PALS Concepts Flashcards
EWL
estimated weight loss
FBAO
foreign body airway obstruction
LVOT
left ventricular outflow tract obstruction
PEFR
peak expiratory flow rate
ROSC
return of spontaneous circulation
what is a prominent sign of ROSC?
sudden increase in EtCO2
RVOT
right ventricular outflow tract obstruction
agonal breathing
half of pts in cardiac arrest will gasp
“snoring, gurgling, moaning, labored breathing”
agonal rhythm
slow complex rhythms that precede asystole
acryocyanosis
blue discoloration of hands and feet and around the mouth and lips
apnea
cessation of breathing for 20 seconds
apnea definition when accompanied by bradycardia, cyanosis, or pallor
<20 seconds
central apnea
no respiratory effort
obstructive apnea
ventilation is impeded by an obstructed airway
mixed apnea
combination of both central and obstructive apnea
what is the most common cause of bradycardia in kids?
apnea/hypoxia
bradycardia definition in children
ranges based on source and age from <60bpm- <100bpm
broselow tape
approximates weight and drug doses
channelopathy
genetic mutation and disorder of the ion channels in myocardial cells that predisposes the heart to arrhythmias
neonate
1-28 days
infant
1month-1yr
child
1 year to puberty
adult
puberty and older
chest compression fraction
proportion of time spent performing chest compressions for pts in cardiac arrest
what should CCF be?
at least 60%
ideally 80%
croup
inflammation of the larynx/vocal cords
mild croup sound
barking cough
moderate croup sound
stridor and retractions at rest
severe croup sound
significant agitation with decreased air entry
cyanosis
bluish discoloration of skin resulting from poor circulation or inadequate oxygen of the blood
when is cyanosis apparent?
at least 5g/dL of Hgb are desaturated
this means that the O2 saturation at cyanosis appearance depends upon Hgb concentration
febrile
temp >38 degrees C
in pals what should you administer when a fever is present?
Abx
common in sepsis and lung tissue disease
in pals when is a patient considered to have hypoxemia?
spO2 is less than OR equal to 94% on room air
when should you consider administering supplemental oxygen in PALs?
spo2 <94
poor signs of perfusion
what can present hypoxemia from turning into tissue hypoxia?
increase in CO
hypoglycemia neonate
blood sugars <45mg/dL
hypoglycemia infant/child/adolescent
<60mg/dL
treatment for hypoglycemia
0.5-1g/kg bolus of glucose
recommended D25W so (4mL)
hypotension systolic neonate
<60
hypotension systolic infants
<70
hypotension systolic children (1-10yr)
<70 + (age in yrs x2)
hypotension systolic children >10yrs
<90
heliox
breathing gas composed of a mixture of helium and oxygen
why does heliox help breathing?
helium gives lower density than air and oxygen alone and produces a higher probability of laminar flow
what does laminar flow in the airways do?
less airway resistance
less mechanical energy to ventilate
decreases work of breathing
what does heliox relieve symptoms of?
upper airway obstruction
middle and upper airway
where does heliox have little effect?
small airways since flow is already laminar
mottling
patchy discolorations of skin caused by vasoconstriction (pallor) mixed with areads of vasodilation (cyanosis or erythema)
what is mottling a sign of?
imminent death
pallor
pale color due to lack of oxygen in the skin
central pallor
pallor seen in the lips and mucous membrane
signs of good peripheral perfusion 5
good pulse (BP adequate) flushed skin brisk capillary refill (<2 sec) warm skin awake and alert
signs of poor peripheral perfusion 5
weak pulse pale or cyanotic skin color delayed capillary refill cool extremities decreased responsiveness or consciousness
permissive hypoxemia
spO2 reading of <94% that may be appropriate in certain circumstances
examples of permissive hypoxemia
pt at high altitude
pt with congenital heart disease
petechiae and purpura
purple discolorations caused by small vessel bleeding
petechiae
small dots
suggest low platelet count
purpura
appear as larger areas
what are petechiae and purpura a sign of in PALS?
