PALS Flashcards
1
Q
What does EWL stand for?
A
Estimated weight loss
2
Q
What does FBAO stand for?
A
Foreign body airway obstruction
3
Q
What does LVOT stand for?
A
Left ventricular outflow tract obstruction
4
Q
What does PEFR stand for?
A
Peak expiratory flow rate
5
Q
What does ROSC stand for?
A
Return of Spontaneous Circulation
6
Q
What is a prominent sign of ROSC?
A
Sudden increase in EtCO2
7
Q
What does RVOT stand for?
A
Right ventricular outflow tract obstruction
8
Q
What should you do when a patient is showing agonal gasps?
A
Immediately start CPR
9
Q
Blue discoloration of hands and feel, and around the mouth and lips
A
Acryocyanosis
10
Q
Cessation of breathing for 20 seconds
A
Apnea
11
Q
When can apnea be considered at less than 20 seconds?
A
When it is accompanied by bradycardia, cyanosis or pallor
12
Q
What is central apnea?
A
No respiratory effort
13
Q
What is obstructive apnea?
A
Pt is trying to breathe but ventilation is impeded by an obstructive airway
14
Q
Most common cause of bradycardia in kids
A
Apnea and/or hypoxia
15
Q
Bradycardia in newborns
A
<80 bpm or <100 bpm
16
Q
Bradycardia in infants and children
A
<60 bpm
17
Q
What does Broselow tape do?
A
Approximates weight and drug doses
18
Q
1st 28 days of life
A
Neonate
19
Q
1 month to 1 year of age
A
Infant
20
Q
1 year to onset of puberty
A
Child
21
Q
Puberty or older
A
Adult
22
Q
The proportion of time spent performing chest compressions for patients in cardiac arrest
A
Chest compression fraction: At least 60% and ideally greater than 80% of the resuscitation attempt
23
Q
Inflammation of the larynx/vocal cords
A
Croup
24
Q
What is mild croup?
A
Barking cough
25
What is moderate croup?
Stridor and retractions at rest
26
What is severe croup?
Significant agitation with decreased air entry
27
Bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood
Cyanosis
28
When is cyanosis apparent?
When at least 5g/dL of hemoglobin are desaturated
29
True/false. The more anemic you are, the lower the SpO2 that will be required for cyanosis to be present
True
30
What should you consider in PALS scenarios when a fever is present?
Administering antibiotics
31
SpO2 that is considered hypoxemia in PALS
<94% on room air
32
When should you consider administering supplemental oxygen in PALS?
1. If SpO2 is <94% or
| 2. There are poor signs of perfusion
33
What can prevent hypoxemia from turning into tissue hypoxia?
An increase in cardiac output
34
What is permissive hypoxemia?
An SpO2 reading of <94% that may be appropriate or normal in certain circumstances
35
Examples of permissive hypoxemia
1. Pt in high altitude
| 2. Pt with CHD (tetralogy of Fallot)
36
Hypoxia due to reduced arterial oxygen saturation
Hypoxemic hypoxia
37
Normal SaO2, but hypoxia due to decreased hemoglobin concentration, which leads to decreased total oxygen content in the blood (CaO2)
Anemic hypoxia
38
Normal SaO2 and hemoglobin concentration, but hypoxia due to decreased blood flow to the tissues
Ischemic hypoxia
39
Normal blood content and oxygen delivery, but hypoxia due to the inability of tissues to take up or utilize the oxygen from the bloodstream
Histotoxic/cytotoxic hypoxia
40
Cyanide poisoning, carbon monoxide poisoning, methemoglobinemia, septic shock/impaired mitochondrial function
Histotoxic/cytotoxic hypoxia
41
low cardiac output, hypovolemia, severe vasoconstriction, etc
Ischemic hypoxia
42
Hypoglycemia in neonates
<45 mg/dL
43
Hypoglycemia in infants/children/adolescents
<60 mg/dL
44
Signs of hypoglycemia in peds
Poor perfusion, hypotension and tachycardia, sweating, irritability, and/or lethargy
45
Glucose dose for treating hypoglycemia
0.5-1 g/kg bolus or 2-4 ml/kg of D25W
46
Treatment for minimal symptoms of hypoglycemia and the child is stable
Oral glucose via juice
47
Systolic BP for hypotension in neonates
<60
48
Systolic BP for hypotension in infants
<70
49
Systolic BP for hypotension in children 1-10 yrs
<70 + (age in years x2)
50
Systolic BP for hypotension in children >10 yrs
<90
51
How low can the systolic pressure of a 3 y/o patient go before they are considered hypotensive?
<76
70 + (age x 2)
52
Patchy discolorations of the skin, caused by areas of vasoconstriction (pallor) mixed with areas of vasodilation (cyanosis or erythema)
Mottling
53
What can mottling be a sign of?
Imminent death
54
Pale color due to lack of oxygen in the skin
Pallor
55
Where is central pallor seen?
In the lips and mucous membrane
56
Signs of good peripheral perfusion (vasodilation)
1. Good pulse (as long as BP is adequate)
2. Flushed skin
3. Brisk capillary refill (,2 seconds)
4. Warm skin
5. Awake and alert
57
Signs of poor/inadequate perfusion
1. Weak pulse
2. Pale or cyanotic skin color
3. Delayed capillary refill and cool extremities (vasoconstriction)
4. Decreased responsiveness and/or consciousness
5. Metabolic acidosis, elevated lactate and decreased urine output
58
Purple discolorations caused by small vessel bleeding
Petechiae and purpura
59
What do petechiae and purpura suggest?
