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Methods of Anesthesia > PALS > Flashcards

PALS Flashcards

1
Q

What does EWL stand for?

A

Estimated weight loss

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2
Q

What does FBAO stand for?

A

Foreign body airway obstruction

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3
Q

What does LVOT stand for?

A

Left ventricular outflow tract obstruction

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4
Q

What does PEFR stand for?

A

Peak expiratory flow rate

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5
Q

What does ROSC stand for?

A

Return of Spontaneous Circulation

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6
Q

What is a prominent sign of ROSC?

A

Sudden increase in EtCO2

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7
Q

What does RVOT stand for?

A

Right ventricular outflow tract obstruction

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8
Q

What should you do when a patient is showing agonal gasps?

A

Immediately start CPR

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9
Q

Blue discoloration of hands and feel, and around the mouth and lips

A

Acryocyanosis

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10
Q

Cessation of breathing for 20 seconds

A

Apnea

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11
Q

When can apnea be considered at less than 20 seconds?

A

When it is accompanied by bradycardia, cyanosis or pallor

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12
Q

What is central apnea?

A

No respiratory effort

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13
Q

What is obstructive apnea?

A

Pt is trying to breathe but ventilation is impeded by an obstructive airway

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14
Q

Most common cause of bradycardia in kids

A

Apnea and/or hypoxia

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15
Q

Bradycardia in newborns

A

<80 bpm or <100 bpm

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16
Q

Bradycardia in infants and children

A

<60 bpm

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17
Q

What does Broselow tape do?

A

Approximates weight and drug doses

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18
Q

1st 28 days of life

A

Neonate

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19
Q

1 month to 1 year of age

A

Infant

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20
Q

1 year to onset of puberty

A

Child

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21
Q

Puberty or older

A

Adult

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22
Q

The proportion of time spent performing chest compressions for patients in cardiac arrest

A

Chest compression fraction: At least 60% and ideally greater than 80% of the resuscitation attempt

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23
Q

Inflammation of the larynx/vocal cords

A

Croup

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24
Q

What is mild croup?

A

Barking cough

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25
Q

What is moderate croup?

A

Stridor and retractions at rest

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26
Q

What is severe croup?

A

Significant agitation with decreased air entry

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27
Q

Bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood

A

Cyanosis

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28
Q

When is cyanosis apparent?

A

When at least 5g/dL of hemoglobin are desaturated

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29
Q

True/false. The more anemic you are, the lower the SpO2 that will be required for cyanosis to be present

A

True

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30
Q

What should you consider in PALS scenarios when a fever is present?

A

Administering antibiotics

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31
Q

SpO2 that is considered hypoxemia in PALS

A

<94% on room air

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32
Q

When should you consider administering supplemental oxygen in PALS?

A
  1. If SpO2 is <94% or

2. There are poor signs of perfusion

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33
Q

What can prevent hypoxemia from turning into tissue hypoxia?

A

An increase in cardiac output

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34
Q

What is permissive hypoxemia?

A

An SpO2 reading of <94% that may be appropriate or normal in certain circumstances

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35
Q

Examples of permissive hypoxemia

A
  1. Pt in high altitude

2. Pt with CHD (tetralogy of Fallot)

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36
Q

Hypoxia due to reduced arterial oxygen saturation

A

Hypoxemic hypoxia

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37
Q

Normal SaO2, but hypoxia due to decreased hemoglobin concentration, which leads to decreased total oxygen content in the blood (CaO2)

A

Anemic hypoxia

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38
Q

Normal SaO2 and hemoglobin concentration, but hypoxia due to decreased blood flow to the tissues

A

Ischemic hypoxia

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39
Q

Normal blood content and oxygen delivery, but hypoxia due to the inability of tissues to take up or utilize the oxygen from the bloodstream

A

Histotoxic/cytotoxic hypoxia

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40
Q

Cyanide poisoning, carbon monoxide poisoning, methemoglobinemia, septic shock/impaired mitochondrial function

A

Histotoxic/cytotoxic hypoxia

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41
Q

low cardiac output, hypovolemia, severe vasoconstriction, etc

A

Ischemic hypoxia

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42
Q

Hypoglycemia in neonates

A

<45 mg/dL

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43
Q

Hypoglycemia in infants/children/adolescents

A

<60 mg/dL

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44
Q

Signs of hypoglycemia in peds

A

Poor perfusion, hypotension and tachycardia, sweating, irritability, and/or lethargy

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45
Q

Glucose dose for treating hypoglycemia

A

0.5-1 g/kg bolus or 2-4 ml/kg of D25W

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46
Q

Treatment for minimal symptoms of hypoglycemia and the child is stable

A

Oral glucose via juice

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47
Q

Systolic BP for hypotension in neonates

A

<60

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48
Q

Systolic BP for hypotension in infants

A

<70

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49
Q

Systolic BP for hypotension in children 1-10 yrs

A

<70 + (age in years x2)

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50
Q

Systolic BP for hypotension in children >10 yrs

A

<90

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51
Q

How low can the systolic pressure of a 3 y/o patient go before they are considered hypotensive?

A

<76

70 + (age x 2)

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52
Q

Patchy discolorations of the skin, caused by areas of vasoconstriction (pallor) mixed with areas of vasodilation (cyanosis or erythema)

A

Mottling

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53
Q

What can mottling be a sign of?

A

Imminent death

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54
Q

Pale color due to lack of oxygen in the skin

A

Pallor

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55
Q

Where is central pallor seen?

A

In the lips and mucous membrane

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56
Q

Signs of good peripheral perfusion (vasodilation)

A
  1. Good pulse (as long as BP is adequate)
  2. Flushed skin
  3. Brisk capillary refill (,2 seconds)
  4. Warm skin
  5. Awake and alert
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57
Q

Signs of poor/inadequate perfusion

A
  1. Weak pulse
  2. Pale or cyanotic skin color
  3. Delayed capillary refill and cool extremities (vasoconstriction)
  4. Decreased responsiveness and/or consciousness
  5. Metabolic acidosis, elevated lactate and decreased urine output
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58
Q

Purple discolorations caused by small vessel bleeding

A

Petechiae and purpura

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59
Q

What do petechiae and purpura suggest?

