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Methods of Anesthesia II > PALS Concepts > Flashcards

PALS Concepts Flashcards

1
Q

EWL

A

estimated weight loss

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2
Q

FBAO

A

foreign body airway obstruction

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3
Q

LVOT

A

left ventricular outflow tract obstruction

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4
Q

PEFR

A

peak expiratory flow rate

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5
Q

ROSC

A

return of spontaneous circulation

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6
Q

what is a prominent sign of ROSC?

A

sudden increase in EtCO2

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7
Q

RVOT

A

right ventricular outflow tract obstruction

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8
Q

agonal breathing

A

half of pts in cardiac arrest will gasp

“snoring, gurgling, moaning, labored breathing”

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9
Q

agonal rhythm

A

slow complex rhythms that precede asystole

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10
Q

acryocyanosis

A

blue discoloration of hands and feet and around the mouth and lips

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11
Q

apnea

A

cessation of breathing for 20 seconds

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12
Q

apnea definition when accompanied by bradycardia, cyanosis, or pallor

A

<20 seconds

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13
Q

central apnea

A

no respiratory effort

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14
Q

obstructive apnea

A

ventilation is impeded by an obstructed airway

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15
Q

mixed apnea

A

combination of both central and obstructive apnea

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16
Q

what is the most common cause of bradycardia in kids?

A

apnea/hypoxia

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17
Q

bradycardia definition in children

A

ranges based on source and age from <60bpm- <100bpm

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18
Q

broselow tape

A

approximates weight and drug doses

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19
Q

channelopathy

A

genetic mutation and disorder of the ion channels in myocardial cells that predisposes the heart to arrhythmias

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20
Q

neonate

A

1-28 days

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21
Q

infant

A

1month-1yr

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22
Q

child

A

1 year to puberty

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23
Q

adult

A

puberty and older

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24
Q

chest compression fraction

A

proportion of time spent performing chest compressions for pts in cardiac arrest

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25
Q

what should CCF be?

A

at least 60%

ideally 80%

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26
Q

croup

A

inflammation of the larynx/vocal cords

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27
Q

mild croup sound

A

barking cough

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28
Q

moderate croup sound

A

stridor and retractions at rest

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29
Q

severe croup sound

A

significant agitation with decreased air entry

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30
Q

cyanosis

A

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

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31
Q

when is cyanosis apparent?

A

at least 5g/dL of Hgb are desaturated

this means that the O2 saturation at cyanosis appearance depends upon Hgb concentration

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32
Q

febrile

A

temp >38 degrees C

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33
Q

in pals what should you administer when a fever is present?

A

Abx

common in sepsis and lung tissue disease

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34
Q

in pals when is a patient considered to have hypoxemia?

A

spO2 is less than OR equal to 94% on room air

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35
Q

when should you consider administering supplemental oxygen in PALs?

A

spo2 <94

poor signs of perfusion

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36
Q

what can present hypoxemia from turning into tissue hypoxia?

A

increase in CO

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37
Q

hypoglycemia neonate

A

blood sugars <45mg/dL

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38
Q

hypoglycemia infant/child/adolescent

A

<60mg/dL

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39
Q

treatment for hypoglycemia

A

0.5-1g/kg bolus of glucose

recommended D25W so (4mL)

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40
Q

hypotension systolic neonate

A

<60

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41
Q

hypotension systolic infants

A

<70

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42
Q

hypotension systolic children (1-10yr)

A

<70 + (age in yrs x2)

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43
Q

hypotension systolic children >10yrs

A

<90

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44
Q

heliox

A

breathing gas composed of a mixture of helium and oxygen

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45
Q

why does heliox help breathing?

A

helium gives lower density than air and oxygen alone and produces a higher probability of laminar flow

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46
Q

what does laminar flow in the airways do?

A

less airway resistance
less mechanical energy to ventilate
decreases work of breathing

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47
Q

what does heliox relieve symptoms of?

A

upper airway obstruction

middle and upper airway

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48
Q

where does heliox have little effect?

A

small airways since flow is already laminar

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49
Q

mottling

A

patchy discolorations of skin caused by vasoconstriction (pallor) mixed with areads of vasodilation (cyanosis or erythema)

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50
Q

what is mottling a sign of?

