PALS Flashcards
In specific settings, when treating pediatric patients with febrile illnesses, the use of restrictive volumes of isotonic crystalloid leads to improved survival T/F
True
administration of IV fluid for children with septic shock
There is evidence that excessive fluid boluses given to febrile patients with shock can lead to complications, especially if there is no ICU unit ( mechanical vent,inotropic support)
There is no evidence to support the routine use of atropine as a premedication to prevent bradycardia in emergency pediatric intubations. T/F
TRUE, is controversial
It may be considered in situations where there is an increased risk of bradycardia.
There is no evidence to support a minimum dose of atropine when used as a premedication for emergency intubation.
If invasive hemodynamic monitoring is in place at the time of a cardiac arrest in a child, it is NOT reasonable to use it to guide CPR quality. T/F
False, it is reasonable!
Which is the recommended vasopressor in pediatric cardiac arrest?
Epi
In children with cardiac diagnoses and in-hospital arrest what do you consider?
If available, extracorporeal CPR
What is Extracorporeal cardiopulmonary resuscitation ?
method of cardiopulmonary resuscitation that passes the patient’s blood through a machine in a process to oxygenate the blood supply. A portable extracorporeal membrane oxygenation device is used as an adjunct to standard CPR
How is the management of fever in a comatose patient after cardiac arrest?
temperature should be monitored continuously and fever should be treated aggressively.
For comatose children resuscitated from OHCA,- maintain either 5 days of normothermia (36°C to 37.5°C) or 2 days of initial continuous hypothermia (32°C to 34°C) followed by 3 days of normothermia.
For children remaining comatose after IHCA, there are insufficient data to recommend hypothermia over normothermia.
IHCA- in hospital cardiac arrest
What do you do after return of spontaneous circulation (ROSC) after cardiac arrest, in terms of fluids/inotropes ?
fluids and inotropes/vasopressors should be used to maintain a systolic blood pressure above the fifth percentile for age.
Intra-arterial pressure monitoring should be used to continuously monitor blood pressure and identify and treat hypotension.
What is the goal of systolic BP after ROSC post arrest?
above the fifth percentile for age.
70 mmHg+ (Age in years x 2)
What do you do after return of spontaneous circulation (ROSC) after cardiac arrest, in terms of O2 ?
Target sat 94-99%
Hypoxemia should be strictly avoided
Targetin normoxemia improves outcomes
CAB sequence
compressions, airway and breathing
CPR- Rate of compressions?
100-120/min
CPR- how deep in chest?
~1/3 of the depth
In infants : 1.5in( 4cm)
In children: 2 in(5cm)
In children reached puberty at least 2 in but no more than 2.4 ( 6cm).
and allow complete chest recoil
compression ventilation ratio?
30: 2 for single
15: 2 for 2 or more rescuers
compression ventilation after an advanced airway is in place?
deliver 10 breaths per min ( 1 min every 6 seconds) while continuous chest compressions.
What is the drug of choice for treating shock refractory Vfib or pVT in children?
Amiodarone or Lidocaine. No benefit of one over the other.
BLS, where do you tap the children and infant to see if they are responsive?
Children: shoulder
Infant : heel
BLS algorithm
- Verify the scene is safe
- Check for responsiveness- “Are you OK”
- If unresponsive - shout for nearby help, ACTIVATE THE EMERGENCY RESPONSE SYSTEM VIA MOBILE IF POSSIBLE
- Assess the child breathing and pulse ( no more than 10 seconds)
breathing: scan victims chest for rise and fall.
if patient is breathing, monitor until additional help
arrives.
if patient is not breathing then he has respiratory or cardiac( .if no pulse) arrest.Check pulse:infant: brachial artery
children: carotid or femoral pulseIf you dont feel pulse within 10 seconds start CPR
Where do you check pulse in infants and children?
Check pulse:
infant: brachial artery -
children: carotid or femoral pulse
if you feel it, attempt to feel the pulse for at least 5 sec
If you dont feel pulse within 10 seconds start CPR
If patient is not breathing, but has a pulse whats next?
