Pals Ch 7.5 + Flashcards
What is the role of pop-off valves with a bag mask, and when does this need to be closed?
-Used so that excessive airway pressures are not used
-Need to be closed if performing CPR, since compressions will open it
What is a self inflating bag, and a flow inflating bag?
Self inflating are the ones used by EMS that will inflate by themselves
Flow inflating bags are the ones used by anesthesiologists, and inflate only with a flow of oxygen AND a good seal
What size (in mL) self inflating bags should be used with infants/children and adults?
500 mL for children
1000 mL for adults
When does the rest of the body catch up to occiput size, and a child no longer needs padding underneath their back for ventilation?
2 years
True or false: Bag mask ventilation can be used to assist a spontaneously breathing child
True
If a pt gets harder to bag, what three major etiologies should come to mind?
-PTX
-Airway obstruction
-Air stacking
Why might suctioning cause bradycardia?
Vagal stimulation
How do you measure an OPA?
Corner of the mouth to the angle of the jaw
What must be considered in children when applying an oxygen mask?
Increased agitation may worsen hypoxemia
What are the two major low flow oxygen delivery devices? High flow?
Low flow = nasal cannula, simple oxygen mask
High flow = Non-rebreather, high flow NC
What is the appropriate level of O2 flow rate for a NC?
4 L/min
What is the appropriate level of O2 flow rate for a simple face mask?
6-10 L/min
What is the appropriate level of O2 flow rate for a Non-rebreather?
10-15 L/min
What is the appropriate level of O2 flow rate for a high-flow NC?
4-40 L/min
What is the appropriate level of medication flow rate for a nebulizer? How long should they use the neb for?
-5-6 L/min
-8-10 minutes
What should be done if there are no infant sized pulse ox probes?
Attach adult sized one to hand of infant
What are the components of the DOPE mnemonic for sudden deterioration in the intubated patient?
Displacement of tube
Obstruction of tube
PTX
Equipment failure
What are the components of the SOAPME mnemonic for checklist prior to intubation?
Suction
Oxygen
Airway equipment
Pharmacologic agents
Monitoring equipment
What are the 4 monitoring devices needed prior to RSI?
-Monitor
-Pulse ox
-BP
-ETCO2
True or false: shock can be present with a normal BP
True
What is ScvO2? What are the two causes of a decrease in this number?
Venous oxygen content
-Decreased cardiac output
-Increased metabolic demand
Why can arrhythmias like heart blocks and junctional rhythms lead to decreased cardiac output?
Loss of appropriately timed atrial kick
Why are infants more dependent on HR to increased CO?
Because SV is fixed more so than in an adult
What are the three factors that determine SV?
Preload
Contractility
Afterload
Why does CVP not perfectly correlate to preload?
If right atrium has increased pressure (e.g. tPTX), then pressure will increased, but there will be no increase or even a decrease in preload
What does the body do when tissue perfusion is inadequate? How does this impair cardiogenic shock caused by increased afterload?
Constricts vessels, which will increase afterload, and worsen problem
What are two major causes of increased afterload in the child?
pHTN/HTN
Aortic stenosis
What happens to pulse pressure with hypovolemic shock?
Decreases
What defines compensated shock?
Decreased perfusion, but normal BP
What can you do to assess if an automated BP cuff is getting an accurate measurement, besides doing a manual check?
See if extremity is well perfused
What is the definition of hypotension in children 1-10- years of age (formula)?
Less than: 70+ (age *2)
What are the four major types of shock?
Obstructive
Cardiogenic
Distributive
Hypovolemic
Why is tachypnea a compensatory mechanism for blood loss?
Respiratory alkalosis to combat lactic acidosis from hypoxia
Why might SvO2 be decreased in septic shock?
-Maldistribution of blood flow
-Sepsis may cause inability to utilize O2 at cellular level
What happens to preload, contractility, and afterload with distributive shock?