- Low platelet count or a symptoms of disseminated intravascular coagulation
- in PALS, septic shock
60
What does it mean if a child is refractory to treatment?
They do not improve or respond to a specific therapy
61
What does fluid refractory hypotension mean?
A child remains hypotensive despite fluid administration
62
What does hypoxic refractory to supplemental oxygen administration mean?
May need they need a breathing treatment, or may need to be mask ventilated or intubated
63
What does norepinephrine refractory shock mean?
A child in shock in unresponsive to norepinephrine therapy
64
Normal capillary refill time
<2 seconds
65
Prolonged capillary refill time
>5 seconds
66
Common causes of prolonged capillary refill time
1. Dehydration
2. Shock
3. Hypothermia
67
SVT rate for infants
>220
68
SVT rate for children
>180
69
Normal oxygen consumption for adults
3-4 ml/kg/min
70
Normal oxygen consumption for infants
6-8 ml/kg/min
71
Normal SpO2 on room air
>94%
72
SpO2 on 100% oxygen that requires intervention
<90%
73
Normal ScvO2
25-30% below the SaO2 (70-75% if the SaO2 is normal)
74
Normal urine output for infants and young children
1.5-2 ml/kg/hr
75
Normal urine output for older children and adolescents
1 ml/kg/hr
76
What is reduced urine output a sign of?
Poor perfusion
77
What is quiet tachypnea caused by?
Non-pulmonary issues such as fever, pain, metabolic acidosis, etc
78
Why are pediatric patients prone to upper airway obstruction?
1. They have a large tongue
| 2. they have a large occiput that causes neck flexion
79
How can you keep a pediatric patient in the sniff position?
Use a shoulder roll
80
Is total resistance in the small airways higher or lower?
Lower
81
Which airways are more prone to turbulent air flow and why?
Larger airways because they have more resistance than the smaller
82
When the radius of the airway decreases, what happens to resistance for laminar flow?
It increases to the 4th power
83
When the radius decreases, what happens to resistance in turbulent airflow?
It increases to the 5th power
84
What does turbulent flow do to airway resistance?
It increases airway resistance and can make it harder to breathe
85
When is airflow laminar (has lower resistance)?
During normal respiration because the driving pressure of air during normal breathing is low
86
When can airflow become turbulent?
1. Partial airway obstruction (usually upper airway obstruction)
2. Labored/agitated breathing/increased respiratory efforts/crying
87
What effect does low gas density have on laminar flow and resistance?
Lower gas density = higher percentage of laminar flow = lower resistance
88
Primary inspiratory muscles
1. Diaphragm
| 2. External intercostals
89
Accessory inspiratory muscles
1. Sternocleidomastoid
2. Internal intercostals
3. Scalene muscles
4. Pectoralis major
5. Pectoralis minor
90
Accessory expiratory muscles
1. Rectus abdominis
2. External oblique
3. Internal oblique
4. Transversus abdominis
91
True/false. Labored breathing helps with oxygenation and ventilation
False
92
Why should you avoid excessive ventilation?
1. It causes air trapping
2. It increases intrathoracic pressure, impedes venous return, decreases CO, coronary perfusion and cerebral blood flow
3. It increases the risk of regurgitation and aspiration in kids without an advanced airway
93
How can you minimize gastric inflation?
1. Ventilating slowly
2. Delivering each breath over 1 second, and ventilating only until chest rise is observed
3. Considering the use of cricoid pressure
94
Tracheal tubes recommended for children <8 years old
Uncuffed
95
Formula for choosing the correct ETT
uncuffed tube = (age/4) +4
| cuffed tube = (age/4) + 3
96
Formula for choosing correct depth (cm) of insertion of ETT
For kids <2 y/o, internal diameter x3
| For kids >2 y/o, (age/2) +12
97
After ___ ventilations, detected CO2 can be presumed to be from the trachea
6
98
Method of administering drugs through the ETT
1. Dilute the drug with 5 ml NS
2. Deliver the drug via the ETT while briefly holding compressions
3. Follow drug delivery with 5 PPV
99
Epinephrine dose through ETT
10x the IV dose
100
Dosing drugs through the ETT (excluding epi)
2-3x IV dose
101
What does DOPE stand for?
Displacement
Obstruction
Pneumothorax
Equipment failure
102
When is DOPE used in PALS?
Anytime an intubated patient deteriorates
103
True/false. Resonant sounds are normal lung sounds with percussion
True
104
When are hyperresonant sounds observed?
In patients with
1. Hyperinflated lung (COPD, acute asthma attack)
2. Hyperinflated chest cavity (tension pneumothorax)
105
What causes wheezing?
Bronchoconstriction
106
Possible causes of rales
1. Fluid in the distal airways
2. Atelectasis
3. Cardiogenic shocks
107
Possible causes of rhonchi
Secretions, mucus or blood in the larger airways
108
Possible causes of stridor
Upper airway obstruction
109
What does grunting mean?
Possible impending respiratory failure
110
What causes grunting?
Lung tissue disease such as pneumonia, pulmonary edema, pulmonary contusion, ARDS or pulmonary edema produced by cardiogenic shock
111
Signs of respiratory distress
1. Flared nostrils
2. Head bobbing
3. Disordered control of breathing
112
What can cause disordered control of breathing?
1. Medication overdose
2. Seizure that led to increased ICP
3. Other neurological problems
113
What is disordered control of breathing?
Irregular respiratory rate and/or insufficient respiratory effort which can lead to hypoxemia and hypercarbia
114
Are substernal and subcostal retractions considered mild/moderate or severe?
