 seconds and then reassess the newborn's heart rate. Blow-by oxygen is indicated if the newborn has central cyanosis, but is otherwise breathing adequately and has a heart rate greater than 100 beats/min. Tactile stimulation (eg, flicking the soles of the feet, rubbing the lateral thorax) is a technique used to stimulate effective breathing, not to increase the heart rate. Visualization of the vocal cords with a laryngoscope (direct laryngoscopy) and tracheal suctioning is indicated only if there is evidence of meconium in the amniotic fluid and the newborn is not vigorous (ie, poor muscle tone, inadequate breathing, severe bradycardia).

What type of trauma is associated with the highest morbidity and mortality rate in infants and children?

Head. Because infants and children have a proportionately larger head when compared to an adult, this area of the body is especially vulnerable to trauma, especially from falls, in which gravity takes them head first. Deceleration incidents, where children are improperly secured or not secured at all, are also associated with head trauma. The body becomes a projectile, with the head striking the first object it encounters.

In addition to viral and bacterial infections, which of the following could also cause fever in a child?

Inflammation. In addition to viral or bacterial infections, pyrogens (fever-causing agents) are also released from white blood cells in response to inflammation and act as chemical mediators on the hypothalamus. A sunburn is a good example of an inflammatory process that can cause a fever. This is a normal response in both children and adults. None of the other options listed is commonly associated with fever.

An 8-year-old male experienced a closed head injury after he fell from the bed of a moving pickup truck. His Glasgow Coma Scale (GCS) score is 7. His respirations are slow and irregular and his pupils are bilaterally dilated and sluggish to react. No posturing is noted. The MOST appropriate management for this child includes:

Intubation and ventilations delivered at a rate of 20 breaths/min. According to the Brain Trauma Foundation (BTF), a child with a closed head injury and a Glasgow Coma Scale (GCS) score of less than 8 should be intubated. Clearly, the child's slow, irregular respirations require ventilatory support. According to the BTF, the head-injured child should be ventilated at a rate of 20 breaths/min unless signs of brain herniation (eg, decerebrate posturing or no motor response to pain, fixed and dilated pupils or asymmetric pupils) are present. If signs of brain herniation are present, brief periods of hyperventilation (30 breaths/min in the child) may be beneficial. Depending on your local protocols, lidocaine may be administered to the child prior to intubation; the pediatric dose is 1 mg/kg.

Why is it important to position a pregnant patient in the later stages of pregnancy on her left side?

It relieves pressure off of the inferior vena cava, preventing hypotension. Positioning a pregnant patient on her left side will relieve pressure of the gravid (pregnant) uterus off of the inferior vena cava, which will prevent a drop in cardiac output with resultant hypotension. Placing the patient in a supine position can result in supine hypotensive syndrome and subsequent shock, which would be detrimental to both mother and baby. This is especially true during the later stages of pregnancy.

A 6-year-old boy fell off his bike and injured himself. His mother tells you that he was wearing a helmet at the time of the incident. The boy is sitting next to his mother on the couch, holding his left arm against his chest. He is conscious and alert, but appears scared. You do not see any obvious bleeding or other injuries. You should:

Kneel down beside him and ask him what his name is. Your initial approach to a sick or injured child is dependent upon two factors: the age of the child and the severity of his or her condition. There is no indication that the child in this scenario is severely injured; therefore, there is no need to rush in and begin an immediate hands-on assessment. Separating an obviously scared sick or injured 6-year-old child from his or her parent will only cause him or her further distress; the parent will probably not be too happy either. Before you lay hands on the child, position yourself at—or better yet, below—his level, ask him what his name is, and then tell him your name. This non-threatening approach will facilitate cooperation, build a rapport with the child, and gain his trust. Towering over any patient typically instills fear and anxiety and should be avoided whenever possible. After you have established a rapport with the child—and hopefully gained his trust—you should then proceed by asking him if you can look at his injured arm. If he allows this, proceed with your assessment, which includes manually stabilizing the injured arm and assessing distal circulation, sensory, and motor functions.

