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Methods I > PALS > Flashcards

PALS Flashcards

1
Q

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

A

acryocyanosis

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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

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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

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4
Q

_____ apnea is a combination of both central and obstructive apnea

A

mixed

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5
Q

what is the most common cause of bradycardia in kids?

A

apnea, hypoxia

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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

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7
Q

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

A

cyanosis

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8
Q

Cyanosis is not apparent until at least ____ of hemoglobin are desaturated

A

5 g/dL

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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

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10
Q

Patients with a temperature _____are considered febrile

A

≥38⁰C

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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

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12
Q

a patient is considered to have hypoxemia if their SpO2 is _____ on room air

A

≤94%

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13
Q

What are 2 reasons we would consider administering supplemental oxygen?

A
  1. the Spo2 is <94%

2. there are poor signs of perfusion

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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)

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15
Q

Hypoxia due to reduced arterial oxygen SATURATION (SaO2)

A

hypoxemia hypoxia

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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

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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

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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

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19
Q

For neonates, blood sugars _____ are considered hypoglycemic and should be treated

A

<45mg/dL

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20
Q

For infants/children/adolescents, blood sugars ___ are considered hypoglycemic and should be treated

A

<60mg/dL

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21
Q

name 5 symptoms of hypoglycemia

A
  1. tachycardia
  2. hypotension
  3. lethargy/irritability
  4. poor signs of perfusion
  5. sweating
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22
Q

What is the dose of glucose for treating hypoglycemia?

A

0.5-1 g/kg bolus

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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

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24
Q

systolic hypotension in neonates

A

<60

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25
Q

systolic hypotension in infants

A

<70

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26
Q

systolic hypotension in children age 1-10

A

70 + (age in years X 2)

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27
Q

systolic hypotension in adolescents

A

<90

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28
Q

How low can the systolic pressure of a 3-year old patient go before they are considered hypotensive?

A

76 mmHg

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29
Q

“patchy” discolorations of the skin, and is caused by areas of vasoconstriction (pallor) mixed with areas of vasodilation (cyanosis or erythema)

A

mottling

The mechanism is unclear, and appears to simply be an irregular supply of oxygenated blood

Mottling can be a sign of imminent death

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30
Q

a pale color due to lack of oxygen in the skin

A

palor

“Central” pallor is pallor seen in the lips and mucous membrane

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31
Q

5 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)
    Very rapid capillary refill (< 2 seconds) is also referred to as “flash capillary refill”
  4. Warm skin
  5. Awake & alert
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32
Q

5 signs of poor peripheral perfusion

A
  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
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33
Q

purple discolorations caused by small vessel bleeding. They can suggest a low platelet count, or can be a symptom of disseminated intravascular coagulation (DIC)

A

Petechiae and purpura

Petechiae are small dots, while purpura appear as larger areas

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34
Q

What are petechia and purpura often a sign of ?

A

septic shock

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35
Q

A child is “_______” to treatment if they do not improve or respond to a specific therapy

A

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
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36
Q

what is a normal capillary refill time?

A

<2 seconds

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37
Q

What is a prolonged capillary refill time?

Name 3 common causes

A

> 5 seconds

  1. Dehydration
  2. shock
  3. hypothermia
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38
Q

What is the SVT rate for infants?

A

> 220

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39
Q

What is the SVT rate for children?

A

> 180

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40
Q

oxygen consumption in adults

A

3-4 mL/kg/min

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41
Q

oxygen consumption in infants

A

6-8 mL/kg/min

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42
Q

SpO2 should be ____ on room air

A

> 94%

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43
Q

SpO2 ____ on 100% oxygen requires intervention

A

<90%

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44
Q

What is a normal ScvO2

A

central venous oxygen saturation
25-30% below SaO2
70-75% if SaO2 is normal

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45
Q

What is the urine output for infants/ young children?

A

1.5-2 mL/kg/hr

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46
Q

What is the urine output for children and adolescents?

A

1 mL/kg/hr

Reduced urine output is a sign of poor perfusion

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47
Q

If a patient is tachypneic, it is defined as “______” if it is not accompanied by signs of labored breathing or respiratory distress

A

quiet tachypnea

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48
Q

What is quiet tachypnea usually caused by?

