PALS Part 2.1 (7-10) (Respiratory & Shock) Flashcards
Hypoxemia VS Hypoxia
Hypoxemia is when there is lower O2/hemoglobin saturation (below 94%)
Hypoxia (generalized = whole body ; tissue = specific region) is when there is inadequate O2 being delivered to the body
They do not happen at the same time in all instances
Early Vs Late signs of tissue hypoxia
Early Signs:
- Tachypnea
- Tachycardia
- Increased resp effort: nasal flaring, retractions
- Pallor, mottling, cyanosis
- Agitation, anxiety, irritability
Late Signs:
- Bradypnea, inadequate resp effort, apnea
- Increased resp effort: head bobbing, seesaw resps, grunting
- Bradycardia
- Pallor, mottling, cyanosis
- Decreased LOC
What exactly is Arterial O2 content and what is the formula for calculating it?
Arterial O2 Content = the total amount of O2 carried in the blood. It consists of the sum of O2 bound to hemoglobin AND the amount dissolved into arterial blood plasma.
Arterial O2 Content = (1.36 X Hgb concentration X SaO2) + (0.003 x PaO2)
Review the 5 different mechanisms of Hypoxia on page 111-112
Seriously review it, they’re not the normal causes of respiratory distress you think of!!!
When should you begin to suspect hypercarbia as the cause of respiratory distress instead of hypoxia/hypoxemia?
When the pt further deteriorates despite adequate O2, which is typically a sign that ventilations are inadequate whether spontaneous via pt or artificial via BVM
Stopped at Airway resistance
Stopped at Airway resistance
What are the 4 major factors associated with increased work of breathing?
AIRWAY RESISTANCE:
- the impedance to airflow within the airways, which is primarily changed by the size of the airway. Larger airways have less resistance than smaller airways. Obviously if there is a blockage or space taken up then the airway will be smaller and thus resistance increased.
LUNG COMPLIANCE:
- The change in lung volume produced by a change in driving pressure across the lung, this is done with the lungs and chest wall/diaphragm expand and relax. There are several conditions that decrease lung compliance such as a pneumo, pneumonia, ARDS, Inflammation, and pulmonary edema; but the root cause of decrease compliance is the increased presence of water/fluids in the interstitial spaces. This acts like a sponge filled with water which decreases its natural elasticity b/c of the extra water weight.
USE OF ACCESSORY MUSCLES:
- The muscles of inspiration are the diaphragm, intercostal muscles, and accessory muscles (mainly the neck and abdomen). The diaphragm creates he most change in pressure by contracting downward in a dome shape, however the range of motion of the diaphragm contraction can be decreased my things like intraabdominal pressure or abdominal distention. In young children and infants the intercostal muscles serve mainly to stabilize the chest and cannot effectively lift the chest wall to increase intrathoracic volume to compensate for a loss of diaphragm motion.
CNS DISORDER OF THE BREATHING CONTROL SYSTEMS:
- Includes brainstem respiratory centers, central/peripheral chemoreceptors, and voluntary control (via the cerebral cortex). Things like an infection of the CNS, traumatic brain injury, and drug overdose can impair these systems.
- NOTE: Central Chemoreceptors are responsive to the hydrogen ion content in the cerebrospinal fluid which is largely determined by the arterial CO2 tension.
Peripheral Chemoreceptors are responsive to a decrease in arterial O2 (though a few also response to CO2 levels)
Laminar Airflow Vs Turbulent Airflow?
Laminar Airflow = quite, smooth, and orderly
Turbulent Airflow = irregular
How is lung and chest wall compliance different for infants and small children?
B/c the infant and smaller children chest wall has not become rigid yet like in older children and adolescents and is still very flexible (i.e. very compliant), when a child changes intrathoracic pressures very quickly and forcefully as in labored breathing, it will bring in the chest wall during a forceful inspiration causing the retractions of the chest wall between the ribs seen during labored breathing.
This actually limits lung expansion and is not useful. Once the chest wall becomes rigid in older kids, the forceful inspiration can be helpful
How is airway swelling different in infants and children than adults?
Obviously the airways are going to be smaller which is fine with their comparatively smaller bodies. However, b/c swelling is circumferential in the airways, the same amount of swelling causes a MUCH smaller airway in infants. Pg 114 has a good picture example.
A crying infants creating turbulent airflow can reduce lumen size causing an increase in airway resistance and cause a 16-32x increase in work of breathing.