1 breath every 3-5 seconds or about 12-20 breaths/min
Add compressions if pulse =< 60/min with signs of poor perfusion
Activate emergency response system after 2 min if not done already
Continue rescue breathing, check pulse every 2 min
signs of poor perfusion
TAPS Temperature: cool extremities Altered mental status: decrease in responsiveness Pulses: weak pulses Skine: paleness, mottling, cyanosis
No breathing/ No pulse
Activate the emergency response system - 911
Get the AED equipment , if there is someone else send them to get it
CPR- remove or move the clothing and do CPR
CPR in children and infant
infant: 2 fingers
Child: 1-2 hands
Infant 2 finger technique ( 1 rescuer)
- Place the infant on a firm flat surface
- Place 2 fingers in the center of the chest, just below the nipple line
- compressions 100-120/min
- At the end of each compression allow recoil
- After every 30 compressions, open airway give 2 breaths, each over 1 second. the chest should rise with each breath.
- After 5 cycles or 2 min ask for AED
- continue compressions until AED
Why do you have to allow for chest recoil?
Allows blood to flow into the heart.
Incomplete recoil–> less filling between compressions and reduces the blood flow created by chest compressions.
Infant 2 thumb-encircling hands technique ( 2 rescuers preferred)
- Place the infant on a firm flat surface
- Place thumbs side by side in the center of infants chest, on lower half of breastbone. (thumbs may overlap in very small children)
- compressions 100-120/min
- At the end of each compression allow recoil
- After every 15 compressions, open airway give 2 breaths, each over 1 second. the chest should rise with each breath.
- After 5 cycles or 2 min ask for AED
- continue compressions until AED
Why is the 2 thumb encircling hand technique the preferred when 2 rescuers? (3)
- produces better blood supply to the heart
- Helps ensure consistent depth and force of chest compressions
- May generate higher BPs
Methods for opening airway
head tilt-chin lift
jaw thrust manuevers
KEEP HEAD IN NEUTRAL POSITION
When there are 2 rescuers- how often they should switch roles?
Every 5 cycles or 2 min
Attenuator in the AED for children , how much reduces the dose of the shock
2/3.
Child vs. Adult pads of AED cutoff age.
Child pads : for infants and children < 8 years. If not available use adult.
Children> 8: adult pads
Location of adult pads/child pads
Adult pads: in the upper right chest and in the left lateral part
Child: in front and back ( most commonly for infants)
In infants why a manual defibrillator is preferred over an AED?
More capabilities than AED, and can provide lower energy doses
if this is not available and nor is an AED with attenuator , use the regular AED as is better to shock than do nothing.
PAT triangle ( Pediatric Assessment triangle)
ABC
Appearance - consciousness, TICLS ( tone, interactiveness, consolability, look/gaze, speech/cry)
breathing -
look patients position ( tripod or sniffing position)
retractions
stridor, sonorous respirations
color
Evaluate-Identify-Intervene approach
If no life-threatening condition
Evaluate
Primary assessment: rapid ABCDE approach, VS, oximetry
Secondary assessment: focused medical history and PE
Diagnostic assessments
Identify
Type and severity of the problem
Intervente
This cycle should be repeated over and over,:
with every single intervention or with any change ( improvement or deterioration) until the child is stable.
ABCDE approach
Airway Breathing Circulation Disability Exposure
How do you determine airway patency ?
- Look for movement of the chest and abdomen
- Listen for air mov and breath sounds
- Feel for movement of air at the nose and mouth
Breathing should be assessed as the same time as you check pulse - T/F
tRUE
Upper Airway Status
- Clear
- Maintenable
- Non maintenable
Definition of clear, maintenable and non maintenable airway
Clear: airway is open and unobstructed for normal breathing
Maintenable: Airway is obstructive but can be maintaned by simple measures( e.g. head tilt chin lift)
Not-maintenable: Airway is obstructed and needs advanced intervations ( intubation)
Signs that suggest that the airway is obstructed?
- increased inspiratory effort with retractions
- Abnormal inspiratory sounds ( snoring, high-pitched stridor)
- Episodes where no airway or breath sounds are present despite respiratory efforts ( complete upper airway obstruction)
Simple measures to maintain airway
POSITIONING:
If responsive child- allow him to assume a position of comfort or elevate the head of the bed.
