PALS Part 2.1 (7-10) (Respiratory & Shock)

Question 1

Hypoxemia VS Hypoxia

Answer 1

Hypoxemia is when there is lower O2/hemoglobin saturation (below 94%)

Hypoxia (generalized = whole body ; tissue = specific region) is when there is inadequate O2 being delivered to the body

They do not happen at the same time in all instances

Question 2

Early Vs Late signs of tissue hypoxia

Answer 2

Early Signs:

• Tachypnea
• Tachycardia
• Increased resp effort: nasal flaring, retractions
• Pallor, mottling, cyanosis
• Agitation, anxiety, irritability

Late Signs:

• Bradypnea, inadequate resp effort, apnea
• Increased resp effort: head bobbing, seesaw resps, grunting
• Bradycardia
• Pallor, mottling, cyanosis
• Decreased LOC

Question 3

What exactly is Arterial O2 content and what is the formula for calculating it?

Answer 3

Arterial O2 Content = the total amount of O2 carried in the blood. It consists of the sum of O2 bound to hemoglobin AND the amount dissolved into arterial blood plasma.

Arterial O2 Content = (1.36 X Hgb concentration X SaO2) + (0.003 x PaO2)

Question 4

Review the 5 different mechanisms of Hypoxia on page 111-112

Answer 4

Seriously review it, they’re not the normal causes of respiratory distress you think of!!!

Question 5

When should you begin to suspect hypercarbia as the cause of respiratory distress instead of hypoxia/hypoxemia?

Answer 5

When the pt further deteriorates despite adequate O2, which is typically a sign that ventilations are inadequate whether spontaneous via pt or artificial via BVM

Question 6

Stopped at Airway resistance

Answer 6

Stopped at Airway resistance

Question 7

What are the 4 major factors associated with increased work of breathing?

Answer 7

AIRWAY RESISTANCE:
- the impedance to airflow within the airways, which is primarily changed by the size of the airway. Larger airways have less resistance than smaller airways. Obviously if there is a blockage or space taken up then the airway will be smaller and thus resistance increased.

LUNG COMPLIANCE:
- The change in lung volume produced by a change in driving pressure across the lung, this is done with the lungs and chest wall/diaphragm expand and relax. There are several conditions that decrease lung compliance such as a pneumo, pneumonia, ARDS, Inflammation, and pulmonary edema; but the root cause of decrease compliance is the increased presence of water/fluids in the interstitial spaces. This acts like a sponge filled with water which decreases its natural elasticity b/c of the extra water weight.

USE OF ACCESSORY MUSCLES:
- The muscles of inspiration are the diaphragm, intercostal muscles, and accessory muscles (mainly the neck and abdomen). The diaphragm creates he most change in pressure by contracting downward in a dome shape, however the range of motion of the diaphragm contraction can be decreased my things like intraabdominal pressure or abdominal distention. In young children and infants the intercostal muscles serve mainly to stabilize the chest and cannot effectively lift the chest wall to increase intrathoracic volume to compensate for a loss of diaphragm motion.

CNS DISORDER OF THE BREATHING CONTROL SYSTEMS:
- Includes brainstem respiratory centers, central/peripheral chemoreceptors, and voluntary control (via the cerebral cortex). Things like an infection of the CNS, traumatic brain injury, and drug overdose can impair these systems.
- NOTE: Central Chemoreceptors are responsive to the hydrogen ion content in the cerebrospinal fluid which is largely determined by the arterial CO2 tension.
Peripheral Chemoreceptors are responsive to a decrease in arterial O2 (though a few also response to CO2 levels)

Question 8

Laminar Airflow Vs Turbulent Airflow?

Answer 8

Laminar Airflow = quite, smooth, and orderly

Turbulent Airflow = irregular

Question 9

How is lung and chest wall compliance different for infants and small children?

Answer 9

B/c the infant and smaller children chest wall has not become rigid yet like in older children and adolescents and is still very flexible (i.e. very compliant), when a child changes intrathoracic pressures very quickly and forcefully as in labored breathing, it will bring in the chest wall during a forceful inspiration causing the retractions of the chest wall between the ribs seen during labored breathing.

This actually limits lung expansion and is not useful. Once the chest wall becomes rigid in older kids, the forceful inspiration can be helpful

Question 10

How is airway swelling different in infants and children than adults?

Answer 10

Obviously the airways are going to be smaller which is fine with their comparatively smaller bodies. However, b/c swelling is circumferential in the airways, the same amount of swelling causes a MUCH smaller airway in infants. Pg 114 has a good picture example.

A crying infants creating turbulent airflow can reduce lumen size causing an increase in airway resistance and cause a 16-32x increase in work of breathing.

Question 11

Respiratory Distress VS Failure

Answer 11

Respiratory Distress:
- This is when there is an increase in respiratory rate and effort. Typically assessment for includes looking at rate, effort, quality of breath sounds, and mental status (typical an AMS indicated more failure than distress)

Respiratory Failure:
- occurs when the pt can no longer maintain adequate oxygenation, ventilation, or both. Typically this is identified by an “abnormal appearance” aka AMS or decreased LOC or cyanotic.

NOTE: When respiratory effort is inadequate, respiratory failure can occur without typical signs of respiratory distress.
For instance if a pt OD’d on an opioid, they may not go through the phase of respiratory distress before reaching failure b/c they are already in a depressed state/LOC before respiratory depression and thus may not fight for air the normal way.

