PALS Flashcards
1
Q
Blue discoloration of hands and feet, and around the mouth and lips
A
acryocyanosis
2
Q
apnea is defined as cessation of breathing for ____ seconds
it can be less if accompanied by what 3 things?
A
20
bradycardia, cyanosis, pallor
3
Q
______ apnea indicates no respiratory effort (i.e. narcotic overdose), while obstructive apnea occurs when the patient is trying to breathe but the ventilation is impeded by an obstructed airway
A
central
4
Q
_____ apnea is a combination of both central and obstructive apnea
A
mixed
5
Q
what is the most common cause of bradycardia in kids?
A
apnea, hypoxia
6
Q
inflammation of the larynx/vocal cords
It can be classified as mild (barking cough), moderate (stridor & retractions at rest), or severe (significant agitation with decreased air entry)
A
croup
7
Q
a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood
A
cyanosis
8
Q
Cyanosis is not apparent until at least ____ of hemoglobin are desaturated
A
5 g/dL
9
Q
the (more/less) anemic you are, the lower the SpO2 that will be required in order for cyanosis to be present
A
more
10
Q
Patients with a temperature _____are considered febrile
A
≥38⁰C
11
Q
What 2 PALS scenarios is a fever present? and what should you consider administering?
A
sepsis and lung tissue disease
consider administering antibiotics
12
Q
a patient is considered to have hypoxemia if their SpO2 is _____ on room air
A
≤94%
13
Q
What are 2 reasons we would consider administering supplemental oxygen?
A
- the Spo2 is <94%
2. there are poor signs of perfusion
14
Q
_____ refers to an SpO2 reading of < 94% that may be appropriate or normal in certain circumstances
A
permissive hypoxemia
For example, if a patient is in high altitude, they may be breathing normally, but have a lower SpO2 due to the lower atmospheric pressure
Another example would be a patient with congenital heart disease (i.e. Tetralogy of Fallot)
15
Q
Hypoxia due to reduced arterial oxygen SATURATION (SaO2)
A
hypoxemia hypoxia
16
Q
Normal SaO2, but hypoxia due to decreased hemoglobin concentration, which leads to decreased total oxygen CONTENT in the blood (CaO2)
A
anemic hypoxia
17
Q
Normal SaO2 and hemoglobin concentration, but hypoxia due to decreased blood flow to the tissues (low cardiac output, hypovolemia, severe vasoconstriction, etc)
A
ischemic hypoxia
18
Q
Normal blood content and oxygen delivery, but hypoxia due to the an inability of the tissues take up or utilize the oxygen from the bloodstream (cyanide poisoning, carbon monoxide poisoning, methemoglobinemia, septic shock/impaired mitochondrial function)
A
histotoxic/cytotoxic hypoxia
19
Q
For neonates, blood sugars _____ are considered hypoglycemic and should be treated
A
<45mg/dL
20
Q
For infants/children/adolescents, blood sugars ___ are considered hypoglycemic and should be treated
A
<60mg/dL
21
Q
name 5 symptoms of hypoglycemia
A
- tachycardia
- hypotension
- lethargy/irritability
- poor signs of perfusion
- sweating
22
Q
What is the dose of glucose for treating hypoglycemia?
A
0.5-1 g/kg bolus
23
Q
What is the dose of D25W
A
“dextrose 25% in water”
2-4 mL/kg
D25 = 250mg/mL (0.25g/mL), so 4mL = 1g
24
Q
systolic hypotension in neonates
A
<60
25
systolic hypotension in infants
<70
26
systolic hypotension in children age 1-10
70 + (age in years X 2)
27
systolic hypotension in adolescents
<90
28
How low can the systolic pressure of a 3-year old patient go before they are considered hypotensive?
76 mmHg
29
“patchy” discolorations of the skin, and is caused by areas of vasoconstriction (pallor) mixed with areas of vasodilation (cyanosis or erythema)
mottling
The mechanism is unclear, and appears to simply be an irregular supply of oxygenated blood
Mottling can be a sign of imminent death
30
a pale color due to lack of oxygen in the skin
palor
“Central” pallor is pallor seen in the lips and mucous membrane
31
5 signs of good peripheral perfusion (vasodilation)
1. Good pulse (as long as BP is adequate)
2. Flushed skin
3. Brisk capillary refill (≤ 2 seconds)
Very rapid capillary refill (< 2 seconds) is also referred to as “flash capillary refill”
4. Warm skin
5. Awake & alert
32
5 signs of poor peripheral perfusion
1. Weak pulse
2. Pale or cyanotic skin color
3. Delayed capillary refill and cool extremities
Due to vasoconstriction
4. Decreased responsiveness and/or consciousness
5. Metabolic acidosis, elevated lactate, and decreased U/O
33
purple discolorations caused by small vessel bleeding. They can suggest a low platelet count, or can be a symptom of disseminated intravascular coagulation (DIC)
Petechiae and purpura
Petechiae are small dots, while purpura appear as larger areas
34
What are petechia and purpura often a sign of ?
septic shock
35
A child is “_______” to treatment if they do not improve or respond to a specific therapy
refractory
1. “Fluid refractory hypotension,” which means that a child remains hypotensive despite fluid administration
(in which case the provider needs to consider using vasopressors or an inotrope)
2. If a child is hypoxic refractory to supplemental oxygen administration, it may mean that they need a breathing treatment, or may need to be mask ventilated or intubated
3. “Norepinephrine refractory shock,” which means that a child in shock is unresponsive to norepinephrine therapy
36
what is a normal capillary refill time?