If unresponsive:
Turn the child on his side if you dont suspect cervical injury or head tilt chin lift or jaw thrust .
If unresponsive and the jaw thrust is not open, use head tilt chin lift or jaw thrust with jaw extension because open airway is a priority.
SUCTIONING-nose and oropharynx , avoid overextending head and neck
Relief techniques if foreign object
AIRWAY ADJUNCTS: eg. oropharyngeal aiway ( to avoid the tongue from falling back) - NEVER RELY ON THIS ALONE, ALWAYS DO SOMETHING ELSE
Simple measures to maintain airway
positioning
suctioning
relief techniques for foreign body airway obstruction
airway adjuncts
If child suspected of aspirating foreign body and has complete airway obstruction? responsive/unresposive
responsive:
< 1 year: give 5 back slaps and 5 chest thrusts
>=1 year: give abdominal thrust
If unresponsive: activate or send someone to activate the emergency response system and start CPR
Advanced interventions to maintain airway patency
Endotracheal intubation
Application of continuous positive airway pressure or non invasive ventilation
Removal of foreign body requires direct laryngoscopy
Cricothyrotomy
5 things to assess breathing
- Respiratory rate and pattern
- Respiratory effort
- Chest expansion and air movement
- Lung and airway sounds
- O2 Saturation by pulse oximeter
Normal respiratory rate in
infant
toodler
preschooler
school-age
30-53 22-37 20-28 18-25 12-20
Abnormal breathing is RR< 10 and more than 60 is abnormal in any child T/F
True
How to determine RR
count the number of times the chest rises in 30 seconds and multipy by 2
*Normal sleeping infants may have irregular( periodic) breathing pauses lasting up to 10 or even 15 seconds.
Normal sleeping infants may have irregular( periodic) breathing pauses lasting up to 10 or even 15 seconds.
True
Irregular respiratory pattern may be a sign of?
Neurological condition
Tachypnea causes
- respiratory distress ( particularly when accompanied of respiratory effort)
- no respiratory causes - when there is just fast RR but no effort:
- fever, pain, anemia, cyanotic heart disease, sepsis
- Dehydration
Causes of bradypnea ( 7)
- respiratory muscle fatigue
- CNS injury or any problem that affects the respiratory control center
- Severe hypoxia
- Severe shock
- Hypothermia
- Drugs that repress respiratory drive
- Muscle disease that causes resp muscle weakness
What does bradypnea or irregular respiratory rate mean in a critically ill child?
signals of impending arrest
Definition of apnea
Cessation of breathing longer than 15 seconds
Classification of apnea
Central : no respiratory effort- abnormality or supression of the brain or spinal cord
Obstructive: inspiratory effort present without airflow. -ventilation is impeded , resulting in hypoxemia, hypercapnia or both.
Mixed apnea: periods of obstructive and periods of central apnea.
Why does increased respiratory effort occur?
In conditions where there is increased resistance to airflow ( asthma, bronchiolitis), or that causes lungs to be stiffer and difficult to inflate (pneumonia, pulmonary edema, pleural effusion)
Non respiratory conditi
Non respiratory conditions that cause increased respiratory effort
whatever that causes severe metabolic acidosis: shock, DKA, salicylate ingestion, inborn errors of metabolism)
Signs of increased respiratory effort?
nasal flaring
retractions( inward mov of the chest wall or tissues or sternum during inspiration)
head bobbing or seesaw respirations
location of retractions correlates to severity?
Yes
Location of retractions if mild-moderate?
subcostal, substernal, intercostal
Location of retraction if severe?
( may include same retractions than in mild-moderate) and
supraclavicular
suprasternal
sternal
retractions accompanied by stridor or inspiratory sound suggest..
upper airway obstruction
retractions accompanied by expiratory wheezing suggest..
lower airway obstruction ie.asthma bronchiolitis
retractions accompanied by grunting or labored resp suggest..
lung tissue disease
why does Head bobbing occur and what does it mean?
use of neck muscles to assist breathing
sign of increased deterioration/ respiratory failure
what are seesaw respirations and what do they mean?
when chest retracts and the abdomen expands during inspiration. During expiration the mov reverses.
Usually indicate UPPER AIRWAY OBSTRUCTION
May also be obseverd in sever lower airway obstruction
Characteristic of infants and chilren with NM weakness.
