Emergency Flashcards
Recognition of Respiratory dirstress
Appearance: the single most important factor
Appearance
Alertness Color or circulation Eye contact Speech or cry Motor activity (limp/flaccid) Distractibility Consolable Work of breathing RR increased or decreased Tachycardia Restlessness Agitation Altered/Lowered LOC
Types of artificial airway
ET tube
LMA (laryngeo-Mask Airway)
24 gauge color
Yellow
22 gauge color
Blue
20 gauge color
Pink
18 gauge color
Green
16 gauge color
Grey
IO use
Fluids
Blood draws
Meds
Not long term use (goal is to remove 3-4 hr , can be left in place for 76-92hr)
IVF reminders
Provide volume replacement
Administer/replace electrolytes
Treat/prevent dehydration
Maintain homeostasis
O2 delivery systems
Blow by
Nasal cannula
Mask
Most common dysrhythmias in Pedi
Bradycardia
Asystole
Pulseless electrical activity (PEA)
Transplant organs
Heart Kidneys Lungs Liver Pancreas Intestines
Transplant tissues
Skin Bones Heart Valves Veins Corneas
Indication of Oxygen
Can administer more than 2L in an emergency
Acute or emergency situations
Child respiratory distress: dyspnea, tachypnea, apnea, pallor, cyanosis, use of accessory muscles and nasal flaring
Target % of O2 saturation
95-97%: children and adults
91-95%: neonates
>60%: cyanotic heart disease
Abnormal O2 saturations
85-90% indicates moderate to severe hypoxia
Below 85% indicates severe to life threatening hypoxemia
Position them first to see if that helps then suction, then tweak oxygen and maybe give them less
When not to do CPR
DNAR order
Signs of irreversible death (rigor mortis, decapitation, dependent lividity)
No physiological benefit can be expected because the vital functions have deteriorated despite maximal therapy for such conditions, such as progressive septic or cardiogenic shock
Withhold attempts to resuscitate in the delivery room is appropriate for newly born infants with confirmed gestation < 23 wk or birth weight <400g (Anencephaly or confirmed trisomy 13 or 1)
When to stop CPR
Normal pulse established
Normal respiratory rate established
Obvious signs of death are apparent
Asystole persist for >20 minutes in the absence of a reversible cause
Termination of Resuscitation: Neonate: Termination
Occurs with parental agreement: Withhold resuscitation for conditions associated with high mortality and poor outcome: gestation, BW, congenital abnormalities, uncertain prognosis with borderline survival and high morbidity rate, pulse is high, chromosomal or anatomical defects is unlikely to result in survival or survival without extreme disability
Termination of Resuscitation: Neonate: Discontinue resuscitation
Infants with no signs of life after 10 minutes of continuous and adequate resuscitative efforts (per MD order)
Termination of Resuscitation: Child
Guidelines for resuscitation termination for children are unreliable
Depends on situation, diagnosis and parental wishes
Children can survive prolonged efforts if: the collapse was witnessed, bystander performed immediate CPR, Early professional treatment ar initiated
Organ donation
Individual donor can save up to 8 lives through organ donation and tissue donation
Skin is used to treat burn patients and individuals with cancer, bone can be used to treat orthopedic injuries and cancer patients
Post resuscitation Care: Gift of life
will come in with orders of what meds to keep them on and will keep the organs perfused and oxygenated until transplant
Post resuscitation Care: Maintain
Normal ventilation
Temperature
Glucose
Post resuscitation Care: Manage post-ischemic myocardial dysfunction
Medication: Dopamine, Dobutamine, Epinephrine
Monitor labs
Post resuscitation Care: Treat post-arrest cardiogenic shock and septic shock aggressively
Fluids
Inotropes
Pressors
Disaster plan: Personal plan
Where will you go What is your route Who will pick up the children/pets Where is meeting place Emergency travel kit? Have extra supplies of medication
Disaster plan: Professional plan
Know your facilities policy and procedure for emergency/disaster situations Protocols Escape routes Form of communication, CoC? Patient evacuation procedures?
Disaster plan: Community plan
Map of city?
Escape routes?
Shelter in place sites?