<2 seconds
37
What is a prolonged capillary refill time?
Name 3 common causes
>5 seconds
1. Dehydration
2. shock
3. hypothermia
38
What is the SVT rate for infants?
>220
39
What is the SVT rate for children?
>180
40
oxygen consumption in adults
3-4 mL/kg/min
41
oxygen consumption in infants
6-8 mL/kg/min
42
SpO2 should be ____ on room air
>94%
43
SpO2 ____ on 100% oxygen requires intervention
<90%
44
What is a normal ScvO2
central venous oxygen saturation
25-30% below SaO2
70-75% if SaO2 is normal
45
What is the urine output for infants/ young children?
1.5-2 mL/kg/hr
46
What is the urine output for children and adolescents?
1 mL/kg/hr
Reduced urine output is a sign of poor perfusion
47
If a patient is tachypneic, it is defined as “______” if it is not accompanied by signs of labored breathing or respiratory distress
quiet tachypnea
48
What is quiet tachypnea usually caused by?
non-pulmonary issues (fever, pain, metabolic acidosis)
49
What are 2 reasons pediatric patients are especially prone to a difficult airway?
1. large tongue
| 2. large occiput
50
Larger airways have (more/less) resistance than smaller airways
more
51
(Larger/Smaller) airways are more prone to turbulent flow
Larger
52
When the radius of the airway decreases, the resistance increases to the ______
4th power
53
With turbulent flow, when the radius of the airway decreases, the resistance increases to the ____
5th power
turbulent flow increases airway resistance and can make it harder to breathe
54
Airflow is _____ during normal respirations
laminar
55
When are 2 instances that airflow can become turbulent?
1. Partial airway obstruction (usually upper airway obstruction)
2. Labored/agitated breathing/increased respiratory efforts/crying
56
The (higher/lower) the gas density, the higher the percentage of laminar flow, and the lower the resistance
lower
57
What are the primary inspiratory muscles?
external intercostals and diaphragm
58
the sternocleidomastoid, internal intercostals, scalene muscles, pectoralis major, and pectoralis minor are the accessory (inspiratory/ expiratory) muscles
inspiratory
59
rectus abdominis, external oblique, internal oblique, and transversus abdominis are the accessory (inspiratory/ expiratory) muscles
expiratory
There aren’t really any PRIMARY expiratory muscles, because expiration is usually a passive process
60
What type of chest wall do infants have? and what problem does this cause?
compliant chest wall
labored breathing can actually worsen oxygenation and ventilation by causing the chest to sink (breathing deeply may induce greater chest wall collapse)
61
Because of the compliant chest wall, it is more efficient for infants to take (smaller/larger) tidal volumes at an (elevated/decreased) respiratory rate
smaller
| elevated
62
The central nervous system causes spontaneous ventilations through _____
central and peripheral chemoreceptors
63
Central chemoreceptors are located in ______ and respond to _____ concentration in the CSF
brain stem/ medulla oblongata
H+ mostly affected by PaCO2
64
peripheral chemoreceptors are located in the _____ and respond to changes in _____
carotid body/ aortic arch
PaO2 levels (few are responsive to PaCO2)
65
3 reasons to avoid excessive ventilation
1. air trapping and can cause barotrauma in kids with airway obstruction
- Providing ventilation at a slower rate allows more time for expiration, which reduces the risk that air will remain inside the chest at the end of expiration.
2. It increases intrathoracic pressure, impedes venous return, which ultimately results in decreased cardiac output, coronary perfusion, and cerebral blood flow
3. increases the risk of regurgitation and aspiration in kids without an advanced airway
66
What are 3 ways gastric inflation can be minimized?
1. Ventilating slowly (1 breath every 3-5 seconds, or 12-20 breaths per minute)
2. Delivering each breath over 1 second, and ventilating only until chest rise is observed
3. Considering the use of cricoid pressure
67
If an Ambu bag is connected to oxygen but NOT CONNECTED TO A RESERVOIR BAG, the Ambu bag will fill with a _____
mixture of oxygen and room air during exhalation
68
If an Ambu bag is connected to oxygen AND CONNECTED TO A RESERVOIR BAG, the Ambu bag will fill with _____
mostly oxygen (and no room air) during exhalation
69
does a self- inflating ambu bag require oxygen to work?
no
70
A ______ Ambu bag requires oxygen flow to operate (cannot inflate without oxygen flow)
flow inflating
-It should only be used by more experienced and trained airway providers, because the pressure in the bag is controlled by an APL valve
71
What size are infant/young children flow inflating ambu bags?
400-500 mL
72
What size are older children and adolescent flow inflating ambu bags?
1000 mL
73
Uncuffed tracheal tubes are recommend for children ____ years old
<8
74
What is the formula for choosing the correct size endotracheal tube?
Uncuffed: (age/4) +4
Cuffed: (age/4) +3
75
What is the formula for choosing the correct depth of insertion
kids ≤ 2: internal diameter of the tube (mm) X 3
| kids >2: age/2 +12
76
How many ventilations are recommended to wash out CO2 that may be present in the abdomen after bag mask ventilation?
