1) S.E. is a 1-year-old boy (weight 10.

8 kg) who presents to the emergency

department (ED) with a 4-day history of fever, bilateral non-purulent
conjunctivitis, cracked red lips, a diffuse maculopapular rash, and a cervical
lymphadenopathy greater than 1.5 cm on the left side. According to his mother,
his temperature has ranged from 102°F to 104°F (38.8°C–40°C). He has been
extremely irritable, especially when febrile, with no runny nose or cough but
some mild congestion. In the ED, serum chemistries are within normal limits;
white blood cell count (WBC) is 10.4 x 103 cells/mm3, platelet count is
250,000/mm3, and erythrocyte sedimentation rate (ESR) and C-reactive protein
(CRP) are markedly elevated. A chest radio- graph is normal, and cultures of
blood and urine, as well as viral swabs, are collected. Because of the child’s
physical examination, laboratory values, and 4-day history of fever, an
echocardiogram (ECHO) is obtained. It reveals normal ejection fraction without
evidence of coronary artery aneurysms (CAAs) or valvular regurgitation. At
this point, which is the best option for managing S.E.?
A. Immune globulin 20 g once with high-dose aspirin starting
immediately.
B. Immune globulin 20 g once with high-dose aspirin after fever has
persisted for 5 days or more.
C. No medications because this patient is not at risk of developing
CAAs according to the results of the ECHO.
D. Immune globulin 4 g once daily for 4 days with high-dose aspirin
starting immediately.

Answer: B
The diagnosis of KD can be made on day 4 of illness in the presence of at
least four principal criteria (i.e., non-purulent conjunctivitis, cracked lips,
maculopapular rash, and cervical lymphadenopathy larger than 1.5 cm for
this child). Initial ECHO serves only as a baseline for long-term
management of patients with KD, so the lack of significant cardiac findings
on ECHO does not rule out the need for treatment, making Answer C
incorrect. Although CAA may be detected as early as 3 days from illness
onset, CAAs more commonly develop in the subacute phase of illness (i.e.,
after fever resolves, but before resolution of all clinical features). Immune
globulin is the standard of care to prevent CAA in children with KD;
therefore, the AHA recommends that all children thought to have the
diagnosis be treated with immune globulin. Treatment with immune globulin
before the fifth day of illness, however, has been associated with persistent
and recrudescent fever that requires retreatment. Therefore, Answer B is
correct and Answer A is incorrect. A single high dose of immune globulin (2
 g/kg) is preferred to a low dose (500 mg/kg) over 4 days because two meta-
analyses showed a significantly lower incidence of CAA in patients
receiving high-dose therapy (Answer D is incorrect). At present, the AHA
recommends adding high-dose aspirin therapy (80– 100 mg/kg/day) for 48–
72 hours after the patient is afebrile and then continuing low-dose aspirin
therapy (3–5 mg/kg/ day) for at least 6–8 weeks until repeat ECHO.
However, use of aspirin (low, medium, or high dose) during the acute phase
of illness is controversial and varies by practice site. Although high-dose
aspirin may shorten the duration of fever, no studies have shown a reduction
in CAA with either low- or high-dose aspirin regimens.

2) G.S. is a 3-month-old girl (weight 3.4 kg, 32 weeks' gestational age, birth
weight 1.5 kg) who received a diagnosis of truncus arteriosus and interrupted
aortic arch. She went to the operating room for repair of the truncus arteriosus.
Unfortunately, during surgery, she had a significant pulmonary hypertensive
crisis with suprasystemic pulmonary artery (PA) pressures. She was initiated on
inhaled nitric oxide at 20 ppm, given sodium bicarbonate, and briefly
hyperventilated. Her PA pressures were lowered, and she was transported to the
pediatric intensive care unit. During the first few hours in the intensive care
unit, her PA pressures began to rise and became equal to her systemic pressures.
Which would be the most appropriate adjustment to therapy for G.S. at this
time?
A. Increase inhaled nitric oxide above 20 ppm indefinitely.
B. Discontinue inhaled nitric oxide, and initiate inhaled iloprost.
C. Continue inhaled nitric oxide at 20 ppm, and initiate sildenafil.
D. Continue inhaled nitric oxide at 20 ppm, and initiate epoprostenol.

Answer: D
Inhaled nitric oxide is currently a first-line treatment to rapidly reduce PA
pressure in patients with newly diagnosed severe PHN or in postoperative
PHN, making Answer B incorrect. Initial dose may be 20 ppm with weaning
once oxygenation improves. Doses should not exceed 20 ppm for prolonged
periods because of the risk of methemoglobinemia and elevation in the toxic
metabolite nitrogen dioxide; therefore, Answer A is incorrect. Because the
patient had rising PA pressures despite inhaled nitric oxide at 20 ppm,
additional therapy should be added versus maintaining high-dose, prolonged
inhaled nitric oxide. Although inhaled iloprost is as beneficial as inhaled
nitric oxide in the acute care setting, this medication requires a special
 delivery system that may be technically difficult to initiate in the immediate
postoperative period after cardiac surgery. Similarly, oral therapy with
sildenafil and bosentan would not be a good choice in the immediate post-
cardiac surgery patient (Answer C is incorrect). Epoprostenol infusion is
effective for managing PHN in the postoperative setting and can be quickly
titrated to effect, making Answer D correct.

