Heartcode PALS
What circulation findings are specific to pericardial tamponade?
-Tachycardia -Narrowed pulse pressures -Muffled or diminished heart sounds
What should you evaluate to recognize septic shock?
-Temp -Heart rate -Systemic perfusion -Blood pressure -Clinical signs of end-organ perfusion
You administer adenosine (0.1 mg/kg) via a rapid bolus followed by a rapid flush of _________ normal saline.
5 to 10 mL
What is the recommendation for fluid bolus of isotonic crystalloids in cardiogenic shock?
5 to 10 mL/kg over 10 to 20 minutes
You administer a second dose of 0.2 mg/kg adenosine but it does not convert the tachycardia. The patient will require synchronized cardioversion. His weight is 6 kg. What should be the setting for the synchronized cardioversion?
6 J
How is tachycardia defined in pediatric patients?
A heart rate that is fast compared with the normal heart rate for the child's age
For stable patients with a regular wide complex, and monomorphic tachycardia consider:
Adenosine
The infant does not respond to the initial dose of adenosine for supraventricular tachycardia and now has these vital signs HR 265 SpO2 96%
Administer a second dose of adenosine at 0.2 mg/kg (maximum second dose 12 mg)
Where do tacharrhythmias originate?
Atria or ventricles
What causes primary bradycardia?
Congenital or acquired heart conditions
Whenever a child has an abnormal heart rate of rhythm, what must be done quickly?
Determine if the arrhythmia is causing hemodynamic instability or other signs of deterioration.
The most common cause of cardiac arrest in infants, children and adolescents is ___________, which is the end result of progressive hypoxia and acidosis.
hypoxic/asphyxial arrest
What is the proper dosing for epinephrine (IV/IO) administration during CPR?
-0.01 mg/kg IO/IV -Repeat every 3 to 5 minutes.
In which patients would bradycardia be an expected finding and not be considered problematic?
-A healthy child who is sleeping This is due to reduced metabolic demand -A well-conditioned athlete This is due to high stroke volume and increased vagal tone
What are the characteristics of ventricular tachycardia?
-A rapid rate compromises ventricular filling -It is a wide QRS complex generated within ventricles -The rapid rate may deteriorate into pulseless ventricular tachycardia or ventricular fibrillation
The patient has characteristics of supraventricular tachycardia, including a heart rate of more than 220/in. How would P waves appear on an ECG in a supraventricular tachycardia?
-Abnormal -Absent
Which signs and symptoms are consistent with supraventricular tachycardia?
-Absent or abnormal P waves -Heart rate 220/min or greater in an infant or 180/min or greater in a child -Heart rate does not vary with activity or stimulation
What signs distinguish anaphylactic shock from other types of shock?
-Angioedema (swelling of the face, lips and tongue) -Urticaria (hives) -Respiratory distress with stridor, wheezing or both
Which of the following should be considered for stable supraventricular tachycardia?
-Ask an older child to try to blow through an obstructed straw -Place a bag with ice water over the upper half of the infant's face
What is considered an initial management priority in managing tachyarrhythmias?
-Assess and support the airway, oxygenation and ventiliation -Obtain a 12-lead electrocardiogram if practical -Attach a continuous electrocardiographic monitor/defibrillator and a pulse oximeter
What are the common initial rhythms in both in-hospital and out-of-hospital pediatric cardiac arrest, especially in children younger than 12 years?
-Asystole -PEA
What are the characteristics of atrial flutter?
-Atrial rate can exceed 300/min and ventricular rate is slow -Can develop in children with congenital heart disease -A narrow-complex tacharrhythmia
What are common causes cardiogenic shock?
-Congenital heart disease -Myocarditis -Drug toxicity -Arrhythmias
After 2 more minutes of CPR, you notice the patient is moving and his skin color improves. his vital signs are 114 RR 8/min and temperature 37.9 C (100.2 F). The infant is still slow to respond but is moving. What should be the next steps for this patient?
-Continue oxygen -Obtain expert consultation -Support ABC's -Identify and treat underlying causes
What is the main objective of managing obstructive shock?
-Correct the cause of cardiac output obstruction -Restore tissue perfusion
What is the focus of the initial management of distributive shock?
-Correcting hypovolemia -Filling expanded dilated vascular space -Expanding intravascular volume
What are the initial assessment findings for septic shock?
-Fever -Hypothermia -Normal, elevated or decreased WBC
What are the electrocardiographic characteristics of bradycardia?
-Heart rate slow compared with normal heart rate for age -P wave and QRS complex may be unrelrated -QRS complex may be narrow or wide
Which signs and symptoms are consistent with sinus tachycardia?
-Heart rate varies with activity or stimulation -Present and normal P waves -Heart rate less than 220/min in an infant or less than 180/min in a child
When you evaluate the patient, you find the lungs are clear, skin is cool and mottled, glucose is 97 mg/dL and capillary refill time is 5 seconds. What are the warning signs that the patient is progressing from compensated shock to hypotensive shock?
