Pediatric Cardiac Arrest

Pupil response to light is a indicator of ______________ function. 1. Cortex 2. Hypothalamus 3. Limbic 4. Brainstem

#4 Brainstem Correct AHA PALS Provider Manual Pg. 58.

Thrombosis

(heart: acute, massive MI): Although rare in infants and children, coronary thrombosis is an occlusion or blockage of blood flow within a coronary artery caused by blood that has clotted within the vessel. The clotted blood causes an acute myocardial infarction which destroys heart muscle and can lead to sudden death, depending on the location of the blockage. ECG signs during PEA indicating coronary thrombosis include ST-segment changes, T-wave inversions, and/or Q waves. Physical signs include elevated cardiac markers on lab tests. Thrombosis (lungs: massive pulmonary embolism): Pulmonary thrombus or pulmonary embolism (PE), which is also rare in children, is a blockage of the main artery of the lung, which can rapidly lead to respiratory collapse and sudden death. There are some causes that should be considered when evaluating for pulmonary embolism. Embolism can be caused by a blood clot, catheter fragment, fat, air, or injected foreign material. There are some factors which predispose certain populations of children to intravascular thrombosis. These include sickle cell disease, malignancy, coagulation disorders, and the presence of an indwelling central venous catheter. Identification of PE may be difficult in children because the signs are very subtle and nonspecific. ECG signs of PE include narrow QRS Complex and rapid heart rate. Physical signs include no pulse felt with CPR, distended neck veins, positive d-dimer test, and/or prior positive test for DVT or PE. Treatment includes surgical intervention (pulmonary thrombectomy) and fibrinolytic therapy. (See PALS Obstructive Shock Page for recognition and management details)

Hyperkalemia and Cardiac Arrest Page)

...

Hypovolemic Shock Page

...

Respiratory Distress/Failure

...

Epinephrine (IV/IO):

0.01 mg/kg (0.1 mg/ml concentration). Administer every 3 to 5 minutes after the first dose. Endotracheal Route: if IV/IO it's not available, epinephrine may be given via ET tube. ET dose: 0.1 mg/kg.

epinephrine

0.01 mg/kg of epinephrine every 3 to 5 minutes.

The AVPU scale is a scale used to evaluate cerebral cortex function and is used to rate a child's level of consciousness. What does the acronym AVPU stand for? 1. Alert, Voice, Painful, Unresponsive 2. Active, Verbal, Painful, Unresponsive 3. Alert, Voice, Pupils, Unresponsive 4. Alive, Voice, Pulses, Understands AHA PALS Provider Manual Pg. 55.

1. Alert, Voice, Painful, Unresponsive Correct AHA PALS Provider Manual Pg. 55.

Which of the following is true regarding high-quality CPR? (choose all that are correct) 1. allow for complete chest recoil after each compression 2. each rescue breath should be given over 5 seconds 3. avoid excessive ventilation 4. with an advanced airway in place, deliver 15 breaths per minute Incorrect AHA PALS Provider Manual Pg. 81. A and C are correct. B and D are incorrect. Each rescue breath should be given over 1 second and when an advanced airway is in place 10 breaths per minute should be given.

1. allow for complete chest recoil after each compression 3. avoid excessive ventilation AHA PALS Provider Manual Pg. 81. A and C are correct. B and D are incorrect. Each rescue breath should be given over 1 second and when an advanced airway is in place 10 breaths per minute should be given.

Choose the scenarios that would require immediate CPR. 1. 3-year-old. not responsive, shallow breathing, weak pulse, HR 70 2. 7-year-old, not responsive, not breathing, weak pulse, poor perfusion, HR 55 3. 1-year-old, opens eyes, lethargic, rapid breathing, skin mottled, HR 55, 4. 4-year-old, not responsive, agonal breathing, no pulse AHA PALS Provider Manual Pg. 30 & 78. The following signs of cardiac arrest should be present for CPR to be initiated: unresponsiveness, no breathing or only gasping (agonal breathing), No pulse or pulse < 60 with signs of poor perfusion.