A

imminent death

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51
Q

pallor

A

pale color due to lack of oxygen in the skin

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52
Q

central pallor

A

pallor seen in the lips and mucous membrane

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53
Q

signs of good peripheral perfusion 5

A 
good pulse (BP adequate)
flushed skin
brisk capillary refill (<2 sec)
warm skin
awake and alert
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54
Q

signs of poor peripheral perfusion 5

A 
weak pulse
pale or cyanotic skin color
delayed capillary refill
cool extremities
decreased responsiveness or consciousness
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55
Q

permissive hypoxemia

A

spO2 reading of <94% that may be appropriate in certain circumstances

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56
Q

examples of permissive hypoxemia

A

pt at high altitude

pt with congenital heart disease

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57
Q

petechiae and purpura

A

purple discolorations caused by small vessel bleeding

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58
Q

petechiae

A

small dots

suggest low platelet count

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59
Q

purpura

A

appear as larger areas

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60
Q

what are petechiae and purpura a sign of in PALS?

A

septic shock

could be said as bruises or discolorations of skin

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61
Q

poikilothermia

A

unable to regulate body temperature

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62
Q

refractory

A

a child is refractory to a treatment if they do NOT improve or respond to therapy

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63
Q

fluid refractory hypotension

A

child remains hypotensive despite fluid admin

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64
Q

hypoxic refractory to supplemental oxygen

A

may mean they need a breathing treatment or need mask vent or intubation

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65
Q

norepinephrine refractory shock

A

child in shock is unresponsive to norepinephrine therapy

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66
Q

normal capillary refill time

A

<2sec in neutral thermal environment with extremity slightly above heart level

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67
Q

prolonged capillary refill time

A

> 5 seconds

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68
Q

what are the common causes of prolonged capillary refill time

A

dehydration
shock
hypothermia

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69
Q

SVT rate infants

A

> 220

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70
Q

SVT rate children

A

> 180

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71
Q

oxygen consumption adults

A

3-4mL/kg/min

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72
Q

oxygen consumption infants

A

6-8mL/kg/min

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73
Q

SpO2 PALS

A

> 94% on room air

<90% on 100% oxygen requires intervention

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74
Q

ScvO2 PALS

A

25-30% below SaO2

70-75% is SaO2 is normal

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75
Q

urine output infants/young children

A

1.5-2mL/kg/hr

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76
Q

urine output older children and adolescents

A

1mL/kg/hr

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77
Q

what is reduced urine output a sign of

A

poor perfusion

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78
Q

large (upper) airways have what kind of air flow

A

more turbulent air flow

more resistance

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79
Q

lower gas density does what to air flow

A

higher % of laminar flow

less resistance

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80
Q

why are peds pts more prone to upper airway obstruction?

A

large tongue

large occiput that causes neck flexion and takes the pt out of sniff position

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81
Q

how should the infant be positioned to open and clear the airway

A

pts head neutral

shoulder roll

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82
Q

severe choking in responsive children

A

providers can do heimlich or abdominal thrusts below xyphoid

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83
Q

severe choking in responsive infant

A

place the pt prone in one arm 5 back slaps

flip and deliver 5 downward chest thrust with two fingers

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84
Q

severe choking in unresponsive patients

A

immediately start CPR (even if pulses are palpable)

each time you open mouth look for opject

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85
Q

after obstruction is relieved what should you do?

A

place pt in recovery position

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86
Q

high flow nasal cannula how much can it deliver and what is the fio2?

A

> 50L/min it can deliver close to 100% FiO2 similar to nonrebreather mask

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87
Q

what is different about high flow nasal cannula that makes the pt tolerate higher flows without discomfort?

A

humidified and warmed

doesnt interrupt ability to communicate, eat or drink

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88
Q

does high flow nasal cannula produce positive airway pressure

A

yes 3cmH2O

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89
Q

low flow oxygen deliver devices and fio2

A

simple face mask (35-60%) requires at least 6L

nasal cannula 22-60%

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90
Q

high flow >10L oxygen deliver devices and fio2

A 
high flow nasal cannula (up to 4L in infants, up to 40L in adolescents) (up to 95%)
nonrebreathing mask (up to 95%)
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91
Q

breathing treatments

A 
nebulizer
metered dose inhaler (MDI)
MDI with spacer
heliox
humidified oxygen
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92
Q

clinical uses for heliox

A

conditions of large airway narrowing (croup, upper airway swelling)
conditions involving the medium airways (asthma, COPD)

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93
Q

2 advantages to humidified oxygen

A

decreases chance of coughing

loosen mucus and provide easier breathing

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94
Q

what should be avoided in patients with respiratory distress

A

coughing bc it can exacerbate the symptoms of croup

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95
Q

what conditions is humidified oxygen used for?