septic shock
could be said as bruises or discolorations of skin
poikilothermia
unable to regulate body temperature
refractory
a child is refractory to a treatment if they do NOT improve or respond to therapy
fluid refractory hypotension
child remains hypotensive despite fluid admin
hypoxic refractory to supplemental oxygen
may mean they need a breathing treatment or need mask vent or intubation
norepinephrine refractory shock
child in shock is unresponsive to norepinephrine therapy
normal capillary refill time
<2sec in neutral thermal environment with extremity slightly above heart level
prolonged capillary refill time
> 5 seconds
what are the common causes of prolonged capillary refill time
dehydration
shock
hypothermia
SVT rate infants
> 220
SVT rate children
> 180
oxygen consumption adults
3-4mL/kg/min
oxygen consumption infants
6-8mL/kg/min
SpO2 PALS
> 94% on room air
<90% on 100% oxygen requires intervention
ScvO2 PALS
25-30% below SaO2
70-75% is SaO2 is normal
urine output infants/young children
1.5-2mL/kg/hr
urine output older children and adolescents
1mL/kg/hr
what is reduced urine output a sign of
poor perfusion
large (upper) airways have what kind of air flow
more turbulent air flow
more resistance
lower gas density does what to air flow
higher % of laminar flow
less resistance
why are peds pts more prone to upper airway obstruction?
large tongue
large occiput that causes neck flexion and takes the pt out of sniff position
how should the infant be positioned to open and clear the airway
pts head neutral
shoulder roll
severe choking in responsive children
providers can do heimlich or abdominal thrusts below xyphoid
severe choking in responsive infant
place the pt prone in one arm 5 back slaps
flip and deliver 5 downward chest thrust with two fingers
severe choking in unresponsive patients
immediately start CPR (even if pulses are palpable)
each time you open mouth look for opject
after obstruction is relieved what should you do?
place pt in recovery position
high flow nasal cannula how much can it deliver and what is the fio2?
> 50L/min it can deliver close to 100% FiO2 similar to nonrebreather mask
what is different about high flow nasal cannula that makes the pt tolerate higher flows without discomfort?
humidified and warmed
doesnt interrupt ability to communicate, eat or drink
does high flow nasal cannula produce positive airway pressure
yes 3cmH2O
low flow oxygen deliver devices and fio2
simple face mask (35-60%) requires at least 6L
nasal cannula 22-60%
high flow >10L oxygen deliver devices and fio2
high flow nasal cannula (up to 4L in infants, up to 40L in adolescents) (up to 95%) nonrebreathing mask (up to 95%)
breathing treatments
nebulizer metered dose inhaler (MDI) MDI with spacer heliox humidified oxygen
clinical uses for heliox
conditions of large airway narrowing (croup, upper airway swelling)
conditions involving the medium airways (asthma, COPD)
2 advantages to humidified oxygen
decreases chance of coughing
loosen mucus and provide easier breathing
what should be avoided in patients with respiratory distress
coughing bc it can exacerbate the symptoms of croup
what conditions is humidified oxygen used for?
moderate to severe croup
asthma
racemic epinephrine
decreases swelling and edema in airway via vasoconstriction
self inflating ambu bag components
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
if an ambu bag is connected to oxygen and NOT reservoir bag
ambu bag fill with mixture of oxygen and air during exhalation
if an ambu bag is connected to oxygen AND reservoir bag
the bag will fill with mostly oxygen during exhalation
is the fio2 higher with or without the reservoir bag (assuming oxygen is always attached)
with reservoir bag fio2 will be higher
flow inflating anesthesia bag
requires oxygen to operate
pressure controlled with apl valve
infant and young children flow inflating bag size
450-500mL
older children and adolescent flow inflating bag size
1000mL
when are uncuffed tracheal tubes recommended?
