Resuscitation Flashcards
1
Q
define rapid sequence intubation (RSI)
A
sequential administration of an induction agent and neuromuscular blocking agent to facilitate intubation
2
Q
equipment needed for airway management in ED
A
O2 source and tubing Ambu bag mask with valve, various sizes and shapes oropharyngeal airways, NP airways suction - catheter and source pulse oximetry CO2 detector endotracheal tubes laryngoscope blades and handles syringes magill forceps stylets tongue blade water soluble lubricant alternative or rescue device: video laryngoscopy, LMA, etc. surgical cric kit medications for topical airway anesthesia, sedation, and RSI
3
Q
how to preoxygenate
A
administer 100% O2 for 3 mins using a non-rebreather with 15L/min of O2
4
Q
ways to improve preoxygenation
A
elevate HOB to 20-30 degrees
short period of non-invasive positive pressure ventilation
use high flow nasal cannula or optiflow during apneic period
5
Q
patient positioning fo rintubation
A
lower the neck and extend the atlanta-occipital joint (sniffing position) to align the oropharyngeal-laryngeal axis
padding under the shoulders improves visualization
ear should be aligned with sternal notch
6
Q
common causes/ situations associated with aspiration
A
iatrogenic BVM NG tube placement neuromuscular paralysis medical conditions trauma bowel obstruction obesity overdose pregnancy hiatus hernia seizures`
7
Q
conditions associated with false negative capnographic or colorimetric CO2 readings
A
low pulmonary perfusion - cardiac arrest, inadequate chest compressions duringg CPR, massive PE
massive obesity
tube obstruction- secretions, blood, foreign body
8
Q
conditions associated with false positive capnographic or colorimetric CO2 readings
A
recent ingestion of carbonated beverage - will not persist beyond 6 breaths
heated humidifier, nebulizer or ETT epinephrine -transient
9
Q
steps in RSI
A
- monitors, IV access, oximetry, capnography
- assess airway and physiologic status to plan procedure
- prepare equipment
- pre oxygenate
- pretreatment agents prn
- induce with sedative agent
- give NM blocking agent immediately after induction
- BVM only if hypoxic, otherwise apneic oxygenation
- intubate trachea
- confirme placement and secure tube
- postinubation sedation nd low tidal volume (6cc/kg) management
10
Q
induction dose of etomidate
A
0.3-0.5 mg/kg IV
11
Q
benefits of etomidate
A
decreases ICP
decreases IOP
neutral BP
12
Q
caveats of using etomidate
A
myoclonic jerking and vomiting in awake patients
decreased cortisol
13
Q
induction dose of propofol
A
0.5-1.5mg/kg IV
14
Q
benefits of using propofol
A
anticonsulvinga
antiemetic
decreases ICP
15
Q
caveats of using propofol
A
no analgesia
hypotension
apnea
16
Q
induction dose of ketamine
A
-2mg/kg IV
17
Q
benefits of using ketamine
A
dissociative amnesia
analgesia
bronchdilators
18
Q
caveats of using ketamine
A
increased secretions
emergence phenomenon
increased BP
19
Q
succinylcholine complications and contraindications
A
hyperkalemia in patients with: burns >5 days old, denervation injury > 5days old, significant crush injuries > 5 days old, severe infection > 5 days old, pre-existing myopathies, preexisting hyperkalemia
fasciculations
transient increpad intragastric, intraocular and ICP
masseter spasm alone or with MH
bradycardia
prolonged apnea with pseudocholinesterase deficiency or myasthenia
20
Q
intubating dose of rocouronium
A
1mg/kg IV
21
Q
succinylcholine intubating dose
A
1.5mg/kg IV
22
Q
intubating dose of vecuronium
A
0.08-0.15 mg/kg IV
23
Q
side effect of rocuronium
A
tachycardia
24
Q
how much does succinylcholine make serum potassium rise
A
0.5
25
what to suspect if unexplained rapid fever with muscle rigidity, acidosis, or hyperkalemia occurs after succinylcholine
malignant hyperthermia
26
treatment of malignant hyperthermia
dantrolene 2.5mg/kg IV
| temperature control
27
reversal agent for nondepolarizing agents
suggamadex- works by encapsulating circulating plasma roc, 2-4mg/kg
neostigmine- not effective unless some degree of spontaneous recovery, cholinergic effects
28
factors suggesting difficult bag valve mask ventilation
```
MOANS
mask seal - ie. beard
obstruction/obesity
aged - older than 55
no teeth
stiffness (Resistance to ventilation)- ie. asthma, COPD, pulmonary edema, restrictive lung disease, term pregnancy
```
29
factors suggesting difficult airway
```
obesity,
a short neck,
small or large chin,
buckteeth,
high arched palate
any airway deformity due to trauma, tumor, or inflammation.
```
30
airway assessment
LEMONS
Look externally
Evaluate- 3,3,2 rule- distance between incisors, distance of mandible from mentum to hyoid bone, thyromental distance
Mallampatti classification
Obstruction- airway edema, smoke inhalation, teeth ,trauma, etc.
