Resuscitation Flashcards
What is the leading cause of death in 1-19 year olds? In < 1 year olds?
1-19: INJURY MVCs > homicide > suicide 80% of deaths occur at the source or in the ED <1: congenital anomalies, prematurity, SIDS
What are the differences between pediatric traumas and adult traumas?
- multisystem more likely in peds - hypotension will be a late finding in peds - increased body surface area means greater heat loss in peds
Name 8 findings which would suggest a difficult airway
small mouth TMJ abnormalities, can’t open mouth overbite, small mandible short, fat necks large tongue no sniffing possible neck mass penetrating neck traumas
What is the most appropriate surgical airway in a: 3 year old 7 year old 10 year old 15 year old
<8 needle cricothyroidotomy (Fleisher, 10-12 years in other sources) with jet ventilation thereafter use a regular cricothyroidotomy
What are the physiologic effects of hypothermia in resuscitation
impaired hemodynamics increased peripheral vascular resistance increased metabolic demand coagulopathy
What are the main differences in pediatric airways? (8)
smaller adenoid and tonsillar hypertrophy large tongue large occiput causing flexion superior and anterior larynx floppy epiglottis, softer trachea narrowest at cricoid cartilage (=5yo) developing teeth
Name differences in pulmonary physiology in peds (4)
increased O2 consumption smaller lungs higher vagal tone increased chest wall compliance (increased atelectasis and collapse)
When is it best to use an uncuffed tube?
in the newborn period, to maximize internal diameter
What are advantages of a cuffed tube? (4)
1) decreased need for tube exchange related to inappropriate sizing 2) better if the airway diameter might change in cases of inhalational injury, edema 3) better protection provided for aspiration 4) better if high ventilatory pressures are anticipated
What is a disadvantage of a cuffed tube?
inadvertent excessive cuff pressures can cause tracheal mucosal ischemia, keep <20-30mmHg loss of 0.5 of internal diameter, smaller
What blades are appropriate for intubating: newborn <1 year old 18 months 2 year old 7 year old 10 year old 15 year old
newborn: straight blade, 0-00 <1 year: straight blade 1 18 months: curved 1 2 years: curved 2 7 years: curved 2 10 years: curved 3 15 years: curved 3 RULES: - straight blades while the epiglottis is floppy, less than one year - curved 2 at 2 years - curved 3 at 10-12 years
how deep do you insert an ETT?
3 x internal tube diameter or ETT size
What category of muscle relaxant is succinylcholine? What are the side effects and special considerations?
depolarizing muscle relaxant, onset within one minute and lasts up to 8 causes fasciculations! muscle pain, myoglobin release, histamine release, POTASSIUM release, transient bradycardia, increased risk of malignant hyperthermia with skeletal muscle myopathies
What is the antidote for malignant hyperthermia?
dantrolene! and lots of it
When should you consider using atropine for intubation?
regularly if patient is less than 1 year old or on hand for succinylcholine associated bradycardia
What is the best way to confirm ETT placement?
capnography! a regular waveform is 100% sensitive
What are the most common pediatric arrhythmias?
sinus bradycardia PEA asystole
What is the out of hospital cardiac arrest survival rate?
<10% usually with poor neurologic recovery
What is the chain of survival for out of hospital cardiac arrest?
rapid CPR / rapid EMS, rapid defibrillation, rapid access to advanced care
What are contraindications to NPA insertion?
basal skull trauma adenoid hypertrophy with bleeding diathesis
What is the rate of rescue breath administration in the following scenarios? - bystander rescue breaths - newborn infants - 1 provider CPR - 2 provider CPR - breaths per minute with advanced airway in CPR
- bystander (BLS) 12-20 - newborn infants 40-60 (3:1 compression breath ratio with 120 events per minute) - 1 provider CPR 30:2 (100-120 events per minute) - 2 provider CPR 15:2 - breaths per minute with advanced airway 8-10 (Fleisher / PALS)
Self inflating bags should have the pressure pop-off valve set to what?