Mild/moderate
115
Are suprasternal or supraclavicular retractions considered mild/moderate or severe?
Severe
116
What happens with seesaw respirations?
The chest retracts during inspiration and the abdominal expands
During expiration, the chest expands and the abdomen moves inward
117
What do seesaw respirations usually indicate?
Upper airway obstruction
118
What are other things seesaw respirations can indicate?
Neuromuscular weakness, lower airway obstruction, lung tissue disease, disordered control of breathing
119
Diagnosis for retractions + inspiratory snoring/stridor
Upper airway obstruction (croup, foreign body)
120
Diagnosis for retractions + expiratory wheezing
Lower airway obstruction (asthma, bronchiolitis)
121
Diagnosis for retractions + grunting or labored respirations
Lung tissue disease or pulmonary edema produced by cardiogenic shock
122
Diagnosis for severe retractions
May be accompanied by head bobbing or seesaw respirations
123
Treatment for severe choking in responsive children
Heimlich maneuver or abdominal thrusts
124
Treatment for severe choking in responsive infant
Place pt prone in one arm and deliver 5 back slaps, flip patient over and deliver 5 downward chest thrusts with 2 fingers
125
Treatment for severe choking in unresponsive patients
CPR
126
Type of airway obstruction associated with expiration
Lower (asthma, bronchoconstriction)
127
Type of airway obstruction associated with inspiration
Upper (soft tissue, croup, swelling, anaphylaxis)
128
When is suctioning contraindicated?
Upper airway obstructions
129
What diagnoses do these symptoms fit under: hypoxemia, possible poor chest rise or decreased air movement, possible breathing with accessory muscles, tachycardia (early), bradycardia (late)
1. Upper airway obstruction
2. Lower airway obstruction
3. Lung tissue disease
4. Disordered control of breathing
130
What are the diagnoses for these symptoms?
| Signs of labored breathing/respiratory distress (retractions, etc)
1. Upper airway obstruction
2. Lower airway obstruction
3. Lung tissue disease
131
What are the diagnoses for these symptoms?
| Stridor, inspiratory snoring, hoarseness, barking cough, drooling, snoring, gurgling
Upper airway obstruction
132
What are the diagnoses of these symptoms?
| Expiratory wheezing, active expiration?
Lower airway obstruction
133
What are the diagnoses for these symptoms?
| Grunting, crackles (rales), fever
Lung tissue disease
134
What are the diagnoses for these symptoms?
| Normal(or shallow) breath sounds with an abnormal respiratory pattern, possible central apnea (no respiratory effort)
Disordered control of breathing
135
What makes a likely cardiogenic shock scenario?
Bad lung sounds and hypotension
136
What makes a likely airway scenario?
Bad lung sounds and normal blood pressure
137
What is the rate and FiO2 of a high flow nasal cannula?
>50 L/min can deliver an FiO2 of close to 100%
138
Low flow oxygen delivery devices
Simple oxygen mask
| Nasal cannula
139
High flow oxygen delivery devices
High flow nasal cannula
| Nonrebreathing mask
140
FiO2 of simple oxygen mask
35-60%
141
FiO2 of nasal cannula
22-60%
142
FiO2 of high flow nasal cannula
Up to 95%
143
FiO2 of nonrebreathing mask
Up to 95%
144
When are breathing treatments indicated?
For lower airway obstruction
145
What does heliox do?
Generates less airway resistance than air (higher laminar flow) to make it easier for patients with an upper airway obstruction to breathe
146
Most prominent example of heliox being used in PALS
croup or other upper airway edema
147
2 primary advantages to humidified oxygen
1. Decreases the chance of coughing
| 2. Humidity can loosen mucus and provide easier breathing
148
When is humidified oxygen considered?
In moderate to severe croup and sometimes asthma
149
When is racemic epi used?
In cases of upper airway obstruction caused by swelling
150
When are steroids used?
To relieve symptoms of upper airway obstruction/swelling/croup
151
What is magnesium used for?
For bronchodilation when patients fail to respond to conventional therapy
152
What is an adverse effect of magnesium?
Hypotension
153
What is mannitol and/or hypertonic saline used for?
Treatment for disordered control of breathing caused by increased intracranial pressure
154
Most commonly used inhaled bronchodilator
Albuterol
155
Anticholinergic and a bronchodilator
Iapotropium
156
Adverse effects of Narcan
Increased heart rate and blood pressure, acute pulmonary edema, cardiac arrhythmias, seizures
157
Possible ways to support the airway in PALS
1. Give supplementary oxygen if SpO2 <94%
2. Assist the airway as needed and consider intubation
3. Suction any secretions
4. Administer antibiotics if febrile
5. Consider ordering labs/CXR
6. Treat bradycardia
7. Give breathing treatments/racemic epi/heliox/humidified O2/steroids
158
Treatments for all 4 airway scenarios
1. Supplementary oxygen if SpO2 is <94%
2. Assist airway if needed
3. Suction secretions
4. Treat bradycardia
159
Treatments for lower airway obstruction and lung tissue disease only
1. Administer breathing treatments and/or bronchodilators
| 2. Consider labs and/or CXR
160
Treatments for upper airway obstruction only
1. Administer heliox and/or humidified oxygen
| 2. Administer raceimic epi and/or steroids
161
Treatment for lung tissue disease only
Administer antibiotics if febrile
162
Treatment for disordered control of breathing only
Consider reversal agents (unless it was a seizure med)
163
When can racemic epi be used?
in lower airway obstruction if other breathing treatments fail
-upper airway obstruction
164
Check for breathing protocol
1. Check responsiveness
2. Check pulse and breathing simultaneously
3. If there is no pulse/you are unsure/pulse is <60 bpm, begin compressions
4. If there is a pulse, but no breathing, give rescue breaths
165
Respiratory rate if there is a pulse but no breathing
1 breath every 3-5 seconds (12-20 breaths per minute) or 10 breaths/min if an advanced airway is placed
166
Leading cause of death in infants younger than 6 months
SIDS
167
Most common cause of arrest in kids
Asphyxial arrest
168
CPR depth in infants
1.5 inches
169
CPR depth in children
2 inches
170
CPR depth in adolescents and adults
<2.4 inches
171
When is a 2 handed CPR technique used?
