6. PALS Flashcards
cardiac scenarios
Vfib/pulseless Vtach
SVT/Vtach w/pulse
aystole/PEA
bradycardia
respiratory scenartios
lower airway obstruction
upper airway obstruction
lung tissue disease
disordered control of breathing
shock scenartios
hypovolemia
obstructive
septic
cardiogenic
bradycardia neonate
< 80 bpm
bradycardia infant/child
< 60 bpm
broselow tape
approximates weight and drug doses based on child length
adult defib pads are used on pts
8+ years old
defib 8+ year old
AED w/adult AED pads
defib 1-8 year old
- AED w/peds pads and dose attenuator
- man defib w/peds pads
- AED w/adult pads
defib < 1 year old
- man defib w/peds pads
- AED w/peds pads
- AED w/adult pads
croup
inflammation of larynx/vocal cords
cause of croup
virus
mild croup
barking cough
mod croup
stridor
retractions at rest
sev croup
significant agitation
decr air entry
CPR > 8 yr old
2-handed
CPR 1-8 year old
2 handed
or 1 handed
CPR infant 2+ rescuers
thumb encircling
CPR infant lone rescuer
2 finger
or
thumb. encircling
when can you consider 1 handed CPR for infant
cannot get adequate depth with other techniques
neonates cpr depth
1.5 inch
infants cpr depth
1.5 inch
kids 1+ cpr depth
2 inch
kids 1+ cpr cycles: 1 rescuer
5 cycles
30:2
kids 1+ cpr cycles 2+ rescuers
5 cycles
15:2
kids 1+ cpr cycles intubated
100-120 compressions/min
20-30 breaths per min
infants cpr cycle 1 rescuer
5 cycles
30:2
infants CPR cycle 2 rescuers
5 cycles
15:2
infants cpr intubated
100-120 compression/min
20-30 breaths/min
neonates cpr 1 rescuer: respiratory arrest
3:1 ratio
neonates cpr 1 rescuer: cardiac arrest
15:2
neonates cpr 2 rescuers: respiratory arrest
3:1
neonates cpr 2 rescuers: cardiac
15:2
neonates cpr intubated
100-120 compressions/min
20-30 breaths/min
when is cyanosis aparent
at least 5 g/dL of hb are desaturated
if you are more anemic will you be cyanotic faster or slower
slower because a higher % of Hb will need to be desaturated
if you are anemic what SpO2 must be present before cyanosis
lower SpO2
defib peds: 1st dose
2 J/kg
defib peds: 2nd dose
4 J/kg
defib peds: 3+ dose
up to 10 J/kg
cardioversion peds: 1st shock
0.5-1 J/kg
cardioversion peds: 2nd shock
2 J/kg
neonates hypoglycemia
< 45 mg/dL
infants/children hypoglycemia
< 60 mg/dL
hypoglycemia S+S
poor perfusion
hypotension
tachycardia
sweating
irritability
lethargy
glu dosing for hypoglycemia
0.5-1 g/kg
D25W glucose
250 mg/mL
how many mL of D25W = 1 g glucose
4 mL = 1 g
how many mL of D5W = 1 g glucose
20 mL = 1 g
how many mL of D50W = 1 g glucose
2 mL = 1g
neonate hTN
SBP < 60
infant hTN
SBP < 70
children hTN
SBP < 70 + (age*2)
children 10+ hTN
SBP < 90
mottling
patchy discoloration of skin caused by areas of vasoconstriction mixed with areas of vasodilation
mottling mechanism
irregular supply of oxy blood
mottling can indicate
imminent death
good peripheral perfusion (vasodilation)
- good pulse
- flushed color
- cap refil
- warm skin
- awake and alert
brisk cap refil
<= 2 seconds
flash cap refill
< 2 seconds
poor perfusion
- weak pulse
- pale/cyanotic
- delayed cap refil
- cold extremities
- decr responsiveness
- met acidosis
- incr lactate
- decr urine output
delayed cap refill
> 5 sec
petechiae and purpura
purple discolorations caused by small vessel bleeding under the skin
petechiae and purpura indicate
low plts
DIC
septic shock
“refractory” to treatment
do not improve or respond to specific therapy
“fluid refractory hypotension”
hypotension despite fluid admin
“NE refractory shock”
child in shock unresponsive to NE therapy
resp distress
incr RR
able to move air
abnormal airway sounds
pallor
tachycardia
improves with initial therapy
resp failure
labored breathing
signs of shock
- cyanosis
- bradycardia
requires intervention to prevent resp/cardiac arrest
may not respond to inital treatments
indications for bag mask ventilation or intubation
low SpO2
abnormal airway sounds
poor signs of perfusion
bradycardia
anxiety
lethargy
etcac
acryocyanosis
blue hand/feet/mouth/lips
most common cause of brady in kids
apnea
apnea
cessation of breathin for 20 seconds
febrile
> = 38C
treatment for feber
abx
hypoxemia
SpO2 <= 94% on room air
permissive hypoxemia
SpO2 < 94% that might be appropriate or normal
permissive hypoxemia example
TOF
normal cap refil
<=2 seconds
prolonged cap refil
> 5 seconds
common causes of prolonged cap refil
dehyhdration
shock
hypothermia
SVT infants
> 220 bpm
SVT children
> 180 bpm
infant O2 consumption
