PALS Flashcards
Stridor is usually high-pitched during?
Inspiration
Wheezing is usually high-pitched during?
Expiration
Snoring and Gurgling are a result of ——– airway obstruction
upper
Crackles happen during?
inspiration
grunting happens during?
expiration
oxygen saturation less that ——- indicates low oxygen saturation, which is know as hypoxemia
94%
pulse oximetry indicates oxygen ——- but not oxygen delivery
saturation
what does A-B-C in the Pediatric Assessment Triangle (PAT) stand for ?
A- Appearance
B- Work of Breathing
C- Circulation
primary assessment
D- Disability
E- Exposure
Conditions that ——– air resistance lead to increase respiratory ———
increase, effort
signs of increased respiratory effort that can lead to fatigue and respiratory failure ?
seesaw respirations
Nasal flaring
Head bobbing
restrictions
Define Apnea?
when breathing stops, typically defined as longer than 20 seconds
Determine the respiratory rate ?
count the number of times the chest rises in 30 seconds and multiple it by 2
Tachypnea is the first sign of respiratory —– in infants
distress
hypotension for children 1 to 10 years of age is a systolic blood pressure of less than
70 mm Hg + (2X the age in years)
automated blood pressure cuffs may provide —— readings when the child is in shock
inaccurately high
What does a prolonged capillary refill time indicate?
Low Cardiac Output
Normal Capillary refill time is —- seconds or less
2 seconds
What pulses should be assessed to monitor systemic perfusion in a child?
Peripheral & Central
what do weak central pulses indicate a need for immediate intervention to prevent ?
cardiac arrest
when oxygen delivery to the extremities becomes inadequate, the —- and —- are the first to exhibit signs
hands & feet
what should be used to assess skin temperature?
back of the hand
if the pupils do not —– in response to bright light, consider increased—- pressure
constrict, intracranial
if hypoglycemia is not identified and treated immediately, it can result in —– injury
brain
PVPU
Responds to pain
Responds to voice, Unresponsive
Alert
Secondary Assessment
SAMPLE mnemonic
Signs and Symptoms Allergies Medications Past Medical History Last meal Events leading up to illness/ injury
which component of SAMPLE assesses immunization status?
Past medical HX
what should be included in the history when asking about medications?
Current prescribed medications
Over-the-counter medications
What are some examples of diagnostic assessments?
Arterial blood gas
Venous blood gas
Hemoglobin concentrations
what dictates the timing of diagnostic assessments?
Clinical situation
which component of effective high-performance teams is represented by the use of real-time feedback devices?
Quality
What is an advantage of effective teamwork?
Division of tasks
what is the best example of the team leader role?
models excellent team behavior
what is the best example of a team member role?
Committed to success
what is the primary purpose of the CPR coach on a resuscitation team?
improve CPR quality
How can the CPR coach improve CPR quality in a resuscitation event?
coach to midrange targets
Which high-performance team member has the responsibility for assigning roles (positions)?
team leader
what element of team dynamics describes when a team member needs to correct actions?
constructive intervention
which of the following describe how to communicate?
clear messaging
closed-loop communication
In the primary assessment, how should you open the airway of a child who is not suspected of having a cervical spine injury?
with a head tilt-chin lift
which resuscitation strategy will result in an improved chest compression fraction?
hovering over the chest during compression pause
what is one way to increase chest compression fraction during a code?
charging the defibrillator 15 seconds before a rhythm check
a chest compression fraction of at least —- is recommended, and a goal of — is often achievable with good teamwork
60% and 80%
What is chest compression fraction?
proportion of time that compressions are performed
What sequence is used when caring for a seriously ill or injured child to help determine the best treatment or intervention? the ——–, ———-, ——- sequence
evaluate
identify
intervene
if the child does not have normal breathing and a pulse of 64/min is present, you will need to —-
provide rescue breathing
What should you look for when exposing the Child?
Bruising
Bleeding
purpura
what is the definition of oxygen saturation?
The amount of oxygen bound to hemoglobin
children develop hypoxemia and tissue hypoxia more quickly than adults because of their
higher metabolic rate
in infants and toddlers, the tongue and epiglottis, relative to those of an adult, are ——-
larger
how can normal, spontaneous breathing be characterized?
