PALS ch 1 Flashcards
What is the rate of ventilation for a child?
1 breath ever 3-5 seconds
Under what pulse rate is CPR indicated for a child?
60 bpm
When a child goes down, do you call 911 first, or start compressions first (for a single rescuer)?
If witnessed, call 911
If not, then start CPR
What is the ventilation to compression ratio in children for 1 and 2 rescuer provider(s)?
1 = 30:2 2 = 15:2
When should you use an AED?
ASAP
Where should you palpate a pulse in an infant? Child?
INfant = brachial pulses Child = carotid or femoral
What is the first step in the BLS primary survey?
Ensure scene safety
Checking for a pulse and breathing should take no longer than how many seconds?
10
If you find an infant with a pulse and breathing, what should be done?
Monitor until help arrives
If you find an infant with a pulse, but not breathing what should be done?
ventilate them at 1 breath every 5 seconds
What is the technique for compressions in an infant?
two fingers
What is the rate of compressions for an infant or child?
Same as adult: 100-120 bpm
What is the chest compression depth for a child?
2 in or 5 cm
What is the chest compression depth for an infant?
1.5 inches, 4 cm or about 1/3 of the AP chest diameter
True or false: adult pads for a kid is better than no pads
True
What age is adult pads preferred over child pads?
8 years
What are the components of the TICLS mnemonic for appearance of a child?
Tone Interactiveness Consolability Look/grimace Speech
What are the components of the primary and secondary survey?
Primary = ABCDEs Secondary = Focused H and P
At what age do back slaps become abdominal thrusts for choking children?
1 year
When should you begin CPR for a choking child?
When they become unresponsive
What is the respiratory rate for:
- Infants =
- Toddler =
- Preschooler =
- School-aged =
- Adolescent =
- Infants = 30-53
- Toddler = 22-37
- Preschooler = 20-28
- School-aged = 18-25
- Adolescent = 12-20
A consistent RR of over (__) or under (__) is abnormal at any age?
Under 10 or over 60
How long can the pause be in an infant periodic breathing be before it is considered abnormal?
15 seconds
What are the common causes of tachypnea without increased signs of respiratory effort?
- Dehydration
- Fever
- Sepsis
- CHD
What are the three categories of apnea?
- Central
- Obstructive
- Mixed
What are three major signs of increased work of breathing for infants?
- Nasal flaring
- Head bobbing
- Retraction
Where in the chest wall will mild to moderate retractions occur? Severe?
- Mild-moderate = subcostal, substernal, intercostal
- Severe = Supraclavicular, suprasternal, sternal
What are seesaw respirations? What does this type of breathing usually indicated?
- When the chest retracts and the abdomen expands during inspiration
- Usually indicated upper airway obstruction
Why is seesaw breathing an emergency?
Cause is usually emergent, but also fatigue will set in soon
What is the normal tidal volume (in mL/kg) that is true throughout life?
5-7 mL/kg
Where are the anterior, lateral, and posterior listening posts for assessing an infant’s breathing?
- Anterior = Just lateral to the sternum
- Lateral = axillae
- Posterior = Both sides of the back
Where is the best place to listen to the lower part of an infant’s lungs? Why?
-Axillae, because chest wall is thin, and this is least likely place breath sounds from other lung or upper airway will be transmitted
What is the purpose of grunting in infants?
Keep lower airways open
What Does grunting in an infant usually indicate?
Sign of lung tissue disease resulting from small airway compromise (e.g. pneumonia, ARDS, pain)
Is wheezing usually present during inspiration or expiration?
Expiration
What is a normal pulse ox reading?
94%+
What is a normal awake heart rate for the following:
- Neonate =
- Infant =
- Toddler =
- Preschooler =
- School aged child =
- Adolescent =
- Neonate = 100-205
- Infant = 100-180
- Toddler = 100-140
- Preschooler = 80-120
- School aged child = 75-120
- Adolescent = 60-100
True or false: weak central pulses are always abnormal
True
How much hemoglobin needs to be desaturated to produce cyanosis? What is the significance of this?