6-8 mL/kg/min
adult O2 consumptionj
3-4 mL/kg/min
what SpO2 on 100% fio2 indicated need for intervention
<90% on 100% FiO2
ScvO2
25-30% lower than SaO2
ScvO2 if SaO2 is normal
70-75%
urine output infants/young child
1.5-2 mL/kg/hr
adolescents
1 mL/kg/hr
quiet tachypnea
fast RR
not accompanied by signs of labored breathing or respiratory distress
cause of quiet tachypena
non-pulmonary issues
-fever
-pain
- metabolic acidosis
peds have ____ tongue
peds have ____ occiput
larger tongue
larger occiput
infant head positioning when giving breaths
neutral/sniffing
individual small airway has _______ resistance
greater resistance
TOTAL resistance in small airway
lower resistance because there are more small airways
larger airways (upper airways) are more prone to
turbulent airflow
airflow during normal resipration
laminar
lower resistance
ways airflow can become turbulent
partial airway obstruction
labored/incr resp efforts/crying
turbulence ______ airway resistance which _______ work of breathing
turbulence incr airway resistance with incr work of breathing
lower gas density = _______ % laminar flow = ______ resistance
lower gas density = higher % laminar flow =. lower resistance
laminar flow resistance to airflow
inversely proportional to airway radius^4
decr airway radius =
incr Resistance^4
turbulent flow resistance to airflow
inversely proportional to airway radius^5
respiratory muscles that LIFT ribcage
all of them
primary inspiratory muscles
diaphragm
external intercostals
accessory inspiratory muscles
muscles in neck
- sternocleidomastoid
- scalene
pecs
- pec major/minor
primary expiratory muscles
non - expiration is passive
accessory expiratory muscle
internal intercostals
abdominals
- rectus abdominis
- external oblique
- internal oblique
- transversus abdominis
chest wall in peds
compliant
chest movement during diaphragm contraction
tugged inward during deep breathing
lung hyperinflation
diaphragm flattens
= less effective ventilation
DOPE
Displacement
Obstruction
Pneumothorax
Equipment failure
Displacement
ETT in place?
Obstruction
ETT kinked?
mucus plug?
Pneumothorax
bilateral breath sounds?
when do you say DOPE
intubated pt deteriorates
percussion exam
L middle finger on body surface
tap w/R middle finger
resonant sounds
normal lung w/percussion
hyperresonant sounds
tension pneumothorax
wheezing
high pitched
expiration
wheezing cause
bronchoconstriction
Rales
intermittent popping sound
rales cause
fluid in distal airways or atelectasis
rales can suggest
cardiogenic shock
lung tissue disease
rales in hypotensive pt
cardiogenic shock
rales in febrile pt
lung tissue disease
Rhonchi
low pitched
snoring
bubbling
rhonchi causes
secretions in larger airways
stridor
high pitched
inspiration
stridor indicates
upper airway obstruction
- foreign body
- croup
- upper airway edema
grunting
low pitch
expiration
grunting means the pt is
closing glotting earlier than usual
PEEP
grunting can indicate
impending respiratory failyre
grunting is seen in
lung tissue disease
- pulm edema
- pneumonia
- ARDS
head bobbing chin lift
inspiration
head bobbing chin galls
expiration
nasal flaring
nostrils dilated during inhalation
disordered control of breathing
irregular RR
insufficient repiratory effort
disordered control of breathing can lead to
hypoxemia
hypercarbia
causes of disordered control of breathing
med overdose
seizure w/incr ICP
neuro problems
retractions
inward movement of chest wall during inspuration
cause of retrations
incr airawy resistance
substernal/subcostal retractions
mild-mod breathing difficulty
suprasternal/supraclavicular retractions
severe breathing difficulty
seesaw respiration
more severe form of retraction
chest wall inward/abdomen expands during inspiration
seesaw respiration typically indicates
upper airway obstruction
seesaw respiration can also indicate
severe lower airway obstruction
lung tissue disease
disordered control of breathing
seesaw respiration is common in children with
neuromusclar weakness
retractions + inspiratory snoring/stridor
upper airway obstruction
- croup
- foreign body
retractions + expiratory wheezing
lower airway obstruction
- asthma
- bronchiolitis
retractions + grunting/labored respirations
lung tissue dz
pulm edema f/cardiogenic shock
abnormal inspiratory sounds indicate
upper airway obstruction
abnormal expiratory sounds indicate
lower airway obstruction
when is suctioning contraindicated?
