Shock, Dehydration, Sepsis, Vascular Access, and Diabetic Ketoacidosis in Children Practice Questions

25 multiple-choice questions on Shock, dehydration, sepsis, vascular access, and diabetic ketoacidosis in children 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. The most common cause of shock in children is:

   1. A. Cardiogenic pump failure
   2. B. Neurogenic shock
   3. C. Hypovolemia
   4. D. Anaphylaxis
   Show answer

   Answer: C. Hypovolemia

   Fluid loss from vomiting, diarrhea, or bleeding causes most pediatric shock. Cardiogenic shock is uncommon in children and is usually due to congenital heart disease, myocarditis, or dysrhythmias.

2. A lethargic 8-month-old in septic shock has been vomiting and refusing feeds. Along with fluids, which bedside test should you do early?

   1. A. Peak expiratory flow rate
   2. B. A 12-lead ECG for ST changes
   3. C. Orthostatic blood pressures
   4. D. Point-of-care blood glucose
   Show answer

   Answer: D. Point-of-care blood glucose

   Infants and young children with sepsis or shock often become hypoglycemic because they have small glycogen reserves and high glucose use, and hypoglycemia worsens outcome; check glucose early and treat with D10 (about 5 mL/kg) if low. An infant cannot perform peak flow. ST changes are not a useful finding in pediatric sepsis. Orthostatic vital signs are unsafe and not meaningful in a shocked infant. (Surviving Sepsis Campaign pediatric guidelines 2020; AHA PALS.)

3. The earliest reliable sign of shock in an infant is usually:

   1. A. Hypotension
   2. B. Tachycardia
   3. C. Bradycardia
   4. D. Absent central pulses
   Show answer

   Answer: B. Tachycardia

   A rising heart rate is the first compensatory response because infants raise cardiac output mainly through heart rate. Bradycardia and loss of central pulses are preterminal findings.

4. An 11-month-old has had diarrhea for 3 days. He is listless, with dry mucous membranes, no tears, a sunken fontanelle, and one wet diaper today. His heart rate is 180 beats/min and capillary refill is 4 seconds. The best management is:

   1. A. Isotonic IV or IO fluid, 20 mL/kg
   2. B. Oral rehydration by bottle en route
   3. C. 5% dextrose in water, 20 mL/kg
   4. D. Hypotonic saline at 2 mL/kg/h
   Show answer

   Answer: A. Isotonic IV or IO fluid, 20 mL/kg

   This infant has signs of severe dehydration with shock, so give an isotonic crystalloid bolus of 10 to 20 mL/kg and reassess. A listless infant in shock cannot rehydrate orally, and dextrose in water is not a resuscitation fluid.

5. A 2-year-old with gastroenteritis is alert with mild dehydration but vomits every time she drinks. Your protocol allows ondansetron. Its main benefit here is that it:

   1. A. Treats the infection causing her illness
   2. B. Helps her keep down oral rehydration
   3. C. Replaces the fluid that she has lost
   4. D. Stops her diarrhea within an hour or two
   Show answer

   Answer: B. Helps her keep down oral rehydration

   A single dose of ondansetron reduces vomiting in children with gastroenteritis, so oral rehydration solution given in small amounts is more likely to succeed, avoiding an IV line in many cases. It does not treat the infection, replace fluid itself, or stop diarrhea, which may even increase slightly.

6. A 7-year-old (about 22 kg) with a suspected liver injury is tachycardic and pale with delayed capillary refill. After hemorrhage control, the initial crystalloid bolus is:

   1. A. About 2,000 mL (adult dose)
   2. B. About 110 mL (5 mL/kg)
   3. C. About 440 mL (20 mL/kg)
   4. D. About 1,300 mL (60 mL/kg)
   Show answer

   Answer: C. About 440 mL (20 mL/kg)

   Pediatric shock is treated with 10 to 20 mL/kg boluses of isotonic crystalloid, here about 220 to 440 mL, with early consideration of blood for hemorrhage. A 2-L adult bolus would be roughly 90 mL/kg.