children <8yrs old
formula for choosing the correct uncuffed endotracheal tube
age/4
formula for choosing the correct cuffed ETT
age/4 +3
formula for choosing the correct depth of insertion <2 yrs old
internal diameter (mm)x3
formula for choosing the correct depth of insertion >2yrs old
age/2 +12
confirming correct endotracheal tube placement PALS
six ventilations recommended to wash out CO2 that may be in the stomach then etCO2 can be presumed from trachea
ETT medications in PALS
LEAN lidocaine epi atropine narcan
method of ETT drug administration
dilute drug with 5mL of N/S
deliver drug via ETT
follow with 5 positive pressure ventilations
rales (crackles, crepitation)
intermittent popping sound
possible causes of rales
fluid in distal airways
atelectasis
in PALS scenarios what does rales suggest?
cardiogenic shock
what is the key diagnosing difference between hypovolemic shock and cardiogenic shock
rales
rhonchi
low pitched noises that have been described as a snoring or bubbling sound
what is rhonchi caused by
secretions
mucus
blood
IN LARGE AIRWAYS
wheezing
high pitched noise during expirationthat is caused by bronchoconstriction
percussion examination
provider lays their left middle finer over body surface and taps on it with right middle finger
what sounds can be heard on percussion?
resonant
hyperresonant
dull
what sounds are normal with percussion?
resonant
when are hyperresonant sounds heard?
hyperinflated lung (COPD, asthma attack) hyperinflated chest cavity (tension pneumo)
airway scenarios in PALS 4
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
DOPE pneumonic use
used in PALS when intubated pt deteriorates
what does DOPE stand for
displacement? (ETT in place?)
obstruction? (ETT kinked?)
pneumothorax? (bilateral breath sounds?)
equiptment failure?
possible interventions for respiratory distress or failure
airway
breathing
circulation
reasons to avoid excessive ventilation
1 it causes air trapping (barotrauma)
2 it increases intrathoracic pressure and impedes venous return
increases risk of regurg and aspiration
what can you do to avoid air trapping in kids?
ventilate at slower rates for longer expiration time
how can you minimize gastric inflation in kids? 3
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
inspiratory muscles
Dont Ever Stop Praying Diaphragm External intercostals Sternocleidomastoid Pectoralis Minor
breathing protocol 5
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
disordered control of breathing
abnormal respiratory pattern
what is disordered control of breathing caused by? 3
1 muscle weakness (inadequate reversal)
2 depressed consciousness
3 elevated ICP
what is disordered control of breathing USUALLY triggered by?
medication overdose
head bobbing
sign of respiratory failure
chin lift inspiration
chin down expiration
neck muscles assist
grunting (low pitch during exhalation)
small airway obstruction/collapse (partially closed glottis)
what is grunting a sign of?
lung tissue disease
(pneumonia, pulmonary edema, pulmonary contusion, ARDS)
severe respiratory distress
impending respiratory failure
nasal flaring
dilation of nostrils with inhalation
sign of respiratory distress
retractions
manifest as inward movement of chest wall during inspiration
using chest muscles to breath
what are retractions caused by?
increased airway resistance (stiff lungs)
seesaw respirations
during inspiration
chest retracts and abdomen expands
during expiration
chest expands and abdomen moves inward
what do seesaw respiration usually indicate?
upper airway obstruction
BUT can also be seen in severe lower airway obstruction, lung tissue disease, disordered control of breathing
children with what usually have seesaw respirations? (not airway issues)
neuromuscular weakness
stridor
high pitched sound on inspiration indicates upper airway obstruction
quiet tachypnea
tachypnea with no signs of respiratory distress or increased respiratory effort
what is quiet tachypnea caused by?
non pulmonary issues:
fever, pain, metabolic acidosis
retractions + inspiratory snoring/stridor diagnosis
upper airway obstruction
croup foreign body
retractions + expiratory wheezing diagnosis
lower airway obstruction
asthma bronchiolitis
retraction + grunting or labored respirations diagnosis
lung tissue disease
severe retractions diagnosis
may be accompanied by head bobbing or seesaw respirations
respiratory distress differentiation 4
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
respiratory failure differentiation 4
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
what are the most immediate causese of pediatric cardiac arrest?
respiratory failure
hypotensive shock
in hospital cardiac arrest survival % vs out of hospital cardiac arrest %
hospital 43%
out of hosp 8%
survival % cardiac arrest shockable rhythm vs asystole
shockable 25-34%
asystole 7-24%
what is the highest rate for survival cardiac arrest and why?
