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Flashcards in PALS Deck (60):

You are called to Urgently evaluate a child. What 3 things should you assess on initial impression?

1. Level of consciousness
-unresponsive, irritable, lethargic, alert
2. Breathing
-not breathing, gasping, abnormal sounds, increased work of breathing
3. Color
-pallor, cyanosis, mottling


You are called to bedside ad child is unresponsive and pale. What do you do?

1. Shout for help/call a code
2. Check for pulse
- yes: start rescue breathing
-no: start chest compressions


How do you assess upper airway patency?

-look for movement of chest or abdomen
-listen for air movement or breath sounds


Who should you suspect cervical spine injury in? How do you open their airway

Suspect cervical spine injury in any kid with head r neck injury

-do jaw thrust without neck extension


A 2yo child is alert, has significant retractions, but is not making a sound. You suspect -----. You do -----.

Alert but unable to make any sound--suspect foreign body

-if < 1 yo: give 5 back slaps and 5 chest thrusts
-if 1 yo or older: give abdominal thrusts


What is the normal RR for: infant, toddler, preschooler, school age, adolescent?

Infant: 30-60
Toddler(1-3 yrs): 24-40
Preschool (4-5yrs): 22-34
School age(6-12 yrs): 18-30
Adolescent: 12-16

RR: count # breaths in 30 secs x 2


True or false: infants may have irregular breathing during sleep with pauses up to 10-15 seconds.


RR should count # breaths in 30 sec


A consistent RR less than ----- or greater than ----- is very abnormal and signals a serious problem

RR < 10 breaths per min

RR > 60 breaths per min


Define apnea

Cessation of breathing for 20 secs or cessation for less than 20 secs if: bradycardia, cyanosis or pallor


Define hypoxemic

O2 sat less than 94%


How can you estimate hypotension if a child is 1-10 years old?

SBP= 70 + (child's age in years x 2) mmHg


True or false: automated BP readings are only accurate when there is good distal perfusion


If distal pulses difficult to palate or extremities are cool, automated BP may be less accurate


You are concerned a child is in shock. Name some things you should evaluate to assess perfusion.

1. Vitals-heart rate and BP
2. Skin exam: pale, mottled, diaphoretic
3. Cap refill
4. Pulses-weak vs bounding, central vs peripheral
5. Decreased urine output/oliguria
6. Decreased level of consciousness (cerebral perfusion)


Name 4 major types of shock

1. Hypovolemic
2. Distributive (septic, anaphylactic)
3. Cardiogenic
4. Obstructive (tamponade,


What does compensated shock mean?

They are in shock but BP is NOT hypotensive

Once hypotensive end organ perfusion severely compromised


Define shock

Critical condition that results from inadequate tissue delivery of O2 and nutrients to meet metabolic need

-usu inadequate peripheral and end organ perfusion.


Name some warning signs of worsening shock

Increased HR
Diminishing or absent peripheral pulses
Weakening central pulses
Narrowing pulse pressure
Cold distal extremities with prolonged cap refill
Decreasing level of consciousness
Hypotension ( late finding)


What are some signs of cardio genie shock?

Signs of poor perfusion AND pulmonary or systemic venous congestion including:

Increased work of breathing
Grunting respirations
Distended neck veins
Clinical worsening in response to giving fluid boluses


Name the 9 important components of managing a child in shock

1. Positioning child
2. Airway and breathing
3. Vascular access
4. Fluid resuscitation
5. Monitoring (vitals, mental status, UOP)
6. Frequent reassessment
7. Lab studies
8. Medications
9. Sub specialty consults


What is the initial fluid bolus for treating shock?

20 ml/kg

Reassess after for need for repeat bolus

For cardiogenic shock, DKA, tamponade, tension pneumo give smaller volumes more slowly


When is blood indicated for management of shock?

In setting of traumatic volume loss after 2-3 boluses of 20 ml/kg of normal saline if perfusion is still not adequate


You decide to give blood as part of management of shock. How much?

10 ml/kg PRBCs


What is the major side effect of over aggressive fluid resuscitation?

Pulmonary edema


What are 3 major complications from giving blood products rapidly during resuscitation?

1. Hypothermia
2. Myocardial dysfunction
3. Ionized hypocalcemia


Why should blood glucose be monitored in critically ill children? Who is at greatest risk for hypoglycemia during shock?

Hypoglycemia is common during critical illness and can result in brain damage if untreated

Infants, children with chronic illness at greatest risk for hypoglycemia during critical illness


Ddx of symptomatic bradycardia

HR < 60 with sx and signs of shock, respiratory distress or altered mental status

-hyper kalmia
-heart block (AV block)
-drugs and toxins (ccbs, opioids, digoxin, organophosphates )


Ddx of symptomatic bradycardia

HR < 60 and shock, respiratory distress, altered mental status

-heart block AV block
-head trauma


How do you classify tachyarrhythmias?

