PICU/ER

Question 1

What type of shock do you suspect if there is evidence of low systemic vascular resistance (SVR) and maldistribution of blood flow (i.e. vasodilation and warm skin)?

Answer 1

Distributive shock

Question 2

Name three commonly cited examples of distributive shock?

Answer 2

1. Sepsis
2. Anaphylaxis (causing loss of vasomotor tone)
3. Neurogenic/ spinal cord injury (causing loss of vasomotor tone)

Question 3

When do you suspect cardiogenic shock?

Answer 3

Suspect cardiogenic shock when there are signs of poor perfusion and pulmonary or systemic venous congestion (i.e. increased WOB, grunting respirations, distended neck veins, hepatomegaly)

Question 4

What vasopressors do you want to use when you have a patient who is in hypotensive vasodilated (WARM) shock?

Answer 4

Norepinephrine

[OR high dose dopamine (10-15) OR high dose epinephrine (0.1-0.3)]

Question 5

What vasopressors do you want to use when you have a patient in hypotension vasoconstricted (COLD) shock?

Answer 5

Low dose Epinephrine (0.01 - 0.1)

[low dose dopamine (5-10) could also work]

Question 6

What vasopressor is the agent of choice for a child with fluid-refractory septic shock who presents with impaired perfusion but adequate blood pressure

Answer 6

Dopamine

Question 7

What does dopamine do at low, intermediate, and high doses?

Answer 7

Low dose = improves splanchnic and renal blood flow
Intermediate dose = improves cardiac contractility
High dose = SVR is increased

Question 8

Name 4 examples of obstructive shock

Answer 8

1. Ductal-dependent (LV outflow tract obstruction)
2. Tension pneumothorax
3. Cardiac tamponade
4. Pulmonary embolism

Question 9

What should your CPR rate be? (# of chest compressions per minute)

Answer 9

At least 100 per minute

Question 10

What should the depth of your chest compressions be?

Answer 10

At least 1/3 of the AP diameter (2 inches in children, 1.5 inches in infants)

Question 11

When should you rotate compressors during CPR?

Answer 11

Rotate compressors every 2 minutes

Question 12

How long should pauses be during CPR?

Answer 12

Minimize and attempt to limit pauses to less than 10 seconds

Question 13

What is the ratio of chest compressions and breaths for CPR?

Answer 13

For children and infants, you provide 30 compressions: 2 breaths for single rescuer and 15 compressions: 2 breaths for more rescuers

Question 14

With an advanced airway, how often do you give breaths during CPR?

Answer 14

1 breath every 6-8 seconds

Breaths should last for 1 second, and look for chest rise

Question 15

When should you start thinking of the possible need for vasopressors or stress-dose hydrocortisone?

Answer 15

They should be immediately available if the shock is fluid refractory or adrenal insufficiency is suspected

Question 16

What is the role of vasopressin in the sepsis PALS algorithm?

Answer 16

Vasopressin infusion may be useful in the setting of norepinephrine-refractory shock. Vasopressin antagonizes the mechanisms of sepsis-mediated vasodilation. It acts synergistically with endogenous and exogenous catecholamines in stabilizing BP but it has no effect on cardiac contractility

Question 17

If you are managing a child under the sepsis algorithm and you are considering that the child is adrenally insufficient (fluid-refractory and dopamine- or norepinephrine- dependent shock), how will you manage?

Answer 17

1. Draw baseline cortisol

2. Give IV hydrocortisone 2 mg/kg bolus (max: 100 mg)

Question 18

What is the mainstay/ first-line treatment for anaphylaxis?

Answer 18

IM Epinephrine (1:1000)
0.01 mg/kg

Question 19

What are other (less important) treatments in the management of anaphylaxis?

Answer 19

1. Antihistamine (H1 blocker like Benadryl or H2 blocker like Ranitidine or Famotidine)
2. Corticosteroids (Prednisone or Methylpred)
3. Salbutamol (Ventolin)
4. Trendelenburg position

Question 20

Why is milrinone often the preferred drug of choice when dealing with children with cariogenic shock?

Answer 20

Milrinone (a phosphodiesterase enzyme inhibitor) will improve contractility (increase cardiac output) and will reduce peripheral vascular resistance (decrease afterload)

Question 21

What mL/kg fluid boluses should be administered in a child you are wondering may be in cardiogenic shock?