A 4-year-old male presents with audible stridor, a barking cough, and increased work of breathing. He is conscious and alert; has pink, warm skin; and has a heart rate of 100 beats/min. Further assessment reveals clear and equal lung sounds over all fields, an oxygen saturation of 97%, and a temperature of 99.2°F. You should:

Let him assume a position of comfort, offer oxygen via the blow-by technique, and administer a 2.25% solution of racemic epinephrine via nebulizer. The child symptoms are consistent with croup (laryngotracheobronchitis), a viral upper airway infection. Parainfluenza virus causes most cases of croup, although respiratory syncytial virus (RSV) and adenovirus have been implicated. Croup typically affects children between 6 months and 6 years of age, usually during fall and winter. Croup causes swelling of the larynx and trachea, resulting in a barking, seal-like cough. Most cases of croup are mild and do not cause respiratory failure. The child is typically alert, has a barking cough, increased work of breathing, stridor with agitation, and normal skin color. Breath sounds are usually clear and equal bilaterally. Allow the child to assume a position of comfort and avoid agitating him. Your patient has respiratory distress, but no overt signs of hypoxia (eg, low Sp02, bradycardia, cyanosis); therefore, assisted ventilation and intubation are not indicated. Give oxygen via the blow-by technique, if tolerated. Consider giving nebulized racemic epinephrine (0.5 mL of a 2.25% solution in 3 mL of normal saline). Epinephrine reduces upper airway edema through vasoconstriction. Croup is an upper airway problem and does not cause wheezing; therefore, bronchodilators (eg, Ventolin, Atrovent) will be of no real benefit. IV access should be deferred; the child is stable and an IV will agitate him, potentially worsening his condition. His temperature does not warrant treatment with Motrin or Tylenol. Transport the child and monitor him en route.

A 9-year-old child has generalized weakness; blood in the stool; and bruising, even from minor trauma. These findings are MOST consistent with:

Leukemia. Signs of leukemia (cancer of the blood) include fatigue or weakness, easy bruising, and spontaneous bleeding. A patient with anemia can have similar signs and symptoms, but tends to have cutaneous bleeding and an unusual craving for ice. Lymphoma, cancer of the lymphatic system, is characterized by weakness, enlarged lymph nodes (lymphadenopathy), fever, weight loss, and anorexia, among others. Signs and symptoms of sickle cell crisis depend on the body system affected, and include severe joint or bone pain, abdominal pain (from an enlarged spleen [splenomegaly]), and chest pain and hemoptysis (coughing up blood).

Which of the following female hormones stimulates ovulation?

Luteinizing hormone (LH). The anterior pituitary gland releases luteinizing hormone (LH), which stimulates the process of ovulation. Progesterone, along with estrogen, prepares the inner uterine lining (endometrium) for implantation by thickening its walls. Follicle-stimulating hormone (FSH) is responsible for producing estrogen. Human chorionic gonadotropin (HCG) prevents the corpus luteum, a yellow glandular structure, from degenerating so that the pregnancy can continue.

Pregnant women with hyperemesis gravidarum are at greatest risk for:

Mallory-Weiss syndrome. Hyperemesis gravidarum—a condition characterized by severe and persistent vomiting during pregnancy—places the woman at risk for Mallory-Weiss syndrome. Mallory-Weiss syndrome is a condition in which the junction between the esophagus and stomach tears, causing severe bleeding and possibly death. During the act of vomiting, pressure within the stomach can increase so greatly that it causes failure of the structure of the esophagus. Because vomiting eliminates acids from the stomach, hyperemesis gravidarum would predispose the mother to metabolic alkalosis. Cholestasis is a disease of the liver that occurs only during pregnancy. Hormones affect the gallbladder by slowing down or blocking the normal flow of bile from the liver. If the normal flow of bile is altered, bile acids accumulate in the liver, and then spill out into the bloodstream. There is no correlation between hyperemesis gravidarum and cholestasis. The most common causes of third trimester bleeding are abruptio placenta, placenta previa, and uterine rupture. Hyperemesis gravidarum does not cause vaginal bleeding.

Following delivery of a newborn and the placenta, a 24-year-old female has continued vaginal bleeding. She is conscious and alert, is breathing adequately, and has a heart rate of 110 beats/min. As your partner places her on supplemental oxygen, you should:

Massage the fundus of her uterus. The quickest and easiest method to control postpartum bleeding is to massage the uterine fundus, the superior aspect of the uterus. As you are performing uterine massage, your partner can establish vascular access after placing the patient on oxygen. Uterine massage promotes vasoconstriction and uterine contraction, thus controlling or minimizing the amount of bleeding. To perform this technique, support the inferior aspect of the uterus with the edge of one hand just above the symphysis pubis and massage the fundus with the other hand. Massage the uterus in a circular motion until it becomes firm and the bleeding stops. Reassess the mother's vital signs, start an IV line (if not already done), and give fluid boluses as needed to maintain adequate perfusion. Encouraging the newborn to breastfeed can also help control postpartum hemorrhage; stimulation of the breasts causes the mother's pituitary gland to secrete oxytocin, a naturally occurring hormone, which promotes uterine contraction. Oxytocin (Pitocin) is not commonly used in the field. However, if your system carries it and your transport time will be long, medical control may order a continuous infusion. Ensure that there is not more than one baby before starting an oxytocin infusion! Follow your protocols regarding the dose for oxytocin.

