Pediatric Emergencies

4 types of vascular access:

1. Peripheral IV 2. Central IV 3. Saphenous Vein (foot/ankle) 4. Intraosseous access

To achieve the two goals of distributive shock treatment: (5)

1. Use crystalloid initially 2. Base additional fluid therapy on lab studies 3. Give up to 40 ml/kg without monitoring central venous pressure 4. Vasoactive/Cardiotonic agents are often necessary 5. Treat the cause

In cases of cardiogenic shock, CO decreases and ultimately results in: (3)

1. Volume retention 2. Pulmonary edema 3. RV failure

When suctioning the child, decrease the suction pressure to less than _____ mm/Hg in infants (green).

100

During endotracheal intubation, be extremely vigilant about repeatedly monitoring proper placement. Check for the following: DOPE

D isplacement--is the tube still in the right place? O bstruction--Secretions, pinched tubing, turned head P neumothorax--Over-bagging, excessive force E quipment failure

Stroke Volume depends on: (3)

1. Myocardial Contractility 2. Preload 3. Afterload

When restoring IV volume, infuse isotonic solutions such as: (3)

1. NS 2. LR 3. 5% albumin

Nursing management of a child with a pediatric emergency includes the following in order of priority: (5)

1. Patent airway 2. Supplemental oxygen 3. Monitoring change in status 4. Assisting ventilation 5. Offering support and education to the child and family.

Avoid excessive suctioning time. Less than ___ sec.

10

Giving artificial breaths: If not intubated, give ____ breaths every ___-____ compressions.

2 breaths every 15-30 compressions

Initial fluid bolus for children:

20 ml/kg

____ albumin should never be give over less than 30 minutes due to pulling power.

25%

Intraosseous access is the first choice for emergency peripheral access in children less than ___ - ___ years.

4-6

Treatment of reduced circulatory volume is based on the presumed etiology. Rapid restoration of IV volume is necessary. Insert peripheral IV within ___ to ____ seconds.

60-90 seconds

The nurse is determining the systolic blood pressure of a 5-year-old girl. The nurse calculates the minimum acceptable systolic BP is:

70 + (age in years X 2) 70 + (5 x 2) 70 + 10 = 80

ABCs of life support:

Airway Breathing Circulation

While suctioning, stimulation of the vagus nerve should be avoided. What is a sign that the vagus nerve has been stimulated. What should the nurse do?

Bradycardia Stop suctioning and give O2

The condition of an 11 year old boy who is on mechanical ventilation begins to deteriorate. Which of the following would the nurse do next? A. Confirm that the ventilator is working properly B. Examine the child for signs of pneumothorax C. Check to see if the tube is displaced D. Suction the tube to remove a mucus plug

C. Displacement (then Obstruction, Pneumothorax, and Equipment Failure in that order)

The nurse is assessing the respiratory status and lungs of a 6-year old child. Which of the following would the nurse report immediately? A. Resonance over the lungs on percussion B. High-pitched breath sounds over the trachea C. Minimal air movement through the lungs D. Low-pitched bronchial sounds over the periphery

C. Minimal air movement through the lungs Rationale: Determines ventilatory status. Child may be well-perfused due to supplemental oxygen but unable to exchange gas on his or her own.

The nurse is assessing the neuro status of an 11 month old girl. Which finding would be cause for concern? A. The child is crying and looking around fearfully B. The child's eyes remain closed unless she is spoken to. C. Inspection shows a sluggish pupillary reaction D. Palpation of the head reveals a closed posterior fontanel.

C. Suggests brain injury

Shock Classification: Blood flow is normal or increased and may be maldistributed (shunted). Vital organ function is maintained.

Compensated

Increased WOB is a ______ mechanisms where as decreased WOB without intervention reflects ______.

Compensatory (trying to overcome underlying problem) Decompensating (no longer trying to fight underlying problem). DECREASED WOB WITHOUT INTERVENTIONS IS A VERY BAD SIGN

Fluid resuscitation begins with 20 ml/kg of _____ or 10 ml/kg of _____ solution.