What respiratory effort pattern is Characteristic of infants and chilren with NM weakness.
seesaw respirations
Cause of seesaw breathing
NM disease, weakness of the abdominal and chest wall muscles.
Strong contraction of diaphragm that dominates the weaker abdominal and chest muscles.
Definition of tidal volume and normal value
volume of air inspired with each breath
Normal: 5-7 mL/kg
Ausculation lungs
anterior ( left and right to the sternum)
under the armpits ( best location to assess lower airway)
posterior: both sides of the back
Where is the best place to assess distal air entry?
auscultate below the axillae
What is minute ventilation
The volume of air that moves into or out of the lungs each min
Vmin= RR X Tidal volume
Causes of Low minute ventilation ( hypovent)
Since Vmin= RR X Tidal volume
low RR
Low Tidal volume ( stiff lungs, airway resistance)
Extremely fast RR that leads to low tidal volume
What is a stridor and what does it indicate?
Coarse, high pitched breathing typically on inspiration but can be heard in both inspiration and expiration.
upper airway ( extrathoracic) obstruction
Stridor causes
foreign body
infection ( croup)
congenital airway abnormalities ( eg, laryngomalacia)
acquired airway abnoramlities( tumor or cyst)
edema of upper airway
Snoring causes besides sleep
soft tissue swelling or decreased level of consciousness
What is grunting and when does it occurs
short, low-pitched sound heard during EXPIRATION
Sometimes misinterpreted as soft cry
Occurs as child exhales against a partial closed glottis
SIGN OF LUNG TISSUE DISEASE- small airway collapse, alveolar collapse or both.
Causes of grunting
progression of respiratory distress to failure
pneumonia
pulmonary contusion
acute respiratory distress syndrome
CHF resulting en pulmonary edema
sign of PAIN ( abdominal pathology: bowel obstruction, perforated viscus, appendicits)
What is gurgling and when does it occur
bubbly sound heard during inspiration or expiration
upper airway obstruction due to airway secretions, vomit, blood
Wheezing and causes
high or low pitched whistling most often during expiration
Indicates lower airway obstruction, especially of smaller airways( asthma, bronchiolitis)
Isolated inspiratory wheezing: foreign body aspiration or partial obstruction of the trachea.
Crackles and rales are the same T/F
True! word embedded
rub several hairs together
Crackles
moist crackles: accumulation of alveolar fluids ( pneumonia and pulmonary edema)
dry crackles : atelectasis and interstitial lung disease
Crackles are always present in pulmonary edema T/F
False, they may not be present
How do you describe crackles?
Type: fine, medium, coarse
when: inspiratory or expiratory
where: bilateral, unilateral, upper lobe, lower lobe etc.
Pulse oxymeter
tool to monitor the percentage of hemoglobin that is fully saturated with oxygen
Does oxyhemoblogin saturation indicate the amount of O2 delivered to the tissues?
NO!
Delivery is the product of the arterial O2 content ( O2 bound to Hb+ Dissolved O2) and CO.
ie. in anemia there is decreased hb and saturation can be 100%- and the delivery is still low.
O2 does not provide information about the effectiveness of ventilation T/F
True
Sat % that indicates hypoxemia?
< 94%, needs additional vent.
How does a pulse oximeter works?
has two parts that must be placed opposite to the other.
Lights of different wavelenghts are produced from one side of the probe and the light is captured on the other side of the tissue by the other probe.
A processor in the oximeter calculates the percent of each light that has been absorbed by tissues.
Hemoglobin that is fully saturated absorbs light different than if its fully saturated.
So the pulseoximeter can estimate the percent of hemoglobin that is fully saturated
Situations to keep in mind with pulseoximeter
- Anemia - sat can be 100%, but O2 delivery is low
- Carboxyhemoglobin-Methemoglob- 100% Sat – obtain ABGs.