64%
bradycardia and CPR and ventilation provided before cardiac arrest
what is the leading cause of death in infants <6mo
SIDS
where to check pulse >1 yr old
carotid or femoral
where to check pulse <1 yr old
brachial pulse
effective CPR 8
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
cpr depth infant
1.5 inches
cpr depth child
2 inches
cpr depth adolescents and adults
<2.4 inches
what etco2 shows effective compressions
> 15-20 mmHg
when is the two handed CPR technique used in PALS
adults and kids >8yrs
when is the one handed CPR technique used in PALS
alternative to two hand in children ages 1-8yrs old
when is the two finger CPR technique used in PALS
infants when ONE responder available
2 fingers above xyphoid process
when is the thumb encircling CPR technique used in PALS?
neonates and infants when TWO responders available
what advantages does the thumb encircling technique have over two finger? 3
better coronary blood flow
more consistent depth
may generate higher blood pressures
when is compression only CPR recommended?
only when the rescuer is unable or unwilling to deliver breaths
CPR summary children 1- puberty 1 provider
30:2
one or two hand tech
CPR summary children 1-puberty 2 providers
15:2
two handed technique
CPR summary children 1-puberty 2 providers AND advanced airway
100-120 comp/min
8-10 breath/min
one vs two hand tech
CPR summary neonates 1 provider
3:1 respiratory arrest
15:2 cardiac arrest
two finger tech
CPR summary neonates 2 providers
3:1 respiratory arrest
15:2 cardiac arrest
thumb encirc tech
CPR summary neonates 2 providers AND advanced airway
100-120 comp/min
age appropriate RR
thumb encirc tech
4 methods for evaluating diability
1 glucose
2 pupil response to light
3 AVPU response scale
4 glascow coma scale
what is the first thing you should try to do when assessing neurologic function?
check glucose
what do you do if the pt is hypoglycemic
bolus dextrose
what3 things should be assessed when checking pupils?
pupil size in mm
equality of pupil size
constriction in response to light
acronym PERRL
normal pupil responses to light
Pupils Equal, Round, Reactive to Light
what is suspected if pupils dont constrict to light
brainstem injury
what may cause unequal pupil size?
increased intracranial pressure
AVPU (best out of hospital)
Alert
responsive to Voice
responsive to Pain
Unresponsive
Glasgow coma scale (best in hospital)
method of assessing consciousness and neurologic status
scoring of glasgow coma scale
eye opening 4 possible points
verbal 5 possible points
motor 6 possible points
what GCS is intubation indicated?
<8
mild head injury GCS
13-15
moderate head injury GCS
9-12
severe head injury GCS
3-8
TBW % infants
70%
TBW % neonates
80%
1kg = ___ liter(s) of water
1
in PALS how much of body weight is water>
100%
two ways that weight loss in PALS can be expressed as volume loss-
expressed as percentage of volume depletion (10% weight loss= 10% volume depletion)
expressed in mL/kg
(10% weight loss= volume loss 10mL/kg)
mild dehydration infant
5% volume depletion
moderate dehydration infant
10% volume depletion
severe dehydration infant
15% volume depletion
mild dehydration adolescent
3% volume depletion
moderate dehydration adolescent
5-6% volume depletion
severe dehydration adolescent
7-9% volume depleteion
why can younger children better tolerate volume loss?
younger children have higher circulating blood volumes so water takes up a larger portion of their TBW
why cant older children tolerate as much volume loss?
water takes up a lower percentage of their TBW
what type of shock can dehydration lead to?
hypotensive shock
treatment for dehydration
multiple 20mL/kg boluses of isotonic crystalloid
what are rapid bolus?