Questions 3 and 4 pertain to the following case:

E.H. is a 19-month-old boy with a 3-day history of vomiting, diarrhea, and
decreased urine output. He is given a diagnosis of gastroenteritis and
dehydration. His current weight is 10 kg (previous weight 10.45 kg). His BP
is stable on admission.

3) Which set of physical signs and symptoms would be most expected for his
severity of dehydration?
A. Anuria, absent tears, capillary refill greater than 8 seconds.
B. Decreased skin turgor, capillary refill greater than 5 seconds,
slightly increased HR.
C. Normal HR, slightly dry mucosa, capillary refill 2 seconds.
D. Normal skin turgor, capillary refill greater than 8 seconds,
dry mucosa.

Answer: B
The percentage of dehydration is calculated as 4.3% [% dehydration =
(10.45 kg − 10 kg)/10.45 kg x 100 = 4.3%]. Therefore, this patient would be
classified as having moderate dehydration (i.e., 4%–6% dehydration for
children). Signs and symptoms typically associated with moderate
dehydration include slightly increased HR, normal-low systolic BP,
markedly decreased urine output, 6%–10% weight loss, dry mucosa, reduced
tears, deep-set eyes, decreased skin turgor, cool skin, reduced fontanelle,
capillary refill of greater than 5 seconds, and irritability. Answer A is
incorrect because these symptoms would be more consistent with severe
dehydration. Answer C is incorrect because these symptoms would be more
consistent with mild dehydration. Answer D is incorrect because the
symptoms of dehydration are mixed between mild, moderate, and severe.
4) Which is the best recommendation for correcting E.H.’s dehydration at this
time?
A. Dextrose 5% in 0.45% normal saline plus potassium chloride
20 mEq/L at 70 mL/hour x 8 hours, followed by dextrose 5% in
0.45% normal saline plus potassium chloride 20 mEq/L at 56
mL/hour x 16 hours.
B. Dextrose 5% in 0.45% normal saline plus potassium chloride
20 mEq/L at 19 mL/hour 24 hours.
C. 200 mL 0.9% normal saline bolus, followed by dextrose 5%
in 0.45% normal saline plus potassium chloride 20 mEq/L at 43
mL/hour 16 hours.
D. 450 mL 0.9% normal saline bolus, followed by dextrose 5%
in 0.45% normal saline plus potassium chloride 20 mEq/L at 43
mL/hour 24 hours.

Answer: A
Based on 4.3% dehydration, this patient’s fluid deficit is around 450 mL
(fluid deficit = 4.3% x 10.45 kg/100 = 449 mL). In addition, using the
Holliday-Segar method for maintenance needs, the patient requires 1023
mL/day for maintenance. The most appropriate way to administer this is to
provide one-half of the deficit over the first 8 hours and one-half over the
next 16 hours. Likewise, the maintenance needs should be replaced by one-
third over the first 8 hours and by two-thirds over the next 16 hours. Answer
B is incorrect because this would only replace the deficit; it would not also
provide maintenance requirements. Answer C is incorrect because a bolus is
not indicated at this time (i.e., BP stable). In addition, this patient will
require maintenance fluids for 24 hours rather than 16. Answer D is
incorrect because a bolus is not indicated at this time (i.e., BP stable).

5) A 9-day-old neonate (weight 1.535 kg) with con- genital diaphragmatic hernia
is currently NPO (nothing by mouth) and receiving PN. The PN formulation is
as follows: 20% Intralipid 23 mL (3 g/ kg), TrophAmine 4% (3.5 g/kg), and
dextrose 21.4% (28.7 g/day). The total volume of the PN is 134 mL, and it is
infusing at a rate of 5.6 mL/hour. Which best represents the calculated dextrose
infusion rate (DIR)?
A. 19.9 mg/kg/minute.
B. 13 mg/kg/minute.
C. 17.5 mg/kg/minute.
D. 14 mg/kg/minute.
 Answer: B
Dextrose infusion rate is measured in milligrams per kilogram per minute.
The DIR in this question can be calculated in two ways:
a. 28.7 g x 1000 mg/g = 28700 mg/day ÷ 1440 minutes/day ÷ 1.535 kg = 13
mg/kg/minute
b. 21.4 g/100 mL x 5.6 mL/hour x 1000 mg ÷ 60 minute÷ 1.535 kg = 13
mg/kg/minute Because of mathematical miscalculations, Answers A, C, and
D are incorrect.