- If it cant detect a consistent pulse or there is an irregular or poor waveform, the child may have poor distal perfusion or the oximeter may not be accurate
Signs of probable respiratory failure 7
- Very rapid or inadequate respiratory rate; possible apnea
- Significant, inadequate, or absent respiratory effort
- Absent distal air movement
- Extreme tachycardia or bradycardia
- Low O2 sat despite high flow supplementary oxygen
- Decreased level of consciousness
- Cyanosis
Circulation assessment components (5)
Heart rate and rhythm Pulses ( both peripheral and central) Capillary refill time Skin color and temperature Blood pressure
Arrhythmia can result from shock or hypoxia T/F
True
Hypoxia ( delivery) is the most common cause of bradycardia in children
True
If you see sign of poor perfusion, support vent with bag and mask and give O2.
If patient is breathing and poor perfusion
check pulse, if =< 60 compressions despite good oxygenation and ventilation.
HR > 180 in infants and > 160 in toddlers/children is ABNORMAL.
Yes, require further assessment.
What do you consider in a kid with congenital heart disease, when evaluating the heart rate and rhythm?
consider its baseline, he may have conduction abnormalities.
Respiratory sinus arrythmia what is it?
HR increases with inspiration and slows with expiration
Central pulses-
Femoral
Brachial ( infants)
Carotid ( in older children)
Axillary
-felt stronger because of the increased vessel size and proximity to the heart
peripheral pulses
Radial
Dorsalis pedis
Posterior tibial
how do the pulses change in shock
peripheral vasoconstriction leads to exaggeration of the central pulses
pulsus paradoxus
is an abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10 mmHg. When the drop is more than 10 mmHg, it is referred to as pulsus paradoxus.
inspiration–> increased venous return–> increased blood in RV and leads to bulging towards the LV decreasing the size/volume.
asthma, pericardial tamponade
Capillary refill time definition and normal val
The time it takes for blood to return to tissue blanches by presssure
Normal: =< 2 seconds.
How do you evaluate capillary refill time?
lift the extremity slightly above the level of the heart, press and remove fast.
Causes of delayed capillary refill time
dehydration
shock
hypothermia
in septic shock it may be normal or even fast!
How do you measure temperature and why?
back of your hand, more sensitive.
palm has thicker layer of skin.
Acrocyanosis
hands, feet and around mouth- normal in newly born but not in older children
Causes of peripheral cyanosis
Shock
CHF
Peripheral vascular disease
Conditions causing venous stasis
Causes of central cyanosis
( lip or other mucous membranes)
Low ambient O2 tension
Alveolar hypoventilation ( TBI, drug overdose)
Diffusion defect ( pneumonia)
Ventilation/perfusion mismatch ( asthma, bronchiolitis, ARDS)
Intracardiac shunt
Central pallor suggests:
Anemia or poor perfusion
When does cyanosis occur?
is apparent when at least 5g/dl of Hb is desaturated.
The O2 saturation at which a child will appear cyanotic depends on the child hemoglobin concentration
Children with different hemoglobin levels will be cyanotic at different levels of O2 Sat.
True,
cyanosis may be detected at higher O2 sats if the Hb is high.
Accurate BP measurement
cuff bladder should cover about 40% of the mid-upper arm circumference. The BP cuff should cover 50-75% of the length of the upper arm.
Hypotension in term neonates, infants,children (1-10y), children(>10)
Is based on the SBP -- the tresholds approximate just above the 5th percentile for age-- term neonates < 60 infants < 70 children (1-10y) <70 +(age in years x 2) children(>10) < 90
What do you think when a patient with hemorrhage develops hypotension
~ has lost 20-25% of circulating volume
Hypotension in septic shock?
can occur due to loss of intravascular volume or
inappropriate vasodlation or severe vasoconstriction, or inadequate CO/CI
Why do we measure urine output?
Indirect measure of kidney perfusion- indicates blood flow and hydration
In critically ill children accurate measurement requires an indwelling catheter.