5 g/dL of Hb need to be desaturated
Children may have significant hypoxemia if they’re anemia, but will not be cyanotic
What percent of the arm should a BP cuff cover in a child?
should cover 50-75% of the length of the upper arm (from axilla to antecubital fossa)
What is the definition of hypotension in terms of SBP for:
- Term neonates
- Infants (1-12 months)
- 1-10 years
- Children over 10
- Term neonates = 60
- Infants (1-12 months) = 70
- 1-10 years = 70 +2*(age in years)
- Children over 10 = 90
What is the normal urinary output for infants? Young children? Adults?
Infants = 2 mL/kg/hr Children = 1 mL/kg/hr Adults = 0.5 mL/kg/hr
What are the components of the verbal parts of the GCS score?
5 = Oriented 4 = Confused 3 = Incoherent words 2 = incomprehensible sounds 1 = none
What are the components of the visual parts of the GCS score?
4 = spontaneously 3 = to voice 2 = to pain 1 = none
What are the components of the motor parts of the GCS score?
6 = obeys commands 5 = localizes pain 4 = withdraws from pain 3 = decorticate 2 = decerebrate 1 = none
How is the severity of TBIs rated by GCS score?
15-13 mild
9-12 moderate
9 or less = severe
What is the verbal scoring system in GCS for small children?
5 = smiles, coos, and babbles 4 = cries, but consolable 3 = inconsolable 2 = Moans, grunts to pain 1 = No response
What is the definition of hypoglycemia in a newborn and a child?
Newborn = less than 45 mg/dL Child = less than 60 mg/dL
Do petechiae and/or purpura blanch with pressure?
No
What is the limitations of using PaO2 in determining the oxygenation status of a patient?
Only measures O2 content in blood. Thus if anemic, the patient may still be hypoxic with normal PaO2
What other variable is needed to determine the oxygen saturation from a PaO2 measurement?
pH
When is a VBG useful?
When the patient is not well perfused
What is the role of PaO2 in a VBG?
Not useful
What is the normal range for SvO2? What about if the arterial concentration is lower?
- 70-75%, assuming arterial is 100%
- Otherwise 25-30% lower than arterial
If a patient has an elevated lactate, what other lab abnormality must be present to correctly diagnose ischemia?
A metabolic acidosis needs to be present
What are the top three causes of cardiac arrest in children?
- Respiratory arrest
- Shock
- Arrhythmia
What are some cardiogenic causes of cardiac arrest in children?
- HOCM
- Long QT syndrome
- Anomalous coronary artery
- Myocarditis
- Channelopathies
What is commotio cordis?
Sharp blow to the chest, causing cardiac arrest
What are the 6 H’s?
- Hypoxia
- Hyper/hypokalemia
- Hypothermia
- Hydrogen Ions
- Hypovolemia
- Hypoglycemia
What are the 5 T’s?
- Tamponade
- Tension PTX
- Toxins
- Thrombosis coronary
- Thrombosis pulmonary
How long should it take to deliver a breath?
About 1 second
What is the relative dose amount for epi given via the ET route as compared to the IV/IO route?
10x
True or false: there is no evidence that performing chest compressions in a child with normal heart activity is harmful
True
What is the dose of epinephrine in PALS?
0.01 mg/kg (0.1 mL/kg of the 0.1 mg/mL concentration)
What is the dose of amiodarone in PALS?
5 mg/kg bolus, repeated up to 2x
What is the dose of lidocaine in PALS?
1 mg/kg bolus, 20-50 mcg/kg/min maintenance
What is the amount of electricity in Joules for the first and second shock for pediatric arrest?
2 j/kg first shock
4 j/kg for each additional shock
What is the max shock dose for children in Vfib/vtach?
10 J/kg
What is the dose of Mg for PALS?
25-50 mg/kg bolus
What are the only two modifications to the BLS algorithm in pediatric drowning cases?
- C-spine precautions
- Hypothermia precaustions
What is the role of monitoring PETCO2 in patients with a single ventricle?