A

non-pulmonary issues (fever, pain, metabolic acidosis)

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49
Q

What are 2 reasons pediatric patients are especially prone to a difficult airway?

A
  1. large tongue

2. large occiput

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50
Q

Larger airways have (more/less) resistance than smaller airways

A

more

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51
Q

(Larger/Smaller) airways are more prone to turbulent flow

A

Larger

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52
Q

When the radius of the airway decreases, the resistance increases to the ______

A

4th power

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53
Q

With turbulent flow, when the radius of the airway decreases, the resistance increases to the ____

A

5th power

turbulent flow increases airway resistance and can make it harder to breathe

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54
Q

Airflow is _____ during normal respirations

A

laminar

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55
Q

When are 2 instances that airflow can become turbulent?

A
  1. Partial airway obstruction (usually upper airway obstruction)
  2. Labored/agitated breathing/increased respiratory efforts/crying
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56
Q

The (higher/lower) the gas density, the higher the percentage of laminar flow, and the lower the resistance

A

lower

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57
Q

What are the primary inspiratory muscles?

A

external intercostals and diaphragm

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58
Q

the sternocleidomastoid, internal intercostals, scalene muscles, pectoralis major, and pectoralis minor are the accessory (inspiratory/ expiratory) muscles

A

inspiratory

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59
Q

rectus abdominis, external oblique, internal oblique, and transversus abdominis are the accessory (inspiratory/ expiratory) muscles

A

expiratory

There aren’t really any PRIMARY expiratory muscles, because expiration is usually a passive process

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60
Q

What type of chest wall do infants have? and what problem does this cause?

A

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)

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61
Q

Because of the compliant chest wall, it is more efficient for infants to take (smaller/larger) tidal volumes at an (elevated/decreased) respiratory rate

A

smaller

elevated

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62
Q

The central nervous system causes spontaneous ventilations through _____

A

central and peripheral chemoreceptors

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63
Q

Central chemoreceptors are located in ______ and respond to _____ concentration in the CSF

A

brain stem/ medulla oblongata

H+ mostly affected by PaCO2

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64
Q

peripheral chemoreceptors are located in the _____ and respond to changes in _____

A

carotid body/ aortic arch

PaO2 levels (few are responsive to PaCO2)

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65
Q

3 reasons to avoid excessive ventilation

A
  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
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66
Q

What are 3 ways gastric inflation can be minimized?

A
  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
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67
Q

If an Ambu bag is connected to oxygen but NOT CONNECTED TO A RESERVOIR BAG, the Ambu bag will fill with a _____

A

mixture of oxygen and room air during exhalation

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68
Q

If an Ambu bag is connected to oxygen AND CONNECTED TO A RESERVOIR BAG, the Ambu bag will fill with _____

A

mostly oxygen (and no room air) during exhalation

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69
Q

does a self- inflating ambu bag require oxygen to work?

A

no

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70
Q

A ______ Ambu bag requires oxygen flow to operate (cannot inflate without oxygen flow)

A

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

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71
Q

What size are infant/young children flow inflating ambu bags?

A

400-500 mL

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72
Q

What size are older children and adolescent flow inflating ambu bags?

A

1000 mL

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73
Q

Uncuffed tracheal tubes are recommend for children ____ years old

A

<8

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74
Q

What is the formula for choosing the correct size endotracheal tube?

A

Uncuffed: (age/4) +4

Cuffed: (age/4) +3

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75
Q

What is the formula for choosing the correct depth of insertion

A

kids ≤ 2: internal diameter of the tube (mm) X 3

kids >2: age/2 +12

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76
Q

How many ventilations are recommended to wash out CO2 that may be present in the abdomen after bag mask ventilation?

