PALS

Question 1

In specific settings, when treating pediatric patients with febrile illnesses, the use of restrictive volumes of isotonic crystalloid leads to improved survival T/F

Answer 1

True

administration of IV fluid for children with septic shock

There is evidence that excessive fluid boluses given to febrile patients with shock can lead to complications, especially if there is no ICU unit ( mechanical vent,inotropic support)

Question 2

There is no evidence to support the routine use of atropine as a premedication to prevent bradycardia in emergency pediatric intubations. T/F

Answer 2

TRUE, is controversial

It may be considered in situations where there is an increased risk of bradycardia.

There is no evidence to support a minimum dose of atropine when used as a premedication for emergency intubation.

Question 3

If invasive hemodynamic monitoring is in place at the time of a cardiac arrest in a child, it is NOT reasonable to use it to guide CPR quality. T/F

Answer 3

False, it is reasonable!

Question 4

Which is the recommended vasopressor in pediatric cardiac arrest?

Answer 4

Epi

Question 5

In children with cardiac diagnoses and in-hospital arrest what do you consider?

Answer 5

If available, extracorporeal CPR

Question 6

What is Extracorporeal cardiopulmonary resuscitation ?

Answer 6

method of cardiopulmonary resuscitation that passes the patient’s blood through a machine in a process to oxygenate the blood supply. A portable extracorporeal membrane oxygenation device is used as an adjunct to standard CPR

Question 7

How is the management of fever in a comatose patient after cardiac arrest?

Answer 7

temperature should be monitored continuously and fever should be treated aggressively.

For comatose children resuscitated from OHCA,- maintain either 5 days of normothermia (36°C to 37.5°C) or 2 days of initial continuous hypothermia (32°C to 34°C) followed by 3 days of normothermia.

For children remaining comatose after IHCA, there are insufficient data to recommend hypothermia over normothermia.

IHCA- in hospital cardiac arrest

Question 8

What do you do after return of spontaneous circulation (ROSC) after cardiac arrest, in terms of fluids/inotropes ?

Answer 8

fluids and inotropes/vasopressors should be used to maintain a systolic blood pressure above the fifth percentile for age.

Intra-arterial pressure monitoring should be used to continuously monitor blood pressure and identify and treat hypotension.

Question 9

What is the goal of systolic BP after ROSC post arrest?

Answer 9

above the fifth percentile for age.

70 mmHg+ (Age in years x 2)

Question 10

What do you do after return of spontaneous circulation (ROSC) after cardiac arrest, in terms of O2 ?

Answer 10

Target sat 94-99%
Hypoxemia should be strictly avoided

Targetin normoxemia improves outcomes

Question 11

CAB sequence

Answer 11

compressions, airway and breathing

Question 12

CPR- Rate of compressions?

Answer 12

100-120/min

Question 13

CPR- how deep in chest?

Answer 13

~1/3 of the depth

In infants : 1.5in( 4cm)
In children: 2 in(5cm)

In children reached puberty at least 2 in but no more than 2.4 ( 6cm).

and allow complete chest recoil

Question 14

compression ventilation ratio?

Answer 14

30: 2 for single
15: 2 for 2 or more rescuers

Question 15

compression ventilation after an advanced airway is in place?

Answer 15

deliver 10 breaths per min ( 1 min every 6 seconds) while continuous chest compressions.

Question 16

What is the drug of choice for treating shock refractory Vfib or pVT in children?

Answer 16

Amiodarone or Lidocaine. No benefit of one over the other.

Question 17

BLS, where do you tap the children and infant to see if they are responsive?

Answer 17

Children: shoulder

Infant : heel

Question 18

BLS algorithm

Answer 18

1. Verify the scene is safe
2. Check for responsiveness- “Are you OK”
3. If unresponsive - shout for nearby help, ACTIVATE THE EMERGENCY RESPONSE SYSTEM VIA MOBILE IF POSSIBLE
4. Assess the child breathing and pulse ( no more than 10 seconds)
   breathing: scan victims chest for rise and fall.
   if patient is breathing, monitor until additional help
   arrives.
   if patient is not breathing then he has respiratory or cardiac( .if no pulse) arrest.Check pulse:infant: brachial artery
   children: carotid or femoral pulseIf you dont feel pulse within 10 seconds start CPR

Question 19

Where do you check pulse in infants and children?

Answer 19

Check pulse:

infant: brachial artery -
children: carotid or femoral pulse

if you feel it, attempt to feel the pulse for at least 5 sec

If you dont feel pulse within 10 seconds start CPR

Question 20

If patient is not breathing, but has a pulse whats next?

Answer 20

1 breath every 3-5 seconds or about 12-20 breaths/min

Add compressions if pulse =< 60/min with signs of poor perfusion

Activate emergency response system after 2 min if not done already

Continue rescue breathing, check pulse every 2 min

Question 21

signs of poor perfusion

Answer 21

TAPS
Temperature: cool extremities
Altered mental status: decrease in responsiveness
Pulses: weak pulses
Skine: paleness, mottling, cyanosis

Question 22

No breathing/ No pulse

Answer 22

Activate the emergency response system - 911
Get the AED equipment , if there is someone else send them to get it
CPR- remove or move the clothing and do CPR

Question 23

CPR in children and infant

Answer 23

infant: 2 fingers
Child: 1-2 hands

Question 24

Infant 2 finger technique ( 1 rescuer)

Answer 24

1. Place the infant on a firm flat surface
2. Place 2 fingers in the center of the chest, just below the nipple line
3. compressions 100-120/min
4. At the end of each compression allow recoil
5. After every 30 compressions, open airway give 2 breaths, each over 1 second. the chest should rise with each breath.
6. After 5 cycles or 2 min ask for AED
7. continue compressions until AED

Question 25

Why do you have to allow for chest recoil?

Answer 25

Allows blood to flow into the heart. Incomplete recoil--> less filling between compressions and reduces the blood flow created by chest compressions.

Question 26

Infant 2 thumb-encircling hands technique ( 2 rescuers preferred)

Answer 26

1. Place the infant on a firm flat surface 2. Place thumbs side by side in the center of infants chest, on lower half of breastbone. (thumbs may overlap in very small children) 3. compressions 100-120/min 4. At the end of each compression allow recoil 5. After every 15 compressions, open airway give 2 breaths, each over 1 second. the chest should rise with each breath. 6. After 5 cycles or 2 min ask for AED 7. continue compressions until AED

Question 27

Why is the 2 thumb encircling hand technique the preferred when 2 rescuers? (3)

Answer 27

1. produces better blood supply to the heart 2. Helps ensure consistent depth and force of chest compressions 3. May generate higher BPs

Question 28

Methods for opening airway

Answer 28

head tilt-chin lift jaw thrust manuevers KEEP HEAD IN NEUTRAL POSITION

Question 29

When there are 2 rescuers- how often they should switch roles?

Answer 29

Every 5 cycles or 2 min

Question 30

Attenuator in the AED for children , how much reduces the dose of the shock

Answer 30

2/3.

Question 31

Child vs. Adult pads of AED cutoff age.

Answer 31

Child pads : for infants and children < 8 years. If not available use adult. Children> 8: adult pads

Question 32

Location of adult pads/child pads

Answer 32

Adult pads: in the upper right chest and in the left lateral part Child: in front and back ( most commonly for infants)

Question 33

In infants why a manual defibrillator is preferred over an AED?

Answer 33

More capabilities than AED, and can provide lower energy doses if this is not available and nor is an AED with attenuator , use the regular AED as is better to shock than do nothing.

Question 34

PAT triangle ( Pediatric Assessment triangle)

Answer 34

ABC Appearance - consciousness, TICLS ( tone, interactiveness, consolability, look/gaze, speech/cry) breathing - look patients position ( tripod or sniffing position) retractions stridor, sonorous respirations color

Question 35

Evaluate-Identify-Intervene approach

Answer 35

If no life-threatening condition Evaluate Primary assessment: rapid ABCDE approach, VS, oximetry Secondary assessment: focused medical history and PE Diagnostic assessments Identify Type and severity of the problem Intervente This cycle should be repeated over and over,: with every single intervention or with any change ( improvement or deterioration) until the child is stable.

Question 36

ABCDE approach

Answer 36

``` Airway Breathing Circulation Disability Exposure ```

Question 37

How do you determine airway patency ?

Answer 37

- Look for movement of the chest and abdomen - Listen for air mov and breath sounds - Feel for movement of air at the nose and mouth

Question 38

Breathing should be assessed as the same time as you check pulse - T/F

Answer 38

tRUE

Question 39

Upper Airway Status

Answer 39

- Clear - Maintenable - Non maintenable

Question 40

Definition of clear, maintenable and non maintenable airway

Answer 40

Clear: airway is open and unobstructed for normal breathing Maintenable: Airway is obstructive but can be maintaned by simple measures( e.g. head tilt chin lift) Not-maintenable: Airway is obstructed and needs advanced intervations ( intubation)

Question 41

Signs that suggest that the airway is obstructed?

Answer 41

- increased inspiratory effort with retractions - Abnormal inspiratory sounds ( snoring, high-pitched stridor) - Episodes where no airway or breath sounds are present despite respiratory efforts ( complete upper airway obstruction)

Question 42

Simple measures to maintain airway

Answer 42

POSITIONING: If responsive child- allow him to assume a position of comfort or elevate the head of the bed. If unresponsive: Turn the child on his side if you dont suspect cervical injury or head tilt chin lift or jaw thrust . If unresponsive and the jaw thrust is not open, use head tilt chin lift or jaw thrust with jaw extension because open airway is a priority. SUCTIONING-nose and oropharynx , avoid overextending head and neck Relief techniques if foreign object AIRWAY ADJUNCTS: eg. oropharyngeal aiway ( to avoid the tongue from falling back) - NEVER RELY ON THIS ALONE, ALWAYS DO SOMETHING ELSE

Question 43

Simple measures to maintain airway

Answer 43

positioning suctioning relief techniques for foreign body airway obstruction airway adjuncts

Question 44

If child suspected of aspirating foreign body and has complete airway obstruction? responsive/unresposive

Answer 44

responsive: < 1 year: give 5 back slaps and 5 chest thrusts >=1 year: give abdominal thrust If unresponsive: activate or send someone to activate the emergency response system and start CPR

Question 45

Advanced interventions to maintain airway patency

Answer 45

Endotracheal intubation Application of continuous positive airway pressure or non invasive ventilation Removal of foreign body requires direct laryngoscopy Cricothyrotomy

Question 46

5 things to assess breathing

Answer 46

1. Respiratory rate and pattern 2. Respiratory effort 3. Chest expansion and air movement 4. Lung and airway sounds 5. O2 Saturation by pulse oximeter

Question 47

Normal respiratory rate in infant toodler preschooler school-age

Answer 47

``` 30-53 22-37 20-28 18-25 12-20 ```

Question 48

Abnormal breathing is RR< 10 and more than 60 is abnormal in any child T/F

Answer 48

True

Question 49

How to determine RR

Answer 49

count the number of times the chest rises in 30 seconds and multipy by 2 *Normal sleeping infants may have irregular( periodic) breathing pauses lasting up to 10 or even 15 seconds.

Question 50

Normal sleeping infants may have irregular( periodic) breathing pauses lasting up to 10 or even 15 seconds.

Answer 50

True

Question 51

Irregular respiratory pattern may be a sign of?

Answer 51

Neurological condition

Question 52

Tachypnea causes

Answer 52

- respiratory distress ( particularly when accompanied of respiratory effort) - no respiratory causes - when there is just fast RR but no effort: - fever, pain, anemia, cyanotic heart disease, sepsis - Dehydration

Question 53

Causes of bradypnea ( 7)

Answer 53

1. respiratory muscle fatigue 2. CNS injury or any problem that affects the respiratory control center 3. Severe hypoxia 4. Severe shock 5. Hypothermia 6. Drugs that repress respiratory drive 7. Muscle disease that causes resp muscle weakness

Question 54

What does bradypnea or irregular respiratory rate mean in a critically ill child?

Answer 54

signals of impending arrest

Question 55

Definition of apnea

Answer 55

Cessation of breathing longer than 15 seconds

Question 56

Classification of apnea

Answer 56

Central : no respiratory effort- abnormality or supression of the brain or spinal cord Obstructive: inspiratory effort present without airflow. -ventilation is impeded , resulting in hypoxemia, hypercapnia or both. Mixed apnea: periods of obstructive and periods of central apnea.