Which of the following interventions is ONLY perfomed at the end of the third stage of labor?

Massaging the uterine fundus in a circular motion The first stage of labor begins with the onset of uterine contractions and ends when the cervix is fully dilated. Cervical dilation cannot be determined in the field; therefore, the presence of crowning is used to indicate the end of the first stage of labor. The second stage of labor begins with crowning and ends when the entire baby is born. The third stage of labor begins with the birth of the baby and ends when the placenta delivers. Oxygen therapy may be indicated for the mother during any of the stages of labor. As soon as the baby's head delivers, you should suction its mouth and nose (the second stage of labor ends when the entire baby is born, not just the head.) Although the baby's mouth and nose will be resuctioned following delivery, it is initially suctioned before the end of the second stage of labor (after the head has delivered, but before the body). As soon as the infant's head delivers, you should also assess for a nuchal cord (umbilical cord wrapped around the neck) and treat if it is present. Of the interventions listed, massage of the uterine fundus is the only one that is exclusively performed at the end of the third stage of labor (after the placenta has delivered) if excessive postpartum bleeding is occurring.

The mother of a 2-year-old girl reports that the child has had a fever for the past 2 days and that she screams every time she tries to pick her up. You note that the child is grabbing both sides of her head. These findings are MOST suggestive of:

Meningitis. Meningitis is defined as infection and inflammation of the meninges surrounding the brain and spinal cord. Signs and symptoms of meningitis include fever; headache; vomiting; and a stiff, painful neck (nuchal rigidity); among others. A child who screams in pain every time he or she is picked up is doing so because traction is being pulled on the inflamed spinal cord; this is called paradoxical irritability. Encephalitis, an infection of the brain, can present similarly to meningitis, but is typically not associated with paradoxical irritability. Dehydration may present with fever, depending on the underlying cause, but is not associated with paradoxical irritability. Seizures may occur as the result of meningitis or encephalitis; by themselves, however, seizures are not associated with paradoxical irritability.

When assessing a 20-year-old woman with bilateral lower abdominal quadrant pain, which of the following findings is MOST suggestive of an ectopic pregnancy?

Missed menstrual period. Any woman of childbearing age who has abdominal pain should be assumed to have an ectopic pregnancy until ruled out by a physician. Lower quadrant abdominal pain, especially with a history of a missed menstrual period, should raise your index of suspicion for an ectopic pregnancy. There are many causes of vaginal discharge, and tachycardia and hypotension can be the result of many other problems. Although a woman's chance of becoming pregnant is significantly higher if she is not using some form of contraception, many women get pregnant while using contraception.

An infant or child with cardiogenic shock:

Often presents with increased work of breathing and an enlarged liver. Cardiogenic shock (pump failure) is uncommon in children, but may be the result of congenital heart disease, myocarditis, or a dysrhythmia. Children in cardiogenic shock are listless or lethargic; are pale or mottled; and have cool, clammy skin. In addition, they also show signs of increased work of breathing owing to congestive heart failure and pulmonary edema. Impaired ventricular function causes an increase in central venous pressure; this manifests as an enlarged liver (hepatomegaly) and jugular venous distention (JVD). However, JVD is difficult to assess in infants; it is more appreciable in older children. In children with certain congenital heart diseases, their Sp02 may remain low despite high-flow oxygen; parents will often alert you of this. Unless you are certain of the diagnosis of cardiogenic shock (the child has congenital heart disease, is afebrile, and has no history of volume loss), err on the side of fluid resuscitation. Administer a single fluid bolus slowly, and monitor carefully to assess its effect. Increased work of breathing, a drop in Sp02, or worsening perfusion after a fluid bolus confirms your suspicion of cardiogenic shock. If your transport time is long, medical control may order a dopamine infusion to increase cardiac contractility and improve perfusion. Epinephrine has more pronounced chronotropic effects than dopamine, which may significantly increase cardiac oxygen consumption and demand; thus, it is not the drug of choice for patients with cardiogenic shock.