Normal value of urine output in infant and younger children
1.5 - 2 mL/kg per hour
Normal value of urine output in older children and adolescents
1 mL/kg per hour
Children with shock typically have decreased urine output. T/F
True
Disability assessment
AVPU ( Alert, responsive to voice, responsive to pain, unresponsive) Pediatric Response scale
GCS
Pupil response to light
Blood glucose test
AVPU Pediatric Response scale
To evaluate cerebral cortex function
Rates the level of consciousness in 4 states:
( Alert, responsive to voice, responsive to pain [sternal rub, pinching trapezius], unresponsive)
Causes of decreased level of consciousness
BRAIN: poor cerebral perfusion TBI Seizure activity Encephalitis/meningitis
OTHERS severe shock hypoglycemia hypoxemia hypercabnia drugs
GCS
EVM 456
Eye
Spontaneous, to voice, to pain, no eye opening
Verbal
Oriented, confused, inappropriate words, incomprehensible words, no response
Motor Obeys commands Localizes pain Withdraws from pain Abnormal flexion Abnormal extension No response
GCS classification
Mild head injury 13-15
Moderate 9-12
Severe < 9
Modified version of GCS for infants
see phone
When do you prefer AVPU vs. GCS
AVPU may be more appropriate in the pre-hospital setting
GCS in the hospital ED.
Correlation AVPU GCS
Alert 15
Response to verbal 13
Pain stimulation 8
Unresponsive to noxious stimuli 6
Pupil response to light should be done in any patient with altered mental status
True
useful indicator of brainstem status
Pinpoint pupils causes
narcotic ingestion - opioids
Dilated pupils causes
Predominant sympathetic activity Sympathomimetic ingestion ( cocaine) Anticholinergic ingestion ( atropine) Increased intracranial pressure
Unilaterally dilated pupils
Inadvertent topical absorption of a breathing treatment ( ipratropium)
Dilating eye drops
Unilaterally dilated pupils with altered mental status
IPSILATERAL uncal herniation
Description of pupils
PERRL
Pupils Equal, Round, Reactive to light.
Hypoglycemia values
In newborn =<45
In child=<60
Exposure is the last component of primary assessment:
Undress
Look for evidence of trauma ( bleeding, burns, abnormal markings)
petequia/purpura
deformities/bruises
Secondary assessment components
Focused history ( SAMPLE)
Focused PE
Ongoing reassessment
SAMPLE for focused history
Signs and Symptoms
Allergies - meds, food,latex/associated reaction
Medications- include overthecounter, vit, last dose and time of recent meds, meds that can be found in childs environment.
Past Medical History - born, Cxs/hospitalizations, illness, immunization
Last meal - time and nautre of last meal. elapsed time between last meal and presentation of current illness
Events - leading to current illness or injury ( sudden, gradual), hazards at scene, treatment during inteval from oset, time of onset.
Components of ongoing reassessment
PAT
ABCDE of primary approach with acquisition of VS and pulseoximetry
Assessment of abnormal anatomic and physiologic findings
Review the effectiveness of treatment interventions with each cycle
PaO2 indicates ..
O2 dissolved in plasma
PaO2 normal and Hb of 3, what can you say about the saturation and delivery to tissue
Saturation can be 100%, but due to the low Hb there is inadequate delivery to the tissues
Acid-Base algorithm
say it
serial ABGs are better than only once, because it just indicate a state in a time point.
true
What is hyperoxia
increased arterial O2 sat detected by direct measure in ABG .
what does increased base deficit means
accumulation of acid in the blood
When do you do venous blood gases, advantages/disadvantages
When there is no arterial sample available, usually not very useful for arterial oxygenation
there are differences based on where the same was taken from, so better central than peripheral.
There are some correlations of VBG to ABGs but not ideal.
Central venous O2 sat value and what does it reflect
indicator of the balance between delivery and O2 consumption
normal is 70-75%, considering an arterial Sat 100%
If sat is lower consider 30% less and that is the SVO2
Why does lactate is high in critically ill patients?
metabolic acidosis –> increase lactate
associated with tissue hypoxia and resultant anaerobic metabolism.
good prognostic indicator, and can be used to measure therapy response.
if no metabolic acidosis, some example of elevtion is stress hyperglycemia
Things to consider when measuring lactate
can be falsely elevated if not taken from a free flowing blood sample
Delayed testing of sample can affect accuracy
What is near infrared spectroscopy and how does it work?
non invasive optical technique to monitor tissue oxygenation in brain and other tissues
measures the concentration of oxyHb and desaturated Hb.
small heart in Xray causes
reduced cardiac preload, severe lung hyperinflation
large heart in Xray causes
normal or increased preload
pericardial effusion
CHF
or patient is unstable to take a deep breath
Heart size is different in the anteroposterior view compared to the posterior-anterior
Anteroposterior will look larger
Which are the most common scenarios of cardiac arrest in infants/children?