-Preload = decreased
-Contractility = normal or decreased
-Afterload = variable
What happens to pulse pressure in distributive shock?
-If warm extremities = widened
-If cold extremities = narrow
What is the role of the adrenal glands in septic shock?
If infarcted or ischemic, will not produce the necessary catecholamines to maintain BP, worsening shock
What causes the decreased cardiac output with anaphylactic shock?
Increased pulmonary resistance
Neurogenic shock is caused by a loss of SNS activity at and above what spinal level?
T6
What happens with pulse pressure in neurogenic shock?
Increased
What happens to HR, afterload, and SVR with cardiogenic shock?
Tachycardia with high SVR and high afterload
How is tachypnea different in cardiogenic shock from other forms of shock?
Pulmonary edema in cardiogenic causes marked respiratory distress, while other forms/causes of shock have a “quiet” tachypnea
How can you differentiate cardiogenic shock from other forms of shock?
-S/sx of CHF
-Cyanosis
-Cool extremities
What is the role of volume resuscitation in cardiogenic shock?
Detrimental–give in small boluses of 5-10 mL/kg (about half normal amount)
What are the four major causes of obstructive shock?
-PE
-tPTX
-Cardiac tamponade
-Ductal dependent lesions
What happens to preload, contractility, and afterload with obstructive shock?
Preload = variable
Contractility = normal
Afterload = increased
What will be heard on auscultation of the heart with cardiac tamponade?
Muffled heart sounds
What is pulsus paradoxus? How do you determine this clinically?
-Decrease in SBP by more than 10 mmHg during inspiration
-Using a manual cuff, inflate the cuff. Deflate slowly, and listen for the first K sounds when child is exhaling. Note the second time when it is heard throughout the respiratory cycle. If this difference is greater than 10 mmHg, then you have it.
When do ductal dependent lesions typically present?
Within the first days to weeks of life
What are the ductal dependent heart syndromes that cause cardiogenic shock?
-Coarctation of the aorta
-Critical aortic stenosis
-Hypoplastic left heart
-Interrupted aortic arch
What are the distinguishing clinical features of cardiogenic shock from ductal dependent lesions?
-Difference in central vs peripheral pulses/BP
-3-4% higher O2 sat on right side
How can you distinguish cardiogenic shock from a PE clinically?
S/sx of right heart failure will be present
Which types of shock have labored breathing?
Cardiogenic and obstructive
Increasing tachycardia in a child = ?
Shock
What are the four main components of treating shock in a child?
-Maximize O2
-Improve cardiac output
-Reduce O2 demand
-Correct metabolic derangements
What are the three main drivers of increased O2 demand in children?
-Pain and anxiety
-Increased work of breathing
-Fever
Why should sedative agents be used cautiously in children in shock?
Will decrease endogenous stress response
What are the four major metabolic derangements in children in shock?
-Hypoglycemia
-Hypocalcemia
-Hyperkalemia
-Lactic acidosis
How does serum ionized Ca relate to pH?
Inversely
What is the relationship between K and H+ ions?
Cell will try to take up more H+, exchanging it with K+, meaning acidosis is often accompanied by hyperkalemia
What cause of acidosis is caused by HCO3 loss?
Diarrhea
When is IO access useful in shock?
Flat veins and quick need for fluids
What is the bolus amount in children, and how fast should it be given? What if cardiogenic shock?
20 mL/kg over 10-20 minutes
10 mL/kg if cardiogenic shock
What is the goal urinary output in infants, children, and adults?
Infants = 2 mL/kg/hr
Children = 1 mL/kg/hr
Adults = 0.5 mL/kg/hr
How many boluses of fluid do you give?
Reassess after each one, and titrate to response
Why get CBC with shock? (3 lab values and their significance)
-Hb = hemorrhage/hemolysis
-WBCs = sepsis
-Platelets = DIC
Why get glucose with shock? (3)
Sepsis
Adrenal insufficiency
Decreased production (liver)
Why get potassium with shock? (4)
-Renal dysfunction
-Acidosis
-Diuresis
-Adrenal insufficiency
Why get Ca with shock? (3)
-Sepsis
-transfusion/colloid hypocalcemia
-NaHCO3 use
Why get lactate with shock?