Neighbors in need? Elderly? Those with physical and mental disabilities
Nurse responsibility in a disaster
Be professionally and personally prepared
Know that you will be called upon and make arrangements with family for absence
Be aware of ethical issues you may encounter when you face patient care decisions
Protect the patient, get them transported to a safer area, crowd control, and triage
Weapons of mass destruction
Chemical Radiological Biological Nuclear Explosive or Enhanced conventional weapons
Disaster preparedness: Know what pt was exposed to
So we can triage
Is it contagious
Precautions?
Disaster preparedness: Better natural resistance to aerosolized biologic or chemical agents
Adults
Children and babies are very vulnerable due to curiosity, small, and have sensitive skin that needs extra protection
Children also breath faster
Disaster preparedness: Who requires more resources
Children
Disaster preparedness: Why are drug formulation availability limited for pedi?
No FDA approval
Limited testing done on infants and children since it requires the parents approval, they are often reluctant to have child on unknown drugs
Disaster preparedness: Are children desirable targets t terrorist attacks?
Yes
School especially because they know that children are our most precious asset and such an attack would psychologically cripple the population
Schools are defenseless and unprepared
Tend to gather in large groups
Have natural curiosity and seek out objects of interest
They evoke extreme emotional reaction by rescuers and the public
Appearance: Color or Circulation
Should be pink, means good perfusion
Pale or white is a sign of lack of O2, poor perfusion form vasoconstriction because the blood is being shunted to the vital organs away from the extremities. Hands and feet are cold. Next -Blue
Blue is cyanosis- meaning that all compensatory mechanisms have failed
Appearance: Eye contact
Are they looking at you?
Are they looking past you?
Glass eyed?
Appearance: Speech or cry
If you’re doing something and they don’t respond, its very concerning
Normal: high pitched, weak, are they crying?
Consolable, Inconsolable?
Appearance: Motor activity
Flaccid or limp?
Appearance: Increased or decreased RR
Pulse is <60/min, and there are signs of poor perfusion (pallor, mottling of the skin, cyanosis) despite supplemental O2 then start compressions
Cause of Pulmonary/Cardiac arrest
Respiratory Infection CV Traumatic CNS disease
Cause of Pulmonary/Cardiac arrest: Respiratory
BPD, Croup, Pneumonia, Apnea, Asthma, Submersion, Aspiration, Epiglottis, Smoke inhalation, Suffocation, Anaphylaxis
Cause of Pulmonary/Cardiac arrest: Infection
Meningitis, Septic shock
Cause of Pulmonary/Cardiac arrest: CV
Congestive heart disease, arrhythmia, myocarditis, pericarditis, hypovolemic shock
Cause of Pulmonary/Cardiac arrest: Traumatic
MVA, fall
Cause of Pulmonary/Cardiac arrest: CNS disease
Hemorrhage, cerebral edema, shaken baby syndrome, hydrocephalus with shunt malfunction, seizure, tumors
Respiratory distress
Can still help them!!! Airway open and maintainable Tachypnea Increased respiratory efforts Grunting Retractions- substernal/intercostal Nasal flaring Abnormal airway sound (wheezing, stridor) Tachycardia Pale to cool skin Change in mental status (anxiety, agitation)/ GCS (manage immediately!! Child will rapidly progress into respiratory failure, shock, and arrest)
Respiratory Failure
Trying to prevent!! Airway not maintainable (NC or facemask will not help, NEED ET) Bradypnea Apnea Decreased or no respiratory effort Poor to absent distal air movement Bradycardia Cyanotic Stupor Coma Flaccid muscle tone Unresponsive
What is Cardiac arrest
Abrupt cessation of normal circulation of the blood due to failure of the heart to contract effectively during systole- cardiovascular collapse is impending shock
Cessation of clinically detectable cardiac mechanical activity
Cardiac Arrest: Characterized by
Unresponsiveness, apnea, absence of detectable central pulses
What to obtain when a child experiences cardio-pulmonary arrest
Age Recent illnesses Previous medical problems Current meds Recent trauma Time of day of incident Location of child during incident Access to toxins/medicines/poisons Access to potential foreign bodies Length of downtime- affect recovery Was CPR initiated and for how long? Overall appearance ABC Vital signs SpO2 LOC/GCS Tracheal deviation Subcutaneous air/crepitus Pupillary response Evidence of trauma Surgical scars