For adults and kids >8 years old
172
When is a one handed CPR technique used?
For children 1-8 years old
173
When is a two finger CPR technique used?
For infants when only one responder is available
174
When is a thumb encircling technique used?
For neonates and infants when two responders are available
175
What are the advantages of the thumb encircling technique when compared to the 2 finger technique?
1. Better coronary blood flow
2. More consistent depth
3. May generate higher blood pressures
176
CPR for children with 1 provider and no advanced airway
30:2 compression/ventilation ratio
| One vs two handed technique
177
CPR for children with 2 providers and no advanced airway
15:2, two handed
178
CPR for children with 2 providers and intubated
100-120 compressions/min
age appropriate RR (8-10 breaths/min)
One vs two handed
179
CPR for neonates with 1 provider and no advanced airway
3:1 respiratory cause
15:2 cardiac cause
2 finger technique
180
CPR for neonates with 2 providers and no advanced airway
3:1 respiratory cause
15:2 cardiac cause
thumb encircling technique
181
CPR for neonates with 2 providers and intubated
100-120 compressions/min
Age appropriate respiratory rate
Thumb encircling technique
182
Type of ECMO for respiratory failure
Venovenous
183
Type of ECMO for cardiac failure
Venoarterial
184
How do you assess neurologic status in PALS?
1. Check blood sugar
2. Check pupil response to light
3. AVPU
4. GCS
185
Neuro signs/symptoms of hypoxia
1. Loss of muscle tone
2. Generalized seizures
3. Dilation of pupils
4. Loss of consciousness
186
Neuro signs/symptoms of cerebral herniation
1. Unequal and/or dilated and/or unresponsive pupils
2. Hypertension
3. Bradycardia
4. Respiratory irregularities or apnea
5. Diminished response to stimuli
6. Sudden increase in ICP
187
When are pediatric manual defib pads used?
On children <1 y/o
188
When are pediatric AED pads used?
On children 1-8 y/o
189
When are adult AED pads used?
On kids >8 years old or on infants in cardiac arrest if pediatric pads are not available
190
Paddle placement for >1 y/o
Anterior posterior placement
191
Paddle placement for <1 y/o
Anterior-anterior
192
Defib dosing for synchronized cardioversion
1st shock: 0.5-1 J/kg
| 2nd shock: 2 J/kg
193
Defib dose for defibrillation
1st shock: 2 J/kg
2nd shock: 4 J/kg
Subsequent shock: >4 J/kg
Max shock: 10 J/kg or adult dose
194
Water takes up what percentage of body weight in infants?
70%
195
Water takes up what percentage of body weight in neonates?
80%
196
1 kg = ___ L of water
1 L
197
PALS assumes water takes up what percentage of body weight?
100%
198
How is weight loss in PALS expressed as volume loss?
1. Percentage of volume depletion
| 2. mL/kg of volume loss
199
When estimated weight loss is expressed in mL/kg, it is ___ the percentage of weight that was lost
10x
200
5% EWL is
50 ml/kg
201
What percent of total fluid volume is blood?
10%
202
EWL of adolescents for mild dehydration
3% (30 mL/kg)
203
EWL of adolescents for moderate dehydration
5-6% (50-60 mL/kg)
204
EWL of adolescents for severe dehydration
7-9% (70-90 mL/kg)
205
EWL of infants for mild dehydration
5%
206
EWL of infants for moderate dehydration
10%
207
EWL of infants for severe dehydration
15%
208
Why can younger children tolerate more volume loss?
They have higher circulating blood volumes / more water to lose
209
When is hypovolemic/hypotensive shock possible?
Possible with 5% EWL, but more likely with 10% or greater EWL
210
What is the treatment for a child with clinically evident dehydration?
20 mL/kg boluses of isotonic crystalloid
211
When are more rapid boluses of crystalloid indicated?
20 mL/kg over 5-10 minutes
1. Hypovolemic/hypotensive shock
2. Distributive shock
212
When are smaller (5-10 ml/kg) and/or slower (10-20 minutes) boluses of crystalloid therapy indicated?
1. Cardiogenic shock
2. Evidence or risk of pulmonary edema
3. Poisonings (beta blocker or CCB)
4. DKA
213
When should fluid boluses be stopped?
When the patient's condition improves or when signs of respiratory distress develop
214
Maximum dose of colloid (and why)
20-40 ml/kg
| higher doses may cause coagulopathies
215
Total dose of albumin
2g/kg
216
Adverse effect of albumin
Lower plasma calcium concentration
217
When are colloids considered?
If hypovolemia/hypotension persists after 3 boluses of crystalloid (20 ml/kg)
218
What should you do before giving fluids?
Check breath sounds in the lower lobes
219
What should you do with fluids if you hear rales?