1. Narrow complex
-sinus tach
-atrial flutter

2. Wide complex


List some common and uncommon causes of sinus tachycardia

Common: exercise, pain, fever, anxiety, tissue hypoxia, hypovolemia (hemorrhage and non-hemorrhagic), shock, injury, toxins, poisons, drugs

Uncommon causes: cardiac tamponade, tension pneumothorax, thromboembolism


What is the presentation of SVT in infants?

Usually goes unnoticed for long period of times so these kids often presents with sx/signs of congestive heart failure

-irritability, poor feeding, increased work of breathing


What are the signs and symptoms of SVT in older kids?

-chest pain


What is the compressions: breaths ratio for 1 person CPR? 2 person CPR?

1 person: 30 compressions 2 breaths. (if in the field ok to just o compressions)

2 person: 15:2 (or if adolescent 30:2)


What are to meds you can give for symptomatic bradycardia?

1. Epi
2. Atropine


What is the dose of epi to give IV/IO during a resuscitation? How long between doses? Max # of doses?

0.01 mg/kg or 0.1 ml/kg 1:10,000 concentration epi

Give q3-5 mins

No max # of doses really


What is a shockable rhythm?

Vfi. Or vtach


How many Jules of shock for defibrillation?

Initial: 2 j/kg
Subsequent: 4 j/kg


What is PEA?

Electrical activity on the monitor but no pulse (so heart is not pumping)


What are the hallmarks of cardiac arrest?

1. Child unresponsive
2. Not breathing or only gasping
3. No pulse


What is the goal compression rate?

100 per min


What is different about rescue breathing when the patient is intubated?

1 breath per 6-8 seconds when compressions person is in recoil from a compression

No longer the synchronized 15:2


What do you do if you find an unresponsive child?

1. Check for breathing
2. Check for pulses

If no to both, shout for help, start CPR, give O2 and attach defibrillator


Initial rhythm on defibrillator is asystole. What do you do?

Start CPR (2 min)
IV/iO access
Epi q3-5 min
Consider et intubation

After 2 min recheck rhythm. Shock if vtach or vfib. Otherwise 2 more min CPR


What are the "Hs and Ts"

=reversible causes of cardiac arrest.

H's: hypoxia, hypovolemia, hyperkalemia, hypoglycemia, hydrogen ions, hypothermia

T's: toxins, trauma, tension pneumo, tamponade, thrombosis (PE or coronary)


What are the first 3 things to evaluate in a kid when you walk in the room?

1. Consciousness/mental status
2. Breathing
3. Color

If yes to all 3 -> start primary evaluation
If unresponsive/altered and not breathing -> shout for help and start CPR


What do you check on primary assessment?

1. Airway (speaking or crying, look for chest or belly movement, listen for breath sounds)
2. Breathing (RR, work of breathing, air movement, lung and airway sounds, O2 sat)
3. Circulation (HR, central pulses, peripheral pulses, cap refill, skin color and temp, BP)
4. Disability (level of consciousness, pupils, GCS)
5. Exposure (temp, bleeding, rashes)


What are some simple measures to open/maintain upper airway

1. Head tilt chin lift
2. Suctioning (bulb or deep)


What can happen sometimes after you deep suction a kid?



When do you consider supplemental O2?

-if O2 sat < 94% on RA
- if O2sat < 90% on 100% O2, consider additional interventions


What is the AVPU scale?

Assesses responsiveness of child

1. Alert
2. Voice-responds only to voice
3. Pain-responds only to painful stimulus
4. Unresponsive


What do you do on secondary assessment?

1. Focused history (SAMPLE)
2. Focused physical exam

Consider lab tests


What is your history on secondary assessment? (hint:sample)

S: signs and sx
A: allergies
P: past medical Hx
L: last meal
E: events


When do you do the primary assessment?

After initial assessment/look at the patient where you've determined they are responsive and breathing


What is cushings triad?

Irregular breathing or apnea


How do you determine if you have adequate ventilation with PPV?

Visible chest rise with each breath
O2 sat
Exhaled CO2
Distal air entry
Improvement in color


You think the child is not adequately ventilated (ie no chest rise). What are some things to troubleshoot?

1. Reposition the head (chin lift)
2. Verify mask size and good seal
3. Suction airway if needed
4. Check O2 source
5. Check ventilation bag and mask


Name 3 vagal maneuvers to try for compensated SVT

1. Bear down/blow through a straw
2. If less than 1year, rectal stim
3. Suction


Name 2 treatments for uncompensated SVT

Uncompensated= abnormal mental status, perfusion

1. Synchronized cardio version
2. Adenosine 0.1 ml/kg


Name 4 things to consider when not good chest rise or breath sounds after intubation.


D=displacement, check right side tube and right distance
O= obstruction, mucus plug try suction
P= pneumothorax
E= equipment, seal, o2 hooked up,


How do you choose the right ET tube size?


If less than 1 year, choose size 0


What is the correct ET tube depth?