Crystalloid or Colloid

A 4-year-old girl, injured in an MVA, is suspected of having a head injury. Which of the following would be the priority? A. Providing manual stabilization of the head and neck B. Hyperventilation with a bag-valve-mask C. Stabilizing the head and neck with a backboard D. Opening the airway using the jaw thrust maneuver.

D. Airway is priority and jaw-thrust is considered safe for patients with suspected head and neck injuries

A 5 year old girl is breathing spontaneously but is unable to maintain an airway. Which of the following would be the priority? A. Placing a towel under her shoulders B. Assisting with tracheal tube insertion C. Positioning her using head tilt/chin lift D. Inserting an oropharyngeal airway

D. Due to her inability to maintain an airway A and C will not do any good. B. may be needed should D not work.

Type of shock with high CO and low SVR (vessels are wide open). Results in maldistribution of blood flow causes inadequate tissue perfusion.

Distributive

Besides hypovolemic shock, three other common types in children:

Distributive (sepsis, anaphylaxis) Cardiogenic (pump problem) Obstructive (Systemic Vascular Resistance)

Type of airway ventilatory method that allows direct visulaization of the lower airway through the trachea. It is the most effective method of controlling a patient's airway.

Endotracheal Intubation

T or F. The nurse accessing a vein to manage a child while CPR is in progress uses the recommended route--the saphenous vein.

False. The femoral route is best for obtaining central venous access while CPR is in progress. It provides a direct route to the heart but is out of the way of the action.

The mainstay of hypovolemic shock treatment:

Fluid administration

The main sign that distinguishes decompensated shock from compensated shock.

HYPOtension

Because CO = HR x SV, children are most dependent on ____ to control CO.

Heart Rate. They cannot regulate stroke volume.

General appearance assesses _____ _____ ______ by looking mostly at interaction with the environment.

Higher Brain Function

_____ can lead to CNS damage and must be corrected for proper cardiovascular function.

Hypoglycemia

Most common type of shock in children. # 1 Cause of death in children worldwide.

Hypovolemic (blood loss and dehydration)

Hypovolemic shock is caused by low preload which decreases stroke volume and cardiac output. How does the body compensate for this state?

Increased heart rate and systemic vascular resistance

Shock Classification: Inadequate perfusion to vital organs. Irreparable damage. Death cannot be prevented.

Irreversible

Type of airway ventilatory method that blocks the esophagus to direct air to the lungs.

Laryngeal mask airway (LMA)

How does one measure the NG tube for proper placement prior to insertion?

Measure the tube from the tip of the nose to the ear to the tip of the xiphoid process.

When combined with other details from the assessment, this should be taken very seriously in children as a sign of decompensation.

Mild hypotension

The most common form of distributive shock. The second most common:

Most: Early septic shock 2nd: Anaphylactic

Drugs that can be administered through a tracheal tube (an outdated method, by the way) can be memorized with the mnemonic device "NAVEL". What does that stand for?

N aloxone A tropine V asopressin E pinephrine L idocaine

A 14 year-old child is brought to the ED. His parents state that they think he took too many of his pain pills (oxycodone for a bone infection). Which agent would the nurse expect to be administered to counteract the analgesic?

Naloxone (Narcan)

Hypotension is defined as systolic pressure: _____ in neonates....____ infants....____ 1-10 years...____ over 10 years of age.

Neonates: < 60 mm Hg Infants: < 70 mm Hg 1-10 years: < 70 + (age in years x 2) Over 10: < 90 mm Hg

____ _____ can cause a hyperchloremic acidosis.

Normal Saline

Type of shock characterized by low CO secondary to a physical obstruction to blood flow. Compensatory increase in systemic vascular resistance.

Obstructive

______ are used to replace blood loss or if the child is still unstable after 3 fluid boluses of 20 ml/kg/bolus.

Packed Red Blood Cells

Shock in children results most often from _____ or _____ compromise.

Respiratory or hemodynamic

ROSC

Return of Spontaneous Circulation

Cardiac output depends on: (2)

Stroke Volume and Heart Rate

In cases of cardiogenic shock, a compensatory increase in ____ occurs to maintain vital organ function. There is then a subesequent increase in left ventricular afterload, work, and cardiac oxygen consumption.