2. 7-year-old, not responsive, not breathing, weak pulse, poor perfusion, HR 55 3. 1-year-old, opens eyes, lethargic, rapid breathing, skin mottled, HR 55, 4. 4-year-old, not responsive, agonal breathing, no pulse AHA PALS Provider Manual Pg. 30 & 78. The following signs of cardiac arrest should be present for CPR to be initiated: unresponsiveness, no breathing or only gasping (agonal breathing), No pulse or pulse < 60 with signs of poor perfusion.

When cerebral hypoxia develops more gradually, the neurologic signs are the same as when severe cerebral hypoxia develops suddenly. 1. True 2. False AHA PALS Provider Manual Pg 55.

2. False Correct AHA PALS Provider Manual Pg 55.

In the seriously ill or injured child, the arterial lactate level can __________ as a result of tissue hypoxia and anaerobic metabolism. 1. Fall 2. Rise

2. Rise Correct AHA PALS Provider Manual Pg. 65. Lactate levels can be monitored and used to evaluate the effectiveness of therapy. For example, when the treatment of shock is effective, the arterial lactate level should decrease. The up or down trend of the lactate level is more important that the specific value. Most labs define normal value from arterial blood as 0.5 - 1.6 mmol/l

After completion of the primary assessment, if the child does not have a life-threatening condition, the secondary assessment should be completed. The secondary assessment consists of which of the following components? (Choose all correct answers) 1. General physical exam 2. Family medical history 3. Focused history 4. Focused physical exam AHA PALS Provider Manual Pg. 60-61. Secondary assessment consists of a focused history and a focused physical examination. A focused history should be obtained to identify important aspects of the child's presenting complaint. A focused physical exam should include an assessment of the primary area of concern of the illness or injury.

3. Focused history 4. Focused physical exam AHA PALS Provider Manual Pg. 60-61. Secondary assessment consists of a focused history and a focused physical examination. A focused history should be obtained to identify important aspects of the child's presenting complaint. A focused physical exam should include an assessment of the primary area of concern of the illness or injury.

The Glasgow coma scale is used to evaluate a child's level of consciousness and neurologic status. The child's best eye-opening, verbal, and motor responses are scored. If a child is intubated, unconscious, or preverbal, the most important part of this scale is _____________ response. 1. Eye-opening 2. Verbal 3. Motor Correct AHA PALS Provider Manual Pg. 57.

3. Motor Correct AHA PALS Provider Manual Pg. 57.

Amiodarone (IV/IO):

5 mg/kg bolus. This dose may be repeated up to 2 times for refractory ventricular fibrillation or pulseless VT. The maximum dose of amiodarone that can be administered over a 24 hour time period is 2.2 g. Amiodarone is not recommended for ET to use in peds.

What is a common cause of vasoconstriction and can result in a discrepancy between the peripheral and central pulses in children?

A cold environment can cause vasoconstriction and a discrepancy between the peripheral and central pulses." Typically, when this occurs, the peripheral pulse may be inadequate but the central pulse will remain strong. Ensure a neutral thermal environmental temperature to correct this discrepancy.

A decrease in the systolic BP of ____ mm Hg from baseline may be an indication of the development of shock.

A decrease in the systolic BP of 10 mm Hg from baseline may be an indication of the development of shock.

Chest compression depth in infants to children should be ____________. 1. at least one-fourth the anteroposterior diameter of the chest 2. at least one-third the anteroposterior diameter of the chest 3. at least one-half the anteroposterior diameter of the chest 4. 2 inches in depth Correct

AHA PALS Provider Manual Pg. 81. Push with enough force to depress the chest at least one third the anteroposterior diameter of the chest in pediatric patients from 1 year up to the onset of puberty.

A 7-year-old male brought to the ER with an airgun pellet injury to the upper part of the anterior chest was transported in a state of shock to a nearby trauma center. On assessment had engorged neck veins, pulsus paradoxus, and hypotension. Had a period of cardiac arrest and was resuscitated with high-quality BLS procedures. With the symptoms present, what 2 H's and/or T's should be considered in this situation? 1. thrombosis, pulmonary 2. tension pneumothorax 3. tamponade 4. hypoxia

AHA PALS Provider Manual Pg. 99. Both tension pneumothorax and cardiac tamponade should be considered when there is any traumatic injury to the chest area.