Hold fluids or administer at a slower pace
220
What is the fluid therapy with febrile illnesses?
Restrictive volumes of isotonic crystalloid
221
What is the fluid therapy in sepsis?
Repeating regular 20 mL/kg fluid boluses, frequently assessing the patient and slowing it down if the pt develops signs of respiratory distress
222
What is the fluid therapy in DKA?
Initial bolus of isotonic crystalloid 10-20 ml/kg over 1-2 hours
-if pt is in hypotensive shock, the treatment approach should be more aggressive
223
Volume of fluid and rate of delivery for hypotensive, hypovolemic, obstructive and/or distributive shock
20 ml/kg bolus over 5-10 minutes, repeat as needed
224
Volume of fluid and rate of delivery for cardiogenic shock
5-10 ml/kg bolus over 10-20 minutes, repeat as needed
225
Volume of fluid and rate of delivery for poisonings (CCB or Beta blocker overdose)
5-10 ml/kg over 10-20 minutes, repeat as needed
226
Volume of fluid and rate of delivery for DKA with compensated shock
10-20 mL/kg over at least 1-2 hours (unless shock is present) follow local protocols and seek expert consultation
227
Volume of fluid and rate of delivery for febrile illness (in the absence of shock)
Restrictive, use extreme caution when access to critical care resources are not available
228
Volume of fluid and rate of delivery for septic shock
Start 20 mL/kg fluid boluses, carefully assess after each bolus and continue fluid boluses unless signs of respiratory distress develop
229
What is critical after every fluid bolus?
Reassessment
230
Indications for blood transfusions in PALS
1. Traumatic volume loss with signs of poor perfusion
2. Hemoglobin concentration less than 7g/dL
3. Children who are hypotensive despite 203 boluses of 20 mL/kg crystalloid
231
Initial dose of PRBCs in PALS
10 mL/kg
232
Priorities for the type of blood
1. Type and crossmatched
2. Type specific blood
3. Type O (O- for females, males can receive O+ IF they have never received a transfusion before)
233
4 stages of assessment in PALS
1. General assessment (pediatric assessment triangle)
2, Primary assessment (ABCDEs)
3. Secondary assessment (SAMPLE/ H's & T's)
4. Tertiary assessment (labs, diagnostic tests, x-rays, etc)
234
What is the goal of the pediatric assessment?
Recognize respiratory distress, respiratory arrest and shock
235
What are the most common causes of cardiac arrest?
Respiratory distress, respiratory arrest and shock
236
What do you look for when checking appearance?
Appearance, breathing and circulation/color
237
Initial ABC steps in unconscious/unresponsive patients
1. Check for pulse and breath sounds
2. Activate EMS and start CPR if there is no pulse
3. Provide rescue breaths and place monitors if there is a pulse but pt is not breathing
238
Initial ABC steps in conscious.responsive patients
1. Monitors/check perfusion
2. IV
3. Oxygen if needed
4. Auscultate breath sounds
239
Treatment for bradycardia and abnormal lung sounds
Oxygenation and ventilation
240
Treatment for bradycardia and clear breath sounds
Epi or atropine
241
Treatment for fever and abnormal lung sounds
Support airway and administer antibiotics (probably lung tissue disease)
242
Treatment for fever and clear breath sounds
Antibiotics, fluids, vasopressors (probably septic shock)
243
Treatment for hypotension and abnormal lung sounds
Inotropes and smaller fluid boluses (probably cardiogenic shock)
244
Treatment for hypotension and clear breath sounds
Rapid fluid boluses (probably hypovolemic shock)
245
Order of ABC steps for unconscious/unresponsive patients
CAB order
246
Order of ABC steps for conscious/responsive patients
Depends on the situation
247
Initial PALS steps
1. Check appearance, breathing, color
| 2. Check responsiveness
248
What does SAMPLE stand for?
```
Signs and symptoms
Allergies
Medications
Past medical history
Last meal consumed
Events
```
249
When should H's & T's be verbalized
If the child is in cardiac arrest
250
When should an ABG be obtained?
Within 10-15 minutes of the establishment of mechanical ventilation
251
What is the problem with venous labs?
They are not good indicators of oxygen and carbon dioxide pressures
252
Possible causes of low cardiac output
1. Bradycardia
2. Hypovolemia
3. Decreased contractility
253
General symptoms of low cardiac output/low ScvO2
1. Hypotension
2. Vasoconstriction and weak pulses
3. Signs of poor perfusion
4. Oliguria
5. Narrow pulse pressure (low SV= low systolic BP, vasoconstriction = high diastolic BP)
254
Additional symptoms of low cardiac output with decreased contractility
1. Pulmonary edema
2. Rales
3. JVD
255
Symptoms of low afterload (vasodilation)
1. High cardiac output (higher SV)
2. Good pulse (if BP is adequate)
3. Decreased preload (blood pooling in legs)
4. Wide pulse pressure
5. Brisk capillary refill (if BP is adequate)
6. Delayed capillary refill (if BP is too low)
7. Flushed skin
8. If severe, it can be accompanied by angioedema
256
Symptoms of high afterload (vasoconstriction)
1. Weak pulses
2. Pale skin
3. Delayed capillary refill
257
Most common cause of vasoconstriction in PALS
Decreased cardiac output
258
Possible causes of high ScvO2
1. High cardiac output
2. Reduced metabolism
3. Sepsis
259
Possible causes of low ScvO2
1. Low cardiac output
2. Hypoxia
3. Increased metabolism
4. Anemia
260
If the patient has low cardiac output and sepsis, ScvO2 may be
low
261
If the patient has high cardiac output OR sepsis, ScvO2 may be
high
262
If a patient has low cardiac output/ScvO2 and hypotension, what is the most likely cause?