Neck ROM
Sat - lower sat = less safe apnea time for intubation
31
Mallampatti classification
I: Faucial pillars, soft palate, and uvula can be visualized
II: Faucial pillars and soft palate can be visualized, but the uvula is masked by the base of the tongue
III: Only the base of the uvula can be visualized
IV: None of the three structures can be visualized.
32
initial ventilator settings in the ED
```
mode: assist-control
FiO2: begin with 100% O2
tidal volume: 6mL/kg (ideal body weight)
RR: 12
inspiratory flow rate: 60L/min
insp:exp ratio 1:2 or 1:3
PEEP: 5cm H2O and titrate to 10
```
33
ventilation goals
```
PaO2: 60-90mmHg
PaCO2: 40mmHg
pH: 7.35-7.45
FiO2: 40-60%
inspiratory peak pressure <35cm H2O
```
34
dose of fentanyl during mechanical ventilation - initial bolus and starting infusion
bolus - 1-2mcg/kg IV
| infusion- 05.-1mg/kg/h
35
dose of remifentanyl during mechanical ventilation initial bolus and starting infusion
bolus- 1.5mcg/kg/IV
| infusion 0.5-1mcg/kg/h
36
dose of midazolam during mechanical ventilation initial bolus and starting infusion
0. 05mg/kg IV
| 0. 025 mg/kg/h
37
dose of propofol during mechanical ventilation initial bolus and starting infusion
0.5mg/kg IV
| 20-50mcg/kg/min
38
dose of ketamine during mechanical ventilation initial bolus and starting infusion
0. 5-1mg/kg IV
| 0. 5mg/kg/h
39
decision to intubate based on
1. failure to maintain or protect airway
2. failure of ventilation or oxygenation
3. patient's anticipated clinical course and likelihood of deterioration
40
how to assess if pt can maintain patent airway
ability to swallow or handle secretions
pt LOC
ability to phonate
41
airway maneuvers to maintain patent airway
reposiion
chin lift
jaw thrust
insertion of oral or nasal airway
42
how to assess pt ability to ventilate/ oxygeation
pt general status
O2 saturation
ventilatory pattern
43
what is needed in preintubation assessment
evaluate pt for difficult intubation, difficult BMV , placement of and ventilation with an extraglottic device, cricothyrotomy
44
predictors of difficult extraglottic device use (ie. LMA)
```
RODS
restricted mouth opening
obstruction/ obesity
distorted anatomy
stiffness (resistance to ventilation)
```
45
predictors of difficult cricothyrotomy
```
SMART
surgery
mass (abscess, hematoma, scarring)
access/anatomy problems (obesity, deem)
radiation
tumor
```
46
how to confirm placement of ETT
EtCO2 - presence of CO2 after six manual breaths indicates tube is in airway (although not necessarily trachea)
if EtCO2 not available - can use POCUS over cricothyroid membrane or upper trachea
aspiration of air through the ETT cuff down - soft walls of esophagus will collapse and occlude ETT, whereas aspiration after tracheal placement is easy
put bougie down ETT- should stop once hits right main stem bronchus- if goes down too far in the stomach
secondary means: physical exam, oximetry, XRAY
47
define crash airway
intubation done in patient agonal, near death or in circulatory collapse = immediate intubation, no drugs
48
if airway is not crash, what is next step
determine difficulty of airway
49
if airway is not crash, not difficult airway what is next step
RSI and attempt intubation
50
what to do if more than one intubation attempt is required
monitor SpO2 continuously and if saturation falls below 90%, BMV performed until SpO2 recovered for another attempt
51
define failed airway
can't intubate, can't ventilate situation (ie. intubation fails and can't BMV)
OR
three unsuccessful attempts at laryngoscopy
52
what to do with failed airway
can try EGD while setting up for cricothyrotomy as long as it doesn't delay cric
FAILED AIRWAY = CRIC
53
potential pretreatments for RSI
reactive airways: salbutamol 2.5mg by neb, or lidocaine 1.5mg/kg IV
CV disease: fentanyl 3mcg/kg to mitigate SNS
elevated ICP: fentanyl ^^^
54
steps of RSI (seven Ps)
```
seven Ps
preparation
preoxygenation
pretreatment
paralysis with induction
positioning
placement of tube
postintubation mgmt
```
55
whats done during preparation step of RSI
pt assessed for difficult airway
intubation planned: drug dosages, sequence of drugs, tube size and laryngoscopic type, blade and size
all equipment assembled
pt on monitors, 2 IVs
rescue plan for intubating failure made known to team
56
whats done during preoxygenation step of RSI
adminster 100% O2 for 3 mins of normal tidal volume or if time does not allow --> eight vital capacity breaths with high flow O2
57
how to improve preoxygenaiton in obese; what is desaturation time with improvements
head-up position and continuing O2 after apnea (via nasal cannula 5-15mL/min) after motor paralysis and during laryngoscopy until ETT placed; 5.3 mins from 3.5 min
58