Evidence of prolonged time since death
Rigor mortis
Dependent lividity
Corneal clouding
Effective CPR prolongs:
Presence of Vfib and improve chances that a shock will terminate this lethal rhythm
Need electrical activity to shock the heart
Compressions
30-2 and 100 compressions a minute
Reserved O2
Many patients have left over O2 in their blood and lungs from their last breath so we can take advantage of that and do compressions until help arrives
Where to palpate pulse on: Infant <1 yr
brachial artery
Where to palpate pulse on: Infant >1 yr-adolescent
Carotid artery
Children HR <60
Start compressions
Children Respiratory rate <10/gasping/apneic
Bag mask ventilation (rescue breaths)
What to do first with unresponsive child
Assess unresponsiveness (gently stimulating them)
Check breathing
Quick check for pulse
Call for help (code button, call out for code cart)
Position for CPR (hard flat surface, backboard, CPR lever)
No pulse, poor perfusion (HR<60 start compressions)
Rescue breaths (gasping isnt enough air for perfusion, slow breathing arent enough for perfusion)
Witnessed arrest vs. didnt witness arrest
Witnessed: call for help then begin compressions
Didnt witness: initiate compressions and continue with rescue breaths for 5 cycles (2 minutes) then call for help
Neonatal arrest
Predominantly axial in nature, so the ABC resuscitation sequence with 3:1 ratio of compressions to ventilations has been maintained, except when etiology is clearly cardiac
Circulation: Compression to ventilation ratio for Infants and children: Single rescuer
30:2
Circulation: Compression to ventilation ratio for Infants and children: 2 HCP rescuers
15:2
Compressions on an infant <1yr
Use 2 thumbs-hands encircling the chest technique, midtesternal or 2 fingers midsternal just below the nipple line
Compress the chest about 1.5 in
(alone: use 2 thumbs, with help: use 2 fingers)
Compressions on a child 1-8yr
Use the heel of one hand to compress the lowe 1/2 of the sternum
Compress about 2 inches
Compressions on >8yr
Use adult method, 2 hands at a depth of 2 inches
Compression techniques
Arms straight, bent over give good force
Ribs break… we want them to breath and live
Effective compression (hard and fast)
Rate: 100/min
Depth: 1.5-2 inches
Always allow for complete recoil of the chest
Compressions must not be interrupted except for ventilation
Re-evaluate after 5 cycles or 2 minutes
Know that the rhythm on the stip will not be accurate
Airway
Maintain patent airway
Use head-tilt chin lift (if no cervical spine injury suspected)
Use jaw thrust (if possible cervical spine injury)
Open mouth, visually inspect and suction
Vomitus or foreign material may obstruct the airway (clear it out)
Nasopharyngeal or Oropharyngeal airway is used/placed
Position to help visualization, and ventilatilation
Sniffing position
Airway: Most common cause of upper airway obstruction
tongue
Sniffing Position
Theres a towel under patients neck to get better visualization of airway, and nose is angles up like their sniffing
For older children, can use a towel behind the neck to extend it for a good head tilt chin lift
Breathing
Start rescue breathing if patient has a palpable pulse of >60, and theres inadequate breathing of <10 breaths/min, and continue until spontaneous breathing returns
Is HR is at <60 then do compressions in addition of rescue breaths
Reassess every 2 minutes
Breathing: Rescue breathing: lone provider
30:2
Just breathing: rate of 12-20 breaths/min (1 breath every 3-5 seconds)
Breathing: Rescue breathing: 2 rescuers
15:2
Just breathing: rate of 10-12 breaths/min (1 breath every 3-10 seconds)
If patient isn’t able to maintain airway
Place an artificial airway
ET tube
Preferred because it allows greatest control of airway
Directly inserted into trachea all the way done to the carina of the bronchi
Can suction fluids and secretions through them
Can prevent aspirations
LMA
Inserted directly into pharynx, and does not go as far down as ET tube
Mostly used when patient is trapped in a sitting position
Also when there’s suspected trauma to cervical spine or head tilt chin lift isn’t possible
Also when intubation with an ET tube is unsuccessful
Easier to insert causing less pain than ET tube
Cannot suction
Do not prevent aspiration
Physician needs for intubation (blades)
L-shaped blade -Miller
Curved blade -MaCintosh
RN responsibility to ask the provider what size ET they want, or RN see what size they needed based on: swelling, age, weight,.