croup
(infection induced edema)
croup treatment
racemic epi nebulizer
lung tissue dz
lungs become stiff due to fluid accumulation in alveoli
common conditions of lung tissue dz
pneumonia
pulm edema
ARDS
lung tissue dz S+S
grunting
rales
fever
ALL airway scenarios contain
hypoxemia
poor chest rise/air movement
breathing w/accessory muscles
early tachycardia
late bradycardia
signs of labored breathing/respiratory distress is found in which scenarios?
upper airway
lower airway
lung tissue
signs of upper airway
stridor
inspiratory snoring
hoarseness
barking cough
drooling
gurgling
signs of lower airway
expiratory wheezing
signs of lung tissue dz
grunting
crackles/rales
fever
signs of disordered control of breathing
normal/shallow breath sounds
abnormal resp pattern
possible central apnea
how to distinguish between airway and cardiac or shock scenarios
airway scenarios will not have hypotension
how to distinguish between airway and bradycardia scenario
airway will have abnormal breath sounds
bradycardia will have normal breath sounds
treatment for ALL airway scenarios
supp O2 if SpO2 < 94%
assist airway/consider intubation
suction secretions
monitor EKG
treat bradycardia (if present)
treatment for upper airway obstruction
heliox
humidified O2
racemic epi
steroids
treatment for lower airway
albuterol
bronchodilators
consider labs/CXR
consider diuretics (pulm edema)
bronchodilators
iaprotropium
magnesium
terbutaline
treatment for lung tissue dz
albuterol
bronchodilators
consider labs/CXR
consider diuretics (pulm edema)
Abx (if febrile)
treatment for disordered control of breathing
reversal agents
(unless seizure meds)
can you use racemic epi for lower airway obstructions?
yes for bronchospasm if all other breathing treatments fail
heliox density
lower than O2
heliox probability of laminar flow
higher probablility of laminar flow due to lower density generating less airway resistance
most common use for heliox in pals
croup
humidified O2 advantages
decr chance of coughing
loosen mucus
humidified O2 is used in
mod-sev croup
asthma
racemic epi effects
airway vasoconstriction
dec vascular permeability
decr swelling/edem
racemic epi causes
bronchodilation
is mg a first or second line bronchodilator
2nd line
used when pts fail to respond to conventional bronchodilator therapy
mg SE
hypotension
treatment for disordered breathing caused by incr ICP
mannitol
hypertonic (3%) saline
iapotropium class
anticholinergic
bronchodilator
can you mix iapotropium and albuterol?
yes
narcan
reverses respiratory depression from narcotic overdose
narcan SE
incr HR
incr BP
acute pulm edema
cardiac arrhythmias
seizures
how can you lower narcan SE risk
IM injection may slow drug onset
PEEP
6-10 cmH2O
excessive PEEP SE
decr venous return
decr CO
decr O2 delivery
uncuffed ETT
(age/4) +4
cuffed ETT
(age/4)+3
ETT insertion depth (<2 years old)
ID*3
ETT insertion depth (>2 years old)
(age/2) + 12
which tubes are recommended
cuffed
ETT cuff inflation pressure
< 20-25 cmH2O
ETT dosing
2-3x IV dose
ETT dosing for Epi
10x IV dose
rapid crystalloid bolus
20 mL/kg over 5-20 mins
(10 mins if severe/hypotensive)
rapid bolus indication
hypotensive
hypovolemic
obstructive
distreibutive
smaller/slower bolus
5-10 mL/kg over 10-20 mins
smaller/slower bolus indications
cardiogenic shock
heart failure
BB/CCB overdose
pulm edema
DKA
how long should you continue fluid boluses
until conditions improve or signs of respiratory distress develop
when are colloids considered?
hypovolemia/hypotension after 3 crystalloid boluses
risk of higher colloid doses
coagulopathies
which is better crystalloid or colloid
volume is key
but maybe slight advantage to crystalloid
first line treatment for poor pefusion/hypotension
fluid bolus
what should you do before giving fluids
check breath sounds in lower lobes
what if you hear rales before giving fluids?
hold fluids
or
admin slowly
are fluids good for febrile pts?
febrile pts do better with less fluids because febrile pts are vasodilated
are fluids good for septic pts?