A

6

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77
Q

____ soluble drugs can be administered via the ETT.

What is the pneumonic for drugs that can be administered in PALS through the ETT

A

Lipid

“LEAN”

Lidocaine
Epinephrine
Atropine
Narcan

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78
Q

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 _____
A
  1. 5 mL NS
  2. hold
  3. 5 positive pressure ventilations
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79
Q

When dosing drugs via the ETT, we typically use _____ times the IV dose

A

2-3 X

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80
Q

When dosing epinephrine via the ETT, we use _____ times the IV dose. Why?

A

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

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81
Q

What pneumonic should be verbalized when a child is intubated and deteriorates?

A

DOPE

Displacement: is the tube still in place?
Obstruction: is the ETT kinked?
Pneumothorax: bilateral breath sounds ( usually associated with trauma)
Equipment failure

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82
Q

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

A

lung percussion examination

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83
Q

Resonant sounds are ____ lung sounds with percussion

A

normal

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84
Q

Hyperresonant lung sounds are found in patients with what two conditions?

A
  1. hyperinflated chest cavity (tension pneumothorax)

2. hyperinflated lung (COPD, acute asthma attack)

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85
Q

Wheezing is a high pitched noise, usually during expiration, that is caused by _____

A

bronchoconstriction

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86
Q

___ is described as an intermittent popping sound

Some describe is as a “velcro” sound of rubbing hair together

A

Rales

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87
Q

What are 2 possible causes of rales?

A
  1. fluid in the distal airways

2. atelectasis

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88
Q

In PALS, hearing rales when auscultating is key to diagnosing ____

A

cardiogenic shock

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89
Q

____ are low pitched noises that have been described as a “snoring,” or “bubbling” sound

A

Rhonchi

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90
Q

Where are Rhonchi usually heard?

A

in the Larger airways caused by secretions, mucous, blood

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91
Q

Stridor usually indicates a ____ airway obstruction

A

upper (foreign body, croup, upper airway edema, etc)

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92
Q

Grunting is a low pitched sound heard during (inhalation/ exhalation)

A

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

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93
Q

What two PALS scenarios can grunting be heard?

What is grunting a sign of?

A

Lung tissue disease and cardiogenic shock

impending respiratory failure

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94
Q

nasal flaring is a sign of respiratory distress where the nares dilate during (inhalation/ exhalation)

A

inhalation

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95
Q

is a sign of respiratory failure in which the chin lifts during inspiration and the chin falls during expiration

A

head bobbing

-neck muscles are being used to assist ventilation

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96
Q

an irregular respiratory rate and/or insufficient respiratory effort, which can lead to hypoxemia and hypercarbia

A

disordered control of breathing

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97
Q

What are 3 things that can cause disordered control of breathing?

A
  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)
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98
Q

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

A

retractions

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99
Q

retractions that are ______ suggest mild to moderate breathing difficulty

A

substernal / subcostal

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100
Q

Retractions that are _____suggest severe breathing difficulty

A

suprasternal/ supraclavicular

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101
Q

Seesaw respirations are just like retractions with what difference?

A

the abdomen distends during inspiration

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102
Q

seesaw respirations are usually indicative of _____ airway obstruction

A

upper

Characteristic of children with neuromuscular weakness

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103
Q

Symptoms: Retractions + inspiratory snoring/stridor

Diagnosis?

A

upper airway obstruction

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104
Q

symptoms: Retractions + expiratory wheezing

Diagnosis?

A

lower airway obstruction

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105
Q

symptoms: Retractions + grunting or labored respirations

Diagnosis?

A

Lung tissue disease or pulmonary edema produced by cardiogenic shock

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106
Q

Symptoms: severe retractions

Diagnosis?

A

May be accompanied by head bobbing or seesaw respirations

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107
Q

abnormal inspiratory sounds indicate ______ airway obstruction

A

upper

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108
Q

abnormal expiratory sounds indicate _____ airway obstruction

A

lower

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109
Q

RESPIRATORY DISTRESS, RESPIRATORY FAILURE, AND SHOCK OFTEN LEAD TO _____ IN CHILDREN

A

cardiac arrest

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110
Q

What are 7 indications for bag mask ventilation or intubation?