A
  • Low platelet count or a symptoms of disseminated intravascular coagulation
  • in PALS, septic shock
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60
Q

What does it mean if a child is refractory to treatment?

A

They do not improve or respond to a specific therapy

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61
Q

What does fluid refractory hypotension mean?

A

A child remains hypotensive despite fluid administration

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62
Q

What does hypoxic refractory to supplemental oxygen administration mean?

A

May need they need a breathing treatment, or may need to be mask ventilated or intubated

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63
Q

What does norepinephrine refractory shock mean?

A

A child in shock in unresponsive to norepinephrine therapy

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64
Q

Normal capillary refill time

A

<2 seconds

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65
Q

Prolonged capillary refill time

A

> 5 seconds

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66
Q

Common causes of prolonged capillary refill time

A
  1. Dehydration
  2. Shock
  3. Hypothermia
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67
Q

SVT rate for infants

A

> 220

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68
Q

SVT rate for children

A

> 180

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69
Q

Normal oxygen consumption for adults

A

3-4 ml/kg/min

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70
Q

Normal oxygen consumption for infants

A

6-8 ml/kg/min

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71
Q

Normal SpO2 on room air

A

> 94%

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72
Q

SpO2 on 100% oxygen that requires intervention

A

<90%

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73
Q

Normal ScvO2

A

25-30% below the SaO2 (70-75% if the SaO2 is normal)

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74
Q

Normal urine output for infants and young children

A

1.5-2 ml/kg/hr

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75
Q

Normal urine output for older children and adolescents

A

1 ml/kg/hr

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76
Q

What is reduced urine output a sign of?

A

Poor perfusion

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77
Q

What is quiet tachypnea caused by?

A

Non-pulmonary issues such as fever, pain, metabolic acidosis, etc

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78
Q

Why are pediatric patients prone to upper airway obstruction?

A
  1. They have a large tongue

2. they have a large occiput that causes neck flexion

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79
Q

How can you keep a pediatric patient in the sniff position?

A

Use a shoulder roll

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80
Q

Is total resistance in the small airways higher or lower?

A

Lower

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81
Q

Which airways are more prone to turbulent air flow and why?

A

Larger airways because they have more resistance than the smaller

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82
Q

When the radius of the airway decreases, what happens to resistance for laminar flow?

A

It increases to the 4th power

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83
Q

When the radius decreases, what happens to resistance in turbulent airflow?

A

It increases to the 5th power

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84
Q

What does turbulent flow do to airway resistance?

A

It increases airway resistance and can make it harder to breathe

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85
Q

When is airflow laminar (has lower resistance)?

A

During normal respiration because the driving pressure of air during normal breathing is low

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86
Q

When can airflow become turbulent?

A
  1. Partial airway obstruction (usually upper airway obstruction)
  2. Labored/agitated breathing/increased respiratory efforts/crying
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87
Q

What effect does low gas density have on laminar flow and resistance?

A

Lower gas density = higher percentage of laminar flow = lower resistance

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88
Q

Primary inspiratory muscles

A
  1. Diaphragm

2. External intercostals

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89
Q

Accessory inspiratory muscles

A
  1. Sternocleidomastoid
  2. Internal intercostals
  3. Scalene muscles
  4. Pectoralis major
  5. Pectoralis minor
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90
Q

Accessory expiratory muscles

A
  1. Rectus abdominis
  2. External oblique
  3. Internal oblique
  4. Transversus abdominis
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91
Q

True/false. Labored breathing helps with oxygenation and ventilation

A

False

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92
Q

Why should you avoid excessive ventilation?

A
  1. It causes air trapping
  2. It increases intrathoracic pressure, impedes venous return, decreases CO, coronary perfusion and cerebral blood flow
  3. It increases the risk of regurgitation and aspiration in kids without an advanced airway
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93
Q

How can you minimize gastric inflation?

A
  1. Ventilating slowly
  2. Delivering each breath over 1 second, and ventilating only until chest rise is observed
  3. Considering the use of cricoid pressure
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94
Q

Tracheal tubes recommended for children <8 years old

A

Uncuffed

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95
Q

Formula for choosing the correct ETT

A

uncuffed tube = (age/4) +4

cuffed tube = (age/4) + 3

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96
Q

Formula for choosing correct depth (cm) of insertion of ETT

A

For kids <2 y/o, internal diameter x3

For kids >2 y/o, (age/2) +12

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97
Q

After ___ ventilations, detected CO2 can be presumed to be from the trachea

A

6

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98
Q

Method of administering drugs through the ETT

A
  1. Dilute the drug with 5 ml NS
  2. Deliver the drug via the ETT while briefly holding compressions
  3. Follow drug delivery with 5 PPV
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99
Q

Epinephrine dose through ETT

A

10x the IV dose

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100
Q

Dosing drugs through the ETT (excluding epi)

A

2-3x IV dose

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101
Q

What does DOPE stand for?

A

Displacement
Obstruction
Pneumothorax
Equipment failure

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102
Q

When is DOPE used in PALS?

A

Anytime an intubated patient deteriorates

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103
Q

True/false. Resonant sounds are normal lung sounds with percussion

A

True

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104
Q

When are hyperresonant sounds observed?

A

In patients with

  1. Hyperinflated lung (COPD, acute asthma attack)
  2. Hyperinflated chest cavity (tension pneumothorax)
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105
Q

What causes wheezing?

A

Bronchoconstriction

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106
Q

Possible causes of rales

A
  1. Fluid in the distal airways
  2. Atelectasis
  3. Cardiogenic shocks
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107
Q

Possible causes of rhonchi

A

Secretions, mucus or blood in the larger airways

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108
Q

Possible causes of stridor

A

Upper airway obstruction

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109
Q

What does grunting mean?

A

Possible impending respiratory failure

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110
Q

What causes grunting?

A

Lung tissue disease such as pneumonia, pulmonary edema, pulmonary contusion, ARDS or pulmonary edema produced by cardiogenic shock

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111
Q

Signs of respiratory distress

A
  1. Flared nostrils
  2. Head bobbing
  3. Disordered control of breathing
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112
Q

What can cause disordered control of breathing?