The correct location to palpate for a pulse in an unresponsive CHILD is _____________. (choose all correct answers) 1. carotid 2. radial 3. femoral 4. brachial AHA PALS Provider Manual pg. 17 & 76. The correct location to palpate for a pulse on a child is at the femoral or carotid location. The correct location in an infant is brachial.

AHA PALS Provider Manual pg. 17 & 76. The correct location to palpate for a pulse on a child is at the femoral or carotid location. The correct location in an infant is brachial.

Toxins:

Accidental overdose of several different kinds of medications can cause pulseless arrest. The arrest may be a result of direct cardiac toxicity or the secondary effects of respiratory depression or circulatory side effects. Ensure rapid communication with a poison control center. (1-800-222-1222) Some of the most common toxins include those that cause respiratory depression resulting in cardiac arrest. Examples include opioids, benzodiazepines, and ETOH. The focus of support for cardiac arrest caused by this type of toxin should focus on support of airway and ventilations and administration of antidotes when indicated. (See Disordered Control of Breathing Page) Reversing agent for opioids: Naloxone Reversing agent for benzodiazepines: Romazicon Some other medications can become toxic and increase the risk of the development of Torsades de Pointes (polymorphic VT). These include antiarrhythmics such as amiodarone and sotalol, tricyclic antidepressants, and calcium channel blockers. Medication overdose or toxicity may also increase the risk of bradyarrhythmias. Medications to consider when bradyarrhythmias are present include calcium channel blockers, Beta-adrenergic blockers, digoxin, opioids, clonidine, cholinesterase inhibitors, and succinylcholine. Support of circulation while an antidote or reversing agent is obtained is of primary importance. Poison control can be utilized to obtain information about toxins and reversing agents. Frequently, toxicity is temporary, and prolonged resuscitation efforts may be necessary. This prolonged effort may significantly improve long-term survival, and ECMO (extracorporeal membrane oxygenation) may also significantly improve long-term survival while toxins are given the time to be reversed or metabolized.

trauma

Although not specifically included in the PALS H's and T's, cardiac arrest caused by unrecognized trauma is something that should be given consideration. Trauma can be a cause of pulseless arrest, and a proper evaluation of the patient's physical condition and history should reveal any traumatic injuries. Treat each traumatic injury as needed to correct any reversible cause or contributing factor to the pulseless arrest.

The final aspect of the evaluate component for the evaluate - identify - intervene sequence is diagnostic tests. What is the primary diagnostic test for assessing the severity of respiratory problems? 1. Central venous oxygen saturation 2. Hemoglobin concentration 3. Arterial blood gas 4. Arterial lactate

Arterial blood gas

Hyper/Hypokalemia:

Both a high potassium level and a low potassium level can contribute to cardiac arrest. The major sign of hyperkalemia, high serum potassium, is taller and peaked T-waves. Also, a widening of the QRS-wave may be seen. This can be treated with a variety of interventions which include sodium bicarbonate (IV), glucose+insulin, calcium chloride (IV), Kayexalate, dialysis, and possibly albuterol. All of these will help reduce serum potassium levels.(See Hyperkalemia and Cardiac Arrest Page)

Most common cause of Pediatric Cardiac arrest

Cardiac arrest in children can occur suddenly; however, it is usually the end result of progressive tissue hypoxia and acidosis caused by respiratory failure and/or shock. Although rarer, sudden cardiac arrest does occur in children. When it does occur, it is often associated with athletic activity.

Tamponade:

Cardiac tamponade is an emergency condition in which fluid accumulates in the pericardium (sac in which the heart is enclosed). The build-up of fluid results in the ineffective pumping of the blood which can lead to cardiac arrest. ECG symptoms include narrow QRS complex and rapid heart rate. Physical signs include jugular vein distention (JVD), no pulse or difficulty palpating a pulse, and muffled heart sounds due to the fluid inside the pericardium. The recommended treatment for cardiac tamponade is pericardiocentesis. (See Obstructive Shock Page)

Asystole

During asystole, there is no blood flow to the brain and other vital organs. This results in very poor outcomes if resuscitation is successful. If asystole is visualized on the monitor, you should ensure that all leads are connected properly. If all leads are properly connected, you should rapidly assess for any underlying causes for the asystole. As with pulseless electrical activity (PEA), asystole can have possible underlying causes which can be remembered using the H's and T's mnemonic. (PALS H & T's are covered thoroughly in another area.)