Question 57

Why does increased respiratory effort occur?

Answer 57

In conditions where there is increased resistance to airflow ( asthma, bronchiolitis), or that causes lungs to be stiffer and difficult to inflate (pneumonia, pulmonary edema, pleural effusion) Non respiratory conditi

Question 58

Non respiratory conditions that cause increased respiratory effort

Answer 58

whatever that causes severe metabolic acidosis: shock, DKA, salicylate ingestion, inborn errors of metabolism)

Question 59

Signs of increased respiratory effort?

Answer 59

nasal flaring retractions( inward mov of the chest wall or tissues or sternum during inspiration) head bobbing or seesaw respirations

Question 60

location of retractions correlates to severity?

Answer 60

Yes

Question 61

Location of retractions if mild-moderate?

Answer 61

subcostal, substernal, intercostal

Question 62

Location of retraction if severe?

Answer 62

( may include same retractions than in mild-moderate) and supraclavicular suprasternal sternal

Question 63

retractions accompanied by stridor or inspiratory sound suggest..

Answer 63

upper airway obstruction

Question 64

retractions accompanied by expiratory wheezing suggest..

Answer 64

lower airway obstruction ie.asthma bronchiolitis

Question 65

retractions accompanied by grunting or labored resp suggest..

Answer 65

lung tissue disease

Question 66

why does Head bobbing occur and what does it mean?

Answer 66

use of neck muscles to assist breathing | sign of increased deterioration/ respiratory failure

Question 67

what are seesaw respirations and what do they mean?

Answer 67

when chest retracts and the abdomen expands during inspiration. During expiration the mov reverses. Usually indicate UPPER AIRWAY OBSTRUCTION May also be obseverd in sever lower airway obstruction Characteristic of infants and chilren with NM weakness.

Question 68

What respiratory effort pattern is Characteristic of infants and chilren with NM weakness.

Answer 68

seesaw respirations

Question 69

Cause of seesaw breathing

Answer 69

NM disease, weakness of the abdominal and chest wall muscles. Strong contraction of diaphragm that dominates the weaker abdominal and chest muscles.

Question 70

Definition of tidal volume and normal value

Answer 70

volume of air inspired with each breath | Normal: 5-7 mL/kg

Question 71

Ausculation lungs

Answer 71

anterior ( left and right to the sternum) under the armpits ( best location to assess lower airway) posterior: both sides of the back

Question 72

Where is the best place to assess distal air entry?

Answer 72

auscultate below the axillae

Question 73

What is minute ventilation

Answer 73

The volume of air that moves into or out of the lungs each min Vmin= RR X Tidal volume

Question 74

Causes of Low minute ventilation ( hypovent)

Answer 74

Since Vmin= RR X Tidal volume low RR Low Tidal volume ( stiff lungs, airway resistance) Extremely fast RR that leads to low tidal volume

Question 75

What is a stridor and what does it indicate?

Answer 75

Coarse, high pitched breathing typically on inspiration but can be heard in both inspiration and expiration. upper airway ( extrathoracic) obstruction

Question 76

Stridor causes

Answer 76

foreign body infection ( croup) congenital airway abnormalities ( eg, laryngomalacia) acquired airway abnoramlities( tumor or cyst) edema of upper airway

Question 77

Snoring causes besides sleep

Answer 77

soft tissue swelling or decreased level of consciousness

Question 78

What is grunting and when does it occurs

Answer 78

short, low-pitched sound heard during EXPIRATION Sometimes misinterpreted as soft cry Occurs as child exhales against a partial closed glottis SIGN OF LUNG TISSUE DISEASE- small airway collapse, alveolar collapse or both.

Question 79

Causes of grunting

Answer 79

progression of respiratory distress to failure pneumonia pulmonary contusion acute respiratory distress syndrome CHF resulting en pulmonary edema sign of PAIN ( abdominal pathology: bowel obstruction, perforated viscus, appendicits)

Question 80

What is gurgling and when does it occur

Answer 80

bubbly sound heard during inspiration or expiration upper airway obstruction due to airway secretions, vomit, blood

Question 81

Wheezing and causes

Answer 81

high or low pitched whistling most often during expiration Indicates lower airway obstruction, especially of smaller airways( asthma, bronchiolitis) Isolated inspiratory wheezing: foreign body aspiration or partial obstruction of the trachea.

Question 82

Crackles and rales are the same T/F

Answer 82

True! word embedded rub several hairs together

Question 83

Crackles

Answer 83

moist crackles: accumulation of alveolar fluids ( pneumonia and pulmonary edema) dry crackles : atelectasis and interstitial lung disease

Question 84

Crackles are always present in pulmonary edema T/F

Answer 84

False, they may not be present

Question 85

How do you describe crackles?

Answer 85

Type: fine, medium, coarse when: inspiratory or expiratory where: bilateral, unilateral, upper lobe, lower lobe etc.

Question 86

Pulse oxymeter

Answer 86

tool to monitor the percentage of hemoglobin that is fully saturated with oxygen

Question 87

Does oxyhemoblogin saturation indicate the amount of O2 delivered to the tissues?

Answer 87

NO! Delivery is the product of the arterial O2 content ( O2 bound to Hb+ Dissolved O2) and CO. ie. in anemia there is decreased hb and saturation can be 100%- and the delivery is still low.

Question 88

O2 does not provide information about the effectiveness of ventilation T/F

Answer 88

True

Question 89

Sat % that indicates hypoxemia?

Answer 89

< 94%, needs additional vent.

Question 90

How does a pulse oximeter works?

Answer 90

has two parts that must be placed opposite to the other. Lights of different wavelenghts are produced from one side of the probe and the light is captured on the other side of the tissue by the other probe. A processor in the oximeter calculates the percent of each light that has been absorbed by tissues. Hemoglobin that is fully saturated absorbs light different than if its fully saturated. So the pulseoximeter can estimate the percent of hemoglobin that is fully saturated

Question 91

Situations to keep in mind with pulseoximeter

Answer 91

1. Anemia - sat can be 100%, but O2 delivery is low 2. Carboxyhemoglobin-Methemoglob- 100% Sat -- obtain ABGs. 3. If it cant detect a consistent pulse or there is an irregular or poor waveform, the child may have poor distal perfusion or the oximeter may not be accurate

Question 92

Signs of probable respiratory failure 7

Answer 92

1. Very rapid or inadequate respiratory rate; possible apnea 2. Significant, inadequate, or absent respiratory effort 3. Absent distal air movement 4. Extreme tachycardia or bradycardia 5. Low O2 sat despite high flow supplementary oxygen 6. Decreased level of consciousness 7. Cyanosis

Question 93

Circulation assessment components (5)

Answer 93

``` Heart rate and rhythm Pulses ( both peripheral and central) Capillary refill time Skin color and temperature Blood pressure ```

Question 94

Arrhythmia can result from shock or hypoxia T/F

Answer 94

True

Question 95

Hypoxia ( delivery) is the most common cause of bradycardia in children

Answer 95

True If you see sign of poor perfusion, support vent with bag and mask and give O2.

Question 96

If patient is breathing and poor perfusion

Answer 96

check pulse, if =< 60 compressions despite good oxygenation and ventilation.

Question 97

HR > 180 in infants and > 160 in toddlers/children is ABNORMAL.

Answer 97

Yes, require further assessment.

Question 98

What do you consider in a kid with congenital heart disease, when evaluating the heart rate and rhythm?

Answer 98

consider its baseline, he may have conduction abnormalities.

Question 99

Respiratory sinus arrythmia what is it?

Answer 99

HR increases with inspiration and slows with expiration

Question 100

Central pulses-

Answer 100

Femoral Brachial ( infants) Carotid ( in older children) Axillary -felt stronger because of the increased vessel size and proximity to the heart

Question 101

peripheral pulses

Answer 101

Radial Dorsalis pedis Posterior tibial

Question 102

how do the pulses change in shock

Answer 102

peripheral vasoconstriction leads to exaggeration of the central pulses

Question 103

pulsus paradoxus

Answer 103

is an abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10 mmHg. When the drop is more than 10 mmHg, it is referred to as pulsus paradoxus. inspiration--> increased venous return--> increased blood in RV and leads to bulging towards the LV decreasing the size/volume. asthma, pericardial tamponade

Question 104

Capillary refill time definition and normal val

Answer 104

The time it takes for blood to return to tissue blanches by presssure Normal: =< 2 seconds.

Question 105

How do you evaluate capillary refill time?

Answer 105

lift the extremity slightly above the level of the heart, press and remove fast.

Question 106

Causes of delayed capillary refill time

Answer 106

dehydration shock hypothermia in septic shock it may be normal or even fast!

Question 107

How do you measure temperature and why?

Answer 107

back of your hand, more sensitive. | palm has thicker layer of skin.

Question 108

Acrocyanosis

Answer 108

hands, feet and around mouth- normal in newly born but not in older children

Question 109

Causes of peripheral cyanosis

Answer 109

Shock CHF Peripheral vascular disease Conditions causing venous stasis

Question 110

Causes of central cyanosis

Answer 110

( lip or other mucous membranes) Low ambient O2 tension Alveolar hypoventilation ( TBI, drug overdose) Diffusion defect ( pneumonia) Ventilation/perfusion mismatch ( asthma, bronchiolitis, ARDS) Intracardiac shunt

Question 111

Central pallor suggests:

Answer 111

Anemia or poor perfusion

Question 112

When does cyanosis occur?

Answer 112

is apparent when at least 5g/dl of Hb is desaturated. The O2 saturation at which a child will appear cyanotic depends on the child hemoglobin concentration

Question 113

Children with different hemoglobin levels will be cyanotic at different levels of O2 Sat.

Answer 113

True, cyanosis may be detected at higher O2 sats if the Hb is high.

Question 114

Accurate BP measurement

Answer 114

cuff bladder should cover about 40% of the mid-upper arm circumference. The BP cuff should cover 50-75% of the length of the upper arm.

Question 115

Hypotension in term neonates, infants,children (1-10y), children(>10)

Answer 115

``` Is based on the SBP -- the tresholds approximate just above the 5th percentile for age-- term neonates < 60 infants < 70 children (1-10y) <70 +(age in years x 2) children(>10) < 90 ```

Question 116

What do you think when a patient with hemorrhage develops hypotension

Answer 116

~ has lost 20-25% of circulating volume

Question 117

Hypotension in septic shock?

Answer 117

can occur due to loss of intravascular volume or | inappropriate vasodlation or severe vasoconstriction, or inadequate CO/CI

Question 118

Why do we measure urine output?

Answer 118

Indirect measure of kidney perfusion- indicates blood flow and hydration In critically ill children accurate measurement requires an indwelling catheter.

Question 119

Normal value of urine output in infant and younger children

Answer 119

1.5 - 2 mL/kg per hour

Question 120

Normal value of urine output in older children and adolescents

Answer 120

1 mL/kg per hour

Question 121

Children with shock typically have decreased urine output. T/F

Answer 121

True

Question 122

Disability assessment

Answer 122

AVPU ( Alert, responsive to voice, responsive to pain, unresponsive) Pediatric Response scale GCS Pupil response to light Blood glucose test

Question 123

AVPU Pediatric Response scale

Answer 123

To evaluate cerebral cortex function Rates the level of consciousness in 4 states: ( Alert, responsive to voice, responsive to pain [sternal rub, pinching trapezius], unresponsive)

Question 124

Causes of decreased level of consciousness

Answer 124

``` BRAIN: poor cerebral perfusion TBI Seizure activity Encephalitis/meningitis ``` ``` OTHERS severe shock hypoglycemia hypoxemia hypercabnia drugs ```

Question 125

GCS

Answer 125

EVM 456 Eye Spontaneous, to voice, to pain, no eye opening Verbal Oriented, confused, inappropriate words, incomprehensible words, no response ``` Motor Obeys commands Localizes pain Withdraws from pain Abnormal flexion Abnormal extension No response ```

Question 126

GCS classification

Answer 126

Mild head injury 13-15 Moderate 9-12 Severe < 9

Question 127

Modified version of GCS for infants

Answer 127

see phone

Question 128

When do you prefer AVPU vs. GCS

Answer 128

AVPU may be more appropriate in the pre-hospital setting | GCS in the hospital ED.

Question 129

Correlation AVPU GCS

Answer 129

Alert 15 Response to verbal 13 Pain stimulation 8 Unresponsive to noxious stimuli 6

Question 130

Pupil response to light should be done in any patient with altered mental status

Answer 130

True useful indicator of brainstem status

Question 131

Pinpoint pupils causes

Answer 131

narcotic ingestion - opioids

Question 132

Dilated pupils causes

Answer 132

``` Predominant sympathetic activity Sympathomimetic ingestion ( cocaine) Anticholinergic ingestion ( atropine) Increased intracranial pressure ```

Question 133

Unilaterally dilated pupils

Answer 133

Inadvertent topical absorption of a breathing treatment ( ipratropium) Dilating eye drops

Question 134

Unilaterally dilated pupils with altered mental status

Answer 134

IPSILATERAL uncal herniation

Question 135

Description of pupils

Answer 135

PERRL | Pupils Equal, Round, Reactive to light.

