Seizures, Meningitis, Hypoglycemia, Poisoning, and Children with Special Health Care Needs Practice Questions

25 multiple-choice questions on Seizures, meningitis, hypoglycemia, poisoning, and children with special health care needs for paramedic and EMT students, from Chapter 44 (Pediatric Emergencies). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. A 2-year-old had a 2-minute generalized seizure at home with a temperature of 39.4°C (103°F). She is now drowsy but arousable and breathing normally. The most likely cause is:

   1. A. Epilepsy with status epilepticus
   2. B. A hypoglycemic seizure
   3. C. A breath-holding spell
   4. D. A simple febrile seizure
   Show answer

   Answer: D. A simple febrile seizure

   A brief generalized seizure with fever in a child aged 6 months to 5 years, followed by a short postictal period, fits a simple febrile seizure. Status epilepticus requires seizure activity lasting 5 minutes or more, or repeated seizures without recovery.

2. Which feature makes a febrile seizure complex rather than simple?

   1. A. Lasting longer than 15 minutes
   2. B. Generalized tonic-clonic movements
   3. C. A temperature over 39°C (102.2°F)
   4. D. A brief postictal period
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   Answer: A. Lasting longer than 15 minutes

   A complex febrile seizure is focal, lasts more than 15 minutes, or recurs within 24 hours. Generalized movements and a short postictal period are features of a simple febrile seizure, and the height of the fever does not define the type.

3. Appropriate care for a febrile child after a seizure includes:

   1. A. An ice-water bath
   2. B. Removing excess clothing
   3. C. Sponging with rubbing alcohol
   4. D. Wrapping in warm blankets
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   Answer: B. Removing excess clothing

   Remove excess clothing and let the child cool passively; antipyretics may be given by protocol. Ice baths cause shivering, and rubbing alcohol can be absorbed through the skin and cause toxicity.

4. An 18-month-old became angry, cried, held her breath, turned blue, and went limp for a few seconds, then woke fully. This is most consistent with:

   1. A. Status epilepticus
   2. B. Absence seizures
   3. C. A breath-holding spell
   4. D. A primary cardiac arrest
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   Answer: C. A breath-holding spell

   Cyanotic breath-holding spells occur from about 6 months to 6 years, are triggered by anger, frustration or pain, and end with full recovery within a minute; a first episode still deserves evaluation. Status epilepticus means seizure activity for 5 minutes or more. Absence seizures are brief staring spells without a crying trigger or cyanosis. A cardiac arrest does not resolve on its own with full recovery. (Caroline 9th ed.)

5. A 6-year-old remains in status epilepticus after two appropriate doses of midazolam. The next priority is to:

   1. A. Support the airway; call medical control
   2. B. Give two more full doses of midazolam now
   3. C. Restrain her limbs to stop the jerking
   4. D. Put a bite block between her teeth
   Show answer

   Answer: A. Support the airway; call medical control

   After two adequate benzodiazepine doses, the American Epilepsy Society algorithm moves to a second-line drug (levetiracetam, fosphenytoin or valproate, which ESETT found similar), usually through medical control or at the hospital, while the airway and ventilation are supported. More benzodiazepine doses add respiratory depression with little added benefit. Restraining the limbs can cause injury and does not stop the seizure. Nothing should be placed in the mouth. (AES 2016 guideline; ESETT, NEJM 2019.)

6. A 10-year-old with epilepsy has a vagus nerve stimulator. During a seizure, his mother swipes a magnet over the device to:

   1. A. Recharge the stimulator's internal battery
   2. B. Trigger an extra burst of stimulation
   3. C. Read out the device's seizure history
   4. D. Switch his medication pump to a higher dose
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   Answer: B. Trigger an extra burst of stimulation

   Swiping the magnet over the generator in the left chest delivers an on-demand burst of stimulation that can shorten or stop a seizure; holding the magnet over it stops stimulation. The magnet does not recharge the battery. It does not read out stored data. A VNS device does not control any medication pump. Treat the seizure as usual if it continues. (LivaNova VNS Therapy manuals.)

