Read the station prompt, start the 4-minute exam timer, and reveal Dr. Saini's model answer.
⏱️ Standard Station Time: 04:00 Minutes
⏱️ Station 1 - ABG Interpretation
Severe Metabolic Acidosis in Septic Shock
A 4-year-old child presents with lethargy, cold peripheries (CRT 4s), and tachycardia (HR 165/min). ABG shows: pH 7.12, PaCO2 22 mmHg, PaO2 92 mmHg, HCO3 7 mEq/L, Lactate 6.8 mmol/L, Na 138 mEq/L, Cl 102 mEq/L.
Questions:
1. Interpret the ABG completely including Anion Gap.
2. State 3 immediate emergency management steps.
Dr. Saini's Model Examiner Solution:
1. ABG Interpretation: • Primary Diagnosis: Severe High Anion Gap Metabolic Acidosis with partial respiratory compensation. • Anion Gap = Na - (Cl + HCO3) = 138 - (102 + 7) = 29 mEq/L (Normal 12 +/- 2 mEq/L). • Hyperlactatemia (6.8 mmol/L) indicates severe tissue hypoperfusion.
2. Emergency Management Steps: a) Administer 10-20 mL/kg Isotonic Crystalloid bolus (0.9% Normal Saline or Ringer's Lactate) over 10-15 mins. b) Initiate Adrenaline inotrope infusion (0.05 - 0.2 mcg/kg/min) for cold septic shock. c) Establish airway & high-flow oxygenation, obtain blood cultures, and administer IV broad-spectrum antibiotics within 1 hour.
⏱️ Station 2 - Mechanical Ventilation
PARDS High Peak Pressure Troubleshooting
A 2-year-old intubated child with severe PARDS on Volume Control Ventilation suddenly triggers the High Airway Pressure Alarm. Peak Airway Pressure (Ppeak) increases from 24 cmH2O to 42 cmH2O, while Plateau Pressure (Pplat) remains unchanged at 22 cmH2O.
Questions:
1. What does the increase in Ppeak with normal Pplat signify?
2. List 4 differential diagnoses.
3. State the step-by-step immediate bedside action.
Dr. Saini's Model Examiner Solution:
1. Pathophysiology: • Increase in Ppeak with unchanged Pplat indicates an Airway Resistance Problem (Transway pressure = Ppeak - Pplat increased from 2 to 20 cmH2O).
2. Differential Diagnoses: a) Endotracheal tube (ETT) kinking or biting. b) Secretion plug / mucous obstruction in ETT. c) Acute severe bronchospasm. d) Mainstem right bronchus intubation displacement.
3. Immediate Bedside Actions: a) Disconnect from ventilator and hand-ventilate with 100% O2 using a self-inflating bag. b) Pass a suction catheter to clear ETT secretions. c) Auscultate chest bilaterally for equal breath sounds and wheeze. d) Check ETT mark at lip and obtain emergency chest radiograph.
⏱️ Station 3 - Airway Management
Acute Stridor & Upper Airway Obstruction
An 18-month-old child presents to the emergency room with acute onset inspiratory stridor, barking cough, and intercostal retractions for 6 hours.
Questions:
1. What is the Westley Croup Score assessment for severity?
2. State the drug of choice and exact dose for neb treatment.
3. What are 2 red flag signs requiring PICU transfer?
Dr. Saini's Model Examiner Solution:
1. Severity Assessment: • Assess stridor at rest, chest wall retractions, cyanosis, and level of consciousness.
2. First-Line Pharmacotherapy: a) Nebulized L-Epinephrine (1:1000) 0.5 mL/kg (max 5 mL) with 100% oxygen. b) Oral/IV Dexamethasone 0.6 mg/kg single dose (max 16 mg).
3. Red Flag Signs for PICU Transfer: a) Stridor at rest with severe sternal retractions & lethargy/agitation. b) SpO2 < 92% despite nebulized Epinephrine and oxygen.
⏱️ Station 4 - Pediatric Neurology
Status Epilepticus 5-Minute Emergency Protocol
A 5-year-old boy is brought in continuous generalized tonic-clonic convulsion lasting 12 minutes.
