PALS Part 1 (1-6) Flashcards
REVIEW MAJOR SCIENCE UPDATES ON PAGE 9-10 AFTER READING TO SEE IF THEY COVERED IT IN THE MATERIAL 1-6
REVIEW MAJOR SCIENCE UPDATES ON PAGE 9-10 AFTER READING TO SEE IF THEY COVERED IT IN THE MATERIAL 1-6
Out-of-Hospital Pediatric Chain of Survival Links? (x6)
- Prevention
- Activation of Emergency Response
- High-Quality CPR
- Advanced Resuscitation
- Post-Cardiac Arrest Care
- Recovery
(Only difference for in-hospital is the first link is “early recognition and prevention)
Infant Vs Child age ranges?
Infant = first year of life (excluding newborn which is first month) (infant = neonate I believe)
Child = 1yo to Puberty (puberty starts when chest or underarm hair begin or any breast development for girls)
Brief Overview of the Pediatric BLS Algorithm - SINGLE Rescuer
(This is not what a paramedic would do)
- Scene safe, check responsiveness, shout for help, activate emergency response
- ONLY FOR 10 SECONDS check for breathing and pulse
- IF pulse but no breath then give breaths every 2-3 seconds (20-30/min), and recheck pulse every 2 minutes; IF pulse is under 60 with signs of poor perfusion then start CPR.
- IF no pulse and no breath then DID YOU SEE COLLAPSE? If NO then start CPR, if YES then activate emergency response if not done and get an AED
- IF no pulse and no breath and no witness collapse then do at least 2 minutes of CPR (30:2 for 1 rescuer or 15:2 for 2 rescuer), after 2 minutes then you can go get AED and or start emergency response if not done
- Once AED is retrieved and connected to PT do a rhythm check and shock if advised and go straight back into CPR for 2 minutes, do this until ALS arrives
Where should you palpate for a pulse on an infant VS a child?
Infant pulse check = brachial
(Place 2-3 fingers on inside of upper arm half way between shoulder and elbow. Press and feel for at least 5 but no longer than 10 seconds)
Child pulse check = carotid or femoral
(Femoral check = place 2 fingers on the inner thigh, midway between the hipbone and the pubic bone and just below the crease where the leg meets the torso. Again for at least 5 but no more than 10 seconds)
What are going to be the 4 critical signs of poor perfusion that are associated with the step of BLS response care where you are checking for pulse rate and signs of poor perfusion after establishing that there is no breathing but does have a pulse
- Temperature: cool extremities
- AMS: continued decline
- Pulses: weak
- Skin: pale, cool, diaphoretic, mottling, cyanosis
When you are alone what is the key turning point to if you get the AED/Call for help or if you immediately start CPR, after you have already established that the child has no breathing or pulse (or pulse<60bpm)
IF YOU WITNESSED COLLAPSE
After you have assessed for breathing and pulse and you find neither, IF you WITNESSED collapse then go get the AED/Call for help FIRST ; IF you DID NOT WITNESS the collapse then first do 2 minutes of 30:2 compression: breaths before you get the AED/CALL for help
USE THE AED AS SOON AS IT IS AVAILABLE
(Obviously if there are two of you then one can go get the AED while the first rescuer stays and does compressions and vents)
Compression/Vent Ratio for 1 or 2 rescuer?
1 Rescuer = 30:2
2 Rescuer = 15:2
Compression Depth for Adult VS Child VS Infant?
Adult = at least 2 inches
Child = at least 1/3rd the AP diameter of the chest or approx. 2 inches
Infant = at least 1/3rd the AP diameter of the chest or approx. 1.5 inches
Steps to the INFANT 2 finger compression technique?
When is this preferred over the thumb-encircling technique?
Use the 2 finger compression technique when there is only 1 rescuer
1) Place on firm, flat surface
2) place 2 fingers on mid chest just below nipple line on lower 1/2 of sternum (do not press the tip of sternum)
3) give compressions at 100-120/min
4) compress at least 1/3rd the AP diameter of the chest or approx. 1.5 inches
5) allow for full recoil, the time of compression and recoil should be about the same.
6) after 30 compressions open airway with head-tilt-chin-lift and give 2 breaths each over 1 second. Minimize interruptions for breath to LESS THAN 10 SECONDS
7) after 5 cycles or about 2 minutes if you are alone you should leave the infant OR CARRY WITH YOU to get the AED and activate ems
8) continue on after AED evaluation of pt with CPR and Breaths until rescue arrives
Steps to the INFANT Thumb-Encircling Hands Technique?
When is this preferred over the 2 finger compression technique?
Use the Thumb-Encircling compression technique when there are 2 RESCUERS because it produces better blood supply to the heart and helps ensure consistent depth and force of compressions, and may generate higher BP.