6) An 8-year-old boy (weight 30 kg) sustained burns to 40% of his body after
accidentally pulling boiling water off the stove. Which is the most appropriate
way to replace his fluids?
A. 300 mL/hour for 24 hours.
B. 450 mL/hour for 8 hours; then 225 mL/hour for 16 hours.
C. 225 mL/hour for 8 hours; then 450 mL/hour for 16 hours.
D. 225 mL/hour for 8 hours; then 112 mL/hour for 16 hours.

Answer: B
The equation is 6 mL/kg per percent TBSA: 6 mL/kg x 30 kg x 40(TBSA) =
7200. Then, treatment is similar to dehydration replacement. Take the total
and divide it by half. The first half is replaced in the first 8 hours, and the
second half is replaced over the next 16 hours: 7200/2 = 3600 mL; 3600 mL
over first 8 hours = 450 mL/hour for 8 hours; 3600 mL over the next 16
hours = 225 mL/ hour for 16 hours (Answer B is correct). Answer A gives
the same amount during the 24-hour period but does not solve the immediate
problem of profound dehydration. Answer C is just switched around.
Answer D would be for a total of 3 mL/kg per percent TBSA, which would
provide inadequate resuscitation for the patient.

7) A 7-year-old patient is currently on a fentanyl infusion at 1 mcg/kg/hour and is

in the process of being deployed on extracorporeal membrane oxygenation
(ECMO). Which best describes the pharmacokinetic change that is expected to
occur with fentanyl while the patient is on ECMO?
A. Decreased volume of distribution.
B. Adsorption to the circuit.
C. Increased clearance.
D. No changes to fentanyl pharmacokinetics.
 Answer: B
Fentanyl has an increased volume of distribution (Answer A is incorrect),
can be adsorbed into the circuit by almost 80% (Answer B is correct), and
has decreased clearance (Answer C is incorrect). Fortunately, because this is
a continuous infusion and the patient is being monitored closely, bolus doses
and increases in the drip rate can occur easily when more sedation is needed.
Answer D is incorrect since there are changes as described.

8) A 6-year-old girl presents in shock. She has a past medical history significant
for a dilated viral cardiomyopathy with a baseline ejection fraction of 45%. Her
current ejection fraction is 35%. Her cur- rent systemic vascular resistance
(SVR) is 130/80. Which is the most appropriate agent to use in this child for
cardiac support?
A. Norepinephrine.
B. Milrinone.
C. Dopamine.
D. Phenylephrine.

Answer: B
The patient has decreased cardiac function. Milrinone is an inotropic agent
that increases cardiac output. The patient also has an increased SVR, which
milrinone would lower slightly (Answer B is correct). Norepinephrine is
mainly used for warm shock (Answer A is incorrect). Dopamine could be
used in a patient with normal cardiac function and hypotension, but this
would not be appropriate for this patient (Answer C is incorrect).
Phenylephrine is an α1-agonist only, which would make the patient
hypertensive but would not affect the cardiac function (Answer D is
incorrect).

9) A 3-year-old is in supraventricular tachycardia (SVT). Which is the most

appropriate way to administer adenosine?
A. Intravenous push over 2–5 minutes, followed by a saline
flush over 2–5 minutes.
B. Diluted infusion over 30 minutes.
C. Rapid intravenous push, followed by a saline flush over 2–5
minutes.
D. Rapid intravenous push, followed by a rapid saline flush.
 Answer: D
Answer D, rapid intravenous push followed by rapid saline using a double-
barrel technique, is correct. Although Answer A is technically rapid
intravenous push, it is too slow. Answer B is incorrect because of the 30-
minute duration, and no dilution is needed with adenosine. Answer C is
incorrect because even though the drug is rapid intravenous push, the flush
must also be rapid intravenous push to get all the medication into
circulation.

10) Cardiac arrest is called on a 4-year-old girl on the floor. The team begins
cardiopulmonary resuscitation (CPR), and the monitor reveals ventricular
fibrillation (VF). The team does three cycles of CPR, defibrillation, and
epinephrine with no return to spontaneous circulation. Which drug would be
best to consider next?
A. Atropine.
B. Adenosine.
C. Amiodarone.
D. Procainamide.

Answer: C
This patient is in VF. The standard sequence of treatments for VF is as
follows: shock, CPR, shock, CPR, epinephrine every 3–5 minutes, shock,
and then amiodarone. Chances are that after the first shock, epinephrine
would have been initiated if intravenous access had been obtained.
Depending on when the third shock came, many doses of epinephrine would
have been given. The next step in the sequence is amiodarone (Answer C is
correct). The other choices have no role in VF. Atropine is for bradycardia
(Answer A is incorrect), adenosine is for SVT (Answer B is incorrect), and
procainamide is not in the PALS guidelines for VF (Answer D is incorrect).

