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Pediatric Emergency MCQ No 23

Question 23

The following are common signs of heart failure in infancy
A. Intercostal retraction.
B. Basal crepitations.
C. Tachycardia.
D. Raised JVP.
E. Enlarged liver.

Answer & Comments:
•ACE
•Comments:
–Intercostals induction and tachypnoea (60-100 respiration/ minute), tachycardia >120-140 bpm, are common.
–Hepatomegaly is a reliable indicator of effectiveness of therapy and is common.
–Frank pulmonary oedema is uncommon and raised JVP, though useful in older children is not a reliable clinical sign in infants.

Pediatric Emergency MCQ No 22

Question 22

In suspected acute rheumatic fever the following indicate carditis:
A. An ESR of 120 mm in one hour.
B. Short apical soft systolic bruit.
C. Strong cardiac impulse at the apex, which is displaced laterally.
D. Sinus arrhythmia.
E. Erythema nodosum.
ANSWER & COMMENTS:
•C
•Comments:
–The confirmation of rheumatic carditis solely depends on the findings of mitral and or aortic incompetence.

Pediatric Emergency MCQ No 21

Question 21
In a heart transplant recipient, each of the following statements is true EXCEPT
A.Sinus tachycardia at rest can be normal
B.The effect of atropine is exaggerated in the denervated heart
C.The response to -adrenergic drugs is normal or increased
D.The ECG is often read as atrial fibrillation or flutter
E.The patient will be immuno-suppressed for life

ANSWER & COMMENTS:
•B
•Comments:
–Atropine has no effect on the denervated heart because it acts by blocking actions of the vagus nerve.
–The response to catecholamines may be increased by upregulation of receptors in the denervated heart.
–The resting heart rate is usually between 90 and 100 beats per minute.
–The ECG often displays multiple P waves, from both the new heart and a residual portion of the original atria.
–Life long immuno-suppression is mandatory to prevent rejection.

Pediatric Emergency MCQ No 20

Question 20

Sudden cardiac death in an adoloscent can occur in
A.Wolf-Parkinson- White Syndrome.
B.Severe Aortic Stenosis.
C.Long QT syndrome.
D.Atrial septal defect.
E.Familial hypercholestolemia.

ANSWER & COMMENTS:
•ABC
•Comments:
–In WPW fast AF may rapidly deteriorate into VF.
–In severe AS and Long QT there may be VT.

Pediatric Emergency MCQ No 19

Question 19
The following are associated with sudden death in childhood:
A.Aortic stenosis.
B.Primary pulmonary hypertension.
C.Atrioventricular septal defect.
D.Fallot's tetralogy.
E.Cardiomyopathy.

ANSWER & COMMENTS:
•A,B,D,E
•Comments:
–Sudden death may be caused by tricyclic antidepressants, haemosiderosis, SIDS, metabolic disorders such as MCAD, child abuse, trauma, hyperthermia, asthma, meningitis/septicaemia, bacterial endocarditis, pertussis, cholera, RSV, gastro-oesophageal reflux, Reye Syndrome, unrecognised diaphragmatic hernia, upper respiratory obstruction, pulmonary thromboembolism, prolonged QT Syndrome, aortic stenosis, mitral valve prolapse, aspiration, anomalous right coronary artery or left coronary artery, Tetralogy of Fallot, pulmonary atresia intact septum, tricuspid atresia, transposition of the great arteries, arrhythmia, coronary artery disease in Hurler's Syndrome, calcinosis of the coronary arteries, viral myocarditis, primary cardiomyopathy, hypertrophic cardiomyopathy, Marfan's Syndrome, achondroplasia secondary to cervical cord compression, and volatile substance abuse.

pediatric emergency MCQ-No18

Question 18

Echocardiographic evidence of tamponade includes which of the following?
A.Pericardial effusion >1 cm in largest diameter.
B.Pericardial effusion with left ventricular collapse.
C.Pericardial effusion with right ventricular collapse.
D.Pericardial fluid collection.