A

moderate to severe croup

asthma

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96
Q

racemic epinephrine

A

decreases swelling and edema in airway via vasoconstriction

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97
Q

self inflating ambu bag components

A

does not require oxygen and inflates on own with room air
has ability to hook up to oxygen to increase fio2
may come with reservoir bag

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98
Q

if an ambu bag is connected to oxygen and NOT reservoir bag

A

ambu bag fill with mixture of oxygen and air during exhalation

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99
Q

if an ambu bag is connected to oxygen AND reservoir bag

A

the bag will fill with mostly oxygen during exhalation

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100
Q

is the fio2 higher with or without the reservoir bag (assuming oxygen is always attached)

A

with reservoir bag fio2 will be higher

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101
Q

flow inflating anesthesia bag

A

requires oxygen to operate

pressure controlled with apl valve

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102
Q

infant and young children flow inflating bag size

A

450-500mL

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103
Q

older children and adolescent flow inflating bag size

A

1000mL

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104
Q

when are uncuffed tracheal tubes recommended?

A

children <8yrs old

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105
Q

formula for choosing the correct uncuffed endotracheal tube

A

age/4

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106
Q

formula for choosing the correct cuffed ETT

A

age/4 +3

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107
Q

formula for choosing the correct depth of insertion <2 yrs old

A

internal diameter (mm)x3

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108
Q

formula for choosing the correct depth of insertion >2yrs old

A

age/2 +12

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109
Q

confirming correct endotracheal tube placement PALS

A

six ventilations recommended to wash out CO2 that may be in the stomach then etCO2 can be presumed from trachea

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110
Q

ETT medications in PALS

A 
LEAN
lidocaine
epi
atropine
narcan
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111
Q

method of ETT drug administration

A

dilute drug with 5mL of N/S
deliver drug via ETT
follow with 5 positive pressure ventilations

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112
Q

rales (crackles, crepitation)

A

intermittent popping sound

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113
Q

possible causes of rales

A

fluid in distal airways

atelectasis

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114
Q

in PALS scenarios what does rales suggest?

A

cardiogenic shock

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115
Q

what is the key diagnosing difference between hypovolemic shock and cardiogenic shock

A

rales

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116
Q

rhonchi

A

low pitched noises that have been described as a snoring or bubbling sound

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117
Q

what is rhonchi caused by

A

secretions
mucus
blood
IN LARGE AIRWAYS

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118
Q

wheezing

A

high pitched noise during expirationthat is caused by bronchoconstriction

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119
Q

percussion examination

A

provider lays their left middle finer over body surface and taps on it with right middle finger

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120
Q

what sounds can be heard on percussion?

A

resonant
hyperresonant
dull

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121
Q

what sounds are normal with percussion?

A

resonant

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122
Q

when are hyperresonant sounds heard?

A 
hyperinflated lung (COPD, asthma attack)
hyperinflated chest cavity (tension pneumo)
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123
Q

airway scenarios in PALS 4

A

1 lower airway obstruction (asthma) wheeze during exhale
2 upper airway obstruction stridor during inhale
3 lung tissue disease (pneumonia, aspiration)
4 disordered control of breathing

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124
Q

DOPE pneumonic use

A

used in PALS when intubated pt deteriorates

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125
Q

what does DOPE stand for

A

displacement? (ETT in place?)
obstruction? (ETT kinked?)
pneumothorax? (bilateral breath sounds?)
equiptment failure?

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126
Q

possible interventions for respiratory distress or failure

A

airway
breathing
circulation

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127
Q

reasons to avoid excessive ventilation

A

1 it causes air trapping (barotrauma)
2 it increases intrathoracic pressure and impedes venous return
increases risk of regurg and aspiration

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128
Q

what can you do to avoid air trapping in kids?

A

ventilate at slower rates for longer expiration time

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129
Q

how can you minimize gastric inflation in kids? 3

A

1 ventilate slowly (1 breath every 3-5 sec or 12-20 breaths per min)
2 deliver each breath over 1 sec until chest rise
3 consider cricoid pressure

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130
Q

inspiratory muscles

A 
Dont Ever Stop Praying
Diaphragm
External intercostals
Sternocleidomastoid
Pectoralis Minor
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131
Q

breathing protocol 5

A

1 check responsiveness
2 check pulse and breathing simultaneously
3 if there is no pulse or <60bpm begin compressions
4 if there is a pulse and no breathing give rescue breaths
5 after rose begin evaluate identify intervene sequence and post cardiac arrest care

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132
Q

disordered control of breathing

A

abnormal respiratory pattern

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133
Q

what is disordered control of breathing caused by? 3

A

1 muscle weakness (inadequate reversal)
2 depressed consciousness
3 elevated ICP

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134
Q

what is disordered control of breathing USUALLY triggered by?

