PICU/ER Flashcards
What type of shock do you suspect if there is evidence of low systemic vascular resistance (SVR) and maldistribution of blood flow (i.e. vasodilation and warm skin)?
Distributive shock
Name three commonly cited examples of distributive shock?
- Sepsis
- Anaphylaxis (causing loss of vasomotor tone)
- Neurogenic/ spinal cord injury (causing loss of vasomotor tone)
When do you suspect cardiogenic shock?
Suspect cardiogenic shock when there are signs of poor perfusion and pulmonary or systemic venous congestion (i.e. increased WOB, grunting respirations, distended neck veins, hepatomegaly)
What vasopressors do you want to use when you have a patient who is in hypotensive vasodilated (WARM) shock?
Norepinephrine
[OR high dose dopamine (10-15) OR high dose epinephrine (0.1-0.3)]
What vasopressors do you want to use when you have a patient in hypotension vasoconstricted (COLD) shock?
Low dose Epinephrine (0.01 - 0.1)
[low dose dopamine (5-10) could also work]
What vasopressor is the agent of choice for a child with fluid-refractory septic shock who presents with impaired perfusion but adequate blood pressure
Dopamine
What does dopamine do at low, intermediate, and high doses?
Low dose = improves splanchnic and renal blood flow
Intermediate dose = improves cardiac contractility
High dose = SVR is increased
Name 4 examples of obstructive shock
- Ductal-dependent (LV outflow tract obstruction)
- Tension pneumothorax
- Cardiac tamponade
- Pulmonary embolism
What should your CPR rate be? (# of chest compressions per minute)
At least 100 per minute
What should the depth of your chest compressions be?
At least 1/3 of the AP diameter (2 inches in children, 1.5 inches in infants)
When should you rotate compressors during CPR?
Rotate compressors every 2 minutes
How long should pauses be during CPR?
Minimize and attempt to limit pauses to less than 10 seconds
What is the ratio of chest compressions and breaths for CPR?
For children and infants, you provide 30 compressions: 2 breaths for single rescuer and 15 compressions: 2 breaths for more rescuers
With an advanced airway, how often do you give breaths during CPR?
1 breath every 6-8 seconds
Breaths should last for 1 second, and look for chest rise
When should you start thinking of the possible need for vasopressors or stress-dose hydrocortisone?
They should be immediately available if the shock is fluid refractory or adrenal insufficiency is suspected
What is the role of vasopressin in the sepsis PALS algorithm?
Vasopressin infusion may be useful in the setting of norepinephrine-refractory shock. Vasopressin antagonizes the mechanisms of sepsis-mediated vasodilation. It acts synergistically with endogenous and exogenous catecholamines in stabilizing BP but it has no effect on cardiac contractility
If you are managing a child under the sepsis algorithm and you are considering that the child is adrenally insufficient (fluid-refractory and dopamine- or norepinephrine- dependent shock), how will you manage?
- Draw baseline cortisol
2. Give IV hydrocortisone 2 mg/kg bolus (max: 100 mg)
What is the mainstay/ first-line treatment for anaphylaxis?
IM Epinephrine (1:1000) 0.01 mg/kg
What are other (less important) treatments in the management of anaphylaxis?
- Antihistamine (H1 blocker like Benadryl or H2 blocker like Ranitidine or Famotidine)
- Corticosteroids (Prednisone or Methylpred)
- Salbutamol (Ventolin)
- Trendelenburg position
Why is milrinone often the preferred drug of choice when dealing with children with cariogenic shock?
Milrinone (a phosphodiesterase enzyme inhibitor) will improve contractility (increase cardiac output) and will reduce peripheral vascular resistance (decrease afterload)
What mL/kg fluid boluses should be administered in a child you are wondering may be in cardiogenic shock?
5 to 10 mL/kg NS bolus over 10-20 minutes, repeat PRN
What is the specific management for a tension pneumothorax?
Needle decompression followed by tube thoracostomy
What is the pathophysiology of a duct-dependent lesion?
Ductal-dependent pulmonary blood flow:
- Severe obstruction to pulmonary blood flow form the R ventricle, so all the pulmonary blood flow comes from the aorta through the PDA
- When ductus closes, the infant becomes profoundly cyanotic and hypoxemic
Ductal-dependent systemic blood flow:
- Obstruction to the outflow through or from the left side of the heart into the aorta
- Systemic blood flow comes from the R ventricle and pulmonary artery into the aorta
- When ductus closes, the child has poor systemic perfusion + shocky
What is the mainstay treatment for a child in obstructive shock due to a ductal-dependent lesion?
Continuous infusion of prostaglandin E1 (PGE1)
What sites should be used for an IO?
Proximal tibia
- Identify the tibial tuberosity, the site should be 1-3 cm below and medial to the bony prominence
Other sites: distal tibia just above the medial malleolus, distal femur, ASIS
What are 4 contraindications to an IO insertion?
- Fractures or crush injuries near the access site
- Conditions with fragile bones (i.e. osteogenesis imperfect)
- Previous attempts to establish access in the same bone
- Infection is present in the overlying tissues
Symptomatic bradycardia in children is usually the result of what?
Progressive hypoxemia and respiratory failure
What are signs of cardiopulmonary compromise?
Hypotension
Acutely altered mental status
Signs of shock
What does first degree AV block mean?
A prolonged PR interval representing slowed conduction through the AV node
What does second degree Mobitz Type 1 block mean?