7. A 12-year-old with cerebral palsy has an intrathecal baclofen pump that ran empty. She now has fever, itching, agitation, and severe muscle stiffness. You should suspect:

   1. A. A simple febrile illness
   2. B. An allergic skin reaction
   3. C. A tension headache
   4. D. Baclofen withdrawal
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   Answer: D. Baclofen withdrawal

   Abrupt loss of intrathecal baclofen causes high fever, altered mental status, itching, rebound spasticity and rigidity, which can progress to rhabdomyolysis, multiorgan failure and death; treat it as an emergency, support the airway, consider a benzodiazepine per protocol, and transport to a center that can restore the drug. A simple febrile illness does not cause severe rigidity. An allergic reaction does not cause fever with rigidity. A tension headache does not explain any of these findings. (Lioresal Intrathecal boxed warning.)

8. A child with complex medical needs has an Emergency Information Form from her physician. This form is most useful because it:

   1. A. Summarizes her baseline and care plan
   2. B. Replaces your physical assessment
   3. C. Acts as a do-not-resuscitate order
   4. D. Gives consent for invasive procedures
   Show answer

   Answer: A. Summarizes her baseline and care plan

   The AAP/ACEP Emergency Information Form lists the child's diagnoses, baseline vital signs and neurologic status, medications, allergies, devices, and specific emergency management, so you can tell what is new. It does not replace your assessment. It is not a DNR order; limits on resuscitation need a separate valid order. It does not give consent for procedures. (AAP/ACEP joint policy, Pediatrics 2010.)

9. Which cause of pediatric seizures can be rapidly identified and corrected in the field?

   1. A. Meningitis
   2. B. Hypoglycemia
   3. C. A brain tumor
   4. D. Epilepsy
   Show answer

   Answer: B. Hypoglycemia

   Every seizing or postictal child should have a glucose check because hypoglycemia is quickly reversed with dextrose. Meningitis requires hospital diagnosis and antibiotics.

10. A 2-year-old drank a small amount of oil of wintergreen. The dangerous ingredient in it is:

    1. A. Ethylene glycol
    2. B. Hydrocarbon solvent
    3. C. Acetaminophen
    4. D. Methyl salicylate
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    Answer: D. Methyl salicylate

    Oil of wintergreen is nearly pure methyl salicylate; one teaspoon holds about 7 g of salicylate, enough to kill a toddler, causing vomiting, tachypnea, tinnitus, metabolic acidosis and seizures, so transport promptly. Ethylene glycol is in antifreeze. Hydrocarbons are in lamp oil and solvents and mainly cause aspiration. Acetaminophen is a different analgesic and is not in wintergreen oil. (Chyka et al., Clin Toxicol 2007.)

11. A 4-year-old swallowed several small, strong magnets an hour ago and feels fine. This ingestion is dangerous mainly because the magnets can:

    1. A. Release toxic metals into the child's bloodstream
    2. B. Burn the esophagus with an electric current
    3. C. Trap bowel walls between them and perforate them
    4. D. Trigger a severe allergy to their nickel coating
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    Answer: C. Trap bowel walls between them and perforate them

    Two or more magnets, or a magnet and a metal object, can attract each other through loops of bowel, cutting off blood flow and causing perforation and fistulas over hours to days, even in a child who looks well. Electrical burns are the danger with button batteries, not magnets. Transport for imaging and removal.

12. In an infant with meningitis, which classic sign seen in older children is often absent?

    1. A. Irritability
    2. B. Poor feeding
    3. C. Lethargy
    4. D. Nuchal rigidity
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    Answer: D. Nuchal rigidity

    Infants frequently lack neck stiffness, so rely on fever or hypothermia, poor feeding, lethargy, paradoxical irritability, and a bulging fontanelle. Irritability and poor feeding are among the most common infant signs.

13. Unintentional poisoning in children is most common in the age group of:

    1. A. Birth to 6 months
    2. B. 6 to 9 years
    3. C. 1 to 3 years
    4. D. 13 to 17 years
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    Answer: C. 1 to 3 years

    Mobile, curious toddlers who put objects in their mouths have the highest rate of unintentional ingestion. Poisonings in adolescents are more often intentional or recreational.