6
77
____ soluble drugs can be administered via the ETT.
What is the pneumonic for drugs that can be administered in PALS through the ETT
Lipid
"LEAN"
Lidocaine
Epinephrine
Atropine
Narcan
78
Method of administration of ETT Drugs:
1. Dilute the drug with _____
2. Deliver the drug via the ETT and _____ compressions
3. Follow the drug delivery with _____
1. 5 mL NS
2. hold
3. 5 positive pressure ventilations
79
When dosing drugs via the ETT, we typically use _____ times the IV dose
2-3 X
80
When dosing epinephrine via the ETT, we use _____ times the IV dose. Why?
10X
at lower doses, epinephrine has the ability to cause beta 2 stimulation (which can produce vasodilation, hypotension, decreased coronary perfusion pressure, and decreased chance of achieving ROSC) without enough alpha 1 (vasoconstriction) stimulation to overcome it
81
What pneumonic should be verbalized when a child is intubated and deteriorates?
DOPE
Displacement: is the tube still in place?
Obstruction: is the ETT kinked?
Pneumothorax: bilateral breath sounds ( usually associated with trauma)
Equipment failure
82
To perform this examination, a provider lays their left middle finger over a body surface, and then taps on it with their right middle finger
lung percussion examination
83
Resonant sounds are ____ lung sounds with percussion
normal
84
Hyperresonant lung sounds are found in patients with what two conditions?
1. hyperinflated chest cavity (tension pneumothorax)
| 2. hyperinflated lung (COPD, acute asthma attack)
85
Wheezing is a high pitched noise, usually during expiration, that is caused by _____
bronchoconstriction
86
___ is described as an intermittent popping sound
| Some describe is as a “velcro” sound of rubbing hair together
Rales
87
What are 2 possible causes of rales?
1. fluid in the distal airways
| 2. atelectasis
88
In PALS, hearing rales when auscultating is key to diagnosing ____
cardiogenic shock
89
____ are low pitched noises that have been described as a “snoring,” or “bubbling” sound
Rhonchi
90
Where are Rhonchi usually heard?
in the Larger airways caused by secretions, mucous, blood
91
Stridor usually indicates a ____ airway obstruction
upper (foreign body, croup, upper airway edema, etc)
92
Grunting is a low pitched sound heard during (inhalation/ exhalation)
exhalation
When a child “grunts,” they are closing the glottis earlier than usual during expiration in an attempt to maintain some positive airway pressure during expiration and to keep the alveoli open
In other words, it works to have the same effect as PEEP, and it happens with small airway obstruction/collapse
93
What two PALS scenarios can grunting be heard?
What is grunting a sign of?
Lung tissue disease and cardiogenic shock
impending respiratory failure
94
nasal flaring is a sign of respiratory distress where the nares dilate during (inhalation/ exhalation)
inhalation
95
is a sign of respiratory failure in which the chin lifts during inspiration and the chin falls during expiration
head bobbing
| -neck muscles are being used to assist ventilation
96
an irregular respiratory rate and/or insufficient respiratory effort, which can lead to hypoxemia and hypercarbia
disordered control of breathing
97
What are 3 things that can cause disordered control of breathing?
1. A medication overdose
2. A seizure (that could be caused by a high fever) that led to increased ICP
3. Other neurological problems (head injury, brain tumor, hydrocephalus, increased intracranial pressure)
98
an inward movement of the chest wall during inspiration, and is a sign that a child is trying to move air into their lungs by using their chest muscles
retractions
99
retractions that are ______ suggest mild to moderate breathing difficulty
substernal / subcostal
100
Retractions that are _____suggest severe breathing difficulty
suprasternal/ supraclavicular
101
Seesaw respirations are just like retractions with what difference?
the abdomen distends during inspiration
102
seesaw respirations are usually indicative of _____ airway obstruction
upper
| Characteristic of children with neuromuscular weakness
103
Symptoms: Retractions + inspiratory snoring/stridor
| Diagnosis?
upper airway obstruction
104
symptoms: Retractions + expiratory wheezing
| Diagnosis?
lower airway obstruction
105
symptoms: Retractions + grunting or labored respirations
| Diagnosis?
Lung tissue disease or pulmonary edema produced by cardiogenic shock
106
Symptoms: severe retractions
| Diagnosis?
May be accompanied by head bobbing or seesaw respirations
107
abnormal inspiratory sounds indicate ______ airway obstruction
upper
108
abnormal expiratory sounds indicate _____ airway obstruction
lower
109
RESPIRATORY DISTRESS, RESPIRATORY FAILURE, AND SHOCK OFTEN LEAD TO _____ IN CHILDREN
cardiac arrest
110
What are 7 indications for bag mask ventilation or intubation?
1. low SpO2
2. abnormal airway signs
3. poor signs of perfusion
4. bradycardia
5. anxiety
6. lethargy
7. increased effort
111
It is an airway scenario if the patient has bad lung sounds and _____ blood pressure
normal
112
it is cardiogenic shock if the patient has bad lung sounds and _____
hypotension
113
at high flows of ____, ahigh flow nasal cannula can deliver an FiO2 of close to ___similar to a nonrebreather mask
>50L/min
| 100%
114
How can you deliver high flows through nasal cannula?
the oxygen is humidified
115
a simple oxygen mask requires at least _____ to prevent rebreathing of CO2
6 L/min
116
a low flow simple oxygen mask provides what percentage of Fi02?