Hypovolemia/hypotensive shock
263
Treatment for hypotensive shock
1. Fluid resuscitate and/or transfuse to Hgb >10 g/dL
| 2. Vasoactive drugs (epi for cold, norepi for warm extremities)
264
Treatment for normotensive/compensated shock (low CO, normal BP)
1. Administer fluid boluses
2. Consider dopamine
3. Consider epi for cold extremities, norepi for warm extremities
4. Vasodilator therapy
265
Treatment for high ScvO2, warm extremities and low BP (warm shock)
1. Continue fluid boluses
| 2. Consider vasopressors (norepi) if fluids do not work
266
Examples of warm shock
1. Anaphylaxis
| 2. Sepsis
267
Why do septic patients have a high ScvO2?
1. Massive vasodilation, leading to increased stroke volume and cardiac output
2. Impaired oxygen uptake at the mitochondrial level, leaving more oxygen in the blood
268
What do all forms of shock produce?
Tissue hypoxia
269
Common shock symptoms
1. Hypotension
2. Decreased cardiac output
3. Vasoconstriction/poor signs of perfusion
4. Vasodilation (in sepsis, anaphylaxis)
270
What is compensated shock?
Normal BP and CO despite poor signs of perfusion
271
What is decompensated shock?
Low blood pressure despite vasoconstriction and tachycardia
272
When is shock considered decompensated?
If BP is less than 50th percentile for that age
273
What causes warm shock?
Vasodilation
274
What is observed in warm shock?
1. Good peripheral pulses
2. Increased cardiac output
3. Wider pulse pressure
4. Warm and flushed skin
275
What causes cold shock?
Low cardiac output (due to hypovolemia or decreased contractility) and subsequent vasoconstriction
276
What are symptoms of cold shock?
1. Pale, mottled skin
2. Peripheral tissues that have decreased blood flow and are thus cold
3. Hypotension with narrower pulse pressure
4. Inaccurate blood pressure readings
277
When does normotensive shock occur?
With compensated shock, hypoxia or anemia
278
Treatments for cold shock and/or decompensated (hypotensive) shock
1. Fluids
2. Vasopressors if fluid refractory
3. Inotropes
279
Treatments for warm shock
1. Fluids
| 2. Vasopressors if fluid refractory
280
Treatments for compensated (normotensive) shock
1. Fluids
2. Inotropes
3. Vasodilators (milrinone, nipride) if hypotensive despite epi
281
Most common cause of shock in kids
Hypovolemic
282
Types of hypovolemic shock
1. Hemorrhagic (loss of about 30%, EBL 25 ml/kg)
| 2. Non-hemorrhagic (GI, burns)
283
Signs/symptoms of hypovolemic shock
1. Hypotension
2. Tachycardia
3. Increased SVR
4. Clear breath sounds
284
Most common cause of decreased stroke volume in children
Inadequate preload
285
Body's first response to inadequate stroke volume
Tachycardia
286
Body's second response to inadequate stroke volume
Increased SVR
287
Treatment for hypovolemic shock
Rapid fluid resuscitation with crystalloids and/or blood products
288
What causes cardiogenic shock?
Decrease in cardiac contractility and EF (heart failure, cardiomyopathy, sepsis, posioning/drugs)
289
What can patients with cardiogenic shock develop?
Pulmonary edema and vasoconstriction, which can lead to cold shock and worsen EF
290
Treatment for cardiogenic shock
1. Smaller fluid bolus (5-10 ml/kg)
2. Inotropes
3. Vasodilators (if pt is normotensive)
4. Diuretics
291
What does PALS suggest to use to reduce afterload/increase stroke volume?
Vasodilator (milrinone, nipride)
292
Occurs with abnormalities in hemoglobin affinity
Dissociative shock
293
Examples of dissociative shock
Carbon monoxide poisoning, methemoglobinemia and cyanide poisoning
294
Treatment for carbon monoxide poisoning
Supplemental oxygen administration
295
Treatment for methemoglobinemia
Methylene blue
296
What are types of obstructive shock?
1. Pulmonary embolism
2. Cardiac tamponade
3. Tension pneumothorax
4. Ductal dependent lesions
297
Signs/symptoms of obstructive shock
Same signs as a patient with impaired contractility (vasoconstriction)
298
Signs and symptoms of pulmonary embolism
hypotension, physical signs of right heart failure (increased CVP, JVD), respiratory distress, chest pain
299
Treatment for pulmonary embolism
1. 20 mL/kg fluid bolus
2. Consider anticoagulants (heparin) and thrombolytics (rTPA)
3. Expert consult
300
Signs/symptoms of cardiac tamponade
1. Physical signs of impaired cardiac contractility
2. Muffled (diminished) heart sounds
3. Pulsus paradoxus
301
Treatment of cardiac tamponade
1. Pericardiocentesis
| 2. 20 mL/kg fluid bolus
302
Signs/symptoms of tension pneumothorax
1. Deflated lung & respiratory distress
2. Tracheal deviation towards the contralateral side
3. Poor signs of perfusion
4. Distended neck veins
5. Pulsus paradoxus
303
Treatment for tension pneumothorax
1. Needle decompression
| 2. Chest tube placement
304
What are ductal dependent lesions?