yes - aggressively hydrate w/10-20 mL/kg boluses
frequently assess pt for respiratory distress
hypotenive
hypovolemic
obstructive
distributive
20 mL/kg bolus
over 5-20 mins
cardiogenic shock
5-10 mL/kg
over 10-20 mins
CCB/BB overdose
5-10 mL/kg
over 10-20 mins
DKA w/compensated shock
10-20 mL/kg
over 1-2 hrs
febrile illness (no shock)
restrict fluids
septic shock
10-20 mL/kg
over 5-20 mins
reassess after each bolus
stop if respiratory disress
blood products recommended if Hb
Hb < 7 g/dL
goal of transfusion
Hb > 10 g/dL
pals recommends giving blood to `
hypotensive kids who are bleeding after 2-3 fluid boluses of 20 ml/kg
initial dose of PRBCs
10 ml/kg
when do you naturally develop anti-blood antibodies?
6 months
do you need to be exposed to antigen to develop ABO antibody?
no - it happens naturally
do you need to be exposed to antigen to develop RH antibody?
yes
Type A antigen
A
Type A antibody
anti-B
Type B antigen
B
Type B antibody
anti-A
Type AB antigen
A
B
Type AB antibody
none
Type O antigen
none
Type O antibody
anti-A
anti-B
universal donor
Type O-
universal receiver
Type AB+
5 main Rh antigemsd
C
c
D
E
e
RhD
+ blood type
will type A blood have a tranfusion reaction to type B blood on first exposure?
yes - anti-B antibodies are already present
will Rh- pts have a transfusion reaction ot Rh+ blood on first exposure
no - it will only happen on second exposure
emergently, males can receive
O+
O-
ermergently, females can receive
O-
estimated water weight in kids (PALS)
100% of total body weight
estimated water weight in kids (reality)
70-80%
1% volume loss =
10 mL/kg water loss
what % of total fluid volume in human body is blood?
10%
losing all of your blood results in
10% estimated weight loss
100 mL/kg volume depletion
do older or younger children tolerate volume loss better?
younger children bc they have a higher % of body weight as water (more volume to lose)
mild dehydration: adolescent
3%
30 mL/kg
mod dehydration: adolescent
5-6%
50-60 mL/kg
sev dehydration: adolescent
7-9%
70-90 mL/kg
mild dehydration: infant
5%
50 mL/kg
mod dehydration: infant
10%
100 mL/kg
sev dehydration: infant
15%
150 mL/kg
clinically significant dehydration
5% volume depletion
5% EWL
50 mL/kg fluid deficit
hypovolemic/hypotensive shock volume loss
10% volume depletion
10% EWL
100 mL/kg fluid deficit
first step in PALS
check appearance and responsiveness
check appearance
appearance
work of breathing
circulation (color)
PALS initial assessment
check appearance
treat conscious pt
monitors
perfusion
IV
O2
auscultate
(primary assessment)
unconscious pt
Responsiveness
Activate EMS/AED
Circ/breathing/CPR
Defib
fever w/abnormal lungs
lung tissue disease
treat w/:
support airway
abx
fever w/normal lungs
sepsis
treat w/:
abx
fluids
pressors
hypotension w/abnormal lungs
cardiogenic shock
treat w:
inotropes
small fluid boluses
hypotension w/normal lungs
hypovolemic shock
treat w/rapid fluid boluses
secondary assessment
SAMPLE
+/- H/Ts
SAMPLE
Signs/Symptoms
Allergies
Meds
Past med history
Last meal
Events
which pts is SAMPLE used for?
ALL of them
which pts is H&Ts used for?
unstable pts
H & Ts
hypovolemia
hypoxia
hypothermia
hypoglycemia
hypokalemia
hyperkalemia
H+ acidosis
Tamponade
Thrombosis
Tension pneumo
Trauma
Toxins
labs/diagnostic tests
CXR
ABD
U/S
EII cycle
evaluate
identify
intervene
continuous - constant reevaluation after every intervention
causes of Low CO
hypovolema
bradycardia
decr contractility
General symptoms of low CO
hypotension
poor perfusion
cold shock
narrow PP
oliguria
cold shock
vasoconstriction
weak pulse
narrow pulse pressure
low SBP (low stroke volume)
high DBP (vasoconstriction)
symptoms of Low CO w/decr contractility
pulm edema
rales/grunting
jugular venous distension
symptoms of low afterload
high CO (high SV)
warm shock (good pulse)
wide PP
decr preload
brisk cap refill
flushed skin
delayed cap refill if hTN
angioedema
wide pulse pressure
low DBP from vasodilation
most common cause of vasoconstriction in PALS
decr CO in hypovolemic or cardiogenic shock
symptoms of high afterload (Vasoconstriction)
cold shock
weak pulses
delayed cap refill
pale skin