11) A 3-year-old involved in a motor vehicle collision sustained a severe

traumatic brain injury (TBI). Mannitol is used to help control the patient’s intra-
cranial pressure (ICP). Which best matches the mechanism of action of ICP
reduction with mannitol’s duration or onset?
A. Blood viscosity reduction lasts 6 hours.
B. Blood viscosity reduction lasts 1 hour.
C. Osmolar agent starts working within 2 minutes.
D. Osmolar agent lasts 1 hour.
 Answer: C
The patient is being well treated for ICP management. Sedation is always an
important consideration in ICP management, but in this case, it is adequate.
Mannitol scheduled every 6 hours will help reduce blood viscosity for a
short while and will work as an osmolar agent. Hypertonic saline is at an
appropriate dose and is optimized, given the osmolar and sodium limits (350
mOsm/L and 175 mEq/L, respectively) (Answer A is incorrect). If an
increased ICP were to occur, an extra dose of mannitol would probably have
no effect (Answer B is incorrect). Phenytoin, which has little effect on ICP,
should be used as seizure prophylaxis, if indicated (Answer D is incorrect).
Barbiturate-induced coma would be the next step for this patient (Answer C
is correct).

12) A 5-kg patient is receiving adequate sedation with fentanyl and midazolam,
scheduled mannitol 5 g every 6 hours, and 3% saline continuous infusion at 5
mL/hour for ICP management. Osmolarity is 350 mOsm/L, and serum sodium
is 175 mEq/L. Which is the next most appropriate agent for management of an
increased ICP?
A. A 7-mL/kg bolus of 3% saline.
B. Mannitol 0.5 g/kg x 1 now (regardless of timing of previous
mannitol).
C. Pentobarbital bolus, followed by continuous infusion.
D. Phenytoin every 8–12 hours.

Answer: C
The patient is being well treated for ICP management. Sedation is always an
important consideration in ICP management, but in this case, it is adequate.
Mannitol scheduled every 6 hours will help reduce blood viscosity for a
short while and will work as an osmolar agent. Hypertonic saline is at an
appropriate dose and is optimized, given the osmolar and sodium limits (350
mOsm/L and 175 mEq/L, respectively) (Answer A is incorrect). If an
increased ICP were to occur, an extra dose of mannitol would probably have
no effect (Answer B is incorrect). Phenytoin, which has little effect on ICP,
should be used as seizure prophylaxis, if indicated (Answer D is incorrect).
Barbiturate-induced coma would be the next step for this patient (Answer C
is correct).
13) A 5-year-old girl was an unrestrained passenger in a motor vehicle collision.
Having sustained a significant TBI with a Glasgow Coma Scale score of 3, she
is brought to the emergency department after undergoing intubation at the
scene. An intracranial monitor is placed, which reveals an ICP of 30 mm Hg.
She is hypotensive and tachycardic. After initial fluid resuscitation, her BP
normalizes, but she remains tachycardic. She will likely require intubation for
more than 7 days.
Which would be the most appropriate therapy for managing her tachycardia?
A. Propofol infusion for length of intubation.
B. Midazolam and fentanyl infusions for length of intubation.
C. Ketamine infusion for length of intubation.
D. Vecuronium infusion for length of intubation.

Answer: B
This patient has been adequately resuscitated with fluids but remains
tachycardic likely because of her pain and sedation needs. Answer B is
correct, standard sedation
with midazolam and fentanyl would be appropriate to initiate. Answer A is
incorrect because propofol should not be used for more than 24 hours in
children. Answer C could be an option, but in TBI, it has been studied only
in procedural sedation as an adjunct. Answer D is incorrect because
paralyzing a patient without adequate sedation is inappropriate.

14) A 5-year-old boy presents in septic shock with a temperature of 102.5°F

(39.2°C). His blood pressure (BP) is 60/40 mm Hg, his heart rate (HR) is 100
beats/minute, and he is cool to the touch. Which is the most appropriate
vasopressor to initiate first?
A. Dopamine.
B. Norepinephrine.
C. Milrinone.
D. Epinephrine.

Answer: A
This patient is in cold shock, for which dopamine is preferred (Answer A is
correct). Norepinephrine is for warm shock (Answer B is incorrect).
Milrinone is reserved for patients with decreased cardiac function and/or
pulmonary hypertension (Answer C is incorrect). Because this patient is
already hypotensive, milrinone would cause an even further decrease in SVR
 (Answer C is incorrect). Epinephrine is an alternative if effects are
inadequate with dopamine (Answer D is incorrect).