14. A 2-year-old bit into a laundry detergent pod and is now coughing, drooling, and vomiting. Compared with regular detergent, pods are more likely to cause:

    1. A. Delayed liver failure in 3 days
    2. B. Airway injury and CNS depression
    3. C. Severe hypoglycemia within hours
    4. D. Bradycardia from heart block
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    Answer: B. Airway injury and CNS depression

    Concentrated pods cause vomiting, aspiration, airway injury with stridor, respiratory distress, CNS depression and eye burns more often than regular detergents. Delayed liver failure is typical of acetaminophen. Severe hypoglycemia points to sulfonylureas. Heart block is a feature of calcium channel blocker or beta-blocker poisoning. (Valdez et al., Pediatrics 2014.)

15. A 3-year-old swallowed a button battery 1 hour ago and can swallow. While you arrange rapid transport, poison center guidance allows the caregiver to:

    1. A. Give 10 mL of honey every 10 minutes
    2. B. Induce vomiting with syrup of ipecac now
    3. C. Give activated charcoal by mouth
    4. D. Wait 24 hours to see if it passes
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    Answer: A. Give 10 mL of honey every 10 minutes

    For a child 1 year or older within 12 hours of ingestion who can swallow, the National Capital Poison Center advises 10 mL of honey every 10 minutes for up to 6 doses on the way to the ED, because it coats the battery and slows the burn; it must not delay transport for X-ray and removal (no honey under age 1). Ipecac is obsolete and risks aspiration. Charcoal does not bind batteries and hampers endoscopy. Waiting allows esophageal burns, which start within about 2 hours. (NCPC button battery guideline.)

16. A 2-year-old is found chewing his grandmother's used fentanyl patch, drowsy with a respiratory rate of 8. After ventilating, a key concern is that:

    1. A. Effects can outlast a naloxone dose
    2. B. Used patches no longer contain drug
    3. C. Naloxone cannot reverse fentanyl
    4. D. Skin contact causes no absorption
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    Answer: A. Effects can outlast a naloxone dose

    A used patch still holds a large amount of fentanyl, and chewing it releases drug that keeps being absorbed, so sedation and apnea can return after naloxone wears off; remove the patch, repeat naloxone as needed, and transport for observation. The FDA warns that used patches retain enough drug to kill a child. Naloxone does reverse fentanyl, though repeat doses may be needed. Fentanyl is absorbed through skin, which is how patches work. (FDA Drug Safety Communication 2013.)

17. A toddler drank e-cigarette refill liquid and is vomiting. Over the next hour you should watch most closely for:

    1. A. Delayed kidney failure in a week
    2. B. Liver failure after 2 to 3 days
    3. C. Ringing in the ears and fast breathing
    4. D. Seizures and breathing problems
    Show answer

    Answer: D. Seizures and breathing problems

    Liquid nicotine is highly concentrated; small amounts cause early vomiting, tachycardia and agitation, then seizures, bradycardia, weakness and respiratory failure, and child deaths have occurred. Delayed kidney failure is typical of ethylene glycol, delayed liver failure of acetaminophen, and ringing in the ears with fast breathing of salicylates, not nicotine. (Kamboj et al., Pediatrics 2016.)

18. A 4-year-old's tracheostomy tube has come out, and a new tube of the same size will not pass into the stoma. You should next try:

    1. A. Pushing harder with the same tube
    2. B. A tube one size smaller
    3. C. Blow-by at the stoma
    4. D. Needle cricothyrotomy above it
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    Answer: B. A tube one size smaller

    A stoma can narrow quickly, so if the same size will not pass, insert a tube one size smaller (or an endotracheal tube of similar outer diameter), and if nothing passes, ventilate over the stoma or by mouth with the stoma covered. Forcing a tube can create a false passage into the neck tissue. Blow-by oxygen does not ventilate a child who needs an airway, and a needle cricothyrotomy is not needed when a smaller tube can usually be passed through the existing stoma. (Caroline 9th ed.)

19. You are suctioning the tracheostomy of a 3-year-old with thick secretions. Each suction pass should last no more than:

    1. A. 30 seconds
    2. B. 45 seconds
    3. C. 10 seconds
    4. D. 60 seconds
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    Answer: C. 10 seconds

    Limit suction to 10 seconds per pass and oxygenate between passes, because suctioning also removes oxygen. Longer passes can cause hypoxia and bradycardia.