Not as useful, since it may not reflect CO
What is the treatment for hypoxia due to a diffusion defect?
Application of non-invasive PPV
What are some causes of V/Q mismatch?
- PE
- Pneumonia
- Atelectasis
- Asthma
- Bronchiolitis
- FB
- ARDS
What is the treatment for a V/q mismatch?
PPV
What are causes of alveolar hypoventilation?
- CNS problem
- TBI
- Drug overdose
- Neuromuscular weakness
- Apnea
What are the two major extrapulmonary diseases that decrease lung compliance?
Pleural effusion
PTX
What are the four major categories of etiologies of respiratory distress?
- Upper airway obstruction
- lower airway obstruction
- Lung tissue disease
- Disordered control of breathing
Which generally denotes an upper and lower airway obstruction: inspiratory noise vs expiratory
Inspiratory = upper Expiratory = lower
What causes the air trapping with asthma?
Proximal bronchioles collapse, trapping air distally
What is the typical response of an infant to asthma?
Tachypnea more so than deep breathes
What is the typical response of infants to lower airway disease? Why?
- Grunting respirations
- This maintains end expiratory pressure to attempt to maintain lower airways open
Most children with respiratory compromise can maintain ventilation (elimination of CO2), but cannot maintain oxygenation. what is the significance of this
hypercarbia is a late manifestation of lung disease
Disordered breathing is typically due to effects in what major organ system?
Neurologic function
How often are breaths delivered for infants and children with respiratory arrest?
1 breath every 3-5 seconds (12-20 breaths per minute)
What are the downsides of suctioning?
May increase respiratory distress and/or agitate the child
What are the characteristics of mild, moderate, and severe croup?
- Mild = Occasional barking cough, no stridor
- Moderate = Frequent barking cough, stridor at rest, but good air entry
- Severe = Barking cough, prominent stridor and poor air entry
What is the treatment for mild croup?
Dexamethasone, supportive
What is the treatment for moderate croup?
- Supplemental O2
- Nebulized epi
- Dexamethasone
- Heliox
What is heliox?
Helium-oxygen mixture used for severe respiatory distress
How long should you observe a child after giving racemic epi? Why?
2 hours to ensure no recurrence of stridor
What is the treatment for severe croup?
- IV/IM dexamethasone
- Assist ventilation
- ET or surgical airway if needed
How often should epi be administered for anaphylaxis in children?
q10-15 minutes as needed
What are the treatments, besides epi, for anaphylaxis? (4)
- Methylprednisolone or = IV
- Albuterol
- Antihistamine
- IVFs, intubation, etc
Over what age is the heimlich maneuver indicated?
Over 1
When is CPR administered with a choking child? What should be done while performing CPR?
- As soon as they become unresponsive
- Between sets of compressions, look in the airway for obstruction
True or false: performing a blind finger sweep is recommended in a unresponsive choking infant
False–this may push the FB further in
What is the first priority in children with lower airway compromise: oxygenation or ventilation (removal of CO2)? Why?
Oxygenation, because children can tolerate hypercarbia without adverse effects
How is bagging a child with a lower airway obstruction different than other bagging?
Slower rate to allow more time to exhale trapped air
What are the risks of bagging a patient?
- Air trapping
- PTX
- Gastric distention
What is the only way to truly distinguish asthma vs bronchiolitis in an infant?
History of reversible wheezing
What is the treatment for bronchiolitis?
Supportive care
What is the role of nebulized epi or albuterol in the treatment of bronchiolitis?
Some infants benefit, can harm others. If using, discontinue if there is no benefit
Breathlessness with what activities characterize mild, moderate, and severe asthma?
Mild = with walking MOderate = with talking Severe = At rest
Is there typically tachycardia with mild, moderate, and/or severe asthma?
Mild no, moderate and severe yes
What PEF value after neb treatment (in %) characterizes mild, moderate, and severe asthma?
Mild = over 80% Moderate = 60-80% Severe = Less than 60%
When does pulsus paradoxus present with asthma (mild, moderate, or severe)?
Moderate and up
What SaO2 levels characterize mild, moderate, and severe asthma?