Question 136

Hypoglycemia values

Answer 136

In newborn =<45 | In child=<60

Question 137

Exposure is the last component of primary assessment:

Answer 137

Undress Look for evidence of trauma ( bleeding, burns, abnormal markings) petequia/purpura deformities/bruises

Question 138

Secondary assessment components

Answer 138

Focused history ( SAMPLE) Focused PE Ongoing reassessment

Question 139

SAMPLE for focused history

Answer 139

Signs and Symptoms Allergies - meds, food,latex/associated reaction Medications- include overthecounter, vit, last dose and time of recent meds, meds that can be found in childs environment. Past Medical History - born, Cxs/hospitalizations, illness, immunization Last meal - time and nautre of last meal. elapsed time between last meal and presentation of current illness Events - leading to current illness or injury ( sudden, gradual), hazards at scene, treatment during inteval from oset, time of onset.

Question 140

Components of ongoing reassessment

Answer 140

PAT ABCDE of primary approach with acquisition of VS and pulseoximetry Assessment of abnormal anatomic and physiologic findings Review the effectiveness of treatment interventions with each cycle

Question 141

PaO2 indicates ..

Answer 141

O2 dissolved in plasma

Question 142

PaO2 normal and Hb of 3, what can you say about the saturation and delivery to tissue

Answer 142

Saturation can be 100%, but due to the low Hb there is inadequate delivery to the tissues

Question 143

Acid-Base algorithm

Answer 143

say it

Question 144

serial ABGs are better than only once, because it just indicate a state in a time point.

Answer 144

true

Question 145

What is hyperoxia

Answer 145

increased arterial O2 sat detected by direct measure in ABG .

Question 146

what does increased base deficit means

Answer 146

accumulation of acid in the blood

Question 147

When do you do venous blood gases, advantages/disadvantages

Answer 147

When there is no arterial sample available, usually not very useful for arterial oxygenation there are differences based on where the same was taken from, so better central than peripheral. There are some correlations of VBG to ABGs but not ideal.

Question 148

Central venous O2 sat value and what does it reflect

Answer 148

indicator of the balance between delivery and O2 consumption normal is 70-75%, considering an arterial Sat 100% If sat is lower consider 30% less and that is the SVO2

Question 149

Why does lactate is high in critically ill patients?

Answer 149

metabolic acidosis --> increase lactate associated with tissue hypoxia and resultant anaerobic metabolism. good prognostic indicator, and can be used to measure therapy response. if no metabolic acidosis, some example of elevtion is stress hyperglycemia

Question 150

Things to consider when measuring lactate

Answer 150

can be falsely elevated if not taken from a free flowing blood sample Delayed testing of sample can affect accuracy

Question 151

What is near infrared spectroscopy and how does it work?

Answer 151

non invasive optical technique to monitor tissue oxygenation in brain and other tissues measures the concentration of oxyHb and desaturated Hb.

Question 152

small heart in Xray causes

Answer 152

reduced cardiac preload, severe lung hyperinflation

Question 153

large heart in Xray causes

Answer 153

normal or increased preload pericardial effusion CHF or patient is unstable to take a deep breath

Question 154

Heart size is different in the anteroposterior view compared to the posterior-anterior

Answer 154

Anteroposterior will look larger

Question 155

Which are the most common scenarios of cardiac arrest in infants/children?

Answer 155

Usually result from progressive respiratory failure, shock or both. --HYPOXIC-ISCHEMIC ARREST Less commonly result from an arrhythmia or ventricular tachycardia 5-15%

Question 156

Respiratory failure without respiratory distress cant occur T/F

Answer 156

False Respiratory failure without respiratory distress can occur ASSOCIATED WITH DECREASED LEVEL OF CONSCIOUSNESS

Question 157

The incidence of cardiac arrest from Vf/pVT increases with age and should be suspected in any patient with SUDDEN collapse T/F

Answer 157

TRUE

Question 158

What is the rate of survival at hospital discharge if cardiac arrest occurs inhospital?

Answer 158

43%

Question 159

What is the rate of survival at hospital discharge if cardiac arrest occurs out-of-hospital?

Answer 159

8%

Question 160

Survival is higher if shockable rhythm vs. asystole

Answer 160

true | 25-34% compared to 7-24%

Question 161

What is cardiac arrest?

Answer 161

cessation of blood circulation resulting from absent or ineffective cardiac mechanical activity no pulse, no breathing( cerebral hypoxia-> loss of consciousness-> stop breathing)

Question 162

2 pathways for cardiac arrest in children

Answer 162

1. Hypoxic ischemic- when there is respiratory failure or hypotensive shock there is progressive tissue hypoxia and acidosis 2. Sudden cardiac arrest

Question 163

Causes of sudden cardiac arrest, and predispositions

Answer 163

Vfib and pulseless Vtach Predisposing conditions are: - HCM - anomalous coronary artery - Long QT syndrome or other channelopathies - Myocarditis - Drug intox ( digoxin, ephedra, cocaine) - Commotio cordis

Question 164

Commotio cordis (Latin, "agitation of the heart")

Answer 164

is an often lethal disruption of heart rhythm that occurs as a result of a blow ( chest impact) to the area directly over the heart (the precordial region), at a critical time during the cycle of a heart beat causing cardiac arrest.

Question 165

Causes of cardiac arrest

Answer 165

< 6 months: SIDS | > 6 months: traumatic cardiac arrest- airway compromise, tension pneumothorax, brain injury

Question 166

Reversible causes of cardiac arrests

Answer 166

6 Hs and 5 Ts ``` Hypoxia Hypothermia Hypovolemia Hypoglycemia H+ ( acidosis) hypo/HyperK ``` ``` Toxins Thrombosis pulmonary Thrombosis coronary Tamponade Tension pneumothorax ```

Question 167

Arrest rhythms

Answer 167

PEA Asystole pulseless Ventriculat Tachycardia, including torsaides de pointes Vfib

Question 168

Which are the most common arrest rhythms based on age

Answer 168

in younger than 12 is PEA, asystole In older is Vfib, pVT and is associated to sudden cardiac arrest and/or predisposing conditions.

Question 169

What is an agonal rhythm

Answer 169

Slow wide QRS complex that immediately precedes asystole

Question 170

What is PEA

Answer 170

There is some sort of activity ( organized cardiac activity) in the ECG but there is no pulse. pulsations may be detected by an arterial waveform or doppler, but no PULSE. EKG may show different things: - low or high amplitude T waves - prolonged PR and QT intervals - AV dissociation , complete heart block, ventricular complexes without p wave

Question 171

Are there pulses in Vfib?

Answer 171

NO! Its a pattern of cardiac arrest. Vfib- no organized rhythm and no coordinated contractions electrical activity is chaotic the heart is not able to pump blood-- pulses are not palpable

Question 172

Vfib may be preceded by a brief period of VT with or without pulses. T/F

Answer 172

True

Question 173

Difference between Vfib and pulseless VTaq

Answer 173

Vfib- disorganized rhythm pVT: organized, wide QRS complexes

Question 174

Torsades de Pointes

Answer 174

polymorphic VT seen in conditions with prolonged QT interval, including congential long QT syndrome, drug toxicity, hypomagnesemia

Question 175

Causes of torsades des pointes

Answer 175

HypoMg, HypoK Anti ABCDE+ opioids( methadone, oxycodone)+ HIV protease inhibitors Arrhythmics ( IA,III) Biotics (Macrolides, antimalarials, fluoroquinolones) Cychotics ( haloperidol, risperidone) Depressants ( SSRIs, TCAs) Emetics ( ondansetron) Congenital Romano Ward- puRe heart Jervell and Lange-Nielsen syndrome: cardiac + sensorineural deafness

Question 176

Antiarrhythmics type I and subtypes

Answer 176

Na+ channel blockers ( slow or block conduction) IA: The Queen Proclaims Disos pyramide ( Quinidine, Procainamide, Disopyramide) IB: Lidia es Mexican, fea y toca en un restaurante ( Lidocaine, Mexiletine, phenytoin, tocamide IC: Propon tener fleco Propafenone, flecainamide

Question 177

Antiarrhythmics type II

Answer 177

B blockers -lol Prolong PR Decrease SA and AV node activity

Question 178

Antiarrhythmics type III

Answer 178

K channel blockers: ``` AIDS Amiodarone Ibutilide Dofetilide Sotalol ``` Prolong QT

Question 179

Antiarrhythmics type IV

Answer 179

Ca channel blockers Verapamil, diltiazem Prolong PR

Question 180

Although hands only CPR is an option, the ideal in hypoxic asphyxial arrest is CPR ( hands and ventilation)!!!!

Answer 180

True Hands ony can be done if the rescuer has no expertise or doesnt want to give breath. Better this than nothing.

Question 181

What is the difference of the Activation of emergency response system step between infants/children and adolescents/adults?

Answer 181

In infants and children: If witnessed and no phone, leave the victim and get AED before CPR If unwitnessed and single rescuer: give 2 min CPR, then go for AED and activation of emergency system, return to kid give CPR and use AED In adolescents and adults: If single rescuer: Activate emergency system and look for AED before starting compressions. Otherwise send someone for AED and begin CPR.

Question 182

How are the rate of compressions without advanced airway different between adolescents/adults and infants/children ?

Answer 182

adolescents/adults: if 1 or more rescuers 30:2 children/infants: 2 rescuers 15:2 1 rescuer 30:2

Question 183

How are the rate of compressions with advanced airway different between adolescents/adults and infants/children ?

Answer 183

SAME continuous compressions at a rate of 100-120/min Give 1 breath every 10 seconds.

Question 184

Hand placement for CPR in adults/adolescents, children ( 1 year-puberty), infants

Answer 184

adults/adolescents: 2 hands on the lower half of the breastbone children ( 1 year-puberty): 2 hands or 1 hand ( rescuer can use either method on a small child) on the lower half of the breastbone ( sternum) infants: 1 rescuer: 2 fingers in the center of the chest just below the nipple line 2 rescuers: 2 thumb encircling hand in the center of the chest just below the nipple line.

Question 185

Breaths in CPR

Answer 185

Each rescue breath should be given over about 1 second Each breast should result in visible chest rise After an advanced airway is in place: 10 breaths per min ( 1 breath every 6 seconds).

Question 186

After an advanced airway is in place how are the breaths in CPR

Answer 186

After an advanced airway is in place: 10 breaths per min ( 1 breath every 6 seconds).

Question 187

What is PETCO2? Why is it useful?

Answer 187

measures ventilation End tidal CO2 - seen in capnography a measure of the amount of carbon dioxide present in the exhaled air. Indirect evidence of que quality of the compressions. Normal value is same as PaCO2: 35-45

Question 188

What does a PETCO2 > 10-15mmHg mean?

Answer 188

CO during CPR is low and not much blood is being delivered to the lungs

Question 189

Capnography

Answer 189

is the monitoring of the concentration or partial pressure of carbon dioxide (CO. 2) in the respiratory gases. presented as a graph of expiratory CO

Question 190

priority for drug delivery routes?

Answer 190

IV>IO>ET

Question 191

Why is not very common to put a central venous access in cardiac arrest?

Answer 191

Although is the best option because of faster onset of meds and higher peak concentration of meds Its placement requires interrumption of chest compressions Complications: hematoma, vascular lacerations, pneumothorax, bleeding.

Question 192

What is required when giving IV meds peripherally?

Answer 192

1. Give them in boluses 2. Give the drug while chest compressions are beign performed 3. Follow with a 5 mL flush of normal saline to mode the drug from the peripheral to the central circulation.

Question 193

IO access, why is a good option if the peripheral access doesnt work?