-Hypotension (late sign) -Increasing tachycardia
What are the causes of secondary bradycardia?
-Hypoxia -Acidosis -Hypotension -Hypothermia -Drugs
What signs are present as obstructive shock progresses?
-Increased respiratory effort -Cyanosis -Signs of vascular congestion
In what conditions is atropine preferred over epinephrine as the first-choice treatment of symptomatic bradycardia?
-Increased vagal tone -Cholinergic drug toxicity (orgranophosphates) -Atrioventricular block due to primary bradycardia
What are the characteristics of ventricular tachycardia?
-It is a wide QRS complex generated within the ventricles -The rapid rate may deteriorate into pulseless ventricular tachycardia or ventricular fibrillation -A rapid rate compromises ventricular filling
What should your next steps be?
-Maintains a patent airway -Apply cardiac monitor to identify rhythm and monitor pulse, blood pressure, and oximetry -Complete the initial and primary assessment
Most patients in cardiogenic shock will need inotropic support with medications. Which of the following could be used?
-Milrinone -Epinephrine
The infant is placed on the ambulance stretcher and responds with a groan when stimulated and has a temperature of 36.3 C (97.3 F)
-Monitor and support ABCs -Establish IV/IO access -Monitor heart rate, blood pressure, and pulse oximetry -Call for assistance if needed
What clinical findings may be presented in a child with a tachyarrhythmia?
-Palpitations -Light-headedness -Syncope
What are causes of cardiac tamponade in children?
-Penetrating trauma -Cardiac surgery -Infection of the percardium
What are causes of obstructive shock?
-Pulmonary embolus -Tension pneumothorax -Congenital heart defects -Cardiac tamponade
What should be included in the initial treatment for this patient?
-Rapid fluid bolus administration -Establishing IV/IO access
In whom should you suspect a tension pneumothorax?
-Victim of chest trauma -Any intubated child who deteriorates suddenly while receiving in positive-pressure ventialtion -A child who deteriorates suddenly while receiving bag-mas ventialtion
What is the initial dose of epinephrine in the treatment of symptomatic bradycardia?
0.01 mg/kg IV/IO
What is the IV/IO dose of atropine for pediatric bradycardia?
0.02 mg/kg
What is the initial dose of denosine?
0.1 mg/kg IV/IO
What is the appropriate initial dose if synchronized cardioversion is needed?
0.5 to 1 J/kg
After synchronized cardioversion of 6 J, the patient remains in a supraventricular tachycardia. A second synchronized cardioversion. What is the recommended energy selection?
12 J
How is bradycardia defined in pediatric patients?
A heart rate that is slow in comparison with a normal heart rate range for the child's age, level of activity and clinical condition.
What is a FIRST-degree atrioventricular block
A prolonged PR interval representing slowed conduction through the atrioventricular node
What is the most appropriate method of delivering rapid fluid boluses to this patient?
A syringe and 3-way stopcock
If amiodarone or procainamide does not terminate the rapid rhythm, why should adenosine be considered?
A wide-complex tachycardia could be supraventricular tachycardia with aberrant ventricular conduction
After you attempt a vagal maneuver , the infrant's vital signs are HR 261/min, BP 72/50, RR 46/mm, SpO2 96% and he is crying. A 12 lead ECG is taken. What actions should be taken next? (IMG_8684)
Administer adenosine
CPR has been ongoing and IV access has been established. A pulse and rhythm check are done. He has the rhythm. What intervention would be most appropriate at this time?
Administer epinephrine
The child is awake, responsive and anxious. Her initial vitals signs are HR 168/min, BP 61/43 mm Hg, RR 44/min, SpO2 66%. What is the initial priority in treatment for this patient?
Administer oxygen (nonrebreating mask)
What is characteristic feature of supraventricular tachycardia?
An abrupt increase in heart rate that does not vary with activity
What is definitive treatment for most children with pulmonary embolism who are not in shock?
Anticoagulants
What electrocardiographic characteristics is consistent with sinus tachycardia?
Beat-to-beat variability with changes in activity
During the initial assessment, you find that the infant is unresponsive and has an HR of less than 60/min. What should be your next action?
Begin CPR
if bradycardia persists after initial treatment and the heart rate remains less than 60/min, what action should be taken next?
Begin CPR
How are tachycardia and tacharrhythmias classifed?
By the width of the QRS complex
How should sinus tachycardia be treated?
By treating the underlying cause
After the first fluid bolus is administered, the child is reassessed and her vital signs are HR 167, BP 58/44 mm Hg, RR 56/min and SpO2 92%. Her skin is still cool and pale and she is still lethargic and weak. What should be the next intervention?
Deliver a second fluid bolus of 20 mL/kg and reassess
How does the clinical presentation of distributive shock compare with hypovolemic shock?