Mild = 95%+ Moderate = 91-9% Severe = 90% or below
What medications are used at the mild, moderate, and severe level of asthma?
- Mild = O2,albuterol, oral steroids
- Moderate = O2, Continuous albuterol, IV steroids, ipratropium, IV mag
- Severe = above +terbutaline IV, bipap or ET tube
What is the goal time to administer Abx to children with pneumonia?
Within 1 hour of ED arrival
What are the two general measures to reduce metabolic demand in children with pneumonia?
- Antipyretics
- Reduce work of breathing
What, generally, is chemical pneumonitis?
Inhalation of a chemical that causes inflammation and noncardiogenic pulmonary edema
What are the interventions, besides O2, for chemical pneumonitis? Last resort?
- Nebs, CPAP, intubation
- ECMO
What, generally, is aspiration pneumonitis?
Aspiration of gastric contents, causing inflammation and noncardiogenic pulmonary edema
When should abx be used in the treatment of aspiration pneumonitis?
If fever and infiltrates on CXR are present
True or false: abx prophylaxis is indicated in cases of aspiration pneumonitis
False
What are the causes of cardiogenic pulmonary edema in children?
- LV dysfunction
- Myocarditis
- Cardiomyopathy
- CHD
- drugs
- hypoxia
What are the components of treatment for cardiogenic pulmonary edema?
- Ventilator (non/invasive) support with PEEP
- Diuretics
- Reduce fever and work of breathing
What are the three major indications for ET intubation in children with cardiogenic pulmonary edema?
- Hemodynamic instability
- Persistent hypoxia despite noninvasive measures
- Impending respiratory failure
How is PEEP dosed?
Start at 5 mm H2O, and work up until oxygenation improves
What are the usual causes of ARDS?
- Systemic inflammation (e.g. pancreatitis, sepsis)
- Pneumonia (aspiration)
What is the defining clinical value for ARDS?
PaO2/FiO2 less than 300 (with ventilation)
What will CXR show in ARDS?
Will show parenchymal disease
What disease process must be excluded to diagnose ARDS?
Cardiogenic pulmonary edema
What is the equation for oxygenation index, and a value of what or greater indicates ARDS?
(FiO2 x mean airway pressure x100) / PaO2
Value 4 or greater
What measures besides vitals should a patient with ARDS have monitored?
ETCO2, cardiac monitor
What are the lab studies that should be obtained in ARDS?
- ABG
- Central venous blood gas
- CBC
Should tidal volumes and PEEP be low or high with ARDS?
TV= low PEEP = higher
What is permissive hypercarbia in the setting of ARDS?
Allowing increased levels of CO2 in the blood because O2 is the more important determinant of outcomes
Maintaining peak inspiratory pressure below what values is important for ARDS?
Below 35 cm H2O
What is the tidal volume (in mL/kg) for treating ARDS in children?
5-8 Ml/kg
Ddx for disordered control of breathing? (7)
- Drugs
- Increased ICP
- CNS infx
- Metabolic /Hyperammonemia
- Hydrocephalus
- Neuromuscular disease
- Seizures
What are the components of Cushing’s triad?
- Irregular breathing
- Increased mean arterial pressure
- Bradycardia
What is the role of IVFs in the treatment of increased ICP?
Give 20 mL/kg in children if s/sx of poor end organ perfusion develop
What is the role of antipyretics in the treatment of increased ICP?
used to avoid or aggressively treat fevers
Why is hyperventilation not longer a treatment for increased ICP unless there is a brainstem herniation?
Reduces cardiac output, and reduces cerebral blood flow
What are the tests that should be ordered for a child with central causes of respiratory failure/drug OD?
- EKG
- ABG
- CXR
- CBC/CMP
- Serum osmols
- Drugs screen
What is the effect of using succinylcholine in patients with neuromuscular diseases?
Hyperkalemia, or worsening of respiratory muscle weakness
What are the three general things that should be avoided with increased ICP (hyper/hypo things)?
- Hypoxemia
- Hypercarbia
- Hyperthermia