Answer 193

1. BM provide access to a noncollapsible marrow venous plexus- so useful in profound shock, dehydration 2. Followed by flush medications may reach central circulation

Question 194

Contraindications and relative contraindications for IO access?

Answer 194

There are no absolute Relative: - trauma to the extremity- we dont know if there is damage of BM -Overlying infection( cellulitis) If an IO access stop working, change of bone. Its likely that if you try in same bone whatever you are inserting will leak through previous bone.

Question 195

Osteogenesis imperfecta or congenital bone diseases are CI for IO access. T/F

Answer 195

False.

Question 196

Equipment for IO access

Answer 196

``` Towel roll Gloves Antiseptic wipes IO needle/drill syringe/blood specimen containers for lab work connector tube saline flush ```

Question 197

Location of IO access

Answer 197

In children: the proximal tibial site is approximately 2 cm below the tibial tuberosity and up to 1 cm medially on the tibial plateau In skeletally mature adolescents and adults, the recommended site is 2 cm medial to and 1 cm above the tibial tuberosity.

Question 198

Procedure of IO access

Answer 198

1. Gloves 2. place towel roll below the knee or straight knee 3. Antiseptic wipes 4. Lidocaine at the site and inside the periostium if conscious 5. Insert the IO needle ( has a trocar/stylet to avoid the core bone to get inside the hollow needle) 6. Aspirate 7. Flush saline and see signs of infiltration anteriorly and posteriorly 8. med 9. flush with saline after med.

Question 199

When does a IO access needs to be replaced

Answer 199

max 24 hrs

Question 200

Alternative locations of the IO access?

Answer 200

distal femur ( needs a larger needle) distal tibia, above medial maleolus proximal humerus always in the flat , tuberosities have growth plates.

Question 201

Needles for the IO drill

Answer 201

3-39 kg: 15 gauge and 15 mm lenght >40kg: 15 gauge and 25 mm lenght obese: extralong

Question 202

Drugs that can be given ET?

Answer 202

Lipid soluble drugs ``` LEAN and vasopressin Lidocaine Epinephrine Atropine Naloxone ```

Question 203

What considerations exist when giving drugs by ET in cardiac arrest?

Answer 203

- Drug absorption in the endotracheal tree is unpredictable - drug dose/effects unpredictable - optimal dose of most of the meds given by ET is unknown. - Recommended drug doses by ET are higher than for IV/IO - For epinephrine is 10x the dose given by IV/IO - For other drugs ~2-3x

Question 204

Technique for administering drugs via ET

Answer 204

1. Instill the drug into the ET tube ( briefly pause compressions during instillation) 2. Follow with a minimum of 5 mL normal saline flush, smaller volume may be needed for neonates 3. Provide 5 rapid positive pressure breaths after drug is instilled

Question 205

depolarizing myocytes with AED and return to organized cardiac activity doesn't ensure survival T/F

Answer 205

True, the organized cardiac rhythm must produce ROSC (defined as palpable pulse) -- can be assessed with PETCO2 or intra arterial pressure.

Question 206

What do you do after AED shock?

Answer 206

resume compressions

Question 207

Goal of meds during cardiac arrest

Answer 207

Increase coronary and cerebral perfusion and blood flow Stimulate spontaneous and forceful myocardial contraction Accelerate heart rate Correct and treat the possible cause of cardiac arrest Suppress or treat arrhythmias

Question 208

Indication of epinephrine

Answer 208

cardiac arrest | high doses may be given for resuscitation in cases of B blocker overdose

Question 209

MOA epinephrine

Answer 209

alpha adrenergic mediated vasoconstriction --> increased aortic diastolic pressure and coronary perfusion

Question 210

Amiodarone indication

Answer 210

shock refractory Vfib or pVT

Question 211

MOA amiodarone

Answer 211

alpha adrenergic and b adrenergic blocking activity blocks K channel prolongs AV refractory period and QT interval slows ventricular conduction ( Widens the QRS)

Question 212

Lidocaine indication

Answer 212

shock refractory Vfib or pVT

Question 213

MOA Lidocaine

Answer 213

Class IB antiarrhythmic | Decreases automaticity and suppresses ventricular arrhythmias

Question 214

Atropine indication

Answer 214

tto of bradycardia, especially if due to excessive vagal tone, organophosphates, complete AV block

Question 215

MOA atropine

Answer 215

Increases HR

Question 216

Calcium indication

Answer 216

not rutinely for cardiac arrest indicated in : - ionized hypoCa ( can be present during sepsis or after cardiopulmonary bypass) - hyperkalemia, if hemodynamic compromise - Ca channel blocker overdose - hyperMg

Question 217

MOA Calcium

Answer 217

Restores Ca Helps maintain the cell membrane action potential treshold helps maintain gradient between intracel K and extracellular Na.

Question 218

Sodium bicarbonate indication

Answer 218

Not recommended in cardiac arrest Recommended in: hyperK TCA overdose Overdose with Na blocking channels

Question 219

MOA Sodium bicarbonate

Answer 219

helpful in TCA overdose | Rapidly reduces K concentrations.

Question 220

Why you have to avoid excessive ventilation during resucitation?

Answer 220

- impedes venous return and decreases CO - increases intrathoracic pressure--RA pressure and decreases coronary perfussion - causes gastric distention- impeding ventilation and increases the risk of regurgitation

Question 221

How do you confirm and monitor ET tube placement?

Answer 221

capnography and clinical exam

Question 222

What if capnography doesnt show CO2 but clinical examination shows adequate position of the ET tube?

Answer 222

use direct laryngoscopy

Question 223

In the OHCA there was no difference in survival between ET tube and effective bag-mask ventilation.

Answer 223

True, but this didnt address in-hospital, but suggest that immediate intubation may not be necessary.

Question 224

shockable rhythms

Answer 224

Vfib/pVT

Question 225

Non shockable rhythms

Answer 225

PEA/Asystole

Question 226

Cardiac arrest algorithm for both shockable and non shockable rhythms

Answer 226

say it

Question 227

Shock energy for defibrillator

Answer 227

First shock 2 J/kg Second shock 4 J/kg Subsequent shocks >= 4 J/kg, maximum of 10J/kg

Question 228

Dose and freq of epinephrine IO/IV

Answer 228

0.01 mg/kg repeat every 3-5 min | ET: 0.1 mg/kg

Question 229

Dose and freq of amiodarone IO/IV

Answer 229

5mg/kg bolus during cardiac arrrest max single dose of 300 mg. May repeat up to 2 times for refractory VF/pulseless VT max 2.2g per 24 hrs.

Question 230

Dose and freq of lidocaine IO/IV

Answer 230

initial: 1 mg/kg loading dose | Maintenance 20-50 mcg/kg/min ( repeat bolus dose if infusion initiated > 15 minutes after initial bolus)

Question 231

Criteria for ROSC

Answer 231

Presence of pulse and BP | Spontaneous arterial pressure waves and intra-arterial monitoring

Question 232

What is the size for uncuffed ET for children 2-10yr ?

Answer 232

(age in years/4)+4

Question 233

What is the size for uncuffed ET for children 2-10yr?

Answer 233

(age in years/4)+3.5

Question 234

What should be the cuffed inflation pressure in the ET?

Answer 234

<20-25 cmH20

Question 235

Monophasic vs biphasic AED

Answer 235

monophasic - current delivered in one direction biphasic- current delivered in both directions monophasic: has higher energeny use, higher risk of trauma, burns, myocytes damange first success rate 60% biphasic: less of all of the above, first success rate 90%.

Question 236

what do you need to consider when using paddles for AED shock delivery?

Answer 236

put conducting gel! to decrease impedance dont put saline soaked gauze pads, alcohol pads.

Question 237

Paddle size for > 10 kg ( 1 year or older)

Answer 237

large adult paddles ( 8-13 cm)

Question 238

Paddle size for <10 kg (< 1 year )

Answer 238

small infant paddle (4.5 cm)

Question 239

Location of pad/paddle for DEA

Answer 239

1 electrode on the upper right side of chest below the right clavicle the other to the left of the left nipple in the anterior axillary line directly over the heart. they shouldnt touch! allow 3 cm between them

Question 240

What do you do before delivering a shock?

Answer 240

Revise that no one is near the child, high flow 02 is not directed to the chest Shout a warning message. "clear for shock, deliverying at the count of 3)

Question 241

Timing of epinephrine

Answer 241

There is no current recommendation for the adequate timing of epinephrine. In a monitored setting it is reasonable to check the rhythm first before the second shock, to avoid unnecessary dose of epi.

Question 242

When should the IV/IO meds be administered in CPR?

Answer 242

During chest compressions because blood flow generated by compressions help circulate the drugs. immediately before or after the shock.

Question 243

Why epinephrine via ET is usually given like 10x the IV/IO dose?

Answer 243

low doses of epi ( because of not adequate absorption via ET) may cause B adrenergic effects --> hypotension, lower coronary artery perfusion pressure and flow reduce the potential for ROSC

Question 244

CPR with advanced airway

Answer 244

1st rescuer: continuous CPR the other team member: 1 breath every 6 seconds ( ~10 breaths per min) rotate every 2 min

Question 245

Mg dose if torsades de pointes

Answer 245

25-50 mg/kg bolus IV/IO | max 2 g

Question 246

Prepare each drug prior to rhythm check, so that can be given with CPR after shock

Answer 246

T

Question 247

Management of traumatic cardiac arrest

Answer 247

CPR plus: 1. control visible hemorrhage 2. Suction airway 2. Try not to movilize cervical spine, so airway with jaw thrust manuever 3. Ventilate with bag mask device using 100% 4. If advanced airway inserted stabilize head 5. if tension pneumothorax- needle decompressions - thoracotomy 6. FLUIDS- so peripheral access and fluids. 7. vasopressor if spinal shock( loss of sympathetic innervation) 8. NO PLACE OF IO IN A BONE WITH CONCERN OF FX.

Question 248

Management of cardiac arrest due to drowning

Answer 248

CPR +ADE plus: bag mask, suction airway Evaluate core body temperature ( rewarming if < 30)-- the heart may be unresponsive to resucitative efforts until this core temperature is achieved. - Extracorporeal circulation is the most rapid and effective technique for rewarming severly hypothermic cardiac arrest after submersion in icy water.

Question 249

When do you suspect spinal shock? What do you give?

Answer 249

-combination of areflexia/hyporeflexia and autonomic dysfunction that accompanies spinal cord injury. loss of sympathetic outflow, resulting in refractory hypotension and bradycardia. The initial hyporeflexia presents as a loss of both cutaneous and deep tendon reflexes below the level of injury Give VASOPRESSOR

Question 250

What is the most rapid and effective technique for rewarming severly hypothermic cardiac arrest after submersion in icy water.

Answer 250

Extracorporeal circulation.

Question 251

What happens in anaphylaxis

Answer 251

airway edema and obstruction profound vasodilation --> relative hypovol bronchoconstriction --compromises oxygenation and O2 delivery

Question 252

4 things that are needed in cardiac arrest due to anaphylaxis

Answer 252

``` CPR Establishment of adequate airway bolus fluid administration - Epinephrine every 3-5 min during cardiac arrest provide epi infusion as needed ``` Post-cardiac arrest period -- give methylprednisolone 1-2 mg/kg IV/IO

Question 253

What should you consider in ET intubation in anaphylaxis?

Answer 253

it is possible that due to airway edema you need to use a smaller ET tube than predicted by the child's age or lenght.

Question 254

What medication should be given in the post-cardiac arrest care after anaphylaxis?

Answer 254

steroids, methylprednisolone 1-2 mg/kg IV/IO

Question 255

Cardiac arrest + hypoglycemic, what do you suspect?

Answer 255

B-blocker or alcohol overdose normalize glucose

Question 256

What are single ventricule defects? Which are these?

Answer 256

A heart that has only one ventricle large and strong enough to pump blood - hypoplastic left heart syndrome - pulmonary atresia - tricuspid atresia

Question 257

In which patients with single ventricle defect is indicated standard resucitation?

Answer 257

- single ventricular anatomy after stage I palliation ( Norwood) - univentricular heart and aortopulmonary shunt.