An 8-year-old child is in ventricular tachycardia. He has a weak pulse; a decreased level of consciousness; and cool, pale skin. You should:

Perform synchronized cardioversion at 1 j/kg. The child in this scenario is clinically unstable. Administer high-flow oxygen (assist his ventilations if needed), and perform synchronized cardioversion without delay. Intubation is not a priority. Unstable V-Tach (or SVT) with a pulse should be treated with prompt cardioversion. Consider sedation with a benzodiazepine (ie, Versed, Valium) prior to cardioversion, as long as it does not delay cardioversion. The initial pediatric energy setting for synchronized cardioversion is 0.5 to 1 J/kg. If this is unsuccessful, repeat the cardioversion at 2 j/kg. Amiodarone (5 mg/kg) is appropriate for infants and children with hemodynamically stable ventricular tachycardia. Obtaining a 12-lead ECG in a patient with unstable tachycardia would delay cardioversion; it is not an immediate priority, although you should acquire a 12-lead ECG if cardioversion successfully converts the dysrhythmia.

To maintain neutral alignment of the airway structures in an 18-month-old child, you should:

Place padding under the shoulders. A child's head—specifically the occiput—is proportionately larger when compared to an adult. The occiput tends to force the child's head forward, potentially causing an airway obstruction. This can be corrected by placing padding underneath the child's shoulders, which will facilitate a neutral position of the head and airway structures. Padding directly underneath the occiput facilitates a sniffing position when intubating small children. The purpose of an oropharyngeal airway is to keep the tongue off of the posterior pharyngeal wall; it does not maintain the head in any position—neutral, sniffing, or otherwise. Flexing a small child's head forward—even slightly—would likely cause an airway obstruction.

A 29-year-old female, who is 32 weeks pregnant, presents with a blood glucose level of 305 mg/dL. This is MOST likely the result of:

Placental hormones blocking the action of insulin. The woman in this scenario is likely experiencing gestational diabetes (GD). During pregnancy, this is most often the result of insulin resistance; placental hormones (estrogen, progesterone) block the actions of the mother's insulin. In some cases, however, the mother may not be able to produce adequate insulin to meet the increased metabolic needs associated with pregnancy; in this case, excess amounts of glucose are transmitted to the fetus where it is stored as fat, which explains why babies born to mothers with GD are often larger than average newborns. GD typically resolves following delivery; however, the mother may develop diabetes mellitus later in life.

You are assessing an 18-month-old female with a high fever. The child is crying, and is tachypneic and tachycardic. There is no evidence of a rash, her rectal temperature is 102.6°F, and her capillary refill time is 1 second. The child's mother states that her daughter has not experienced vomiting or diarrhea, and further denies any past medical history. You should:

Remove her clothing to minimize heat retention, give ibuprofen, and transport. Fever is a common pediatric complaint. By itself, fever is typically not a life-threatening condition; however, it does indicate an underlying infectious or inflammatory process. Most pediatric fevers are caused by viral infections, which are typically mild and self-limiting. In other cases, fever is a sign of a serious bacterial infection (ie, meningitis, encephalitis). Although there are no overt signs of sepsis (ie, rash) or hypoperfusion (her capillary refill time is less than 2 seconds) in this child, she should still be transported to the hospital for evaluation. Her tachypnea and tachycardia are likely a physiologic response to fever, not hypovolemia. Therefore, IV therapy is not necessary at this point. Prehospital treatment for pediatric fever is mainly supportive. Remove the child's clothing to avoid heat-trapping, administer an antipyretic (eg, ibuprofen, acetaminophen), and transport. Aspirin should not be given to children; it has been linked to a rare illness called Reye's syndrome, which can result in cerebral edema and liver failure. Furthermore, you should not perform interventions that may cause the child's fever to drop too fast, such as cool water immersion or wrapping the child in a towel soaked with cool water; these measures may cause the child to shiver, potentially causing a sudden spike in body temperature that can induce a febrile seizure. Oxygen may be given if the child will tolerate it; however, do not force it. Agitating the child may also cause an acute spike in her fever.

After treating and transporting a child that you suspect has been physically abused, you should:

Report your suspicions to the receiving physician. EMS providers are "mandatory reporters" regarding cases of suspected abuse. Any and all cases of suspected abuse must be reported. After treating and transporting a child who you suspect has been abused, you should report your suspicions to the receiving physician at the emergency department. The emergency department is generally the best place to report your suspicions because they will be able to address the issue immediately; they will notify law enforcement, and, if necessary, child protective services. Do not confront the caregiver(s) and make accusations; if you are wrong, you could be held liable for slander. Thoroughly document the call afterwards, reporting only objective findings. Do not document your personal opinion or in any way infer that the child was abused or that you suspect he or she was abused; if you are wrong, you could be held accountable for libel.