Mobitz Type 1 AV block (Wenckebach) occurs at the AV node, progressive prolongation of the PR interval until an atrial impulse is not conducted to the ventricles. The P wave corresponding to that atrial impulse is not followed by a QRS complex. The cycle repeats.
What does a second degree Mobitz Type 2 block mean?
Mobitz Type 2 AV block occurs below the level of the AV node. It is characterized by non conduction of some atrial impulses to the ventricle without any change in the PR interval of the conducted impulses.
What are the two AV blocks that can be present in healthy children?
First degree AV block and second degree Mobitz Type 1 AV block (Wenckebach phenomenon)
What is the epinephrine dose we use in the PALS bradycardia algorithm?
Epinephrine IV/IO 0.1 mL/kg of the 1:10,000
Repeat every 3-5 minutes as needed
In which situations would you want to give atropine over epinephrine in the PALS bradycardia algorithm?
Increased vagal tone, cholinergic drug toxicity (e.g. organophosphates), complete AV block, symptomatic AV block
In which situations should you consider cardiac pacing in the PALS bradycardia algorithm?
Selected cases of bradycardia caused by complete heart block or abnormal sinus node function
What are the two most common potentially reversible causes of bradycardia?
Hypoxia and increased vagal tone
Name three narrow complex (QRS complex less than 0.09 seconds) tachyarrhythmias?
Sinus tachycardia
Supra ventricular tachycardia (SVT)
Atrial flutter
Name two wide complex (QRS complex more than 0.09 seconds)
Ventricular tachycardia (VT) Supraventricular tachycardia (SVT) with aberrant intraventricular conduction
Typically how quick is the heart rate in a child or infant in probable SVT?
Infants: heart rate is usually greater or equal to 220
Children: heart rate is usually greater or equal to 180
What conditions and agents predispose a patient to torsades de pointes?
Long QT syndromes (often congenital or inherited)
Hypomagnesemia
Hypokalemia
Antiarrhythmic drug toxicity
Other drug toxicities (TCA, CCB, phenothiazines)
What PALS algorithm do you initiate in a child who is tachycardic and who does not have a pulse?
Paediatric Cardiac Arrest Algorithm
How do you manage a probable SVT in the paediatric patient with a pulse but poor perfusion?
Give adenosine 0.1 mg/kg rapid bolus (slam) along with the use of a saline flush
If adenosine not effective, synchronized cardioversion
Can consider vagal maneuvers if child is stable or while preparations are being made for synchronized cardioversion
What kind of cardioversion do you use in the paediatric tachycardia with a pulse and poor perfusion algorithm? What dose do you use?
Synchronized cardioversion 0.5-1 Joule/kg; if not effective increase to 2 Joules/kg
How do you treat possible ventricular tachycardia with a pulse and poor perfusion?
Synchronized cardioversion 0.5-1 Joule/kg; if not effective increase to 2 Joules/kg
Name the 6 Hs (causes of cardiac arrest that are reversible)
- Hypoxia
- Hypovolemia
- Hypothermia
- Hypo/hyperkalemia
- Hypoglycemia
- Hydrogen Ion (acidosis)
Name the 5 Ts (causes of cardiac arrest that are reversible)
- Tension pneumothorax
- Cardiac tamponade
- Toxins
- Pulmonary thrombosis
- Coronary thrombosis
What does pulseless electrical activity mean?
Term describing any organized electrical activity (not VF, VT, or systole) on an ECG or cardiac monitor that is associated with no palpable pulse
Should ventilation bags used for CPR have or have not a pop up valve?
If the child’s lung compliance is poor, airway resistance is high, or CPR is needed, the automatic pop-off valve may prevent delivery of sufficient tidal volume resulting in inadequate ventilation and chest expansion. Ventilation bags used in CPR should not have a pop-off valve or the valve should be twisted in the closed position
What are your anatomic landmarks for a needle decompression?
2nd intercostal space, mid-clavicular line
What does SAMPLE history stand for?
Signs/symptoms Allergies Meds PMHx Last Meal Events leading up to present illness/injury
During a resuscitation, what should you always ask for along with the vitals?
Temperature
POCT glucose reading
What is the endotracheal tube size formula for children?
ETT size (uncuffed) = age/4 +4
Name three examples of disordered control of breathing?
Increased ICP
Poisoning/ Overdose
Neuromuscular disease
Name 3 upper airway obstruction emergencies
Croup
Anaphylaxis
Aspirated FB
Name 2 lower airway obstruction emergencies
Bronchiolitis
Asthma
Name 2 lung tissue disease emergencies
Pneumonia
Pulmonary edema
What are the parameters that indicate response to shock therapy?
Heart rate BP Distal pulses and capillary refill Urine output Mental status
What does DOPE stand for?
Used in the context of an intubated patient who deteriorates
Displacement
Obstruction
Pneumothorax
Equipment Failure
What does compensated shock mean?
Systolic BP is within the normal range but there are signs of inadequate tissue perfusion
What is a key sign of hypotensive shock?
A key clinical sign of deterioration is a change in level of consciousness as brain perfusion declines
Name 4 secondary causes of bradycardia
- Hypoxia
- Acidosis
- Hypothermia
- Drugs
Without a definitive airway, what is the rate that you should be bagging a patient with bag-mask ventilation?
1 breath every 3-5 seconds
What is the consensus definition of hypoglycemia in a 1) neonate and 2) infant, children, and adolescents
Neonates
When is bicarb indicated?
Metabolic acidosis that is caused by significant bicarb losses from a renal or GI source (non-anion gap metabolic acidosis)