Question 258

Norwood Procedure

Answer 258

Treatment for hypoplastic left heart syndrome three-step surgical procedure called staged palliation to create a new functional systemic circuit Stage 1 of the Norwood procedure involves atrial septectomy and transection and ligation of the distal main pulmonary artery. Stage 1 shortly after birth It converts the right ventricle into the main ventricle pumping blood to both the lungs and the body. The main pulmonary artery and the aorta are connected and the main pulmonary artery is cut off from the two branching pulmonary arteries that direct blood to each side of the lungs. Shunt between pulmonary arteries and the aorta to supply blood to the lungs. ``` Stage 2 (Bi-directional Glenn Operation) six months after the Norwood to divert half of the blood to the lungs when circulation through the lungs no longer needs as much pressure from the ventricle. The shunt to the pulmonary arteries is disconnected and the right pulmonary artery is connected directly to the superior vena cava, the vein that brings deoxygenated blood from the upper part of the body to the heart. This sends half of the deoxygenated blood directly to the lungs without going through the ventricle. ``` ``` Stage 3 (Fontan Operation) This is the third stage, usually performed about 18 to 36 months after the Glenn. It connects the inferior vena cava, the blood vessel that drains deoxygenated blood from the lower part of the body into the heart, to the pulmonary artery by creating a channel through or just outside the heart to direct blood to the pulmonary artery. At this stage, all deoxygenated blood flows passively through the lungs. ```

Question 259

Considerations for resucitation in single ventricular defects

Answer 259

standard CPR if indicated Heparin in kids with aortopulmonary or right ventricular pulmonary shunt if the shunt patency is a concern. PETCO2 may be not a reliable ERCP may be considered.

Question 260

Resuscitation in pulmonary HTN

Answer 260

- Correct hypercapnia/acidosis - isotonic crystalloid to maintain preload - if patient was receiving pulmonary vasodilator ( eg, NO, prostacyclin) continue giving - Consider inhaled Nitric oxide or prostacyclin to reduce pulmonary resistance - Consider ECPR

Question 261

What is Respiratory distress

Answer 261

condition of abnormal respiratory rate or effort

Question 262

What is the O2 consumption in infants vs. adults

Answer 262

infants 6-8mL/kg | adults: 3-4 mL/kg

Question 263

Define hypoxemia? | Permissive hypoxemia?

Answer 263

decreased arterial oxygen SATURATION detected by pulse oximeter or direct measurement in ABG Permissive hypoxemia is a pulseoximetry < 94% which may be appropriate in certain conditions ( eg, congenital heart disease)

Question 264

Difference between hypoxemia and tissue hypoxia

Answer 264

hypoxemia: low arterial 02 saturation (Sat<94%) hypoxia: body as a whole (generalized hypoxia) or a region of the body ( tissue hypoxia) is deprived of an adequate oxygen supply.

Question 265

hypoxemia does not necessarily lead to tissue hypoxia T/F

Answer 265

True

Question 266

tissue hypoxia may occur when arterial O2 sat is normal T/F

Answer 266

True , in chronic diseases like in cyanotic heart disease where compensatory mechanisms help maintain arterial O2 content near normal.

Question 267

In tissue hypoxia, what is the responding mechanism

Answer 267

hyperventilation pCO2< 35. ( dont let it be < 30) tachycardia can be due to increased respiratory rate, increased tidal volume

Question 268

What are the early and late signs of tissue hypoxia?

Answer 268

``` Early: Tachypnea Increased respiratory effort Tachycardia Pallor, mottling, Agitation, anxiety, irritable ``` Late: bradypnea, inadequate respiratory effort, apnea increased respiratory effort/: head bobbing, seesaw respirations, grunting. Bradycardia mottling/pallor,cyanosis decreased level of consciousness

Question 269

Arterial O2 content formula

Answer 269

[1.36 x Hb concentration x SaO2] + (0.003x PaO2) Dissolved O2- (0.003 x PaO2)

Question 270

Mechanism of hypoxia in alveolar hypoventilation

Answer 270

increased tension of CO2 displaces alveolar O2--> so if alveolar O2 is low--> arterial O2 is low--> PaO2 low.

Question 271

Causes of alveolar hypoventilation

Answer 271

CNS lesion TBI NM disease drug overdose/sedation/apnea

Question 272

Mechanism of hypoxia in diffusion defect

Answer 272

no exchange between CO2 and O2. examples: pulmonary edema, alveolar proteinosis, interstitial pneumonia

Question 273

Mechanism of hypoxia in V/Q mismatch

Answer 273

blood flow through areas of the lung that are inadequately oxygenated -> incomplete oxygenation of the blood returning to the right heart. There is decreased arterial O2 and Saturation , and to a lesser extent increased PaCO2.

Question 274

causes of V/Q mismatch

Answer 274

``` pneumonia atelectasis ARDS Asthma Bronchiolitis Foreign Body ```

Question 275

Mechanism of hypoxia in R to left shunt

Answer 275

shunting of unoxygenated blood from the R side of the heart to the left ( or from the pulmonary artery into the aorta)-- results in low PaO2

Question 276

Causes of R to left shunt causing hypoxia

Answer 276

Cyanotic congenital diseases Extracardiac vascular shunt PLUS SAME CAUSES OF V/Q MISMATCH ``` pneumonia atelectasis ARDS Asthma Bronchiolitis Foreign Body ```

Question 277

Define Hypercabia and what does it mean

Answer 277

increased CO2 tension in the arterial blood ( PaCO2) Means that ventilation is inadequate.

Question 278

Causes of hypercabia

Answer 278

airway obstruction ( lower or upper) Lung tissue disease Decreased or inadequate respiratory effort ( central hypoventilation)

Question 279

Best way to measure hypercapnia

Answer 279

ABG | Capnography showing the end tidal CO2 may be not identical to arterial CO2.

Question 280

What clinical sign makes you think of hypercabia?

Answer 280

decreased level of consciousness

Question 281

The Sat O2 can be normal in some cases with hypercabia T/F

Answer 281

True

Question 282

What are the factors associated with increased work of breathing?

Answer 282

Increased airway resistance Decreased lung compliance Use of accessory muscles Disorder in CNS control of breathing

Question 283

Formula for resistance and meaning when airflow is laminar vs. turbulent

Answer 283

Normal breathing-> laminar flow ( organized,quiet) Resistance is 1/r^4 ( means that small changes in diameter will increase significantly resistance and work of breathing. Agitation, crying--> turbulent flow Resistance is 1/r^5( meaning that in addition to small size this flow will increase the resistance . So maintain patient calmed to decrease resistance.

Question 284

Definition of compliance

Answer 284

change in lung volume produced by a change in driving pressure across the lung

Question 285

Name the inspiratory muscles of respiration

Answer 285

``` diaphgram intercostal muscles accessory muscles( abdomen, neck) ```

Question 286

How does Inspiration occurs:

Answer 286

inspiratory muscles ( mainly diaphgram) increases intrathoracic volume--> decreases pressure When intrathoracic pressure is less than the atmopsheric. air flows into the lungs.

Question 287

How does expiration occurs:

Answer 287

relaxation of inspiratory muscles and elastic recoil of the lung and the chest wall. These changes increase intrathoracic pressure more than atmospheric leading to expiration.

Question 288

How is diaphgram contraction different if dome shape and flattened?

Answer 288

dome shaped- more forceful | flattened ( ie. lung hyperinflation in asthma)-contraction is less forceful and ventilation is less efficient.

Question 289

How is the control of breathing through central and peripheral chemoreceptors

Answer 289

centrally- respond to changes in H+ in CSF, PaCO2 | peripherally (eg carotid body)- respong to decrease in PaO2 ; and some respond to increased PaCO2

Question 290

Mechanisms involved in breathing control

Answer 290

Brainstem respiratory centers Central and peripheral chemoreceptors Voluntary control (cerebral cortex)

Question 291

Mild vs. severe respiratory distress

Answer 291

Mild: Tachypnea Mild increase in respiratory effort ( eg.nasal flaring,retractions) Abnormal airway sounds( strictor, wheezing, grunting) Mottling ``` Severe or possible respiratory failure: Marked tachypnea, apnea hypoventilation or bradypnea abnormal airway sounds pale, cool skin, cyanosis DECREASED LEVEL OF CONSCIOUSNESS. ```

Question 292

Respiratory failure

Answer 292

``` state of inadequate oxygenation, ventilation or both. abnormal appearance ( altered consciousness), poor color, and reduced responsiveness. ```

Question 293

Where do you auscultate during respiratory physical exam?

Answer 293

Anterior ( on either side of the breastbone) Posterior Lateral ( under the axilla)

Question 294

Which are the types of respiratory distress/failure?

Answer 294

Upper airway obstruction Lower airway obstruction Lung tissue disease Disordered control of breathing

Question 295

Causes of upper airway obstruction

Answer 295

foreign body infection swelling of airway ( anaphylaxis, tonsillar hyperthrophy, croup, epiglottitis) mass ( pharyngeal or peritonsilar abscess) thick secretions congenital abnormalities ( congenital subglotic stenosis) decreased level of consciousness- muscles relax, tongue falls back and obstruct the oropharynx

Question 296

Common causes of lower airway obstruction

Answer 296

Asthma | Bronchiolitis

Question 297

Presentation of upper airway obstruction

Answer 297

``` respiratory distress drooling, snoring, gargling sounds stridor poor air entry at auscultation poor chest rise ```

Question 298

Presentation of low airway obstruction

Answer 298

``` increased RR, respiratory effort possible decreased air movement on auscultation Prolonged expiratory phase wheezing cough ```

Question 299

Explain the mechanism of air trapping and lung hyperinflation

Answer 299

there is an increase in intrapleural pressure because of the forced expiration. increased intrapleural pressure compresses airways proximal to the alveoli So further expiratory obstruction. - children tend to breath slower to increase tidal volume - is different from infants ! (pg 125)

Question 300

Why does grunting occurs?

Answer 300

grunting produces early glottic closure during expiration-- compensatory mechanism to maintain positive airway pressure and prevent collapse of the alveoli and small airways.

Question 301

In lung disease hypoxia occurs first than hypercapnia T/F

Answer 301

True, in lung tissue disease the kids have better ventilation than oxygenation.

Question 302

Causes of disordered control of breathing

Answer 302

neurologic ( seizures, CNS infections, head injury, tumor) metabolic abnormalities drug overdose

Question 303

Breath sounds in upper airway obstruction

Answer 303

stridor(typically inspiratory) barking cough hoarseness

Question 304

Breath sounds in lower airway obstruction

Answer 304

wheezing (typically expiratory) | prolonged expiratory phase

Question 305

Breath sounds in lung tissue disease

Answer 305

Grunting Crackles Decreased breath sounds.

Question 306

Rescue breathing in respiratory arrest

Answer 306

- Give 12 to 20 breaths per min ( 1 breath every 3-5 seconds) - Give each breath in one second - Visible chest rise - check pulse every 2 minutes, if pulseless CPR - Use o2 as soon as possible

Question 307

How to do you know the size of the oropharyngeal airway in children?

Answer 307

it should extend from the corner of the patients lips to the tragus or the angle of the jaw

Question 308

How do you place an oropharnygeal airway?

Answer 308

use a tongue depressor and put the oropharyngeal airway in horizontal and then put it into place check for adequate air exchange, place bag mask and see inflation

Question 309

How to do you know the size of the nasoopharyngeal airway in children?

Answer 309

it should extend from the nare to the tragus or the angle of the jaw

Question 310

How do you place a nasopharyngeal airway?

Answer 310

add lubricant and insert it into the patients nose | insert all the way into the disc

Question 311

Mac vs Miller blade for intubation

Answer 311

Mac is curved | Miller is straight

Question 312

When is Miller (straight) blade preferred over the Mac?

Answer 312

In children younger than 2 years they have a floppy omega shaped epiglottis with the miller you can put the blade on top of the epiglottis and facilitate view of vocal cords

Question 313

In which situations is preferred cuffed and uncuffed ET tubes?

Answer 313

uncuffed: - young children cuffed ET: - higher pressures - mechanical ventilation for prolonged time - aspiration concern

Question 314

What do you do if a patient is with respiratory distress or failure? (heart ok)

Answer 314

Airway - check patency- let children positioning or implement manuevers: head tilt chin lift, jaw thrust - airway suctioning if indicated - consider an oropharyngeal airway or nasopharyngeal to improve airway patency or openness ( usually in decreased consciousness, or patients with gag reflex loss) Breathing - monitor SaO2 - Provide O2. use a high concentration delivery device such as non rebreathing mask - Administer inhaled medication( albuterol or epinephrine) if needed - reduce airway swelling - Assist ventilation with bag mask device - prepare for advanced airway Circulation -Check heart rate, rhythm, blood pressure

Question 315

In which conditions of respiratory distress you have to be careful with suctioning?