Cardiopulmonary arrest in infants and children is MOST often secondary to:

Respiratory failure. According to the American Academy of Pediatrics (AAP), cardiopulmonary arrest in infants and children is most often the result of respiratory failure. This means that many cardiopulmonary arrests in children can be prevented by paying meticulous attention to their airway and ventilatory status. Life-threatening sepsis can result from an infection and hypovolemic shock can result from severe dehydration. While these can cause cardiopulmonary arrest in infants and children, they are less common than respiratory failure. Children usually have healthy hearts; primary cardiac arrhythmias (ie, V-Fib, V-Tach) are far more common in adults.

A 9-month-old male has had numerous episodes of vomiting and diarrhea. On assessment, the infant is listless. He has unlabored tachypnea; absent radial pulses and weak brachial pulses; and cool, mottled extremities. This infant is experiencing:

Severe dehydration with decompensated shock. One of the most common causes of dehydration in infants and children is vomiting and diarrhea secondary to acute gastroenteritis—usually of a viral etiology. In infants and small children, it may take only a few episodes of vomiting and/or diarrhea to cause significant dehydration. This infant's clinical presentation is clearly that of severe dehydration and decompensated shock—also referred to as hypotensive shock. He is listless (a sign of decreased cerebral perfusion); has absent peripheral pulses and weak central pulses (indicates hypotension); and cool, mottled extremities (poor end-organ perfusion). Unlabored tachypnea—an increased respiratory rate without retractions or other signs of increased work of breathing—is also a sign of shock; it is not consistent with a primary respiratory etiology. Marked tachypnea is often followed by bradypnea in children with decompensated shock; this is an ominous sign and indicates impending cardiopulmonary arrest.

A woman began experiencing contractions 30 minutes ago. She is 38 weeks pregnant. You determine that she is gravida-5 and para-3. Which of the following statements regarding this patient is correct?

She will become para-4 when she delivers her baby. Gravida refers to the number of times a woman has been pregnant, regardless of the length or outcome of the pregnancy. Para refers to the number of pregnancies carried to more than 28 weeks' gestation, regardless of whether the baby was born alive or dead. Gravida-5 indicates that your patient has been pregnant 5 times, including her current pregnancy. Para-3 indicates that she has delivered 3 babies beyond 28 weeks' gestation. When she delivers her baby, she will become para-4 because her current pregnancy has surpassed 28 weeks. In general, the first stage of labor decreases in length with each pregnancy and delivery. A term pregnancy is 37 to 42 weeks. She is not in preterm labor, although this does not indicate that she will not experience any complications.

A 4-year-old child has labored breathing. During your assessment, you note that his pulse rate is 70 beats/min. This pulse rate is:

Significant as it indicates hypoxia. Because infants and small children rely heavily on their pulse rate to maintain perfusion, bradycardia, if present, is an ominous sign indicating late hypoxia and requires immediate ventilatory support (eg, bag-mask ventilations). If the pulse rate falls below 60 beats/min despite adequate ventilatory support, chest compressions should be initiated. Vagal-induced bradycardia is not common in infants and children.

Following delivery of an infant, you suction, warm, and position the newborn. The infant is breathing, but has a pulse rate of 80 beats/min. After 30 seconds of positive-pressure ventilation, the heart rate remains at 80 beats/min. You should:

Suction the newborn's mouth and nose again if needed. A pulse rate of less than 100 beats/min indicates hypoxia in a newborn. If the pulse rate remains below 100 beats/min after 30 seconds of positive-pressure ventilation (PPV), the infant's airway must be checked again to ensure patency, which may include repositioning of the head to ensure a neutral position, resuctioning any secretions, or ventilating the infant with its mouth slightly open. If these techniques fail to increase the newborn's heart rate, endotracheal intubation may be needed. Chest compressions are indicated when the newborn's pulse rate falls below 60 beats/min, despite 30 seconds of adequate PPV. Dextrose (10%) should be given if the newborn shows signs of hypoglycemia (ie, jitteriness, lethargy, pallor) and has a blood glucose level of less than 40 mg/dL. Naloxone (Narcan) should be a consideration if bradycardia and respiratory depression persist and/or if there is a history of maternal narcotic use, particularly within the previous 4 hours. Follow your local protocols or contact medical control regarding the administration of naloxone in newborns.

A 3-year-old child with a high fever experienced a seizure that lasted approximately 5 minutes. Treatment should consist of:

Supportive care and transport. Fortunately, most children with febrile seizures do well and very few require hospitalization. Treatment for the child after the seizure has occurred is mainly supportive, consisting of monitoring the airway, removing any heavy clothing, and offering the child oxygen. IV therapy is rarely indicated. Diazepam (Valium) is not indicated unless the child is actively seizing. Placing a child in cool water after a febrile seizure should be avoided because it may cause the child to shiver, resulting in an abrupt rise in body temperature and the possibility of another seizure.

