Peds Crisis Flashcards
Air Embolism s/s
drop in ETCO2
hypoxia
hypotension
mill-wheel murmur
Air Embolism treatment
LLD + Tburg 100% FiO2 Flood field, stop all insufflation, N2O etc Central Line + Aspirate CPR 100 - 120/m
crani case - compress jugular veins
epi 1 - 10mcg/kg; epi 0.02-1 mcg/kg/m
Anaphylaxis s/s
hypotension
tachycardia
rash, bronchospasm
Anaphylaxis tx
- 100% FiO2
- treat hypotension w/fluids - 10 - 30 mL/kg
- pressors - epi 1-10 mcg/kg, vasopressin 10 mu/kg
- diphenhydramine 1 mg/kg or pepcid 0.25 mg/kg
- methylprednisone 2 mg/kg
- albuterol 4 - 6 puffs
Anterior mediastinal mass airway collapse
oxygen 100%
CPAP/PEEP
lateral/prone
rigid bronch
anterior mediastinal mass CV collapse
Increase O2 to 100% Give fluid bolus Reposition to lateral or prone Ask surgeon for sternotomy and elevation of mass Consider ECMO
bradycardia definition
< 30 days = < 100
<1 yr = <80
> 1 yr < 60
bradycardia + hypotension
chest compressions
epi 10 mcg/kg
bradycardia (no hypotension)
100% oxygen
fix ventilation
vagal - atropine 0.01 mg/kg
CCB overdose
cacl 10 - 20 mg/kg IV
ca gluconate 50 mg/kg IV
BB overdose
glucagon 50 mcg/kg
bronchospasm s/s
drop in ETCO2
drop in O2
airway pressure increases
shark fin
bronchospasm tx (intubated pt)
Increase FiO2 to 100%
1. Auscultate the chest:
• Equal breath sounds?
• Endobronchial ETT?
• Wheezing?
2. Check ETT:
• Kinked?
• Secretions/blood in ETT? Needs suctioning?
3. albuterol 2-10 puffs
4. deepen anesthetic
5. ketamine 1-2 mg/kg IV
6. EPI 1-2 MICROgrams/kg IV (MAX 1 mg)
7. steroids: methylprednisolone 2 mg/kg IV(MAX 60 mg) or dexamethasone 0.15-0.25 mg/kg(MAX 16 mg)
8. Consider chest radiograph
9. For refractory bronchospasm, consider magnesium
sulfate 50-75 mg/kg (MAX 2 grams) bolused over 20
minutes, (CAUTION, may cause hypotension)
bronchospasm tx (non-intubated)
- Administer supplemental oxygen
- Auscultate the chest, differentiate from
stridor/extrathoracic airway obstruction - albuterol (with spacer) 2.5-5 mg. If severe, 5-20 mg/hr inhaled
- chest radiograph
- Consider IV steroids:
methylprednisolone 1 mg/kg IV
or dexamethasone 0.15-0.25 mg/kg - EPINEPHrine
1-2 MICROgrams/kg IV (MAX 1 mg) or
10 MICROgrams/kg
subcutaneous/intramuscular (MAX 0.5 mg)
Cardiac Arrest
Increase O2 to 100%. Turn off anesthetics. Start timer
1. If ETT, 100-120 chest compressions/min + 10 breaths/min. Avoid hyperventilation
2. If no ETT, 15:2 compression
3. For chest compressions, maximize EtCO2 > 10 mmHg
• Use sudden increase in EtCO2 for ROSC, Do NOT stop compressions for pulse check
4. Obtain defibrillator. Attach pads. If VF/VT, shock 2 joules/kg. Continue chest compressions for 2
minutes
cardiac arrest part 2
If still in VF/VT, shock 4 joules/kg q2 min (up to 10 joules/kg on subsequent shocks)
-Resume chest compressions immediately regardless of rhythm
- EPINEPHrine 10 MICROgrams/kg IV q 3-5 min while in arrest (MAX 1 mg)
• If still no ROSC after second dose of EPINEPHrine, activate ECMO (if available)
- Check pulse & rhythm q 2 min during compressor change
-Lidocaine 1 mg/kg bolus (MAX 100 mg); may repeat (total: 2 doses) OR amiodarone 5 mg/kg
bolus; may repeat (total: 3 doses)
H&Ts
hypoxia hypotension tension pneumothorax hypovolemia hypothermia acidosis hyperkalemia cardiac tamponade hypoglycemia thrombosis toxin trauma
difficult airway unexpected
100% fio2 call for help - surgical airway cart, rigid bronch OPA/NPA/LMA attempts OG decompression reverse?