Respiratory Distress VS Failure
Respiratory Distress:
- This is when there is an increase in respiratory rate and effort. Typically assessment for includes looking at rate, effort, quality of breath sounds, and mental status (typical an AMS indicated more failure than distress)
Respiratory Failure:
- occurs when the pt can no longer maintain adequate oxygenation, ventilation, or both. Typically this is identified by an “abnormal appearance” aka AMS or decreased LOC or cyanotic.
NOTE: When respiratory effort is inadequate, respiratory failure can occur without typical signs of respiratory distress.
For instance if a pt OD’d on an opioid, they may not go through the phase of respiratory distress before reaching failure b/c they are already in a depressed state/LOC before respiratory depression and thus may not fight for air the normal way.
Where should you auscultate lung sounds when doing a respiratory exam?
- Anterior (either side of the chest wall)
- Posterior
- Lateral (under the axillae)
NOTE: remember though that due to small chest cavity space, sometimes the lung on the opposite side can be heard while auscultating the other side and mask problems. So listening under the armpit where you are the furthest away from the opposite lung may yield the most accurate sounds
What are the 4 types of respiratory problem types?
more like locations of cause
UPPER AIRWAY OBSTRUCTION:
- Nose, pharynx, larynx (airways above the thorax)
- Typically from some sort of obstruction (Ex. FBAO), inflammation (Ex. Epiglottitis), or infection (Croup)
- Most common signs are stridor, hoarseness, change in voice/cry, typically during inspiration. Other signs could be increased resp rate/effort, drooling, snoring, gurgling, poor chest rise, poor air entry sounds on auscultation
LOWER AIRWAY OBSTRUCTION:
- Lower trachea, bronchi, bronchioles (airway within the thorax)
- Commonly caused by asthma and bronchiolitis.
- Typically signs are seen during inspiration where there is a wheeze and prolonged expiratory phase the requires increased expiratory effort.
LUNG TISSUE DISEASE:
- Disease of the lung tissues/substances
- This causes stiff lungs b/c of the increase in fluids accumulated in the alveoli, interstitium, or both. This causes severe respiratory effort seen by accessory muscle use/retractions and marked hypoxia (from alveolar collapse or pulmonary edema and/or inflammation debris in the alveoli
- The disease can be caused by a ton of things including, pulmonary contusion, allergic reaction, toxins, CHF, ARDS, pneumonia, ect.
- Often signs and symptoms will include, crackles/rales, decreased air movement, decreased breath sounds, tachypnea, increased effort, tachycardia, and hypoxemia despite O2 supp).
(EARLY SIGN = hypoxemia b/c of damaged alveoli, low oxygenation ; LATE SIGN = grunting and hypercarbia b/c of decreased ventilation and hypercarbia)
DISORDERED CONTROL OF BREATHING:
- in this state there is inadequate respiratory effort (often the parent will say the child is “breathing funny”) which leads to hypoventilation and hypercarbia. Typically the LOC will be decreased as a result of the other two.
- Can be caused by neurologic disorders, metabolic abnormalities, and drug overdose.
- Signs often include, variable/irregular breathing patterns and effort, shallow breathing with inadequate effort, central apnea, normal or decreased air movement
Specific Management for Different Types of Upper Airway Obstructions
ALL Emergencies Get the Basic:
- airway positioning
- suction as needed
- oxygen
- Pulse Ox
- ECG Monitoring as needed
- BLS as indicated
UPPER AIRWAY OBSTRUCTION
- Croup:
a) nebulized epi
b) corticosteroids (dexamethasone) - Anaphylaxis
a) IM Epi:
b) albuterol
c) antihistamine
d) corticosteroids - FBAO:
a) position of comfort
b) specialty consulation
Specific Management for Different Types of Lower Airway Obstructions
ALL Emergencies Get the Basic:
- airway positioning
- suction as needed
- oxygen
- Pulse Ox
- ECG Monitoring as needed
- BLS as indicated
LOWER AIRWAY OBSTRUCTION
- Bronchiolitis:
a) nasal suctioning
b) consider bronchodilator trial - Asthma:
a) albuterol + ipratropium
b) corticosteroids
c) magnesium sulfate (for status asthmaticus)
d) IM epi (if severe)
e) Terbutaline
Specific Management for Different Types of Lung Tissue Disease
ALL Emergencies Get the Basic:
- airway positioning
- suction as needed
- oxygen
- Pulse Ox
- ECG Monitoring as needed
- BLS as indicated
LUNG TISSUE DISEASE
- Pneumonia, Infectious/Chemical/Aspiration Pneumonitis
a) albuterol
b) antibiotics as needed
c) consider non invasive or invasive ventilatory support with PEEP - Pulmonary Edema, Cardiogenic/NonCardio (ARDS):
a) consider non invasive or invasive ventilatory support with PEEP
b) consider vasoactive support
c) consider diuretic
Specific Management for Different Types of Disordered Control of Breathing
ALL Emergencies Get the Basic:
- airway positioning
- suction as needed
- oxygen
- Pulse Ox
- ECG Monitoring as needed
- BLS as indicated
DISORDERED CONTROL OF BREATHING
- Increased ICP:
a) avoid hypoxemia
b) avoid hypercarbia
c) avoid hyperthermia
d) avoid hypotension - Poisoning/Overdose:
a) antidote as indicated
b) contact poison control - Neuromuscular Disease:
a) consider non invasive or invasive ventilatory support with PEEP
Why might you not want to use succinylcholine in a ped pt with a neuromuscular disease?