35-60%
117
a low flow nasal cannula provides what percentage of Fi02?
22-60%
118
a high flow nasal cannula provides what percentage of Fi02?
up to 95%
119
high flow nasal cannula can deliver up to ____L/min of oxygen to infants
4 L/min
120
a high flow nasal cannula can deliver up to ___ L/min of oxygen to adolescents
40 L/min
121
A non- rebreathing mask can provide what percentage of FiO2?
95%
122
breathing treatments are indicated for (lower/upper) airway obstruction
lower
123
_____ is a breathing gas composed of a mixture of helium & oxygen and gives it a (lower/higher) density which produces a higher probability of ( laminar/turbulent) flow
Heliox
lower
laminar
124
heliox is used to relieve symptoms of (upper/lower) airway obstruction
upper
-It has a lesser effect in the smaller airways (since flow is already more laminar), but it has the greatest effect in airways where flow is more turbulent (middle & upper airways)
125
What are 2 primary advantages to humidified oxygen
1. It decreases the chance of coughing (because patients are more likely to cough if their airway is dry)
2. The humidity can loosen mucus and provide easier breathing
126
racemic epi is considered in (upper/lower) airway obstruction caused by swelling
upper
127
Racemic epi reduces swelling and edema in the airway via (vasoconstriction/ vasodilation)
It also causes (bronchoconstriction/bronchodilation) and can be used to treat ____ if other treatments fail
vasoconstriction
-The vasoconstriction decreases vascular permeability in the airway, which leads to less intravascular fluid leaking into the interstitial space (which decreases edema)
bronchodilation, bronchospasm
128
Steroids (dexamethasone) can be used to relieve symptoms of (upper, lower) airway obstruction
upper
| swelling, croup
129
What drug is not a first line for bronchoconstriction but can be used in in patients that fail to respond to bronchodilator therapy
magnesium
130
What side effect can magnesium cause and what should be monitored if this drug is used?
hypotension
| patient's BP
131
what drugs can be considered in the treatment of disordered control of breathing caused by increased intracranial pressure?
mannitol and hypertonic saline
132
When albuterol is combined with theophylline or used simultaneously with other adrenergic agents like terbutaline and dopamine, there is an increased risk of _______
tachyarrhythmias
133
________ is an anticholinergic and a bronchodilator. It can be mixed with albuterol in the same inhaler
ipratropium bromide
134
______ reverses respiratory depression for narcotic overdose and can markedly increase heart rate and blood pressure, and can cause acute pulmonary edema, cardiac arrhythmias (including asystole) and seizures
Narcan (Naloxone)
135
How should narcan be administered to lower the risks and slow the drugs onset?
IM
136
PEEP should generally be started at around _____
6-10 cm H20
137
List 7 possible ways to support the airway in PALS
1. Give supplementary oxygen if SpO2 is <94%
2. Assist the airway as needed (chin lift, jaw thrust, oral/nasal airway, assist ventilation/CPAP, etc) and consider intubation
3. Suction any secretions
4. Administer Abx if febrile
5. Consider ordering labs/CXR
6. Treat bradycardia if present
7. Give breathing treatments/racemic epi/heliox/humidified O2/steroids
138
When giving rescue breaths, each breath should be given over ______ , or _____ if an advanced airway is placed
3-5 seconds
| 10/ min
139
_____ is the most common type of arrest in kids
asphyxial arrest
140
What is the leading cause of death in infants under 6 months?
SIDS
141
In children >1 year, what two pulse areas should be checked?
carotid or femoral
142
in children <1 year, what pulse area should be checked?
brachial
143
What is the chest compression depth for an:
infant?
children?
adolescents/adults?
1.5 in
2 in
<2.4 in
144
When doing chest compressions, end tidal CO2 should be ______
>10-15 mmHg
145
At what age should a 2 handed CPR technique be used?
>8 years
146
What CPR technique should be used in kids ages 1-8 years?
one handed
147
What technique is used for one responder infant CPR?
two finger
148
What technique is used for two responder infant CPR?
thumb encircling technique
149
What are the 3 advantages to the thumb encircling technique?
1. better coronary blood flow
2. more consistent depth
3. may generate higher blood pressures
150
in neonates and children with an advanced airway and 2 providers, what is the compression to ventilation ratio?
100-120 compressions per minute with an age appropriate respiratory rate
151
What is the compression to ventilation ratio for a respiratory cause in neonates without an advanced airway?