15) T.K. is a 5-year-old girl (weight 20 kg) with acute respiratory distress
syndrome (ARDS) admitted to the PICU 2 days ago. Her medical history
includes several acute otitis media episodes. The most recent episode was about
1 week ago. She is currently intubated on a fraction of inspired oxygen (Fio2)
of 0.8 (80% O2) and a positive end expiratory pressure (PEEP) of 12 cm H2O.
She has no wheezing but is positive for rales on the left upper chest area. Which
would be the best treatment option for this patient?
A. Methylprednisolone 20 mg intravenously every 6 hours.
B. Salbutamol 2.5 mg nebulized every 6 hours.
C. Tidal volume of 120 mL.
D. Inhaled nitric oxide at 20 ppm.

Answer: C
Low tidal ventilation (Answer C) has the most evidence to support its use in
adult ARDS. There is little to no definitive evidence in pediatric patients, but
it is still generally practiced in the pediatric world. Although several studies
look at corticosteroid (Answer A) use for ARDS and the pathophysiology of
ARDS would suggest a benefit of corticosteroids, there has been no good
conclusive evidence that corticosteroids have clinical outcome benefits.
Salbutamol (Answer B) relieves symptoms and has some supportive benefit,
but it lacks good evidence to support its use. It is especially not usually of
benefit if the patient has no wheezing. Inhaled nitric oxide (Answer D) has
the most benefit with pulmonary hypertension as a comorbidity.

16) L.T. is a 14-year-old male adolescent (weight 40 kg) with a history of

seizure disorder. He was at a friend’s house during the weekend and forgot his
seizure medications of topiramate and tiagabine. He got home from his friend’s
house and began having a generalized clonic status epilepticus (GCSE) event.
His mother administered 5 mg of rectal diazepam and called EMS (emergency
medical services). Diazepam stopped his seizure during transport, but on
admission to the PICU, he began seizing again. The EMS personnel were able
to place a peripheral line before the seizure. Which would be the best option to
manage his GCSE now?
A. Another 5-mg dose of rectal diazepam.
B. Lorazepam 4 mg intravenously.
 C. Topiramate 50 mg orally.
D. Midazolam continuous infusion at 0.1 mg/kg/hour.

Answer: B
The best and quickest option for this patient would be lorazepam 4 mg
intravenously (Answer B) because the patient is now in the PICU with
placement of a line. Although another dose of rectal diazepam (Answer A)
could be given without adversely affecting this patient, it has a slower onset
than the immediate intravenous effect and is not necessary when the patient
has a peripheral line. Topiramate (Answer C) is this patient’s home
medication; however, topiramate is not usually used acutely for GCSE
episodes, and it does not come in an
intravenous form. The oral form would take too long to take effect. A
midazolam continuous infusion (Answer D) could also be given, but it is
probably unnecessary at this point. An intravenous continuous infusion
could be considered if the patient is refractory to previous therapies or has
continuous seizures.

17) R.M. is a 7-month-old boy (weight 8 kg) admitted to the PICU for new-
onset GCSE. He has no pertinent medical history and had a normal vaginal
birth. He has a social history of two sisters in day care and a dog and a cat. He
presented to the PICU seizing for 10 minutes. He was given two doses of
lorazepam 0.8 mg intravenously, but they did not terminate the seizures. Which
would be the next best option for this patient?
A. Diazepam rectally 1 mg.
B. Phenytoin 160 mg intravenously over 2 minutes.
C. Fosphenytoin 160 mg phenytoin equivalents (PE)
intravenously over 6 minutes.
D. Valproic acid 320 mg intravenously over 10 minutes.

Answer: C
A phenytoin derivative is the next best option after lorazepam or
benzodiazepines. There is no reason to administer another benzodiazepine
(Answer A) after two standard doses have already been given. Increased
benzodiazepine administration could result in increased respiratory
depression and potentially unnecessary intubation of this patient. Phenytoin
160 mg (Answer B) could be given but not at the rate of 2 minutes. The
maximum rate that phenytoin should be given is 1 mg/ kg/minute (50
mg/minute ceiling). Giving phenytoin over 2 minutes would be
 administering it at 80 mg/ minute. Valproic acid (Answer D) has more
recently been shown to be effective for SE in pediatric patients but is
probably still not an accepted option for patients younger than 2 years
because of its risk of hepatotoxicity. Fosphenytoin (Answer C) is currently
the best option for pediatric patients. Fosphenytoin should be administered
at a maximum rate of 150 mg PE/minute. It is also a safer option than
phenytoin because it is water soluble and therefore does not cause as much
extravasation or cardiac arrhythmias.