It can trigger hyperkalemia or malignant hyperthermia
What is a pop off valve and when should it not be used?
A pop off valve is a pressure limited valve on a BVM that prevents excessive airway pressure above 35-45 cm H2O being vented into the patient.
When you are doing CPR on a ped patient who with poor lung compliance, has airway resistance, or needs CPR the automatic pop-off valve may prevent sufficient tidal volume from being delivered. Therefore when doing CPR you should TAKE OR TURN OFF THE POP OFF VALVE
SIDE NOTE*** even with O2 supp ventilations using a reservoir and secondary 100% O2 source, the O2 concentration can vary from 30-80%. So do make sure you deliver high O2 concentration (60-95%) you must make sure you are using a reservoir and supp O2 flow of at least 15L/min
What is a fish-mouth or leaf-flap operated nonrebreathing outlet valve?
They are adult specific non rebreathing valves that DO NOT provide a continuous flow of O2 to the mask. They only open when the bag is squeezed or enough inspiratory pressure forces the valve to open (when spontaneous breaths are present). However, kids cannot generate enough inspiratory force to open these valves so DO NOT USE ON CHILDREN.
What size volume self-inflating bags should be used for infants/children and which for adolescents?
For infants and small children used a 450-500mL bag
For adolescents use a 1000mL (adult) bag
What steps should you take when equipment testing your BVM?
- Check bag for leaks by placing finger on outlet valve and squeezing bag
- Check gas flow control valves to verify function
- Check the pop-off valve to ensure it can be closed/taken off
- Check that the O2 tubing is securely connected to the device and O2 source
- Listen for the sound of O2 flowing into the bag
- Ensure that the cuff of the mask is adequately inflated
What is the ideal position for infants and toddlers to make an open/patent airway through positioning?
The “sniffing” position
Aim to place the external ear canal in line with the anterior of the top of the shoulder by flexing the neck forward and extending the head.
For children OLDER than 2 you may need to put padding under the occiput and for children YOUNGER than 2 you may need to pad under the shoulder blades.
How many rescuers are recommended in order to use a BVM?
How does the technique change when there is 1 vs 2 rescuers?
When might a 2 person rescuer control over the BVM be necessary?
AHA says 2, and if there is only 1 they recommend the mouth-to-barrier technique
A 1 rescuer using a BVM should use the E-C clamp technique (the normal one; thumb & pointer make a C holding the mask secure to face, the other 3 fingers go under chin to hold the head back)
A 2 rescuer using a BVM should have one rescuer doing essentially an E-C clamp with both hands while the other squeezes the bag
Time when a 2 rescuer team may be necessary is if:
- making a seal is difficult
- one provider’s hands are too small
- significant airway resistance
- restricting spinal motion is necessary
What are 3 reasons to avoid over ventilation?
- Increases intrathoracic pressure and impedes venous return, thus reducing filling of the heart between compressions, reducing blood flow generated by the next compression, and reducing coronary perfusion and cerebral blood flow
- Causes air trapping and barotrauma in children with small airway obstruction
- Increases risk of regurgitation and aspiration in children without an advanced airway
When is a low flow-inflating bag (anesthesia bag) more beneficial than a self-inflating bag?
When a child has spontaneous breathing is can be difficult to time the compression of a self inflating bag with the child’s breaths and miss-timing it can cause regurgitation, coughing, laryngospasm, or gastric inflation.
Therefore a low flow-inflating bag may be more beneficial b/c they can provide CPAP and the flow can be manipulated to the needs of the child.
These bags are typically used in the intensive care unit, delivery room, and operating room.
Causes of gastric inflation during artificial ventilations
- partial airway obstruction
- high airway pressures are needed, such as in a child with poor lung compliance
- the BVM rate is too fast
- the tidal volume is too much
- the Peak inspiratory pressure created is excessive (more than 30 cm H20)
- the child is unconscious or is in cardiac arrest (b/c the gastro-esophageal sphincter opens at a lower than normal pressure)
How much suction is provided with a wall mounted VS portable suction device?