Answer 315

in cases of upper airway edema from infection- this may lead to agitation in children and further respiratory distress.

Question 316

CROUP what is it? organism?

Answer 316

layngotracheitis common in winter,infectious characterized by inspiratory stridor, barking cough, and hoarseness Parainfluenza type 1 (MC) VERY less common: RSV Mycoplasma pneumoniae

Question 317

Classification of croup

Answer 317

Mild- occasional barking cough, little or no stridor at rest, absent or mild retractions. Moderate- frequent barking cough, easily audible stridor at rest, retractions at rest, little or not agitation, good air entry by auscultation of the peripheral lung fields Severe- frequent barking cough, prominent inspiratory and occasional expiratory stridor, marked retractions, significant agitation, decreased air entry by auscultation of the lungs impending respiratory failure: all of severe plus lethargy/decreased level of consciousness and pallor/cyanosis despite supplementary O2

Question 318

Treatment of croup per severity degree

Answer 318

mild dexamethasone Moderate to severe: - NPO - Dexamethasone, humidified O2, NEBULIZED EPINEPHRINE - Observe for at least 2 hours after giving nebulized epinephrine to ensure no recurrence of stridor - consider heliox ( helium -oxygen mixture) for severe disease if the child requires no higher than 40% inspired O2 concentration Impending respiratory failure - high [O2]- non rebreathing mask - assisted ventilation( bag masked ventilation timed to support child's own inspiration) for peristent , severe hypoxemia despite O2 vent. - Dexamethasone IV/IM - Endotracheal intubation ( smaller ET tube than expected to reduce injury to subglottic area) - prepare for surgical airway if needed

Question 319

What ET tube size do you use in respiratory failure due to croup?

Answer 319

smaller ET tube than expected to reduce injury to subglottic area

Question 320

Anaphylaxis measures if mild and moderate/severe

Answer 320

Mild - remove offensive agent - ask caregiver or patient about history of allergies, look bracelent - consider antihistamine dose Moderate/severe -IM epinephrine each 15-20 minutes; repeated doses may be needed. - Methylprednisolone or equivalent steroid IV - If bronchospasm - give albuterol by meter dose inhaler or nebulized sln - If severe bronchospasm, give nebulized solution -Anticipate use of ET - Anaphylaxis-->hypotension Administer NSS or LR 20 ml/KG bolus ( repeat as needed) - For hypotension unresponsive to fluids and iM epinephrine, administer an epinephrine infusion titrated to achieve adequate BP for age

Question 321

What do you do in anaphylaxis if patient has refractory hypotension?- not responding to fluids/epinephrine boluses?

Answer 321

epinephrine infusion titrated to achieve adequate BP for age

Question 322

Foreign body airway obstruction management in infants

Answer 322

If mild, do not intervene. Call for help and allow the infant to spill it out coughing If severe: 1. confirm airway obstruction 2. Give up to 5 back slaps and up to 5 chest thrusts ( 2 fingers) 3. repeat step 2 until objects comes out or kid unresponsive If unresponsive activate emergency response system, CPR, and with each breath delivery check airway to see if object is there. NO blind FINGER

Question 323

Foreign body airway obstruction management in >1 yr to puberty

Answer 323

If mild, do not intervene. Call for help and allow the infant to spill it out coughing If severe: 1. confirm airway obstruction , ask are you choking? 2. Stand or kneel-- Heimlich manuever 3. repeat step 2 until objects comes out or kid unresponsive If unresponsive activate emergency response system, CPR, and with each breath delivery check airway to see if object is there. NO blind FINGER

Question 324

Complications of hyperventilation

Answer 324

-providing too many breaths or breaths with too much volume. Complications: - Gastric distention-->high risk of vomit/aspiration, can prevent adequate mov of diaphgram affecting ventilation - pneumothorax: decreased blood return to heart, risk of lung collapse and complications ( hypoxemia, obstructive shock) -severe air trapping - decrease oxygenation, decreased venous return to heart and CO.

Question 325

What is bronchiolitis?

Answer 325

lower airway obstruction secondary to airway edema, mucous and cellular debris. Impaired gas exchange can occur as a result of airway obstruction and ventilation- perfusion inequalities. < 2 years current or antecedent upper respiratory tract infection symptoms late fall or winter months.

Question 326

What causes bronchiolitis?

Answer 326

MC- RSV other viruses: adenovirus, influenza, human metapneumovirus, and parainfluenza,

Question 327

Bronchiolitis Dx?

Answer 327

Clinical: < 2 years current or antecedent upper respiratory tract infection symptoms late fall or winter months. respiratory distress, such as tachypnea, intercostal retractions, and wheezing, are not necessarily correlated with the level of hypoxemia. Labs: Often not done, but PCR is the most accurate Chest X ray ABGs

Question 328

Treatment of bronchiolitis

Answer 328

Suctioning and supplemental oxygen - if they persist with ss, trial with bronchodilators- if work they continue. - Pts with bronchiolitis dont respond to steroids so dont give them!

Question 329

Why pulsus paradoxus in severe asthma

Answer 329

airways start to tighten and swell. The lungs start to overinflate in response, which puts extra pressure on the veins carrying unoxygenated blood from the heart to the lungs. As a result, blood backs up in the right ventricle which presses against the left side of the heart.

Question 330

Management of acute asthma

Answer 330

- humidified O2 in high concentration via nasal cannula or O2 mask; titrate with pulseox > 94% - Albuterol by meter-dose inhaler or nebulizer solution - Oral corticosteroids

Question 331

Management of moderate/severe asthma

Answer 331

- humidified O2 in high concentration to maintain SaO2 > 95%;use non-breathing mask if needed. If unsuccessful- noninvasive positive pressure ventilation or ET intubation - Albuterol by meter-dose inhaler or nebulizer solution. If wheezing or aeration not alleviated-- continuous albuterol - Corticosteroids PO/IB PLUS - Ipratropium by nebulizer solution - Magnesium sulfate by slow (15-30 min)IV bolus infusion , monitoring heart rate and BP - Perform ABGs, Chest Xray

Question 332

Peak expiratory flow in mild, moderate and severe asthma

Answer 332

mild: > 80% moderate 60-80% severe <60%

Question 333

Why giving magnesium in asthma?

Answer 333

produces smooth muscle relaxation | thought to act by enhancing calcium uptake in the sarcoplasmic reticulum(3) and/or as a calcium antagonist

Question 334

Management of impending respiratory failure in asthma?

Answer 334

- O2 via nonrebreathing mask - Albuterol via continuous nebulizer - Corticosteroid - Terbutaline SC or IV infusion titrate but monitor for toxicity - b adrenergic so risk of seizures, angina, hypertension or hypotension, tachycardia with rates up to 200 beats per minute, arrhythmias, nervousness, headache, - bilevel positive airway pressure - Endotracheal intubation

Question 335

Examples of lung tissue disease

Answer 335

``` Infectious pneumonia Chemical pneumonitis Aspiration pneumonitis Cardiogenic pulmonary edema Noncardiogenic pulmonary edema( ARDS) ```

Question 336

What is chemical pneumonitis,

Answer 336

inflammation of the lung tissue caused by inhalation or aspiration of toxic liquids, gases or particulate matter such as dust or fumes. -can lead to pulmonary edema and increased capillary permeabilty

Question 337

Management of chemical pneumonitis

Answer 337

Albuterol | CPAP or noninvasive ventilation, potentially ET intubation

Question 338

Management of aspiration pneumonia

Answer 338

Consider CPAP or noninvasive ventilation, potentially ET intubation Abcs if fever + infiltrate on chest x ray

Question 339

prophylaxis with Ab is indicated in aspiration pneumonia T/F

Answer 339

FALSE Abcs only if fever + infiltrate on chest x ray

Question 340

What is the most common cause of acute cardiogenic pulmonary edema in children?

Answer 340

Left ventricular myocardial dysfunction can be congenital heart disease, myocarditis, cardiomyopathy, inflammatory processes..

Question 341

Interventions besides airway, breathing and circulation for cardiogenic pulmonary edema

Answer 341

Ventilatory support ( noninvasive or mechanical ventilation with PEEP) Diuretics Normalize temperature.

Question 342

Indications for ventilatory support ( noninvasive vent or ET intubation) in cardiogenic pulmonary edema

Answer 342

1. Persistent hypoxemia despite oxygen administration and noninvasive ventilation 2. Impending respiratory failure 3. Hemodynamic compromise ( hypotension, severe tachycardia)

Question 343

ARDS criteria

Answer 343

``` Acute onset ( within 7 days of insult) PaO2/FiO2 300 or less Oxygenation Index >=4 New infiltrate on chest xray No evidence for a cardiogenic or fluid overload cause of pulmonary edema ``` Oxygenation Index([FIO2 x mean airway pressure x100]/PaO2)

Question 344

Oxygenation Index FORMULA

Answer 344

([FIO2 x mean airway pressure x100]/PaO2)

Question 345

Medications to avoid in NM disease

Answer 345

syccynilcholine for intubation--> hyperK, malignant hyperthermia amino glycosides: intrinsic neuromuscular activity that worsen respiratory muscle weakness.

Question 346

self-inflating bags vs. free flow bag

Answer 346

constant concentration of oxygen refill even if the seal is poor or ventilation is inadequate resucitation scenario not as experienced personnel if o2 source is empty is not connected, snesthesia, ICU care team depends on adequate sealing, and rate of squeezing to deliver adequate vol.

Question 347

Bag size

Answer 347

at least 450-500 mL or larger in infants and young child | in older children or adolescents 1000mL or larger

Question 348

The bag mask ventilation is for scenario were there are two rescuers, if one it should be mouth to barrier device technique T/F

Answer 348

True In case there are 2 , there can also be two ventilating the patient. one rescuer does the E-C clamp technique with both hands while the other delivers O2.

Question 349

Situations in which 2 person bag mask ventilation may be necessary

Answer 349

1. Difficulty making a seal 2. providers hands are too small 3. Significant airway resistance or poor lung compliance 4. Spinal motion restriction is necesary

Question 350

Once you are giving oxygen through bag mask, how do you check is correct?

Answer 350

- chest rise with each breath - O2 saturation - Exhaled CO2 - HR - BP - Distal air entry - Signs of improvement of deterioration

Question 351

What do you think of when there is sudden increase in lung stiffness during ventilation with bag mask?

Answer 351

May indicate: airway obstruction decreased lung compliance development of a pneumothorax also- if there is excessive ventilation which leads to lung distention

Question 352

Types of suction devices

Answer 352

Portable suction devices (not very adequate force -80 to -120mmHg) Bulb or syringe suction device ( no requirement of outside vacuum, but inadequate in large patients or copious secretions) Wall mounted suction (higher suction force more than -300mmHg)

Question 353

Complications of suctioning

Answer 353

``` hypoxia vagal stimulation resulting in bradycardia gagging,vomiting soft tissue injury agitation ```

Question 354

use of soft vs rigid catheter for suctioning

Answer 354

soft- aspiration of thin secretions, suctioning in an advanced airway (ET tube) rigid-suctioning of the oropharynx, particularly if thick secretions

Question 355

Why suctioning attempts should be 10 seconds or less?

Answer 355

reduces risk of hypoxemia. And you can give short periods of Oxygen 100% immediately before and after. EXCEPT in patients who have really copius secretions needed to be removed for breathing

Question 356

When do you use an oropharyngeal airway?

Answer 356

Unconscious child with no gag reflex procedures to open airway didnt work NEVER USE IN SEMICONSCIOUS OR CONSCIOUS- stimulates gagging reflex and vomit.

Question 357

What is the FiO2 and flow of a low flow nasal cannula?

Answer 357

FiO2- 20-60% | Flow 0.5-4L/min

Question 358

What is the FiO2 and flow of a low flow face mask?

Answer 358

FiO2- 35-60% | Flow 4-10 L/min

Question 359

What is the FiO2 and flow of a high flow non rebreathing mask with reservoir?

Answer 359

FiO2- 60-95% | Flow 10-15 L/min

Question 360

What is the FiO2 and flow of a high flow nasal cannula?

Answer 360

FiO2> 60% | Flow 4-40L/min

Question 361

Name parts of the nebulizer

Answer 361

``` Mouthpiece or face mask T piece spacer nebulizer cup nebulizer reservoir tubing compressor ```

Question 362

What is the gas flow you have to maintain for nebulizer

Answer 362

5-6 lts

Question 363

How long should be the treatment with neulizer

Answer 363

8-10 minutes

Question 364

For inhaled medications, why do you need a spacer?

