Resuscitation and Pharmacology Flashcards
Pediatric differences in anatomy/ physiology and how they relate to trauma (5)?
- Inc BSA = inc heat loss
- Abdominal organs less protected
- More likely multi-organ trauma
- Developmental/ behavioral challenges
- Hypotension is a late finding
- Fluid requirements vary by age/ weight
Weight estimation by age?
(age x 2) + 8
Most common cause of hypoxemia in children?
V/Q mismatch
How to reposition airway if on c-spine precautions?
Jaw thrust
Components of pediatric assessment triangle?
C-B-C
Color, breathing, consciousness
2 types of respiratory failure?
Type 1 = hypoxic
Type 2 = hypoxia+ hypercarbia
List 5 sites for IO insertion
proximal tibia Distal femur humerus sternum ASIS proximal to medial malleolus
List 3 contraindications to IO insertion
recently fractured bone, osteogenesis imperfecta, osteopetrosis, IO use in same limb
Complications of IO use
extravasation, epiphyseal injury, fracture, compartment syndrome, fat embolism, thrombosis
How does the pediatric airway differ from the adult airway?
- larger tongue
- larynx more anterior/ superior
- epiglottis is U-shaped, floppy
- larger occiput
- cricoid is the narrowest part
Equipment required for intubation?
SOAP ME
Suction, oxygen, airways, pharmacology/personnel, monitors/ meds
How to estimate ETT size?
Age/4 +4 = uncuffed tube (subtract 0.5 for cuffed)
When is a cuffed tube preferred?
- airway diameter may change over course of treatment (ie. inhalational injury, angioedema)
- risk of aspiration
- need for higher ventilator pressures (bronchiolitis, asthma, CLD)
Etomidate, what is the advantage, what are 2 disadvantages?
Advantage: rapid onset and recovery, minimal HD effects
Disadvantage: adrenal suppression, vomiting, resp depression, myoclonus
Ketamine - advantages and disadvantages
Advantages: good for shock/hypotension, preserves airway reflexes and respiratory drive, bronchodilator DisadvantagesL vomiting ( 5-10%), apnea, laryngospasm, emergence delirium, sialagogue (increases oral secretions)
When is atropine recommended for intubation, according to ACEP?
recommended for children < 1 years old, those being intubated with succinylcholine or pts with bradycardia
succinylcholine – 4 contraindications
- Elevated CK or K (rhabdo, burns/crush/trauma (usually 48-72 hrs later), muscular dystrophy/myopathies
- Risk of malignant hyperthermia
Relative
- Increased ICP or increased intraocular pressure (theoretical risk w/ fasciculations that can raise this)
- Known pseudocholinesterase deficiency (myasthenia gravis) due to prolonged duration of action
If intubated patient deteriorates, consider
- Displacement of the tube
- Obstruction of the tube
- Pneumothorax
- Equipment failure
Indications of a difficult airway?
LEMON: Look Evaluate mouth opening/thyromental distance Mallampati Opening of the mouth Neck mobility
3 ways to manage a difficult airway
LMA Esophageal combitube Perilaryngeal sealer Bougie Video laryngoscopy (glidoscope) Crichothyroidotomy
Good starting ventilator settings?
Pressure-control modes are preferred:
TV 7-10 ml/kg
RR at normal for age
PIP 20-25
PEEP 5-10
Propofol - 4 advantages to using in ED?
- Fastest onset action
- Fastest recovery time
- Reduced ICP
- Can be combined with other agents – ketamine, fentanyl
- Decreased incidence of post nausea
3 indications for intubation?
- inadequate oxygenation
- inadequate ventilation
- airway protection
What is the chain of survival after OHCA?
rapid access to EMS - rapid CPR - rapid defib - rapid advanced care
Name epinephrine’s main action in CPR?
Increases coronary perfusion pressure - good predictor of ROSC
What are 8 causes of PEA?
5Hs and 5Ts:
Hypoxia, hypothermia/hyperthermia, hypoglycemia, hypokalemia/hyperK, H+ (acidosis), Thrombus arterial or venous, tamponade, tension pneumothorax, toxins
Initial defib dose?
2-4 J/kg –> 4J/kg –> max 10 J/kg or 200 J
adult = 200 J
Compression/ventilation rate in CPR when intubated?
Asynchronous
Compressions 100-120 beats/minute but no interruptions + Ventilation 8-10 breaths/minute (or every 6-8 seconds).
2nd line medications for V.fib /pulseless VTach?
lidocaine 1 mg/kg load followed by infusion or amiodarone 5 mg/kg
5 things you do after achieving ROSC?
Prevent secondary injury/ongoing shock
target sats 94-99%
consider advanced airway if not yet intubated
avoid hypotension
avoid hypoglycemia
avoid hyperthermia
treat agitation/ seizures
arrange transport to tertiary pediatric center/PICU
Adenosine side effects?
Flushing, Chest discomfort, Nausea, Headache, Transient sinus bradycardia or heart block, Bronchospasm (in asthmatic)
What is the minimum dose of atropine?
Old question - 0.1mg, due to a study showing that very low doses are associated with mild slowing of the HR, but AHA says no minimum for intubation (0.02mg/kg)
What are 2 indications for atropine use in the resuscitation of a pediatric patient?
- Bradycardia with intubation
- Dec secretions
What is the mechanism of action of atropine?
parasympatholytic drug –> increased HR by accelerating the sinus and atrial pacemaker and improving conduction through the AV node
what is the name and location of receptor that acetylcholine acts on?
Acetylcholine receptor
Nicotinic and Muscarinic
Located at the neuromuscular junction (n) and other post ganglionic neurons (m)
Fentanyl - 3 advantages aside from analgesia and one uncommon complication
HD stability, fast onset and off, fast time to peak effect
S/E: rigid chest
Compare the cardiovascular effects of fentanyl and morphine and explain the difference
Morphine leads to histamine release –> hypotension.
Fentanyl is synthetic opioid, no histamine release, more HD stability
List 4 indications for calcium administration
Calcium chloride = central, calcium gluconate = peripheral
- HyperK, hypoCa, CCB overdose, HypoMg
What is target temperature after ROSC?
For infants and children between 24 hours and 18 years of age who remain comatose after OHCA or IHCA, it is reasonable to use either TTM 32°C to 34°C (for 48 hours) followed by TTM 36°C to 37.5°C (for 3 days) or to use TTM 36°C to 37.5°C
Definition of wide QRS?
> 0.09 msec ( 2 small boxes)
Features of SVT?
regular, HR > 220, no waves, not variable
Dose of adenosine?
0.1 mg kg –> 0.2 mg /kg (max 6 mg, 12 mg)
When to stop CPR in NRP?
Stop resuscitation after 10 minutes if HR remains undetectable
What are two actions of epinephrine other than cardiac?
Alpha 1 = vasoconstriction
Beta 1 = cardiac contractility, inc HR
Beta 2 = bronchodilation
Norepinephrine - main receptor, and effect on HR
alpha receptor = vasoconstriction
No effect on HR (some increase)
Dobutamine - main receptor, and effect on HR
Increase HR, vasodilator (afterload reduction), beta-1 receptor
Recommended laryngoscope sizing?
Size 0 = neonate
Size 1 < 2 years old
Size 2: 2-10 years old
Size 3: >10 years old
How does milrinone work?
Lusitrope - peripheral vasodilation
Phosphodiesterase inhibitor—slows cyclic adenosine monophosphate breakdown