You are assessing the cardiac rhythm of a 7-year-old child who says his chest is "fluttering." P waves are not visible, the QRS complexes measure 0.07 seconds in duration, the heart rate is 200 beats/min, and there is no variation in the R-R intervals when the child moves. These findings are MOST consistent with:

Supraventricular tachycardia. Most narrow-complex tachycardias in infants and children are sinus tachycardia. However, some children present with supraventricular tachycardia (SVT). In children older than 1 year of age, SVT is characterized by a ventricular rate greater than 180 beats/min (> 220 beats/min in infants), narrow (less than or equal 0.09 seconds) QRS complexes, and no variability in the R-R intervals with movement or activity. Furthermore, children with SVT typically do not present with a history that is compatible with common causes of sinus tachycardia (ie, fever, hypovolemia); in some cases, the child may have a history of SVT. In sinus tachycardia, the heart rate in children is usually less than 180 beats/min (< 220 in infants), the R-R intervals vary with activity or movement, and the child has a history that is compatible with common causes of sinus tachycardia (ie, fever, hypovolemia). Ventricular tachycardia (V-Tach) is uncommon in children, but should be suspected if the QRS complexes measure greater than 0.09 seconds in duration. Ectopic atrial tachycardia (EAT), also uncommon in children, is characterized by P waves of varying morphologies. Diagnosing EAT in children with tachycardia is often not possible, however, because the P waves are usually not visible.

Which of the following actions would MOST effectively decrease oxygen demand and consumption in a small child who is in shock?

Take measures to reduce anxiety in the child. One of the most simplistic, yet effective ways of reducing oxygen demand and consumption in a child is to reduce anxiety (ie, omit unnecessary procedures, allow the parents to hold the child if practical). Another method is to maintain a normal ambient body temperature. If you make an attempt to increase the body temperature, the child's metabolic rate will increase, which requires more oxygen. Instead, prevent further heat loss by keeping the child warm. Sympathomimetic drugs, such as epinephrine, increase the body's demand for oxygen. Crystalloid fluid boluses increase circulating volume and facilitate perfusion, but are not as effective as simply keeping the child calm.

Standard treatment for an infant born at 34 weeks' gestation, regardless of its appearance at birth, includes:

Taking extra measures to prevent rapid heat loss. A full-term infant is born between 37 and 42 weeks and weighs more than 5.5 lb (2.5 kg). A premature infant is is born before 37 weeks or weighs less than 5.5 lb. Premature infants require special care that many full-term infants do not. In addition to keeping the airway clear, you should take extra measures to prevent heat loss. All newborns are prone to heat loss; however, premature infants are at an especially high risk. Compared to full-term newborns, premature newborns have even less natural body insulation and an even larger surface area in relation to mass, so they are much more vulnerable to rapid heat loss. To minimize this increased risk of hypothermia, some premature infants are covered with Saran wrap (excluding the face of course), which acts as an extra layer of skin and minimizes heat loss. Fetal transition, the anatomic and physiologic processes that facilitate survival in an extrauterine environment, may be impaired in hypothermic newborns. Hypothermic newborns are also less likely to respond to resuscitative efforts. Not all premature newborns require intubation or vascular access. The need to perform these interventions is based on the newborn's clinical status. Do not be so quick to clamp and cut the umbilical cord of any newborn, premature or full-term. You should clamp and cut the umbilical cord only after it has stopped pulsating and the infant is breathing adequately. If the newborn requires resuscitation beyond the simple steps of drying, warming, and suctioning, do not clamp and cut the cord; keep the infant at the level of the perineum and provide any needed resuscitation there.

The risks of vomiting and aspiration are greater in unresponsive pregnant women than non-pregnant women because:

The enlarged uterus displaces the stomach and intestines upward and laterally. Several anatomic changes occur during pregnancy that increase the risk of aspiration. Gastrointestinal tone and motility decrease, resulting in delayed gastric emptying; therefore, food remains in the stomach for longer periods of time. Furthermore, the enlarged uterus displaces the stomach and intestines upward and laterally. In combination with delayed gastric emptying, this places the unresponsive pregnant woman at higher risk for vomiting and aspiration than the non-pregnant woman.

Which of the following airway devices or interventions is contraindicated in children?

Which of the following airway devices or interventions is contraindicated in children? Multilumen airway devices, such as the Combitube and pharyngotracheal lumen airway (PtL), are contraindicated in children younger than 14 years of age. They are also contraindicated in patients with caustic ingestions, known esophageal disease, and in patients with an intact gag reflex. Orotracheal intubation can be performed in patients of any age. Supraglottic airway devices (ie, King LT, CobraPLA, LMA), can also be used in children. Surgical (open) or needle cricothyrotomy can be performed on children; compared to adults, however, it can be more difficult to perform.