how long to wait after neuromuscular blockade given to intubate
45 sec after succinylcholine 1.5mg/kg
60 sec after roc 1mg/kg
equal intubating conditions as long as roc dose between 1-1.2mg/kg
59
positiong for intubation
sniffing position, head elevation
60
whats involved in postintubation management
confirm tube placement with EtCO2
CXR
opioid + sedative (ie. fentanyl 3-5mcg/kg IV, and midazolam 0.1-0.2mg/kg IV )
OR
propofol infusion (5-50mcg/kg/min IV) with supplemental analgesia
only add long acting NMBA if sedation and analgesia fail to control pt adequately or when ventilation is challenging because of muscular activity
61
what is delayed sequence intubation
technique proposed to maximize pre oxygenation in preparation for intubation
ie. useful in agitation/delirium when preoxygenation challenging
uses dissociative doses of ketamine 1mg/kg IV
62
when to do awake oral intubation
difficult airway
63
how to do awake oral intubation
sedative and topic anesthestics administered to permit management of a difficult airway
can use ketamine 0.5mg/kg IV titrated to desired level of sedation and procedural tolerance
can use dexmedetomidine (central acting alpha receptor blocker) alone or with bentos 1mg/kg IV infused over 5-10mins
once pt sedated, topical anesthesia given, gentle direct VL or flexible endoscopic laryngoscopy performed
64
how to treat massetter spasm after succinylcholine
give competitive NMBA- i.e.. roc
65
what is recomnede intubation technique for pt with status asthmaticus
RSI
may be more challenging to bag due to airway resistnace
66
recommended ventilation parameters for pt with status asthma
low tidal volume and RR
high inspiratory flow rate
reducing resp rate important to give adequate exhalation to prevent auto-PEEP and breath stacking
67
hemodynamic consequences of intubation
laryngoscopy and intubating cause release of catecholamines leading to increased BP and HR
relevant in setting of increased ICP, CV diseases( ICH, SAH, aortic dissection or aneurysm, ischemic heart disease)
68
considerations in induction/intubatino in pt with elevated ICP
maintain MAP at 100mmHg or higher to support CPP and prevent secondary injury
RSI agents should dosed to minimize hypotension
etomidate recommended agent, propofol if not hemodynamically compromised
69
considerations in induciton/ intubation of pt with hypotension nd shocks
volume resuscitation prior to induction (isotonic fluid bolus or PRBCs)
reduced dose induction agent administration - etomidate or ketamine only - dose reduced by 50%
pretreatment with per-intubation pressor agents (phenylephrine 50-100mcg IV push)
70
considerations for C Spine precautions in intubation
videolaryngoscopy should be used and if not available ,DL can be used -provides better larygneal views with less neck manipulation
71
effects of positive pressure ventilation on CV system
venous return is diminished, cardiac output falls and there is a decreased pressure gradient between LV and aorta
relative hypotension can occur -exaggerated in patients with hypovolemic or vasodilatory states
72
how does PCV - pressure-controlled ventilation work
set amount of pressure is applied to the airway to expand the lungs for a specified amount of time
target pressure and inspiratory time set by provier
tidal volume and inspiratory flow rate variable based on lung compliance and airway resistance
73
how does volume controlled ventilation work
breath is defined by delivery of a set tidal volume
inspiratory volume and flow rate are set by provider and inhalation ends once a preset tidal volume has been delivered
lung pressure - peak inspiratory pressures and end-inspiratory alveolar pressures vary based on compliance and set tidal volume
74
benefit of PCV
controls pressure delivered so prevents barotrauma, especially important in asthma/COPD to prevent autoPEEP
improved ventilator synchrony in intubated patients with high respiratory drive
75
disadvantage of PCV
tidal volume changes with a cute changes in lung compliance
76
benefit of VCV
ability to control tidal volume and minute ventilation
77
disadvantage of VCV
cannot set pressure, so may cause spikes in peak pressures when lung compliance poor
78
when to use VCV
when need guaranteed delivery of tidal volume
used in ARDS - low tidal volume strategies = decreased mortality
obesity, severe burns
79
when to use PCV
severe asthma, COPD, salicylate tox
80
what is PRVC
pressure regulated volume control - set to deliver specific tidal volume while simultaneously minimizing airway pressure
81
how does ventilatory mode continuous mechanical ventilation (CMV) work, aka assist-control