Quiet, with unlabored inspiration
increase work of breathing can be associated with ——– airway resistance and/or —– lung compliance
increased
decreased
what happens when airway resistance increases?
work of breathing incraeases
which of the following describes laminar or normal airflow?
low airway resistance and a small driving pressure
what is the role of the diaphragm contraction during normal breathing in infants?
pulls the ribs slight inwards
which is a characteristic of muscle weakness?
seesaw breathing
During spontaneous breathing, what are the inspiratory muscles attempting to do?
increase intrathoracic volume
which of the following is true about airway resistance?
when airway resistance increases, work of breathing increases
which of these can override brainstem control of breathing in an infant?
breath holding
what do central chemoreceptors respond to?
hydrogen ions in the cerebrospinal fluid
why may excessive ventilation during CPR be harmful?
it increases intrathoracic pressure
it impedes venous return
what should you do if you cannot achieve effective ventilation with a bag-mask device?
verify the mask size
reposition the airway
how effective oxygenation and ventilation assessed?
oxygen saturation
exhaled carbon dioxide
visible chest rise with each breath
how can gastric inflation impair bag-mask ventilation?
it decreases lung compliance
what is the most appropriate precautionary action to minimize gastric inflation during bag-mask ventilation?
deliver each breath over about 1 second
Where can you check a pulse on an infant and a child?
Infant- brachial
Child- Femoral
which is true about the difference between hypoxemia nad tissue hypoxia?
tissue hypoxia can occur with normal arterial oxygen saturation
what does hyperventilation, which refers to increased alveolar ventilation, result in?
PaCo2 less than 35 mm HG
what happens to the arterial oxygen level in a child with severe anemia?
may incrase when dissolved oxygen is increased
which is true if increased carbon dioxide tension in arterial blood?
may be caused by disordered control of breathing
what happens when ventilation is inadequate?
PaCO2 increases
what is a critical symptom of hypercarbia?
decreased level of consciousness
which of the following indicates mild respiratory distress?
mild increases in respiratory effort
which of the following indicates severe respiratory distress?
MArked tachypnea and/or apnea
which of the following statements about respiratory failure is true?
may occur without signs of respiratory distress
what actions are appropriate when providing 1-person bag-mask ventilation?
Perform a head tilt, insert an oral airway, and squeeze the bag until chest rise
when suctioning a patient, which of the following should be monitored?
heart rate
clinical appearance
oxygen saturation
Which are appropriate interventions for an apneic child?
- Provide a breath every 2 to 3 seconds
- Watch for chest rise
which of the following should be included in rescue breathing for an infant?
Use oxygen ASAP
When should the use of an endotracheal tube be considered in a child?
Child cannot maintain oxygenation despite initial intervention
What are the common causes of upper airway obstruction?
- Thick secretions
- Tonsillar hypertrophy
- Airway Swelling
Which anatomical features may contribute to upper airway obstruction in infants?
- Large tongue
- Large occiput
What are the signs of upper airway obstruction?
- Stridor
- Use of accessory muscles
What should you do to help reduce the risk of hypoxemia during suctioning?
Limit suction attempts to 10 seconds or less
Which diagnosis may present with upper airway obstruction?
- Epiglottitis
- Croup
- Foreign body obstruction
What should you do before suctioning a child who has upper airway obstruction?
Determine the underlying cause of the obstruction
in a less severe case of upper airway obstruction in a child, what intervention can relieve obstruction caused by the tongue?
insert an oral airway
A child presents with a barking cough, good air entry during auscultation, a pulse oximetry reading 93% on room air, and retractions at rest.
What is the severity of the child’s presentation?
Moderate croup
A child presents with a barking cough, good air entry during auscultation, a pulse oximetry reading 93% on room air, and retractions at rest.
what are appropriate initial interventions?
- Administer oxygen and nebulized epinephrine
- consider dexamethasone
When using a metered-dose inhaler (or MDI) with a spacer device, what should you do?
Shake the MDI and spacer vigorously
what is the treatment for a mild allergic reaction?
- Remove the offending agent (e.g. antibiotic)
- Consider an antihistamine
what is the most appropriate treatment for severe anaphylaxis?
Administer IM epinephrine
A responsive infant present with severe foreign-body airway obstruction.
What is the appropriate management?
Give 5 back blows followed by 5 chest thrusts
A responsive Child present with severe foreign-body airway obstruction. and is unable to speak.
you determine that the child?
Should receive abdominal thrusts
What are the components of the breathing assessment?
- Respiratory effort
- Respiratory rate
- Oxygen saturation
- Lung and airway sounds
- Chest expansion and air movement
What are the common causes of lower airway obstruction?
- Bronchiolitis
- Asthma
What is the first step for and an intubated child whose condition deteriorates?
Support oxygenation and ventilation
How can small airways be obstructed in acute lower airway obstruction?