Also give stylet to be place in ET tube before insertion
Also ask what size blade and endoscope they want
Artificial airway established
Once placed, continue compressions and no longer need to cycle to ventilate
Rescue breaths are provided 1 breath every 6-8 seconds (about 8-10 breaths/min)
ABGs are drawn (how we know what to set the ventilator to)
Excessive ventilation should be avoided
NGT placed to decompress the stomach, preventing aspitations, and get air out of tummy
Document size, depth of ET tube and that it is secured
IV sites
Scalp
Heel
Antecubital
Last resort: IO (after 2 unsuccessful attempts)
Causes of difficulty getting IV in children
Shock, hypothermia, vasoconstriction
IO placement
Only in emergency situations when IV access is not available or feasible
Can be done on any age except preterm neonates
Placed in the proximal medial aspect of the tibia
Ultimately central circulation
Marrow functions as a non-collapsible venous access route, whereas peripheral veins do collapse due to vasoconstriction
Need to push hard to get fluids in
IO complications
Extraversion of fluids when needle is misplaced Compartment syndrome Infection Pain Fracture
Most commonly used IVF pedi
0.9%: Normal saline (20mL/kg bolus) Lactated ringers: LR 5% dextrose in water: D5W 5% dextrose and 0.9% NS: D5NS 5% dextrose and 0.45% NS: D5 half NS Any K added to their IVF will be indicated in RED!!
IVF rate
100mL for first 10kg
50mL for next 10kg
20mL for any remaining kg
Drug therapy: Cardiac arrest
Next to last line of treatment
Majority of pediatric resuscitations will not require a lot of drugs
Pediatric drug doses are based on weight
Some medications in the crash cart will tell you the dosages
IV medications administration
ALWAYS look at the concentration
Triple check calculations
When pulling up medication: show to another person and say what and how much, then pass it to whos delivering it, they will say what and how much given now. The person documenting will document what and how much given at ___ time.
Code drugs
Epinephrine Atropine Amiodarone & Lidocaine Dextrose Sodium bicarbonate Naloxone Adenosine Dopamine Dobutamine
Code drugs that can be given through ET tube
"LEAN" Lidocaine Epinephrine Atropine Naloxone
Epinephrine
Increased HR, contractility, and BP
Atropine
Increased HR
Amiodarone & Lidocaine
Converts V.fib, pulseless Vtach or Vtach with pulse
Some atrial tachyarrhythmias
Dextrose
Reverse hypoglycemia
Sodium bicarbonate
Reverse metabolic acidosis
Naloxone
Reverse opiate narcotic depression
Adenosine
Converts paroxysmal SVT, push hard and fast, momentarily stops the heart
Dopamine
Improves BP
Dobutamine
Increases contractility of heart
Blow by O2
Keep their head midline
May be either a narrow O2 catheter with small perforations through with O2 can flow or corrugated tubing
Blow by used when
The child will not tolerate other means of O2 therapy, Low O2 concentrations with humidification are needed, if they are vomiting, or have facial injuries
Concentration of O2 delivery varies according to the flow rate and proximity to the face
Can be used for young infants
Nasal cannula
Low flow
High flow
Can be use to deliver low concentrations of O2
Flow rate set higher than 6L will irritate the nasopharynx without improving the child’s oxygenations
Correct placement of nasal prongs
NC Liters/ Min percentages
1L/min: 24% 2L/min: 28% 3L/min: 32% 4L/min: 36% 5L/min: 40% 6L/min: 44%
O2 Facemask
Agitated and refused facemask: mom can hold baby and facemask near face
Bag has to be full
Size of the mask is important when administering O2
-Mask should extend from the bridge of the nose to the cleft of the chin
-Should fit snugly on the face but put not pressure on the eyes to avoid stimulating the vagal response
Types of facemask
Simple face mask
Non rebreather
Simple face mask
30-60% O2 with a flow rate of 6-10L/min when a tight seal is maintained on face
Non-rebreather
60-90% O2 with a flow rate of 12-15L/min when a tight seal is maintained on face
Common dysrhythmias
Bradycardia
Asystole
Pulseless electrical activity (PEA)
Asystole
Do not administer shock because there is no electrical activity, continue CPR until something else is figured out
PEA: Characterized
Unresponsiveness and the lack of a palpable pulse in the presence of an organized cardiac electrical activity
Some situations that cause sudden changes in preload, afterload, or contractility often cause this.