Asystole:

ECG tracing that is usually a flatline on the monitor. During asystole, there is no blood flow to the brain and other vital organs. This results in a very poor outcome if resuscitation is successful. Review asystole page here.

(True or False) When assessing circulation, it is only necessary to assess the central pulses.

False Pals page 49

Tx of Pediatric Hypovolemic Shock

Fluid resuscitation consists of rapid boluses of isotonic crystalloid IV fluids (NS-normal saline or LR-lactated Ringer's). This treatment is primarily focused on correcting the intravascular fluid volume loss. The normal minimum dosing is at least three fluid boluses of 20 ml/kg each. As each 20 ml/kg fluid bolus is given, the Evaluate → Identify→ Intervene Sequence of the Systematic Approach Algorithm is carried out. The child's response to each fluid bolus should dictate the course of further treatment. Each bolus should be given over 5-10 minutes and reevaluation should take place. When reevaluation takes place, typical signs that would indicate improvement are decrease in heart rate, improved urine output, decreased respiratory rate, and improved level of consciousness. If the hypovolemic shock is a result of blood loss, this is classified as hemorrhagic hypovolemic shock. For hemorrhagic hypovolemic shock, boluses of isotonic crystalloid IV fluids are indicated, but the shock may not improve significantly. In this case, packed red blood cells (PRBCs) are indicated, and the standard dosing of PRBCs for refractory hemorrhagic hypovolemic shock is 10 mL/kg.

Hypoglycemia

Hypoglycemia, low serum blood glucose, can have many negative effects on the body and it is a common finding among critically ill children. Normal blood glucose levels should be greater than 60 mg/dl in children and 45 mg/dl in infants. Treat hypoglycemia with IV dextrose to reverse a low blood glucose.

Hypovolemic Shock Overview

Hypovolemic Shock Overview Hypovolemic shock occurs as a result of a reduction in intravascular fluid volume. This reduction of the intravascular fluid volume causes a decrease in stroke volume because of the resulting decrease in preload. The decrease in preload impairs cardiac output which ultimately leads to inadequate delivery of oxygen and nutrients to the tissues and organs (shock). Hypovolemic shock is the most common form of shock that occurs in children. The most common cause of hypovolemic shock and infant deaths worldwide in the pediatric population is dehydration resulting from diarrhea. Remember: Heart Rate x Stroke Volume (preload, afterload, contractility) = Cardiac Output. When preload is decreased, there are three compensatory mechanisms that can be possibly altered. The three compensatory mechanisms are increased HR, increased afterload, and/or increased contractility. These three compensatory mechanisms can be altered in an attempt to maintain cardiac output and may be used to help identify the presence of shock. If compensatory mechanisms fail and hypotensive shock (low systolic BP) develops, the chances of survival and recovery are significantly decreased.

Hypothermia

If a patient has been exposed to the cold, warming measures should be taken. The hypothermic patient may be unresponsive to drug therapy and electrical therapy (defibrillation or pacing) until warmed. Core temperature should be raised above 86 F (30 C) as soon as possible.

The D(disability) of the primary assessment is a quick evaluation of neurologic function. Which standard evaluations are included in this assessment? (choose all correct answers) 1. AVPU scale 2. Glasgow coma scale 3. Pupil response to light 4. NIH stroke scale 5. Blood glucose test

Incorrect AHA PALS Provider Manual Pg. 55. Standard evaluations include AVPU, Glascow coma scale, pupil response to light, and also a blood glucose test. Blood glucose is now included because a BG less than 45 in infants and a BG less than 60 in children can result in brain injury if not recognized and treated.

Lidocaine (IV/IO):

Initial bolus dose: 1 mg/kg Maintenance infusion: 20-50 mcg/kg/min Note: repeat the bolus dose if the infusion was initiated greater than 15 minutes after the initial bolus therapy. Not recommended for ET tube use in peds.