18) S.S. is a 7-year-old girl (weight 20 kg) who has been having polydipsia,
polyuria, and nausea/vomiting for the past week. She has no significant medical
history. On admission to the emergency department (ED), her Accu-Chek
glucose reading was 1005 mg/ dL, and she had Kussmaul breathing. She is
slightly obtunded, has extremely dry mucous membranes and skin tenting. She
received 100 mL of 0.9% nor- mal saline in the ED, after which she was
admitted to the PICU. Laboratory values were pending on her transfer to the
PICU. Which would be the best initial management for this patient?
A. Obtain an ABG to learn her pH value.
B. Rehydrate with 300 mL of 0.9% normal saline over 1
hour.
C. Rehydrate with 250 mL of 0.9% normal saline with 20
mEq of potassium over 1 hour.
D. Initiate insulin continuous intravenous infusion at 0.1
unit/kg/hour.

Answer: B
This patient has new-onset DKA. The first thing to consider and do in all
patients with DKA is rehydration (Answer B). Even if you do not have the
laboratory values yet, you can rehydrate. The estimated amount of
rehydration can be calculated as 10–20 mL/kg for the first hour over 1–2
hours. This patient did not get the full replacement of 10–20 mL/kg (200–
400 mL) in the ED; therefore, you could replete with the rest of the fluid
needed, 100–300 mL, over 1 hour. This should allow enough time to obtain
the laboratory values. You should not add potassium (Answer C) to your
fluids until you have obtained the laboratory values. You should obtain an
ABG (Answer A) when this patient presents, but you need not wait for the
results to give fluid. Fluids should still come first, but you could do the
blood gas almost immediately afterward. You should not initiate insulin
 (Answer D) until you have given fluids and received the results of the
laboratory tests.

19) D.K. is a 9-year-old boy (height 57 inches [145 cm], weight 45 kg) with type
1 diabetes mellitus who has been sick for the past week with nausea, vomiting,
and dehydration. He is on an insulin pump, but it stopped working 2 days ago,
and he did not tell any- one. He has been admitted to the PICU with a pH of 7.0,
bicarbonate 5 mEq/L, and Pco2 32 mm Hg. His blood glucose initially was
1050 mg/dL. One hour later, it was 903 mg/dL, and 1 hour after that, it was 780
mg/dL. His temperature is 101°F, RR is 12 breaths/minute, HR is 120
beats/minute, and BP is 135/80 mm Hg. Which factor places D.K. at most risk
of cerebral edema?
A. High glucose.
B. pH of 7.0.
C. Decrease in glucose from 1050 mg/dL to 800 mg/dL.
D. His use of the insulin pump.

Answer: B
Typically, the lower the pH (Answer B), the more severe the DKA,
and this is believed to be a large risk factor for cerebral edema.
Decreases in blood glucose greater than 50–100 mg/dL (Answer C)
have also been believed to cause cerebral edema, but some studies
have refuted this. It is unclear whether decreases in blood glucose
represent a risk factor for cerebral edema, but it is still considered
prudent to decrease glucose slowly to decrease rapid changes in serum
osmolality in the brain. The patient’s extremely high glucose and use
of an insulin pump (Answers A and D) do not increase his risk of
cerebral edema.

20) D.P. is an 8-month-old male infant (weight 6 kg) with a medical history of
bronchopulmonary dysplasia, for which he is on furosemide and hydrocortisone
at home. He is now in the PICU for ARDS and on mechanical ventilation, with
an Fio2 of 40%, a PEEP of 7, and a respiratory rate of 24 breaths/minute. He is
currently on albuterol, furosemide, hydrocortisone (stress dosed), and sodium
bicarbonate inhalations. D.P. is still not moving air well and sounds tight. The
resident asks you for the best, most economical therapeutic option to add that is
available in the pharmacy. Which is the best reply?
A. Surfactant.
B. Nitric oxide.
 C. Albumin.
D. Methylprednisolone.

Answer: D
Many therapies for ARDS have limited supportive evidence, and large
controlled randomized trials have not been done or have been unable
to show a meaningful difference. Therefore, therapy is generally
targeted at supportive care. There is limited evidence for surfactant
(Answer A) use in ARDS. The best literature and greatest efficacy
occur in neonates. However, some adult and PICU literature have
used surfactant effectively. Unfortunately, surfactant is a very
expensive and time- intensive option. Nitric oxide (Answer B) has
shown some benefit in improved oxygenation but no effect on
mortality; typically, it is most efficacious when pulmonary
hypertension is involved. Nitric oxide would not be an option because
it is extremely expensive and is not available through the pharmacy. It
is distributed through respiratory care. Albumin (Answer C) can be
used to promote fluid diuresis in the lungs, but it is also expensive and
is a blood product, so availability can be limited. Corticosteroids
(Answer D) have been used as a tool to improve outcomes in adult
ALI and ARDS and have shown some degree of success when used
early in the course of ARDS.

