CPEN Neurological Emergencies 3 — Questions and Answers
Question 1: A 2-year-old presents with fever, bulging fontanelle, and seizure. CSF gram stain shows gram-positive diplococci. The MOST appropriate antibiotic choice is:
- Ampicillin and gentamicin
- Vancomycin and ceftriaxone (Correct answer)
- Penicillin G alone
- Metronidazole and cefepime
Correct answer: Vancomycin and ceftriaxone
Vancomycin plus ceftriaxone is the empiric treatment for pneumococcal meningitis to cover possible penicillin-resistant strains.
Question 2: A 10-year-old with a GCS of 9 after blunt head trauma has a BP of 140/90 mmHg and HR of 52 bpm. This combination MOST likely indicates:
- Neurogenic shock
- Cushing's triad with impending herniation (Correct answer)
- Hypovolemic shock
- Normal physiologic response to pain
Correct answer: Cushing's triad with impending herniation
Hypertension with bradycardia (Cushing's triad) is a late, ominous sign of severely elevated ICP and impending brainstem herniation.
Question 3: Which position is MOST appropriate for a child with suspected increased ICP who is not in spinal precautions?
- Trendelenburg (head down 15°)
- Head of bed elevated 30° with head midline (Correct answer)
- Supine flat with no head elevation
- Left lateral decubitus
Correct answer: Head of bed elevated 30° with head midline
Head of bed at 30° with neutral head alignment promotes cerebral venous drainage and helps reduce ICP.
Question 4: A 4-year-old with new-onset focal seizures and a fever of 39.5°C has CSF showing 120 WBC (lymphocytic), elevated protein, and normal glucose. Which pathogen is MOST likely?
- Neisseria meningitidis
- Streptococcus pneumoniae
- Herpes simplex virus (Correct answer)
- Listeria monocytogenes
Correct answer: Herpes simplex virus
Lymphocytic pleocytosis, elevated protein, normal glucose, focal seizures, and fever together are classic for HSV encephalitis, requiring urgent acyclovir.
Question 5: What is the CORRECT pediatric dose of lorazepam for an actively seizing child?
- 0.01 mg/kg IV, max 0.5 mg
- 0.05–0.1 mg/kg IV, max 4 mg per dose (Correct answer)
- 0.5 mg/kg IV, max 10 mg
- 1 mg/kg IV, max 20 mg
Correct answer: 0.05–0.1 mg/kg IV, max 4 mg per dose
Lorazepam 0.05–0.1 mg/kg IV (max 4 mg per dose) is the first-line benzodiazepine for acute pediatric seizure management.
Question 6: Which condition is characterized by episodic, severe, unilateral headache with ipsilateral lacrimation, nasal congestion, and ptosis in a 12-year-old?
- Classic migraine with aura
- Cluster headache (Correct answer)
- Tension-type headache
- Pseudotumor cerebri
Correct answer: Cluster headache
Cluster headaches present with severe unilateral periorbital pain plus ipsilateral autonomic features (lacrimation, rhinorrhea, ptosis) in episodic attacks.
Question 7: A 6-year-old develops ascending weakness starting in the legs 3 weeks after a GI illness. Reflexes are absent. The MOST likely diagnosis is:
- Myasthenia gravis
- Guillain-Barré syndrome (Correct answer)
- Transverse myelitis
- Botulism
Correct answer: Guillain-Barré syndrome
Guillain-Barré syndrome presents with ascending flaccid paralysis and areflexia following a triggering infection, typically weeks prior.
CPEN Neurological Emergencies 3
A 2-year-old presents with fever, bulging fontanelle, and seizure.
CSF gram stain shows gram-positive diplococci.
The MOST appropriate antibiotic choice is: