Methods of ANS II Unit 1 - PALS Concepts

Cyanosis is not apparent until at least _____g/dL of hemoglobin are desaturated. Who will need a lower SpO2 in order for cyanosis to be present - an anemic pt or normal pt?

"Cyanosis is not apparent until at least 5g/dL of hemoglobin are desaturated." This means that the more anemic you are, the lower the SpO2 that will be required in order for cyanosis to be present -For example, if a child starts with a hemoglobin concentration of 16g/dL, cyanosis will appear once 5g/dL are desaturated and 11g/dL are saturated, which correlates to an SaO2 of roughly 68% (11g/dL ÷ 16g/dL = 68%) • With a starting hemoglobin of 16g/dL, cyanosis starts to appear at an SpO2 of 68% -If a child starts with a hemoglobin concentration of 8g/dL, cyanosis will appear when 5g/dL are desaturated and 3g/dL are saturated, which correlates to an SaO2 of roughly 38% (3g/dL ÷ 8g/dL = 38%). • With a starting hemoglobin of 8g/dL, cyanosis starts to appear at an SaO2 of 38% If you are anemic you will not show cyanosis as easily. More resistant to it.

Define Permissive Hypoxemia

"Permissive hypoxemia" refers to an SpO2 reading of < 94% that may be appropriate or normal in certain circumstances. An example in PALS is congenital heart disease (i.e. Tetralogy of Fallot). These patients can be breathing perfectly fine, but because of the intracardiac shunting of blood, the SpO2 can remain quite low, no matter how much supplemental oxygen is used

What is Quiet tachypnea? what is it caused by?

"Quiet tachypnea" is a term that refers to a fast respiratory rate that is NOT accompanied by signs of labored breathing or respiratory distress. In other words, "quiet tachypnea" is caused by "non-pulmonary" issues (such as fever, pain, metabolic acidosis, etc)

What is the lidocaine dose used to treat Vfib/Pulseless Vtach?

1 mg/kg

What are the 3 drugs used to treat Vfib/Pulseless Vtach?

1. Epi 2. Lidocaine 3. Amiodarone

What are the 3 drugs used to treat torsades?

1. Epi 2. Magnesium 3. Lidocaine

The Four Airway Scenarios In PALS

1. Lower airway obstruction 2. Upper airway obstruction 3. Lung tissue disease 4. Disordered control of breathing.

What are two examples of a Lower airway obstruction? when do signs of a lower airway obstruction typically occur? what are we likely to hear?

1. Lower airway obstruction (asthma/bronchoconstriction, etc) -Signs of lower airway obstruction (wheezing, etc) most often occur during expiration

Prior to taking this course, students should have mastered (and will be responsible for) the material in the "Concepts Of Adult & Child Resuscitation" PPT from 2nd semester. Students should pay particular attention to the following:

1. Team dynamics and definitions 2. Proper ventilation and chest compression rates and techniques for children 3. Principles of effective CPR and goals for chest compressions 4. Methods of evaluating neurologic function ("disability") 5. Synchronized cardioversion, defibrillation, pad and paddle placement, correct pad choice for children, and correct energy dosing for defibrillation and synchronized cardioversion in children 6. The BLS and primary and secondary assessments, and the steps to take based on whether a patient is conscious or unconscious 7. Post-resuscitation management for children, including targeted temperature management

What are the 5 Abnormal Lung Sounds?

1. Wheezing 2. Rales (crackles, crepitation) 3. Rhonchi 4. Stridor 5. Grunting

What are the 3 drugs used for bradycardia?

1. atropine 2. epi 3. dopamine

What are the 10 Possible Treatments In The Airway Scenarios?

1. breathing treatments 2. heliox 3. humidified oxygen 4. racemic epinephrine 5. steroids 6. magnesium 7. mannitol and/or hypertonic saline 8. Ipratropium bromide 9. Naloxone (Narcan) 10. Intubation And/Or PEEP

What are the two drugs used to treat PALS shock?

1. epi 2. calcium

What are the 5 Signs Of Labored Breathing/Respiratory Distress?

1. head bobbing 2. nasal flaring 3. disordered control of breathing 4. retractions 5. seesaw respirations Tell me 4 signs of labored breathing. - exam question

What are the 3 drugs used to treat Monomorphic Vtach With A Pulse?

1. lidocaine 2. Amiodarone 3. Procainamide We can choose EITHER Amiodarone or Procainamide, but NOT BOTH at the same time

What is the dose of epi used to treat Vfib/Pulseless Vtach? how often can it be repeated?

10mcg/kg every 3-5 min "The pediatric cardiac arrest algorithm does not state a specific time for delivering the first dose of epinephrine. However, the 2020 AHA Guidelines for CP and ECC states that the earlier the epinephrine is administered after CPR initiation, the more likely the patient is to survive...A provider may choose to administer epinephrine before or after the second shock"

What is the dose of epi to treat torsades? how often can it be repeated?

10mcg/kg every 3-5 minutes

What is the dose of epi to treat bradycarida? how often can it be repeated?

10mcg/kg, repeat every 3-5min

What is the Procainamide dose to treat Monomorphic Vtach With A Pulse?

15mg/kg over 20-60 minutes

What is the dose of lidocaine to treat torsades?

1mg/kg

What is the lidocaine dose to treat Monomorphic Vtach With A Pulse?

1mg/kg

Defibrillation In Children - What is the 1st dose? 2nd dose? subsequent doses?

1st dose: 2J/kg 2nd dose: 4J/kg Subsequent doses: up to 10J/kg

Synchronized Cardioversion In Children - What is the 1st shock dose? 2nd shock dose?

1st shock: 0.5-1 joule/kg 2nd shock: 2 joules/kg

Upper airway obstruction's include what? when do signs typically occur?

2. Upper airway obstruction (soft tissue obstruction, croup, swelling, anaphylaxis, etc) -Signs of upper airway obstruction (stridor, etc) most often occur during inspiration

What is the dose of atropine to treat bradycardia? how often can it be repeated? what is the max single dose? max total dose for a child? max total dose for an adolescent? what is the minimum dose of atropine?

20mcg/kg, may repeat once The max SINGLE dose of atropine for a child is 0.5mg; the max TOTAL dose for a child is 1mg; the max TOTAL dose for an ADOLESCENT is 3mg Some sources say the minimum dose of atropine is 0.1mg; others say there is no minimum dose

What is the dose of calcium used to treat PALS shock? what is it used for?

20mg/kg For hypocalcemia in sepsis

What is a normal Scvo2 (Central Venous Oxygen Saturation) in PALS?

25-30% below the SaO2 (70-75% if the SaO2 is normal)

What is the dose of magnesium to treat torsades?

25-50mg/kg

Lung tissue disease affects the lungs at what level? what occurs in lung tissue disease? what are 4 conditions that fall under this umbrella? What are the 3 signs of a lung tissue disease?

3. Lung tissue disease (pneumonia, aspiration, ARDS, etc) Lung tissue (parenchymal) disease encompasses several conditions that affect the lung at the alveolar-capillary level. In this state, the child's lungs become stiff because of fluid accumulation in the alveoli - Common conditions that fall under the umbrella of "lung tissue disease" include pneumonia, aspiration, pulmonary edema, acute respiratory distress syndrome (ARDS), etc Signs of lung tissue disease include grunting, rales, and perhaps fever

What is Disordered control of breathing? what are the 3 possible causes?

4. Disordered control of breathing. This is simply an abnormal respiratory pattern, which can be caused by: 1. Muscle weakness (inadequate reversal) 2. Depressed consciousness (from sedative overdose, poisoning, or seizures) 3. Elevated intracranial pressure (ICP)

What is the dose of dopamine to treat bradycardia?

5-20mcg/kg/min

What is the amiodarone dose used to treat Vfib/Pulseless Vtach? What is the max mg/kg dose? max mg dose?

5mg/kg bolus Can give up to 15mg/kg, or 300mg

What is the Amiodarone dose to treat Monomorphic Vtach With A Pulse?

5mg/kg bolus over 20-60 minutes

What is the normal oxygen consumption for infants? adults?

6-8mL/kg/min (infants) 3-4mL/kg/min (adults) 6-8mL/kg/min (infants) KNOW THIS ON EXAM!!!

What is considered the SVT rate for infants? children?

>220 (for infants) >180 (for children)

What does it mean if a child is "Refractory"?

A child is "refractory" to treatment if they do not improve or respond to a specific therapy. Examples include: 1. "Fluid refractory hypotension," which means that a child remains hypotensive despite fluid administration - (in which case the provider needs to consider using vasopressors or an inotrope) 2. If a child is hypoxic refractory to supplemental oxygen administration, it may mean that they need a breathing treatment, or may need to be mask ventilated or intubated 3. "Norepinephrine refractory shock," which means that a child in shock is unresponsive to norepinephrine therapy Means the treatment did not work.

What is a normal Capillary Refill Time? prolonged Capillary Refill Time? what are the 3 common causes of a prolonged capillary refill time?

A normal capillary refill time is ≤ 2 seconds in a neutral thermal environment and with the extremity slightly above heart level A prolonged capillary refill time is > 5 seconds, and common causes include: -1. Dehydration -2. Shock -3. Hypothermia

What drug is used to treat SVT? what is the first dose? max first dose? second dose? max second dose?

Adenosine 1st dose is 100mcg/kg (max 6mg) 2nd dose is 200mcg/kg (max 12mg)

How is Stridor described? Does it occur during inspiration or expiration? what does it indicate?

Again, stridor is a high pitched sound, usually on inspiration, and indicates upper airway obstruction (foreign body, croup, upper airway edema, etc) Heard on inspiration and an indict croop

When does laminar airflow occur? airflow can become turbulent in what two situations? If airflow does become turbulent, airway resistance increases or decreases?

Airflow is laminar (has low resistance) during normal respiration, and airflow can become turbulent in the following situations: -1. Partial airway obstruction (usually upper airway obstruction) -2. Labored/agitated breathing/increased respiratory efforts/crying If airflow becomes turbulent, airway resistance increases, which makes it harder for the patient to breathe. Therefore, caregivers should work to prevent the onset of turbulent airflow that can be brought on by agitation/crying, or by any other increased respiratory efforts

It's important to remember that just because a patient has labored breathing, it doesn't mean that the patient is in an airway scenario! They could be in a cardiac or shock scenario (because labored breathing can also be observed in cardiogenic shock and maybe even SVT). In order to tell if you're in an airway scenario on a patient with labored breathing, simply look at?

Airway Scenario vs. Cardiac Or Shock Scenarios It's important to remember that just because a patient has labored breathing, it doesn't mean that the patient is in an airway scenario! They could be in a cardiac or shock scenario (because labored breathing can also be observed in cardiogenic shock and maybe even SVT) -In order to tell if you're in an airway scenario on a patient with labored breathing, simply look at the blood pressure In the AIRWAY scenarios, the labored breathing is usually not associated with hypotension In the CARDIOGENIC SHOCK or SVT scenarios, the patient is more likely to have hypotension accompanying their labored breathing

Similarly, when a pediatric patient has bradycardia, they could either be a "bradycardia" scenario, or an "airway scenario" (since poor ventilation can lead to bradycardia). In order to tell whether or not you're in an airway scenario on a patient with bradycardia is to look at?

Airway Scenarios vs. Bradycardia Scenario Similarly, when a pediatric patient has bradycardia, they could either be a "bradycardia" scenario, or an "airway scenario" (since poor ventilation can lead to bradycardia) -In order to tell whether or not you're in an airway scenario on a patient with bradycardia is to listen to the breath sounds In the AIRWAY scenarios, the patient could have bradycardia, but should have ABNORMAL BREATH SOUNDS In the BRADYCARDIA scenario, the patient will have bradycardia and NORMAL BREATH SOUNDS

All of the Inspiratory Muscles work to? what is the role of the primary inspiratory muscles? what are the two inspiratory muscles? what is the role of the accessory inspiratory muscles? where are they found? what muscles do they include?

All of the inspiratory muscle work to LIFT the ribcage The PRIMARY inspiratory muscles (the ones working during normal inspiration) include the diaphragm and EXTERNAL intercostals. The ACCESSORY inspiratory muscles (the ones that help with inspiration during labored breathing) include the muscles in the neck (sternocleidomastoid, scalene muscles) and pecs (pectoralis major, and pectoralis minor)

Intrathoracic Airway Resistance - Do larger airways or smaller airways have larger TOTAL resistance?

An individual small airway (red) has much greater resistance than a large airway (blue), but since there are a ton more smaller airways than larger airways, TOTAL resistance in the small airways is much lower (because the sum diameter in the small airways is greater than the sum diameter in the large airways) Large airways are more pone to resistance and turbulent airflow. We want laminar airflow

How is Apnea defined? Apnea is the most common cause of what in kids?

Apnea is the MOST COMMON CAUSE OF BRADYCARDIA IN KIDS, and is defined as cessation of breathing for 20 seconds

Clinical Uses For Heliox - when is heliox most helpful? when is it typically used in PALS?

Because heliox is useful for combating turbulent airflow, it is most likely to be helpful in relieving symptoms of UPPER airway obstruction (since the upper airways have more resistance and are more prone to turbulent flow) -Heliox has a lesser effect in the smaller airways (since flow is already more laminar) The most prominent example of heliox being used in PALS is croup (or any other kind of upper airway edema) -It can also sometimes be considered for conditions involving the medium airways (asthma, COPD, etc)

Define Acrocyanosis

Blue discoloration of hands and feet, and around the mouth and lips

Breathing Treatments are usually indicated for? what is an example of an agent that is used during a breathing treatment?

Breathing treatments (such as beta 2 agonists like Albuterol) are usually indicated for lower airway obstruction (asthma, etc)

What is Color-Coded Length-Based Resuscitation Tape (Broselow Tape)?

Broselow tape approximates weight and drug doses based on child length

CPR Technique In Children - what is the Chest Compression Technique used on children >8 years old? 1-8 years old? infants with 2 or more rescuers? infants with a lone rescuer?

Children >8 years old - 2-handed CPR technique Children 1-8 years old - Choice between 2-handed or 1-handed CPR techniques Infants with 2 or more rescuers - Thumb-encircling CPR technique Infants with a lone rescuer - Choice between 2-finger or thumb-encircling CPR techniques - We can CONSIDER a one-handed CPR technique for infants, but only if we can't get an adequate depth the 2-finger or thumb-encircling CPR techniques

Pediatric Airway Physiology - how might neuromuscular disorders effect a child's breathing? what can it produce?