A
  1. Medication overdose
  2. Seizure that led to increased ICP
  3. Other neurological problems
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113
Q

What is disordered control of breathing?

A

Irregular respiratory rate and/or insufficient respiratory effort which can lead to hypoxemia and hypercarbia

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114
Q

Are substernal and subcostal retractions considered mild/moderate or severe?

A

Mild/moderate

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115
Q

Are suprasternal or supraclavicular retractions considered mild/moderate or severe?

A

Severe

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116
Q

What happens with seesaw respirations?

A

The chest retracts during inspiration and the abdominal expands
During expiration, the chest expands and the abdomen moves inward

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117
Q

What do seesaw respirations usually indicate?

A

Upper airway obstruction

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118
Q

What are other things seesaw respirations can indicate?

A

Neuromuscular weakness, lower airway obstruction, lung tissue disease, disordered control of breathing

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119
Q

Diagnosis for retractions + inspiratory snoring/stridor

A

Upper airway obstruction (croup, foreign body)

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120
Q

Diagnosis for retractions + expiratory wheezing

A

Lower airway obstruction (asthma, bronchiolitis)

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121
Q

Diagnosis for retractions + grunting or labored respirations

A

Lung tissue disease or pulmonary edema produced by cardiogenic shock

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122
Q

Diagnosis for severe retractions

A

May be accompanied by head bobbing or seesaw respirations

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123
Q

Treatment for severe choking in responsive children

A

Heimlich maneuver or abdominal thrusts

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124
Q

Treatment for severe choking in responsive infant

A

Place pt prone in one arm and deliver 5 back slaps, flip patient over and deliver 5 downward chest thrusts with 2 fingers

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125
Q

Treatment for severe choking in unresponsive patients

A

CPR

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126
Q

Type of airway obstruction associated with expiration

A

Lower (asthma, bronchoconstriction)

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127
Q

Type of airway obstruction associated with inspiration

A

Upper (soft tissue, croup, swelling, anaphylaxis)

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128
Q

When is suctioning contraindicated?

A

Upper airway obstructions

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129
Q

What diagnoses do these symptoms fit under: hypoxemia, possible poor chest rise or decreased air movement, possible breathing with accessory muscles, tachycardia (early), bradycardia (late)

A
  1. Upper airway obstruction
  2. Lower airway obstruction
  3. Lung tissue disease
  4. Disordered control of breathing
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130
Q

What are the diagnoses for these symptoms?

Signs of labored breathing/respiratory distress (retractions, etc)

A
  1. Upper airway obstruction
  2. Lower airway obstruction
  3. Lung tissue disease
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131
Q

What are the diagnoses for these symptoms?

Stridor, inspiratory snoring, hoarseness, barking cough, drooling, snoring, gurgling

A

Upper airway obstruction

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132
Q

What are the diagnoses of these symptoms?

Expiratory wheezing, active expiration?

A

Lower airway obstruction

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133
Q

What are the diagnoses for these symptoms?

Grunting, crackles (rales), fever

A

Lung tissue disease

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134
Q

What are the diagnoses for these symptoms?

Normal(or shallow) breath sounds with an abnormal respiratory pattern, possible central apnea (no respiratory effort)

A

Disordered control of breathing

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135
Q

What makes a likely cardiogenic shock scenario?

A

Bad lung sounds and hypotension

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136
Q

What makes a likely airway scenario?

A

Bad lung sounds and normal blood pressure

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137
Q

What is the rate and FiO2 of a high flow nasal cannula?

A

> 50 L/min can deliver an FiO2 of close to 100%

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138
Q

Low flow oxygen delivery devices

A

Simple oxygen mask

Nasal cannula

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139
Q

High flow oxygen delivery devices

A

High flow nasal cannula

Nonrebreathing mask

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140
Q

FiO2 of simple oxygen mask

A

35-60%

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141
Q

FiO2 of nasal cannula

A

22-60%

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142
Q

FiO2 of high flow nasal cannula

A

Up to 95%

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143
Q

FiO2 of nonrebreathing mask

A

Up to 95%

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144
Q

When are breathing treatments indicated?

A

For lower airway obstruction

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145
Q

What does heliox do?

A

Generates less airway resistance than air (higher laminar flow) to make it easier for patients with an upper airway obstruction to breathe

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146
Q

Most prominent example of heliox being used in PALS

A

croup or other upper airway edema

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147
Q

2 primary advantages to humidified oxygen

A
  1. Decreases the chance of coughing

2. Humidity can loosen mucus and provide easier breathing

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148
Q

When is humidified oxygen considered?

A

In moderate to severe croup and sometimes asthma

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149
Q

When is racemic epi used?

A

In cases of upper airway obstruction caused by swelling

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150
Q

When are steroids used?

A

To relieve symptoms of upper airway obstruction/swelling/croup

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151
Q

What is magnesium used for?

A

For bronchodilation when patients fail to respond to conventional therapy

152
Q

What is an adverse effect of magnesium?

A

Hypotension

153
Q

What is mannitol and/or hypertonic saline used for?

A

Treatment for disordered control of breathing caused by increased intracranial pressure

154
Q

Most commonly used inhaled bronchodilator

A

Albuterol

155
Q

Anticholinergic and a bronchodilator

A

Iapotropium

156
Q

Adverse effects of Narcan

A

Increased heart rate and blood pressure, acute pulmonary edema, cardiac arrhythmias, seizures

157
Q

Possible ways to support the airway in PALS

A
  1. Give supplementary oxygen if SpO2 <94%
  2. Assist the airway as needed and consider intubation
  3. Suction any secretions
  4. Administer antibiotics if febrile
  5. Consider ordering labs/CXR
  6. Treat bradycardia
  7. Give breathing treatments/racemic epi/heliox/humidified O2/steroids
158
Q

Treatments for all 4 airway scenarios

A
  1. Supplementary oxygen if SpO2 is <94%
  2. Assist airway if needed
  3. Suction secretions
  4. Treat bradycardia
159
Q

Treatments for lower airway obstruction and lung tissue disease only

A
  1. Administer breathing treatments and/or bronchodilators

2. Consider labs and/or CXR

160
Q

Treatments for upper airway obstruction only

A
  1. Administer heliox and/or humidified oxygen

2. Administer raceimic epi and/or steroids

161
Q

Treatment for lung tissue disease only

A

Administer antibiotics if febrile

162
Q

Treatment for disordered control of breathing only

A

Consider reversal agents (unless it was a seizure med)

163
Q

When can racemic epi be used?