7. For a child with suspected cardiogenic shock from myocarditis, fluid boluses should be:

   1. A. Smaller, 5 to 10 mL/kg given slowly
   2. B. Larger, 40 mL/kg given rapidly
   3. C. Repeated at 20 mL/kg until BP rises
   4. D. Given as rapid 30 mL/kg pushes
   Show answer

   Answer: A. Smaller, 5 to 10 mL/kg given slowly

   A failing heart cannot handle large volumes, so cardiogenic shock calls for 5 to 10 mL/kg over 10 to 20 minutes with careful reassessment. Rapid large boluses can precipitate pulmonary edema.

8. While you give a third 20 mL/kg bolus to a child in septic shock, new crackles develop and the liver edge enlarges. You should:

   1. A. Speed up the remaining bolus
   2. B. Switch to a hypotonic fluid
   3. C. Give another bolus right away
   4. D. Stop the bolus and reassess
   Show answer

   Answer: D. Stop the bolus and reassess

   Crackles and hepatomegaly signal fluid overload, so stop fluids and consider vasopressor support. Continuing boluses worsens pulmonary edema.

9. A 2-year-old has a temperature of 40°C (104°F), lethargy, mottled skin, a heart rate of 190 beats/min, capillary refill of 5 seconds, and a BP of 90/50 mm Hg. The most likely condition is:

   1. A. Benign febrile tachycardia
   2. B. Supraventricular tachycardia
   3. C. Anaphylactic shock
   4. D. Septic shock
   Show answer

   Answer: D. Septic shock

   Fever with altered appearance and poor perfusion means septic shock even though the blood pressure is maintained. Simple fever raises the heart rate but does not cause lethargy, mottling, or prolonged capillary refill.

10. In pediatric septic shock, current guidance for initial fluid resuscitation is:

    1. A. 10 to 20 mL/kg boluses with reassessment
    2. B. A single 60 mL/kg bolus over just 5 minutes
    3. C. Maintenance-rate fluid until arrival
    4. D. 2 mL/kg boluses of 5% dextrose in water
    Show answer

    Answer: A. 10 to 20 mL/kg boluses with reassessment

    Give 10 to 20 mL/kg isotonic boluses, reassessing after each, up to about 40 to 60 mL/kg in the first hour if there are no signs of overload (Surviving Sepsis Campaign 2020). A single rapid 60 mL/kg bolus without reassessment risks fluid overload. Maintenance-rate fluid does not restore circulating volume in shock. D5W is not a resuscitation fluid. (SSC 2020 pediatric guidelines.)

11. Flash capillary refill, bounding pulses, and warm skin in a febrile child with altered mental status suggest:

    1. A. Normal hydration status
    2. B. Cardiogenic shock
    3. C. Warm septic shock
    4. D. Hypovolemic shock
    Show answer

    Answer: C. Warm septic shock

    Warm shock comes from vasodilation in sepsis, producing bounding pulses and very rapid refill despite poor organ perfusion. Hypovolemic and cardiogenic shock cause cool, mottled skin with delayed refill.

12. In an infant, heart failure from a heart defect or myocarditis often shows first as:

    1. A. Swollen ankles at the end of the day
    2. B. Sweating and tiring during feeds
    3. C. Clearly distended neck veins when upright
    4. D. Chest pain with exertion
    Show answer

    Answer: B. Sweating and tiring during feeds

    Feeding is an infant's exercise, so heart failure shows as sweating, fast breathing and tiring during feeds, poor weight gain and an enlarged liver. Ankle edema appears in walking children and adults, not infants. An infant's short, chubby neck makes jugular distension hard to see. Infants cannot describe chest pain. (AHA PALS provider manual; Caroline 9th ed.)

13. A 5-year-old in septic shock is still hypotensive after 40 mL/kg of fluid, and an epinephrine infusion is ordered. The only access is a tibial IO line. You should:

    1. A. Wait until a central line can be placed
    2. B. Run the infusion through the IO line
    3. C. Give small repeated IM doses instead
    4. D. Hold it until a peripheral IV is found
    Show answer

    Answer: B. Run the infusion through the IO line

    The 2020 Surviving Sepsis Campaign pediatric guidelines support starting vasoactive infusions through a peripheral IV or IO line rather than delaying them until central access is available. Delaying the infusion in fluid-refractory shock worsens organ hypoperfusion. Watch the IO site closely for swelling or leakage.