Answer 21

5 to 10 mL/kg NS bolus over 10-20 minutes, repeat PRN

Question 22

What is the specific management for a tension pneumothorax?

Answer 22

Needle decompression followed by tube thoracostomy

Question 23

What is the pathophysiology of a duct-dependent lesion?

Answer 23

Ductal-dependent pulmonary blood flow:

1. Severe obstruction to pulmonary blood flow form the R ventricle, so all the pulmonary blood flow comes from the aorta through the PDA
2. When ductus closes, the infant becomes profoundly cyanotic and hypoxemic

Ductal-dependent systemic blood flow:

1. Obstruction to the outflow through or from the left side of the heart into the aorta
2. Systemic blood flow comes from the R ventricle and pulmonary artery into the aorta
3. When ductus closes, the child has poor systemic perfusion + shocky

Question 24

What is the mainstay treatment for a child in obstructive shock due to a ductal-dependent lesion?

Answer 24

Continuous infusion of prostaglandin E1 (PGE1)

Question 25

What sites should be used for an IO?

Answer 25

Proximal tibia - Identify the tibial tuberosity, the site should be 1-3 cm below and medial to the bony prominence Other sites: distal tibia just above the medial malleolus, distal femur, ASIS

Question 26

What are 4 contraindications to an IO insertion?

Answer 26

1. Fractures or crush injuries near the access site 2. Conditions with fragile bones (i.e. osteogenesis imperfect) 3. Previous attempts to establish access in the same bone 4. Infection is present in the overlying tissues

Question 27

Symptomatic bradycardia in children is usually the result of what?

Answer 27

Progressive hypoxemia and respiratory failure

Question 28

What are signs of cardiopulmonary compromise?

Answer 28

Hypotension Acutely altered mental status Signs of shock

Question 29

What does first degree AV block mean?

Answer 29

A prolonged PR interval representing slowed conduction through the AV node

Question 30

What does second degree Mobitz Type 1 block mean?

Answer 30

Mobitz Type 1 AV block (Wenckebach) occurs at the AV node, progressive prolongation of the PR interval until an atrial impulse is not conducted to the ventricles. The P wave corresponding to that atrial impulse is not followed by a QRS complex. The cycle repeats.

Question 31

What does a second degree Mobitz Type 2 block mean?

Answer 31

Mobitz Type 2 AV block occurs below the level of the AV node. It is characterized by non conduction of some atrial impulses to the ventricle without any change in the PR interval of the conducted impulses.

Question 32

What are the two AV blocks that can be present in healthy children?

Answer 32

First degree AV block and second degree Mobitz Type 1 AV block (Wenckebach phenomenon)

Question 33

What is the epinephrine dose we use in the PALS bradycardia algorithm?

Answer 33

Epinephrine IV/IO 0.1 mL/kg of the 1:10,000 | Repeat every 3-5 minutes as needed

Question 34

In which situations would you want to give atropine over epinephrine in the PALS bradycardia algorithm?

Answer 34

Increased vagal tone, cholinergic drug toxicity (e.g. organophosphates), complete AV block, symptomatic AV block

Question 35

In which situations should you consider cardiac pacing in the PALS bradycardia algorithm?

Answer 35

Selected cases of bradycardia caused by complete heart block or abnormal sinus node function

Question 36

What are the two most common potentially reversible causes of bradycardia?

Answer 36

Hypoxia and increased vagal tone

Question 37

Name three narrow complex (QRS complex less than 0.09 seconds) tachyarrhythmias?

Answer 37

Sinus tachycardia Supra ventricular tachycardia (SVT) Atrial flutter

Question 38

Name two wide complex (QRS complex more than 0.09 seconds)