PEA: Most common cause
Hypovolemia
PEA: Treatment
Rapid fluid bolus of 20ml/kg of NS IV
Treatment of PEA and Asystole
Determine reversible causes (PAT2H4)
PAT2H4
P: pneumothorax
A: acidosis
T2: toxic ingestion, tamponade
H4: hypovolemia, hypoxia, hypo/hyperK, hypothermia
Vfib/Vtach
Not common in children
May be seen in adolescents with OD
Vfib
Abnormal heart rhythm and is seen in sudden cardiac arrest
Chaotic and unorganized
Heart quivers and cannot effectively pump blood
Short lived and will deteriorate to asystole if not treated properly and promptly
Vfib cause
By an abnormal and very fast electrical activity in heart
Vfib Treatment
Only effective treatment is electrical shock called defibrillation ( an electrical current applied to the chest)
Vfib Defibrillation goal
Electrical current pass through the heart stopping the Vfib and giving an opportunity for heats normal electrical system to take over
The defibrillation helps the heart reorganize and start pumping blood effectively again
AED
Comes in various sizes
They give you verbal instructions of how to apply pads, and will set amount of Joules according to the patient’s rhythm
Defibrillator
Manual and you’ll adjust this according to Broslowe tape of instructions or your code sheet
AED/Defibrillator pads
Different size for 1-8yrs
Adult pads
If there isn’t Pedi pads then you can use adult pads but make sure they dont touch. Place one in the center of the child’s chest and the other on the center of the child’s back
AED/Defibrillation: Reminders
Make sure chest hair is out of the way
Make sure there is no pacemaker (place pad at least 1in from the device)
Look for medicinal patches, don’t place pad on the patch
Clear before activating it
Dont use in water!! Dry the patient off before shocking, remove the patient from any water before shocking
Bradycardia Treatment
Oxygenation/ventilation
F/u with Epinephrine, atropine and transcutaneous pacing
V tach (hemodynamically stable) Treatment
Amiodarone or lidocaine or Procainamide
Unstable Tachyarrhythmia Treatment
Immediately synchronized cardioversion for PSVT
IV access available give adenosine before cardioversion
Vfib or pulseless Vtach Treatment
Immediate defibrillation, epinephrine, intubation
Consider amiodarone, lidocaine, magnesium sulfate
Asystole and PEA Treatment
We want to establish some type of rhythm/electrical activity Cant use AED Not shockable Continue CPR Intubation Epinephrine Determine cause - reverse it
Nurses role in resuscitation
Patient assessment
Start CPR
Breathing really fast or stop breathing: start CPR
Witnessed it? Not witnessed?
CPR: Team leader
Oversees the entire process, monitors effectiveness, orders drugs, treatments, labs,
Doctor is the one that runs the code not the nurse
CPR: Team member
Each has a specific job: compressions, BMV, starting IV, drawing labs, labeling and giving meds, “go-fer”: labs, equipment, recorder, charting, keeping family members informed
Any time an order is given, it must be repeated back to physician for confirmation and so that every team member hears
There has to be someone whose role is to just document on the ode sheet
CPR: Nursing intervention: Family support
During arrest: support is aimed at keeping family informed of child’s status, assuring them that all is being done
Must consider needs, fears and concerns of family members
Family should be able to be present during code
