PALS Flashcards
You are called to Urgently evaluate a child. What 3 things should you assess on initial impression?
- Level of consciousness
- unresponsive, irritable, lethargic, alert - Breathing
- not breathing, gasping, abnormal sounds, increased work of breathing - Color
- pallor, cyanosis, mottling
You are called to bedside ad child is unresponsive and pale. What do you do?
- Shout for help/call a code
- Check for pulse
- yes: start rescue breathing
- no: start chest compressions
How do you assess upper airway patency?
- look for movement of chest or abdomen
- listen for air movement or breath sounds
Who should you suspect cervical spine injury in? How do you open their airway
Suspect cervical spine injury in any kid with head r neck injury
-do jaw thrust without neck extension
A 2yo child is alert, has significant retractions, but is not making a sound. You suspect —–. You do —–.
Alert but unable to make any sound–suspect foreign body
- if < 1 yo: give 5 back slaps and 5 chest thrusts
- if 1 yo or older: give abdominal thrusts
What is the normal RR for: infant, toddler, preschooler, school age, adolescent?
Infant: 30-60 Toddler(1-3 yrs): 24-40 Preschool (4-5yrs): 22-34 School age(6-12 yrs): 18-30 Adolescent: 12-16
RR: count # breaths in 30 secs x 2
True or false: infants may have irregular breathing during sleep with pauses up to 10-15 seconds.
True.
RR should count # breaths in 30 sec
A consistent RR less than —– or greater than —– is very abnormal and signals a serious problem
RR < 10 breaths per min
RR > 60 breaths per min
Define apnea
Cessation of breathing for 20 secs or cessation for less than 20 secs if: bradycardia, cyanosis or pallor
Define hypoxemic
O2 sat less than 94%
How can you estimate hypotension if a child is 1-10 years old?
SBP= 70 + (child’s age in years x 2) mmHg
True or false: automated BP readings are only accurate when there is good distal perfusion
True
If distal pulses difficult to palate or extremities are cool, automated BP may be less accurate
You are concerned a child is in shock. Name some things you should evaluate to assess perfusion.
- Vitals-heart rate and BP
- Skin exam: pale, mottled, diaphoretic
- Cap refill
- Pulses-weak vs bounding, central vs peripheral
- Decreased urine output/oliguria
- Decreased level of consciousness (cerebral perfusion)
Name 4 major types of shock
- Hypovolemic
- Distributive (septic, anaphylactic)
- Cardiogenic
- Obstructive (tamponade,
What does compensated shock mean?
They are in shock but BP is NOT hypotensive
Once hypotensive end organ perfusion severely compromised
Define shock
Critical condition that results from inadequate tissue delivery of O2 and nutrients to meet metabolic need
-usu inadequate peripheral and end organ perfusion.
Name some warning signs of worsening shock
Increased HR Diminishing or absent peripheral pulses Weakening central pulses Narrowing pulse pressure Cold distal extremities with prolonged cap refill Decreasing level of consciousness Hypotension ( late finding)
What are some signs of cardio genie shock?
Signs of poor perfusion AND pulmonary or systemic venous congestion including:
Increased work of breathing Grunting respirations Distended neck veins Hepatomegaly Clinical worsening in response to giving fluid boluses
Name the 9 important components of managing a child in shock
- Positioning child
- Airway and breathing
- Vascular access
- Fluid resuscitation
- Monitoring (vitals, mental status, UOP)
- Frequent reassessment
- Lab studies
- Medications
- Sub specialty consults
What is the initial fluid bolus for treating shock?
20 ml/kg
Reassess after for need for repeat bolus
For cardiogenic shock, DKA, tamponade, tension pneumo give smaller volumes more slowly
When is blood indicated for management of shock?
In setting of traumatic volume loss after 2-3 boluses of 20 ml/kg of normal saline if perfusion is still not adequate
You decide to give blood as part of management of shock. How much?
10 ml/kg PRBCs
What is the major side effect of over aggressive fluid resuscitation?
Pulmonary edema
What are 3 major complications from giving blood products rapidly during resuscitation?
- Hypothermia
- Myocardial dysfunction
- Ionized hypocalcemia
Why should blood glucose be monitored in critically ill children? Who is at greatest risk for hypoglycemia during shock?
Hypoglycemia is common during critical illness and can result in brain damage if untreated
Infants, children with chronic illness at greatest risk for hypoglycemia during critical illness
Ddx of symptomatic bradycardia
HR < 60 with sx and signs of shock, respiratory distress or altered mental status
Ddx
- hypoxia
- acidosis
- hyper kalmia
- hypothermia
- heart block (AV block)
- drugs and toxins (ccbs, opioids, digoxin, organophosphates )
Ddx of symptomatic bradycardia
HR < 60 and shock, respiratory distress, altered mental status
Ddx
- hypoxia
- acidosis
- hyperkalemia
- hypothermia
- heart block AV block
- toxins/drugs
- head trauma
How do you classify tachyarrhythmias?
