LATEST PEDIATRIC CRITICAL CARE MEDICINE
CERTIFICATION EXAM OFFERED BY
AMERICAN BOARD OF PEDIATRICS |
COMPLETE EXAM Q&A WITH RATIONALES
1. A 4-year-old child presents to the pediatric
intensive care unit (PICU) with respiratory distress,
fever, and hypotension. Chest X-ray shows bilateral
pulmonary infiltrates. The patient is intubated and
started on vasopressors. What is the most
appropriate initial antibiotic regimen for suspected
community-acquired septic shock?
A) Ceftriaxone + vancomycin
B) Piperacillin-tazobactam + vancomycin
C) Meropenem + vancomycin
D) Ampicillin + gentamicin
Correct answer: B
Rationale: For pediatric septic shock, broad-
spectrum antibiotics are essential. Piperacillin-
tazobactam (antipseudomonal beta-lactam) +
vancomycin (MRSA coverage) is appropriate.
Meropenem (C) is broader but reserved for
nosocomial or resistant organisms.
Ampicillin+gentamicin (D) is for neonatal sepsis.
,2. A 2-year-old child is intubated for respiratory
failure due to viral bronchiolitis (RSV). The patient is
on pressure-controlled ventilation with settings: PIP
25 cm H2O, PEEP 6 cm H2O, rate 30, FiO2 0.5. The
patient has decreased breath sounds on the left side
and oxygen desaturation to 85%. What is the most
appropriate next step?
A) Stat chest X-ray (to rule out pneumothorax or
endotracheal tube malposition)
B) Increase FiO2 to 1.0
C) Increase PEEP to 10 cm H2O
D) Administer surfactant
Correct answer: A
Rationale: Sudden desaturation with decreased
breath sounds raises concern for pneumothorax
(especially in mechanically ventilated children with
bronchiolitis) or right mainstem intubation.
Immediate chest X-ray is indicated. Increasing FiO2
(B) is temporizing.
3. A 10-year-old child with diabetic ketoacidosis
(DKA) is in the PICU. Initial labs: pH 7.10, bicarbonate
8 mEq/L, glucose 600 mg/dL, potassium 4.0 mEq/L,
sodium 135 mEq/L. The patient is started on insulin
,infusion (0.1 unit/kg/hr) and IV fluids. After 2 hours,
the patient develops severe headache and altered
mental status. What is the most likely diagnosis?
A) Cerebral edema (complication of DKA)
B) Hypoglycemia (from insulin infusion)
C) Hypokalemia (from insulin)
D) Hyponatremia (from IV fluids)
Correct answer: A
Rationale: Cerebral edema is the most feared
complication of DKA in children, presenting with
headache, altered mental status, and seizures. Risk
factors include rapid correction of hyperglycemia
and sodium shifts. Treatment: mannitol (0.5-1 g/kg) or
hypertonic saline (3% NaCl).
4. A 3-year-old child is post-operative day 1 after
cardiac surgery for tetralogy of Fallot (TOF) repair.
The patient has low cardiac output syndrome (LCOS)
with hypotension (mean arterial pressure 45 mm Hg),
poor perfusion, and elevated lactate (4 mmol/L). What
is the most appropriate first-line inotrope?
A) Milrinone (phosphodiesterase inhibitor)
B) Dopamine (5-10 mcg/kg/min)
C) Epinephrine (0.05-0.3 mcg/kg/min)
, D) Norepinephrine (0.05-0.3 mcg/kg/min)
Correct answer: C
Rationale: In post-cardiac surgery low cardiac
output, epinephrine is a potent inotrope and
vasopressor (increases contractility and heart rate).
Milrinone (A) is a vasodilator (inodilator) and is used
for afterload reduction, not first-line for hypotension.
Dopamine (B) is used for mild hypotension.
5. A 6-month-old infant is intubated for respiratory
failure due to pertussis (Bordetella pertussis). The
infant has severe paroxysms of coughing with post-
tussive apnea and desaturation. What is the most
appropriate additional therapy?