Answer & Comments
•C
Comments:
–Although not always seen, right-sided collapse (decreased filling) due to pericardial effusion is evidence of tamponade.
–Presence of pericardial fluid does not equate to tamponade, while the absence of fluid does exclude the diagnosis.

pediatric emergency MCQ-No17

Question 17

A 3 month old infant presents with acute dyspnoea and cyanosis. On examination the pulse rate is 180 per minute, he has a grade 3/6 pan systolic murmur at the left sternal edge, basal crepitations and a liver measuring 4 cm below the right costal margin.

A. The most likely diagnosis is a ventricular septal defect.
B. He requires a diuretic.
C. He should be digitalised with 50ug/kg of Digoxin given over 24 hours.
D. He should make a spontaneous recovery.
E. Chest x-ray would be likely to show a small cardiac shadow.

Answer & Comments
•B & C
Comments:
–Ventricular septal defects cause shunting of oxygenated blood from the left ventricle to the right.
–Cyanosis is a later occurrence-followin g the development of Eisenmenger’s syndrome ie shunt reversal.
–Diuretics are required to offload pulmonary venous congestion.
–Digoxin has a positive inotropic effect.
–Cyanotic congenital heart disease requires surgical correction of vascular or shunt anomalies.
–The differential diagnosis of cyanosis and congestive cardiac failure in neonates includes transposition of great vessels, total anomalous pulmonary venous drainage, hypoplastic left heart , single ventricle and tricuspid valve abnormalities and each is associated with cardiomegaly.

pediatric emergency MCQ-No16

Question 16

•A baby girl is considered normal at birth but on the second day of age cyanosis is noted. No murmur is heard and there is no respiratory distress. On the third day, cyanosis is more obvious and the respiratory rate is increased. Which of the following is correct concerning this patient?

A.Cyanosis is most likely due to congenital heart defect.
B.The baby’s colour should improve rapidly after giving 100% 02.
C.Echocardiography can often tell the anatomic state of the newborn’s circulation.
D.The baby’s chest x-ray shows a small heart. This is against the diagnosis of congenital heart disease.
E.The lack of murmur is against the diagnosis of CHD.

Answer & Comments
•A&C
Comments:
–Cyanosis is most likely due to a congenital heart defect and a right to left shunt.
–100% Oxygen will not improve the degree of cyanosis in the presence of a right to left shunt where deoxygenated blood is entering the systemic circulation.
–Echocardiogram has a high diagnostic accuracy rate and increasingly surgery is performed following echo findings without interim catheterisation.
–Certain congenital heart defects such as tetralogy of fallot are associated with small cardiac size.
–Cyanosis is often the only clinical sign present in patients with CHD.

pediatric emergency MCQ-No15

Question 15

•A 2-year-old male is rushed in by his parents after being found unconscious near open bottles of his grandfather' s medications. The airway is secure, and successful bag-valve ventilations are started. He is pulseless and unresponsive. Intravenous access is being obtained. The cardiac monitor shows a wide complex tachycardia at a rate of 260. What is the next step in management?
A.Shock the patient with 200 J.
B.Shock the patient with 0.5 J/kg.
C.Shock the patient with 2 J/kg.
D.Administer epinephrine 0.01 mg/kg IV.

Answer & Comments
•C
Comments:
–Although ventricular tachycardia and ventricular fibrillation are uncommon in children, they can occur with toxidromes or severe metabolic derangement.
–This child has pulseless ventricular tachycardia and should be immediately defibrillated.
–The appropriate initial energy setting for defibrillation in pediatric patients is 2 J/kg, then doubled for subsequent attempts.
–Cardioversion of unstable tachy-arrhythmias with a pulse begins at 0.5 J/kg and if unsuccessful is doubled for subsequent attempts.
–Epinephrine is indicated for pulseless arrest with ventricular tachycardia in children after unsuccessful defibrillation.