A
  1. low SpO2
  2. abnormal airway signs
  3. poor signs of perfusion
  4. bradycardia
  5. anxiety
  6. lethargy
  7. increased effort
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111
Q

It is an airway scenario if the patient has bad lung sounds and _____ blood pressure

A

normal

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112
Q

it is cardiogenic shock if the patient has bad lung sounds and _____

A

hypotension

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113
Q

at high flows of ____, ahigh flow nasal cannula can deliver an FiO2 of close to ___similar to a nonrebreather mask

A

> 50L/min

100%

114
Q

How can you deliver high flows through nasal cannula?

A

the oxygen is humidified

115
Q

a simple oxygen mask requires at least _____ to prevent rebreathing of CO2

A

6 L/min

116
Q

a low flow simple oxygen mask provides what percentage of Fi02?

A

35-60%

117
Q

a low flow nasal cannula provides what percentage of Fi02?

A

22-60%

118
Q

a high flow nasal cannula provides what percentage of Fi02?

A

up to 95%

119
Q

high flow nasal cannula can deliver up to ____L/min of oxygen to infants

A

4 L/min

120
Q

a high flow nasal cannula can deliver up to ___ L/min of oxygen to adolescents

A

40 L/min

121
Q

A non- rebreathing mask can provide what percentage of FiO2?

A

95%

122
Q

breathing treatments are indicated for (lower/upper) airway obstruction

A

lower

123
Q

_____ 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

A

Heliox
lower
laminar

124
Q

heliox is used to relieve symptoms of (upper/lower) airway obstruction

A

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
Q

What are 2 primary advantages to humidified oxygen

A
  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
Q

racemic epi is considered in (upper/lower) airway obstruction caused by swelling

A

upper

127
Q

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

A

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
Q

Steroids (dexamethasone) can be used to relieve symptoms of (upper, lower) airway obstruction

A

upper

swelling, croup

129
Q

What drug is not a first line for bronchoconstriction but can be used in in patients that fail to respond to bronchodilator therapy

A

magnesium

130
Q

What side effect can magnesium cause and what should be monitored if this drug is used?

A

hypotension

patient’s BP

131
Q

what drugs can be considered in the treatment of disordered control of breathing caused by increased intracranial pressure?

A

mannitol and hypertonic saline

132
Q

When albuterol is combined with theophylline or used simultaneously with other adrenergic agents like terbutaline and dopamine, there is an increased risk of _______

A

tachyarrhythmias

133
Q

________ is an anticholinergic and a bronchodilator. It can be mixed with albuterol in the same inhaler

A

ipratropium bromide

134
Q

______ 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

A

Narcan (Naloxone)

135
Q

How should narcan be administered to lower the risks and slow the drugs onset?

A

IM

136
Q

PEEP should generally be started at around _____

A

6-10 cm H20

137
Q

List 7 possible ways to support the airway in PALS

A
  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
Q

When giving rescue breaths, each breath should be given over ______ , or _____ if an advanced airway is placed

A

3-5 seconds

10/ min

139
Q

_____ is the most common type of arrest in kids

A

asphyxial arrest

140
Q

What is the leading cause of death in infants under 6 months?

A

SIDS

141
Q

In children >1 year, what two pulse areas should be checked?

A

carotid or femoral

142
Q

in children <1 year, what pulse area should be checked?

A

brachial

143
Q

What is the chest compression depth for an:
infant?
children?
adolescents/adults?

A

1.5 in
2 in
<2.4 in

144
Q

When doing chest compressions, end tidal CO2 should be ______

A

> 10-15 mmHg

145
Q

At what age should a 2 handed CPR technique be used?

A

> 8 years

146
Q

What CPR technique should be used in kids ages 1-8 years?

A

one handed

147
Q

What technique is used for one responder infant CPR?

A

two finger

148
Q

What technique is used for two responder infant CPR?

A

thumb encircling technique

149
Q

What are the 3 advantages to the thumb encircling technique?

A
  1. better coronary blood flow
  2. more consistent depth
  3. may generate higher blood pressures
150
Q

in neonates and children with an advanced airway and 2 providers, what is the compression to ventilation ratio?

A

100-120 compressions per minute with an age appropriate respiratory rate

151
Q

What is the compression to ventilation ratio for a respiratory cause in neonates without an advanced airway?