Usually result from progressive respiratory failure, shock or both. –HYPOXIC-ISCHEMIC ARREST
Less commonly result from an arrhythmia or ventricular tachycardia 5-15%
Respiratory failure without respiratory distress cant occur T/F
False
Respiratory failure without respiratory distress can occur
ASSOCIATED WITH DECREASED LEVEL OF CONSCIOUSNESS
The incidence of cardiac arrest from Vf/pVT increases with age and should be suspected in any patient with SUDDEN collapse T/F
TRUE
What is the rate of survival at hospital discharge if cardiac arrest occurs inhospital?
43%
What is the rate of survival at hospital discharge if cardiac arrest occurs out-of-hospital?
8%
Survival is higher if shockable rhythm vs. asystole
true
25-34% compared to 7-24%
What is cardiac arrest?
cessation of blood circulation resulting from absent or ineffective cardiac mechanical activity
no pulse, no breathing( cerebral hypoxia-> loss of consciousness-> stop breathing)
2 pathways for cardiac arrest in children
- Hypoxic ischemic- when there is respiratory failure or hypotensive shock there is progressive tissue hypoxia and acidosis
- Sudden cardiac arrest
Causes of sudden cardiac arrest, and predispositions
Vfib and pulseless Vtach
Predisposing conditions are:
- HCM
- anomalous coronary artery
- Long QT syndrome or other channelopathies
- Myocarditis
- Drug intox ( digoxin, ephedra, cocaine)
- Commotio cordis
Commotio cordis (Latin, “agitation of the heart”)
is an often lethal disruption of heart rhythm that occurs as a result of a blow ( chest impact) to the area directly over the heart (the precordial region), at a critical time during the cycle of a heart beat causing cardiac arrest.
Causes of cardiac arrest
< 6 months: SIDS
> 6 months: traumatic cardiac arrest- airway compromise, tension pneumothorax, brain injury
Reversible causes of cardiac arrests
6 Hs and 5 Ts
Hypoxia Hypothermia Hypovolemia Hypoglycemia H+ ( acidosis) hypo/HyperK
Toxins Thrombosis pulmonary Thrombosis coronary Tamponade Tension pneumothorax
Arrest rhythms
PEA
Asystole
pulseless Ventriculat Tachycardia, including torsaides de pointes
Vfib
Which are the most common arrest rhythms based on age
in younger than 12 is PEA, asystole
In older is Vfib, pVT and is associated to sudden cardiac arrest and/or predisposing conditions.
What is an agonal rhythm
Slow wide QRS complex that immediately precedes asystole
What is PEA
There is some sort of activity ( organized cardiac activity) in the ECG but there is no pulse.
pulsations may be detected by an arterial waveform or doppler, but no PULSE.
EKG may show different things:
- low or high amplitude T waves
- prolonged PR and QT intervals
- AV dissociation , complete heart block, ventricular complexes without p wave
Are there pulses in Vfib?
NO! Its a pattern of cardiac arrest.
Vfib- no organized rhythm and no coordinated contractions
electrical activity is chaotic
the heart is not able to pump blood– pulses are not palpable
Vfib may be preceded by a brief period of VT with or without pulses. T/F
True
Difference between Vfib and pulseless VTaq
Vfib- disorganized rhythm
pVT: organized, wide QRS complexes
Torsades de Pointes
polymorphic VT
seen in conditions with prolonged QT interval, including congential long QT syndrome, drug toxicity, hypomagnesemia
Causes of torsades des pointes
HypoMg, HypoK
Anti ABCDE+ opioids( methadone, oxycodone)+ HIV protease inhibitors
Arrhythmics ( IA,III)
Biotics (Macrolides, antimalarials, fluoroquinolones)
Cychotics ( haloperidol, risperidone)
Depressants ( SSRIs, TCAs)
Emetics ( ondansetron)
Congenital
Romano Ward- puRe heart
Jervell and Lange-Nielsen syndrome: cardiac + sensorineural deafness
Antiarrhythmics type I and subtypes
Na+ channel blockers ( slow or block conduction)
IA: The Queen Proclaims Disos pyramide ( Quinidine, Procainamide, Disopyramide)
IB: Lidia es Mexican, fea y toca en un restaurante ( Lidocaine, Mexiletine, phenytoin, tocamide
IC: Propon tener fleco
Propafenone, flecainamide
Antiarrhythmics type II
B blockers -lol
Prolong PR
Decrease SA and AV node activity
Antiarrhythmics type III
K channel blockers:
AIDS Amiodarone Ibutilide Dofetilide Sotalol
Prolong QT
Antiarrhythmics type IV
Ca channel blockers
Verapamil, diltiazem
Prolong PR
Although hands only CPR is an option, the ideal in hypoxic asphyxial arrest is CPR ( hands and ventilation)!!!!