Measure and trend acidosis and treat it
Why get ABG with shock?
Determine etiology of shock (lactic acidosis, poisoning, anion gap)
Why get SvO2 with shock?
-If low, need to maximize O2 delivery
-If high, maldistribution
When should vasopressor be used in shock?
Only after several fluid boluses
Why are vasodilators helpful in cardiogenic shock?
Reduces SVR and afterload
What is Milrinone, and what is its effects?
Phosphodiesterase inhibitor
-Decreases SVR
-Improves coronary blood flow
-Improves contractility
What are the three major inotropes?
-Epi
-Dopamine
-Dobutamine
What vasodilator does not increased cardiac contractility?
Vasopressin
What may happen to a sick child with a bolus of fluids that is too much or too fast?
Pulmonary and/or peripheral edema
What can colloids cause that crystalloids cannot?
-Hypersensitivity rxns
-Coagulopathies
-Hypocalcemia (?)
What is the risk of giving fluids too fast with DKA?
Cerebral edema due to high osmolarity of blood
What is the rate of fluid bolus for kids in DKA? What is the exception to this?
10-20 mL/kg over 1-2 hours instead of 10-20 minutes
If crashing in hypotensive shock, then give the usual amount
OD of what medications may lead to fluid boluses causing pulmonary edema?
CCBs or BBs
What is the rate of IVF boluses in poisonings? Why?
5-10 mL/kg over 10-20 minutes, since some meds (e.g. CCBs, BB) will lead to pulmonary edema
Do standard infusion pumps have a high enough rate for bolus infusion?
No
What needs to be done after each fluid bolus in a shock child?
Reassess and look/listen for pulmonary edema or other untoward effects
Deterioration after fluid boluses = ?
Cardiogenic shock
Persistently delayed cap refill in a shock child with several boluses = ?
Ongoing hemorrhage
What is the dose of pRBCs for children with hemorrhagic shock?
10 mL/kg
What is the difference between crossmatch and type specific blood?
Crossmatched has been ensured that no antibodies that will cause side effects are present, while type specific is Rh and ABO compatible, but may have these
When should Ca be administered to children receiving blood?
If hypotensive or has hypocalcemia
What three major side effects can occur if administering cold blood?
-Hypothermia
-Myocardial dysfunction
-Ionized hypocalcemia
True or false: you should treat hypoglycemia in shock
True
Why might hyperglycemia happen with shock, and should you treat it?
-Cortisol increases and decreased perfusion
-Can treat with maybe better outcomes, but risk hypoglycemia, which is worse
What is the definition of hypoglycemia in a preterm or term neonate? Infants? Children? Adults?
Preterm/term neonates = 45 or less
Everyone else = 60 or less
What is the treatment for asymptomatic and symptomatic hypoglycemia? Dose?
-Asymptomatic = oral glucose (e.g. OJ)
-Symptomatic = 5-10 mL/kg of D10
What percent and mL/kg represent mild, moderate, and severe dehydration in children?
Mild = 5% or 50 mL/kg
Moderate = 10% or 100 mL/kg
Severe = 15% or 150 mL/kg
What is the amount of blood in a child (in mL/kg)?
80 mL/kg
At what level of volume loss do infants and children become lethargic and altered (mild, mod, or severe)?
Moderate
What is the IVF to blood ratio given in hemorrhagic shock in children?
3:1
What is the dose (in mL/kg) of pRBCs and whole blood for children?
pRBCs = 10 mL/kg
Whole blood = 20 mL/kg
When is bicarb indicated for the treatment of acidosis 2/2 hypovolemia?
Moribund patients or slightly earlier if due to GI losses
What two things does a persistent metabolic acidosis signify in hypovolemic shock?