A

3:1

152
Q

What type of ECMO is used in cases of respiratory failure?

A

venovenous

153
Q

What type of ECMO is used in cases of cardiac arrest?

A

venoarterial

154
Q

List 4 ways we can check “disability” in PALS

A
  1. blood sugar
  2. pupil response to light
  3. AVPU pediatric response scale
  4. Glasgow Coma scale
155
Q

4 symptoms of hypoxia for neurologic dysfunction

A
  1. loss of muscle tone
  2. generalized seizures
  3. dilation of pupils
  4. loss of consciousness
156
Q

6 symptoms of cerebral herniation

A
  1. unequal/ unresponsive/dilated pupils
  2. hypertension
  3. bradycardia
  4. respiratory irregularities/ apnea
  5. diminished response to stimuli
  6. sudden increase in ICP
157
Q

When checking a patient’s neurologic function, what is the first thing you should check?

A

glucose

158
Q

In the exposure step of PALS, what is an additional thing we check?

A

temperature; to assess fever, and warm or cold shock

159
Q

What type of defibrillator pads are used on children ≤ 1 years old?

A

pediatric manual defibrillator pads

-can use lower doses than an AED

160
Q

At what age are pediatric AED pads used?

A

on children 1-8 years old, less than 25 kg

161
Q

When are adult AED pads used?

A

> 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
Q

in infants <1 year or who weigh less than 10kg, how should the paddles be placed

A

anterior-anterior

163
Q

in infants >1 year or who weigh more than 10 kg, how should the paddles be placed?

A

can use anterior placement or anterior-posterior paddle placement

164
Q

What is the dose of synchronized cardioversion for the 1st shock?
2nd shock?

A

0.5-1 J/kg

2 J/kg

165
Q

What is the defibrillation dose for the 1st shock?
2nd shock?
subsequent shocks?
max shock?

A

2 J/kg
4 J/kg
≥ 4 joules/kg
10 J/kg or adult dose

166
Q

Water takes up to ____% in infants and ____% in neonates

A

70%

80%

167
Q

1 kg is = to _____ of water

A

1 L

168
Q

in order to estimate dehydration, how can we estimate fluid loss?

A

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
Q

What are 2 ways that weight loss in PALS can be expressed as volume loss?

A
  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
Q

5% EWL is _____ mL/kg

A

50

171
Q

10% EWL is ____ ml/kg

A

100

172
Q

100% EWL is ____ ml/kg

A

1000

173
Q

What percent of the total fluid volume in the human body is blood?
How is this expressed in mL/kg?

A

10%

100mL/kg

174
Q

(Younger/older) children can tolerate more volume loss, because they have higher circulating blood volumes

A

younger

- they have more water to lose

175
Q

hypovolemic/hypotensive shock is more LIKELY with a ______ or greater estimated weight loss

A

10% (volume depletion >100mL/kg)

-it is POSSIBLE with a 5% EWL (volume depletion >50mL/kg), it is

176
Q

What is the treatment for a child in dehydration?

A

multiple 20mL/kg boluses of isotonic crystalloid

177
Q

What type of fluid bolus is indicated for hypovolemic/hypotensive shock and distributive (septic) shock?

A

rapid boluses of 20mL/kg over 5-10 minutes

178
Q

What type of fluid bolus is indicated for cardiogenic shock?

A

Smaller (5-10mL/kg) and/or slower (10-20 minutes) boluses

179
Q

When are colloid boluses indicated?

A

if hypovolemia/hypotension persists after 3 boluses of crystalloid (20mL/kg)

180
Q

What is the maximum dose of colloids?

A

20-40mL/kg (higher doses may cause coagulopathies)

181
Q

What is the dose for albumin?

A

2mg/kg

A standard 250mL 5% vial contains 12.5g

182
Q

What is a side effect of albumin?

A

hypocalcemia

-Albumin binds calcium, so Albumin administration may lower plasma calcium concentration

183
Q

Before giving fluids, what should we always check?