Answer 364

to effectively deliver to the lungs. If no spacer, only 1/3 arrives to the lungs and the rest stays at the mouth

Question 365

How do you use a Metered Dose Inhaler with spacer device?

Answer 365

While the child is exhaling, activate the MDI by pressuring down. Tell the child to take 5 slow, deep, breaths through the mouth piece and hold the last breath for 10 seconds.

Question 366

Pulse oximetry can accurately estimate oxygen saturation but does not provide evidence of oxygen delivery! It also doesnt directly evaluate the effectiveness of ventilation (CO2).

Answer 366

TRUE

Question 367

Sudden deterioration in an intubated patient causes

Answer 367

DOPE mnemonic Displacement of the tube - out of trachea or into the R/L trachea Obstruction of the tube- secretions( blood, pus, foreign body), kinking of the body Pneumothorax simple: decreased SAO2, breath sounds and chest expansion decreased in the affected sides. tension: same as simple plus hypotension and decreased CO. Trachea is shifted away from affected side. Equipment failure - disconnection of the O2 supply from ventilation system - Leak in ventilator circuit - failure of power supply to the ventilator

Question 368

Presentation of simple vs. tension Pneumothorax

Answer 368

Pneumothorax simple: decreased SAO2, breath sounds and chest expansion decreased in the affected sides. tension: same as simple plus hypotension and decreased CO. Trachea is shifted away from affected side.

Question 369

Management of intubated patient who has a sudden deterioration

Answer 369

In addition to DOPE ``` Observe for chest rise and symmetry auscultate check monitors (SaO2, HR, Capnography) Suction ET tube if secretions Use sedatives or analgesics to reduce agitation and control of ventilation; ONLY when you have ruled out a correctable cause ```

Question 370

Definition of shock

Answer 370

physiologic state characterized by inadequate tissue perfusion to meet metabolic demands and tissue oxygenation. - is often but NOT ALWAYS characterized by inadequate peripheral and end organ perfusion)

Question 371

What are the consequences of inadequate tissue perfusion

Answer 371

``` tissue hypoxia anaerobic metabolism accumulation of lactic acid and CO2 irreversible cell damage organ damage ```

Question 372

Goal for treating shock

Answer 372

improve systemic perfusion and O2 delivery

Question 373

Explain utility of Central Venous Oxygen Saturation (ScvO2) in shock

Answer 373

normally, arterial blood contains MORE O2 than what tissues need. If demands increase-tissues extract more leading to reduced O2 saturation in the Scvo2 so it helps us identify when there are increased demands in the body. If O2 content is normal and metabolic demands normal, and Scvo2, think of decreased CO

Question 374

Adequate tissue delivery depends on 3 things..

Answer 374

1. Sufficient O2 content in the blood 2. Adequate blood flow ( CO) 3. Appropriate distribution of blood flow to tissues

Question 375

Arterial oxygen content formula

Answer 375

Saturated + unsaturated | 1.34xHb x SaO2)+(0.003 x PaO2

Question 376

Oxygen delivery formula

Answer 376

CO + Arterial Oxygen content CO X ( (1.34xHb x SaO2)+(0.003 x PaO2))

Question 377

Formula for CO

Answer 377

HR X SVR

Question 378

BP formula

Answer 378

CO x SVR

Question 379

O2 delivery may be normal despite hypoxemia if the CO increases commesurate with the decrease in 02 content

Answer 379

true! O2 delivery=CO + Arterial Oxygen content

Question 380

Compensatory mechanisms for hypoxia

Answer 380

Increased CO initially | polycythemia if hypoxia is chronic

Question 381

Which is the compensatory mechanism if CO decreases

Answer 381

CO= SVx HR So either one, or both can increase HR increases is LIMITED-Otherwise arrythmia and less time of diastole and filling ventricle.

Question 382

How are the compensatory mechanisms for increasing CO different between infants and children/adolescents?

Answer 382

In infants, CO highly depends on HR. Their SV is small and has limited capacity to increase. In child/adolescent is HR and SV but remember that HR is limited.

Question 383

How is the appropriate distribution of blood determined?

Answer 383

by the size of the blood vessels supplying a specific organ. -- vascular resistance. - vessels large-> resistance is low - vessel small-> resistance high

Question 384

Vasconstriction = abnormally increased resistance

Answer 384

True

Question 385

Determinants of Stroke volume

Answer 385

Preload, contractility, afterload

Question 386

Indirect measure of preload?

Answer 386

Central venous pressure, but is partially true. Because this also depends on ventricle compliance and pressure and volume measures are different.

Question 387

Compensatory mechanisms of shock

Answer 387

First: Increase HR When O2 delivery to tissues is compromised BLOOD FLOW IS REDIRECTED to VITAL ORGANS--> occurs through selective increase in SVR: reduced peripheral perfusion (delayed capillary refill, cool extremities, less easily palpable peripheral pulses) and reduced perfusion to gut and kidneys (decreased urine output) Increased contractility Increase in venous smooth tone-- improving venous return and preload.

Question 388

As CO decreases in shock, BP can be normal or slighly elevated because increased SVR compensation

Answer 388

True

Question 389

Pulse pressure

Answer 389

SBP-DBP

Question 390

What happens with Pulse pressure in shock?

Answer 390

narrows, because an increased in SVR raises DBP. In sepsis, SVR is low, so diastolic pressure decreases and pulse pressure widens.

Question 391

Compensated vs. decompensated shock

Answer 391

depends on the SBP. Compensated: signs of inadequate tissue perfusion but bp IS within nom al range. SPB above fifth percentile of age ( 70+(agex2)) Decompensated: hypotension SHOCK CAN BE PRESENT EVEN IF THE BP IS NORMAL.

Question 392

SHOCK CAN BE PRESENT EVEN IF THE BP IS NORMAL.

Answer 392

True, is a compensatory mechanism

Question 393

Hypotensive shock is the new name for Decompensated shock

Answer 393

True

Question 394

Hypotension is generally a late finding in most types of shock.

Answer 394

Partially true, | In sepsis can occur early because mediators of sepsis produce vasodilation and reduce SVR.

Question 395

When SVR is decreased hypotension will be an early rather than a late sign of shock

Answer 395

True, septic shock.

Question 396

Hypotension formula

Answer 396

SBP: 70 + [age in years x2]

Question 397

compensated shock--> hypotensive shock--> cardiac arrest

Answer 397

True warning signs: loss of peripheral pulses and decreased level of consciousness Bradycardia and weak central pulses- omnious signs of impending cardiac arrest

Question 398

What does third space mean

Answer 398

plasma loss into the interstitium or capillary leak

Question 399

Goals of shock treatment

Answer 399

``` Improve O2 delivery Balance tissue perfusion and metabolic demand Reverse perfusion abnormalities support organ function prevent progression to cardiac arrest ```

Question 400

Optimization of O2 content in shock

Answer 400

High flow O2 ( Nonrebreathing mask) invasive or noninvasive ventilation to improve oxygenation If Hb low, provide RBC

Question 401

Ionized serum Ca changes with ph

Answer 401

Acidosis--> increased Ca

Question 402

General management of shock

Answer 402

1. Positioning 2. Support airway, oxygenation and ventilation 3. Establishing vascular access 4. Provide fluid resuscitation 5. Monitoring 6. Performing frequent reassessment 7. Obtaining labs 8. Meds 9. Consulting specialists.

Question 403

Fluid resuscitation in shock

Answer 403

In general, isotonic crystalloids in a 20mL/kg bolus over 5-20 min. In severe hypotension, hypovolemic shock: over 5-10 min In cardiogenic shock-smaller bolus ( 5-10 mL/kg given over 10-20 min) Overall, reassess and repeat boluses as needed.

Question 404

Good urine output response after shock therapy in infants/young children, and older children and adolescents

Answer 404

infants and young children: 1.5-2 mL/kg/hr | older children and adolescents: 1 mL/kg/hr

Question 405

Possible etiology and intervention for decreased Hb and Hcto in shock

Answer 405

Hemorrhage Fluid resuscitation (dilution) Hemolysis Possible interventions: Administer O2 Control bleeding, transfuse blood Titrate fluid administration

Question 406

Possible etiology and intervention for decreased or increased WBCs in shock

Answer 406

sepsis obtain appropriate cultures give Abcs

Question 407

Possible etiology and intervention for decreased platelets in shock

Answer 407

DIC Decreased platelet production Transfuse platelets if has serious bleeding ibtain PT,PTT, fibrinogen, D-dimers

Question 408

Possible etiology and intervention for increased or decreased glucose in shock

Answer 408

stress sepsis decreased production ( liver failure) adrenal insufficiency give dextrose bolus and start infusion of dextrose-containing solution if needed.

Question 409

Possible etiology and intervention for increased or decreased K in shock

Answer 409

``` Renal dysfunction Acidosis (increases K) Diuresis ( decreased) Adrenal insufficiency (increased) ``` correct acidosis treat hypo or hyperK

Question 410

Possible etiology and intervention for decreased ionized [Ca] in shock

Answer 410

Sepsis Transfusion of blood preserved with citrate phosphate dextran Colloid administration Buffering agents ( Sodium bicarbonate) Give Ca.

Question 411

Possible etiology and intervention for increased Lactate in shock

Answer 411

increased as product of anaerobic metabolism from tissue hypoperfusion - tissue hypoxia - increased glucose production - Decreased metabolism( liver failure) Increase tissue perfusion Treat acidosis if end-organ dysfunction is impaired.

Question 412

Inotropes examples and MOA

Answer 412

- Dopamine - Epinephrine - Dobutamine MOA Increase cardiac contractility, HR Variable effect on SVR -includes agents with both adrenergic and B adrenergic effects.

Question 413

PDE examples and MOA

Answer 413

Milrinone Decrease SVR Improve coronary artery blood flow improve contractility

Question 414

Vasodilators examples and MOA

Answer 414

Nitroglycerin Nitroprusside Decrease SVR and venous tone

Question 415

Vasopressors examples and MOA

Answer 415

Epi ( doses>0.3 mcg/kg/min) NE Dopamine ( >10mcg/kg/min) Vasopressin Increase SVR Increase myocardial contractility ( except vasopressin)

Question 416

Examples of isotonic crystalloid solutions

Answer 416

NS and lactate ringer

Question 417

isotonic crystalloid solutions are the first choice of resucitation fluid

Answer 417

True

Question 418

advantages isotonic crystalloid solutions

Answer 418

inexpensive, readily available, no sensitivity reactions

Question 419

disadvantages colloid solutions

Answer 419

not readily available, may cause sensitivity reactions, | use limmited to 20-40mL/kg

Question 420

Volume of fluid and rate for hypovolemic/distributive shock

Answer 420

20mL/kg bolus over 5-10 min ( repeat as needed)

Question 421

Volume of fluid and rate for Cardiogenic shock( non-poisoning)

Answer 421

5-10 mL/kg bolus over 10-20 min ( repeat as needed)

Question 422

Volume of fluid and rate for poisoning ( Ca channel blockers, B adrenergic blockers

Answer 422

same as cardiogenic shock, | 5-10 mL/kg bolus over 10-20 min ( repeat as needed)

Question 423

Volume of fluid and rate for DKA with compensated shock

Answer 423

10-20 mL/kg PER LOCAL PROTOCOL~ 1-2 HRS

Question 424

Rapid fluid delivery system

Answer 424

2 large IV catheters Place an in line 3 way stopcock deliver fluid by using a 30- to 60 mL syringe to push fluids throught the stopcock

Question 425

Indication for blood product administration

Answer 425

Inadequate perfusion despite 2-3 boluses of 20 mL/kg OF isotonic crystalloid. administer 10 mL/kg of blood product.

Question 426

crossmatching meaning

Answer 426

is testing before a blood transfusion to determine if the donor's blood is compatible with the blood of an intended recipient

Question 427

Priority for the blood type or blood products

Answer 427

Crossmatched Type specific Type O negative ( O negative preferred in females, O+/- in males) *predered for females of childbearing age to avoid Rh sensitization

Question 428

Rapid infusion of cold blood or blood products, mparticularly in large vol, may lead to

Answer 428

hypothermia myocardial dysfunction ionized hypoCa To minimize: warm blood and blood products and if hypoCa is anticipated with a specific product administer Ca empirically

Question 429

Clinical signs of hypoglycemia

Answer 429

``` poor perfusion diaphoresis tachycardia hypothermia irritability or lethargy hypotension ```

Question 430

Definition of. hypoglycemia

Answer 430

preterm/term neonates < 45 infants/children/adolescents < 60

Question 431

Management of hypoglycemia

Answer 431

minimal ss and normal mental status: oral glucose( eg,orange juice) symptomatic- IV glucose 0.5-1 g/kg. IV dextrose D25W(2-4mL/kg) OR D10W(5-10 mL/kg)

Question 432

IV dextrose solutions

Answer 432

IV dextrose D25W(2-4mL/kg) OR D10W(5-10 mL/kg)

Question 433

Why not routinely infuse dextrose containing fluids for volume resucitation -

Answer 433

hyperglycemia--> osmotic diuresis--> exacerbation of hypovolemia

Question 434

Children with hypovolemic shock who receive fluids within the first hour have better chance of recovery and survival.