A

medication overdose

135
Q

head bobbing

A

sign of respiratory failure
chin lift inspiration
chin down expiration
neck muscles assist

136
Q

grunting (low pitch during exhalation)

A

small airway obstruction/collapse (partially closed glottis)

137
Q

what is grunting a sign of?

A

lung tissue disease
(pneumonia, pulmonary edema, pulmonary contusion, ARDS)
severe respiratory distress
impending respiratory failure

138
Q

nasal flaring

A

dilation of nostrils with inhalation

sign of respiratory distress

139
Q

retractions

A

manifest as inward movement of chest wall during inspiration

using chest muscles to breath

140
Q

what are retractions caused by?

A

increased airway resistance (stiff lungs)

141
Q

seesaw respirations

A

during inspiration
chest retracts and abdomen expands
during expiration
chest expands and abdomen moves inward

142
Q

what do seesaw respiration usually indicate?

A

upper airway obstruction

BUT can also be seen in severe lower airway obstruction, lung tissue disease, disordered control of breathing

143
Q

children with what usually have seesaw respirations? (not airway issues)

A

neuromuscular weakness

144
Q

stridor

A

high pitched sound on inspiration indicates upper airway obstruction

145
Q

quiet tachypnea

A

tachypnea with no signs of respiratory distress or increased respiratory effort

146
Q

what is quiet tachypnea caused by?

A

non pulmonary issues:

fever, pain, metabolic acidosis

147
Q

retractions + inspiratory snoring/stridor diagnosis

A

upper airway obstruction

croup foreign body

148
Q

retractions + expiratory wheezing diagnosis

A

lower airway obstruction

asthma bronchiolitis

149
Q

retraction + grunting or labored respirations diagnosis

A

lung tissue disease

150
Q

severe retractions diagnosis

A

may be accompanied by head bobbing or seesaw respirations

151
Q

respiratory distress differentiation 4

A

1 increased respiratory rate and effort but able to move air
2 potential abnormal airway sounds and pallor
3 tachycardia and anxiety
4 improves with initial therapy

152
Q

respiratory failure differentiation 4

A

1 inadequate oxygenation/ventilation that requires intervention
2 increased OR decreased respiratory effort or apneic
3 bradycardia, cyanosis, lethargy
4 may not respond to initial breathing treatments and interventions

153
Q

what are the most immediate causese of pediatric cardiac arrest?

A

respiratory failure

hypotensive shock

154
Q

in hospital cardiac arrest survival % vs out of hospital cardiac arrest %

A

hospital 43%

out of hosp 8%

155
Q

survival % cardiac arrest shockable rhythm vs asystole

A

shockable 25-34%

asystole 7-24%

156
Q

what is the highest rate for survival cardiac arrest and why?

A

64%

bradycardia and CPR and ventilation provided before cardiac arrest

157
Q

what is the leading cause of death in infants <6mo

A

SIDS

158
Q

where to check pulse >1 yr old

A

carotid or femoral

159
Q

where to check pulse <1 yr old

A

brachial pulse

160
Q

effective CPR 8

A 
1 push fast (100-120 per min)
2 push hard 
3 minimize interuptions
4 press on lower 1/2 breastbone
5 allow complete chest recoil
6 rotate compressors
7 avoid excessive ventilation
8 use monitoring to guide effectiveness
161
Q

cpr depth infant

A

1.5 inches

162
Q

cpr depth child

A

2 inches

163
Q

cpr depth adolescents and adults

A

<2.4 inches

164
Q

what etco2 shows effective compressions

A

> 15-20 mmHg

165
Q

when is the two handed CPR technique used in PALS

A

adults and kids >8yrs

166
Q

when is the one handed CPR technique used in PALS

A

alternative to two hand in children ages 1-8yrs old

167
Q

when is the two finger CPR technique used in PALS

A

infants when ONE responder available

2 fingers above xyphoid process

168
Q

when is the thumb encircling CPR technique used in PALS?

A

neonates and infants when TWO responders available

169
Q

what advantages does the thumb encircling technique have over two finger? 3

A

better coronary blood flow
more consistent depth
may generate higher blood pressures

170
Q

when is compression only CPR recommended?