Systemic Vascular Resistance

Ventilations are extremely important in pediatrics due to the large percentage of asphyxial arrests. Ventilations are, however, often delayed while assembling equipment. Therefore, START CHEST COMPRESSIONS immediately. What is the rationale for this?

The blood is already oxygenated but must be circulated to the tissues.

Pulses are weak in these types of shock (2) but may be bounding in these types (3)

Weak: 1. Hypovolemic 2. Cardiogenic Bounding: 1. Anaphylactic 2. Neurogenic 3. Septic

This is more informative in children than absolute respiratory rate.

Work of Breathing

Interpret the following colors observed on an In Tidal CO2 detector: Yellow. Purple.

Yellow--Yes, in the right place Purple--Problem. Not in the airway

Metabolic _____ develops secondary to tissue hypoperfusion. Profound cases depress myocardial contractility and impairs the effectiveness of catecholamines (decreasing the effectiveness of drugs given to combat shock). Treat with fluid administration and controlled ventilation.

acidosis

Excessive ventilation may cause _____ _____ and _____ in patients with small airway obstruction.

air trapping and barotrauma

According to PALS avoid delivering excessive ventilation during _____ _____ because it may lead to acidosis, increased intrathoracic pressure (impeding venous return) which will reduce CO and cerebral and coronary blood flow.

cardiac arrest

In states of shock, the body compensates by:

constricting large vessels and shunting blood to vital organs

Isotonic ______ infusion is always a good choice to treat hypovolemic shock. 20-50ml/kg rapidly if cardiac function is normal.

crystalloid

Initial therapy for cardiogenic shock is a ___ _____ because the presenting symptoms can be identical to hypovolemic shock.

fluid challenge

Excessive ventilation can increase the risk of stomach inflation which may lead to _______ and ______.

regurgitation and aspiration

When assessing a child with a traumatic injury, which of the following would be the priority assessment? A. Airway patency and airflow B. Breathing effectiveness and breath sounds C. Pulse rate and skin color D. LOC and pupillary reaction.

A. (then B, C, D in that order)

_____ is important for cardiac function and for the pressor effect of catecholamines.

Calcium

Blood pressure depends on: (2)

Cardiac output and systemic vascular resistance

According to PALS, ventilatory support should only use the force and tidal volume necessary to achieve:

visible chest rise.

Whereas supplemental oxygen is always provided in cases of shock, consider endotracheal intubation and controlled ventilation is suggested if ____ ____ or _____ ______ is likely.

respiratory failure or airway compromise

Capillary refill is a good measure in kids, especially when done in _______ fashion in a ________ environment.

serial fashion normothermic (always check the thermostat)

Shock classification: Microvascular perfusion is compromised; significant reductions in effective circulating volume.

Uncompensated

The two goals of treating distributive shock:

1. Maintain intravascular volume 2. Minimize increases in interstitial fluid

Indications for Endotracheal Intubation: (6)

1. Need for prolonged artificial ventilation 2. Inadequate ventilatory support with bag-valve-mask 3. Cardiac/Respiratory Arrest 4. Control of an airway in a patient without a cough or gag reflex 5. Route of drug administration (NAVEL) 6. Access to airway for suctioning.

The cause should be treated in cases of obstructive shock. Examples of treatment include: (3)

1. Pericardial drain 2. Chest tube 3. Surgical intervention

Causes of obstructive shock: (5)

1. Pericardial tamponade 2. Tension pneumothorax 3. Critical coarctation of the aorta 4. Aortic stensosis 5. Hypoplastic Left Heart Syndrome

Clinical assessment of cardiac output includes: (6)

1. Peripheral perfusion 2. Temperature 3. Cap refill 4. Urine output 5. Mentation 6. Acid-Base Balance

Study methods to maintain an open airway:

1. Positioning (Towel placement under neck) 2. Head tilt 3. Jaw thrust

Distributive shock may be caused by: (4)

1. Release of endotoxins (sepsis) 2. Vasoactive substances (allergic reactions) 3. Complement cascade activation (don't ask me) 4. Microcirculation thrombosis

Work of breathing reflects: (3)

1. Resistance in small air passages 2. Dependence on diaphragm 3. Weakness of chest wall muscles

Goals of hypovolemic shock therapy: (3)