Answer 38

``` Ventricular tachycardia (VT) Supraventricular tachycardia (SVT) with aberrant intraventricular conduction ```

Question 39

Typically how quick is the heart rate in a child or infant in probable SVT?

Answer 39

Infants: heart rate is usually greater or equal to 220 Children: heart rate is usually greater or equal to 180

Question 40

What conditions and agents predispose a patient to torsades de pointes?

Answer 40

Long QT syndromes (often congenital or inherited) Hypomagnesemia Hypokalemia Antiarrhythmic drug toxicity Other drug toxicities (TCA, CCB, phenothiazines)

Question 41

What PALS algorithm do you initiate in a child who is tachycardic and who does not have a pulse?

Answer 41

Paediatric Cardiac Arrest Algorithm

Question 42

How do you manage a probable SVT in the paediatric patient with a pulse but poor perfusion?

Answer 42

Give adenosine 0.1 mg/kg rapid bolus (slam) along with the use of a saline flush If adenosine not effective, synchronized cardioversion Can consider vagal maneuvers if child is stable or while preparations are being made for synchronized cardioversion

Question 43

What kind of cardioversion do you use in the paediatric tachycardia with a pulse and poor perfusion algorithm? What dose do you use?

Answer 43

Synchronized cardioversion 0.5-1 Joule/kg; if not effective increase to 2 Joules/kg

Question 44

How do you treat possible ventricular tachycardia with a pulse and poor perfusion?

Answer 44

Synchronized cardioversion 0.5-1 Joule/kg; if not effective increase to 2 Joules/kg

Question 45

Name the 6 Hs (causes of cardiac arrest that are reversible)

Answer 45

1. Hypoxia 2. Hypovolemia 3. Hypothermia 4. Hypo/hyperkalemia 5. Hypoglycemia 6. Hydrogen Ion (acidosis)

Question 46

Name the 5 Ts (causes of cardiac arrest that are reversible)

Answer 46

1. Tension pneumothorax 2. Cardiac tamponade 3. Toxins 4. Pulmonary thrombosis 5. Coronary thrombosis

Question 47

What does pulseless electrical activity mean?

Answer 47

Term describing any organized electrical activity (not VF, VT, or systole) on an ECG or cardiac monitor that is associated with no palpable pulse

Question 48

Should ventilation bags used for CPR have or have not a pop up valve?

Answer 48

If the child's lung compliance is poor, airway resistance is high, or CPR is needed, the automatic pop-off valve may prevent delivery of sufficient tidal volume resulting in inadequate ventilation and chest expansion. Ventilation bags used in CPR should not have a pop-off valve or the valve should be twisted in the closed position

Question 49

What are your anatomic landmarks for a needle decompression?

Answer 49

2nd intercostal space, mid-clavicular line

Question 50

What does SAMPLE history stand for?

Answer 50

``` Signs/symptoms Allergies Meds PMHx Last Meal Events leading up to present illness/injury ```

Question 51

During a resuscitation, what should you always ask for along with the vitals?

Answer 51

Temperature | POCT glucose reading

Question 52

What is the endotracheal tube size formula for children?

Answer 52

ETT size (uncuffed) = age/4 +4

Question 53

Name three examples of disordered control of breathing?

Answer 53

Increased ICP Poisoning/ Overdose Neuromuscular disease

Question 54

Name 3 upper airway obstruction emergencies

Answer 54

Croup Anaphylaxis Aspirated FB

Question 55

Name 2 lower airway obstruction emergencies

Answer 55

Bronchiolitis | Asthma

Question 56

Name 2 lung tissue disease emergencies

Answer 56

Pneumonia | Pulmonary edema

Question 57

What are the parameters that indicate response to shock therapy?

Answer 57

``` Heart rate BP Distal pulses and capillary refill Urine output Mental status ```

Question 58

What does DOPE stand for? | Used in the context of an intubated patient who deteriorates

Answer 58

Displacement Obstruction Pneumothorax Equipment Failure

Question 59

What does compensated shock mean?

Answer 59

Systolic BP is within the normal range but there are signs of inadequate tissue perfusion

Question 60

What is a key sign of hypotensive shock?

Answer 60

A key clinical sign of deterioration is a change in level of consciousness as brain perfusion declines

Question 61

Name 4 secondary causes of bradycardia

Answer 61

1. Hypoxia 2. Acidosis 3. Hypothermia 4. Drugs

Question 62

Without a definitive airway, what is the rate that you should be bagging a patient with bag-mask ventilation?

Answer 62

1 breath every 3-5 seconds

Question 63

What is the consensus definition of hypoglycemia in a 1) neonate and 2) infant, children, and adolescents

Answer 63

Neonates

Question 64

When is bicarb indicated?

Answer 64

Metabolic acidosis that is caused by significant bicarb losses from a renal or GI source (non-anion gap metabolic acidosis)