A

only when the rescuer is unable or unwilling to deliver breaths

171
Q

CPR summary children 1- puberty 1 provider

A

30:2

one or two hand tech

172
Q

CPR summary children 1-puberty 2 providers

A

15:2

two handed technique

173
Q

CPR summary children 1-puberty 2 providers AND advanced airway

A

100-120 comp/min
8-10 breath/min
one vs two hand tech

174
Q

CPR summary neonates 1 provider

A

3:1 respiratory arrest
15:2 cardiac arrest
two finger tech

175
Q

CPR summary neonates 2 providers

A

3:1 respiratory arrest
15:2 cardiac arrest
thumb encirc tech

176
Q

CPR summary neonates 2 providers AND advanced airway

A

100-120 comp/min
age appropriate RR
thumb encirc tech

177
Q

4 methods for evaluating diability

A

1 glucose
2 pupil response to light
3 AVPU response scale
4 glascow coma scale

178
Q

what is the first thing you should try to do when assessing neurologic function?

A

check glucose

179
Q

what do you do if the pt is hypoglycemic

A

bolus dextrose

180
Q

what3 things should be assessed when checking pupils?

A

pupil size in mm
equality of pupil size
constriction in response to light

181
Q

acronym PERRL

A

normal pupil responses to light

Pupils Equal, Round, Reactive to Light

182
Q

what is suspected if pupils dont constrict to light

A

brainstem injury

183
Q

what may cause unequal pupil size?

A

increased intracranial pressure

184
Q

AVPU (best out of hospital)

A

Alert
responsive to Voice
responsive to Pain
Unresponsive

185
Q

Glasgow coma scale (best in hospital)

A

method of assessing consciousness and neurologic status

186
Q

scoring of glasgow coma scale

A

eye opening 4 possible points
verbal 5 possible points
motor 6 possible points

187
Q

what GCS is intubation indicated?

A

<8

188
Q

mild head injury GCS

A

13-15

189
Q

moderate head injury GCS

A

9-12

190
Q

severe head injury GCS

A

3-8

191
Q

TBW % infants

A

70%

192
Q

TBW % neonates

A

80%

193
Q

1kg = ___ liter(s) of water

A

1

194
Q

in PALS how much of body weight is water>

A

100%

195
Q

two ways that weight loss in PALS can be expressed as volume loss-

A

expressed as percentage of volume depletion (10% weight loss= 10% volume depletion)
expressed in mL/kg
(10% weight loss= volume loss 10mL/kg)

196
Q

mild dehydration infant

A

5% volume depletion

197
Q

moderate dehydration infant

A

10% volume depletion

198
Q

severe dehydration infant

A

15% volume depletion

199
Q

mild dehydration adolescent

A

3% volume depletion

200
Q

moderate dehydration adolescent

A

5-6% volume depletion

201
Q

severe dehydration adolescent

A

7-9% volume depleteion

202
Q

why can younger children better tolerate volume loss?

A

younger children have higher circulating blood volumes so water takes up a larger portion of their TBW

203
Q

why cant older children tolerate as much volume loss?

A

water takes up a lower percentage of their TBW

204
Q

what type of shock can dehydration lead to?

A

hypotensive shock

205
Q

treatment for dehydration

A

multiple 20mL/kg boluses of isotonic crystalloid

206
Q

what are rapid bolus?

A

20mL/kg over 5-10 min

207
Q

what are rapid bolus indicated for? 2

A

hypovolemic/hypotensive shock

distributive shock

208
Q

what are smaller OR slower boluses

A

5-10mL/kg 10-20min

209
Q

what are smaller or slower boluses indicated for? 4

A

cardiogenic shock
evidence of pulmonary edema
poisonings (BB or CCB)
diabetic ketoacidosis

210
Q

synthetic colloids

A

considered if hypovolemia/hypotension persists after 3 boluses of crystalloids

211
Q

maxiumum dose of colloid

A

20-40mL/kg

212
Q

what could a high dose of colloid cause?

A

coagulopathy

213
Q

total dose of albumin

A

should not exceed the amount in body

2g/kg

214
Q

indications for blood therapy

A

traumatic volume loss

children unresponsive to 2-3 boluses of rapid crystalloid

215
Q

initial dose PRBC

A

10mL/kg

216
Q

goal Hgb for blood therapy PALS

A

> 10g/dL

217
Q

priorities for the type of blood

A 
crossmatched
type specific (within 10 min)
type O blood
218
Q

why should female patients only receive O- blood?

A

they will have the Rh antibody, and if pregnant with postitive blood type baby the antibodies cross placenta

219
Q

what should you always check prior to a fluid bolus?

A

breath sounds in lower lobes

220
Q

fluid therapy for DKA

A

isotonic 10 to 20mL/kg over 1 to 2 hours UNLESS they are hypotensive shock then be more aggressive

221
Q

fluid therapy with febrile illnesses

A

restrictive volumes of isotonic crystalloid

222
Q

at what age are pediatric manual defib pads used?