How much force is typically needed to remove secretions?
Wall Mounted = more than -300 mmHg
Portable = varies by machine but is definitely way less than 300 and may not be adequate when patient is large or secretions are thick/copious
Typically at least a suction power of -80 to -120 mmHg is needed to remove secretions
When should you use soft vs rigid catheters for suctioning?
Use a soft catheter when secretions are thin or for suctioning an ET or trach tube.
Use a rigid catheter when suctioning THICK secretions
What things should you be sure to monitor while suctioning?
- Heart rate
- O2 Sat
- clinical appearance
You may need to give O2 and ventilations before and after secretions to avoid hypoxia.
Typically you should not suction for longer than 10 seconds but when secretions are blocking an airway so bad you may need to go over as you wont be able to give vents and O2 without the removal of large amounts of fluids
Where should the tip of the OPA land when placed and sized correctly?
How should you size the OPA and what can happen if it is too large or too small?
A correctly sized and placed OPA should land the tip at the angle of the jaw which should align with the glottis opening.
To size an OPA the tip should extend from the corner of the mouth to the angle of the jaw
If it is too LARGE it can block the airway or cause trauma to the laryngeal structures (& soft tissue)
If is is too SMALL it can push the tongue into the back of the throat
(Remember they recommend to use a tongue depressor to push the tongue down before inserting, this replaces the need to insert at a 45 or 90 degree angle and then twisting into place)
What 3 clinical situations should you automatically think to give a child O2 supp?
- resp compromise (distress/failure/arrest)
- Shock
- AMS
REMEMBER to try to get a humidifier attached asap to prevent airway dryness (don’t think this is on truck)
What considerations should you have when it comes to giving O2 to a conscious child or infant?
Sometimes giving O2 supp can freak the child out more b/c the equipment can be scary, this will cause an increase in O2 consumption secondary to agitation.
Weigh the risk vs reward/need and consider letting the parent introduce the O2 equipment or if one method agitates the child try a different less aggressive one like nasal cannula or blow by technique
What are considered low-flow O2 delivery systems vs high-flow O2 delivery systems?
LOW-FLOW O2 DELIVERY SYSTEMS: (22-60% O2, typically used when child is relatively stable and require minimal aid)
- NASAL CANNULA:
a) offers O2 concentration of 22%-60%
b) Recommended flow rate is 0.25 to 4Lpm
c) the exact inspired O2 concentration cannot be determined alone by the flow rate b/c other conditions affect it such as the child’s size, inspiratory flow rate, volume inspired, Naso or Oro volume, Nasal or Oro resistance. - SIMPLE OXYGEN MASK
a) offers O2 concentration of 35%-60%
b) recommended flow rate is 6 to 10 Lpm
c) this does not offer as much O2 concentration as a non-rebreather b/c there are not ports that close off when the pt is breathing in to prevent room air from entering. I.E. this will deliver mixed room air and O2 line the nasal cannula
HIGH_FLOW O2 DELIVERY SYSTEMS: (O2 concentration delivery of over 60% at a minimum of 10 Lpm, typically given to critical pts in shock or resp distress)
- NON-REBREATHER:
a) an O2 concentration of 95% can be reached with a flow rate of 10-15Lpm and a tight seal on face - HIGH FLOW NASAL CANNULA:
a) for adolescents and older the 4Lpm can be turned up to 40+ Lpm titrated to effect
b) keep in mind though that this will still deliver mixed room air and O2 from the compressed source
At what flow rate should a nebulizer be set at?
5-6 Lpm
How should you tell the child to breath when administering a MDI with a spacer device?
After pressing on the inhaler to release the medicine, have the child breath normally for 3-5 breaths and then hold their breath for 10 seconds on the last breath
What are 2 things you should look at for discrepancies in what the Pulse Ox may be reading at?
There may be a malfunction if the heart rate the pulse ox is saying does not match the actual pts heart rate
There may be a malfunction if the O2 sat does not match the presentation of the child
What are 6 situations when the Pulse Ox reading may be inaccurate?
- cardiac arrest
- shock or hypovolemia
- motion, shivering, or bright overhead light
- problem with the skin probe interface
- misaligning the sensor with light source
- cardiac arrhythmias with low cardiac output
The definition of shock does not require the presence of ______?
Hypotension!
The definition of shock does not require the presence of HYPOTENSION, shock can be present with a normal, increased, or decreased systolic blood pressure.
(this is b/c by definition it is when tissue perfusion does not meet metabolic demands and tissue oxygenation)