3:1
152
What type of ECMO is used in cases of respiratory failure?
venovenous
153
What type of ECMO is used in cases of cardiac arrest?
venoarterial
154
List 4 ways we can check "disability" in PALS
1. blood sugar
2. pupil response to light
3. AVPU pediatric response scale
4. Glasgow Coma scale
155
4 symptoms of hypoxia for neurologic dysfunction
1. loss of muscle tone
2. generalized seizures
3. dilation of pupils
4. loss of consciousness
156
6 symptoms of cerebral herniation
1. unequal/ unresponsive/dilated pupils
2. hypertension
3. bradycardia
4. respiratory irregularities/ apnea
5. diminished response to stimuli
6. sudden increase in ICP
157
When checking a patient's neurologic function, what is the first thing you should check?
glucose
158
In the exposure step of PALS, what is an additional thing we check?
temperature; to assess fever, and warm or cold shock
159
What type of defibrillator pads are used on children ≤ 1 years old?
pediatric manual defibrillator pads
| -can use lower doses than an AED
160
At what age are pediatric AED pads used?
on children 1-8 years old, less than 25 kg
161
When are adult AED pads used?
>8 years or more than 25 kg
| although they’re acceptable to use on infants in cardiac arrest if pediatric pads aren’t available
162
in infants <1 year or who weigh less than 10kg, how should the paddles be placed
anterior-anterior
163
in infants >1 year or who weigh more than 10 kg, how should the paddles be placed?
can use anterior placement or anterior-posterior paddle placement
164
What is the dose of synchronized cardioversion for the 1st shock?
2nd shock?
0.5-1 J/kg
| 2 J/kg
165
What is the defibrillation dose for the 1st shock?
2nd shock?
subsequent shocks?
max shock?
2 J/kg
4 J/kg
≥ 4 joules/kg
10 J/kg or adult dose
166
Water takes up to ____% in infants and ____% in neonates
70%
| 80%
167
1 kg is = to _____ of water
1 L
168
in order to estimate dehydration, how can we estimate fluid loss?
look at weight loss
For example, 5% estimated weight loss (EWL) is expressed as 5% volume depletion in PALS
PALS assumes that water takes up 100% (instead of 80%) of body water
169
What are 2 ways that weight loss in PALS can be expressed as volume loss?
1. Weight loss can be expressed as a percentage of volume depletion
- For example, 10% weight loss is estimated as 10% volume depletion
2. Weight loss can be expressed in mL/kg of volume loss
- The weight loss expressed in mL/kg is 10x higher than the weight loss expressed as a percentage of volume depletion
170
5% EWL is _____ mL/kg
50
171
10% EWL is ____ ml/kg
100
172
100% EWL is ____ ml/kg
1000
173
What percent of the total fluid volume in the human body is blood?
How is this expressed in mL/kg?
10%
| 100mL/kg
174
(Younger/older) children can tolerate more volume loss, because they have higher circulating blood volumes
younger
| - they have more water to lose
175
hypovolemic/hypotensive shock is more LIKELY with a ______ or greater estimated weight loss
10% (volume depletion >100mL/kg)
-it is POSSIBLE with a 5% EWL (volume depletion >50mL/kg), it is
176
What is the treatment for a child in dehydration?
multiple 20mL/kg boluses of isotonic crystalloid
177
What type of fluid bolus is indicated for hypovolemic/hypotensive shock and distributive (septic) shock?
rapid boluses of 20mL/kg over 5-10 minutes
178
What type of fluid bolus is indicated for cardiogenic shock?
Smaller (5-10mL/kg) and/or slower (10-20 minutes) boluses
179
When are colloid boluses indicated?
if hypovolemia/hypotension persists after 3 boluses of crystalloid (20mL/kg)
180
What is the maximum dose of colloids?
20-40mL/kg (higher doses may cause coagulopathies)
181
What is the dose for albumin?
2mg/kg
| A standard 250mL 5% vial contains 12.5g
182
What is a side effect of albumin?
hypocalcemia
| -Albumin binds calcium, so Albumin administration may lower plasma calcium concentration
183
Before giving fluids, what should we always check?
breath sounds in the lower lobes
We should fluid resuscitate aggressively if breath sounds in the lower lobes are clear
Rales may suggest fluid overload (ex: cardiogenic shock), so you would either hold the fluids or administer them at a slower pace
184
what type of fluid bolus is indicated for poisonings (calcium channel or beta blocker overdose)?
Smaller (5-10mL/kg) and/or slower (10-20 minutes) boluses
185
what type of fluid bolus is indicated for DKA with compensated shock?
10-20 mL/kg over at least 1-2 hours (unless shock is present)
186
what type of fluid bolus is indicated for febrile illness (in the absence of shock)
"restrictive"
| -Use extreme caution when access to critical care resources are not available
187
what type of fluid bolus is indicated for septic shock?
Start 20mL/kg fluid boluses
Carefully assess after each bolus and continue fluid boluses unless signs of respiratory distress develop
188
What are 3 indications for blood transfusions in PALS?
1. traumatic volume loss with signs of poor perfusion
2. hemoglobin concentration is less than 7 g/dL
3. 3. Children who are hypotensive despite 2-3 boluses of 20mL/kg crystalloid
189
What is the initial dose of packed red blood cells (PRBC) in PALS?
10 mL/kg
190
What are the 3 priories of blood in order?
1. type and crossmatched
2. type specific
- can be available in 10 minutes
3. Type O blood
- negative Rh in females
191
What are the 4 stages of assessment in PALS?
1. general assessment
- focuses on Childs appearance
2. primary assessment
- ABCDEs
3. Secondary assessment
- Hs &Ts
4. Tertiary Assessment
- labs, diagnostic tests, x-ray
192
What is the first step you take in the PALs assessment?
appearance
193
What are the 3 things we check when looking at appearance?
