PALS - Pediatric Advanced Life Support Pediatric Shock Management Questions and Answers — Questions and Answers
Question 1: A 4-year-old child presents with a two-day history of fever, vomiting, and diarrhea. On examination, the child is lethargic with cool extremities, a capillary refill time of 4 seconds, and a heart rate of 160/min. The blood pressure is 80/50 mmHg. What is the most appropriate initial fluid resuscitation for this child in suspected hypovolemic shock?
- Administer a 5 mL/kg bolus of 5% dextrose over 60 minutes.
- Administer a 20 mL/kg bolus of 0.9% normal saline over 5-20 minutes. (Correct answer)
- Administer a 10 mL/kg bolus of packed red blood cells immediately.
- Administer a 20 mL/kg bolus of 0.45% saline over 30 minutes.
Correct answer: Administer a 20 mL/kg bolus of 0.9% normal saline over 5-20 minutes.
According to PALS guidelines, the initial management for a child in hypovolemic or septic shock is a rapid bolus of an isotonic crystalloid solution. The standard dose is 20 mL/kg of 0.9% normal saline or Lactated Ringer's, administered over 5-20 minutes. This patient's presentation is consistent with compensated shock progressing to decompensated shock, and rapid volume expansion is critical.
Question 2: A 6-year-old is brought to the emergency department with suspected septic shock. The child is febrile, tachycardic, and has a prolonged capillary refill. After administering three 20 mL/kg boluses of isotonic crystalloid, the child remains hypotensive with poor perfusion. Which of the following is the most appropriate next step in management?
- Administer another 20 mL/kg fluid bolus.
- Initiate an epinephrine or norepinephrine infusion. (Correct answer)
- Administer a dose of furosemide to prevent fluid overload.
- Start a dopamine infusion.
Correct answer: Initiate an epinephrine or norepinephrine infusion.
For fluid-refractory septic shock in children, PALS guidelines recommend initiating vasoactive support. After 40-60 mL/kg of fluid resuscitation without improvement, a vasopressor like epinephrine (for cold shock) or norepinephrine (for warm shock) should be started to improve vascular tone and cardiac output. Dopamine is no longer recommended as a first-line agent.
Question 3: You are managing a 2-year-old with cardiogenic shock secondary to myocarditis. The child has tachypnea, increased work of breathing, and crackles on lung auscultation. Blood pressure is low for age. Which fluid management strategy is most appropriate for this patient?
- Rapid 20 mL/kg bolus of normal saline.
- Cautious 5-10 mL/kg bolus of isotonic crystalloid over 10-20 minutes. (Correct answer)
- No fluids should be given; start diuretics immediately.
- Administer 20 mL/kg of albumin over one hour.
Correct answer: Cautious 5-10 mL/kg bolus of isotonic crystalloid over 10-20 minutes.
In cardiogenic shock, the heart's pumping function is impaired. Aggressive fluid resuscitation can worsen pulmonary edema and cardiac strain. Therefore, PALS guidelines recommend administering fluids cautiously, with smaller boluses of 5-10 mL/kg of an isotonic crystalloid given slowly over 10-20 minutes, while closely monitoring for signs of fluid overload.
Question 4: Which of the following is considered a late and ominous sign of shock in a pediatric patient?
- Tachycardia
- Delayed capillary refill
- Hypotension (Correct answer)
- Cool extremities
Correct answer: Hypotension
In pediatric shock, compensatory mechanisms like tachycardia and peripheral vasoconstriction (leading to cool extremities and delayed capillary refill) work to maintain blood pressure. Hypotension is a late sign, indicating that these compensatory mechanisms are failing and the child is in decompensated shock, which can quickly lead to cardiopulmonary arrest.
Question 5: A 5-year-old boy with a known severe peanut allergy accidentally ingested a cookie containing peanuts. He is now anxious, has diffuse urticaria, wheezing, and a blood pressure of 70/40 mmHg. What is the immediate, first-line medication for managing his condition?
- Intravenous diphenhydramine
- A rapid 20 mL/kg bolus of normal saline
- Intravenous hydrocortisone
- Intramuscular epinephrine (Correct answer)
Correct answer: Intramuscular epinephrine
This patient is presenting with anaphylactic shock, a type of distributive shock. The immediate and most critical treatment is intramuscular epinephrine. Epinephrine addresses the life-threatening symptoms by causing vasoconstriction, bronchodilation, and decreasing capillary permeability. While fluids, antihistamines, and corticosteroids are also part of the management, epinephrine is the first-line and life-saving intervention.
Question 6: A 10-year-old presents with signs of shock, including tachycardia, cool skin, and altered mental status, but their systolic blood pressure is 95 mmHg, which is within the normal range for their age. This clinical state is best described as:
- Septic shock
- Decompensated shock
- Compensated shock (Correct answer)
- Irreversible shock
Correct answer: Compensated shock
Compensated shock is a stage where the body's compensatory mechanisms (like tachycardia and increased systemic vascular resistance) are still able to maintain a normal blood pressure despite inadequate tissue perfusion. The presence of other shock signs (tachycardia, poor perfusion, altered mental status) with a normal blood pressure is the key feature of compensated shock.
PALS - Pediatric Advanced Life Support Pediatric Shock Management Questions and Answers
A 4-year-old child presents with a two-day history of fever, vomiting, and diarrhea.
On examination, the child is lethargic with cool extremities, a capillary refill time of 4 seconds, and a heart rate of 160/min.
The blood pressure is 80/50 mmHg.
What is the most appropriate initial fluid resuscitation for this child in suspected hypovolemic shock?