PALS: CARDIAC ARREST

Question 1

Approach to Cardiopulmonary Arrest

Answer 1

INITIAL IMPRESSION:
Check Level of Consciousness, breathing, circulation

IF UNREPONSIVE:
shout for help
check breathing / pulse:
No breathing
OR
Only gasping
AND
No pulse

START CPR
100-120 compressions / min

Monitor
Oxygen
Vitals
IV / IO
ECG / Airway Equipment

Use Breslow tape if between 1-40 kg

AIRWAY / BREATHING:
Bag Valve Mask

Consider supraglottic device

Capnography > 20 mmHg reassuring
Pulse Oximetry

CIRCULATION:
IV access, IO within 2 min
Monitor
Continue CPR

V-Vib / Pulseless V Tach:
Defibrillate 2 J / kg
epinephrine (0.01 mg/kg = 0.1 mL/kg of 1:10,000 dilution)
Defibrillate 4 J / kg
epinephrine (0.01 mg/kg = 0.1 mL/kg of 1:10,000 dilution)
Defibrillate 4-10 J / kg
Amiodarone 5 mg / kg over 30 min

PEA / Asystole:
epinephrine (0.01 mg/kg = 0.1 mL/kg of 1:10,000 dilution) q 3-5 min

DISABILITY
POC Glucose

Question 2

Most common recognizable signs of cardiac arrest

Answer 2

Unresponsiveness
No breathing or only gasping
No pulse

Question 3

Criteria to initiate CPR

Answer 3

All three of:
Unresponsiveness
No breathing or only gasping
No pulse

Question 4

First Step of Pulseless Arrest

Answer 4

Shout for Help
Activate Emergency Response

Question 5

Second step of Pulseless arrest

Answer 5

Start CPR
Give Oxygen
Attach Monitor / Defibrillator

Question 6

6 key characteristics of Quality CPR

Answer 6

Push hard: >/ 1/3 the anteroposterior diameter of the chest with complete recoil

Push fast: 100-120 compressions/min

Minimize interruptions in chest compressions

Rotate compressors every 2 minutes or sooner

Avoid excessive ventilation

If NO advanced airway, 15:2 compression-ventilation ratio

Question 7

Ventilation rate if NO advanced airway (2 rescue vs. 1 rescue CPR)

Answer 7

2 rescue: 15:2
1 rescue: 30:2

Question 8

Ventilation rate for advanced airway

Answer 8

1 breath every 6 seconds

Question 9

Ventilation Cadence

Answer 9

Infant = squeeze, release
Young Child = squeeze, release, release
Older Child = squeeze, release, release, release

Question 10

Formula to estimate ET size for children 2-10 years old: Cuffed vs. Uncuffed

Answer 10

Cuffed:
(age / years/4) + 3.5

Uncuffed:
(age / years/4) + 4

Question 11

Standard pediatric dosing for defibrillation

Answer 11

First shock: 2 J/kg

2nd shick: 4 J/kg

Subsequent shocks:
4 J/kg - 10 J/kg
Max 10 J / kg or 360 J

Question 12

Cardiac Arrest Epinephrine Dose, Concentration & frequency

Answer 12

0.01 mg/kg = 0.1 mL/kg of 1:10,000 dilution) IV/IO

0.1 mg/mL conc

Administer q 3-5 min

Question 13

Cardiac Arrest Amiodarone Dosing

Answer 13

5mg/kg IV / IO over 30 min

May repeat X 2 for refractory VF/pulseless VT

Question 14

Lidocaine dose, maintenance infusion

Answer 14

Initial bolus dose: 1 mg/kg IV / IO
Maintenance infusion: 20-50 mcg/kg/min

Question 15

Magnesium Indications, Dosing, max Dose

Answer 15

torsades de pointes
25-50 mg/kg
Max: 2 g

Question 16

List the reversible causes of cardiac arrest (H’s & T’s)

Answer 16

Hypovolemia
Hypoxia
Hypoglycemia
Hydrogen Ion (Acidosis)
Hypothermia
Hypo / Hyperkalemia

Tension Pneumo
Tamponade
Toxins
Thrombosis: massive MI
Thrombosis: massive PE

Question 17

Hypovolemia Intervention

Answer 17

Expose patient and look for signs of blood loss
Obtain IV access

Use fluid challenge to determine if arrest is related to hypovolemia

20 ml / kg bolus

10 ml / kg blood

Question 18

Hypoxia Intervention

Answer 18

Ensure that the airway
is open.
Ensure adequate
ventilation and bilateral
breath sounds.
Ensure oxygen supply is
connected properly.

Question 19

Hydrogen Ion (acidosis) intervention

Answer 19

VBG

Provide Adequate Ventilations

1 mEq / kg IV sodium bicarbonate to prevent metabolic acidosis if necessary

Question 20

Hypoglycemia intervention

Answer 20

obtain a POC blood glucose (BG) level.

A BG ≤ 3.3 mmol/l in a child and ≤ 2.5 mg/dl in an infant

5 cc / kg D10 W - neonate

2 cc / kg D25 W - infant

1 cc / kg D50 W - child

Glucagon 0.03 mg / kg IM / SC (max 0.5 mg)

Question 21

Hyper / Hypokalemia intervention:

Calcium Gluconate

Clacium Chloride

Answer 21

Obtain ECG

Give diluted potassium

OR

Calcium gluconate:
60 mg / kg (0.6 ml/kg)

Calcium chloride:
20 mg / kg (0.2 ml/kg)

Question 22

Calcium Gluconate dosing

Answer 22

1 amp = 1 g

Question 23

Hypothermia intervention

Answer 23

Core temp. should be
raised above (30 C)
as soon as possible.

The patient may not
respond to drug or
electrical therapy while
hypothermic.

Question 24

Tension Pneumothorax ECG signs, Physical Signs, intervention

Answer 24

ECG signs: Narrow QRS complexes and slow or fast heart rate.

Physical signs: JVD, tracheal deviation, unequal breath
sounds, difficulty with ventilation, and no pulse felt
with CPR.

Treatment: Needle decompression.

Question 25

Etiology of cardiac arrest with toxins

Answer 25

Cardiac Toxicity
Respiratory Depression or circulatory side effects

Question 26

Examples of drugs causing respiratory depression

Answer 26

opioids
benzodiazepines
ETOH

Question 27

Examples of drugs causing torsades

Answer 27

amiodarone
sotalol
tricyclic antidepressants
calcium channel blockers.

Question 28

Toxicity associated with bradyarrhythmias.

Answer 28

calcium channel blockers
Beta-adrenergic blockers
digoxin
opioids
clonidine
cholinesterase inhibitors
succinylcholine.

Question 29

Naloxone dosing

Answer 29

0.4 - 2 mg IV
4 mg IN

Question 30

Best sites for IO access

Answer 30

Proximal tibia: 2 finger breadths below and 2 finger breadths medial to the tibial tuberosity (flat area of tibia)

Distal femur: Lateral surface, approximately 3 finger breadths above the rostral tip of the patella

Distal tibia: 2-3 cm proximal to the center of the medial malleolus
The needle is inserted as close to the tibia center as possible.

Question 31

IO Needle Length

Answer 31

<40 kg: 15-mm needle
>40 kg: 25-mm needle