A

<1yr

bc they can use lower energy dose than AED

223
Q

at what age are pediatric AED pads used?

A

1-8yrs

automatically recognized by aed

224
Q

pediatric dose attenuator

A

the aed has a key or switch that can deliver child shock dose

225
Q

when are adult aed pads used in PALS

A

kids >8yr

acceptable use on infants in cardiac arrest if peds pads arent there

226
Q

can you cut adult pads to fit a child?

A

no

227
Q

paddle choice and placement >1yr

A

large paddles

anterior posterior

228
Q

paddle choice and placement <1yr

A

small infant paddles

anterior anterior

229
Q

synch cardioversion 1st and 2nd shock doses

A

0.5-1 J/kg

2 J/kg

230
Q

defib 1st,2nd, subsequent and max shocks

A

2 J/kg
4 J/kg
>4 J/kg
10 J/kg

231
Q

what is the set of ABCs in PALS thats (not ABCDE)

A

appearance (crying? unresponsive?)
breathing (are they breathing? difficult?)
circulation/color (cyanosis? poor perfusion?)
(assessment triangle)

232
Q

5 steps to the primary assessment in PALS

A 
1 check responsiveness
2 perform CAB
3 do initial intervention based on CAB (compressions, oxygen, IV etc)
4 perform diability step (check glucose)
5 perform exposure step (physical exam)
233
Q

how to perform CAB

A
  1. check pulse cap refill/perfusion
    2 place monitors, IV, o2 if needed
    3 see if airway is open and able to breath
    4 ASCULTATE
234
Q

(secondary assessment) SAMPLE

A 
signs/symptoms
allergies
medications
past medical history
last meal
events
235
Q

what is the diagnostic assessment?

A

continuation of secondary assessment
diagnostic tests (chest xray, ultrasound)
Hs Ts

236
Q

what is EII?

A

evaluate, identify, intervene

pattern when looking at scenarios

237
Q

what does it mean to identify?

A

diagnose the type and severity of problem

238
Q

possible causes of low CO

A

bradycardia
hypovolemia
decreased contractility

239
Q

general symptoms of low CO (Low ScvO2) 5

A 
hypotension
vasoconstriction and weak pulse
signs of poor perfusion
oliguria
narrow pulse pressure
240
Q

additional symptoms of low CO (low ScvO2) if pt has decreased contractility 3

A

pulmonary edema
rales on auscultation
jugular venous distention

241
Q

symptoms of low afterload (vasodilation) 7

A 
high CO
good pulse
decreased preload
wide pulse pressure
brisk capillary refill (if BP is adequate)
delayed capillary refill (if BP is too low)
flushed skin
if severe angioedema
242
Q

symptoms of high afterload (vasoconstriction)

A

weak pulse
pale skin
delayed capillary refill

243
Q

what is the most common cause of vasoconstriction in PALS?

A

decreased CO

244
Q

ScvO2

A

oxygen saturation of blood in the superior vena cava

245
Q

causes of low ScvO2 4

A

low CO
hypoxia
increased metabolism
anemia

246
Q

how does anemia cause low ScvO2

A

less RBC then higher portion of O2 taken off of each RBC leads to lower ScvO2

247
Q

causes of high ScvO2 3

A

high CO
reduced metabolism (hypothermia)
sepsis

248
Q

how does sepsis cause high ScvO2?

A

mitocondrial dysfunction impairs oxygen uptake and consumption at cellular level

249
Q

if CO is low will ScvO2 always be low?

A

usually but if pt is in sepsis in addition to low CO then it may be elevated

250
Q

If ScvO2 is low will CO always be low?

A

no, other things can cause low ScvO2

251
Q

what are the 3 possible ScvO2 scenarios

A

low ScvO2 low BP
low ScvO2 normal BP
high ScvO2 low BP

252
Q

low ScvO2 and low BP

A

hypotensive shock

hypovolemia or decreased contractility

253
Q

is someone is hypotensive shock vasocontricted or vasodilated?

A

constricted to compensate

254
Q

treatment for hypotensive shock 2

A 
1 fluid resusitation/transfuse to Hb >10g/dL
2 after (1) consider vasoactive drugs
255
Q

drug for hypotensive cold shock

A

epi

256
Q

drug for hypotensive warm shock

A

norepi

257
Q

low ScvO2 with normal BP

A

normotensive shock

or compensative shock

258
Q

is someone is normotensive shock vasoconstricted or vasodilated?