Congenital heart disease with left sided blockages
305
Unique symptoms of ductal dependent lesions
1. Rapid deterioration in consciousness
2. CHF
3. BP/SpO2 differences in preductal and postductal circulation
306
Treatment for ductal dependent lesions
1. Prostaglandin E1
| 2. Expert consult
307
Occurs when massive vasodilation leads to abnormal distribution of blood flow and subsequent inadequate supply of blood to the body's organs
Distributive shock
308
3 types of distributive shock in PALS
1. Anaphylactic shock
2. Neurogenic shock
3. Septic shock
309
Most common form of distributive shock
Septic shock
310
Initial management of all types of distributive shock
Fluid administration followed by vasopressors for fluid refractory hypotension
311
Anaphylactic shock leads to:
1. Systemic vasodilation
| 2. Pulmonary vasoconstriction
312
Treatment for anaphylactic shock
1. Subcutaneous/IM epi
2. Bronchodilators
3. 20 mL/kg fluid bolus
4. Corticosteroids
5. H1 and H2 blockers (benadryl, zantac)
6. Magnesium
7. Consider humidified oxygen, bipap, intubation
313
Occurs after a spinal cord or head injury when the injury causes the sympathetic pathway of the spinal cord to be disrupted/lose
Neurogenic shock
314
Diagnosis of neurogenic shock
1. Spinal cord or head injury
2. Vasodilation and subsequent wide pulse pressure
3. Hypotension and warm shock
4. Absence of tachycardia
315
Treatment of neurogenic shock
1. Fluid boluses
2. Trendelenburg to increase venous return
3. Vasopressors if the patient is fluid refractory hypotensive
4. Supplemental warming or cooling may be necessary, especially for children with spinal shock
316
An acute loss of sensation and motor function after a spinal injury, with gradual recovery
Spinal shock
317
Autonomic dysreflexia may occur in spinal cord injuries above
T6
318
What criteria must be met for a patient to have systemic inflammatory response syndrome? (SIRS)
At least 2 of the 4 (one must be temp or abnormal WBC)
1. Temperature > 38.5C or below 36 C
2. Unexplained tachycardia in adults or bradycardia in children <1 year old
3. Respiratory rate >20 unrelated to pain or other factors
4. WBC >12,000
319
Infectious causes of sepsis
1. CNS infections (meningitis or encephalitis)
2. Cardiovascular infections (infective endocarditis)
3. Respiratory infections (PNA)
4. GI infections (peritonitis)
5. UTI (pyelonephritis)
6. Generalized abscesses
320
Non-infectious causes of sepsis
1. Severe trauma or hemorrhage
| 2. Acute systemic disease (MI, PE, pancreatitis)
321
Pathophysiology of sepsis
1. Infection activates the immune system, which releases inflammatory mediators (cytokines)
2. Cytokines promote vasodilation and increase capillary permeability
3. Pts may suffer from mitochondrial dysfunction, causing subsequent hypoxia
4. Pts may develop adrenal insufficiency
5. Pts may develop hyperglycemia or hypoglycemia
6. Pts may develop hypocalcemia
7. Pts may have increased CO early on and decreased CO in later stages
8. Pathway starts with SIRS, then sepsis, then severe sepsis, then septic shock
322
Vasodilation in sepsis can cause
relative hypovolemia, decreased tissue perfusion, metabolic acidosis, and potential eventual organ failure
323
When is sepsis considered severe?
1. Cardiovascular dysfunction
2. Acute respiratory distress syndrome
3. Failure/dysfunction of at least 2 other organs
324
When is a patient in septic shock?
If they display cardiovascular dysfunction after fluid resuscitation
325
Diagnosis of sepsis
1. Signs of infection
2. Metabolic acidosis, elevated lactate and respiratory acidosis
3. Potential hypotension, hypoglycemia or hyperglycemia, hypocalcemia and adrenal insufficiency
4. Possible petechiae
326
Treatment of sepsis
1. Treat the source of infection with antibiotics or with surgical intervention
2. Fluid resuscitate (with caution)
3. Start vasopressor therapy if pt has fluid refractory hypotension
4. Attempt to fix the metabolic acidosis
5. Consider inotropes
6. Consider steroid therapy
7. Correct any potential hypoglycemia with dextrose
8. Correct any potential hypocalcemia with calcium chloride
327
If a random cortisol level is below ___ it is considered adrenal insufficiency
18 mcg/dl
328
Why are steroids controversial in sepsis?
They prevent induction of nitric oxide synthase, reduce inflammatory response, but they can also worsen underlying infection and hyperglycemia
329
Septic shock algorithm in PALS within the first 10-15 minutes
1. Identify shock
2. Monitors, IV, oxygen, auscultation
3. Draw blood cultures and labs
330
Septic shock algorithm in PALS within the first hour
4. Start and repeat 20 ml/kg fluid boluses (3-4 boluses)
5. Start vasopressors
6. Identify metabolic derangements
7. Administer broad spectrum antibiotics
331
Septic shock management after the first hour
8. Administer 2mg/kg hydrocortisone
9. Correct hypoglycemia and hypocalcemia (calcium = 20mg/kg)
10. Start invasive lines and treat based on ScvO2
11. Consider intubation
332
Vasopressor therapy for warm shock
- norepinephrine first
| - vasopressin
333
Vasopressor therapy for normotensive shock
- dopamine (2-20 mcg/kg/min, >5 mcg/kg/min beta, >10 mcg/kg/min alpha)
- if dopamine is not effective, use epi or norepi
- if those do not work, dobutamine, milrinone, nitroprusside
334
When should epi be used in normotensive shock?