Sudden infant death syndrome (SIDS) is defined as:

The sudden and unexpected death of an infant under 1 year of age for whom a thorough postmortem exam fails to demonstrate an appreciable cause of death. According to the American SIDS institute, sudden infant death syndrome (SIDS) is defined as the sudden and unexpected death of an infant under 1 year of age that remains unexplained after a thorough case investigation, including a complete autopsy (postmortem), examination of the death scene, and review of the infant's clinical history. SIDS cannot be predicted or prevented, although a number of potential risk factors have been identified. These include male sex; prematurity; low birth weight; young maternal age; sleeping in a prone position; sleeping with soft, bulky blankets or soft objects; and exposure to tobacco smoke. Some infants who die of SIDS had recent symptoms of an upper respiratory tract infection. SIDS is the leading cause of death in infants aged 1 month to 1 year, with a peak incidence between 2 and 4 months of age. According to the American SIDS Institute, the rate of SIDS in the United States has decreased by over 50% since 1983; however, approximately 2,500 cases still occur each year.

As you are assessing the skin color and condition of a newborn, you note that it is red and abnormally warm to the touch. Suspecting fever, you should recall that:

This is an uncommon finding and suggests a serious illness. Because newborns have immature immune systems and a decreased ability to produce pyrogens (fever-causing agents), fever is uncommon and suggests a serious illness. Fever is a newborn should be considered to be sepsis until proven otherwise. Cooling is not recommended because of the risk of causing the newborn to shiver, which will only increase the body temperature and could precipitate a seizure. Acetaminophen is not administered to newborns in the prehospital setting.

You receive a call for a baby not breathing. Upon arriving at the scene, the 4-month-old infant's panicked mother tells you that her daughter turned blue and went limp while she was bottle feeding her. On appearance, the infant does not look ill. She is breathing without difficulty; has pink, warm skin; strong peripheral pulses; and a heart rate of 120 beats/min. Further assessment reveals that her breath sounds are clear and equal bilaterally, and her oxygen saturation on room air is 97%. You should:

Transport the infant to the hospital and let mom accompany her in the back of the ambulance. An apparent life-threatening event (ALTE) occurs when an infant becomes pale or cyanotic; chokes, gags, or has an apneic spell; or loses muscle tone. The cause of an ALTE may be benign, such as a brief episode of laryngospasm during feedings (the likely case in this scenario) or gastroesophageal reflux, or serious, such as sepsis, congenital heart disease, or seizures. ALTEs were thought to be related to sudden infant death syndrome (SIDS); hence, they were called "near-miss SIDS." However, more recent evidence shows that, while both events occur in early infancy, they are unrelated. It is common to find a distraught caregiver and a well-appearing infant on arrival at the scene. All infants with an ALTE should be transported to the hospital for evaluation. This is a challenging age group to assess, and overtriage is the safest path. Do not tell mom that her child is at high risk for SIDS; this is probably not true and she is terrified as it is! Transport the infant to the hospital and allow mom to accompany her in the back of the ambulance. Based on the infant's condition, she does not require treatment beyond transport and observation. Monitoring her heart rate with the ECG is advisable.

A 4-year-old female presents with lethargy, weak intercostal retractions, and a heart rate of 70 beats/min. You should:

Ventilate the child with high-flow oxygen. Cardiopulmonary arrest in the pediatric population is most often the result of respiratory failure. However, by recognizing the signs of respiratory failure and rapidly intervening, this potential catastrophe may be avoided. The child in this scenario is clearly in respiratory failure; her mental status is depressed, she has weak intercostal retractions (a sign of physical exhaustion), and bradycardia (heart rate less than 80 beats/min). Immediate treatment for a child with respiratory failure involves providing positive-pressure ventilations (PPV) with high-flow oxygen. In fact, any child with symptomatic bradycardia should be treated initially with PPV. Blow-by (free-flow) oxygen is appropriate for children with respiratory distress (ie, increased work of breathing, heart rate greater than 100 beats/min, age-appropriate mentation). If the child's heart rate falls below 60 beats/min, continue PPV and begin chest compressions. Apply the cardiac monitor as soon as possible after establishing a patent airway and ensuring adequate ventilation and oxygenation. Pulse oximetry and capnography should also be monitored. Epinephrine is indicated if the child's heart rate remains below 60 beats/min despite PPV and chest compressions.