A

in lower airway obstruction if other breathing treatments fail
-upper airway obstruction

164
Q

Check for breathing protocol

A
  1. Check responsiveness
  2. Check pulse and breathing simultaneously
  3. If there is no pulse/you are unsure/pulse is <60 bpm, begin compressions
  4. If there is a pulse, but no breathing, give rescue breaths
165
Q

Respiratory rate if there is a pulse but no breathing

A

1 breath every 3-5 seconds (12-20 breaths per minute) or 10 breaths/min if an advanced airway is placed

166
Q

Leading cause of death in infants younger than 6 months

A

SIDS

167
Q

Most common cause of arrest in kids

A

Asphyxial arrest

168
Q

CPR depth in infants

A

1.5 inches

169
Q

CPR depth in children

A

2 inches

170
Q

CPR depth in adolescents and adults

A

<2.4 inches

171
Q

When is a 2 handed CPR technique used?

A

For adults and kids >8 years old

172
Q

When is a one handed CPR technique used?

A

For children 1-8 years old

173
Q

When is a two finger CPR technique used?

A

For infants when only one responder is available

174
Q

When is a thumb encircling technique used?

A

For neonates and infants when two responders are available

175
Q

What are the advantages of the thumb encircling technique when compared to the 2 finger technique?

A
  1. Better coronary blood flow
  2. More consistent depth
  3. May generate higher blood pressures
176
Q

CPR for children with 1 provider and no advanced airway

A

30:2 compression/ventilation ratio

One vs two handed technique

177
Q

CPR for children with 2 providers and no advanced airway

A

15:2, two handed

178
Q

CPR for children with 2 providers and intubated

A

100-120 compressions/min
age appropriate RR (8-10 breaths/min)
One vs two handed

179
Q

CPR for neonates with 1 provider and no advanced airway

A

3:1 respiratory cause
15:2 cardiac cause
2 finger technique

180
Q

CPR for neonates with 2 providers and no advanced airway

A

3:1 respiratory cause
15:2 cardiac cause
thumb encircling technique

181
Q

CPR for neonates with 2 providers and intubated

A

100-120 compressions/min
Age appropriate respiratory rate
Thumb encircling technique

182
Q

Type of ECMO for respiratory failure

A

Venovenous

183
Q

Type of ECMO for cardiac failure

A

Venoarterial

184
Q

How do you assess neurologic status in PALS?

A
  1. Check blood sugar
  2. Check pupil response to light
  3. AVPU
  4. GCS
185
Q

Neuro signs/symptoms of hypoxia

A
  1. Loss of muscle tone
  2. Generalized seizures
  3. Dilation of pupils
  4. Loss of consciousness
186
Q

Neuro signs/symptoms of cerebral herniation

A
  1. Unequal and/or dilated and/or unresponsive pupils
  2. Hypertension
  3. Bradycardia
  4. Respiratory irregularities or apnea
  5. Diminished response to stimuli
  6. Sudden increase in ICP
187
Q

When are pediatric manual defib pads used?

A

On children <1 y/o

188
Q

When are pediatric AED pads used?

A

On children 1-8 y/o

189
Q

When are adult AED pads used?

A

On kids >8 years old or on infants in cardiac arrest if pediatric pads are not available

190
Q

Paddle placement for >1 y/o

A

Anterior posterior placement

191
Q

Paddle placement for <1 y/o

A

Anterior-anterior

192
Q

Defib dosing for synchronized cardioversion

A

1st shock: 0.5-1 J/kg

2nd shock: 2 J/kg

193
Q

Defib dose for defibrillation

A

1st shock: 2 J/kg
2nd shock: 4 J/kg
Subsequent shock: >4 J/kg
Max shock: 10 J/kg or adult dose

194
Q

Water takes up what percentage of body weight in infants?

A

70%

195
Q

Water takes up what percentage of body weight in neonates?

A

80%

196
Q

1 kg = ___ L of water

A

1 L

197
Q

PALS assumes water takes up what percentage of body weight?

A

100%

198
Q

How is weight loss in PALS expressed as volume loss?

A
  1. Percentage of volume depletion

2. mL/kg of volume loss

199
Q

When estimated weight loss is expressed in mL/kg, it is ___ the percentage of weight that was lost

A

10x

200
Q

5% EWL is

A

50 ml/kg

201
Q

What percent of total fluid volume is blood?

A

10%

202
Q

EWL of adolescents for mild dehydration

A

3% (30 mL/kg)

203
Q

EWL of adolescents for moderate dehydration

A

5-6% (50-60 mL/kg)

204
Q

EWL of adolescents for severe dehydration

A

7-9% (70-90 mL/kg)

205
Q

EWL of infants for mild dehydration

A

5%

206
Q

EWL of infants for moderate dehydration

A

10%

207
Q

EWL of infants for severe dehydration

A

15%

208
Q

Why can younger children tolerate more volume loss?

A

They have higher circulating blood volumes / more water to lose

209
Q

When is hypovolemic/hypotensive shock possible?

A

Possible with 5% EWL, but more likely with 10% or greater EWL

210
Q

What is the treatment for a child with clinically evident dehydration?

A

20 mL/kg boluses of isotonic crystalloid

211
Q

When are more rapid boluses of crystalloid indicated?

A

20 mL/kg over 5-10 minutes

  1. Hypovolemic/hypotensive shock
  2. Distributive shock
212
Q

When are smaller (5-10 ml/kg) and/or slower (10-20 minutes) boluses of crystalloid therapy indicated?

A
  1. Cardiogenic shock
  2. Evidence or risk of pulmonary edema
  3. Poisonings (beta blocker or CCB)
  4. DKA
213
Q

When should fluid boluses be stopped?

A

When the patient’s condition improves or when signs of respiratory distress develop

214
Q

Maximum dose of colloid (and why)

A

20-40 ml/kg

higher doses may cause coagulopathies

215
Q

Total dose of albumin

A

2g/kg

216
Q

Adverse effect of albumin

A

Lower plasma calcium concentration

217
Q

When are colloids considered?