A

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
Q

what type of fluid bolus is indicated for poisonings (calcium channel or beta blocker overdose)?

A

Smaller (5-10mL/kg) and/or slower (10-20 minutes) boluses

185
Q

what type of fluid bolus is indicated for DKA with compensated shock?

A

10-20 mL/kg over at least 1-2 hours (unless shock is present)

186
Q

what type of fluid bolus is indicated for febrile illness (in the absence of shock)

A

“restrictive”

-Use extreme caution when access to critical care resources are not available

187
Q

what type of fluid bolus is indicated for septic shock?

A

Start 20mL/kg fluid boluses

Carefully assess after each bolus and continue fluid boluses unless signs of respiratory distress develop

188
Q

What are 3 indications for blood transfusions in PALS?

A
  1. traumatic volume loss with signs of poor perfusion
  2. hemoglobin concentration is less than 7 g/dL
    1. Children who are hypotensive despite 2-3 boluses of 20mL/kg crystalloid
189
Q

What is the initial dose of packed red blood cells (PRBC) in PALS?

A

10 mL/kg

190
Q

What are the 3 priories of blood in order?

A
  1. type and crossmatched
  2. type specific
    - can be available in 10 minutes
  3. Type O blood
    - negative Rh in females
191
Q

What are the 4 stages of assessment in PALS?

A
  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
Q

What is the first step you take in the PALs assessment?

A

appearance

193
Q

What are the 3 things we check when looking at appearance?

A
  1. appearance
  2. work of breathing
  3. circulation (color)
194
Q

Checking the child’s appearance in PALs is referred to as the _____ assessment

A

general or pediatric assessment triangle

195
Q

What 2 scenarios can Bradycardia be present?

A

bradycardia or airway scenario

196
Q

If the patient is bradycardic, but lung sounds are clear, what scenario may the patient be in?j

What is the most effective treatment?

A

bradycardia scenario

epinephrine/atropine

197
Q

if the patient is bradycardic but lung sounds are abnormal, what scenario may the patient be in?

A

airway scenario

effective oxygenation and ventilation

198
Q

what 2 scenarios can a fever be present in?

A

Septic shock or lung tissue disease

199
Q

If the patient has a fever and abnormal breath sounds, what scenario is the patient most likely in?

What is the most effective treatment?

A

lung tissue disease

supporting the airway and administering Abx

200
Q

if the patient has a fever and clear breath sounds, what scenario is the patient most likely in?

what is the most effective treatment?

A

septic shock

abx, fluids, vasopressors

201
Q

What 2 scenarios can be present with hypotension?

A

hypovolemic shock and cardiogenic shock

202
Q

if the patient has hypovolemia with normal breath sounds, what scenario is the patient most likely in?

What is the most effective treatment?

A

hypovolemic shock

rapid fluid boluses

203
Q

if the patient has hypovolemia with abnormal breath sounds, what scenario is the patient most likely in?

What is the most effective treatment?

A

cardiogenic shock

inotropes and smaller fluid boluses

204
Q

ABGs should be obtained within _____ min of establishment of mechanical ventilation

A

10-15 min

205
Q

PaCO2 should be compared to ____

A

EtCO2

206
Q

If venous blood is to be used for blood gas values, you should use _____ veins rather than _____ veins

A

central, peripheral

207
Q

_____ measurements of venous blood and arterial blood are generally comparable.”

A

Hydrogen ion (pH)

208
Q

Venous labs are “not good indicators of ____ and _____ pressures”

A

oxygen and carbon dioxide

209
Q

3 possible causes of low cardiac output

A
  1. bradycardia
  2. hypovolemia
  3. decreased contractility
210
Q

5 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 stroke volume (low systolic BP)
    Vasoconstriction (high diastolic BP)
211
Q

what are 3 symptoms of decreased contractility?

A 
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
Q

7 symptoms of low afterload (vasodilation)

A
  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
  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 (like in anaphylactic shock)
213
Q

3 symptoms of vasoconstriction

A
  1. Weak pulses
  2. Pale skin
  3. Delayed capillary refill
214
Q

What is the most common cause of vasoconstriction in PALS?