1) Place on firm, flat surface
2) Place both thumbs side by side in the mid chest just below nipple line on lower 1/2 of sternum (do not press the tip of sternum). Thumbs may overlap if infant is very small. Encircle hands around infant torso and use fingers of of both hands to support the infants back
3) give compressions at 100-120/min
4) compress at least 1/3rd the AP diameter of the chest or approx. 1.5 inches
5) allow for full recoil, the time of compression and recoil should be about the same.
6) after 15 compressions allow the second rescuer to open airway with head-tilt-chin-lift and give 2 breaths each over 1 second. Minimize interruptions for breath to LESS THAN 10 SECONDS
7) after 5 cycles or about 2 minutes if you are alone you should leave the infant OR CARRY WITH YOU to get the AED and activate ems
8) Switch roles with other provider every 2 minutes or 5 rounds to avoid fatigue. Remember that in two rescuer the second rescuer should have gone to get he AED and activate EMS, and the first responder would do the 2 finger technique until the second rescuer got back and applied the AED. So at this point the AED should already be in play if not used b/c the AED SHOULD BE USED AS SOON AS IT IS AVAILABLE
What is a landmark took you can use for infants as a goal to maximize airway patency when adjusting the airway?
Try to aim for the external ear canal to be in line with the top of shoulders
Why are rescue breaths even more important in the child and infant cardiac arrest patients?
Normally with adults, there is oxygen in the blood just prior to arrest, so compression are effective at oxygenating the body for the first few minutes until that reserve is depleted.
BUT, in infants in children, respiratory arrest prior to cardiac arrest is often main cause of the cardiac arrest, so they do not have that O2 reserve in their blood to be circulated prior to arrest so the early compression may not circulate as much O2 as with an adult arrest
What is the main difference between the 1 and 2 BLS rescuer algorithms?
There is no decision to either get the AED and call for help or start CPR immediately and do it later. So it doesn’t matter if the collapse was witnessed because one rescuer can immediately start CPR while the other goes and gets the AED and calls for help.
The other difference is after the second rescuer comes back with the AED and attaches it to the pt, the 2 rescuers can now begin 15:2 compression to ventilations instead of 30:2
What are 3 ways that you can get the shock dose reduced on an AED for infants or children?
- A Pediatric Dose Attenuator (looks almost like a surge protector that you attach the pads to and then to the machine; which reduces the dose by about 2/3rds
- A preprogrammed option on the device which may be rare to find
- USING THE CHIILD SIZED PADS will often in most machine automatically tell the AED to reduce the shock dosage
At what age to kids get the adult AED pads or the child AED pads?
What if there are no child sized pads but you have an obvious child?
At 8 years old or above use the ADULT PADS
If there are no child sized pads then use the adult pads; because over shock is better than no shock (risk vs rewards)
What is the preferred method of Infant Defibrillation?
What is the preferred method is not available?
How does AED pad placement often differ on infant?
The preferred method of defib for an infant is with a MANUAL DEFIBRILLATOR, because they have more capabilities to fine tune the lower amount of voltage needed.
If there is no manual defibrillator then an AED with an pediatric dose attenuator is preferred
If even a pediatric dose attenuator is not available you may use the AED without the attenuator b/c again, an over shock is better than no shock.
PAD PLACEMENT for an infant with an AED is often MID ANTEROPOSTERIOR (middle front, middle back)
What are the 4 important key areas of focus for a high-performance team to increase survival rates?
TIMING:
- time to first compression
- time to first shock
- CCF ideally greater than 80%
- Minimizing pre-shock pause
- Early MES response time
QUALITY:
- rate, depth, and recoil
- minimize interuptions
- switching compressors
- avoiding excessive ventilation
- use a feedback device
COORDINATION:
- Team dynamics including team members working together and procifient in their roles
ADMINISTRATION:
- leadership
- measurement
- continuous quality improvement
- number of code team members
What is Chest Compression Fraction?
What are some ways to increase CCF? (x5)
CCF is the proportion of resuscitation time without spontaneous circulation during which chest compressions were administered. AKA the amount of time during a cardiac arrest call that actual compressions are being performed vs how long during the call they are not being preformed.
- PRECHARGE THE DEFIBRILLATOR 15 seconds before a routine 2 min rhythm check so that you can initiate a defib as soon as the AED says the rhythm is shockable. This allows for shock within 10 seconds of stopping compressions
- Perform a pulse check during the precharge phase in anticipation of an organized rhythm during analysis
- Compressor HOVERS THE CHEST ready to start compressions immediately after a shock
- Have the next compressor ready to take over immediately after shock/rhythm check
- Intubate and/or give meds WITHOUT PAUSING compression
What does the Team Leader do and what is their main job?
What are 8 specific responsibilities of the Team Leader?
The team leader is in charge of making sure everything is done at the right time and the right way by monitoring individual performance. They must focus on the comprehensive care of the patient.