- Mucus plugging
- Smooth muscle bronchial constriction
how do infants initially respond to lower airway obstruction?
Decreased interpleural pressure
What is the first priority in managing lower airway obstruction?
Restore adequate oxygenation
bag-mask ventilation has been used on a child with lower airway obstruction
which complication may occur?
- Risk of lung collapse
- Deceased blood supply to the heart
A child presents with audible wheezing, a heart rate greater than 120/min, a respiratory rate of 36/min, and the inability to talk in sentences
what is the severity of this presentation?
severe
When should administration of magnesium sulfate be considered in a child with asthma?
Moderate to severe distress
What is the most accurate definition of shock?
Inadequate tissue perfusion
What are the characteristics of shock?
- Decreased level of consciousness
- Inadequate peripheral perfusion
- Decreased end-organ perfusion
What will occur if adequate oxygen delivery to the tissues is not maintained?
Organ dysfunction
What are the major function(s) of the cardiopulmonary system?
- Delivers oxygen to body tissues
- Removes metabolic by-products of cellular metabolism
what is the definition of cardiac output?
The volume of blood pumped by the heart per minute
What is the body’s first action to maintain cardiac output?
Increase heart rate
T/F
if cardiac output is compromised, signs of poor perfusion will be “present” even if blood pressure is normal?
True
What are the goals in treating shock?
- Balance tissue perfusion and metabolic demand
- improve oxygen delivery
- support organ function
- prevent progression to cardiac arrest
T/F
As the more time passes between the onset of signs of shock and the restoration of adequate oxygen delivery and organ perfusion, the outcome is “Worse”
True
What is included is the treatment of shock?
Optimizing oxygen content in the blood
What is the preferred initial fluid for shock resuscitation?
Isotonic crystalloids
For general shock management, administer an isotonic crystalloid bolus of —— ml/kg over —- to —– minutes
20 mL/kg
5 to 20 min
Hypotension in children is calculated as a systolic blood pressure of less than — mm Hg plus — times the age in years
70mm Hg
2 times
What are some common causes of hypovolemic shock?
- Large burns
- Osmotic diuresis
- Hemorrhage
what is a characteristic clinical finding associated with hypovolemic shock?
Tachypnea
hypovolemic shock refers to a clinical state of ?
- reduced intravascular volume
- Reduced extravascular volume
What is the primary therapy for hypovolemic shock?
Rapid administration of isotonic crystalloids
what could be the reason a child with hypotensive shock does not improve after at least 3 fluid boluses?
The initial assumption about the etiology may be incorrect
what best assesses a child’s response to each fluid bolus?
- vital signs
- physical examination
- urinary output
what are the goals in treating shock?
- Balance tissue perfusion and metabolic demand
- support organ function
- Improve oxygen delivery
- Prevent progression to cardiac arrest
What is the most common type of distributive shock?
Septic
T/F
Septic shock often develops over “Hours, while Anaphylactic shock may occur over minutes
True
What should you use to begin fluid resuscitation in hemorrhagic shock?
Isotonic crystalloids
When is distributive shock present?
When there is inadequate blood flow to some tissue beds but too much to others
what treatment should be implemented if a child remains hemodynamically unstable despite 2 to 3 boluses of 20 mL /kg isotonic crystalloids?
Transfuse PRBCs
What determines adequate fluid resuscitation in hypovolemic shock?
- Type of volume loss
- Extent of volume depletion
What signs distinguish anaphylactic shock from other types of shock?
- Respiratory distress with stridor, wheezing, or both
- Urticaria (hives)
- Angioedema (swelling of the face, lips, and tongue)
How soon after exposure do symptoms typically occur in anaphylactic shock?
seconds to minutes
when should vasoactive therapy be considered in managing distributive shock?
if the child remains hypotensive and poorly perfused despite rapid bolus fluid administration
in a child with anaphylactic shock, what is the most appropriate initial treatment ?
IM epinephrine
how des the clinical presentation of distributive shock compare with hypovolemic shock?
distributive shock has a more variable presentation than that of hypovolemic shock
what should you evaluate to recognize septic shock?
- Heart rate
- Blood pressure
- Temperature
- Systemic perfusion
- Clinical signs of end-organ perfusion
When should antibiotic be administered in septic shock ?
Within the first hour
what is the most appropriate vasoactive drug to use in fluid-refectory septic shock?
epinephrine or norepinephrine
for septic shock, how soo should fluid resuscitation begin?
within 10 to 15 minutes after recognizing shock
What is the recommendation for fluid bolus of isotonic crystalloids in cardiogenic shock?