A) Azithromycin (macrolide) for the infant and post-
exposure prophylaxis for contacts
B) Corticosteroids (methylprednisolone) to reduce
airway inflammation
C) IVIG (intravenous immunoglobulin) to neutralize
pertussis toxin
D) Surfactant (to improve lung compliance)
Correct answer: A
Rationale: Pertussis treatment: azithromycin
(macrolide) reduces transmission and may decrease
severity if given early. Corticosteroids (B) and IVIG
CERTIFICATION EXAM OFFERED BY
AMERICAN BOARD OF PEDIATRICS |
COMPLETE EXAM Q&A WITH RATIONALES
1. A 4-year-old child presents to the pediatric
intensive care unit (PICU) with respiratory distress,
fever, and hypotension. Chest X-ray shows bilateral
pulmonary infiltrates. The patient is intubated and
started on vasopressors. What is the most
appropriate initial antibiotic regimen for suspected
community-acquired septic shock?
A) Ceftriaxone + vancomycin
B) Piperacillin-tazobactam + vancomycin
C) Meropenem + vancomycin
D) Ampicillin + gentamicin
Correct answer: B
Rationale: For pediatric septic shock, broad-
spectrum antibiotics are essential. Piperacillin-
tazobactam (antipseudomonal beta-lactam) +
vancomycin (MRSA coverage) is appropriate.
Meropenem (C) is broader but reserved for
nosocomial or resistant organisms.
Ampicillin+gentamicin (D) is for neonatal sepsis.
,2. A 2-year-old child is intubated for respiratory
failure due to viral bronchiolitis (RSV). The patient is
on pressure-controlled ventilation with settings: PIP
25 cm H2O, PEEP 6 cm H2O, rate 30, FiO2 0.5. The
patient has decreased breath sounds on the left side
and oxygen desaturation to 85%. What is the most
appropriate next step?
A) Stat chest X-ray (to rule out pneumothorax or
endotracheal tube malposition)
B) Increase FiO2 to 1.0
C) Increase PEEP to 10 cm H2O
D) Administer surfactant
Correct answer: A
Rationale: Sudden desaturation with decreased
breath sounds raises concern for pneumothorax
(especially in mechanically ventilated children with
bronchiolitis) or right mainstem intubation.
Immediate chest X-ray is indicated. Increasing FiO2
(B) is temporizing.
3. A 10-year-old child with diabetic ketoacidosis
(DKA) is in the PICU. Initial labs: pH 7.10, bicarbonate
8 mEq/L, glucose 600 mg/dL, potassium 4.0 mEq/L,
sodium 135 mEq/L. The patient is started on insulin
,infusion (0.1 unit/kg/hr) and IV fluids. After 2 hours,
the patient develops severe headache and altered
mental status. What is the most likely diagnosis?
A) Cerebral edema (complication of DKA)
B) Hypoglycemia (from insulin infusion)
C) Hypokalemia (from insulin)
D) Hyponatremia (from IV fluids)
Correct answer: A
Rationale: Cerebral edema is the most feared
complication of DKA in children, presenting with
headache, altered mental status, and seizures. Risk
factors include rapid correction of hyperglycemia
and sodium shifts. Treatment: mannitol (0.5-1 g/kg) or
hypertonic saline (3% NaCl).
4. A 3-year-old child is post-operative day 1 after
cardiac surgery for tetralogy of Fallot (TOF) repair.
The patient has low cardiac output syndrome (LCOS)
with hypotension (mean arterial pressure 45 mm Hg),
poor perfusion, and elevated lactate (4 mmol/L). What
is the most appropriate first-line inotrope?
A) Milrinone (phosphodiesterase inhibitor)
B) Dopamine (5-10 mcg/kg/min)
C) Epinephrine (0.05-0.3 mcg/kg/min)
, D) Norepinephrine (0.05-0.3 mcg/kg/min)
Correct answer: C
Rationale: In post-cardiac surgery low cardiac
output, epinephrine is a potent inotrope and
vasopressor (increases contractility and heart rate).
Milrinone (A) is a vasodilator (inodilator) and is used
for afterload reduction, not first-line for hypotension.
Dopamine (B) is used for mild hypotension.
5. A 6-month-old infant is intubated for respiratory
failure due to pertussis (Bordetella pertussis). The
infant has severe paroxysms of coughing with post-
tussive apnea and desaturation. What is the most
appropriate additional therapy?
A) Azithromycin (macrolide) for the infant and post-
exposure prophylaxis for contacts
B) Corticosteroids (methylprednisolone) to reduce
airway inflammation
C) IVIG (intravenous immunoglobulin) to neutralize
pertussis toxin
D) Surfactant (to improve lung compliance)
Correct answer: A
Rationale: Pertussis treatment: azithromycin
(macrolide) reduces transmission and may decrease
severity if given early. Corticosteroids (B) and IVIG