A

decreased cardiac output, as seen in hypovolemic and cardiogenic shock

215
Q

What are 3 possible causes of high ScvO2?

A
  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
Q

4 possible causes of low ScvO2?

A
  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
Q

in PALS, a low ScvO2= ____

A

low cardiac output

218
Q

in PALS, if ScvO2 is high = _____

A

high cardiac output or sepsis

219
Q

low ScvO2 and low blood pressure = ______

A

hypotensive shock

-patient will be vasoconstricted but not compensating for BP

220
Q

What drug is considered for warm shock?

A

norepinephrine

221
Q

What drug is considered for cold shock?

A

epinephrine

222
Q

low ScvO2 and normal blood pressure =

A

normotensive shock

-vasoconstriction can compensate for BP

223
Q

What is the treatment for normotensive/ compensated shock?

A
  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
Q

high ScvO2 and low blood pressure = ______

A

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
Q

What are 2 examples of warm shock in PALS

A
  1. Anaphylaxis
  2. Sepsis
    Septic patients have a high ScvO2 for two reasons:
  3. They have massive vasodilation, leading to increased stroke volume & cardiac output
  4. They have impaired oxygen uptake at the mitochondrial level, leaving more oxygen in the blood
226
Q

If the child’s blood pressure is greater than the 50th percentile for their age, it is considered (compensated/uncompensated)

A

compensated

227
Q

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
A
  1. good
  2. Increased (because of reduced afterload)
  3. Wide
  4. warm
228
Q

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
A
  1. pale/ mottled
  2. decreased (and are thus cold)
  3. narrow
  4. inaccurate
229
Q

What is the most common type of shock in kids?

A

hypovolemic

230
Q

What are the 2 types of hypovolemic shock?

A
  1. Hemorrhagic

Loss of blood volume of about 30% (EBL of 25mL/kg)

  1. Non-hemorrhagic (hypotensive)
    From GI losses, burns, etc
231
Q

When should vasodilators be considered in shock?

A

When the patient has decreased cardiac output but normal blood pressure

232
Q

How does dissociative shock occur?

A

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
Q

4 types of obstructive shock

A
  1. Pulmonary embolism
  2. Cardiac tamponade
  3. Tension pneumothorax
  4. Ductal dependent lesions
234
Q

4 signs of pulmonary embolism

A
  1. Hypotension
  2. Physical signs of right heart failure (increased CVP, jugular venous distention, etc)
  3. Respiratory distress
  4. Chest pain
235
Q

What is the treatment for pulmonary embolism?

A
  1. 20mL/kg fluid bolus
  2. Consider anticoagulants (heparin) and thrombolytics (rTPA)
  3. Expert consult
236
Q

3 signs of cardiac tamponade

A
  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
Q

2 treatments for cardiac tamponade

A
  1. Pericardiocentesis

2. 20mL/kg fluid bolus

238
Q

5 signs of tension pneumothorax

A
  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
Q

2 treatments for tension pneumothorax

A
  1. Needle decompression
    (2nd-3rd intercostal space, mid clavicular line)
  2. Chest tube placement
    (6th-7th intercostal space, mid-axillary line)
240
Q

Ductal dependent lesions refer to congenital heart disease with (LEFT/RIGHT) sided blockages

A

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
Q

What are 2 treatments for ductal dependent lesions

A
  1. Prostaglandin E1

2. Expert consult

242
Q

What are the 3 types of distributive shock?

A
  1. Anaphylactic shock
  2. Neurogenic shock
  3. Septic shock
243
Q

What is the most common type of distributive shock/

A

septic shock

244
Q

anaphylactic shock leads to systemic (vasodilation/ vasoconstriction) and pulmonary (vasodilation/ vasoconstriction)

A

vasodilation

vasoconstriction

245
Q

5 treatments for anaphylactic shock

A
  1. Subcutaneous/IM epi
    Causes systemic vasoconstriction & pulmonary vasodilation
  2. Bronchodilators
  3. 20mL/kg fluid bolus
  4. Corticosteroids
  5. H1 & H2 blockers (Benadryl, Zantac)
  6. Magnesium
    Bronchodilating and anti-inflammatory effects
  7. Consider humidified oxygen, BiPAP, and intubation
246
Q