-Ongoing losses
-Inadequate resuscitation
What are the three main goals of treating sepsis?
-Restore hemodynamic stability
-Support organ function
-Identify and control infection
What is the goal time to identify and treat shock respectively?
Recognize within 15 minutes, and have several boluses in before 1 hour
What is the dose of IVFs for neonates with shock?
10 mL/kg
What are the five major identifier of shock listed on the septic shock algorithm for peds?
-AMS
-HR changes
-Hypotension
-Perfusion (cap refill)
-Temperature
What will cap refill time be with septic shock?
normal to increased
What should be done if a child in septic shock does not respond to IVFs?
Pressors and critical care consultation
When should epi/dopamine be used to treat shock? Norepi?
Epi/dopamine if cold extremities, poor cap refill
Norepi if warm extremities, flash cap refill
When should cortisone administration be considered in the treatment of shock?
If not responding to fluids/pressors
If a child enters the critical stage of hypovolemic shock, what procedural interventions need to happen?
-Central line
-Art line
-Intubation
What is the first step in stabilizing a pediatric septic shock patient?
ABCs
What should be done for the critical patient in septic shock whose SvO2 is less than 70% and extremities still cold despite epi administration? With low BP? Adequate BP?
-continue IVFs, blood, epi
-If DBP low, add norepi
-If BP adequate, add milrinone or other vasodilator therapy
What should be done for the critical patient in septic shock whose SvO2 is greater than 70% and extremities are warm despite norepi administration?
-IVFs, norepi
-Add additional vasopressor/inotropic support
What should be done for the critical patient in septic shock whose SvO2 is greater than 70%, with resolution of sign of shock?
-transfer to ICU
What is the goal time for administering abx in septic shock?
1 hour
What is the normal range for ScvO2?
65-85% (should be 25-30% below arterial)
What does a very high ScvO2 indicate? (3)
-Cyanide poisoning
-Microcirculatory shunting (e.g. sepsis)
-L to R shunts
Why is milrinone given to patients with shock with low SvO2 but adequate BP?
Improves cardiac output with inotropic effects and vasodilation
Why is norepi given to patients with shock with low SvO2 and low BP?
Raise BP
Why is norepi given to patients with SvO2 less than 70% with warm extremities?
Vasoconstrictive effects to increase BP, without increasing HR
What is vasopressin?
ADH
What sort of patients are at risk for adrenal insufficiency?
Chronic steroid use
What is the dose of hydrocortisone used in fluid refractory shock?
1-2 mg/kg IV bolus
What is the low dose infusion of epi for anaphylactic shock in children?
0.05 mcg/kg/min
When is albuterol indicated for the treatment of anaphylactic shock?
If bronchospasm occurs
Should H1 and H2 blockers be given in combination for anaphylactic shock?
yes–may have synergistic effects
How long must a child be watched after development and treatment of anaphylaxis? Is there any correlation between severity of anaphylaxis and the chances of delayed symptoms
-several hours
-Yes, more severe, more likely to develop symptoms
Why is there a wide pulse pressure with neurogenic shock?
Low DBP due to loss of SNS
What are the mainstays of treatment for neurogenic shock (2)?
-Vasopressors
-Warm blankets (due to dysautonomia)
What is the most effective way to increase cardiac output in patients with cardiogenic shock?
Vasodilators to reduce afterload
What is the problem with inotropes in cardiogenic shock? Do you still give them?
Will increase cardiac oxygen demand, but still give cautiously and judiciously because increased CO is needed
What are the clinical features of cardiogenic shock?
-Pulmonary edema
-JVD
-Hepatomegaly
What is the role of the ER provider in the treatment of cardiogenic shock?
-Stabilize as much as possible, but cardiothoracic surgeon/cardiologist will be needed to diagnose and fix problem
What is the hallmark way to diagnose cardiogenic shock?