You are assessing the cardiac rhythm of a 6-year-old child. The rhythm is regular, the rate is 170 beats/min, the QRS complexes measure 0.11 seconds, and P waves are not visible. You should suspect:

Ventricular tachycardia. The cardiac rhythm described fits the definition of ventricular tachycardia (V-Tach). V-Tach in children is characterized by a regular rhythm, a rate greater than 150 beats/min (often much faster), QRS complexes that are greater than 0.09 seconds in duration, and absent P waves. Supraventricular tachycardia (SVT) in children is characterized by a regular rhythm, a rate greater than 180 beats/min (> 220 beats/min in infants), QRS complexes that are equal to or less than 0.09 seconds in duration, and absent P waves (P waves may be present, but the ventricular rate is often too fast for them to be visible). In SVT, there is no beat-to-beat variability during patient movement. Sinus tachycardia in children is characterized by a regular rhythm, a rate less than 180 beats/min (< 220 beats/min in infants), QRS complexes that are equal to or less than 0.09 seconds in duration, and visible P waves (the rate can often bury the P waves). In sinus tachycardia, beat-to-beat variability is noted during patient movement. Atrial fibrillation in children is characterized by an irregularly irregular rhythm, a variable rate, QRS complexes that are less than or equal to 0.09 seconds in duration, and absent P waves.

A febrile seizure would MOST likely occur in a child:

With a fever that acutely spikes. Febrile seizures are caused by fever and fever alone. They occur when a child's body temperature acutely rises; the child may be afebrile or may already have a fever. Either way, it's not how high the child's temperature rises, it's how quickly it rises. Febrile seizures can occur in children between 6 months and 6 years of age, with the greatest incidence occurring in children between the ages of 6 months and 3 years. The presence of neck pain or stiffness (nuchal rigidity) and/or a headache indicates meningitis. Fever and seizures commonly occur in children with meningitis; however, the seizure is caused by increased intracranial pressure rather than the fever. Remember, febrile seizures and seizures with a fever are NOT the same thing.

A 6-year-old male fell from a second-story balcony and struck his head on a concrete sidewalk. He is unresponsive; has slow, irregular respirations; and has a slow pulse. Your rapid assessment reveals a fixed and dilated left pupil and a large hematoma to the right side of his head. His blood pressure is 138/88 mm Hg. You should:

Vssist his ventilations, establish vascular access at a keep vein open rate, intubate him, and guide your ventilations by capnography. The child has a traumatic brain injury (TBI) with significant intracranial pressure (ICP). He is hypertensive; bradycardic; has slow, irregular breathing; and asymmetric pupils. You must first ensure a patient airway (protect his c-spine), and then assist his ventilations with a bag-mask device. Establish vascular access, and with the assistance of pharmacologic aids (ie, sedation, paralytics), intubate his trachea. Apply full spinal precautions and transport without delay; monitor the ECG en route. Hypercarbia aggravates ICP; consider mild hyperventilation guided to an ETCO2 of 32 to 35 mm Hg. A ventilation rate of 35 to 40 breaths/min is too fast. The child is hypertensive for his age (138/88 mm Hg); fluid boluses are not indicated. The high normal SBP for a 6-year-old child is 102 mm Hg (age [in years] × 2 + 90). If his SBP drops below 80 mm Hg, however, give fluid boluses as needed maintain a SBP of at least 80 mm Hg. A single hypotensive episode in the TBI patient can cause cerebral ischemia, which could result in permanent brain damage or death. Atropine, if used before intubating a child, is given in a dose of 0.02 mg/kg. Hyperthermia may occur in TBI patients; do not apply blankets unless signs of hypothermia are present. Lidocaine, if given, would be administered before intubation for patients with increased ICP.

Which of the following is an obvious clinical indicator of decompensated shock in an infant?

Weak brachial pulses. When assessing an infant with signs of shock, you must be able to determine if the infant's compensatory mechanisms are maintaining adequate perfusion to the core of the body (compensated shock) or if the compensatory mechanisms have failed (decompensated [hypotensive] shock). An infant or child in compensated shock will have signs of decreased peripheral perfusion (ie, delayed [> 2 seconds] capillary refill time, pallor), which is due to peripheral vasoconstriction and shunting of blood to the vital organs. Signs of nervous system compensation (ie, tachycardia, tachypnea) will also be present. However, the blood pressure of an infant or child with compensated shock will be maintained and core perfusion will remain adequate. In decompensated (hypotensive) shock, the infant or child's compensatory mechanisms have failed, resulting in hypotension and inadequate core perfusion. Weak central pulses (brachial pulse in infants; carotid or femoral pulse in older children) indicate physiologic decompensation and hypotension.