1. Restore IV volume 2. Correct metabolic acidosis 3. Treat the underlying cause

Neurologic assessment of a child with a pediatric emergency includes: (7)

1. Sensorium in an older child 2. Interest in the environment in an infant 3. The child's head 4. Eyes 5. Face 6. Spontaneous extremity movement 7. Pediatric Glasgow Coma Scale

Early signs of shock: (3)

1. Sinus tachycardia 2. Delayed cap. refill 3. Fussy and irritable

Common causes of respiratory arrest in children: (5)

1. Smaller airways 2. Underdeveloped immune systems 3. Lacking coordination (sucking, breathing, swallowing) 4. Susceptible to choking 5. SIDS

If rescue breathing only, give ___ breath every __-__ seconds. The younger the child, the higher the rate.

1 breath every 3-5 seconds

Giving artificial breaths: If intubated, give ___ breath every __ -___ seconds.

1 breath every 6-8 seconds

Giving artificial breaths: Give each breath over ____ second(s).

1 second

Cap refill time can be influenced by: (4)

1. Ambient temperature 2. Site 3. Age 4. Lighting can affect interpretation

Etiologies of distributive shock: (6)

1. Anaphylaxis 2. Anaphylactoid reactions 3. SCI/ spinal shock 4. Head injury 5. Early sepsis 6. Drug intoxication (barbituates, phenothiazines, antihypertensives)

Tips for pediatric ventilation: (5)

1. Avoid excessive bag pressure and volume 2. Obtain chest rise and fall 3. Allow time for exhalation 4. Do not use bag-valve-masks with pop-off valves (increases pressure...often used for patients with COPD or asthma) 5. Avoid hyperextension of the neck.

The risk of gastric inflation during ventilation can be decreased by: (2)

1. Avoiding excessive peak inspiratory pressures by ventilating slowly and giving only enough to achieve visible chest rise 2. Pass an NG tube or OG tube to relieve gastric inflation

Late signs of shock: (6)

1. Bradycardia 2. Altered mentation 3. Hypotonia, decreased DTRs 4. Cheyne-Stokes breathing 5. Hypotension (VERY LATE SIGN) 6. Lower limit of SBP --70 + (Age in years x 2)

Etiologies of Cardiogenic Shock: (6)

1. Congenital Heart Disease 2. Arrhythmias 3. Ischemic Heart Disease 4. Myocarditis 5. Myocardial injury 6. Acute and chronic drug toxicity

Mistakenly sized or misplaced endotracheal intubation can quickly lead to hypoxia, resulting in: (2)

1. Death 2. Persistent vegetative state

While not a great indicator of circulatory volume by itself, a capillary refill time greater than 2 seconds is a useful indicator of moderate dehydration when combined with: (4)

1. Decreased urine output 2. Absent tears 3. Dry mucous membranes 4. Generally ill appearance

Types of vasoactive agents used in cases of shock: (5)

1. Dopamine 2. Dobutamine 3. Norepinephrine 4. Milirinone 5. Phenylephrine

The three parts of the pediatric assessment triangle (PAT)

1. General Appearance (quick, done from a distance, takes seconds, repeated as necessary) 2. Work of breathing 3. Circulation

Higher brain function depends on: (3)

1. Good oxygenation 2. Ventilation 3. Perfusion to the brain.

What two questions does the general appearance answer?

1. How sick is the child? 2. How acute is the situation?

Indications for NG intubation: (2)

1. Inability to achieve adequate tidal volume during ventilation due to gastric distention 2. Presence of gastric distention in an unresponsive patient

3 signs in response to which the nurse should anticipate shock:

1. Increased respiratory rate with signs of distress 2. Inadequate respiratory rate, effort, or chest excursion with mental status depression 3. Cyanosis with abnormal breathing despite supplementation

How does one check the placement of the endotracheal tube? (3)

1. Listen for gastric insufflation sounds over the stomach. Should be ABSENT 2. Check for exhaled CO2 3. If there is perfusing rhythm, check O2 Saturation with Pulse Ox.

Signs of compensated shock: (5)

1. Tachycardia 2. Cool and pale distal extremities 3. Prolonged (> 2 SECONDS) cap refill 4. Weak peripheral pulses compared to central pulses 5. NORMAL SYSTOLIC BP