CXR showing cardiomegaly in a shock pt but Echo best
What is the amount of fluid boluses (in mL/kg) and over how long (minutes) should fluid be given in cardiogenic shock peds?
5-10 mL/kg over 10-20 minutes
What intervention should be undertaken if a child develops pulmonary edema?
PPV (noninvasive or invasively)
What are the 5 major tests that help to diagnose cardiogenic shock?
-Hb
-ABG
-Troponin
-lactate
-Thyroid
What three studies (not labs) can help diagnose cardiogenic shock?
-ECG
-CXR
-Echo
What is the preferred drug for the treatment of cardiogenic shock?
Milrinone
What treatment will maintain a patent ductus?
Prostaglandin E1
What are the four general locations for IO devices in children?
-Below tibial plateau
-Above the medial malleolus
-Distal femur
-ASIS
Where is the tibial location site for IO access?
Finger breadth below and medial to the tibial plateau
What is the first test of the IO to ensure it did not go through bone or into SQ tissue?
IVFs–no swelling should occur
What are the 4 major causes of primary bradycardia in children?
-CHD
-Surgical injury
-Myocarditis
-cardiomyopathy
What are the 5 major causes of secondary bradycardia in children?
-Hypoxia
-Drugs
-Hypotension
-Acidosis
-Hypothermia
What two major classes of drugs can cause 2nd degree type I AV block?
BBs and CCBs
What are the etiologies of second degree type II AV block?
Intrinsic conduction abnormalities from drugs or MI
What are the etiologies of third degree AV block? (3)
-Extensive injury to the heart
-MI
-Congenital lesions
The HR is usually under what value for sinus tachycardia in infants and children respectively?
220 bpm for infants
180 for children
When is SVT usually diagnosed in a child? Why?
Not until pulmonary edema occurs (weeks) since no other symptoms (that an infant can vocalize anyway)
What are the s/sx of SVT in infants? (4)
-Irritability/sleepiness
-Poor feedings
-Gray or mottled skin
-Tachypnea
What are ways to differentiate SVT from ST?
ST is gradual in onset, and will vary with activity
SVT is sudden and invariant.
When is CPR indicated for a bradycardia in peds?
If less than 60 bpm and have cardiopulmonary compromise despite interventions
What should be done if CPR alone does not improve pediatric bradycardia?
Give epi and/or atropine. Consider pacing.
What is the dose of epi for pediatric bradycardia?
0.01 mg/kg or 0.1 mL/kg of the 0.1 mg/mL concentration
What is the dose of atropine for pediatric bradycardia? What is the minimum and max dose? How often can this be repeated?
0.02 mg/kg
Min dose = 0.1 mg
Max dose = 0.5 mg
May repeat once
What is the epi dose given via ET tube for pediatrics?
0.1 mg/kg (0.1 mL/kg)
What is the infusion rate of epi for bradycardia?
0.1 -0.3 mcg/kg/min
When is atropine the first line drug for peds bradycardia When is it not?
Is with primary bradycardia (e.g. AV block)
Is not if secondary (e.g. hypoxia)
What changes in the brady/tachy algorithms in heart transplant patients?
Since nerves are not reattached completely, atropine/epi may be ineffective. Thus pacing should be considered early
What are the 5 Hs and 2 Ts of peds bradycardia?
-Hypoxia
-H+ ions
-Hyperkalemia
-Hypothermia
-Heart block
-Toxins
-Trauma
Bradycardia in a head trauma = ?
Cushings from increased ICP
If a monitor is unable to identify R waves for synchronized cardioversion, what can be done?
Increase amplitude of EKG
What is the dose in J/kg for synchronized cardioversion in children with SVT? What is the first dose is ineffective?
0.5 to 1 j/kg, increasing to 2 j/kg if ineffective
Why must paddles/pads never touch each other?
Arc of electricity
What is the role of cardioversion with a-flutter?
No effect because does not go through the AV node
What are the acute side effects of amiodarone?