1. appearance
2. work of breathing
3. circulation (color)
194
Checking the child's appearance in PALs is referred to as the _____ assessment
general or pediatric assessment triangle
195
What 2 scenarios can Bradycardia be present?
bradycardia or airway scenario
196
If the patient is bradycardic, but lung sounds are clear, what scenario may the patient be in?j
What is the most effective treatment?
bradycardia scenario
epinephrine/atropine
197
if the patient is bradycardic but lung sounds are abnormal, what scenario may the patient be in?
airway scenario
effective oxygenation and ventilation
198
what 2 scenarios can a fever be present in?
Septic shock or lung tissue disease
199
If the patient has a fever and abnormal breath sounds, what scenario is the patient most likely in?
What is the most effective treatment?
lung tissue disease
supporting the airway and administering Abx
200
if the patient has a fever and clear breath sounds, what scenario is the patient most likely in?
what is the most effective treatment?
septic shock
abx, fluids, vasopressors
201
What 2 scenarios can be present with hypotension?
hypovolemic shock and cardiogenic shock
202
if the patient has hypovolemia with normal breath sounds, what scenario is the patient most likely in?
What is the most effective treatment?
hypovolemic shock
rapid fluid boluses
203
if the patient has hypovolemia with abnormal breath sounds, what scenario is the patient most likely in?
What is the most effective treatment?
cardiogenic shock
inotropes and smaller fluid boluses
204
ABGs should be obtained within _____ min of establishment of mechanical ventilation
10-15 min
205
PaCO2 should be compared to ____
EtCO2
206
If venous blood is to be used for blood gas values, you should use _____ veins rather than _____ veins
central, peripheral
207
_____ measurements of venous blood and arterial blood are generally comparable.”
Hydrogen ion (pH)
208
Venous labs are “not good indicators of ____ and _____ pressures”
oxygen and carbon dioxide
209
3 possible causes of low cardiac output
1. bradycardia
2. hypovolemia
3. decreased contractility
210
5 symptoms of low cardiac output ( low ScvO2)
1. Hypotension
2. Vasoconstriction and weak pulses
3. Signs of poor perfusion
4. Oliguria
5. Narrow pulse pressure
Low stroke volume (low systolic BP)
Vasoconstriction (high diastolic BP)
211
what are 3 symptoms of decreased contractility?
```
Additional symptoms if the patient has decreased contractility:
1. Pulmonary edema
(and subsequent respiratory distress)
2. Rales (crackles) on auscultation
3. Jugular venous distention
```
212
7 symptoms of low afterload (vasodilation)
1. High cardiac output
Afterload is lower, leading to higher stroke volumes
2. Good pulse
(as long as BP is adequate)
3. Decreased preload
(blood pooling in the legs)
4. Wide pulse pressure
4. Brisk capillary refill (if BP is adequate)
5. Delayed capillary refill (if BP is too low)
6. Flushed skin
7. If severe, it can be accompanied by angioedema (like in anaphylactic shock)
213
3 symptoms of vasoconstriction
1. Weak pulses
2. Pale skin
3. Delayed capillary refill
214
What is the most common cause of vasoconstriction in PALS?
decreased cardiac output, as seen in hypovolemic and cardiogenic shock
215
What are 3 possible causes of high ScvO2?
1. High cardiac output
If the cardiac output is high, the cells don’t have as much time to pick up oxygen, so the blood has a higher oxygen concentration (i.e., the ScvO2 will be higher)
2. Reduced metabolism
(i. e., hypothermia)
3. Sepsis
Mitochondrial dysfunction impairs oxygen uptake and consumption at the cellular level
216
4 possible causes of low ScvO2?
1. Low cardiac output
Longer circulation time = more time for tissue oxygen extraction
2. Hypoxia (low SaO2)
3. Increased metabolism
4. Anemia
When there are less RBCs, a higher portion of oxygen will be taken off of each RBC, which leads to a lower ScvO2
217
in PALS, a low ScvO2= ____
low cardiac output
218
in PALS, if ScvO2 is high = _____
high cardiac output or sepsis
219
low ScvO2 and low blood pressure = ______
hypotensive shock
| -patient will be vasoconstricted but not compensating for BP
220
What drug is considered for warm shock?
norepinephrine
221
What drug is considered for cold shock?
epinephrine
222
low ScvO2 and normal blood pressure =
normotensive shock
| -vasoconstriction can compensate for BP
223
What is the treatment for normotensive/ compensated shock?