A

If hypovolemia/hypotension persists after 3 boluses of crystalloid (20 ml/kg)

218
Q

What should you do before giving fluids?

A

Check breath sounds in the lower lobes

219
Q

What should you do with fluids if you hear rales?

A

Hold fluids or administer at a slower pace

220
Q

What is the fluid therapy with febrile illnesses?

A

Restrictive volumes of isotonic crystalloid

221
Q

What is the fluid therapy in sepsis?

A

Repeating regular 20 mL/kg fluid boluses, frequently assessing the patient and slowing it down if the pt develops signs of respiratory distress

222
Q

What is the fluid therapy in DKA?

A

Initial bolus of isotonic crystalloid 10-20 ml/kg over 1-2 hours
-if pt is in hypotensive shock, the treatment approach should be more aggressive

223
Q

Volume of fluid and rate of delivery for hypotensive, hypovolemic, obstructive and/or distributive shock

A

20 ml/kg bolus over 5-10 minutes, repeat as needed

224
Q

Volume of fluid and rate of delivery for cardiogenic shock

A

5-10 ml/kg bolus over 10-20 minutes, repeat as needed

225
Q

Volume of fluid and rate of delivery for poisonings (CCB or Beta blocker overdose)

A

5-10 ml/kg over 10-20 minutes, repeat as needed

226
Q

Volume of fluid and rate of delivery for DKA with compensated shock

A

10-20 mL/kg over at least 1-2 hours (unless shock is present) follow local protocols and seek expert consultation

227
Q

Volume of fluid and rate of delivery for febrile illness (in the absence of shock)

A

Restrictive, use extreme caution when access to critical care resources are not available

228
Q

Volume of fluid and rate of delivery for septic shock

A

Start 20 mL/kg fluid boluses, carefully assess after each bolus and continue fluid boluses unless signs of respiratory distress develop

229
Q

What is critical after every fluid bolus?

A

Reassessment

230
Q

Indications for blood transfusions in PALS

A
  1. Traumatic volume loss with signs of poor perfusion
  2. Hemoglobin concentration less than 7g/dL
  3. Children who are hypotensive despite 203 boluses of 20 mL/kg crystalloid
231
Q

Initial dose of PRBCs in PALS

A

10 mL/kg

232
Q

Priorities for the type of blood

A
  1. Type and crossmatched
  2. Type specific blood
  3. Type O (O- for females, males can receive O+ IF they have never received a transfusion before)
233
Q

4 stages of assessment in PALS

A
  1. General assessment (pediatric assessment triangle)
    2, Primary assessment (ABCDEs)
  2. Secondary assessment (SAMPLE/ H’s & T’s)
  3. Tertiary assessment (labs, diagnostic tests, x-rays, etc)
234
Q

What is the goal of the pediatric assessment?

A

Recognize respiratory distress, respiratory arrest and shock

235
Q

What are the most common causes of cardiac arrest?

A

Respiratory distress, respiratory arrest and shock

236
Q

What do you look for when checking appearance?

A

Appearance, breathing and circulation/color

237
Q

Initial ABC steps in unconscious/unresponsive patients

A
  1. Check for pulse and breath sounds
  2. Activate EMS and start CPR if there is no pulse
  3. Provide rescue breaths and place monitors if there is a pulse but pt is not breathing
238
Q

Initial ABC steps in conscious.responsive patients

A
  1. Monitors/check perfusion
  2. IV
  3. Oxygen if needed
  4. Auscultate breath sounds
239
Q

Treatment for bradycardia and abnormal lung sounds

A

Oxygenation and ventilation

240
Q

Treatment for bradycardia and clear breath sounds

A

Epi or atropine

241
Q

Treatment for fever and abnormal lung sounds

A

Support airway and administer antibiotics (probably lung tissue disease)

242
Q

Treatment for fever and clear breath sounds

A

Antibiotics, fluids, vasopressors (probably septic shock)

243
Q

Treatment for hypotension and abnormal lung sounds

A

Inotropes and smaller fluid boluses (probably cardiogenic shock)

244
Q

Treatment for hypotension and clear breath sounds

A

Rapid fluid boluses (probably hypovolemic shock)

245
Q

Order of ABC steps for unconscious/unresponsive patients

A

CAB order

246
Q

Order of ABC steps for conscious/responsive patients

A

Depends on the situation

247
Q

Initial PALS steps

A
  1. Check appearance, breathing, color

2. Check responsiveness

248
Q

What does SAMPLE stand for?

A 
Signs and symptoms
Allergies
Medications
Past medical history
Last meal consumed
Events
249
Q

When should H’s & T’s be verbalized

A

If the child is in cardiac arrest

250
Q

When should an ABG be obtained?

A

Within 10-15 minutes of the establishment of mechanical ventilation

251
Q

What is the problem with venous labs?

A

They are not good indicators of oxygen and carbon dioxide pressures

252
Q

Possible causes of low cardiac output

A
  1. Bradycardia
  2. Hypovolemia
  3. Decreased contractility
253
Q

General symptoms of low cardiac output/low ScvO2

A
  1. Hypotension
  2. Vasoconstriction and weak pulses
  3. Signs of poor perfusion
  4. Oliguria
  5. Narrow pulse pressure (low SV= low systolic BP, vasoconstriction = high diastolic BP)
254
Q

Additional symptoms of low cardiac output with decreased contractility

A
  1. Pulmonary edema
  2. Rales
  3. JVD
255
Q

Symptoms of low afterload (vasodilation)

A
  1. High cardiac output (higher SV)
  2. Good pulse (if BP is adequate)
  3. Decreased preload (blood pooling in legs)
  4. Wide pulse pressure
  5. Brisk capillary refill (if BP is adequate)
  6. Delayed capillary refill (if BP is too low)
  7. Flushed skin
  8. If severe, it can be accompanied by angioedema
256
Q

Symptoms of high afterload (vasoconstriction)

A
  1. Weak pulses
  2. Pale skin
  3. Delayed capillary refill
257
Q

Most common cause of vasoconstriction in PALS

A

Decreased cardiac output

258
Q

Possible causes of high ScvO2

A
  1. High cardiac output
  2. Reduced metabolism
  3. Sepsis
259
Q

Possible causes of low ScvO2

A
  1. Low cardiac output
  2. Hypoxia
  3. Increased metabolism
  4. Anemia
260
Q

If the patient has low cardiac output and sepsis, ScvO2 may be

A

low

261
Q

If the patient has high cardiac output OR sepsis, ScvO2 may be

A

high

262
Q

If a patient has low cardiac output/ScvO2 and hypotension, what is the most likely cause?