provides full ventilatory support for patients with little or no spontaneous respiratory activity - will provide continuous delivery of preset breaths (ie. rate of 12 = 1 breath q 5 secs) but if pt makes inspiratory effort will be assisted by ventilator (after this breath timer resets another 5 secs)
82
what is the main challenge with assist control ventilation
patient initiated breaths are not proportional to patient effort, can result in hyperventilatino, air trapping, hypotension, and poor ventilator synchrony
83
how does intermittent mandatory ventilation work
delivers mandatory and spontaneous breaths- mandatory breath at preset rate but breath is synchronized to pt effort - useful for its who are sedated but have weak resp efforts
extra breaths above set rate are proportional to pt effort
84
what are examples of continuous spontaneous ventilation (CSV) and how do they work
PSV- pressure support ventilation - delivers pressure on airway after patient triggered breath - when inhalation stops, pressure support ceases and exhalation proceeds spontaneously - good for spontaneously breathing patients with good resp effort requiring minimal support
CPAP- constant airwpressure throughout resp cycle
BiPAP- alternates between higher pressure during inspiration and lower pressure during exhalation
both CPAP and BiPAP need alert, spontaneously breathing patients with immediately reversible causes of respiratory distress
85
what is PEEP
maintenance of positive airway pressure after passive exhalation
86
benefits of PEEP
increases functional residual capacity, improves oxygenation and decreased intrapulmonary shunting
reduces portions of non aerated lung that my contribute to ventilator induced lung injury
87
adverse effects of PEEP
decreased cardiac output
lung overdistension
pneumothorax
88
contraindications to noninvasive positiv epressure ventilation
```
decreased LOC
lack of respiratory drive
increased secretions
hemodynamic instability
facial trauma/other conditions that prevent mask seal
```
89
what factors predict failure of NPPV at 1 hour of therapy
increased hr
| decreased PaO2/FiO2 ratio
90
if BiPAP applied and no improvement of work of breathing, what adjustments can be made
increased IPAP can reduce hypercarbia by increasing tidal volume and minute ventilation
increased EPAP can improve oxygenation by combating atelectasis and promoting alveolar recruitment
91
initial settings for ventilator in intubated patient
```
tidal volume - 6-8ml/kg of IBW
rate: 12-14 breaths/min
initial pressures: should not exceed 30 cm H2O
FiO2: 1.0 -can titrate down
PEEP: 5cm H2O
```
92
what is the PIP (peak inspiratory pressure)
max pressure in ventilator circuit during a breath cycle
in PCV, PIP = target pressure + PEEP
93
what is Pplat
pressure measured at the end of inspiration as flow in circuit stops, in VCV
94
approach to mechanically ventilated patient whose condition suddenly deteriorates and they are acutely unstable
remove from ventilator and manually bag with 100% O2, examine pt (listen for breath sounds), confirm ETT placement
causes: tension pneumo, auto-PEEP (breath stacking)
if improves after disconnect from ventilator, likely autoPEEP
if doesn't improve, needle decompression for presumed tension pneumothorax
if after this remains unstable, consider PE
95
approach to mechanically ventilated patient whose condition suddenly deteriorates and they are not acutely unstable
confirm ETT placement, evaluate airway pressures
if elevated PIP and Pplat- indicates decreased resp system compliance ie. worsening lung compliance from underlying pathology, pneumothorax, abdominal distension, inadequate sedation/vent dyssynchorny
if elevated PIP only - indicates increased airway or circuit resistance, ie. worsening airway obstruction from underlying pathology, new bronchospasm (eg. allergic rxn), ETT obstructed, ventilator circuit obstruction
96
considerations when ventilating pt with AECOPD
aim to minimize autoPEEP by decreasing airway resistance with bronchodilators and corticosteroids
adequate oxygenation achieved while minimizing barotrauma by reducing minute ventilation - permissive hypercapnia
I:E ratio 1:4
PEEP -5
97
considerations when ventilating status asthmaticus
low resp rate, maximize expiratory time
| VCV with tidal volume 6-8cc/kg, RR of 10-15, and little or no PEEP
98
consdierations when ventilating patient with ARDS
tidal volume below 7cc/kg of IBW and Pplat of less than 31 confer mortality benefit
99
what is gold standard for BP and when to use it
arterial line
used for persistent/recurrent hemodynamic instability, monitoring of conditions or treatments that result in large fluid or bp shifts, frequent arterial blood sampling and expected inaccuracies in noninvasive bp mgmt (eg. obesity/ dysrhythmias)
100
when does pulse oximetry fail