A

vasoconstricted but is able to compensate the low CO

259
Q

treatment for normotensive 3

A

1 fluid bolus
2 administer epi (cold shock)
3 if symptoms continue after 1 and 2 then consider vasodilator Milrinone or nipride

260
Q

high ScvO2, warm extremities, low BP

A

warm shock

261
Q

what are two types of warm shock?

A

anaphylaxis

sepsis

262
Q

treatment for warm shock

A

fluid boluses

consider vasopressors

263
Q

shock definition

A

a physiologic state characterized by inadequate tissue perfusion

264
Q

4 common shock symptoms

A

hypotension
decreased CO
poor signs of perfusion
vasodilation

265
Q

compensated shock

A

maintains normal BP and CO

266
Q

what are the two wats the body can compensate during shock

A

increase SVR

increase HR

267
Q

decompensated shock

A

BP remains low despite any compensatory efforts by body

268
Q

warm shock is caused by what

A

vasodilation

269
Q

4 symptoms of warm shock

A

good peripheral pulses
increased CO
wider pulse pressure
warm flushed skin

270
Q

cold shock

A

caused by low CO (bc hypovolemia or decreased contractility) and vasoconstriction

271
Q

3 symptoms of cold shock

A

pale mottled skin
peripheral tissues are cold
hypotension with narrow pulse pressure

272
Q

what other times can normotensive shock occur other than compensated shock?

A

hypoxia

anemia

273
Q

hypovolemic shock 2 types

A 
hemorrhagic (loss of 30%blood volume)
non hemorrhagic (GI losses)
274
Q

what shock is most common in kids?

A

hypovolemic shock

275
Q

how is hypovolemic shock treated?

A

fluids and or blood products

276
Q

cardiogenic shock

A

caused by decrease in cardiac contractility

277
Q

how do you treat cardiogenic shock

A

smaller fluid bolus (5-10mL/kg)
inotropes
vasodilators (only if BP is normal)

278
Q

dissociative shock

A

adnormalities in hemoglobin affinity

carbon monoxide poisoning and methemoglobinemia

279
Q

obstructive shock

A

shock caused by an obstruction to blood flow somewhere

280
Q

4 types of obstructive shock

A

pulmonary embolism
cardiac tamponade
tension pneumothorax
ductal dependent lesions

281
Q

signs/symptoms of obstructive shock 2

A

same as with impaired contractility

additional signs for each type

282
Q

signs and symptoms of pulmonary embolism 4

A

signs of impaired cardiac contractility
respiratory distress
chest pain
right heart failure

283
Q

treatment for PE 3

A

20mL/kg fluid bolus
consider thrombolytics and anticoagulants
expert consult

284
Q

signs and symptoms of cardiac tamponade 3

A

signs of impaired cardiac contractility
muffled heart sounds
pulsus paradoxus

285
Q

treatment of cardiac tamponade 2

A

pericardiocentesis

20mL/kg fluid bolus

286
Q

signs and symptoms of tension pneumothorax 5

A

deflated lung and respiratory distress (unilateral sounds)
tracheal deviation towards contralateral side
poor signs perfusion
distended neck veins
pulsus paradoxus

287
Q

treatment tension pneumo 3

A

needle decompression

chest tube placement

288
Q

needle decompression

A

2nd-3rd intercostal space

mid clavicular

289
Q

chest tube

A

6th-7th intercostal space

mid axillary line

290
Q

unique symptom of ductal dependent lesion

A

rapid deterioration in consciousness

291
Q

treatment of ductal dependent lesion

A

prostaglandin e1

expert consult

292
Q

distributive shock

A

caused by vasodilation and “relative hypovolemia”

293
Q

3 types of distributive shock

A

anaphylactic shock
neurogenic shock
septic shock most common

294
Q

anaphylactic shock

A

severe allergic reaction
massive histamine release
1 systemic vasodilatino
2 pulmonary vasoconstriction

295
Q

7 treatment for anaphylactic shock

A 
1 subQ/IM epi
2 bronchodilator
3 20mL/kg fluid bolus
4 corticosteriods
5 H1 and H2 blockers
6 magnesium
7 consider humidified oxygen, bipap and intubation
296
Q

neurogenic shock

A

loss of sympathetic tone following spinal cord injury

leads to: vasodilation, bradycardia, hypothermia

297
Q

treatment of neurogenic shock

A

fluid boluses and vasopressors

298
Q

spinal shock

A

acute loss of sensation and motor function with gradual recovery

299
Q

what may occur in spinal injuries above T6?