A

Hypovolemia/hypotensive shock

263
Q

Treatment for hypotensive shock

A
  1. Fluid resuscitate and/or transfuse to Hgb >10 g/dL

2. Vasoactive drugs (epi for cold, norepi for warm extremities)

264
Q

Treatment for normotensive/compensated shock (low CO, normal BP)

A
  1. Administer fluid boluses
  2. Consider dopamine
  3. Consider epi for cold extremities, norepi for warm extremities
  4. Vasodilator therapy
265
Q

Treatment for high ScvO2, warm extremities and low BP (warm shock)

A
  1. Continue fluid boluses

2. Consider vasopressors (norepi) if fluids do not work

266
Q

Examples of warm shock

A
  1. Anaphylaxis

2. Sepsis

267
Q

Why do septic patients have a high ScvO2?

A
  1. Massive vasodilation, leading to increased stroke volume and cardiac output
  2. Impaired oxygen uptake at the mitochondrial level, leaving more oxygen in the blood
268
Q

What do all forms of shock produce?

A

Tissue hypoxia

269
Q

Common shock symptoms

A
  1. Hypotension
  2. Decreased cardiac output
  3. Vasoconstriction/poor signs of perfusion
  4. Vasodilation (in sepsis, anaphylaxis)
270
Q

What is compensated shock?

A

Normal BP and CO despite poor signs of perfusion

271
Q

What is decompensated shock?

A

Low blood pressure despite vasoconstriction and tachycardia

272
Q

When is shock considered decompensated?

A

If BP is less than 50th percentile for that age

273
Q

What causes warm shock?

A

Vasodilation

274
Q

What is observed in warm shock?

A
  1. Good peripheral pulses
  2. Increased cardiac output
  3. Wider pulse pressure
  4. Warm and flushed skin
275
Q

What causes cold shock?

A

Low cardiac output (due to hypovolemia or decreased contractility) and subsequent vasoconstriction

276
Q

What are symptoms of cold shock?

A
  1. Pale, mottled skin
  2. Peripheral tissues that have decreased blood flow and are thus cold
  3. Hypotension with narrower pulse pressure
  4. Inaccurate blood pressure readings
277
Q

When does normotensive shock occur?

A

With compensated shock, hypoxia or anemia

278
Q

Treatments for cold shock and/or decompensated (hypotensive) shock

A
  1. Fluids
  2. Vasopressors if fluid refractory
  3. Inotropes
279
Q

Treatments for warm shock

A
  1. Fluids

2. Vasopressors if fluid refractory

280
Q

Treatments for compensated (normotensive) shock

A
  1. Fluids
  2. Inotropes
  3. Vasodilators (milrinone, nipride) if hypotensive despite epi
281
Q

Most common cause of shock in kids

A

Hypovolemic

282
Q

Types of hypovolemic shock

A
  1. Hemorrhagic (loss of about 30%, EBL 25 ml/kg)

2. Non-hemorrhagic (GI, burns)

283
Q

Signs/symptoms of hypovolemic shock

A
  1. Hypotension
  2. Tachycardia
  3. Increased SVR
  4. Clear breath sounds
284
Q

Most common cause of decreased stroke volume in children

A

Inadequate preload

285
Q

Body’s first response to inadequate stroke volume

A

Tachycardia

286
Q

Body’s second response to inadequate stroke volume

A

Increased SVR

287
Q

Treatment for hypovolemic shock

A

Rapid fluid resuscitation with crystalloids and/or blood products

288
Q

What causes cardiogenic shock?

A

Decrease in cardiac contractility and EF (heart failure, cardiomyopathy, sepsis, posioning/drugs)

289
Q

What can patients with cardiogenic shock develop?

A

Pulmonary edema and vasoconstriction, which can lead to cold shock and worsen EF

290
Q

Treatment for cardiogenic shock

A
  1. Smaller fluid bolus (5-10 ml/kg)
  2. Inotropes
  3. Vasodilators (if pt is normotensive)
  4. Diuretics
291
Q

What does PALS suggest to use to reduce afterload/increase stroke volume?

A

Vasodilator (milrinone, nipride)

292
Q

Occurs with abnormalities in hemoglobin affinity

A

Dissociative shock

293
Q

Examples of dissociative shock

A

Carbon monoxide poisoning, methemoglobinemia and cyanide poisoning

294
Q

Treatment for carbon monoxide poisoning

A

Supplemental oxygen administration

295
Q

Treatment for methemoglobinemia

A

Methylene blue

296
Q

What are types of obstructive shock?

A
  1. Pulmonary embolism
  2. Cardiac tamponade
  3. Tension pneumothorax
  4. Ductal dependent lesions
297
Q

Signs/symptoms of obstructive shock

A

Same signs as a patient with impaired contractility (vasoconstriction)

298
Q

Signs and symptoms of pulmonary embolism

A

hypotension, physical signs of right heart failure (increased CVP, JVD), respiratory distress, chest pain

299
Q

Treatment for pulmonary embolism

A
  1. 20 mL/kg fluid bolus
  2. Consider anticoagulants (heparin) and thrombolytics (rTPA)
  3. Expert consult
300
Q

Signs/symptoms of cardiac tamponade

A
  1. Physical signs of impaired cardiac contractility
  2. Muffled (diminished) heart sounds
  3. Pulsus paradoxus
301
Q

Treatment of cardiac tamponade

A
  1. Pericardiocentesis

2. 20 mL/kg fluid bolus

302
Q

Signs/symptoms of tension pneumothorax

A
  1. Deflated lung & respiratory distress
  2. Tracheal deviation towards the contralateral side
  3. Poor signs of perfusion
  4. Distended neck veins
  5. Pulsus paradoxus
303
Q

Treatment for tension pneumothorax

A
  1. Needle decompression

2. Chest tube placement

304
Q

What are ductal dependent lesions?