methemoglobinemia and carboxyhemoglobinemia
| can only detect oxy and deoxyHb, reads others as oxyHb
101
how does colorimetric EtCO2 work
purple < 4mmHg CO2
tan 4-15
yellow > 20
102
phases of EtCO2 monitor
3 ______4
/ \
_1__2/ \ 5___
1-2: CO2 free portion, inspiratory phase
2-3: transition from inspiratory to expiratory, mixing of dead space and alveolar gas
3-4: alveolar plateau - CO2 rich alveolar fas in breath system and tends to slope gently upward toward uneven emptying of alveoli
4- max CO2 concentration in each breath - # on the monitor
4-5 : inspiratory downstroke - nearly vertical drop to baseline
103
EtCO2 - what does elevation of baseline from 1-2 represent
3 ______4
/ \
_1__2/ \ 5___
rebreathing of CO2 - as in increased dead space in the circuit or contamination of the sensor
104
EtCO2- what does prolongation of 2-3 represent
3 ______4
/ \
_1__2/ \ 5___
obstruction to expiratory gas flow, ie. obstructive lung disease, bronchospasm, kinked ETT or leaks in the breathing system
105
EtCO2 what does an increased 3-4 mean
3 ______4
/ \
_1__2/ \ 5___
obstruction to expiratory gas flow, ie. obstructive lung disease, bronchospasm, kinked ETT or leaks in the breathing system
normal physiologic variant in pregnancy
106
EtCO2 what does a dip in the 3-4 alveolar plateau mean
3 ______4
/ \
_1__2/ \ 5___
spontaneous respiratory effort during mechanical ventilation as in hypoxia, hypercarbia, or inadequate anesthesia
107
EtCO2 what does a prolongation of Phase 4-5 represent
3 ______4
/ \
_1__2/ \ 5___
endotracheal cuff leaks
108
what is gold standard to confirm intubation of trachea
EtCO2 or direct visualization of tracheal rings on bronchoscopy
109
how does EtCO2 detect difference between patients with and without DKA
with DKA, HCO3 < 15, therefore increased compensatory minute ventilation and EtCO2 is lower
without DKA, HCO3 > 15, EtCO2 normal
110
DDX for flat EtCO2 trace
```
Ventilator disconnection
Airway misplaced – extubation, oesophageal intubation
Capnograph not connected to circuit
Respiratory/Cardiac arrest
Apnoea test in brain death dead patient
Capnongraphy obstruction
```
111
DDX for increased EtCO2
```
CO2 Production:
Fever
Sodium bicarbonate
Tourniquet release
Venous CO2 embolism
Overfeeding
Increased metabolism - NMS
Release of tourniquet
```
Pulmonary perfusion:
Increased cardiac output
Increased blood pressure
```
Alveolar ventilation:
Hypoventilation
Bronchial intubation
Partial airway obstruction
Rebreathing
```
```
Apparatus malfunctioning:
Exhausted CO2 absorber
Inadequate fresh gas flows
Leaks in ventilator tubing
Ventilator malfunctioning
```
112
DDX for decreased EtCO2
CO2 production:
Hypothermia
Acidosis
```
Pulmonary perfusion:
Reduced cardiac output
Hypotension
Hypovolemia
Pulmonary embolism
Cardiac arrest
```
```
Alveolar ventilation:
Hyperventilation
Apnea
Total airway obstruction (note high airway pressures)
Extubation
```
```
Apparatus malfunctioning:
Circuit disconnection (note low airway pressures)
Leaks in sampling tube
Ventilator malfunctioning
```
113
DDX for sudden flatline of EtCO2 to zero
Kinked ET tube
CO2 analyzer defective
Total disconnection
Ventilator defective
114
DDX for sudden change in baseline of EtCO2 - not to zero though
Calibration error
CO2 absorber saturated (check capnograph with room air)
Water drops in analyzer or condensation in airway adapter
115
DDX for sudden increased in baseline of EtCO2
ROSC
| correct ETT placement
116
DDX for elevated inspiratory baseline
```
CO2 rebreathing (e.g. soda lime exhaustion)
Contamination of CO2 monitor (sudden elevation of base line and top line)
Inspiratory valve malfunction (elevation of the base line, prolongation of down stroke, prolongation of phase III)
```
117
clinical manifestations associated with acute airway obstruction
vascular: hematoma, external hemorrhage, hypotension, hemoptysis
laryngotracheal: stridor, subQair, hoarseness, dysphonia, hemoptysis
pharyngeal: subQ air, hematemesis, dysphagia, sucking wound
118
what to do in trauma if suspected disruption of trachea or larynx in terms of airway mgmt
do NOT attempt cricothyrotomy
an emergency tracheostomy is needed
119
what size of tube to use in cricothyrotomy
a 6-mm tracheostomy or 6- to 7-mm endotracheal tube. Do not choose a larger (≥7 mm) tube or one smaller than 4 mm
120
equipment needed to prepare for cricothyrotomy
Personal protective equipment
Scalpel with a #10 (preferable because of its greater width) or #11 blade
A 6-mm endotracheal tube or tracheostomy tube (latter preferred), plus a smaller one available
Tape to secure the tube in place
Cloth ribbon and sutures to secure tracheostomy tube in place
Bag-valve mask device and oxygen source