Children with neuromuscular disorders may have an even weaker chest wall and weak respiratory muscles, which can make breathing and coughing ineffective and/or produce seesaw respirations

Defibrillator Pads For Pediatrics - For children 8 or older what type of pads to we use? what about for children 1-8 years old? less than 1 years old?

Children ≥8 years old - Use an AED with adult AED pads 1-8 year old - 1. Use an AED with pediatric AED pads & pediatric dose attenuator if available - 2. If the pediatric pads are not available, use a manual defibrillator with pediatric pads - 3. If neither of the above are available, use adult AED pads < 1 year old - 1. Use a manual defibrillator with pediatric pads - 2. If the manual defibrillator is not available, use an AED with child pads & pediatric dose attenuator - 3. If neither of the above are available, use adult AED pads

Diagnosing The Airway Scenarios In PALS - State whether the following symptoms are found in Upper Airway Obstruction, Lower Airway Obstruction, Lung Tissue Disease, and/or Disordered Control of Breathing Hypoxemia, possible poor chest rise or decreased air movement, possible breathing with accessory muscles, tachycardia (early), bradycardia (late) Signs of labored breathing/respiratory distress (retractions, etc) Stridor, inspiratory snoring, hoarseness, barking cough, drooling, snoring, gurgling Expiratory wheezing, active expiration Grunting, crackles (rales), fever Normal (or shallow) breath sounds with an abnormal respiratory pattern, possible central apnea (no respiratory effort)

Come on! How easy can I make it?! To know what specific airway scenario you're in, all you have to do is listen to the breath sounds and take the child's temperature! Will have crappie lung sounds and normal blood pressure. KNOW THIS SLIDE.

What is croup and what is it caused by? what are the 3 classifications?

Croup (Laryngotracheobronchitis) Croup is described as inflammation of the larynx/vocal cords -It is a caused by a viral infection that can also be associated with low grade fever Croup can be classified as mild (barking cough), moderate (stridor & retractions at rest), or severe (significant agitation with decreased air entry)

Disordered Control Of Breathing may encompass what two things? what two things can it lead to? what are the 3 triggers/causes?

Disordered control of breathing may encompass an irregular respiratory rate and/or insufficient respiratory effort, which can lead to hypoxemia and hypercarbia. It can be triggered/caused by: 1. A medication overdose 2. A seizure (that could be caused by a high fever) that led to increased ICP 3. Other neurological problems (head injury, brain tumor, hydrocephalus, increased intracranial pressure)

What is the DOPE Pneumonic? when do we use it in PALS?

Displacement Is the ETT still in place? Obstruction Is the ETT kinked? Is there a mucus plug? Pneumothorax Are there bilateral breath sounds? Pneumothorax is commonly (but not always) associated with trauma Equipment Failure The "DOPE" pneumonic is used in PALS anytime an intubated patient deteriorates - You must verbalize this pneumonic in any scenario where an intubated child's condition deteriorates Will have to say this out load during PALs. Verbalize this when you have an intubated child that is deteriorating (low sat and hypotensive)

What drug is used to treat Asystole/PEA? what is the dose? how often can it be repeated?

Epi 10mcg/kg every 3-5 minutes

What is a normal Urine Output for infants and young children? older children and adolescents? reduced urine output is a sign of what?

For infants & young children, the goal is 1.5-2mL/kg/hr For older children & adolescents, the goal is 1mL/kg/hr Reduced urine output is a sign of poor perfusion

Hypoglycemia - blood sugars below what indicate hypoglycemia in neonates? what about in infants/children/adolescents? what are the signs of hypoglycemia?

For neonates, blood sugars <45mg/dL are considered hypoglycemic and should be treated. For infants/children/adolescents, blood sugars <60mg/dL are considered hypoglycemic and should be treated -Keep in mind that these are the ranges for unstressed and fasted children. Stressed and unfasted patients may still have abnormally low blood sugar even their blood sugar is slightly higher than these lower ranges, know what I'm sayin'? "Symptoms of hypoglycemia may be difficult to recognize. Many hypoglycemic children and infants may not exhibit obvious symptoms until glucose levels drop to a dangerous point." (ACLS.com) -Signs of hypoglycemia (other than low blood sugar) include signs of poor perfusion, hypotension and tachycardia, sweating, irritability, and/or lethargy Will use D25. 0.5mg/kg dose of glucose How many mL of it would you need to get to 1g. - 4 mL. -This is important bc the dose of glucose for a child 0.5mg/kg dose of glucose

What are the 5 signs of Good Peripheral Perfusion? 5 signs of poor/inadequate perfusion?

Good peripheral perfusion (vasodilation) 1. Good pulse 2. Flushed skin/good color 3. Brisk capillary refill (≤ 2 seconds) Very rapid capillary refill (< 2 seconds) is also referred to as "flash capillary refill" 4. Warm skin 5. Awake & alert Poor/inadequate perfusion 1. Weak pulse 2. Pale or cyanotic skin color 3. Delayed capillary refill (>5 seconds) and cool extremities -Due to vasoconstriction or hypothermia 4. Decreased responsiveness and/or consciousness 5. Metabolic acidosis, elevated lactate, and decreased U/O Know this slide.

Head Bobbing is a sign of what? Does the child lift their chin during inspiration or expiration? when does the child's chin fall? why does it occur? Nasal Flaring is a sign of? Do the nostrils dilate during inspiration or expiration?

Head bobbing is a sign of respiratory failure in which the chin lifts during inspiration and the chin falls during expiration -It occurs because the neck muscles are being used to assist ventilation Nasal flaring is a sign of respiratory distress where the nostrils dilate during inhalation

What is Heliox? what is its effect on airflow?

Heliox is a breathing gas composed of a mixture of helium & oxygen. The helium gives the gas mix a lower density, and the low density produces a higher probability of laminar flow (generates less airway resistance than air). Heliox can thus make it easier for patients to breathe if they have an airway obstruction that has been causing more turbulent flow in the airway

Treating Hypoglycemia - If a hypoglycemic child shows minimal symptoms and is stable what should be done? what is the dose of glucose in PALS? what is the concentration of glucose? how many mL = 1 g? In general when should glucose be used with regards to infants?

If a hypoglycemic child shows minimal symptoms and is stable, administration of oral glucose via juice is recommended. If treating hypoglycemia with glucose, the treatment is a 0.5-1g/kg bolus of glucose -In the PALS book it recommends using 2-4mL/kg of D25W (which means "Dextrose 25% in water") -D25 = 250mg/mL (0.25g/mL), so 4mL = 1g "Dextrose should, with few contraindications, be used in all maintenance fluids, especially for infants and for patients with or at risk for hypoglycemia." If a child is 10 kg you give 5 g D25

In PALS a pt is considered to have Hypoxemia when? what should we consider administering? An increase in ________ can prevent hypoxemia from turning into?

In PALS, a patient is considered to have hypoxemia if their SpO2 is ≤94% on room air. Therefore, we should only consider administering supplemental oxygen if the SpO2 is <94%, or there are poor signs of perfusion. An increase in cardiac output can prevent hypoxemia (low SaO2) from turning into tissue hypoxia (inadequate oxygen delivery to the tissues)

Pediatric Airway Physiology - In infants and young children, their chest wall is compliant or noncompliant? Because of this what can happen during forceful diaphragm contractions and labored breathing? In other words, why is labored breathing problematic? because of this it is more efficient for infants to do what?

In infants and young children, the CHEST WALL is compliant. Because of this, the chest will be tugged inward during FORCEFUL diaphragm contraction/labored breathing, which can hinder lung expansion and cause insufficient tidal volumes, especially if the patient has decreased LUNG compliance. In other words, labored breathing can actually worsen oxygenation and ventilation by causing the chest to sink (breathing deeply may induce greater chest wall collapse) -Because of the compliant chest wall, it is more efficient for infants to take smaller tidal volumes at an elevated respiratory rate Greater chest wall compliance increases risk for chest wall collapse so one thing you can do is calm them down.

Opening & Clearing the Airway - It's important to keep an infant's head in what position when giving breaths?

It's important to keep an infant's head in the neutral position when giving breaths because if the infant's head is flexed or extended beyond the neutral (sniffing) position, the infant's airway may become blocked -Placement of a shoulder roll is oftentimes necessary to place a pediatric patient in a sniff position

Lung Percussion Sounds - what do resonant sounds indicate? dull sounds? hyperresonant sounds?

Lung Percussion Sounds RESONANT sounds •Low pitched and hollow, which indicate hollow, air containing structures, which are normal for percussing the lungs •Resonant sounds are NORMAL lung sounds with percussion DULL sounds •Quieter and "thudlike," which can indicate a solid mass (tumor) or fluid in the lungs HYPERRESONANT sounds •Louder and lower pitched than resonant sounds (similar sound to percussion of the cheeks), and are observed in patients that have a hyperinflated lung or a hyperinflated chest cavity •Hyperresonant sounds in PALS indicate tension pneumothorax

Magnesium is considered when? what are its effects? what can it cause?

Magnesium isn't necessarily considered a first line treatment for bronchoconstriction. However, it is considered in cases where patients fail to respond to conventional bronchodilator therapy. It can cause hypotension, so the child's blood pressure should be monitored if magnesium is administered Bronchodilator

When is Mannitol And/Or Hypertonic Saline considered?

Mannitol and/or hypertonic saline can be considered in the treatment of disordered control of breathing caused by increased intracranial pressure

What is Mottling? what is it caused by? what is it a sign of?

Mottling is described as "patchy" discolorations of the skin, and is caused by areas of vasoconstriction (pallor) mixed with areas of vasodilation (cyanosis or erythema) -The mechanism is unclear, and appears to simply be an irregular supply of oxygenated blood Mottling can be a sign of imminent death This will be on midterm. Mottling is a sign of vasoconstriction!! EXAM ANSWER. It is a sign of imminent death

What drug is used during a respiratory arrest? what is the dose? max dose? how often can it be repeated?

Narcan 0.1mg/kg; up to 2mg May repeat the dose after 4 minutes

Define the following: neonate, infant, child, adult. When do we use adult protocols for compressions and ventilation? adult defibrillator pads?

Neonate (1st 28 days of life) Infant (1 month to ≈1 year of age) Child (1 year to the onset of puberty) - Puberty is assumed to be ≈12 to 14 years of age or more precisely breast development in females and the presence of axillary hair in males Adult (puberty or older) - We use adult protocols for compressions and ventilations when for all patients with signs of puberty (breast development in females or axillary hair in males) - We use adult defibrillator pads for ages 8 and above (the defibrillator pads change at 8 years old)

Pediatric Airway Physiology - What is the normal shape of the diaphragm? How does this change during hyperinflation.? what does this result in?

Normally, the diaphragm is shaped like a dome, and it is most efficient in this form Lung hyperinflation, as in asthma, can cause the diaphragm to become flattened, which causes its contractions to become less forceful, which in turn results in less effective ventilation

How is Febrile defined? what should we consider administering?

Patients with a temperature ≥38⁰C are considered febrile. In PALS, consider administering Abx in the scenarios when a fever is present (which is common in sepsis and lung tissue disease)

Pediatric patients are especially prone to upper airway obstruction due to what two reasons?

Pediatric patients are especially prone to upper airway obstruction due to: -1. A larger tongue (relative to the size of the oropharynx) -2. A larger occiput that causes neck flexion and takes the patient out of the sniff position

What is Petechiae? Purpura? what are they caused by? what do they suggest? In PALS they are often a sign of what?

Petechiae and purpura are purple discolorations caused by small vessel bleeding under the skin. They can suggest a low platelet count, or can be a symptom of disseminated intravascular coagulation (DIC) - Petechiae are small dots, while purpura appear as larger areas In PALS, petechiae & purpura are often a OFTEN A SIGN OF SEPTIC SHOCK - In the septic shock algorithm, they may not say "petechiae or purpura;" they may just say "bruises," or "discolorations of the skin" Fat embolism syndrome can also cause this. If you ever see this in PALs you should immediately think of septic shock. They will say discoloration of skin or bruises or petechiae you need to think of septic shock.

The Twelve Possible Scenarios In PALS - What are the 4 possible cardiac scenarios? 4 possible respiratory scenarios? 4 possible shock scenarios?

Possible cardiac scenarios 1. Bradycardia 2. SVT/Vtach with a pulse 3. Vfib/pulseless Vtach 4. Asystole/PEA - Asystole & PEA are the most common initial rhythms in pediatric cardiac arrest Possible respiratory scenarios 5. Lower airway obstruction 6. Upper airway obstruction 7. Lung tissue disease 8. Disordered control of breathing Possible shock scenarios 9. Hypovolemic shock 10. Obstructive shock 11. Septic (distributive) shock 12. Cardiogenic shock In PALS, you will face: 1. One cardiac scenario 2. One respiratory scenario or one shock scenario Note: The respiratory scenarios can be combined with bradycardia, because hypoxia (from hypoventilation) is the most common cause of bradycardia in kids 3. defib, epi (doses different), amnioerone (doses different) 2. Stable vagal maneuvers, give adenosine (dose different) unstable, you would do cardioversion immediately 4. CPR, and epi 1.Way different. Big deal in children bc of fixed SV. Mostly due to hypoxia. Start chest compressions below 60. First step is oxygenation and ventilation in addition to chest compressions. Then Epi first (in ACLS we would do atropine first). If they suspect that brady is due to vagal input due to manipulation of airway. In this case you would give atropine first. BUT in all other cases you would give epi first. 5. Bronchospasm or pulmonary edema. Simply listen to the pt. bronchospasm would should like weezing. Pulmonary edema sounds like rails which is crackling 6. Croup which is an imflammed laryx. Leads to inspiratory straighter. Made worse by coughing. Give humidified oxygen to decrease dryness of air. 7. Pnemonia or aspiration 8. Abnormal RR which can be causes by increased ICP, neuromuscular disorder, or overdose Septic shock is massive vasodilation. Cardiogenic shock is pretty much HF due to congential heart defect and reduced SV. If pt is hypotensive it could be hypovolemic shock or cardiogenic shock. So you listen. If breath sounds are good then it is hypovolemic. Cardiogenic shock would have cracking breaths sounds due to pulmonary edema. NEVER give a fluid boluse to a pt in PALs without listen to breath sounds!!!!!!! Quiz question 11 and 7 both cause fever so listen to breath sounds. If poor then 7 if not then 11. If pt has bad lung sounds and normal BP then it is usually a respiratory prob but if breathing sounds and hypotension it is prob a cardiac problem.