35-40mmHg
What are the features of effective cardiac compressions? (5)
- pushing hard (1/3 AP diameter) - pushing fast (at least 100 events per minute) - minimizing interruptions (<10 sec pulse check) - rotate compressors every 2 minutes - allow full chest recoil - avoid hyperinflation (<12 breaths per min) In the best case scenario, you’ll achieve 1/3 of regular cardiac output
What are complications of IO placement? (6)
extravasation epiphyseal injury fracture compartment syndrome fat embolism thrombosis
What medications can be absorbed by the lungs?
Lidocaine Epinephrine Atropine Naloxone (LEAN) double doses by at least 2, epix10, mix with 5mL NS and 5 manual vents to distribute Fat-soluble medications
Contraindications to IO placement?
recently fractured bone or IO elsewhere on it osteogenesis imperfecta osteopetrosis overlying skin infection or cellulitis
What are subcutaneous or IM treatments for asthma
epinephrine terbutaline
What doses of energy are used for defibrillation? 2nd dose? Thereafter?
2J/kg 4J/kg Keep escalating up to 10J/kg Adults start with 150J, up to 360J
Name reversible causes of cardiac arrest
Hypovolemia. Hypoxia. Hydrogen ion (acidosis). Hypo- or hyperkalemia. Hypothermia. Tension pneumothorax. Tamponade, cardiac. Toxins. Thrombosis, pulmonary. Thrombosis, coronary.
In what resuscitation scenarios is sodium bicarbonate indicated? Side effects?
hyperkalemia hypermagnesemia TCA overdose Ca2+ blocker overdose hyperosmolality hyperNa increased lactate catecholamine inactivation decreased cerebral perfusion pressure
What are indications for adenosine? Potential side effects? (10)
paroxysmal SVT, short-acting anti-arrhythmic depression of SA & AV nodal activity, antagonises cAMP-mediated catecholamine stimulation of ventricular muscle s/e’s: facial flushing, chest pain, anxiety, dyspnea, bronchospasm, apnea, accelerated ventricular rhythm, wide-complex tachycardia. brief asystole
What are indications for amiodarone? Potential side effects? (4)
pulseless VT, pulseless VF blocks K+ channels prolonging phase III of the cardiac action potential prolongs QT interval, bradycardia, tachydysrhythmias, hypotension, bradycardia, nausea/flushing, Torsades
What are indications for synchronized cardioversion?
Perfusing arrhythmias such at SVT and VT, refractory to medical management
What are calcium chloride indications? Mechanism of action?
hypocalcemia, hyperkalemia, hypermagnesemia, Ca2+ blocker overdose vascular smooth muscle excitation-contraction coupling enhances systolic function and systemic vascular resistance via vascular smooth muscle contractions
What are magnesium sulfate indications? Mechanism of action?
hypomagnesemia, asthma, torsade de pointes inhibits calcium channels thereby decreasing intracellular Ca resulting in smooth muscle relaxation s/e: hypotension
Outline the algorithm for bradycardia
Outline the algorithm for VF or pulseless VTach
Outline the algorithm for SVT or VTach with a pulse
Outline the algorithm for PEA or asystole
What HR suggests SVT in infants? in children?
>220 in infants
>180 in children
What is the likelihood that aberrant conduction leads to wide complex SVT in kids?
<10% of the time
If a kid has SVT and is unstable, what should you do if no IV access?
go straight to synchronized cardioversion, do not delay if they’re unstable
(ie: don’t waste time on IO)
What are usual VT rates?
What are usual VT causes? (5)
120-200 bpm
long QT, structural heart disease, myocarditis, cardiomyopathies, poisonings
What newborn features suggest non-resuscitation is appropriate at birth?