after 2 attempts change providers; consider alternative approaches
macroglossia (beckwith-wiedemann, Pierre robin, mediastinal mass - prone or lateral)
younger kids difficult airway
rigid bronch
older kids difficult airway
jet ventilation or cricothyrotomy or trach
hyperkalemia
s/s tall peaked T waves heart block sine wave v fibb/asystole
hyperkalemia treatment
- CPR/PALs if unstable
- 100% fio2
- ca gluconate 60 - 100 mg/kg OR cacl 20 mg/kg
- switch to NS
- dextrose 1 g/kg and insuline 0.1 units/kg
- albuterol
Hyperkalemia other treatments
bicarb 1 mEq/kg
lasix 1 mg/kg
terbutaline 10 mcg/kg
dopamine
2 - 20 mcg/kg/m
epinephrine
1 - 10 mcg/kg
0.02 - 1mcg/kg/m
cacl
10 - 30 mg/kg or caglu 50 mg/kg
phenylephrine bolus
1 mcg/kg
phenylephrine gtt
0.1 - 2 mcg/kg/m
ICP increased
- Secure airway
- Sedation prior to transport
- PaCO2 30 - 35 and PaO2 > 80
- HOB @ 30
- hypertonic saline 3% 1-5 mL/kg over 20 m
- mannitol 1 g/kg
- lasix 1 mg/kg
transfusion reactions
- epi 1 mcg/kg
- diphenhydramine 1 mg/kg
- methylprednisolone 2 mg/kg
tension pneumothorax
14 - 16G for teens
18 - 20 G for infants
tachycardia definition
> 220 for infant, > 180 for a child
tachycardia treatment
100% fio2
vagal
adenosine for SVT 0.1 mg/kg
synchronized cardiovert 1 J/kg
wide complex tachycardia
amiodarone 5 mg/kg
torsades
magnesium 50 mg/kg (max 2 g)
lidocaine 1 mg/kg IV (max 100 mg)
pulmonary HTN
iNO 20 - 40 ppm
- deepen sedation
- paralyze
- if hypotensive, vasopressin 0.03 u/kg
MI
oxygen 100% (anemia, hypotension?) - drop demand on the heart - nitro 5 mcg/kg/m -heparin 10 u/kg
massive hemorrhage
O - PRBCs and AB + plasma until cross matched
- monitor for hyperkalemia
- monitor calcium
- warm PRBCs and FFP
Hct < 21%
4 mL/kg PRBC increase Hct by 3%
Plt < 50 k
10 mL/kg apheresed platelets increases plt by 30 - 50 k
INR > 1.5
10 mL/kg plasma increases coags by 20%
fibrinogen < 100 mg
10 mL/kg cryo increases it by 30 - 50
MH
- attach charcoal filter
- oxygen 10 L/m
- hyperventilate
- dantrolene 2.5 mg/kg
dantrolene
20 mg/vial
mix w/60 mL
max dose 10 mg/kg
ryanodex
250 mg in 5 mL
LA toxicity
100% oxygen
- midaz 0.1 mg/kg
- epi 1 mcg/kg
- avoid prop/vasopressin/CCB/BB
intralipid therapy
20% @ 1.5 mL/kg
gtt @ 0.25 mL/kg/m
repeat q3-5m
double if BP remains low
continue for 10m once BP stablizes
max IL therapy
10 mL/kg over first 30m
laryngospasm s/s
inspiratory stridor
accessory muscles
drop in oxygen, HR
loss of end tidal
laryngospasm tx
- oxygen + remove stimulus
- positive pressure + jaw thrust
- propofol bolus
- succinylcholine 0.1 mg/kg IV or 4 mg/kg IM
- atropine 0.02 mg/kg IV or 0.04 mg/kg IM
- DVL and ETT
what are the RF for cardiac arrest? (6)
- cardiac surgery
- < 1 mo old
- ASA >= 3
- prematurity
- CHD
- emergency
heart disease r/t cardiac arrest
AS
CM
single ventricle
54% arrested in a general operating room
name the drug etiologies of cardiac arrest during anesthesia
- OD
- Sux
- Neo dysrhythmia
- Med swap
- drug rxn
- LA
- inadequate reversal of paralytic
- opioid respiratory depression
name the CV causes of cardiac arrest
hypovolemia hemorrhage inadequate volume administration hypeerK, hypoCa, hypoglucosee vagal (abd. eye. neck. heart)
ROSC
return of perfusing rhythm and BP for 20 mins post-arrest
full recovery after OR cardiac arrest in kids =
48 - 61%
asystole in the OR -
most likely an initial rhythm in response to vagal stimulation
reversal of vagal stimulation
glyco 10 - 20 mcg/kg
atropine 10 - 20 mcg/kg
insufflation, carotid massage
predictor of mortality
CPR > 15m
when should ECMO be initiated
10 m after failed resuscitation
hypotension for a neonate
<60 sbp
infant hotn
< 70 sbp
hotn child
SBP <70 + 2xage
hotn for > 10y
SBP < 90
where do you check pulse in a newborn
umbi
where do you check pulse for infant
brachial
child pulse check?
carotid or brachial
what drugs can go down ett
naloxone atropine vasopressin epi lido
2 - 5 x IV dose + 5mL flush
defibb
vtach
vfibb
cardiovert
afibb
afluttere
svt
how much do you flish drugs during cardiac arrest
0.25 mL/kg
5 mL = infant
10 mL = child
preferred site for an IO
anterior tibia, below growth plate
afteer ROSC -
avoid hyperthermia, hyperglycemkia, seizures