Retractions With Other Signs of Airway Obstruction - state the diagnosis for the following symptoms Retractions + inspiratory snoring/stridor Retractions + expiratory wheezing Retractions + grunting or labored respirations Severe retractions Abnormal INSPIRATORY sounds indicate _______ airway obstruction, while abnormal EXPIRATORY sounds indicate ________ airway obstruction

REMEMBER: RESPIRATORY DISTRESS, RESPIRATORY FAILURE, AND SHOCK OFTEN LEAD TO CARDIAC ARREST IN CHILDREN KNOW THIS SLIDE.

What are the effects of Racemic Epinephrine? when is it indicated in PALS?

Racemic epi causes vasoconstriction in the airway, which leads to decreased swelling & edema in the airway -The vasoconstriction decreases vascular permeability in the airway, which leads to less intravascular fluid leaking into the interstitial space (which decreases edema) Racemic epi is thus indicated in cases of upper airway obstruction caused by swelling. It can also cause bronchodilation, so although not a first line treatment for bronchospasm, it can be considered for bronchospasm if other breathing treatments fail Used for airway swelling for example if pt had 5 intubation attempts. We would use this bc Decadron would not work enough.

Rales are described as? what are the two possible causes? in PALS, rales suggest what two situations?

Rales (Crackles, Crepitation) "Rales" is described as an intermittent popping sound -Some describe is as a "velcro" sound of rubbing hair together Possible causes include fluid in the distal airways or atelectasis IN THE PALS SCENARIOS -"Rales" can suggest cardiogenic shock or lung tissue disease •Rales in a hypotensive patient suggests cardiogenic (instead of hypovolemic) shock •Rales in a febrile patient suggests lung tissue disease (instead of sepsis) Indicated pulm edema or atelectasis suggest cardiogenic shock or lung tissue disease - Can differentiate two by blood pressure

Respiratory Distress vs. Respiratory Failure

Respiratory DISTRESS 1.Increased respiratory rate and effort, but able to move air 2.Potential abnormal airway sounds and pallor 3.Tachycardia and anxiety/altered mental state 4.If a patient improves with initial therapy, they are probably just in distress (not failure) Respiratory FAILURE 1.Labored breathing that is accompanied by signs of shock (cyanosis, lethargy, bradycardia, coma) 2.REQUIRES INTERVENTION/ASSISTANCE to prevent respiratory and or cardiac arrest (patients can have bradypnea, poor air movement, or even total apnea). For example, an SpO2 <90% on 100% FiO2 requires additional intervention 3.They may not respond to initial breathing treatments & interventions (low SpO2 despite high flow supplemental oxygen administration) In the PALS airway scenarios, they may ask you to list some indications for bag mask ventilation or intubation. This slide has a lot of those indications you can list (low SpO2, abnormal airway sounds, poor signs of perfusion, bradycardia, anxiety, lethargy (potentially due to hypercarbia), etc) Will have signs of labored breathing but can improve with therapy = distress Failure = they do not improve with oxygen or therapy. You would need to take over the airway. Need to know differences.

Retractions are manifested by? what is it a sign of? what are they caused by?

Retractions are manifest as an inward movement of the chest wall during inspiration, and is a sign that a child is trying to move air into their lungs by using their chest muscles. They are caused by increased airway resistance (or "stiff" lungs) impairing air movement

Classification of Retractions - what are the 2 classifications of retractions and what do they suggest?

Retractions that are substernal or subcostal suggest mild to moderate breathing difficulty Retractions that are suprasternal or supraclavicular suggest severe breathing difficulty

How is Rhonchi described? The sound is typically caused by what 3 things in what area?

Rhonchi are low pitched noises that have been described as a "snoring," or "bubbling" sound The sounds are typically caused by secretions, mucus, blood, etc IN THE LARGER AIRWAYS Can happen with any of the airway scenarios

Seesaw Respirations can be thought of as? what are they a sign of? what occurs during inspiration? what is it caused by? what do they usually indicate? when else can they be seen?

Seesaw respirations may be thought of as a more severe form of retractions, can quickly lead to fatigue, and are a sign of impending respiratory failure. Like retractions, the chest wall moves inward and the abdomen expands during inspiration, and the opposite happens during expiration (one goes up while the other goes down). It can be caused by neuromuscular disease (where diaphragm contraction dominates the weaker chest wall and abdominal muscles). They USUALLY indicate upper airway obstruction, but can also be seen in severe lower airway obstruction, lung tissue disease, and states of disordered control of breathing.

Seesaw Respirations are characteristic of children with? why does this occur?

Seesaw respirations usually indicate upper airway obstruction, but can also be seen in severe lower airway obstruction, lung tissue disease, and disordered control of breathing They are characteristic of children with neuromuscular weakness -The strong contraction of the diaphragm dominates the weaker abdominal and chest wall muscles, resulting in retraction of the chest and expansion of the abdomen during inspiration

What is a normal SpO2 in PALS on room air? _____% on 100% oxygen required intervention?