- Narrow complex
- sinus tach
- SVT
- atrial flutter - Wide complex
- VT
List some common and uncommon causes of sinus tachycardia
Common: exercise, pain, fever, anxiety, tissue hypoxia, hypovolemia (hemorrhage and non-hemorrhagic), shock, injury, toxins, poisons, drugs
Uncommon causes: cardiac tamponade, tension pneumothorax, thromboembolism
What is the presentation of SVT in infants?
Usually goes unnoticed for long period of times so these kids often presents with sx/signs of congestive heart failure
-irritability, poor feeding, increased work of breathing
What are the signs and symptoms of SVT in older kids?
- palpitations
- SOB
- chest pain
- dizziness
- light-headedness
- syncope
What is the compressions: breaths ratio for 1 person CPR? 2 person CPR?
1 person: 30 compressions 2 breaths. (if in the field ok to just o compressions)
2 person: 15:2 (or if adolescent 30:2)
What are to meds you can give for symptomatic bradycardia?
- Epi
2. Atropine
What is the dose of epi to give IV/IO during a resuscitation? How long between doses? Max # of doses?
0.01 mg/kg or 0.1 ml/kg 1:10,000 concentration epi
Give q3-5 mins
No max # of doses really
What is a shockable rhythm?
Vfi. Or vtach
How many Jules of shock for defibrillation?
Initial: 2 j/kg
Subsequent: 4 j/kg
What is PEA?
Electrical activity on the monitor but no pulse (so heart is not pumping)
What are the hallmarks of cardiac arrest?
- Child unresponsive
- Not breathing or only gasping
- No pulse
What is the goal compression rate?
100 per min
What is different about rescue breathing when the patient is intubated?
1 breath per 6-8 seconds when compressions person is in recoil from a compression
No longer the synchronized 15:2
What do you do if you find an unresponsive child?
- Check for breathing
- Check for pulses
If no to both, shout for help, start CPR, give O2 and attach defibrillator
Initial rhythm on defibrillator is asystole. What do you do?
Start CPR (2 min)
IV/iO access
Epi q3-5 min
Consider et intubation
After 2 min recheck rhythm. Shock if vtach or vfib. Otherwise 2 more min CPR
What are the “Hs and Ts”
=reversible causes of cardiac arrest.
H’s: hypoxia, hypovolemia, hyperkalemia, hypoglycemia, hydrogen ions, hypothermia
T’s: toxins, trauma, tension pneumo, tamponade, thrombosis (PE or coronary)
What are the first 3 things to evaluate in a kid when you walk in the room?
- Consciousness/mental status
- Breathing
- Color
If yes to all 3 -> start primary evaluation
If unresponsive/altered and not breathing -> shout for help and start CPR
What do you check on primary assessment?
- Airway (speaking or crying, look for chest or belly movement, listen for breath sounds)
- Breathing (RR, work of breathing, air movement, lung and airway sounds, O2 sat)
- Circulation (HR, central pulses, peripheral pulses, cap refill, skin color and temp, BP)
- Disability (level of consciousness, pupils, GCS)
- Exposure (temp, bleeding, rashes)
What are some simple measures to open/maintain upper airway
- Head tilt chin lift
2. Suctioning (bulb or deep)
What can happen sometimes after you deep suction a kid?
Bonchospasm
When do you consider supplemental O2?
- if O2 sat < 94% on RA
- if O2sat < 90% on 100% O2, consider additional interventions
What is the AVPU scale?
Assesses responsiveness of child
- Alert
- Voice-responds only to voice
- Pain-responds only to painful stimulus
- Unresponsive
What do you do on secondary assessment?
- Focused history (SAMPLE)
- Focused physical exam
Consider lab tests
What is your history on secondary assessment? (hint:sample)
S: signs and sx A: allergies M:medications P: past medical Hx L: last meal E: events
When do you do the primary assessment?
After initial assessment/look at the patient where you’ve determined they are responsive and breathing
What is cushings triad?
Hypertension
Bradycardia
Irregular breathing or apnea
How do you determine if you have adequate ventilation with PPV?
Visible chest rise with each breath O2 sat Exhaled CO2 HR BP Distal air entry Improvement in color
You think the child is not adequately ventilated (ie no chest rise). What are some things to troubleshoot?
- Reposition the head (chin lift)
- Verify mask size and good seal
- Suction airway if needed
- Check O2 source
- Check ventilation bag and mask
Name 3 vagal maneuvers to try for compensated SVT
- Bear down/blow through a straw
- If less than 1year, rectal stim
- Suction
Name 2 treatments for uncompensated SVT
Uncompensated= abnormal mental status, perfusion
- Synchronized cardio version
- Adenosine 0.1 ml/kg
Name 4 things to consider when not good chest rise or breath sounds after intubation.
DOPE
D=displacement, check right side tube and right distance
O= obstruction, mucus plug try suction
P= pneumothorax
E= equipment, seal, o2 hooked up,
How do you choose the right ET tube size?
Age+16/4
If less than 1 year, choose size 0
What is the correct ET tube depth?
= 3x ET TUBE SIZE