If dopamine does not work, in normal or high vascular resistance
335
When should norepi be used in normotensive shock?
If dopamine does not work, in low vascular resistance
336
Vasopressor treatment for cold shock
- epi
| - combo of dobutamine and norepinephrine
337
Reducing oxygen demand requires us to manage what conditions?
1. Increased respiratory effort and breathing work
2. Fever
3. Pain and anxiety
338
How can we reduce oxygen demand?
1. Mechanical ventilation or intubation
2. Administration of antipyretics and/or cooling measures to control fever
3. Use of analgesics and sedatives (with caution) to control pain and anxiety
339
Goal of shock treatment
Restore normal perfusion and prevent cardiac arrest by:
1. Optimizing oxygenation of blood
2. Improving cardiac output and cardiac volume
3. Reducing tissue/organ demand for oxygen
4. Correcting metabolic derangements
340
Signs of hypovolemic shock, cardiogenic shock, obstructive shock, distributive shock
1. Tachypnea
2. Tachycardia
3. Decreased urine output
4. Metabolic acidosis
5. Irritable early
6. Lethargic late
7. Variable temperature
341
Signs of hypovolemic shock, cardiogenic shock, obstructive shock
1. Decrease perfusion/cold shock (delayed capillary refill, etc)
2. Decreased cardiac output
3. Narrow pulse pressure
342
Signs of distributive shock
1. Warm shock
2. Increased cardiac output
3. Wide pulse pressure
4. Bounding pulses
343
When is tachycardia not present in shock situations?
1. Neurogenic shock
2. Late signs of tension pneumothorax
3. Some ductal dependent lesions
344
True/false. Distributive shock is considered warm shock, but can turn into cold shock
True
345
What should you do in all cases of shock?
Administer high flow oxygen until the patient's condition improves
346
What should you do in all cases of hypotension?
Consider 30 degree head down Trendelenburg (unless breathing compromised)
347
Situations to consider prolonging resuscitative efforts
1. Recurring or refractory vfib/vtach
2. Drug toxicity
3. Hypothermia
348
2 phases of resuscitation management
1. Immediate post-arrest management focused on the ABCs (intubation, capnography, ABGs, +/- chest xray, BP, treat arrhythmias, draw labs and maintain normal lab values)
2. Broader multi-organ supportive care (TTM, transfer)
349
Airway and breathing goals of post resuscitation management
1. Keep the SpO2 between 94-99%
| 2. Avoid hypercarbia or hypocarbia
350
Circulation goals of post resuscitation management
1. Use fluid boluses and/or vasopressors and/or inotropes to manage and treat shock, and to keep systolic BP within the 5th percentile for age
2. Draw labs (blood sugar, ABGs, electrolytes, etc)
3. Consider the H's & T's
351
Disability and exposure for post resuscitation management
1. Monitor for and treat hypoglycemia
2. Continually monitor temperature (avoid fever & shivering) & initiate TTM
3. Treat seizures
4. Avoid increases in ICP, if applicable and consider ordering a CT scan
352
TTM in PALS for infants and children remaining comatose after OHCA
1. Avoid a fever/maintain normothermia for 5 days or
| 2. Maintain 2 days of initial continuous hypothermia followed by 3 days of continuous normothermia
353
TTM in PALS for infants and children remaining comatose after IHCA
There is insufficient evidence to recommend cooling over normothermia, but fever should still be treat/avoided
354
What should you do when delivering IV drugs via peripheral line?
Follow with a 5 mL saline flush
355
IV/IO pediatric dose of atropine
20 mcg/kg
| -can be repeated if the initial dose doesn't achieve the desired effect
356
ETT pediatric dose of atropine
40-60 mcg/kg (2-3xIV dose)
357
Maximum single dose of atropine for a child
0.5 mg
358
Maximum total dose of atropine for a child
1 mg
359
Maximum total dose of atropine for an adolescent
3 mg
360
Minimum dose of atropine in PALS
0.1 mg
361
Epinephrine IV dose in PALS for bradycardia
10 mcg/kg (0.01 mg/kg)
362
ETT dose for epinephrine in PALS
100 mcg/kg
363
Infusion dose for epinephrine for shock in PALS
<0.03 mcg/kg/min
364
First dose of adenosine in PALS for SVT
100 mcg/kg (max 6mg)
365
What happens if adenosine is administered slowly?
The drug may not be effective
366
When will the rhythm convert after dosing adenosine?
Within 10-15 seconds
367
What is the second dose of adenosine in PALS for SVT?
200 mcg/kg (max 12mg)
368
When a second dose of adenosine more likely to be needed?
If an initial dose is administered via peripheral IV line
369
Amiodarone dose for SVT/stable vtach in PALS
5 mg/kg over 20-60 minutes
370
Procainamide dose in PALS SVT/Stable Vtach
15 mg/kg over 30-60 minutes
371
Epinephrine dose in PALS for vfib/pulseless vtach
10 mcg/kg every 3-5 minutes
372
Amiodarone dose in PALS for vfib/pulseless vtach
5mg/kg rapid bolus
| -may repeat up to a total dose of 15 mg/kg, or 300 total mg
373
When is amiodarone contraindicated?
In Torsades de Pointes
374
Lidocaine dose in PALS for vfib/pulseless vtach
Loading dose of 1mg/kg
| -an infusion 20-50 mcg/kg can be considered
375
Magnesium dose in PALS for vfib/pulseless vtach
- only indicated for Torsades de Pointes
| - The dose is 25-50 mg/kg