Question 12

Where should you auscultate lung sounds when doing a respiratory exam?

Answer 12

• Anterior (either side of the chest wall)
• Posterior
• Lateral (under the axillae)

NOTE: remember though that due to small chest cavity space, sometimes the lung on the opposite side can be heard while auscultating the other side and mask problems. So listening under the armpit where you are the furthest away from the opposite lung may yield the most accurate sounds

Question 13

What are the 4 types of respiratory problem types?

more like locations of cause

Answer 13

UPPER AIRWAY OBSTRUCTION:

• Nose, pharynx, larynx (airways above the thorax)
• Typically from some sort of obstruction (Ex. FBAO), inflammation (Ex. Epiglottitis), or infection (Croup)
• Most common signs are stridor, hoarseness, change in voice/cry, typically during inspiration. Other signs could be increased resp rate/effort, drooling, snoring, gurgling, poor chest rise, poor air entry sounds on auscultation

LOWER AIRWAY OBSTRUCTION:

• Lower trachea, bronchi, bronchioles (airway within the thorax)
• Commonly caused by asthma and bronchiolitis.
• Typically signs are seen during inspiration where there is a wheeze and prolonged expiratory phase the requires increased expiratory effort.

LUNG TISSUE DISEASE:
- Disease of the lung tissues/substances
- This causes stiff lungs b/c of the increase in fluids accumulated in the alveoli, interstitium, or both. This causes severe respiratory effort seen by accessory muscle use/retractions and marked hypoxia (from alveolar collapse or pulmonary edema and/or inflammation debris in the alveoli
- The disease can be caused by a ton of things including, pulmonary contusion, allergic reaction, toxins, CHF, ARDS, pneumonia, ect.
- Often signs and symptoms will include, crackles/rales, decreased air movement, decreased breath sounds, tachypnea, increased effort, tachycardia, and hypoxemia despite O2 supp).
(EARLY SIGN = hypoxemia b/c of damaged alveoli, low oxygenation ; LATE SIGN = grunting and hypercarbia b/c of decreased ventilation and hypercarbia)

DISORDERED CONTROL OF BREATHING:

• in this state there is inadequate respiratory effort (often the parent will say the child is “breathing funny”) which leads to hypoventilation and hypercarbia. Typically the LOC will be decreased as a result of the other two.
• Can be caused by neurologic disorders, metabolic abnormalities, and drug overdose.
• Signs often include, variable/irregular breathing patterns and effort, shallow breathing with inadequate effort, central apnea, normal or decreased air movement

Question 14

Specific Management for Different Types of Upper Airway Obstructions

Answer 14

ALL Emergencies Get the Basic:

• airway positioning
• suction as needed
• oxygen
• Pulse Ox
• ECG Monitoring as needed
• BLS as indicated

UPPER AIRWAY OBSTRUCTION

• Croup:
  a) nebulized epi
  b) corticosteroids (dexamethasone)
• Anaphylaxis
  a) IM Epi:
  b) albuterol
  c) antihistamine
  d) corticosteroids
• FBAO:
  a) position of comfort
  b) specialty consulation

Question 15

Specific Management for Different Types of Lower Airway Obstructions

Answer 15

ALL Emergencies Get the Basic:

• airway positioning
• suction as needed
• oxygen
• Pulse Ox
• ECG Monitoring as needed
• BLS as indicated

LOWER AIRWAY OBSTRUCTION

• Bronchiolitis:
  a) nasal suctioning
  b) consider bronchodilator trial
• Asthma:
  a) albuterol + ipratropium
  b) corticosteroids
  c) magnesium sulfate (for status asthmaticus)
  d) IM epi (if severe)
  e) Terbutaline

Question 16

Specific Management for Different Types of Lung Tissue Disease

Answer 16

ALL Emergencies Get the Basic:

• airway positioning
• suction as needed
• oxygen
• Pulse Ox
• ECG Monitoring as needed
• BLS as indicated

LUNG TISSUE DISEASE

• Pneumonia, Infectious/Chemical/Aspiration Pneumonitis
  a) albuterol
  b) antibiotics as needed
  c) consider non invasive or invasive ventilatory support with PEEP
• Pulmonary Edema, Cardiogenic/NonCardio (ARDS):
  a) consider non invasive or invasive ventilatory support with PEEP
  b) consider vasoactive support
  c) consider diuretic

Question 17

Specific Management for Different Types of Disordered Control of Breathing

Answer 17

ALL Emergencies Get the Basic:

• airway positioning
• suction as needed
• oxygen
• Pulse Ox
• ECG Monitoring as needed
• BLS as indicated

DISORDERED CONTROL OF BREATHING

• Increased ICP:
  a) avoid hypoxemia
  b) avoid hypercarbia
  c) avoid hyperthermia
  d) avoid hypotension
• Poisoning/Overdose:
  a) antidote as indicated
  b) contact poison control
• Neuromuscular Disease:
  a) consider non invasive or invasive ventilatory support with PEEP

Question 18

Why might you not want to use succinylcholine in a ped pt with a neuromuscular disease?

Answer 18

It can trigger hyperkalemia or malignant hyperthermia

Question 19

What is a pop off valve and when should it not be used?

Answer 19

A pop off valve is a pressure limited valve on a BVM that prevents excessive airway pressure above 35-45 cm H2O being vented into the patient.