Questions:
1. Outline the 0-5 min, 5-10 min, and 10-20 min AED escalation steps.
2. State the exact dosage of first-line Midazolam and second-line Levetiracetam.
Dr. Saini's Model Examiner Solution:
1. Timeline Escalation Protocol: • 0-5 min: Airway protection, high-flow O2, check capillary blood glucose (CBG). • 5-10 min: First-line Benzodiazepine: Intranasal/IV Midazolam 0.2 mg/kg (max 10 mg). Repeat once after 5 mins if seizure continues. • 10-20 min: Second-line IV Antiepileptic: IV Levetiracetam 60 mg/kg over 10 mins (max 4500 mg) OR IV Fosphenytoin 20 mg PE/kg. • >20 min: Refractory Status: Prepare for ETT intubation and continuous infusion Midazolam (0.1-2 mg/kg/hr) or Propofol/Thiopental.
⏱️ Station 5 - Endocrine Emergency
Diabetic Ketoacidosis (DKA) & Cerebral Edema
A 10-year-old child with newly diagnosed Type 1 Diabetes presents with Kussmaul breathing, pH 7.05, HCO3 5 mEq/L, Blood Glucose 480 mg/dL. During fluid resuscitation, the child becomes bradycardic and uncooperative.
Questions:
1. Identify the emergency complication.
2. State 2 immediate hyperosmolar therapies and exact doses.
Dr. Saini's Model Examiner Solution:
1. Diagnosis: • Acute DKA-related Cerebral Edema.
2. Immediate Hyperosmolar Treatment: a) 3% Hypertonic Saline: 3-5 mL/kg IV over 10-15 minutes. b) Mannitol: 0.5 - 1.0 g/kg IV over 20 minutes. c) Elevate head of bed to 30 degrees and reduce maintenance fluid rate by 20%.
⏱️ Station 6 - Neonatology NRP
Neonatal Resuscitation Program (NRP 8th Ed)
A term neonate born through thick meconium-stained liquor is apneic and limp at birth after drying and stimulation.
Questions:
1. What is the initial action within the first 60 seconds (Golden Minute)?
2. Outline the MR SOPA corrective ventilation steps if heart rate is < 100 bpm.
Dr. Saini's Model Examiner Solution:
1. Golden Minute Action: • Initiate Positive Pressure Ventilation (PPV) using room air (21% O2) at 40-60 breaths/min within 60 seconds of birth.
2. MR SOPA Corrective Steps: • M: Mask adjustment. • R: Reposition head/neck. • S: Suction mouth and nose. • O: Open mouth. • P: Pressure increase (5 cmH2O increments up to 40 cmH2O). • A: Alternative airway (Endotracheal tube or Laryngeal Mask Airway).
⏱️ Station 7 - Hemodynamics
Inotrope Selection in Cold vs Warm Septic Shock
Explain the hemodynamic differentiation and first-line vasoactive agent selection in Pediatric Septic Shock.
Questions:
1. Define Cold Shock vs Warm Shock clinical parameters.
2. Name first-line inotropes for each shock state.
A 6-month-old infant presents with extreme irritability and feeding refusal. ECG shows narrow complex regular tachycardia with a heart rate of 280 bpm.
Questions:
1. Differentiate SVT from Sinus Tachycardia.
2. State first-line non-pharmacological maneuver and first-line drug with dose.
Dr. Saini's Model Examiner Solution:
1. Differentiation: • SVT: HR > 220 in infants (>180 in children), absent P waves, fixed heart rate with no beat-to-beat variability. • Sinus Tachycardia: HR < 220, visible P waves, variable HR with crying/fever.
2. Management: a) Vagal Maneuver: Apply ice bag to upper face for 10-15 seconds (do not occlude airway). b) Rapid IV Adenosine: 0.1 mg/kg rapid IV push (max 6 mg) followed immediately by 5-10 mL Normal Saline flush. If unsuccessful, double dose to 0.2 mg/kg (max 12 mg).