PALS Post Cardiac Arrest Care

PALS Post Cardiac Arrest Care Introduction: Once ROSC is obtained, treatment moves from the cardiac arrest algorithm to the evaluate, identify, intervene sequence of the systematic approach algorithm. During the post-cardiac arrest phase, a systems approach is used to support and maintain the stability of the patient. The objective is to reduce morbidity and mortality through the assessment and management of the respiratory system, the cardiovascular system, and the neurologic system. Each system is assessed and managed to ensure optimization of oxygenation, ventilation, and perfusion. These actions are carried out in order to stabilize cardiopulmonary function and preserve neurologic function. Open the systematic approach algorithm diagram to visualize this movement from the cardiac arrest algorithm to the systematic approach algorithm. PALS Systematic Approach Algorithm diagram or Members Download the Hi-Resolution PDF here. Goals for Post-Cardiac Arrest: The goals for the post cardiac arrest phase center around the identification and treatment of organ system dysfunction. Respiratory system: Goals: Optimize and stabilize airway, oxygenation, and ventilation Interventions: Confirm proper ET tube placement Provide adequate oxygenation and ventilation Assessments: Monitor end-tidal CO2 (Capnography), evaluate blood gas, chest x-ray Full Review: Respiratory System and Post Cardiac Arrest Cardiovascular system: Goals: Support tissue perfusion and cardiovascular function Prevent shock Interventions: Maintain adequate blood pressure and perfusion Treat arrhythmias Assessments: Assess tissue perfusion by monitoring lactate concentration, venous oxygen saturation, and base deficit Hemodynamic monitoring of intra-arterial blood pressure Urine output, capillary refill, skin temperature Full Review: Cardiovascular System and Post Cardiac Arrest Review of Post-Cardiac Arrest Shock Review of Post-Cardiac Arrest IV Medications Neurologic system: Goals: Neurologically intact survival Interventions: Implement TTM (targeted temperature management) Avoid hyperthermia Adequate analgesia and sedation Treat seizures and increased intracranial pressure Avoid hyperventilation Assessments: Monitor core temperature Point of care blood glucose level Perform ongoing neurological assessments Full Review: Neurologic System and Post Cardiac Arrest

Skin color changes with low tissue perfusion and low oxygen

Pallor Paleness, lack of normal color in the skin or mucous membrane. Mottling Irregular or patchy discoloration of the skin which may be caused hypoxemia, hypovolemia, or shock. Cyanosis Blue discoloration of the skin and mucous membranes Acrocyanosis Bluish discoloration of the hands and feet commonly seen during the newborn period. Peripheral cyanosis Bluish discoloration of the hands and feet seen beyond the newborn period.

Pediatric Caediac Arrest Signs, Symptoms

Signs/Symptoms: The most common recognizable signs of cardiac arrest include unresponsiveness, no breathing or only gasping, and no pulse. A pulse check should be attempted for no longer than 10 seconds and should not delay the initiation of CPR. In light of the progressive nature of most pediatric cardiac arrest events, there will usually be impending signs of cardiac arrest. These impending signs of cardiac arrest can be categorized using the ABCDE acronym. A: airway (obstruction, complete or severe) B: breathing (apnea, significantly increased work of breathing, bradypnea) C: circulation (weak or absent pulses, poor perfusion, hypotension, bradycardia) D: disability (decreased level of consciousness, unresponsiveness) E: exposure (significant hypothermia, significant bleeding, petechiae, or purpura consistent with septic shock or coagulation problems)

Signs and Symptoms of Pediatric Hypovolemic Shock

The Primary Assessment (ABCDE) of the Pediatric Systematic Approach Algorithm can be used to identify symptoms consistent with hypovolemic shock. The Primary Assessment acronym stands for Airway, Breathing, Circulation, Disability, and Exposure. A: Typically the airway of the child with hypovolemic shock will not be significantly affected. B: The patient may experience some Breathing changes and this may be recognized by a nonlabored tachypenea. C: The most notable changes will likely be seen with circulation. These circulation changes include tachycardia, narrowing pulse pressure, possible systolic hypotension, capillary refill time > 2 seconds, cool/pale skin, weak to absent peripheral pulses, reduced urine output. D: Disability or neurological changes include decreased level of consciousness. E: Exposing the patient to observe the child's skin and extremities will often reveal cool, pale, and mottled extremities.

sinus arrythmia The heart rate may normally _________with inspiration and _________with expiration. This is a normal physiologic response in children and is called sinus arrhythmia.