When you are doing CPR on a ped patient who with poor lung compliance, has airway resistance, or needs CPR the automatic pop-off valve may prevent sufficient tidal volume from being delivered. Therefore when doing CPR you should TAKE OR TURN OFF THE POP OFF VALVE

SIDE NOTE*** even with O2 supp ventilations using a reservoir and secondary 100% O2 source, the O2 concentration can vary from 30-80%. So do make sure you deliver high O2 concentration (60-95%) you must make sure you are using a reservoir and supp O2 flow of at least 15L/min

Question 20

What is a fish-mouth or leaf-flap operated nonrebreathing outlet valve?

Answer 20

They are adult specific non rebreathing valves that DO NOT provide a continuous flow of O2 to the mask. They only open when the bag is squeezed or enough inspiratory pressure forces the valve to open (when spontaneous breaths are present). However, kids cannot generate enough inspiratory force to open these valves so DO NOT USE ON CHILDREN.

Question 21

What size volume self-inflating bags should be used for infants/children and which for adolescents?

Answer 21

For infants and small children used a 450-500mL bag

For adolescents use a 1000mL (adult) bag

Question 22

What steps should you take when equipment testing your BVM?

Answer 22

• Check bag for leaks by placing finger on outlet valve and squeezing bag
• Check gas flow control valves to verify function
• Check the pop-off valve to ensure it can be closed/taken off
• Check that the O2 tubing is securely connected to the device and O2 source
• Listen for the sound of O2 flowing into the bag
• Ensure that the cuff of the mask is adequately inflated

Question 23

What is the ideal position for infants and toddlers to make an open/patent airway through positioning?

Answer 23

The “sniffing” position

Aim to place the external ear canal in line with the anterior of the top of the shoulder by flexing the neck forward and extending the head.

For children OLDER than 2 you may need to put padding under the occiput and for children YOUNGER than 2 you may need to pad under the shoulder blades.

Question 24

How many rescuers are recommended in order to use a BVM?

How does the technique change when there is 1 vs 2 rescuers?

When might a 2 person rescuer control over the BVM be necessary?

Answer 24

AHA says 2, and if there is only 1 they recommend the mouth-to-barrier technique

A 1 rescuer using a BVM should use the E-C clamp technique (the normal one; thumb & pointer make a C holding the mask secure to face, the other 3 fingers go under chin to hold the head back)

A 2 rescuer using a BVM should have one rescuer doing essentially an E-C clamp with both hands while the other squeezes the bag

Time when a 2 rescuer team may be necessary is if:

• making a seal is difficult
• one provider’s hands are too small
• significant airway resistance
• restricting spinal motion is necessary

Question 25

What are 3 reasons to avoid over ventilation?

Answer 25

- Increases intrathoracic pressure and impedes venous return, thus reducing filling of the heart between compressions, reducing blood flow generated by the next compression, and reducing coronary perfusion and cerebral blood flow - Causes air trapping and barotrauma in children with small airway obstruction - Increases risk of regurgitation and aspiration in children without an advanced airway

Question 26

When is a low flow-inflating bag (anesthesia bag) more beneficial than a self-inflating bag?

Answer 26

When a child has spontaneous breathing is can be difficult to time the compression of a self inflating bag with the child's breaths and miss-timing it can cause regurgitation, coughing, laryngospasm, or gastric inflation. Therefore a low flow-inflating bag may be more beneficial b/c they can provide CPAP and the flow can be manipulated to the needs of the child. These bags are typically used in the intensive care unit, delivery room, and operating room.

Question 27

Causes of gastric inflation during artificial ventilations

Answer 27

- partial airway obstruction - high airway pressures are needed, such as in a child with poor lung compliance - the BVM rate is too fast - the tidal volume is too much - the Peak inspiratory pressure created is excessive (more than 30 cm H20) - the child is unconscious or is in cardiac arrest (b/c the gastro-esophageal sphincter opens at a lower than normal pressure)

Question 28

How much suction is provided with a wall mounted VS portable suction device? How much force is typically needed to remove secretions?

Answer 28

Wall Mounted = more than -300 mmHg Portable = varies by machine but is definitely way less than 300 and may not be adequate when patient is large or secretions are thick/copious Typically at least a suction power of -80 to -120 mmHg is needed to remove secretions

Question 29

When should you use soft vs rigid catheters for suctioning?

Answer 29

Use a soft catheter when secretions are thin or for suctioning an ET or trach tube. Use a rigid catheter when suctioning THICK secretions

Question 30

What things should you be sure to monitor while suctioning?

Answer 30

- Heart rate - O2 Sat - clinical appearance You may need to give O2 and ventilations before and after secretions to avoid hypoxia. Typically you should not suction for longer than 10 seconds but when secretions are blocking an airway so bad you may need to go over as you wont be able to give vents and O2 without the removal of large amounts of fluids

Question 31

Where should the tip of the OPA land when placed and sized correctly? How should you size the OPA and what can happen if it is too large or too small?

Answer 31

A correctly sized and placed OPA should land the tip at the angle of the jaw which should align with the glottis opening. To size an OPA the tip should extend from the corner of the mouth to the angle of the jaw If it is too LARGE it can block the airway or cause trauma to the laryngeal structures (& soft tissue) If is is too SMALL it can push the tongue into the back of the throat (Remember they recommend to use a tongue depressor to push the tongue down before inserting, this replaces the need to insert at a 45 or 90 degree angle and then twisting into place)

Question 32

What 3 clinical situations should you automatically think to give a child O2 supp?