21) To compare the pain control offered by two different analgesics in pediatric
patients, the authors selected the Wong-Baker FACES pain rating scale as the
pri- mary end point. Before beginning the clinical trial, the authors sought to
validate this ordinal scale by showing a correlation with a previously validated
visual analog scale. Which statistical test is most appropriate to assess whether
a correlation exists between these two measures?
A. Pearson correlation.
B. Analysis of variance (ANOVA).
C. Spearman rank correlation.
D. Regression analysis.

Answer: C
The Spearman rank correlation is a nonparametric test of the
strength of an association between two ordinal or continuous
variables (Answer C is correct). Answer A is incorrect because
the Pearson correlation requires the variables of interest to be
 continuous, and Answer D is incorrect because regression
analysis is used to develop predictive models and requires
continuous data. Answer B is incorrect because the ANOVA is
used to test for differences between three or more groups, not
correlation between two variables.

22) Using a regression model, investigators were able to show that children with
cancer had an odds ratio (OR) of 1.5 (95% CI, 1.2–2.0) compared with children
without cancer. Which is the best interpretation of the reported results?
A. Children with cancer had 1.5 times the odds of
having the outcome compared with children
without cancer, but the difference was not
statistically significant.
B. Children with cancer had 1.5 times the odds of
having the outcome compared with children
without cancer, and the difference was statistically
significant.
C. Children without cancer had 1.5 times the odds
of having the outcome compared with children
with cancer, and the difference was statistically
significant.
D. Without a p value, the reader cannot discern
whether the difference between groups was
statistically significant.

Answer: B
An OR greater than 1 indicates an increase in the odds of
having an outcome (Answer B is correct). Answers A and D are
incorrect because the 95% CI does not include 1; therefore, the
difference in odds is statistically significant, and a p value does
not need to be reported. Answer C is incorrect because children
without cancer have a lower versus higher odds of having the
outcome.

Questions 23 and 24 pertain to the following case:

23) Investigators have chosen the Wong-Baker FACES pain rating scale to show
that a new analgesic works better than placebo in children. The authors plan to
randomize subjects to two separate groups.
 3. Which is the most appropriate statistical test? A. Student t-
test.
B. Paired Student t-test.
C. Wilcoxon rank sum.
D. Pearson correlation.

Answer: C
The Wong-Baker FACES pain rating scale is an ordinal scale, and the
Wilcoxon rank sum is a nonparametric test that can be used to compare
ordinal data between two independent groups (Answer C is correct).
Answers A and B are incorrect because both the Student t-test and the paired
Student t-test are parametric tests and would not be appropriate for data on
an ordinal scale. Answer D is incorrect because the Pearson correlation test
is used to determine the strength of association between two continuous
variables.

24) While designing this study, the investigators realized that they did not have a
large enough budget to support the sample size estimated. Which statistical test
is best if they decide to use a paired design to decrease the number of subjects
required while maintaining similar power?
A. Paired Student t-test.
B. Wilcoxon rank sum.
C. Wilcoxon signed rank.
D. McNemar test.

Answer: C
Even though both the Wilcoxon signed rank and the Wilcoxon rank sum
tests can be used for ordinal data, the Wilcoxon signed rank test is for paired
samples (Answer C is correct), whereas the Wilcoxon rank sum test is
designed for independent groups (Answer B is incorrect). Answer A is
incorrect; although the paired Student t-test can be used in a paired design,
the criteria for using this parametric test include continuous, normally
distributed data. The McNemar test can be used for a study that has a paired
design; however, Answer D is incorrect because the test is designed for
nominal versus ordinal data, and use of this test would result in less power to
find a difference.

25) K.M. is a 21-month-old girl admitted to the hospital with a 3-day history of
fussiness, decreased appetite, and high temperature (40°C). Meningitis is
suspected, and a lumbar puncture is performed with the following results: white
 blood cell count (WBC) 8 x 103 cells/mm3 (72 segs, 15 bands, 11 lymphs),
glucose 22 mg/dL, and protein 95 mg/dL. The Gram stain also reveals the
presence of gram-positive cocci. The patient is placed on empiric therapy with
vancomycin and ceftriaxone. Three days later, her cerebrospinal fluid (CSF)
grows Streptococcus pneumoniae with the following sensitivities:
Penicillin R 2 mcg/mL
Cefotaxime S 1 mcg/mL
Ceftriaxone I 2 mcg/mL
Vancomycin S 1 mcg/mL
Which would be the best changes to K.M.’s antibiotic regimen, given these
culture and sensitivity results?
A. Continue vancomycin and ceftriaxone.
B. Discontinue ceftriaxone, continue vancomycin, and add rifampin.
C. Change ceftriaxone to cefotaxime, and continue vancomycin.
D. Discontinue vancomycin, continue ceftriaxone, and add rifampin.