Overview of Specific Responsibilities:
- Organize the group (assign roles if needed)
- Monitor individual performance
- Back up the team members as needed
- Models excellent team behavior
- Trains and coaches (during and after, even future leaders)
- Facilitates understanding
- Focuses on comprehensive pt care
- Temporarily designates another team member to take over as team leader if an advanced procedure is required (like an ET tube)
What are 6 specific responsibilities of aTeam Member?
- Proficient in performing the skills in their scope
- Clear about role assignment
- Prepared to fulfill their role responsibilities
- Well-Practiced in resuscitation skills
- Knowledgeable about the algorithms
- Committed to success
What are 5 specific responsibilities of the CPR Coach ?
Remember that the CPR coach can be integrated into another role as well. Often because they need clear line of sight to the compressor they will also be in charge of the Monitor/Defibrillator. Their main responsibility is to help team members provide high-quality CPR and minimize pauses in compressions.
- Coordinate the start of CPR
- Coach to improve the quality of chest compressions
- States midrange targets (state 110comp/min instead of 100-120)
- Coach to the midrange targets
- Help minimize the length of pauses in compressions
What are the 7 elements of an effective team dynamic?
- CLEAR ROLES AND RESPONSIBILITES
- KNOWING YOUR LIMITATIONS: Do not try a new skill if not confident, it is OK to ask for help and better than waiting till the pt deteriorates further. If you do not know a skill it will help the Team Lead know if additional backup needs to be called
- CONTRSUCTIVE INTERVENTIONS: it is ok to questions or ask for clarification if a team member is about to make a wrong intervention and this should be done calmly and talked about after the call
- KNOWLEDGE SHARING: communicate as a team if the pt is deteriorating or something is not working. If pt is not getting better it is good to go back to basics and talk as a team if something was missed or needs to be done
- SUMMARIZING AND REEVALUATING: a Team Lead should reevaluate interventions and make sure they are still working or need to be changed as the pts status changes
- HOW TO COMMUNICATE:
a) Closed Loop Communications: give message, clear response and eye contact from team member, confirm the task is done before assigning a new task
b) Clear Message: deliver clear message, calmly and directly without shouting - MUTUAL RESPECT: say good job to others and act respectful even if you are upset. Never raise your voice at another
What are the 6 total roles/positions in a High Performance Team in a Cardiac Arrest situation?
Which 3 are a part of the Resuscitation Triangle and which 3 are a Leadership Role?
Resuscitation Triangle: (form an actual triangle at head, left, and right side of pt)
- Airway
- Compressor
- Monitor/Defibrillator/CPR Coach
Leadership Roles: (standing out of the way of the resuscitation triangle but close by, Team Lead will pace around)
- Team Leader
- IV/IO Meds
- Time Recorder
What is the Pediatric Assessment Triangle aka PAT and when should it be used?
PAT is used for the “from the door” observation and is the first thing you do when you start your assessment. (your going to do this, and then begin your primary assessment)
PAT includes assessing the following in the first few seconds the pt is visible and should give you an idea if your pt is having a respiratory, circulatory, or neurologic emergency.
- Appearance
- Breathing (work of breathing)
- Circulation (color)
(its sort of the “from the door” ABC and then when you get closer and make contact you do your normal ABC)
For the PALS Systematic Approach Algorithm for assessing a ill or injured pediatric pt, what is the main thing that separates it from the BLS Pediatric Algorithm for health care providers?
Since you don’t know the problem yet and are just getting to the child, you are first going to do the Pediatric Assessment Tool (PAT) and look at appearance, breathing, and color.
Next you are going to assess if the child is unresponsive or appears to need immediate intervention.
a) if they are responsive, breathing, and have a pulse and no observable compromise to airway, breathing, or perfusion are observed then just support the vitals and monitor
b) if they are unresponsive or do have a compromised system then jump into the BLS Pediatric Algorithm for health care providers
(check pulse/breathing and if either is compromised, begin CPR or rescue breaths and call for help, etc.)
Break down what exactly your looking for during the Appearance part of PAT.
What is TICLS?
In the Appearance section you are looking for level of consciousness, muscle tone, are they crying, are the looking at you, ect. You can use TICLS to remember the things to look at during the appearance phase:
- Tone
- Interactiveness
- Consolability
- Look/gaze
- Speech/cry (depending on age and how upset)
Break down what exactly your looking for during the Work of Breathing part of PAT.
Look at how they are positioned: sniffing position, tripod, laying down etc
How hard are they working to breath: are they flaring nostrils, can you see contractions, are they head bobbing, etc.
Listen to lung sounds: can you hear wheezing or stridor from the door? what does it sound like when you auscultate
Break down what exactly your looking for during the Circulation part of PAT.
What color are they? Are they blue, mottling, pale/diaphoretic, visible wounds or petechiae, flushed, bruised, etc?
How often/when should you repeat the Evaluate-Identify-Intervene sequence on a pt?
(Evaluate = initial, primary, secondary assess)
- Until the child is stable
- After each intervention (to assess the effect, good/bad)
- When the pts condition changes/deteriorates