5 to 10 mL/kg over 10 to 20 minutes
What is the focus of the initial management of distributive shock?
- Expanding intravascular volume
- Correcting hypovolemia
- Filling expanded dilated vascular space
what are causes of obstructive shock?
- Tension pneumothorax
- Pulmonary embolus
- Cardiac tamponade
- Congenital heat defect
what signs are present as obstructive shock progresses?
- increased respiratory effort
- cyanosis
- signs of vascular congestion
what is the main objective of managing obstructive shock?
- restore tissue perfusion
- correct the cause of cardiac output obstruction
why is it important to immediately identify obstructive shock?
obstructive shock can rapidly progress to cardiopulmonary failure and then cardiac arrest
most patients in cardiogenic shock will need inotropic support with medications.
which of the following could be used?
- Milrinone
- Epinephrine
what are the initial assessment findings for septic shock?
- Fever
- Normal, elevated, or decreased WBC
- hypothermia
in whom should you suspect a tension pneumothorax?
- Victim of chest trauma
- Any intubated child who deteriorates suddenly while receiving positive-pressure ventilation
- A child who deteriorates suddenly while receiving bag-mask ventilation
how do you know if a needle decompression is successful?
There is a gush of air when the needle is placed
what are common causes of cardiogenic shock?
- Myocarditis
- Arrhythmia
- Congenital heart disease
- Drug toxicity
What is an assessment finding unique to tension pneumothorax?
Tracheal deviation
what is the immediate treatment for tension pneumothorax?
Needle decompression
why do children with cardiac tamponade improve temporarily with fluid administration?
Fluid augment cardiac and tissue perfusion until pericardial drainage can be performed
what circulation findings are specific to pericardial tamponade?
- Tachycardia
- Muffled or diminished heart sounds
- Narrowed pulse pressures
in the setting of impending or actual pulseless arrest when there is a strong suspicion of pericardial tamponade, what is the appropriate management?
Emergency pericardiocentesis
pulmonary embolisms are ——– in children
rare
in children with severe cardiovascular compromise from pulmonary embolism, what treatment should be considered?
Fibrinolytic agents
what are causes of cardiac tamponade in children?
- Cardiac surgery
- Penetrating trauma
- Infection of the pericardium
whenever a child has an abnormal heart rate or rhythm, what must be done quickly?
Determine if the arrhythmia is causing hemodynamic instability or other signs of deterioration
what is the priority in initially managing arrhythmias?
Support the airway, breathing, and circulation
what is the definitive treatment for most children with pulmonary embolism who are not in shock ?
Anticoagulants
what findings help distinguish pulmonary embolism from hypovolemic shock?
systemic venous congestion and right heart failure
what are the causes of secondary bradycardia?
- Hypoxia
- Acidosis
- Drugs
- Hypotension
- Hypothermia
What cases primary bradycardia?
Congenital or acquired heart conditions
How is bradycardia defined in pediatric patients?
A heart rate that is slow in comparison with a normal heart rate range for the child’s age, level of activity, and clinical condition
in which patients would bradycardia be an expected finding and not be considered problematic?
- A Well- conditioned athlete
- A healthy child who is sleeping
what is the leading cause of symptomatic bradycardia in children?
Tissue hypoxia
What are the ECG characteristics of bradycardia?
- Heart rate slow compared with normal heart rate for age
- QRS complex may be narrow or wide
- P wave and QRS complex may be unrelated
what is the initial treatment for pediatric bradycardia with cardiopulmonary compromise?
provide bag mask ventilation with 100% oxygen
what is a first-degree AV block?
A prolonged PR interval representing slowed conduction through the AV node
what is a third-degree AV block?
None of the atrial impulses conduct to the ventricles
what is the initial dose of epinephrine is the treatment of symptomatic bradycardia?
0.01 mg/kg IV/IO
what is the IV/IO dose of atropine for pediatric bradycardia?
0.02 mg/kg
if bradycardia persists after initial treatment and the heart rate remains less than 60/min, what action should be taken next?
begin CPR
what clinical findings may be present in a child with a tachyarrhythmia?
- light-headedness
- Syncope
- Palpitations
where do tachyarrhythmias originate?
Atria or ventricles
how is tachycardia defined in pediatric patients?
A heart rate that is fast compared with the normal heart rate for the child’s age
why does sinus tachycardia typically develop?
the body needs increased cardiac output
What are characteristics of atrial flutter?