A

Congenital heart disease with left sided blockages

305
Q

Unique symptoms of ductal dependent lesions

A
  1. Rapid deterioration in consciousness
  2. CHF
  3. BP/SpO2 differences in preductal and postductal circulation
306
Q

Treatment for ductal dependent lesions

A
  1. Prostaglandin E1

2. Expert consult

307
Q

Occurs when massive vasodilation leads to abnormal distribution of blood flow and subsequent inadequate supply of blood to the body’s organs

A

Distributive shock

308
Q

3 types of distributive shock in PALS

A
  1. Anaphylactic shock
  2. Neurogenic shock
  3. Septic shock
309
Q

Most common form of distributive shock

A

Septic shock

310
Q

Initial management of all types of distributive shock

A

Fluid administration followed by vasopressors for fluid refractory hypotension

311
Q

Anaphylactic shock leads to:

A
  1. Systemic vasodilation

2. Pulmonary vasoconstriction

312
Q

Treatment for anaphylactic shock

A
  1. Subcutaneous/IM epi
  2. Bronchodilators
  3. 20 mL/kg fluid bolus
  4. Corticosteroids
  5. H1 and H2 blockers (benadryl, zantac)
  6. Magnesium
  7. Consider humidified oxygen, bipap, intubation
313
Q

Occurs after a spinal cord or head injury when the injury causes the sympathetic pathway of the spinal cord to be disrupted/lose

A

Neurogenic shock

314
Q

Diagnosis of neurogenic shock

A
  1. Spinal cord or head injury
  2. Vasodilation and subsequent wide pulse pressure
  3. Hypotension and warm shock
  4. Absence of tachycardia
315
Q

Treatment of neurogenic shock

A
  1. Fluid boluses
  2. Trendelenburg to increase venous return
  3. Vasopressors if the patient is fluid refractory hypotensive
  4. Supplemental warming or cooling may be necessary, especially for children with spinal shock
316
Q

An acute loss of sensation and motor function after a spinal injury, with gradual recovery

A

Spinal shock

317
Q

Autonomic dysreflexia may occur in spinal cord injuries above

A

T6

318
Q

What criteria must be met for a patient to have systemic inflammatory response syndrome? (SIRS)

A

At least 2 of the 4 (one must be temp or abnormal WBC)

  1. Temperature > 38.5C or below 36 C
  2. Unexplained tachycardia in adults or bradycardia in children <1 year old
  3. Respiratory rate >20 unrelated to pain or other factors
  4. WBC >12,000
319
Q

Infectious causes of sepsis

A
  1. CNS infections (meningitis or encephalitis)
  2. Cardiovascular infections (infective endocarditis)
  3. Respiratory infections (PNA)
  4. GI infections (peritonitis)
  5. UTI (pyelonephritis)
  6. Generalized abscesses
320
Q

Non-infectious causes of sepsis

A
  1. Severe trauma or hemorrhage

2. Acute systemic disease (MI, PE, pancreatitis)

321
Q

Pathophysiology of sepsis

A
  1. Infection activates the immune system, which releases inflammatory mediators (cytokines)
  2. Cytokines promote vasodilation and increase capillary permeability
  3. Pts may suffer from mitochondrial dysfunction, causing subsequent hypoxia
  4. Pts may develop adrenal insufficiency
  5. Pts may develop hyperglycemia or hypoglycemia
  6. Pts may develop hypocalcemia
  7. Pts may have increased CO early on and decreased CO in later stages
  8. Pathway starts with SIRS, then sepsis, then severe sepsis, then septic shock
322
Q

Vasodilation in sepsis can cause

A

relative hypovolemia, decreased tissue perfusion, metabolic acidosis, and potential eventual organ failure

323
Q

When is sepsis considered severe?

A
  1. Cardiovascular dysfunction
  2. Acute respiratory distress syndrome
  3. Failure/dysfunction of at least 2 other organs
324
Q

When is a patient in septic shock?

A

If they display cardiovascular dysfunction after fluid resuscitation

325
Q

Diagnosis of sepsis

A
  1. Signs of infection
  2. Metabolic acidosis, elevated lactate and respiratory acidosis
  3. Potential hypotension, hypoglycemia or hyperglycemia, hypocalcemia and adrenal insufficiency
  4. Possible petechiae
326
Q

Treatment of sepsis

A
  1. Treat the source of infection with antibiotics or with surgical intervention
  2. Fluid resuscitate (with caution)
  3. Start vasopressor therapy if pt has fluid refractory hypotension
  4. Attempt to fix the metabolic acidosis
  5. Consider inotropes
  6. Consider steroid therapy
  7. Correct any potential hypoglycemia with dextrose
  8. Correct any potential hypocalcemia with calcium chloride
327
Q

If a random cortisol level is below ___ it is considered adrenal insufficiency

A

18 mcg/dl

328
Q

Why are steroids controversial in sepsis?

A

They prevent induction of nitric oxide synthase, reduce inflammatory response, but they can also worsen underlying infection and hyperglycemia

329
Q

Septic shock algorithm in PALS within the first 10-15 minutes

A
  1. Identify shock
  2. Monitors, IV, oxygen, auscultation
  3. Draw blood cultures and labs
330
Q

Septic shock algorithm in PALS within the first hour

A
  1. Start and repeat 20 ml/kg fluid boluses (3-4 boluses)
  2. Start vasopressors
  3. Identify metabolic derangements
  4. Administer broad spectrum antibiotics
331
Q

Septic shock management after the first hour

A
  1. Administer 2mg/kg hydrocortisone
  2. Correct hypoglycemia and hypocalcemia (calcium = 20mg/kg)
  3. Start invasive lines and treat based on ScvO2
  4. Consider intubation
332
Q

Vasopressor therapy for warm shock

A
  • norepinephrine first

- vasopressin

333
Q

Vasopressor therapy for normotensive shock

A
  • dopamine (2-20 mcg/kg/min, >5 mcg/kg/min beta, >10 mcg/kg/min alpha)
  • if dopamine is not effective, use epi or norepi
  • if those do not work, dobutamine, milrinone, nitroprusside
334
Q

When should epi be used in normotensive shock?