Answer: C
For the treatment of bacterial meningitis caused by ceftriaxone-
intermediate S. pneumoniae, two treatment
options are recommended by the guidelines. Rifampin can be added to
vancomycin and ceftriaxone, or vancomycin can be combined with
another third-generation cephalosporin. In this patient, the organism is
sensitive to an alternative third-generation cephalosporin, so changing
to that agent is the best choice, given the culture and sensitivity results
(Answer C is correct). If rifampin is added, ceftriaxone should be
continued (Answer B is incorrect). It is not appropriate to continue
ceftriaxone and vancomycin because of the intermediate sensitivity
and potential for treatment failure and complications (Answer A is
incorrect). Vancomycin should be used together with a third-
generation cephalosporin for all penicillin-resistant S. pneumoniae;
therefore, it is not appropriate to discontinue vancomycin and use
ceftriaxone and rifampin (Answer D is incorrect).

26) B.F. is a 16-year-old patient admitted for management of worsening lower

leg cellulitis. Three days ago, he slammed his leg in a car door, and during the
past 12 hours, it has become much worse. His leg is warm, erythematous,
edematous, and painful to the touch. There is concern for necrotizing fasciitis
because the area of cellulitis is also firm on palpation and appears to have an
area of necrosis. He undergoes surgery for debridement of the necrotic area. A
 Gram stain of the skin tissue is performed, which shows gram-positive cocci in
chains. Which antibiotic therapy would be best to initiate in this patient?
A. Vancomycin.
B. Penicillin G.
C. Penicillin G plus clindamycin.
D. Clindamycin.

Answer: C
Necrotizing fasciitis caused by S. pyogenes should be treated with a
combination of penicillin G and clindamycin. Combination therapy
with clindamycin is recommended because it can neutralize the
exotoxin produced by streptococcal species and decrease cytokine
production (Answer C is correct). Vancomycin can be considered an
alternative in a patient with a β-lactam allergy (Answer A is
incorrect). Penicillin monotherapy would provide inadequate coverage
against any possible toxin production (Answer B is incorrect).
Clindamycin monotherapy would provide inadequate coverage against
potential GAS- resistant strains (Answer D is incorrect).

27) Your new patient in the pediatric intensive care unit (ICU) this morning is a
2-year-old girl with severe renal failure. She is being initiated on continuous
renal replacement therapy (CRRT), and you note in her medical history that she
has a 1-week history of gastroenteritis and bloody stools. Her parents state that
she was fine until 24 hours before admission, when she seemed very sleepy and
was too tired to get out of bed. She has a working diagnosis of HUS, though her
stool studies are pending. The pediatric ICU attending asks you about using
eculizumab (Soliris) for this patient. Which is the most appropriate response?
A. Eculizumab is not indicated for patients with typical
HUS.
B. Eculizumab, which costs thousands of dol- lars per
dose, should not be used as first-line therapy.
C. Eculizumab can increase the risk of infection, and
because she is likely already infected with Escherichia
coli, it may worsen her course.
D. The CRRT circuit will remove eculizumab, so she
cannot start therapy until she is off CRRT.

Answer: A
The classic symptoms of typical HUS (STEC) are described in the
case, though there are not yet any stool studies confirming it.
 Eculizumab is not indicated for typical HUS at this time (Answer A is
correct). Although eculizumab therapy is quite expensive, many still
consider it the first-line therapy for atypical HUS (Answer B is
incorrect). Eculizumab increases the risk of meningococcal infection;
therefore, vaccination with or without antibiotic coverage during
treatment is recommended. However, eculizumab has not been
associated with a worsening in the underlying STEC in patients with
typical HUS who have received eculizumab (case reports) (Answer C
is incorrect). Eculizumab is a recombinant antibody with a molecular
weight of 148 kDa. Although studies examining the effect of CRRT
on eculizumab removal have not been done, there is currently no
recommendation for alternation in dosing, except for patients
undergoing plasmatherapy. Therefore, it is not expected that
significant removal would occur in the setting of CRRT (Answer D is
incorrect).

28) K.T. is a previously healthy 8-year-old girl who was admitted to the hospital
with pneumonia. She is febrile and requiring oxygen. K.T. attends school, her
immunizations are up to date, and she lives at home with her two older siblings.
Which is the best empiric treatment for K.T.’s pneumonia?
A. Amoxicillin.
B. Ampicillin.
C. Ceftriaxone.
D. Clindamycin.

Answer: B
The Infectious Diseases Society of America CAP guidelines
recommend ampicillin (Answer B) as first- line treatment for CAP in
fully immunized hospitalized patients. Amoxicillin (Answer A) is the
recommended outpatient treatment, and the patient should be
transitioned to amoxicillin once she shows clinical improvement.
Ceftriaxone (Answer C) is recommended first line if the patient is not
fully immunized. Clindamycin (Answer D) is a recommended
addition to ampicillin if the patient has risk factors for MRSA.