Answer 32

- resp compromise (distress/failure/arrest) - Shock - AMS REMEMBER to try to get a humidifier attached asap to prevent airway dryness (don't think this is on truck)

Question 33

What considerations should you have when it comes to giving O2 to a conscious child or infant?

Answer 33

Sometimes giving O2 supp can freak the child out more b/c the equipment can be scary, this will cause an increase in O2 consumption secondary to agitation. Weigh the risk vs reward/need and consider letting the parent introduce the O2 equipment or if one method agitates the child try a different less aggressive one like nasal cannula or blow by technique

Question 34

What are considered low-flow O2 delivery systems vs high-flow O2 delivery systems?

Answer 34

LOW-FLOW O2 DELIVERY SYSTEMS: (22-60% O2, typically used when child is relatively stable and require minimal aid) - NASAL CANNULA: a) offers O2 concentration of 22%-60% b) Recommended flow rate is 0.25 to 4Lpm c) the exact inspired O2 concentration cannot be determined alone by the flow rate b/c other conditions affect it such as the child's size, inspiratory flow rate, volume inspired, Naso or Oro volume, Nasal or Oro resistance. - SIMPLE OXYGEN MASK a) offers O2 concentration of 35%-60% b) recommended flow rate is 6 to 10 Lpm c) this does not offer as much O2 concentration as a non-rebreather b/c there are not ports that close off when the pt is breathing in to prevent room air from entering. I.E. this will deliver mixed room air and O2 line the nasal cannula HIGH_FLOW O2 DELIVERY SYSTEMS: (O2 concentration delivery of over 60% at a minimum of 10 Lpm, typically given to critical pts in shock or resp distress) - NON-REBREATHER: a) an O2 concentration of 95% can be reached with a flow rate of 10-15Lpm and a tight seal on face - HIGH FLOW NASAL CANNULA: a) for adolescents and older the 4Lpm can be turned up to 40+ Lpm titrated to effect b) keep in mind though that this will still deliver mixed room air and O2 from the compressed source

Question 35

At what flow rate should a nebulizer be set at?

Answer 35

5-6 Lpm

Question 36

How should you tell the child to breath when administering a MDI with a spacer device?

Answer 36

After pressing on the inhaler to release the medicine, have the child breath normally for 3-5 breaths and then hold their breath for 10 seconds on the last breath

Question 37

What are 2 things you should look at for discrepancies in what the Pulse Ox may be reading at?

Answer 37

There may be a malfunction if the heart rate the pulse ox is saying does not match the actual pts heart rate There may be a malfunction if the O2 sat does not match the presentation of the child

Question 38

What are 6 situations when the Pulse Ox reading may be inaccurate?

Answer 38

- cardiac arrest - shock or hypovolemia - motion, shivering, or bright overhead light - problem with the skin probe interface - misaligning the sensor with light source - cardiac arrhythmias with low cardiac output

Question 39

The definition of shock does not require the presence of ______?

Answer 39

Hypotension! The definition of shock does not require the presence of HYPOTENSION, shock can be present with a normal, increased, or decreased systolic blood pressure. (this is b/c by definition it is when tissue perfusion does not meet metabolic demands and tissue oxygenation)

Question 40

What are two of the first effected organs (besides the heart) in the presence of shock and can be big clues to shock being present?

Answer 40

THE BRAIN AND KIDNEYS The brain will develop a decreased level of consciousness, and the kidneys will have a decreased or no urine output (obviously the heart will also be affected quickly)

Question 41

What are 4 main causes/types of shock? What can make shock worse or progress faster?

Answer 41

HYPOVOLEMIC SHOCK - Inadequate blood volume or oxygen-carrying capacity - Caused by gastroenteritis, burns, hemorrhage, dehydration, sepsis, or osmotic diuresis DISTRIBUTIVE SHOCK - Poor distribution of blood volume and flow - Caused by sepsis, anaphylaxis, or spinal cord injury CARDIOGENIC SHOCK - Impaired cardiac contractility - Caused by congenital heart disease, myocarditis, cardiomyopathy, or arrhythmia OBSTRUCTIVE SHOCK - Obstructed blood flow - Caused by tension pneumo, cardiac tamponade, PE, or constriction of the ductus arteriosus in infants with ductal-dependent congenital heart lesions Anything that increases O2 demand will make shock worse or progress faster. These include things like fever, infection, injury, resp distress, and pain.

Question 42

What is the main goal in treating shock?

Answer 42

To increase systemic perfusion and O2 delivery to help prevent end-organ injury and stop the progression to cardiopulmonary failure and cardiac arrest

Question 43

What is produced by anaerobic metabolism?

Answer 43

Lactic Acid

Question 44

What 3 things does adequate tissue O2 delivery depend on? What primarily determines blood O2 content?

Answer 44

Adequate tissue O2 delivery depends on: - Sufficient O2 content in the blood - Adequate blood flow to the tissues (cardiac output) - Appropriate distribution of blood flow to the tissues The hemoglobin concentration and % of saturated hemoglobin determine blood O2 content. (plasma carries only a small amount of O2)

Question 45

Does the presence of hypoxemia automatically mean there is tissue hypoxia?

Answer 45

NO Hypoxemia is when there is an overall low O2 count bound to hemoglobin (low O2 sats) but hypoxia is when there is inadequate tissue perfusion or inadequate O2 delivery to the systems. So if there is hypoxemia present, the heart can increase cardiac output as a compensatory mechanism which will offset the low O2 sats by pumping more blood to the tissues and thus delivery a semi normal amount of O2.