1. administer fluid boluses
2. consider dopamine
3. consider epi (cold) or norepinephrine (warm)
4. consider vasodilator (dobutamine, milrinone)
Vasodilators can increase stroke volume (by decreasing afterload), but should only be considered to increase cardiac output if blood pressure is normal
224
high ScvO2 and low blood pressure = ______
vasodilation
-Patients who are vasodilated will typically have warm extremities (because blood flow to the extremities is typically good when a patient is vasodilated), and these patients are thus considered to be in “warm shock”
225
What are 2 examples of warm shock in PALS
1. Anaphylaxis
2. Sepsis
Septic patients have a high ScvO2 for two reasons:
1. They have massive vasodilation, leading to increased stroke volume & cardiac output
2. They have impaired oxygen uptake at the mitochondrial level, leaving more oxygen in the blood
226
If the child’s blood pressure is greater than the 50th percentile for their age, it is considered (compensated/uncompensated)
compensated
227
In warm shock, the following results are most likely to be observed (in spite of decreased organ perfusion):
1. (good/poor) peripheral pulses (because of increased peripheral flow)
2. (Decreased/Increased) cardiac output
3. (Wide/Narrow) pulse pressure
4. (Warm/ cold) skin
1. good
2. Increased (because of reduced afterload)
3. Wide
4. warm
228
Symptoms of cold shock may include:
1. ______ skin
2. Peripheral tissues that have (increased/decreased) blood flow
3. Hypotension with (narrow/wide) pulse pressure
4. (Inaccurate/ accurate) blood pressure readings
1. pale/ mottled
2. decreased (and are thus cold)
3. narrow
4. inaccurate
229
What is the most common type of shock in kids?
hypovolemic
230
What are the 2 types of hypovolemic shock?
1. Hemorrhagic
Loss of blood volume of about 30% (EBL of 25mL/kg)
2. Non-hemorrhagic (hypotensive)
From GI losses, burns, etc
231
When should vasodilators be considered in shock?
When the patient has decreased cardiac output but normal blood pressure
232
How does dissociative shock occur?
abnormalities in hemoglobin affinity
-Examples include carbon monoxide poisoning, methemoglobinemia, and cyanide poisoning
The treatment for carbon monoxide poisoning is supplemental oxygen administration, and the treatment for methemoglobinemia is methylene blue
233
4 types of obstructive shock
1. Pulmonary embolism
2. Cardiac tamponade
3. Tension pneumothorax
4. Ductal dependent lesions
234
4 signs of pulmonary embolism
1. Hypotension
2. Physical signs of right heart failure (increased CVP, jugular venous distention, etc)
3. Respiratory distress
4. Chest pain
235
What is the treatment for pulmonary embolism?
1. 20mL/kg fluid bolus
2. Consider anticoagulants (heparin) and thrombolytics (rTPA)
3. Expert consult
236
3 signs of cardiac tamponade
1. Physical signs of impaired cardiac contractility
2. Muffled (diminished) heart sounds
Caused by sounds that can’t transmit effectively through the fluid
3. Pulsus paradoxus
237
2 treatments for cardiac tamponade
1. Pericardiocentesis
| 2. 20mL/kg fluid bolus
238
5 signs of tension pneumothorax
1. Deflated lung & respiratory distress
Unilateral absent breaths sounds
Hyperresonance
2. Tracheal deviation towards the contralateral side
3. Poor signs of perfusion
4. Distended neck veins
5. Pulsus paradoxus
239
2 treatments for tension pneumothorax
1. Needle decompression
(2nd-3rd intercostal space, mid clavicular line)
2. Chest tube placement
(6th-7th intercostal space, mid-axillary line)
240
Ductal dependent lesions refer to congenital heart disease with (LEFT/RIGHT) sided blockages
left
unique symptoms of ductal dependent lesions include rapid deterioration in consciousness, congestive heart failure, and blood pressure/SpO2 differences in preductal & postductal circulation
241
What are 2 treatments for ductal dependent lesions
1. Prostaglandin E1
| 2. Expert consult
242
What are the 3 types of distributive shock?
1. Anaphylactic shock
2. Neurogenic shock
3. Septic shock
243
What is the most common type of distributive shock/
septic shock
244
anaphylactic shock leads to systemic (vasodilation/ vasoconstriction) and pulmonary (vasodilation/ vasoconstriction)
vasodilation
| vasoconstriction
245
5 treatments for anaphylactic shock
1. Subcutaneous/IM epi
Causes systemic vasoconstriction & pulmonary vasodilation
2. Bronchodilators
3. 20mL/kg fluid bolus
4. Corticosteroids
5. H1 & H2 blockers (Benadryl, Zantac)
4. Magnesium
Bronchodilating and anti-inflammatory effects
5. Consider humidified oxygen, BiPAP, and intubation
246
_____ shock occurs after a spinal cord or head injury when the injury causes the sympathetic pathway of the spinal cord to be disrupted/lost (the reflex activity of the spinal cord to be depressed)
neurogenic
247
patients in neurogenic shock will have (hyper/hypo) tension and (vasodilation/ vasoconstriction)
hypotension
vasodilation
Whenever the sympathetic innervation to the heart and blood vessels is interrupted from these types of injuries, compensatory mechanisms (such as tachycardia and vasoconstriction) cannot take place
they may also develop temperature deregulation
248
4 ways to diagnose neurogenic shock
1. Spinal cord or head injury
2. Vasodilation and subsequent wide pulse pressure
3. Hypotension and warm shock
4. Absence of tachycardia
(normal heart rate or bradycardia)
249
4 treatments of neurogenic shock
1. Fluid boluses (although neurogenic shock generally doesn’t respond to fluids)
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
250
_______refers to an acute loss of sensation & motor function after a spinal injury, with gradual recovery
spinal shock
-This is more of a decrease in sensation rather than a decrease in blood pressure or heart rate
251
In spinal cord injuries above ___, autonomic dysreflexia may occur
T6
252
4 criteria for Sepsis
1. Temperature > 38.5⁰C or below 36⁰C
2. Unexplained tachycardia in adults or bradycardia in children < 1 year old
3. Respiratory rate > 20 unrelated to pain or other factors
4. WBC count > 12,000
-At least 2 of the 4 criteria must be met for a patient to have Systemic Inflammatory Response Syndrome (SIRS) (and one of them must either be the temperature criteria or the abnormal white count)
253
8 steps of Sepsis
1. An infection activates the immune system, which releases inflammatory mediators (cytokines)
2. The cytokines promote vasodilation and increase capillary permeability, which can lead to massive hypotension/shock
3. mitochondrial dysfunction, which impairs oxygen uptake. This can cause subsequent hypoxia, even if oxygen delivery is normal
4. adrenal insufficiency
5. hyperglycemia or hypoglycemia
6. hypocalcemia
7. increased cardiac output early on (due to the vasodilation/low afterload), and decreased cardiac output in the later stages (due to acidosis and decreased organ perfusion/function)
8. starts with SIRS, then sepsis (SIRS + infection), then severe sepsis (sepsis + organ dysfunction/damage), then septic shock (severe sepsis + hypotension)
254
Sepsis is considered severe if it is accompanied by any one of what 3 criteria?