Distributive shock has more variable presentation than that of hypovolemic shock
Vagal maneuvers are indicated for an infant with supraventricular tachycardia who is stable and they should be performed while preparations are being made for admistering adenosine and synchronized cardioversion (if necessary). Ice for the face is vagal maneuver that can be performed in infants and children of all ages. What precautions should be taken when performing this vagal maneuver?
Do not cover the nose or mouth
In the setting of impending or actual pulseless arrest when there is a strong suspicion of pericardial tamponade, what is the appropriate management?
Emergency pericardiocentesis
In children with severe cardiovascular compromise from pulmonary embolism, what treatment should be considered?
Fibrinolytic agents
Why do children with cardiac tamponade improve temporarily with fluid administration?
Fluids augment cardiac and tissue perfusion until pericardial drainage can be performed
For general shock management, administer an isotonic crytalloid bolus of __ mL/kg over __ to __ minutes
For general shock management, administer an isotonic crytalloid bolus of 20 mL/kg over 5 to 20 minutes
Based on the child's blood pressure, what type of shock is the patient in?
Hypotensive
The patient still has a blood pressure of 58/38 mm Hg. Her condition would be classified as ___________ shock.
Hypotensive
in a child with anaphylactic shock, what is the most appropriate initial treatment?
IM epinephrine
When should vasoactive therapy be considered be considered in managing distributive shock?
If the child remains hypotensive and poorly perfused despite rapid bolus fluid administration
What is heart rate is consistent with sinus tachycardia?
Infant: Less than 220/min Child: Less than 180/min
Your initial assessment indicates that the child is irritable and breathing rapidly. Which of the following is the most appropriate initial intervention?
Maintain patent airway; administer oxygen
The mother does not recall the infant's most recent weight. What is the most appropriate way to rapidly determine her weight and calculate correct medication?
Measure her by using color-coded length-based tape
Treatment for tension pneumothorax should not be delayed. Based on the child's assessment, what immediate intervention should be performed?
Needle decompression
What is the immediate treatment for tension pneumothorax?
Needle decompression
What is a THIRD-degree atrioventricular block?
None of the atrial impulses conduct to the ventricles
You measure the infant to be 7 kg and prepare to administer a fluid bolus of what type?
Normal saline 20 mL/kg
Why is it important to immediately identify obstructive shock?
Obstructive shock can rapidly progress to cardiopulmonary failure and then cardiac arrest
After the chest tube is inserted, the patient's breathing and oxygenation are improved. Her vital signs are HR 98/min, BP 108/72 mm Hg, RR 18/min, SpO2 98%. How should proper chest tube placement be confirmed?
Obtain a chest x-ray
Needle decompression is performed on the patient. As the needle is inserted, there is a rush of air coming from the hub of the needle. Vital signs are reassessed and are now Hr 134/min, BP 70/40 mm Hg and SpO2 82%. The patient still has labored breathing. Her SpO2 does not go above 82%; lung sounds are more present but are still diminished on the right side. Which of the following interventions is the most incorporate to do next?
Performs a thoracostomy for chest tube placement
What is initial treatment for pediatric bradycardia with cardiopulmonary compromise?
Provide bag-mask ventilation with 100% oxygen
What is the role of the diaphragm contraction during normal breathing in infants?
Pulls the ribs slight inward However, forcefully contracting the diaphragm results in a large drop in pressure within the chest, retracting
Pulmonary embolisms are ____ in children.
Rare
Where should the needle be inserted for proper needle decompression?
Right side of the chest, over the third rib (second intercostal space) in the midclavicular line
How soon after exposure do symptoms typically occur in anaphylactic shock?
Seconds to minutes
What is the priority in initially managing arrhythmias?
Support the airway, breathing and circulation
Identify this rhythm (IMG_8654)
Supraventricular tachycardia
What is the most likely rhythm? (IMG_8681)
Supraventricular tachycardia
What history is consistent with supraventricular tachycardia?
Symptoms of congenital heart disease
What findings help distinguish pulmonary embolism from hypovolemic shock?
Systemic venous congestion and right heart failure
Ausculating the patient's lungs demonstrates clear lung sounds on the left but absent lung sounds on the right. What is the most likely diagnosis for this patient?
Tension pneumothorax
What electrocardiographic characteristic is consistent with ventricular tachycardia?
The QRS complex is greater than 0.09 seconds
Why does sinus tachycardia typically develop?
The body needs increased cardiac output
How do you know if a needle decompression is successful?
There is gush of air when the needle is placed
What is the leading cause of symptomatic bradycardia in children?
Tissue hypoxia
What is an assessment finding unique to tension pneumothorax?
Tracheal deviation
For septic shock, how soon should fluid resuscitation begin?
Within 10 to 15 minutes after recognizing shock
When should antibiotics be administered in septic shock?
Within the first hour
