Pediatrics ITE Sample Question
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Your Free PEDS ITE Sample Question
A 5-week-old male presents to the emergency department after he turned blue while feeding. He has a history of failure to thrive with poor weight gain and a cardiac murmur noted at his 4-week well-child examination. Per chart review, the murmur is a III/VI murmur best appreciated at the left sternal border.
During the initial assessment, the infant starts crying and becomes cyanotic. Lung examination is unremarkable, without crackles or rhonchi appreciated. The patient is tachycardic with a III/VI murmur appreciated at the left sternal border. An EKG is obtained (as below).
Which of the following is the most appropriate next step in management?
A. Obtain a chest x-ray
B. Administer a bolus of furosemide intravenously
C. Start the patient on an IV prostaglandin drip
D. Place the infant in the knee to chest position
E. Administer supplemental oxygen
The Answer and Explanation
Did you get it right? The correct answer is: D
This patient likely has tetralogy of Fallot. Tetralogy of Fallot accounts for 10% of all cases of congenital heart disease. It is defined as the presence of right ventricular outflow tract obstruction, ventricular septal defect, overriding aorta, and right ventricular hypertrophy.
Older children will become cyanotic with episodes of exertion (crying or feeding). If severe right ventricular outflow tract obstruction exists, infants may have an underlying cyanosis at baseline. The episodes of cyanosis are known as “tet spells.” The overall goal of treatment of a tet spell is to increase systemic vascular resistance (SVR), which will increase right ventricular preload and improve flow through the right ventricular outflow tract obstruction. It is also important to correct the underlying metabolic acidosis and abolish hyperpnea.
To increase SVR quickly, an infant should be placed in a knee-to-chest position. Once an intravenous line is placed, adjunctive medications including opioids, IV fluids, and sodium bicarbonate can be given.
Incorrect Answer Explanations
Answer A: While helpful. a chest x-ray should be obtained after placing a patient in the knee-to-chest position.
Answer B: Intravenous furosemide should be given to those patients with signs of volume overload resulting in cyanosis. This patient does not have signs of pulmonary edema.
Answer C: Prostaglandin E should be given to those patients who are dependent upon the ductus arteriosus for blood flow in early infancy. The ductus is likely already closed in this patient, and this patient does not have a ductal-dependent congenital heart lesion.
Answer E: Supplemental oxygen therapy is of little value by itself during a tet spell.
Bottom Line
Initial treatment of a tet spell requires placement of the infant in the knee-to-chest position.
For more information, see:
Cardiac disorders. In: Walls RM et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th Ed. Philadelphia: Elsevier; 2018: 2099-2125.
Puri K, Allen HD, Qureshi AM. Congenital heart disease. Pediatr Rev. 2017 Oct;38(10):471-486. doi: 10.1542/pir.2017-0032.Wackel P, Cannon B. Heart rate and rhythm disorders.Pediatr Rev. 2017 Jun;38(6):243-253. doi: 10.1542/pir.2016-0119.
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