- Atrial rate can exceed 300/ min, and ventricular rate is slower
- A narrow- complex tachyarrhythmia
- Can develop in children with congenital heart disease
how are tachycardia and tachyarrhythmias classified ?
By the width of the QRS complex
what are the characteristics of ventricular tachycardia?
- Rapid rate compromises ventricular filling
- The rapid rate deteriorate into pulseless ventricular tachycardia or ventricular fibrillation
- it is wide QRS complex generated within the ventricles
what heart rate is consistent with sinus tachycardia?
infant -> less than 220/ min
Child -> less than 180/min
what is a characteristic feature of supraventricular tachycardia?
An abrupt increase in heart rate that does not vary with activity
in what conditions is atropine preferred over epinephrine as the first0choice treatment of symptomatic bradycardia?
Atrioventricular block due to primary bradycardia
increased vagal tone
cholinergic drug toxicity (organophosphates)
What electrocardiographic characteristic is consistent with ventricular tachycardia?
The QRS complex is greater than 0.09 seconds
What history is consistent with supraventricular tachycardia?
Symptoms of congenital heart disease
What electrocardiographic characteristics are consistent with sinus tachycardia?
Beat to Beat Variability with changes in activity
which signs and symptoms are consistent with supraventricular tachycardia (SVT)?
- Absent or abnormal P waves
- Heart rate does not vary with activity or stimulation
- Heart rate 220/min or greater in an infant or 180/min or greater in a child
which signs and symptoms are consistent with sinus tachycardia?
- Heart rate less than 220/min in an infant or less than 180/min in a child
- Present and normal P waves
- Heart rate caries with activity or stimulation
How should sinus tachycardia be treated?
By treating the underlying case
if amiodarone or procainamide does not terminate the rapid rhythm, why should adenosine be considered?
A wide-complex could be supraventricular tachycardia with aberrant ventricular condition
Which of the following should be considered for stable SVT?
- Place a bag with ice water over the upper half of the infants face
- ASK an older child to try ti blow through an obstructed straw
what is the initial dose of adenosine?
0.1 mg/kg IV/IO
What are signs of cardiac arrest in children?
- Agonal
- Unresponsivess
- No pulse felt
T/F
The most common cause of cardiac arrest in infants, children, and adolescents is “hypoxic/asphyxial arrest, which is the end result of progressive hypoxia and acidosis?
True
What is considered an initial management priority in managing tachyarrhythmias?
- Attach a continuous electrocardiographic monitor/defibrillator and a pulse oximeter
- Assess and support the airway, oxygenation, and ventilation
- Obtain a 12-lead electrocardiogram if practical
what are the most common initial rhythms in both in hospital and out of hospital pediatric cardiac arrest, especially in children younger than 12 years?
- PEA
- Asystole
what is the appropriate initial dose if synchronized cardioversion I needed?
0.5 to 1J/kg
when treating persistent VF/pVT during cardiac arrest, administer epinephrine?
every 3 to 5 min
T/F
When “PEA” is present, the heat has no organized rhythm and no coordinated contractions?
False
VF is the answer
what is considered part of post cardiac arrest care?
- Ensuring adequate analgesia and sedation
- Correcting acid-base and electrolyte imbalance
- Providing adequate oxygenation and ventilation
what does optimal post-cardiac arrest care include?
Identifying and treating organ system dysfunction
what are the initial steps of the VF/pVT pathway of the pediatric cardiac arrest algorithm?
- Perform CPR
- Deliver 1 shock
- Establish IV/IO access
what is included in the first phase of post-cardiac arrest management?
Continued advanced life support for immediate life-threating conditions
what is included in the second phase of post cardiac arrest management?
Provide broad multiogan supportive care
oxygen should be titrated to maintain a pulse oximetry saturation level between what range?
94% to 99%
for stable patients with a regular wide complex, and monomorphic tachycardia, consider?
Adenosine
how should appropriate endotracheal tube placement be confirmed?
End-tidal carbon dioxide or capnography
what are initial steps of treating asystole/PEA?
- Administer epinephrine
- Provide CPR
- Consider advanced airway
- Establish IV/IO access
to optimize preload in a post-cardiac arrest child, what fluid bolus amount should be administered ?
5 to 10 mL/kg over 10 to 20 min
what can cause secondary brain injury?
- Hypoxia
- Hypoglycemia
- Hypotension
- Hyperthermia
which component of SAMPLE assesses immunization status?
Past medical HX
what happens to the arterial oxygen level in a child with severe anemia?
may increase when dissolved oxygen is increased