20mL/kg over 5-10 min
what are rapid bolus indicated for? 2
hypovolemic/hypotensive shock
distributive shock
what are smaller OR slower boluses
5-10mL/kg 10-20min
what are smaller or slower boluses indicated for? 4
cardiogenic shock
evidence of pulmonary edema
poisonings (BB or CCB)
diabetic ketoacidosis
synthetic colloids
considered if hypovolemia/hypotension persists after 3 boluses of crystalloids
maxiumum dose of colloid
20-40mL/kg
what could a high dose of colloid cause?
coagulopathy
total dose of albumin
should not exceed the amount in body
2g/kg
indications for blood therapy
traumatic volume loss
children unresponsive to 2-3 boluses of rapid crystalloid
initial dose PRBC
10mL/kg
goal Hgb for blood therapy PALS
> 10g/dL
priorities for the type of blood
crossmatched type specific (within 10 min) type O blood
why should female patients only receive O- blood?
they will have the Rh antibody, and if pregnant with postitive blood type baby the antibodies cross placenta
what should you always check prior to a fluid bolus?
breath sounds in lower lobes
fluid therapy for DKA
isotonic 10 to 20mL/kg over 1 to 2 hours UNLESS they are hypotensive shock then be more aggressive
fluid therapy with febrile illnesses
restrictive volumes of isotonic crystalloid
at what age are pediatric manual defib pads used?
<1yr
bc they can use lower energy dose than AED
at what age are pediatric AED pads used?
1-8yrs
automatically recognized by aed
pediatric dose attenuator
the aed has a key or switch that can deliver child shock dose
when are adult aed pads used in PALS
kids >8yr
acceptable use on infants in cardiac arrest if peds pads arent there
can you cut adult pads to fit a child?
no
paddle choice and placement >1yr
large paddles
anterior posterior
paddle choice and placement <1yr
small infant paddles
anterior anterior
synch cardioversion 1st and 2nd shock doses
0.5-1 J/kg
2 J/kg
defib 1st,2nd, subsequent and max shocks
2 J/kg
4 J/kg
>4 J/kg
10 J/kg
what is the set of ABCs in PALS thats (not ABCDE)
appearance (crying? unresponsive?)
breathing (are they breathing? difficult?)
circulation/color (cyanosis? poor perfusion?)
(assessment triangle)
5 steps to the primary assessment in PALS
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)
how to perform CAB
- check pulse cap refill/perfusion
2 place monitors, IV, o2 if needed
3 see if airway is open and able to breath
4 ASCULTATE
(secondary assessment) SAMPLE
signs/symptoms allergies medications past medical history last meal events
what is the diagnostic assessment?
continuation of secondary assessment
diagnostic tests (chest xray, ultrasound)
Hs Ts
what is EII?
evaluate, identify, intervene
pattern when looking at scenarios
what does it mean to identify?
diagnose the type and severity of problem
possible causes of low CO
bradycardia
hypovolemia
decreased contractility
general symptoms of low CO (Low ScvO2) 5
hypotension vasoconstriction and weak pulse signs of poor perfusion oliguria narrow pulse pressure
additional symptoms of low CO (low ScvO2) if pt has decreased contractility 3
pulmonary edema
rales on auscultation
jugular venous distention
symptoms of low afterload (vasodilation) 7
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
symptoms of high afterload (vasoconstriction)
weak pulse
pale skin
delayed capillary refill
what is the most common cause of vasoconstriction in PALS?
decreased CO
ScvO2
oxygen saturation of blood in the superior vena cava
causes of low ScvO2 4
low CO
hypoxia
increased metabolism
anemia
how does anemia cause low ScvO2
less RBC then higher portion of O2 taken off of each RBC leads to lower ScvO2
causes of high ScvO2 3
high CO
reduced metabolism (hypothermia)
sepsis
how does sepsis cause high ScvO2?