The heart rate may normally increase with inspiration and decrease with expiration. This is a normal physiologic response in children and is called sinus arrhythmia.

Magnesium (IV/IO):

The standard dose of magnesium that is administered for torsades de pointes is 25-50 mg/kg. The maximum recommended dose of magnesium is 2 grams.

ABGs

This value tells us about the acid-base balance. pH This value tells us whether oxygenation is adequate. PaO2 This value tells us whether ventilation is adequate. PaCO2 This value is used to determine if the source of an acid-base disturbance is respiratory or metabolic. HCO3 (bicarbonate) This value tells us the percentage of hemoglobin saturated with oxygen. SaO2

Hydrogen Ion (Acidosis):

To determine if the patient has respiratory acidosis, an arterial blood gas evaluation must be performed. Prevent and treat respiratory acidosis by providing adequate ventilation. Prevent metabolic acidosis by giving the patient sodium bicarbonate.

T or F A low hemoglobin (anemia) may make it harder to detect cyanosis in a critically ill child.

True PALS page 52

arterial blood gases

a test performed on arterial blood to determine levels of oxygen, carbon dioxide, and other gases present

Which of the following signs may be present with sudden and severe cerebral hypoxia? (Choose all correct answers) 1. Decreased level of consciousness 2. Loss of muscular tone 3. Generalized seizures 4. Pupil dilation

all Correct AHA PALS Provider Manual Pg. 55.

When cardiac arrest is associated with respiratory distress/failure or shock, the rhythms typically associated with the arrest include :

asystole, PEA, ventricular fibrillation, and pulseless ventricular tachycardia.

hypovolemic shock causes

dehydration from vomiting and diarrhea, hemorrhage, decreased intake of fluids, pathologic urinary losses (e.g. diabetic ketoacidosis, diabetes insipidus), and translocation of body fluids (e.g. burns, peritonitis, small bowel obstruction).

Hypoxia:

deprivation of adequate oxygen supply, can be a significant contributing cause to cardiac arrest. You must ensure that the patient's airway is open and that the patient has chest rise and fall and bilateral breath sounds with ventilation. Also, ensure that your oxygen source is connected properly. (See Respiratory Distress/Failure Page)

The standard pediatric dosing for defibrillation is

is 2-4 J/kg. Typically, defibrillation will start with 2 J/kg for the first shock, and then if VF or pVT persists, the dosage would be increased to 4 J/kg for the second shock. If VF or pVT persists after the second shock of 4 J/kg, use at least 4 J/kg or higher but do not exceed 10 J/kg or the maximum adult dose of 360 J. For defibrillation, place the electrode pads so that the heart is between them. The two most common positions for pad placem

major signs of hypokalemia

low serum potassium, are flattened T-waves, prominent U-waves, and possibly a widened QRS complex. Treatment of hypokalemia involves rapid but controlled infusion of potassium. Giving IV potassium has risks. Always follow the appropriate infusion standards. Never give undiluted intravenous potassium.

Tension pneumothorax

occurs when air is allowed to enter the pleural space and is prevented from escaping naturally. This leads to a build-up of tension that causes shifts in the intrathoracic structure that can rapidly lead to cardiovascular collapse and death. ECG signs include narrow QRS complexes and slow heart rate. Physical signs include JVD, tracheal deviation, unequal breath sounds, difficulty with ventilation, and/or no pulse felt with CPR. Treatment of tension pneumothorax is needle decompression. (See Obstructive Shock Page)

Hypovolemia

the loss of fluid volume in the circulatory system, can be a major contributing cause to cardiac arrest. Looking for obvious blood loss in the patient with pulseless arrest is the first step in determining if the arrest is related to hypovolemia. After CPR, the most important intervention is obtaining intravenous access/IO access. A fluid challenge (fluid bolus) may also help determine if the arrest is related to hypovolemia. (See also .)Hypovolemic Shock Page

compensatory mechanisms for decreased preload

three compensatory mechanisms that can be possibly altered. The three compensatory mechanisms are increased HR, increased afterload, and/or increased contractility. These three compensatory mechanisms can be altered in an attempt to maintain cardiac output and may be used to help identify the presence of shock.

Normal capillary refill time in children is ___________.

≤ 2 seconds