رضيع عمره ٤ أشهر عنده رباعية فالو تنتظر الجراحة. أثناء أخذ الدم بكى بشدة، وصار أزرق بشدة ويتنفس بسرعة وصار أقل تفاعلاً. التشبع نزل من ٨٢٪ إلى ٦٠٪، والنبض ١٨٠. ما أول إجراء؟

A 4-month-old with tetralogy of Fallot awaiting surgery cries hard during a blood draw and becomes deeply cyanotic, breathing fast and less responsive. SpO2 falls from 82% to 60%, HR 180. What is the first action?

1. Encourage crying to increase ventilation
2. Lay him flat on his back with the head raised
3. Give a quick feed to settle him
4. Bring the knees up to the chest (knee-chest position)

Answer: D) Bring the knees up to the chest (knee-chest position). This is a tet spell. The knee-chest position raises systemic resistance, reducing right-to-left shunting and increasing pulmonary blood flow. Then oxygen and calming, with morphine or fluids as ordered.