1. Cardiovascular dysfunction
2. Acute respiratory distress syndrome (ARDS)
3. Failure/dysfunction of at least two other organs
Kidneys may fail due to hypotension, and patients can develop respiratory distress (hypercarbia, low SpO2, etc) from increased alveolar capillary membrane permeability
255
a patient is considered to be in septic shock if they display ______ after fluid resuscitation
cardiovascular dysfunction
Signs of cardiovascular dysfunction may include hypotension, poor signs of perfusion, or the necessity of vasopressors to maintain normal blood pressure, or poor signs of perfusion
256
In what shock scenario should we consider administering steroids?
sepsis
257
What 3 things should be done in the first 10-15 minutes of treating septic shock?
1. Identify the shock (poor signs of perfusion, fever, petechiae, etc)
2. Monitors, IV, oxygen (if needed), auscultation
3. Draw blood cultures and labs (including glucose and calcium)
258
What 4 things should be done in the first hour of treating septic shock?
3. Start and repeat 20mL/kg fluid boluses (3-4 boluses), but assess carefully after each bolus and stop if rales or respiratory distress develop
4. Start vasopressors if shock persists despite fluid boluses
Epi for cold shock; norepi for warm shock
5. Identify metabolic derangements (electrolyte abnormalities, etc)
6. Administer broad spectrum Abx
259
What 4 things should be done after the first hour in the treatment of septic shock?
6. Administer 2mg/kg hydrocortisone if adrenal insufficiency is suspected
7. Correct hypoglycemia and hypocalcemia
Calcium dose = 20mg/kg; Dextrose dose = 0.5-1g/kg
8. Start invasive lines (A-line, central line) and treat based on ScvO2
9. Consider intubation
260
what is the dose of hydrocortisone steroid therapy in septic shock?
2 mg/kg
261
What is the calcium chloride dose in septic shock?
20 mg/kg
262
When is dopamine administered and what is the dose/
(2-20mcg/kg/min; >5mcg/kg/min (beta); >10mcg/kg/min (alpha)) is the preferred agent in PALS for a normotensive child in septic shock
263
milrinone and dobutamine function as both _____ and ____
inotropes and vasodilators
264
What are 3 ways we can reduce oxygen demand in septic shock?
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
A simple act such as allowing a child to be held by a parent can help in this endeavor
265
What is the goal SpO2 of of post resuscitation?
94-99% ( NOT 100%)
266
The IV/IO pediatric dose of Atropine is ____
20 mcg/kg
267
The ETT pediatric dose of Atropine is ____
40-60 mcg/kg (2-3x the IV dose)
268
The maximum SINGLE dose for a child is _____, and the maximum TOTAL dose for a child is ____
The maximum TOTAL dose for an ADOLESCENT is ____
0.5mg
1mg
3 mg
269
PALS book says that the minimum dose of atropine is ___
0.1 mg
270
IV dose of epi is ____
10mcg/kg (0.01mg/kg)
repeated every 3-5 min as needed
low doses (<0.3mcg/kg/min), epinephrine lowers systemic vascular resistance, but at higher doses (>0.3mcg/kg/min) it produces an alpha adrenergic effect and increases systemic vascular resistance
271
ETT dose of epi is ____
100mcg/kg
272
What is the 1st dose for Adenosine in SVT?
100 mcg/kg ( max 6 mg)
273
What is the 2nd dose for Adenosine in SVT?
200 mcg/kg (max 12 mg)
274
What is the amiodarone dose for SVT/ Stable VTach
5mg/kg over 20-60 minutes
275
What is the procainamide dose for SVT/ stable Vtach
15mg/kg over 30-60 minutes
276
What heart rhythm is amiodarone contraindicated?
torsades de pointes
277
What is the loading dose of lidocaine in Vfib/ pulseless Vtach?
1 mg/kg
278
What is the infusion dose of lidocaine in vfib/pulseless Vtach?
20-50mcg/kg can be considered
279
in what heart rhythm is magnesium indicated?
torsades de pointes
280
What is the dose of magnesium?
25-50mg/kg