mitocondrial dysfunction impairs oxygen uptake and consumption at cellular level
if CO is low will ScvO2 always be low?
usually but if pt is in sepsis in addition to low CO then it may be elevated
If ScvO2 is low will CO always be low?
no, other things can cause low ScvO2
what are the 3 possible ScvO2 scenarios
low ScvO2 low BP
low ScvO2 normal BP
high ScvO2 low BP
low ScvO2 and low BP
hypotensive shock
hypovolemia or decreased contractility
is someone is hypotensive shock vasocontricted or vasodilated?
constricted to compensate
treatment for hypotensive shock 2
1 fluid resusitation/transfuse to Hb >10g/dL 2 after (1) consider vasoactive drugs
drug for hypotensive cold shock
epi
drug for hypotensive warm shock
norepi
low ScvO2 with normal BP
normotensive shock
or compensative shock
is someone is normotensive shock vasoconstricted or vasodilated?
vasoconstricted but is able to compensate the low CO
treatment for normotensive 3
1 fluid bolus
2 administer epi (cold shock)
3 if symptoms continue after 1 and 2 then consider vasodilator Milrinone or nipride
high ScvO2, warm extremities, low BP
warm shock
what are two types of warm shock?
anaphylaxis
sepsis
treatment for warm shock
fluid boluses
consider vasopressors
shock definition
a physiologic state characterized by inadequate tissue perfusion
4 common shock symptoms
hypotension
decreased CO
poor signs of perfusion
vasodilation
compensated shock
maintains normal BP and CO
what are the two wats the body can compensate during shock
increase SVR
increase HR
decompensated shock
BP remains low despite any compensatory efforts by body
warm shock is caused by what
vasodilation
4 symptoms of warm shock
good peripheral pulses
increased CO
wider pulse pressure
warm flushed skin
cold shock
caused by low CO (bc hypovolemia or decreased contractility) and vasoconstriction
3 symptoms of cold shock
pale mottled skin
peripheral tissues are cold
hypotension with narrow pulse pressure
what other times can normotensive shock occur other than compensated shock?
hypoxia
anemia
hypovolemic shock 2 types
hemorrhagic (loss of 30%blood volume) non hemorrhagic (GI losses)
what shock is most common in kids?
hypovolemic shock
how is hypovolemic shock treated?
fluids and or blood products
cardiogenic shock
caused by decrease in cardiac contractility
how do you treat cardiogenic shock
smaller fluid bolus (5-10mL/kg)
inotropes
vasodilators (only if BP is normal)
dissociative shock
adnormalities in hemoglobin affinity
carbon monoxide poisoning and methemoglobinemia
obstructive shock
shock caused by an obstruction to blood flow somewhere
4 types of obstructive shock
pulmonary embolism
cardiac tamponade
tension pneumothorax
ductal dependent lesions
signs/symptoms of obstructive shock 2
same as with impaired contractility
additional signs for each type
signs and symptoms of pulmonary embolism 4
signs of impaired cardiac contractility
respiratory distress
chest pain
right heart failure
treatment for PE 3
20mL/kg fluid bolus
consider thrombolytics and anticoagulants
expert consult
signs and symptoms of cardiac tamponade 3
signs of impaired cardiac contractility
muffled heart sounds
pulsus paradoxus
treatment of cardiac tamponade 2
pericardiocentesis
20mL/kg fluid bolus
signs and symptoms of tension pneumothorax 5
deflated lung and respiratory distress (unilateral sounds)
tracheal deviation towards contralateral side
poor signs perfusion
distended neck veins
pulsus paradoxus
treatment tension pneumo 3
needle decompression
chest tube placement
needle decompression
2nd-3rd intercostal space
mid clavicular
chest tube
6th-7th intercostal space
mid axillary line
unique symptom of ductal dependent lesion
rapid deterioration in consciousness
treatment of ductal dependent lesion
prostaglandin e1
expert consult
distributive shock
caused by vasodilation and “relative hypovolemia”
3 types of distributive shock
anaphylactic shock
neurogenic shock
septic shock most common
anaphylactic shock
severe allergic reaction
massive histamine release
1 systemic vasodilatino
2 pulmonary vasoconstriction
7 treatment for anaphylactic shock
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
neurogenic shock
loss of sympathetic tone following spinal cord injury
leads to: vasodilation, bradycardia, hypothermia
treatment of neurogenic shock
fluid boluses and vasopressors
spinal shock
acute loss of sensation and motor function with gradual recovery
what may occur in spinal injuries above T6?