Question 46

Cardiac output = ? x ?

Answer 46

Cardiac output = heart rate X stroke volume ***NOTE: remember that infants and young children have a harder time changing stroke volume and therefore depend on their heart rate for compensatory mechanisms. This is why bradycardia is so bad b/c they cannot compensate like an adult by changing their stroke volume

Question 47

What 2 things determine adequate blood flow to the tissues?

Answer 47

Cardiac output and vascular resistance CO = HR X SV

Question 48

What is Stroke Volume? | What 3 things determine stroke volume?

Answer 48

Stroke volume is the amount of blood ejected by the ventricles with each contraction and is determined by: - Preload - Contractility - Afterload

Question 49

Increased Vascular Resistance = ? | Decreased Vascular Resistance = ?

Answer 49

Increased Vascular Resistance = Vasoconstriction Decreased Vascular Resistance = Vasodilation (obviously things like an emboli or plaque build up will also increase vascular resistance)

Question 50

What is the most common cause of low stroke volume and therefore low cardiac output?

Answer 50

Inadequate Preload! This is typically caused by hemorrhaging, severe dehydration, and vasodilation THIS RESULTS IN HYPOVOLEMIC SHOCK (i.e. hypovolemic shock is related to inadequate preload!!!)

Question 51

At a steady state, where does most of the blood reside?

Answer 51

In the VEINS, about 70%

Question 52

How can you assess the right ventricular preload?

Answer 52

By measuring the Central Venous Pressure in the superior vena cava or the right atrium!

Question 53

Poor cardiac contractility is related to what type of shock? | What are some things that can cause poor contractility?

Answer 53

Poor cardiac contractility is related to Cardiogenic Shock, this is b/c it directly impairs cardiac output via decreased stoke volume. This is also considered to be "myocardial dysfunction" and can be caused by inflamed heart muscle (myocarditis), metabolic problems like hypoglycemia, or toxic ingestions like calcium channel blockers.

Question 54

What is the bodies normal response to a decrease in cardiac output and how does that further hurt the body?

Answer 54

When the body experiences a decrease in cardiac output it maintains tissue perfusion by vasoconstriction. This further hurts the cardiac output however b/c it increases AFTERLOAD, so the heart is having a harder time ejecting blood out of the left ventricle, decreasing stroke volume and cardiac output further still

Question 55

What are the 4 main compensatory mechanisms the body does to compensate for shock?

Answer 55

- Increased Heart Rate (Tachycardia) (First sign to occur) - Increased systemic vascular resistance (SVR) (vasoconstriction) (this is seen by selectively causing peripheral vasoconstriction to shunt blood towards the core organs. This shunting is seen through delayed cap refill, cold extremities, weaker peripheral pulses, and reduced perfusion to the gut and kidneys which produces a low urine output (oliguria)) - Increased Cardiac Contractility - Increase in Venous Smooth Muscle Tone

Question 56

What 2 things determine blood pressure?

Answer 56

Cardiac Output and SVR (Systemic Vascular Resistance)

Question 57

Compensated Shock VS Hypotensive Shock

Answer 57

COMPENSATED SHOCK: - Clinical state where there are signs of inadequate tissue perfusion but the pts blood pressure is in the normal range. - Clinical findings include tachycardia, delayed cap refill, mental status changes, and decreased urine output. (recall the 4 main comp mechanisms on the other note card; tachy offsets the low stroke volume, delayed cap refill, cool extremities, weak peripheral pulses and low urine output (oliguria) are all signs of blood shunting to core) HYPOTENSIVE SHOCK: - THIS IS THE NEW NAME FOR DECOMP SHOCK - This is when blood pressure has dropped below normal b/c the vasoconstriction is no longer able to offset the low cardiac output. - Clinical findings include weak peripheral AND central pulses, mottling, cool extremities, and altered LOC. WHEN YOU FIND SIGNS OF SHOCK, DO NOT WAIT FOR BLOOD PRESSURE BEFORE YOU START TREATING!

Question 58

In what ways does septic shock not follow the normal path of Comp shock to Decomp shock to Arrest? What is the Hypotension Formula for pts 1-10yo?

Answer 58

Septic shock can skin right to decomp shock because it will quickly cause vasodilation, taking away the main pathway for the heart to attempt to compensate for shock. Therefore, hypotension can be an early or late sign of septic shock. Often if it is an early sign you will have hypotension but still warm extremities, brisk or flash capillary refill, and full peripheral pulses. HYPOTENSION FORMULA FOR AGES 1-10yo: If the BP is LESS than the below formula then the pt is Hypotensive : (Child's age x 2)mmHg + 70 mmHg

Question 59

What is the relationship between shock and the term "Accelerating Process"?

Answer 59

It is referring to the fact that shock progression is UNPREDICTBLE. It may take HOURS for compensated shock to develop into hypotensive shock, but only MINUTES for hypotensive shock to develop into cardiac arrest

Question 60

What is a special aspect of septic and anaphylactic shock that increases severity outside of their vasodilatory effects causing distributive shock? What is a late sign of distributive shock?

Answer 60

B/c of their added effects to the permeability of capillaries (it increases it), there is also loss of fluids from the intravascular space to the extravascular space, causing increased loss of circulating fluids. Also b/c of the fast progression of vasodilation that leads to fast blood flow to tissue beds but not away from them, once the metabolic processes switch to anaerobic it causes a pooling of lactic acid at the tissue beds, this combo of blood not being shunted away and build up of lactic acid is why the extremities stay warm and in fact WHEN THEY GO COLD IS A LATE SIGN OF DISTRIBUTIVE SHOCK

Question 61

How does neurologic injury cause distributive shock? | What are the main three signs?