Gum elastic bougie for guiding tube
Suction devices
121
what is survival rate in paediatric cardiac arrest
infants -2-3%
| older children 9%
122
what is the breakdown in percentages of aetiologies of cardiac arrest in pediatrics
33% - cardiac causes
21%- trauma
remainder = mostly respiratory
123
what is the most common presenting rhythm in peds cardiac arrest
systole - 66%
PEA and bradycardia next most common
VF and VT in less than 10% of kids
124
where is ideal spot for pulse check in kids
unclear --
infants -brachial, femoral
adolescent- carotid
125
worrisome vital sign findings in children
SBP < 70 + (2 x age) is hypotension
RR > 60 breaths per min; declining RR in previously tachypneic patient can represent improvement OR fatigue and imminent respiratory failure
each 1 degree of fever increases HR by only 10bpm and RR by 2-5 breaths per min
EtCO2
progressive increase or decrease precede desaturation and respiratory failure
126
differences in infant CPR
two thumbs or hands encircle chest
depth 1.5inches
ratio 15:2
127
differences in children CPR
two hands
2 inches
15:2
128
dose of epinephrine in paediatric cardiac arrest
0.01mg/kg IV/IO (0.1mL/kg of 1: 10,000) q 4 min
OR
0.1mg/kg (0.1mg/kg of 1:1000) via ETT
129
what antiarrhythmics can be used during pediatric refractory VF/Vt
amiodarone 5mg/kg bolus , may repeat up to 2 times
lidocaine 1mg/kg loading doses, maintenance 20-50mcg/kg per minute infusion (repeat bolus dose if inufosn initiated > 5 mins after initial bolus)
130
reversible causes in cardiac arrest
Hs and Ts
```
hypovolemia
hypoxemia
hypothermia
H+ - acidosis
hypoglycaemia
hypo/hyperK
tension pnuemothorax
tamponade
toxins
thrombosis, pulmonary
thrombosis, coronary
```
131
when can you use compression only CPR in kids
cardiac etiology for arrest - kids had same outcome with conventional vs. comopression only
132
defibrillation dose in kids in cardiac arrest with shockable rhythm
2-4 J/ kg
133
what are the indications for epinephrine in paediatric cardiac arrest
asystole, PEA, bradycadia, VF, pulseless VT
134
what is the indication for atropine in paediatric cardiac arrest, and what dose
bradycardia
| 0.02mg/kg, usually second line after epinephrine
135
what is the indication for vasopressin in paediatric cardiac arrest
refractory cardiac arrest, mixed evidence -last resort option
136
what are the indications for amiodarone in pediatric cardiac arrest
VF, VT, SVT - unclear if superior to lidocaine for VF/VT
137
what are the indicaitons for lidocaine in paediatric cardiac arrest
VF, VT - avoid din WPW
138
what are the indications for procainamide in paediatric cardiac arrest
SVT refractory to adenosine, stable VT
first line for SVT in WPW
139
what are indication for adenosine in paediatric arrest
SVT first line
| avoid in WPW, wide complex tachycardia, long QT
140
what is indication for glucose in paediatric cardiac arrest and how to give
hypoglycaemia
D10W: 5ml/kg, D25W: 2ml/kg, D50W: 1ml/kg
do not use empirically
141
what is indication for calcium chloride in paediatric arrest
hyperkalemia, hypocalcemia, CCB overdose
142
what is indication for sodium bicarb in paediatric arrest
hyperkalemia, TCA overdose
143
what is indication for magnesium in paediatric arrest
torsades de pointes, hypomagnesemia
144
goals of post cardiac arrest care in pediatrics (6)
1. oxygenation: avoid hypoxemia and hyperopia SpO2 94-98, avoid PaO2 >300 mmHg
2. ventilation: avoid hypercapnia and hypocapnia, maintain PCO2 of 35-50
3. CV support: avoid hypotension - maintain euvolemia with fluids, supplement norepinephrine if needed, monitor lactate
4. temp: avoid hyperthermia, TTM 32-36
5. glucose: maintain modest euglycemia - monitor glucose levels, supplement glucose for hypoglycaemia
6. ECMO: potentially beneficial if initiated rapidly, underlying cardiac etiology, arrest with environmental hypothermia, hospital with high volume of ECMO patients
145
how does time of resusciation in peds arrest relate to survival
every minute of CPR = 2.1% decrease in survival and 1.2% decrease in favourable neurological outcome
146
when to consider termination of resuscitation in peds arrest
30 minutes of unsuccessful resuscitation in traumatic arrests
prolonged rests may be beneficial for hypothermia with growing or electrocution, in hospital arrest or prompt access to ECMO)
in atraumatic TOR should be considered after 30 minutes
147
what is appropriate fluid resuscitation in paediatric sepsis
20ml/kg boluses over 5 to 15 minutes followed by reassessment and potentially additional boluses
148
if peadiatric sepsis continues to be in shock after 60ml/kg of isotonic fluid boluses, or signs of fluid overload develop, what is treatment OR hypotension lasting more than 1 hour ?