SpO2 >94% on room air <90% on 100% oxygen requires intervention

Steroids can be considered in what situations?

Steroids (such as dexamethasone) can be considered to relieve symptoms of UPPER airway obstruction/swelling/croup

When is suctioning contraindicated in PALS? what can we do instead?

Suctioning In Upper Airway Obstruction "Exercise caution as an obstruction caused by infection-induced edema will be aggravated by suctioning and may induce or worsen respiratory distress. Suctioning is contraindicated in this case; instead it is recommended to help the child find a comfortable position and administer a nebulizer treatment of epinephrine or racemic epinephrine." Contraindicated in croop bc it can make it worse.

How is airflow, resistance, and gas density related? For example, the lower the gas density the higher or lower the percentage of laminar flow? the higher or lower the resistance?

The amount of laminar (red) and turbulent (blue) airflow in our airways can also be affected by the density of the gas we breathe. The lower the gas density, the higher the percentage of laminar flow, and the lower the resistance -We'll talk more about this when we talk about Heliox in a few minutes... Heliox lowers the density of gas and reduces turbulent flow. It is indicated for upper airway obstructions?

How is Grunting described? does it occur during inspiration or expiration? When a child grunts what is occuring in their airway? why? what is it a sign of? what does it require? it can be seen in what 2 situations?

The grunting sound is a low pitched sound during EXPIRATION -When a child "grunts," they are closing the glottis earlier than usual during expiration in an attempt to maintain some positive airway pressure during expiration and to keep the alveoli open •In other words, it works to have the same effect as PEEP, and it happens with small airway obstruction/collapse Grunting is a very serious sign of respiratory distress and possible impending respiratory failure. It requires immediate intervention. It can be seen in lung tissue disease (pneumonia, pulmonary edema, pulmonary contusion, and ARDS) or pulmonary edema produced by cardiogenic shock Grunting is the worst sound to hear!! Know this.

What are the 2 primary advantages of Humidified Oxygen? when is it considered in PALs? why?

There are 2 primary advantages to humidified oxygen: -1. It decreases the chance of coughing (because patients are more likely to cough if their airway is dry) -2. The humidity can loosen mucus and provide easier breathing Clinically, coughing should be avoided in patients with respiratory distress, because it can exacerbate the symptoms of croup -Therefore, humidified oxygen is considered in moderate to severe croup (upper airway obstruction), and it can also be considered in asthma

What are the primary Expiratory Muscles? what is the role of the accessory expiratory muscles? where are they found and what do they include?

There aren't really any PRIMARY expiratory muscles, because expiration is usually a passive process. When exhalation needs to be more forceful, there are some ACCESSORY expiratory muscles, which include the INTERNAL intercostals and abdominal muscles: rectus abdominis, external oblique, internal oblique, and transversus abdominis

Larger vs. Smaller Airways - which is more prone to turbulent air flow?

Therefore, because the larger airways have more resistance than the smaller airways, the larger (upper) airways are more prone to more turbulent air flow Therefore (again), one of the things we can do in UPPER airway obstruction is to strive to decrease the amount of turbulent airflow (and we'll cover that here in a little bit...)

Hypotension (Systolic BP Readings) - Below what systolic BP is a neonate considered hypotensive? infants? children 1-10? older than 10? what is the equation to estimate a hypotensive systolic BP reading?

To make sure that you understand the formula, answer the following question: How low can the systolic pressure of a 3-year old patient go before they are considered hypotensive? 76 would be the lowest their systolic BP can go. HAVE TO NO THIS EQUATION FOR EXAM/QUIZ.

How is a Percussion Examination performed? what does it allow us to determine? what are the 3 different sounds that can be heard during percussion?

To perform this examination, a provider lays their left middle finger over a body surface, and then taps on it with their right middle finger -Listening to the sound that comes as this tapping is performed can help a provider determine the nature of the underlying structures The types of sounds that can be heard on percussion include "resonant," "hyperresonant," and "dull" When sound is resonant it is normal. Hyperresonant it indicates a tension pneumothorax. THIS IS ALL YOU NEED TO KNOW ABOUT THIS SLIDE AND NEXT SLIDE.

What is Wheezing? Does it occur during inspiration or expiration? what is it cause by?

Wheezing is a high-pitched noise, usually during expiration, that is caused by bronchoconstriction Expiatory and indicates bronchospasm. Lower airway obstruction

Resistance With Laminar & Turbulent Airflow

With laminar flow, resistance to airflow is inversely proportional to the FOURTH power of the airway radius. In other words, when the radius of the airway decreases, resistance increases to the FOURTH power With turbulent airflow, resistance to airflow is inversely proportional to the FIFTH power of the radius of the airway lumen

What is the "lower" dose of epi use to treat PALS shock? "higher" dose? which dose lowers SVR? raises SVR?

·"Lower" dose = <0.3mcg/kg/min ·"Higher" dose = >0.3mcg/kg/min The lower doses lowers SVR, and the higher doses raise SVR