Answer 434

True! Adequate timing is very important!

Question 435

Dehydration definition

Answer 435

loss of water with varying loss of electrolytes leading to a hypertonic ( hypernatremic) , isotonic, hypotonic ( hyponatremic) state.

Question 436

Clinically significant dehydration in children

Answer 436

at least 5% of volume depletion- corresponding to a fluid deficit of 50 mL/kg or greater.

Question 437

Degrees of dehydration and %(mL/kg)

Answer 437

Mild - 5% (50) Moderate 10% (100) Severe 15%(150)

Question 438

Failure to improve hypovolemic shock with at least 3 boluses of isotonic crystalloid solution indicates..

Answer 438

o The extent of fluid losses may be underestimated oThe type of fluid replacement may need to be altered (eg, need for colloid or blood) oThere are ongoing fluid lossess( occult bleeding) oInitial assumption about the etiology may be incorrect

Question 439

Classification of blood loss

Answer 439

mild -< 30% moderate 30-45% Severe > 45%

Question 440

Management of hypovolemic shock

Answer 440

- Rapidly infuse 20 mL/kg boluses of isotonic crystalloid - May repeat up to 3 boluses - If pt continues unstable consider transfusion of RBCs if hemorrhagic, or consider re-evaluate what is going on.

Question 441

3 mL to 1 mL route

Answer 441

In hemorrhagic shock, give about 3 mL of isotonic crystalloid for every 1 mL of blood lost.

Question 442

blood replacement in hemorrhagic shock

Answer 442

use PRBCs in 10mL/kg

Question 443

Indications for transfusion in hemorrhagic shock

Answer 443

Crystalloid refractory hypotension or poor perfusion | Known significant blood loss

Question 444

Any medication that can be administered IV can be given IO route T/F

Answer 444

True

Question 445

Contraindications to IO access

Answer 445

Fractures and crush injuries near the access site Conditions withf fragile bones ( osteogenesis imperfecta) Previous attempts to establish IO access in the same bone. Avoid IO cannulation if infection is present in the overlying tissues

Question 446

Symptomatic bradycardia

Answer 446

bradycardia ( usually < 60/min) + cardiopulmonary compromise cardiopulmonary compromise: hypotension, altered mental status, signs of shock

Question 447

Primary vs. Secondary Bradycardia

Answer 447

Primary: congenital or acquired heart conditions that slow the spontaneous depolarization rate of the hearts normal pacemaker cells or slow conduction through system Secondary: result fo noncardiac conditions affecting the heart

Question 448

Causes of primary bradycardia

Answer 448

Congenital abnormality of the heart pacemaker or conduction system Surgical injury to the pacemaker or conduction system Cardiomyopathy myocarditis

Question 449

Causes of secondary bradycardia

Answer 449

``` hypoxia acidosis hypotension hypothermia drug effects ```

Question 450

ECG characteristics of bradycardia

Answer 450

HR- slow P waves- may or not be visible QRS narrow or wide ( depending on the origin of the rhythm and/or location of injury to the conduction system)

Question 451

Conditions in which bradycardia may be normal

Answer 451

- healthy children when metabolic demands are relatively low( ie sleep) - athletes

Question 452

why athletes have lower HR- Sinus bradycardia?

Answer 452

they have high SV and increased vagal tone

Question 453

AV block

Answer 453

disturbance of electrical conduction through the AV nose

Question 454

First degree AV block

Answer 454

Prolonged PR asymptomatic

Question 455

Causes of First degree AV block

Answer 455

- May be present in normal children - Increased vagal tone - myocarditis - MI - cardiac surgery - electrolytes( hyperK) - hypoxemia - acute rheumatic fever - intrinsic AV nodal disease - Drugs ( Ca channel blockers,digoxin, B adrenergic blockers)

Question 456

Second Degree AV block, Mobitz I

Answer 456

Occurs at the level of AV node progressive prolongation of the PR interval until an atrial impulse is not conducted to the ventricles. So until a p wave is not followed by a QRS presyncope

Question 457

Causes Second Degree AV block, Mobitz I

Answer 457

- Note: may be present in healthy children - Any condition that stimulates vasovagal tone - MI - Drugs ( Ca channel blockers,digoxin, B adrenergic blockers)

Question 458

Second Degree AV block, Mobitz II

Answer 458

Occurs below the AV node Non-conduction of some atrial impulses to the ventricle without any change in the PR. Often consistent ratio of atrial to ventricular depolarizations~ 2pwaves :1QRS palpitations, syncope, pre-syncope

Question 459

Causes Second Degree AV block, Mobitz II

Answer 459

- Intrinsic conduction normal abnormalities - Cardiac surgery - Myocardial infarction

Question 460

Third degree AV block (aka complete AV block)

Answer 460

None of the atrial pulses conduct to the ventricles No relationship between P waves and QRS complexes No atrial impulse reaches the ventricle Ventricular rhythm maintained by a slower pacemaker. fatigue, syncope, pre-syncope

Question 461

Causes Third degree AV block (aka complete AV block)

Answer 461

- Extensive conduction system disease or injury, myocarditis - Cardiac surgery - Congenital complete heart block - MI - Increased parasympathetic tone, toxic drug effects or severe hypoxia/acidosis.

Question 462

Signs of hemodynamic instability associated with tachyarrythmias

Answer 462

hypotension altered mental status signs of shock others: sudden collapse with rapid, weak pulses respiratory distress/failure

Question 463

How tachyarrhythmia affects cardiac output and coronary perfusion?

Answer 463

decreased SV due to insufficient time of filling during diastole no diastole--poor perfusion Tachyarrhythmia increases myocardial O2 demand leading to myocardial dysfunction. Inadequate CO--> cardiogenic shock

Question 464

What is sinus tachycardia

Answer 464

a sinus node depolarization rate faster than normal for the childs age. in response to need for increased CO or O2 delivery. Narrow tachycarida (=<0.09)- is not a tachyarrythmia.

Question 465

Causes of sinus tachycardia

Answer 465

- exercise - fever - pain - anxiety - tissue hypoxia - hypovolemia - shock - fever - metabolic stress - injury - toxins/poisons/drugs - anemia

Question 466

Characteristics of sinus tachycardia

Answer 466

usually < 220 in infants <180 in children R-R variable QRS narrow P waves and PR normal

Question 467

Cause of SVT

Answer 467

Reentry mechanism through accessory pathway or within AV node Other mechanisms that can cause SVT: Atrial flutter Ectopic atrial focus

Question 468

In infants SVT is often diagnosed when CHF develops

Answer 468

True, common signs of CHF includes irritability, poor feeding, rapid breathing, unusual sleepiness, vomiting, pale In order children signs may be shortness of breath, palpitations, chest pain, light headedness

Question 469

ECG characteristics SVT

Answer 469

infants > 220 children > 180 P waves may be absent or abnormal ( after P wave) RR constant QRS narrow

Question 470

Which is the most common type of SVT in children

Answer 470

Narrow QRS complex SVT , IN> 90%

Question 471

What are the types of SVT?

Answer 471

Narrow QRS complex SVT ( MC in ediatrics) Wide QRS complex SVT

Question 472

What is Wide QRS complex SVT

Answer 472

SVT with aberrant intraventricular conduction ( uncommon in peds) produces a wide complex QRS Occurs as a result of rate-related bundle branch block within the ventricles or pre-existing bundle branch block -Can be also caused by accessory pathway ( different from AV node) from atria to ventricle, and then return through AV node or another accessory pathway

Question 473

Sinus tach vs. SVT

Answer 473

Sinus tach - Gradual onset - Hx compatible with ST- fever, pain, dehydration - PE: Signs of underlying condition( crackles, fever, hypovol) - HR in infants < 220/min, children< 180/min SVT: -Abrupt onset or termination, or both Infant: symptoms of CHF ( rales, hepatomegaly) CHild: sudden onset of palpitations - HR in infants >=220/min, children>= 180/min

Question 474

Signs of instability in patient with arrhythmia

Answer 474

- Respiratory distress or failure - Shock with poor end organ perfusion, which may occur with or without hypotension - Irritability or a decreased level of consciousness - Chest pain or vague feeling of discomfort in older children - Sudden collapse

Question 475

Algorithm for pediatric bradycardia with pulse and poor signs of perfusion

Answer 475

all.

Question 476

MOA epinephrine

Answer 476

b adrenergic activity: increases heart rate and cardiac contractility alpha adrenergic: causes vasoconstriction

Question 477

In bradycardia, when do you prefer atropine over epinephrine

Answer 477

in bradycardia caused by increased vagal tone, cholinergic drug toxicity ( organophosphates) or complete AV bloc

Question 478

why do you use atropine over epi in AV block due to primary bradycardia?

Answer 478

epi can cause ventricular arryhtmias if the myocardium is abnormal or hypoxic/ischemic. So first atropine, if not working then give epi

Question 479

synchronized vs unsynchronized cardioversion

Answer 479

synchronized: shock delivery is timed to coincide with the R wave of the patient QRS complex Unsynchronized: delivered at any time in the cardiac cycle, used for cardiac arrest rhythms that have no QRS.

Question 480

When to you use synchronized vs. unsynchronized cardioversion

Answer 480

synchronized: in SVT and Vtaq with pulse Unsynchronized: in cardiac arrest rhythm

Question 481

Defibrillation vs. Cardioversion

Answer 481

Defibrillation - is the treatment for immediately life-threatening arrhythmias with which the patient does not have a pulse, ie ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). Cardioversion - is any process that aims to convert an arrhythmia back to sinus rhythm.

Question 482

Indications for synchronized cardioversion

Answer 482

unstable patients ( poor perfusion, hypotension, or heart failure) with tachyarrthythmias (SVT, atrial flutter, VT) , but palpable pulses Elective cardioversion, under direction of pediatric cardiologist, for children STABLE with SVT, Atrial flutter, VT with a pulse.

Question 483

Energy dose for cardioversion

Answer 483

less than defibrillation dose Start with 0.5-1 J/kg for cardioversion of SVT or VT with pulse If inefective, 2 J/kg

Question 484

Drug of choice for SVT

Answer 484

Adenosine

Question 485

Indications adenosine

Answer 485

SVT

Question 486

adenosine MOA and precautions

Answer 486

Blocks conduction through the AV node temporarily ( ~10 seconds) a cause of failure is if its given too slowly or with inadequate IV flush. A brief period of bradycardia ( asystole or complete AV block) may ensue, so warn the pt.

Question 487

Amiodarone MOA

Answer 487

Inhibits alpha and B adrenergic receptors, producing vasodilation and AV nodal suppression Inhibits outward potassium current, prolonging the QT duration Inhibits Na channels, slowing conduction in the ventricles and prolongs QRS.

Question 488

Amiodarone SE

Answer 488

are rare bradycardia hypotension polymorphic VT

Question 489

Precautions of Amiodarone

Answer 489

be careful in prolonged QT conditions as it prolongs further the QT. hepatic patients.

Question 490

Procainamide indications

Answer 490

SVT, atrial flutter, VT with pulse

Question 491

MOA Procainamide

Answer 491

Blocks Na channels so prolongs the effective refractory period of both atria and ventricles and depresses conduction within system So by slowing intraventricular conduction, prolongs QT, QRS, PR intervals.