A

autonomic dysreflexia

300
Q

distributive shock (septic)

A

infection usually associated with:
potentially fatal inflammatory reaction of whole body (SIRS)
an immune response that can lead to multiple organ dysfunction syndrome

301
Q

what are the 4 examples of an immune response the body can have in septic shock?

A

extreme vasodilation
hypoxia (leads to elevated serum lactate conc)
lung failure (pulm edema)
potential renal failure

302
Q

mechanism of sepsis

A

endotoxins induce nitric oxide synthase
produces relaxation of vascular smooth muscle tone
results in hypotension and reduced contractility

303
Q

treatment for sepsis 3

A

early ABX
fluid resuscitation
vasopressor to maintain MAP >65

304
Q

unique septic shock symptoms

A 
petechiae purpura
infection
high or low WBC count
acid base abnormalities
adrenal insufficiency
hypocalcemia, hypoglycemia, hyperglycemia
305
Q

3 additional treatments for septic shock-

A

laboratory work (WBC, plasma calc, plasma glucose)
steroids
possible calc and glucose replacement

306
Q

mechanism of steroids in sepsis

A

prevent induction of nitric oxide synthase
enhance response to catecholamines
reduce inflammatory response

307
Q

problem with steroids in sepsis

A

can worsen underlying infection and hyperglycemia

308
Q

septic shock management within first 10-15 min 3

A

1 identify shock
2 monitors oxygen IV
3 draw blood cultures and labs

309
Q

septic shock management within first hour 3

A

1 start 20mL/kg fluid boluses (stop if rales)
2 start vasopressors
3 administer broad spectrum Abx

310
Q

septic shock management critical care (after first hor) 4

A

1 administer stress dose steriods if needed
2 correct hypoglycemia and hypocalcemia
3 start invasive lines (a line and central line)
4 consider intubation

311
Q

calcium dose

A

20mg/kg

312
Q

dextrose dose

A

0.5-1g/kg

313
Q

in what situations would you consider prolonging resuscitative efforts?

A

recurring or refractory vfib/vtach
drug toxicity
hypothermia

314
Q

2 phases of post resuscitation management

A

1 immediate post arrest management ABCs

2 broader multi-organ supportive care

315
Q

8 goals of post resusciation management in PALS

A

1 SpO2 94-99
2 use fluids/vadopressors to keep systolic within 5th percentile for age
3 avoid hyper or hypocarbia 35-45
4 continually monitor temp/initiate TTM
5 monitor/treat hypoglycemia
6 manage and treat shock after ROSC
7 consider CT scan and avoid increases in ICP if applicable

316
Q

if intubated at what cmH2O should there be a leak

A

20-25cmH2O

317
Q

what things can you do to prevent increases in ICP?

A

elevating bed 30 degrees
mannitol
normocapnea

318
Q

TTM in PALS for infant and children remaining comatose after OHCA

A

avoid fever/maintain normothermia (36-37.5)for 5 days
OR
maintain 2 days of initial continuous hypothermia (32-34) followed by 3 days of continuous normothermia

319
Q

TTM for infants and children remaining comatose after IHCA

A

fever should be treated/avoided

320
Q

pediatric dose of atropine

A

20mcg/kg

can be repeated

321
Q

max single dose of atropine for child

A

0.5mg

322
Q

max total dose of atropine for child

A

1mg

323
Q

max total dose of atropine for adolescent

A

3mg

324
Q

IV dose epi in PALS bradycardia

A

10mcg/kg (0.01mg/kg)

repeat every 3-5 min as needed

325
Q

ETT dose of epi in PALS bradycardia

A

100mcg/kg

326
Q

adenosine in PALS SVT

A

dose 1 100mcg/kg (max 6mg)

dose 2 200mcg/kg (max 12mg)

327
Q

how should adenosine be administered

A

rapidly followed by 5-10mL bolus of N/S

328
Q

Amiodarone dose (SVT/Stable Vtach)

A

5mg/kg over 20-60min

329
Q

procainamide dose (SVT/Stable Vtach)

A

15mg/kg over 30-60min

330
Q

Epi (Vfib/Pulseless Vtach)

A

10mcg/kg every 3-5min

331
Q

lidocaine PALS vfib/pulseless vtach

A

1mg/kg

332
Q

amiodarone PALS vfib/pulseless vtach

A

5mg/kg rapid bolus

may repeat up to total dose of 15mg/kg OR 300mg total

333
Q

when is amiodarone contraindicated?

A

torsades

334
Q

magnesium indication and dose

A

torsades

25-50mg/kg

Methods of Anesthesia II (13 decks)

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