Answer 61

An injury that causes neurological damage such as to the upper cervical spine, can cause a loss of vascular tone via a disruption in nervous system signal reaching the smooth muscle; which in effects results in severe vasodilation like in sepsis and anaphylaxis which all three cause distributive shock. The main three signs of neurologic distributive shock are: - hypotension with wide pulse pressure - normal heart rate or bradycardia (the loss of NS signals to the smooth muscle also prevents tachycardia - Hypothermia

Question 62

What is the most common form of distributive shock?

Answer 62

Septic Shock - an abnormal host immune response to infectious organisms or their by-products (endotoxins) that lead to small blood vessels dilating and leaking fluids into tissues.

Question 63

What are the 5 steps to the Systemic Inflammatory Cascade leading to Septic shock?

Answer 63

- Infectious organism or its by products activates the immune system including neutrophils, monocytes, and macrophages - These cells stimulate release or activation of inflammatory mediators (cytokines) that perpetuate inflammatory response - Cytokines produce vasodilation and damage to the lining of the blood vessels (endothelium), causing increased capillary permeability - Cytokines activate the coagulation cascade and may result in microvascular thrombosis and disseminated intravascular coagulation - Specific inflammatory mediators can impair cardiac contractility and cause myocardial dysfunction

Question 64

What makes treating sepsis so hard?

Answer 64

B/c the inadequate perfusion combined with possible microvascular thrombosis leads to ischemia that is diffuse and patchy so the individual organs get varying degrees of hypoxia and ischemia.

Question 65

How are the Adrenal Glands effected by sepsis?

Answer 65

The Adrenal Glands are especially prone to microvascular thrombosis and hemorrhage in septic shock; and since the adrenal glands produce cortisol (which is an important hormone in the body's stress response), the lowered levels of cortisol that may be present as a result contributes to low SVR (systemic vascular resistance) and myocardial dysfunction

Question 66

What is microvascular thrombosis?

Answer 66

I LOOKED THIS UP, THIS IS NOT FROM AHA I think it is when fibrin and other clotting factors close off small vessels in the presence of a septic infection to try to prevent the infection from spreading. The end result is it blocks off small vessels. Later, leukocytes will eliminate the infection and repair the damaged vessels

Question 67

REVIEW DIFFERENT SIGNS AND SYMPTOMS ASSOCIATED WITH DIFFERENT TYPES OF SHOCKS IN THE SECOND HALF OF PART 9, LOOK FOR ONES THAT ARE SPECIFIC TO EACH TYPE

Answer 67

REVIEW DIFFERENT SIGNS AND SYMPTOMS ASSOCIATED WITH DIFFERENT TYPES OF SHOCKS IN THE SECOND HALF OF PART 9, LOOK FOR ONES THAT ARE SPECIFIC TO EACH TYPE

Question 68

What is angioedema?

Answer 68

Swelling of the face, lips, and tongue (common in anaphylaxis)

Question 69

What are going to be your main clues that differentiate Neurogenic Shock and Hypovolemic Shock?

Answer 69

Hypovolemic Shock is typically associated with: - hypotension - NARROW pulse pressure (from compensatory vasoconstriction) - Tachycardia (from compensatory mechanism) Neurogenic shock the compensatory mechanisms above, vasoconstriction and tachycardia, do not occur because of interruption between the sympathetic nervous system and the heart and blood vessels (neuro will have hypotension with a WIDE pulse pressure and no tachy)

Question 70

DEFINITELY LOOK AT THE COMPARISON CHART OF THE DIFFERENT SIGNS AND SYMPTOMS PRESENT WITH THE 4 DIFFERENT TYPES OF SHOCK ON PAGE 188!!!!!

Answer 70

DEFINITELY LOOK AT THE COMPARISON CHART OF THE DIFFERENT SIGNS AND SYMPTOMS PRESENT WITH THE 4 DIFFERENT TYPES OF SHOCK ON PAGE 188!!!!!

Question 71

What are the 3 main characteristics of Cardiogenic shock? What are the 6 main pathological reactions occurring in the presence of cardiogenic shock?

Answer 71

The 3 main characteristics are tachycardia, high SVR, and decreased cardiac output (remember this is pump failure). - Increased heart rate and left Vent afterload, which increases vent work and myocardial O2 demand - Compensatory increase in SVR to redirect blood from peripheral and splanchnic tissues to the heart and brain. (remember that this increase in SVR actually helps in hypovolemic ​shock to shunt peripheral blood to core, but in cardiogenic shock it also makes the failing left vent work harder and increase O2 demand which can be detrimental to the heart) - Decreased stroke volume due to decreased myocardial contractility and increased afterload - Increased venous tone, which increases central venous (right atrial) and pulmonary capillary (left atrial) pressures - Diminished renal blood flow resulting in fluid retention - Pulmonary Edema resulting in myocardial failure and high left ventricular end-diastolic, left atrial, and pulmonary venous pressures, and from increased venous tone and fluid retention

Question 72

What is the main distinguishing S&S between hypovolemic and cardiogenic shock?

Answer 72

Increased Resp Effort (secondary to pulmonary edema) Remember that in cardiogenic shock, the decreased contractility is causing left vent pump failure, and that fluid is going to back up into the lungs as end-diastolic volume in the L and R vents rise.