_____ 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)

A

neurogenic

247
Q

patients in neurogenic shock will have (hyper/hypo) tension and (vasodilation/ vasoconstriction)

A

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
Q

4 ways to diagnose 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
    (normal heart rate or bradycardia)
249
Q

4 treatments of neurogenic shock

A
  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
Q

_______refers to an acute loss of sensation & motor function after a spinal injury, with gradual recovery

A

spinal shock

-This is more of a decrease in sensation rather than a decrease in blood pressure or heart rate

251
Q

In spinal cord injuries above ___, autonomic dysreflexia may occur

A

T6

252
Q

4 criteria for Sepsis

A
  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
Q

8 steps of Sepsis

A
  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
Q

Sepsis is considered severe if it is accompanied by any one of what 3 criteria?

A
  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
Q

a patient is considered to be in septic shock if they display ______ after fluid resuscitation

A

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
Q

In what shock scenario should we consider administering steroids?

A

sepsis

257
Q

What 3 things should be done in the first 10-15 minutes of treating septic shock?

A
  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
Q

What 4 things should be done in the first hour of treating septic shock?

A
  1. Start and repeat 20mL/kg fluid boluses (3-4 boluses), but assess carefully after each bolus and stop if rales or respiratory distress develop
  2. Start vasopressors if shock persists despite fluid boluses
    Epi for cold shock; norepi for warm shock
  3. Identify metabolic derangements (electrolyte abnormalities, etc)
  4. Administer broad spectrum Abx
259
Q

What 4 things should be done after the first hour in the treatment of septic shock?

A
  1. Administer 2mg/kg hydrocortisone if adrenal insufficiency is suspected
  2. Correct hypoglycemia and hypocalcemia
    Calcium dose = 20mg/kg; Dextrose dose = 0.5-1g/kg
  3. Start invasive lines (A-line, central line) and treat based on ScvO2
  4. Consider intubation
260
Q

what is the dose of hydrocortisone steroid therapy in septic shock?

A

2 mg/kg

261
Q

What is the calcium chloride dose in septic shock?

A

20 mg/kg

262
Q

When is dopamine administered and what is the dose/

A

(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
Q

milrinone and dobutamine function as both _____ and ____

A

inotropes and vasodilators

264
Q

What are 3 ways we can reduce oxygen demand in septic shock?

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
    A simple act such as allowing a child to be held by a parent can help in this endeavor
265
Q

What is the goal SpO2 of of post resuscitation?

A

94-99% ( NOT 100%)

266
Q

The IV/IO pediatric dose of Atropine is ____

A

20 mcg/kg

267
Q

The ETT pediatric dose of Atropine is ____

A

40-60 mcg/kg (2-3x the IV dose)

268
Q

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 ____

A

0.5mg

1mg

3 mg

269
Q

PALS book says that the minimum dose of atropine is ___

A

0.1 mg

270
Q

IV dose of epi is ____

A

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
Q

ETT dose of epi is ____

A

100mcg/kg

272
Q

What is the 1st dose for Adenosine in SVT?

A

100 mcg/kg ( max 6 mg)

273
Q

What is the 2nd dose for Adenosine in SVT?

A

200 mcg/kg (max 12 mg)

274
Q

What is the amiodarone dose for SVT/ Stable VTach

A

5mg/kg over 20-60 minutes

275
Q

What is the procainamide dose for SVT/ stable Vtach

A

15mg/kg over 30-60 minutes

276
Q

What heart rhythm is amiodarone contraindicated?

A

torsades de pointes

277
Q

What is the loading dose of lidocaine in Vfib/ pulseless Vtach?

A

1 mg/kg

278
Q

What is the infusion dose of lidocaine in vfib/pulseless Vtach?

A

20-50mcg/kg can be considered

279
Q

in what heart rhythm is magnesium indicated?

A

torsades de pointes

280
Q

What is the dose of magnesium?

A

25-50mg/kg

Methods I (4 decks)

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