20. Suctioning does not clear a child's obstructed tracheostomy tube, and she is deteriorating. You should next:

    1. A. Replace the tracheostomy tube
    2. B. Give more blow-by oxygen
    3. C. Wait for the hospital team
    4. D. Suction again at a higher pressure
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    Answer: A. Replace the tracheostomy tube

    If suctioning fails, remove the obstructed tube and insert a new one, usually the spare from the caregiver's emergency kit, then ventilate through the new tube or the stoma. More oxygen does not help when air cannot pass the obstruction. Waiting for the hospital leaves her hypoxic. Higher suction pressure injures the airway and does not clear a plugged tube. (Caroline 9th ed.)

21. A 2-year-old living in a house built in the 1950s has been eating paint chips. She is irritable, constipated, and less active. You should suspect:

    1. A. Iron poisoning
    2. B. Lead poisoning
    3. C. Acetaminophen poisoning
    4. D. Carbon monoxide poisoning
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    Answer: B. Lead poisoning

    Old houses often have lead paint, and toddlers who eat chips (pica) can develop chronic lead poisoning, with irritability, abdominal pain, constipation, poor appetite, developmental regression and, at high levels, seizures and encephalopathy. Iron poisoning follows a single ingestion of tablets and causes vomiting and GI bleeding. Acetaminophen poisoning follows ingestion of the drug and causes delayed liver injury. Carbon monoxide causes headache and vomiting that affect everyone in the home and does not come from eating paint. (CDC Childhood Lead Poisoning Prevention; Caroline 9th ed.)

22. Which household practice is most likely to prevent a toddler's fatal medication poisoning?

    1. A. Storing pills in a plastic bag
    2. B. Telling the child the pills are candy
    3. C. Keeping pills in a purse on the floor
    4. D. Child-resistant caps kept locked away
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    Answer: D. Child-resistant caps kept locked away

    Most toddler poisonings come from medicines left within reach, often in bags or purses or in pill organizers without child-resistant closures; storing medicines up, away and out of sight, ideally locked and in child-resistant containers, prevents them. Plastic bags have no safety closure. Calling medicine candy invites a child to eat it. Purses on the floor are a common source of toddler ingestions. (Caroline 9th ed.)

23. A 9-year-old with a tracheostomy and home ventilator has a 'go bag' packed by his parents. When you transport him, you should:

    1. A. Leave the bag, since the ambulance has gear
    2. B. Bring just his medication list from the bag
    3. C. Bring the bag and his own equipment along
    4. D. Wait for the parents to bring the bag later
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    Answer: C. Bring the bag and his own equipment along

    A child with special health care needs usually has a bag with spare tracheostomy tubes in his size and smaller, suction catheters, and supplies matched to his equipment. Ambulance stock often lacks his exact sizes, so the bag and his own device should travel with him.

24. A 5-year-old with a central venous catheter for chemotherapy has a temperature of 38.9°C (102°F). You should consider:

    1. A. A mild viral cold in the family
    2. B. A kinked or blocked catheter
    3. C. Fluid overload
    4. D. Line infection and sepsis
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    Answer: D. Line infection and sepsis

    Children with central lines, especially those immunosuppressed by chemotherapy, can quickly become septic from a line infection, so fever is an emergency that needs prompt antibiotics. Assuming a mild cold delays care. A kinked catheter causes infusion problems, not fever. Fluid overload causes edema and crackles, not fever. (Caroline 9th ed.; Surviving Sepsis Campaign pediatric guidelines.)

25. A ventilator-dependent child's home ventilator alarms and the child is in distress. Your first step is to:

    1. A. Increase the FiO2 on the ventilator
    2. B. Increase the set tidal volume
    3. C. Disconnect and ventilate with a BVM
    4. D. Reset the ventilator to its defaults
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    Answer: C. Disconnect and ventilate with a BVM

    When a ventilated child is in distress, remove the ventilator from the equation and bag through the tracheostomy, then troubleshoot. Changing ventilator settings without knowing the cause, whether the tidal volume or the oxygen, can worsen the problem or miss it, and resetting the device to its defaults discards the child's prescribed settings while the cause remains.