14. A conscious 6-year-old (20 kg) has a new tibial IO line. Before the flush, many protocols give preservative-free lidocaine at:

    1. A. 0.5 mg/kg, about 10 mg
    2. B. 5 mg/kg, about 100 mg
    3. C. 0.05 mg/kg, about 1 mg
    4. D. 2 mg/kg, about 40 mg
    Show answer

    Answer: A. 0.5 mg/kg, about 10 mg

    For a conscious child, the manufacturer's guidance is 0.5 mg/kg of preservative-free 2% lidocaine (maximum 40 mg) given slowly into the IO before the flush, to blunt the pain of infusion; for 20 kg that is about 10 mg. 5 mg/kg (100 mg) risks lidocaine toxicity. 0.05 mg/kg is too little to help. 2 mg/kg (40 mg) is four times the weight-based dose and reaches the adult maximum in a 20-kg child. (Teleflex EZ-IO pediatric guidance.)

15. A 3-month-old has a seizure and a low temperature. The parents have been mixing extra water into the formula to make it last longer. The most likely cause is:

    1. A. High blood sugar from too much formula intake
    2. B. A febrile seizure from a viral infection
    3. C. Dehydration from too little fluid intake overall
    4. D. Low blood sodium from overdiluted formula
    Show answer

    Answer: D. Low blood sodium from overdiluted formula

    Infants' kidneys cannot excrete large amounts of free water. Diluting formula or giving plain water can drop the serum sodium enough to cause swelling of the brain, seizures, and hypothermia. Check glucose, manage the seizure, and transport; tell the hospital about the formula preparation.

16. Which finding confirms proper placement of an intraosseous needle?

    1. A. Marrow must be aspirated before use
    2. B. The flush is painful for the child
    3. C. Fluid flows freely without swelling
    4. D. The calf swells as fluid runs
    Show answer

    Answer: C. Fluid flows freely without swelling

    A properly placed IO needle stands firmly and fluid flows easily without swelling of the surrounding tissue; marrow aspiration may or may not occur, so its absence does not mean the needle is misplaced. Pain with the flush is common in an awake child whether or not the needle is in the marrow, which is why lidocaine is often given first. Swelling of the calf means infiltration and requires stopping the infusion.

17. Which finding indicates severe rather than mild dehydration in a toddler?

    1. A. Thirst with slightly decreased tears
    2. B. Lethargy and delayed capillary refill
    3. C. Tachycardia with normal capillary refill
    4. D. Dry mucous membranes with normal play
    Show answer

    Answer: B. Lethargy and delayed capillary refill

    Severe dehydration impairs perfusion and brain function, producing lethargy, delayed capillary refill, and tachycardia. Thirst, slightly reduced tears, dry mucous membranes with normal activity, and tachycardia with normal capillary refill fit mild to moderate dehydration rather than severe.

18. You are preparing a fluid bolus for a 12-kg toddler in hypovolemic shock from vomiting. Which fluid should you hang?

    1. A. 5% dextrose in water
    2. B. Half-normal saline
    3. C. 10% dextrose in water
    4. D. Lactated Ringer's
    Show answer

    Answer: D. Lactated Ringer's

    Isotonic crystalloids such as lactated Ringer's or normal saline stay in the vascular space long enough to restore volume. Dextrose solutions and hypotonic saline move into cells and can cause hyponatremia and cerebral edema.

19. A 15-kg toddler in hypovolemic shock is to receive a 20 mL/kg bolus of isotonic crystalloid. PALS guidance is to give each bolus over about:

    1. A. 5 to 20 minutes
    2. B. 60 to 90 minutes
    3. C. 4 to 6 hours
    4. D. Under 30 seconds
    Show answer

    Answer: A. 5 to 20 minutes

    For shock, PALS calls for rapid boluses: 20 mL/kg over about 5 to 20 minutes, using a pressure bag or push-pull syringe if needed, with reassessment of perfusion, lungs, and liver after each one. An hour or more is too slow for shock, and 4 to 6 hours is a maintenance rate. Pushing it in under 30 seconds is too fast to control or reassess.