(Fleisher)
<23 weeks
<400g
anencephaly
After how much good quality CPR is it reasonable to terminate efforts in a newborn?
if after 10 minutes of good quality resuscitation and NO hearbeat is detected, it is reasonable to stop
When to consider surfactant administration to newborns?
If PREM <35 weeks
If meconium aspiration syndrome
When do you switch from room air or blended oxygen to 100% O2 in newborn resuscitations?
If persistent bradycardia despite 90 seconds of good ventilation
What is the usual progression in pulse oximetry after birth?
at 1 minute
2 minutes
3 minutes
4 minutes
5 minutes
10 minutes
1 min: 60-65%
2 min: 65-70%
3 min: 70-75%
4 min: 75-80%
5 min: 80-85%
10 min: 85-90%
What is the proper ETT tube depth in newborns?
depth in cm= 6 + weight in kg
What are the cooling criteria for newborns?
1) moderate to severe encephalopathy
2) GA >36wks and <6 hours of life
3) Abnormal EEG
4) within 60 minutes of birth
either cord pH <7.0 or base deficit > -16
OR
history of perinatal event, continuous need for resuscitation with APGARs <5 at 10 minutes, PPV after 10 minutes and pH 7.01-7.15, base deficit -15.9 to -10
What materials do you need to drain a tension pneumothorax in a newborn?
20 gauge catheter over needle with three way stop-cock
How do you manage a diaphragmatic hernia at birth?
Intubate AND insert an OG
When can you stop resuscitation in CPR?
If there has been good CPR administered with two cycles of epinephrine
low to no meaningful survival
Do not go past 20 minutes
What are the AHA ROSC hypothermia recommendations?
32-34C for 12-24hrs
doesn’t apply to kids
only newborns and adults :/
Define shock and name 6 different types of shock
SHOCK: inadequate delivery of oxygen and nutrients to meet end organ demands
hypovolemic (hemorrhage, fluid loss, burns)
cardiogenic
obstructive (tamponade, pneumothorax, PE, CHD)
distributive (septic anaphylactic, drug ingestions)
neurogenic (spinal shock)
dissociative (methemoglobinemia, severe anemia, CO poisoning)
What are the criteria for ARDS?
1) acute, meaning onset over 1 week or less
2) bilateral opacities consistent with pulmonary edema must be present and may be detected on CT or chest radiograph
3) PF ratio (PaO2/Fi02 ratio) <300mmHg with a minimum of 5 cmH20 PEEP (or CPAP)
4) “must not be fully explained by cardiac failure or fluid overload,”
What is Beck’s triad?
Findings in cardiac tamponade:
1) distended neck veins
2) distant hear sounds
3) hypotension
What is the indication, mechanism of action and dosing range for dopamine?
Fluid refractory shock
alpha-1, beta-1&2, D1 receptor stimulation: variable stimulation of receptors based on dose , Inotrope and chronotrope, vasoconstrictor at higher doses
5-10 microg/kg/min
What is the indication, mechanism of action and dosing range for epinephrine?
Fluid refractory shock, COLD shock
alpha-1, beta1&2
β effects predominate at lower doses (vasodilation),
α effects predominate at higher doses (vasoconstriction)
Inotrope and chronotrope
Inhibits insulin and effects lactate metabolism
0.05-1 microg/kg/min
What is the indication, mechanism of action and dosing range for norepinephrine?
Warm shock with low blood pressure
alpha-1, beta-1 stimulation
inotrope and vasopressor
0.05-1 mcg/kg/min
What is the indication, mechanism of action and dosing range for milrinone?
Cold shock with normal blood pressure
type III phosphodiesterase inhibitor
long half-life, use with caution in impaired renal function
0.25-1 mcg/kg/min
What are special considerations for intubating a septic patient?
Sedation agent of choice is ketamine to avoid hypotensive side-effects. It is a catecholamine depletor but NOT a myocardial depressant.
Extra fluid boluses should be available as switching to PPV results in decreased preload and subsequent decreased cardiac output, be prepared to intervene