vasoactive agetns
kids often had depressed CO with septic shock, so dopamine or epinephrine preferred first line, epi>top in terms of increased risk of death with dopamine in adults
NE also technically first line, better for "warm shock"
149
when to use steroid sin sepsis
in patients with shock despite epinephrine or NE, testing serum cortisol level and giving hydrocortisone to those at risk of adrenal insufficiency (HPA axis abnormalities, chronic illness, chronic steroid use, purport fulminant)
150
how to control glucose during sepsis
correct hypoglycaemia when present
cautious use of insulin and frequent glucose monitoring for blood glucose levels more than 10mmol/L
151
define ALTE / BRUE
episode that is frightening to observer and characterzired by apnea, color change, change in tone, choking or gagging
age typically 2-4months
152
risk factors for serious etiology following ALTE/BRUE
PMHX: prematuriy, comorbities, <1mo old, prior ALTE
hx: color change to blue, >1 event in 24 h, absence of choking absence of URI symptoms,fever
physical: abnormal findings in ED, ill-appearing, fever
153
potential workup as guided by hx in ALTE/BRUE
```
CBC - anemia
viral and bacterial cultures, including RSV and pertussis
UA
lytes- dehydration
liver enzymes- metablic disorder
toxicology screen - poisoning
CXR - infection, cardiomegaly
brain CT- mass, hemorrhage
skeletal survey - nonaccidental trauma
ECG - arrhythmia, congenital cardiac abnormalitiy
```
154
dispositiona fter ALTE/BRUE
observe in ED fo 3-4 hours to watch for progression
high risk, ill-appearing and those with more ethan one epsideo or requiring resusuction should be admitted
healthy infants with first episode, particularly when associated with feeding and a normal physical exam may be discharged assuming close follow up can be guaranteed
155
when is antiseizure prophylaxis indicated
traumatic brain injury
do not use in ICH -associated with worse neuro outcomes
in post arrest patients, dont prophylaxis but treat seizures prompty
156
what medicationt o use in seizure prophylaxis
phenytoin, leviteracetam, or valproic 20mg/kg loading dose
levetiracetom 500mg BID preferred option in TBI patients (better tolerateD)
157
what is blood glucose target in brain injury/ICH/stroke etc
under 10mmol/L
158
targets for adequate brain resuscitation
bp: keep MAP > 65 and CPP of 50-70mmHg
PaCO2: target 35-40, don't hyperventilate except as rescue for coning to bridge to OR
glucose: below 10mmol/L
treat seizures, prophylaxis in appropriate cases
159
3 major cardioresp changes from intrauterine to extrauterine life of neonate
removal of fluid from unexpanded alveoli to allow ventilation
lung expansion and establishment of functional residual capacity
redistribution of CO to provide lung perfusion
160
what is a major indicator of hypoxia in neonate
bradycardia
161
neonatal conditions suggesting need for resuscitation
```
hypoxia
hypothermia
hypoglycemia
hypovolemia
prematurity
meconium stained amniotic fluid
```
162
what other effects does hypothermia have on neonate
accelerates metabolic acidosis, O2 consumption, hypogylcemia and apnea
163
what neonates at risk for hypoglycemia
SGA
premature
diabetic mothers
164
what may be some underlying causes of hypoglycaemia inneonate
```
respiratory illness
hypothermia
polycythemia
asphxyia
sepsis
```
165
what symptoms suggest hypoglycemia in neonate
```
apnea
color change
respiratory disress
lethargy
jitteriness
seizures
acidosis
poor myocardial contractility
```
166
cutoff of glucose for neonatal hypoglycaemia
< 2.2mmol/L
167
risk factors for neonate hypovolemia
maternal hemorrhage during delivery, prematurity, newborns with overt shock, and initiation of CPR
168
what should newborn MAP be
diastolic pressure + (pulse pressure/3) = GA in weeks
169
when is tracheal suctioning in meconium aspiration indicated
signs of airway obstruction secondary to meconium that do not improve with resuscitation including warming, drying, initiation of PPV
170
how to perform tracheal suctioning in meconium aspiration
meconium aspirator placed on ETT, place ETT with direct laryngoscopy, then withdraw with suction applied x 2
if bradycardia or apnea persist beyond2 passes, ongoing resuscitations with BMV and endotracheal intubation to secure airway
171
when is is approrpiate to withhold neonatal resus
GA < 23 weeks, weight less than 400g, those with confirmed anencephaly, trisomy 13 or 18
parental requests - age 22-25 weeks
more than 25 weeks = must resus
neonates with no signs of life (asystole, apnea), after 10 mins of resuscitation have high mortality or severe lifelong developmental delay and resuscitations can be terminated; however therapeutic hypothermia has shown some improvement in outcomes even with APGAR of 0 at 10 mins
172
exam findings suggestive of congenital diaphgramatic hernia
barel chest, ipsilateral absence of breath sounds, tracheal or PMI discoid ,scaphoid abdomen
173
how to manage congenital diaphragmatic hernia
intubate
dont BMV will distend stomach and worsen respiratory status
174
special considerations for neonate with myelomeningocele
never place supine ! put prone or on side
wrap defect with sterile gauze pads soaked in warm sterile saline and enclosed with plastic wrap
elevated risk of latex allergy so avoid latex
175
special considerations for neonate with omphalocele
cover defects with occlusive plastic wrapping to decrease water and heat loss
often require IV fluids, OG tube for gastric decompression, and abx prophylaxis
176
special considerations for neonate with choanal atresia
can diagnose by inability to pass cather through either saris into posterior oropharynx
use oral airway device to bypass obstruction
look for other congenital anomalies
177
what is Pierre Robin sequence
profound micrognathia resulting in glossoptosis (retraction or downward displacement of tongue) and cleft palate
178
special considerations in neonate with Pierre Robin sequece
high risk of upper airway obstruction - nasal or oral airway should be able to bypass, if not intubate using fiberoptic intubation
can attempt prone position and LMA
may need to consult ENT/anesthesia
179
exam findings suggestive of congenital heart disease
```
bp difference between upper and lower extremities
weak femoral pulses
central cyanosis
pathologic murmur
hepatomegaly
```
180
lab findings in congenital heart dsiease
polycythemia
| uneplained acidosis
181
what congenital cardiac lesions are ductal-dependent
```
ductal dependent pulmonary blood flow:
-critical pulmonary stenosis, atresia
-severe tricuspid stenosis, atresia
-severe tetralogy of Fallot
ductal dependent systemic blood flow:
-hypoplastic left heart
-crtiical aortic stenosis
-interrupted aortic arch
```
182
equipment checklist for neonatal resuscitation
1. gown, gloves, eye protection
2. timing device
3. blankets (to warm and dry infant)
4. plastic wrap
5. radiant warmer
6. bulb syringe
7. suction and suction catheters
8. bag / masks
10. larygoscope - miller- 00, 0, and 1
11. ETT with stylets (2.5, 3.0, 3.5 and 4.0mm)
12. scissors and tape to stabilize ETT
13. ped CO2 detector
14. meconium aspiratory
15. umbilical catheters (3.5 and 5 Fr)
16. hemostat, sterile drapes and gloves, iodine, scalpel, umbilical tape, suture and 2 way stopcock for umbilical vessel catheterization
183
what med for kids with ductal dependent cardiac lesion
prostaglandin E1 - PGE1 with dose titration to max of 0.1ug/min
184
maternal hx questions for neonatal resus
```
GA?