A

If dopamine does not work, in normal or high vascular resistance

335
Q

When should norepi be used in normotensive shock?

A

If dopamine does not work, in low vascular resistance

336
Q

Vasopressor treatment for cold shock

A
  • epi

- combo of dobutamine and norepinephrine

337
Q

Reducing oxygen demand requires us to manage what conditions?

A
  1. Increased respiratory effort and breathing work
  2. Fever
  3. Pain and anxiety
338
Q

How can we reduce oxygen demand?

A
  1. Mechanical ventilation or intubation
  2. Administration of antipyretics and/or cooling measures to control fever
  3. Use of analgesics and sedatives (with caution) to control pain and anxiety
339
Q

Goal of shock treatment

A

Restore normal perfusion and prevent cardiac arrest by:

  1. Optimizing oxygenation of blood
  2. Improving cardiac output and cardiac volume
  3. Reducing tissue/organ demand for oxygen
  4. Correcting metabolic derangements
340
Q

Signs of hypovolemic shock, cardiogenic shock, obstructive shock, distributive shock

A
  1. Tachypnea
  2. Tachycardia
  3. Decreased urine output
  4. Metabolic acidosis
  5. Irritable early
  6. Lethargic late
  7. Variable temperature
341
Q

Signs of hypovolemic shock, cardiogenic shock, obstructive shock

A
  1. Decrease perfusion/cold shock (delayed capillary refill, etc)
  2. Decreased cardiac output
  3. Narrow pulse pressure
342
Q

Signs of distributive shock

A
  1. Warm shock
  2. Increased cardiac output
  3. Wide pulse pressure
  4. Bounding pulses
343
Q

When is tachycardia not present in shock situations?

A
  1. Neurogenic shock
  2. Late signs of tension pneumothorax
  3. Some ductal dependent lesions
344
Q

True/false. Distributive shock is considered warm shock, but can turn into cold shock

A

True

345
Q

What should you do in all cases of shock?

A

Administer high flow oxygen until the patient’s condition improves

346
Q

What should you do in all cases of hypotension?

A

Consider 30 degree head down Trendelenburg (unless breathing compromised)

347
Q

Situations to consider prolonging resuscitative efforts

A
  1. Recurring or refractory vfib/vtach
  2. Drug toxicity
  3. Hypothermia
348
Q

2 phases of resuscitation management

A
  1. Immediate post-arrest management focused on the ABCs (intubation, capnography, ABGs, +/- chest xray, BP, treat arrhythmias, draw labs and maintain normal lab values)
  2. Broader multi-organ supportive care (TTM, transfer)
349
Q

Airway and breathing goals of post resuscitation management

A
  1. Keep the SpO2 between 94-99%

2. Avoid hypercarbia or hypocarbia

350
Q

Circulation goals of post resuscitation management

A
  1. Use fluid boluses and/or vasopressors and/or inotropes to manage and treat shock, and to keep systolic BP within the 5th percentile for age
  2. Draw labs (blood sugar, ABGs, electrolytes, etc)
  3. Consider the H’s & T’s
351
Q

Disability and exposure for post resuscitation management

A
  1. Monitor for and treat hypoglycemia
  2. Continually monitor temperature (avoid fever & shivering) & initiate TTM
  3. Treat seizures
  4. Avoid increases in ICP, if applicable and consider ordering a CT scan
352
Q

TTM in PALS for infants and children remaining comatose after OHCA

A
  1. Avoid a fever/maintain normothermia for 5 days or

2. Maintain 2 days of initial continuous hypothermia followed by 3 days of continuous normothermia

353
Q

TTM in PALS for infants and children remaining comatose after IHCA

A

There is insufficient evidence to recommend cooling over normothermia, but fever should still be treat/avoided

354
Q

What should you do when delivering IV drugs via peripheral line?

A

Follow with a 5 mL saline flush

355
Q

IV/IO pediatric dose of atropine

A

20 mcg/kg

-can be repeated if the initial dose doesn’t achieve the desired effect

356
Q

ETT pediatric dose of atropine

A

40-60 mcg/kg (2-3xIV dose)

357
Q

Maximum single dose of atropine for a child

A

0.5 mg

358
Q

Maximum total dose of atropine for a child

A

1 mg

359
Q

Maximum total dose of atropine for an adolescent

A

3 mg

360
Q

Minimum dose of atropine in PALS

A

0.1 mg

361
Q

Epinephrine IV dose in PALS for bradycardia

A

10 mcg/kg (0.01 mg/kg)

362
Q

ETT dose for epinephrine in PALS

A

100 mcg/kg

363
Q

Infusion dose for epinephrine for shock in PALS

A

<0.03 mcg/kg/min

364
Q

First dose of adenosine in PALS for SVT

A

100 mcg/kg (max 6mg)

365
Q

What happens if adenosine is administered slowly?

A

The drug may not be effective

366
Q

When will the rhythm convert after dosing adenosine?

A

Within 10-15 seconds

367
Q

What is the second dose of adenosine in PALS for SVT?

A

200 mcg/kg (max 12mg)

368
Q

When a second dose of adenosine more likely to be needed?

A

If an initial dose is administered via peripheral IV line

369
Q

Amiodarone dose for SVT/stable vtach in PALS

A

5 mg/kg over 20-60 minutes

370
Q

Procainamide dose in PALS SVT/Stable Vtach

A

15 mg/kg over 30-60 minutes

371
Q

Epinephrine dose in PALS for vfib/pulseless vtach

A

10 mcg/kg every 3-5 minutes

372
Q

Amiodarone dose in PALS for vfib/pulseless vtach

A

5mg/kg rapid bolus

-may repeat up to a total dose of 15 mg/kg, or 300 total mg

373
Q

When is amiodarone contraindicated?

A

In Torsades de Pointes

374
Q

Lidocaine dose in PALS for vfib/pulseless vtach

A

Loading dose of 1mg/kg

-an infusion 20-50 mcg/kg can be considered

375
Q

Magnesium dose in PALS for vfib/pulseless vtach

A
  • only indicated for Torsades de Pointes

- The dose is 25-50 mg/kg

Methods of Anesthesia (20 decks)

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