autonomic dysreflexia
distributive shock (septic)
infection usually associated with:
potentially fatal inflammatory reaction of whole body (SIRS)
an immune response that can lead to multiple organ dysfunction syndrome
what are the 4 examples of an immune response the body can have in septic shock?
extreme vasodilation
hypoxia (leads to elevated serum lactate conc)
lung failure (pulm edema)
potential renal failure
mechanism of sepsis
endotoxins induce nitric oxide synthase
produces relaxation of vascular smooth muscle tone
results in hypotension and reduced contractility
treatment for sepsis 3
early ABX
fluid resuscitation
vasopressor to maintain MAP >65
unique septic shock symptoms
petechiae purpura infection high or low WBC count acid base abnormalities adrenal insufficiency hypocalcemia, hypoglycemia, hyperglycemia
3 additional treatments for septic shock-
laboratory work (WBC, plasma calc, plasma glucose)
steroids
possible calc and glucose replacement
mechanism of steroids in sepsis
prevent induction of nitric oxide synthase
enhance response to catecholamines
reduce inflammatory response
problem with steroids in sepsis
can worsen underlying infection and hyperglycemia
septic shock management within first 10-15 min 3
1 identify shock
2 monitors oxygen IV
3 draw blood cultures and labs
septic shock management within first hour 3
1 start 20mL/kg fluid boluses (stop if rales)
2 start vasopressors
3 administer broad spectrum Abx
septic shock management critical care (after first hor) 4
1 administer stress dose steriods if needed
2 correct hypoglycemia and hypocalcemia
3 start invasive lines (a line and central line)
4 consider intubation
calcium dose
20mg/kg
dextrose dose
0.5-1g/kg
in what situations would you consider prolonging resuscitative efforts?
recurring or refractory vfib/vtach
drug toxicity
hypothermia
2 phases of post resuscitation management
1 immediate post arrest management ABCs
2 broader multi-organ supportive care
8 goals of post resusciation management in PALS
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
if intubated at what cmH2O should there be a leak
20-25cmH2O
what things can you do to prevent increases in ICP?
elevating bed 30 degrees
mannitol
normocapnea
TTM in PALS for infant and children remaining comatose after OHCA
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
TTM for infants and children remaining comatose after IHCA
fever should be treated/avoided
pediatric dose of atropine
20mcg/kg
can be repeated
max single dose of atropine for child
0.5mg
max total dose of atropine for child
1mg
max total dose of atropine for adolescent
3mg
IV dose epi in PALS bradycardia
10mcg/kg (0.01mg/kg)
repeat every 3-5 min as needed
ETT dose of epi in PALS bradycardia
100mcg/kg
adenosine in PALS SVT
dose 1 100mcg/kg (max 6mg)
dose 2 200mcg/kg (max 12mg)
how should adenosine be administered
rapidly followed by 5-10mL bolus of N/S
Amiodarone dose (SVT/Stable Vtach)
5mg/kg over 20-60min
procainamide dose (SVT/Stable Vtach)
15mg/kg over 30-60min
Epi (Vfib/Pulseless Vtach)
10mcg/kg every 3-5min
lidocaine PALS vfib/pulseless vtach
1mg/kg
amiodarone PALS vfib/pulseless vtach
5mg/kg rapid bolus
may repeat up to total dose of 15mg/kg OR 300mg total
when is amiodarone contraindicated?
torsades
magnesium indication and dose
torsades
25-50mg/kg