Hypotension and bradycardia
Where is amiodarone eliminated (liver or kidneys)? What is the significance of this?
Liver
Cautious use if hepatic failure
What is the dose of amiodarone in pediatric tachycardia with poor perfusion, and over how long should this be given?
5 mg/kg infused over 20-60 minutes
What is the max dose of amiodarone in a child?
15 mg/kg
What is the dose of procainamide in children, and over how long should this be given?
15 mg/kg over 30-60 minutes
What must be done when giving procainamide?
Constant monitoring of ECG and BP
What are the acute side effects of procainamide?
Hypotension
Heart block
QT prolongation
Why should verapamil NEVER be used in infants?
Refractory hypotension and cardiac arrest have been documented
What is the first and second dose of adenosine in mg/kg for SVT in peds?
0.1 mg/kg
0.2 mg/kg
True or false: adenosine will not cause harm if given to patients with wide, monomorphic VT, if you mistakenly think it is SVT with aberrancy
True
What are the two second line drugs and their dosages for the treatment of SVT?
Amiodarone 5 mg/kg over 20-60 minutes
Procainamide 15 mg/kg over 30-60 minutes
When should you consult a cardiologist when a child presents with hemodynamically stable SVT?
If adenosine doesn’t work (before amiodarone, procainamide, or cardioversion)
What is the dose of electricity for cardioversion in kids with SVT?
0.5-1 j/kg for first dose, 2 j/kg for each additional dose
What is the treatment for a wide complex tachycardia if the patient is hemodynamically UNstable?
Synchronized cardioversion
What is the treatment for a wide complex tachycardia if the patient is hemodynamically stable?
Consider adenosine
Call cardiologist before giving antiarrhythmics
What is a normal QRS duration?
less than 0.09 seconds
What is the treatment for sinus tach in peds?
Search for and treat underlying cause
What is the treatment for a wide complex tachycardia resistant to cardioversion?
COnsult cardiologist before giving antiarrhythmics
Why should amiodarone and procainamide never be administered together?
QT prolongation
What is the first phase of post cardiac arrest care in children?
Stabilizing the ABCs
What is the second phase of post cardiac arrest care?
-Support general organ function
-correct electrolyte and acid/base abnormalities
-Target temp management
What three major organ systems are targeted with post cardiac arrest care?
-Cardiovascular
-Pulmonary
-Neuro
What is the goal O2 sat for post cardiac arrest care?
Over 94%, but the least amount O2 necessary to get there
What should be used to target adequate oxygenation in a child: O2 sat or PaO2? (2)
O2 sat if not anemic
PaO2 if anemic
True or false: in children with asthma and respiratory failure, rapid correcting of hypercarbia is unnecessary post arrest
True
In what patients does hypercapnia need urgent recorrecting post arrest? (2)
If they have CHD or pHTN
How soon after initial vent settings are placed should you get an ABG?
Within 15 minutes
What is the goal SpO2 in kids with CHD post arrest?
Back to their baseline
When is an art line generally needed? Why?
When shock occurs, because cuffs are not accurate in these situations
What should the BP be in children post ROSC? What is the role of vasopressors in this?
-Above the 5th percentile (use the 70+2*age formula)
-Use pressors as needed
Why is intubation a double edged sword with cards problems in kids?
Meds and the procedure can cause cardiovascular collapse
When trying to optimize the following parameters, what drugs or intervention should be given:
-Preload
-Contractility
-Afterload
-HR
-Preload = IVFs
-Contractility = inotropic
-Afterload = vasopressors or vasodilators
-HR = Chronotropes or pacing
What are the three major drugs for hypotensive shock?
Epi
Dopamine
Norepi
What are the four major drugs used for normotensive shock?
Dobutamine
Dopamine
Epi
Milrinone
What is the predominant effect of epi (alpha or beta) with low and high doses respectively?
Low = beta (1 and 2) effect
High = alpha effect