True
Hands ony can be done if the rescuer has no expertise or doesnt want to give breath. Better this than nothing.
What is the difference of the Activation of emergency response system step between infants/children and adolescents/adults?
In infants and children:
If witnessed and no phone, leave the victim and get AED before CPR
If unwitnessed and single rescuer: give 2 min CPR, then go for AED and activation of emergency system, return to kid give CPR and use AED
In adolescents and adults:
If single rescuer: Activate emergency system and look for AED before starting compressions.
Otherwise send someone for AED and begin CPR.
How are the rate of compressions without advanced airway different between adolescents/adults and infants/children ?
adolescents/adults: if 1 or more rescuers 30:2
children/infants: 2 rescuers 15:2
1 rescuer 30:2
How are the rate of compressions with advanced airway different between adolescents/adults and infants/children ?
SAME
continuous compressions at a rate of 100-120/min
Give 1 breath every 10 seconds.
Hand placement for CPR in adults/adolescents, children ( 1 year-puberty), infants
adults/adolescents: 2 hands on the lower half of the breastbone
children ( 1 year-puberty): 2 hands or 1 hand ( rescuer can use either method on a small child) on the lower half of the breastbone ( sternum)
infants: 1 rescuer: 2 fingers in the center of the chest just below the nipple line
2 rescuers: 2 thumb encircling hand in the center of the chest just below the nipple line.
Breaths in CPR
Each rescue breath should be given over about 1 second
Each breast should result in visible chest rise
After an advanced airway is in place: 10 breaths per min ( 1 breath every 6 seconds).
After an advanced airway is in place how are the breaths in CPR
After an advanced airway is in place: 10 breaths per min ( 1 breath every 6 seconds).
What is PETCO2? Why is it useful?
measures ventilation
End tidal CO2 - seen in capnography
a measure of the amount of carbon dioxide present in the exhaled air.
Indirect evidence of que quality of the compressions.
Normal value is same as PaCO2: 35-45
What does a PETCO2 > 10-15mmHg mean?
CO during CPR is low and not much blood is being delivered to the lungs
Capnography
is the monitoring of the concentration or partial pressure of carbon dioxide (CO. 2) in the respiratory gases.
presented as a graph of expiratory CO
priority for drug delivery routes?
IV>IO>ET
Why is not very common to put a central venous access in cardiac arrest?
Although is the best option because of faster onset of meds and higher peak concentration of meds
Its placement requires interrumption of chest compressions
Complications: hematoma, vascular lacerations, pneumothorax, bleeding.
What is required when giving IV meds peripherally?
- Give them in boluses
- Give the drug while chest compressions are beign performed
- Follow with a 5 mL flush of normal saline to mode the drug from the peripheral to the central circulation.
IO access, why is a good option if the peripheral access doesnt work?
- BM provide access to a noncollapsible marrow venous plexus- so useful in profound shock, dehydration
- Followed by flush medications may reach central circulation
Contraindications and relative contraindications for IO access?
There are no absolute
Relative:
- trauma to the extremity- we dont know if there is damage of BM
-Overlying infection( cellulitis)
If an IO access stop working, change of bone. Its likely that if you try in same bone whatever you are inserting will leak through previous bone.
Osteogenesis imperfecta or congenital bone diseases are CI for IO access. T/F
False.
Equipment for IO access
Towel roll Gloves Antiseptic wipes IO needle/drill syringe/blood specimen containers for lab work connector tube saline flush