20. A 3-year-old has had a fever for 6 days, red eyes without discharge, cracked red lips, a rash, and swollen hands. You should suspect:

    1. A. Viral conjunctivitis
    2. B. Hand, foot, and mouth disease
    3. C. Kawasaki disease
    4. D. A simple drug rash
    Show answer

    Answer: C. Kawasaki disease

    Fever for 5 days or more with bilateral conjunctival injection without pus, red cracked lips or strawberry tongue, rash, swollen hands or feet, and neck lymph nodes is the classic picture of Kawasaki disease, a vasculitis that can cause coronary artery aneurysms and shock, so the child needs hospital evaluation. Viral conjunctivitis does not cause a week of fever with lip and hand changes. Hand, foot, and mouth disease causes mouth ulcers and small blisters on the hands and feet, not swollen hands with red eyes. A drug rash does not explain prolonged fever with these mucosal findings. (McCrindle BW et al. AHA Scientific Statement on Kawasaki disease. Circulation 2017;135:e927-e999.)

21. For a child in DKA without hypotension, the initial fluid bolus is usually:

    1. A. 40 to 60 mL/kg, given rapidly
    2. B. 5 mL/kg of 5% dextrose in water
    3. C. 10 to 20 mL/kg, given with caution
    4. D. Withheld until an insulin drip is started
    Show answer

    Answer: C. 10 to 20 mL/kg, given with caution

    ISPAD 2022 advises an initial isotonic bolus of 10 to 20 mL/kg over 20 to 30 minutes for a child in DKA who is not in shock, followed by measured rehydration; the PECARN FLUID trial found that faster rehydration did not increase brain injury, but large unmeasured boluses are still not needed. 40 to 60 mL/kg given rapidly is the old septic-shock approach and is not required here. D5W is not a resuscitation fluid. Fluids come before insulin, not after. (ISPAD 2022; PECARN FLUID, NEJM 2018.)

22. A 7-year-old being treated for DKA, with a glucose of 310 mg/dL, develops headache, a falling heart rate, rising blood pressure, and decreasing responsiveness. You should suspect:

    1. A. Cerebral edema
    2. B. Hyperkalemia
    3. C. Hypokalemia from insulin
    4. D. Insulin-induced hypoglycemia
    Show answer

    Answer: A. Cerebral edema

    Headache, Cushing-type vital signs, and declining mental status during DKA treatment suggest cerebral edema, the leading cause of DKA death in children. Hyperkalemia and hypokalemia cause dysrhythmias and weakness rather than headache with a rising blood pressure and falling heart rate, and a glucose of 310 mg/dL rules out hypoglycemia.

23. A home apnea monitor alarms for a 4-month-old. Your first action is to:

    1. A. Reset the alarm and see if it sounds again
    2. B. Check the infant before the device
    3. C. Change the monitor's leads first
    4. D. Call the monitor's company first
    Show answer

    Answer: B. Check the infant before the device

    Treat the patient, not the machine: look at the infant's breathing, color, tone and heart rate, and stimulate or ventilate if needed, then troubleshoot the leads, because false alarms are common but real apnea or bradycardia must be ruled out first. Resetting the alarm or changing leads first delays care for a child who may not be breathing. The company can help with the device later. (AAP/ACEP emergency information form statement; Caroline 9th ed.)

24. A 6-year-old has a heart rate of 150 beats/min, weak radial pulses, cool extremities, and confusion after a bicycle crash. His BP is 76/50 mm Hg. This child is in:

    1. A. Compensated shock
    2. B. Neurogenic shock
    3. C. A normal stress response
    4. D. Decompensated shock
    Show answer

    Answer: D. Decompensated shock

    The minimum systolic pressure for a 6-year-old is 70 + (2 × 6) = 82 mm Hg, so 76 mm Hg with altered mental status means decompensated shock. Compensated shock has a normal blood pressure.

25. Adequate urine output in a child is at least about:

    1. A. 0.1 mL/kg/h
    2. B. 5 mL/kg/h
    3. C. 1 mL/kg/h
    4. D. 10 mL/kg/h
    Show answer

    Answer: C. 1 mL/kg/h

    Children should produce about 1 mL/kg/h of urine (about 2 mL/kg/h in infants); fewer wet diapers than usual is a useful field clue to dehydration. Output of 0.1 mL/kg/h is oliguria.