Question 73

What are some way to distinguish that Cardiac Tamponade is the cause of obstructive shock?

Answer 73

The ECG will have small QRS complexes showing low voltage There may be the presence of pulsus paradoxus, a drop of more than 10mmHg on inspiration

Question 74

How do you use a manual BP cuff to assess the presence of Pulsus Pardoxus?

Answer 74

Inflate the cuff as normal, as you slowly decrease the pressure note wen you hear the initial KOROKOFF SOUNDS, which will be when the child is exhaling. Continue to deflate the cuff and note when you consistently hear the Korotkoff sounds throughout the respiratory cycle. If the difference between these 2 points is greater than 10 mmHg, the child has pulsus paradoxus

Question 75

What is a major difference noted between hypovolemic shock and obstructive shock?

Answer 75

Time of Onset! Obstructive shock from a PE, cardiac tamponade, or tension pneumo will be an ACUTE ONSET

Question 76

What is the end result of cardiac tamponade and tension pneumo if left untreated?

Answer 76

They will develop into cardiac arrest with PEA

Question 77

What are the 4 main goals in treating shock? What are the 4 main treatment plans to achieve these goals?

Answer 77

Shock Treatment Goals: - improve O2 delivery - balance tissue perfusion and metabolic demand - support organ function - prevent progression to cardiac arrest Shock Treatment Interventions: - Optimize O2 content of blood: this is done by; a) admin high flow O2 b) use invasive or noninvasive mechanical vents c) if hemoglobin is low, admin blood transfusion - Improve Volume and Distribution of Cardiac Output: a) fluid boluses/drips (for most not all) b) vasopressors - Reducing O2 Demand: a) reduce work of breathing, pain, anxiety, and fear - Correct Metabolic Derangements: a) these include hypoglycemia, hypocalcemia, hyperkalemia, metabolic acidosis (lactic acid levels), all affect heart contractility b) correct this with things like oral glucose, D50W, sodium bi carb, etc.

Question 78

Overview of fluid resuscitation guidelines

Answer 78

In general all should be given as a bolus of 20mL/Kg over 5-20 minutes: - 10-20mL/kg for septic patients over 5-10min - 20mL/kg over 5-10 minutes for ALL other forms of shock unless specified (like cardiogenic) - In cardiogenic shock when pulmonary edema is likely, reduce the bolus to 5-10mL and increase the time given to 10-20min

Question 79

REVIEW TABLE 51 ON PAGE 197 GOING OVER VASOACTIVE DRUGS AND WHAT CLASS AND EFFECT THEY HAVE (it goes over which drugs are inotropes, vasodilators, ect)

Answer 79

REVIEW TABLE 51 ON PAGE 197 GOING OVER VASOACTIVE DRUGS AND WHAT CLASS AND EFFECT THEY HAVE (it goes over which drugs are inotropes, vasodilators, ect)

Question 80

When are vasoactive drugs indicated for a shock pt?

Answer 80

When shock persists despite adequate volume resuscitation to optimize preload. Ex. If a septic pt is still hypotension after fluid boluses, they may greatly benefit from a vasoconstrictor

Question 81

REVIEW SUMMARY OF INITIAL MANAGEMENT PRINCIPALS OF SHOCK MANAGEMENT ON PG 198. (it has the general overview of what to do early and for all forms of shock)

Answer 81

REVIEW SUMMARY OF INITIAL MANAGEMENT PRINCIPALS OF SHOCK MANAGEMENT ON PG 198. (it has the general overview of what to do early and for all forms of shock)

Question 82

What is the goal of fluid therapy in shock? Which types of shock benefit the most from fluid therapy? What is the preferred fluid and why?

Answer 82

The primary objective of fluid resuscitation is to restore intravascular volume and tissue perfusion. Hypovolemic and Distributive shock benefit the MOST from fluid therapy Isotonic Crystalloid Solutions such as normal saline or lactated ringer's are preferred because they are widely available, inexpensive, and do NOT cause many sensitivity reactions. (Colloid Solutions are not widely available, may take time to prepare, may cause sensitivity reactions, and synthetic versions may cause coagulopathies.

Question 83

LOOK AT TABLE OF EXACT FLOW RATES AND VOLUMES OF FLUID RESUSCITATION FOR EACH TYPE OF SHOCK ON PAGE 201

Answer 83

LOOK AT TABLE OF EXACT FLOW RATES AND VOLUMES OF FLUID RESUSCITATION FOR EACH TYPE OF SHOCK ON PAGE 201

Question 84

What is considered hypoglycemic for pre-term and term neonates Vs infants, children, and adolescents? How should you treat it?

Answer 84

Pre-term and Term Neonates are hypoglycemic if they are below: 40 mg/dL Infants, Children, & Adolescents are hypoglycemic if they are below : 60 mg/dL If they are normal mental status and minimal symptoms then give oral glucose If they are AMS or critically symptomatic then give: - IV Glucose at a dose of 0.5-1 g/kg - D25W at 2-4mL/kg - D10W at 5-10mL/kg (All three are separate options) (Dextrose is the SAME SUBSTANCE as glucose)

Question 85

Can a pt have only 1 type of shock at a time?

Answer 85

NO A pt can have several different types of shock, for example a septic pt will start off as distributive shock but may develop into cardiogenic shock as the myocardium begins to become ischemic and as contractility fails, it becomes cardiogenic shock. But septic shock is still the MAIN source

Question 86

What is the primary therapy for hypovolemic shock?