multiple gestation?
meconium present?
hx of vag bleeding?
meds given or drugs taken
documented maternal fever?
prenatal care ? any abnormalities on US?
```
185
recommended ETT size and depth for infant <1 kg or <28 weeks GA
ETT- 2.5 mm uncuffed
| depth- 7cm
186
recommended ETT size and depth for infant 1-2kg or 28-34 weeks GA
ETT- 3.0 uncuffed
| depth- 8cm
187
recommended ETT size and depth for infant 2-3kg or 34-38 weeks GA
ETT- 3.5 uncuffed
| depth - 9cm
188
recommended ETT size and depth for infant 3+ kg or 38+ weeks
ETT- 3.5-4 uncuffed
| depth- 10cm
189
targeted pre ductal SpO2 after birth by time
```
1 min- 60-65%
2min - 65-70%
3 min- 70-75%
4 min- 75-80%
5 min- 80-85%
10 min- 85-95%
```
190
APGAR Score
0 1 2
HR absent <100 >100
resp- absent slow, irreg good, crying
tone- limp some flexion active, good flexion
grimace none grimace cough,sneeze
color blue, pale pink w. blue hands all pink
191
intubation corrective action in NRP
MRSOPA
```
Mask adjustment
Reposiiton airway
Suction mouth and nose
Open Mouth
Pressur increase
Airway alternative
```
192
possible cause of deterioration while intubated
```
DOPE
displacement of ETT
obstruction of ETT
pneumothorax
Equipment failure
```
193
airway differences in pediatrics
larynx more anterior and cephalic
epiglottis composed of more flexible cartilage
larger occipital = neck flexion when supine and potential airway obstruction - -may need roll under shoulders for intubation
large tongue- obstructs airway easier - can us NP airway
smaller airways more easily obstructed
preferential nose breathers= suction the nose to improve WOB
194
CV differences in pediatrics
tachycardia is earliest sign of CV collapse, hypotension LATE
tachycardia in calm or sleeping child is concerning
bradycardia is ominous may signal impending cardio or respiratory arrest
195
MSK differences in children
ligaments strongly than immature bone, more likely to # bones, if tender on growth plate, physeal injury should be considered in children with normal Xray
196
normal behaviour in infants younger than 2 months
sleeping, crying, quiet alert time, feeding and stooling
197
normal behaviour in infants under 12 months
social smile, track close objects by 2 months
| after 6 months- stranger anxiety
198
what do look for under appearance in paediatric assessment triangle
```
TICLS
tone
irritable, interactive
consolable
look, gaze
speech, cry
```
199
what to look for under work of breathing in paediatric assessment triangle
abnormal sounds - stridor, grunting, snoring, wheezing
abnormal positing - sniffing, tripoding, refusal to lie down
retractions
head bobbing
nasal flaring
200
what to look for under circulation in paediatric assessment triangle
```
pallor
delayed cap refill >2s
cyanosis
mottling
petechiae
```
201
child with norml appearence, abnormal WOB, normal circulation has
respiratory distress
202
chid with abnormal appearance, abnormal WOB, normal to abnormal circulation has
respiratory failure
203
child with normal appearnce, normal WOB, abnormal circiaultino has
compensated shock
204
child with abnormal appearnce, normal-abnormal WOB, abnormal circulation has
decompensated shock
205
child with abnormal appearance, normal WOB, normal circulation has
brain injury or dysfunction
206
child with abnormal appearance, abnormal WOB, abnormal circulation has
cardiopulmonary failure
207
what breathing styles indicate impending respiratory failure in kids
head bobbing - use of neck muscles to assist respiration
| seesaw breathing - ineffective breathing pattern where abdomen moves outward while chest moves inward during inspiration
208
physical exam and radiologic findings concerning for abuse
any bruises in young pre cruising infants
patterned ecchymosis, burns or skin marks
bruises on ears, trunk, inner thighs, neck or groin
posterior oropharynx bruising or laceration
posterior rib fractures
classic metaphyseal fractures
any fracture in nonambulatory child
fractures in different stages of healing