Answer 86

Rapid Fluid Administration! Other components include: - identifying type of volume loss (hemorrhagic or not) - replacing volume deficit - preventing and replacing ongoing losses - restoring acid-base balance - correcting metabolic derangements

Question 87

How much fluid loss constitutes clinical dehydration?

Answer 87

After a pt has lost at least 5% volume, is equates to about 50mL/kg or more, the pt is clinically dehydrated. B/c of this giving the initial fluid bolus of 20mL/kg may be insufficient to completely correct dehydration. Conversely, it is not really necessary to replenish ALL lost fluids within the first hour; the total fluid deficit can be corrected over the next 24-48 hours. Basically so long as the pt receives the initial 20mL/kg fluid bolus WITHIN THE FIRST HOUR then pt outcome is much better

Question 88

Hemorrhagic VS Nonhemorrhagic Hypovolemic Shock

Answer 88

NONHEMORRHAGIC volume loss contains electrolyte containing fluids through things like diarrhea, vomiting, and osmotic diuresis; as well as protein & electrolyte containing fluids from things like burns and peritonitis.

Question 89

LOOK AT STAGES OF DEHYDRATION ON PGS 206 AND 207, IT GIVES RANGES OF FLUID LOSS ASSOCIATED TO WHAT S&Ss YOU MAY SEE

Answer 89

LOOK AT STAGES OF DEHYDRATION ON PGS 206 AND 207, IT GIVES RANGES OF FLUID LOSS ASSOCIATED TO WHAT S&Ss YOU MAY SEE

Question 90

What is the 3mL to 1mL rule?

Answer 90

It relates to HEMORRHAGIC SHOCK in that for every 1mL of blood lost from bleeding, administer 3mL of isotonic crystalloid IT MAY BE NECESSARY TO GIVE 3 BOLUSES OF 20ml/kg TO FIGHT HEMORRHAGIC SHOCK, THIS MEANS UP TO 60 ml/kg (I believe this is similar to the recommendation for septic shock as needed)

Question 91

What is Crystalloid-refractory hemorrhagic shock?

Answer 91

Hypotension that persists despite the admin of 40-60ml/kg of a crystalloid solution

Question 92

When is sodium bicarb indicated and not indicated when metabolic acidosis is present?

Answer 92

Sodium Bicarb is NOT INDICATED when the metabolic acidosis is caused by hypovolemic shock, this is because so long as fluid resuscitation is administered and improves end-organ function, then metabolic acidosis will be well tolerated as it is gradually corrected. Sodium Bicarb IS INDICATED when metabolic acidosis is caused by significant bicarbonate loss from renal or gastrointestinal losses (a non-anion gap metabolic acidosis)

Question 93

What are the 3 primary goals of the initial management of septic shock? Anaphylactic shock? Cardiogenic Shock?

Answer 93

Septic Shock Goals: - restoration of hemodynamic stability - support of organ function - identification and control of infection Anaphylactic Shock Primary Goal: - Treating life threatening cardiopulmonary problems and reversing or blocking the mediators released as part of the uncontrolled allergic response Cardiogenic Shock Primary Goal: - improve the effectiveness of cardiac function and cardiac output by increasing the efficiency of ventricular ejection.

Question 94

When dealing with a distributive shock pt, the first thing to do is to give fluid resuscitation. But what is the next step if the BP stays low despite fluids or if the diastolic pressure remains low with a wide pulse pressure?

Answer 94

Give Vasoactive agents!

Question 95

For a fluid refractory septic shock pt, which vasoactive med is preferable as a next step: epinephrine, norepinephrine, or dopamine?

Answer 95

Epinephrine and Norepinephrine are considered to be equally sufficient but both are better than dopamine. The book says that epi is preferred for ped with septic shock and cold extremities

Question 96

What may be wrong if the septic child is fluid refractory and epi/norepi resistant?

Answer 96

They probably have an Adrenal insufficiency, especially if they have a history of it (like prolonged steroid users) If this is suspected administer 1-2mg/kg of Hydrocortisone IV bolus early.

Question 97

What is a main concern in forming a treatment plan for a patient with cardiogenic shock?

Answer 97

The regular amount of fluids given in other forms of shock may WORSEN the patient. Only give small fluid boluses (5-10ml/kg) over longer periods of time 10-20min and monitor frequently!

Question 98

Specific management recommendations for the different causes of obstructive shock`

Answer 98

Ductal Dependent: - prostaglandin E1 - Expert Consultation Tension Pneumo: - Needle Decompression - Tube Thoracostomy Cardiac Tamponade: - Pericardiocentesis - 20mL/kg NS/LR bolus PE: - 20mL/kg NS/LR bolus repeat PRN - Consider thrombolytics, anticoagulants - Expert Consultation

Question 99

What are acceptable sites for IO access? What are 3 contraindications for IO access?

Answer 99

- Proximal Tibia (just below the growth plate) - Distal Tibia (just above the medial malleolus) - Distal Femur - Anterior-Superior iliac spine - New drills allows for Proximal Humerus in older children, adolescents, and adults Contraindications: - fractures or crush injury near the site - conditions with fragile bones - previous attempts to establish access in the same bone REVIEW IO ACCESS PROCEDURE ON PG 223 (main take away is for the normal spot at proximal tibia, place insertion 1-3cm or 1 finger width below the tibial tuberosity)