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171 Cards in this Set
- Front
- Back
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PALS primary assessment differs a bit from other assessment algorithms we have presented in that it also includes________. In other assessment algorithms including PHTLS, we have included "that" as a first step in the secondary assessment.
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-Pulse oximetry
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PALS "Identify" step in their assessment process includes identification of four types of respiratory problems. What are they?
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-Upper airway obstruction
-Lower airway obstruction -Lung tissue disease -Disordered control of breathing |
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PALS "Identify" step in their assessment process includes identification of four types of circulatory problems. What are they?
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-Hypovolemic shock
-Distributive shock -Cardiogenic shock -Obstructive shock |
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PALS categorizes the respiratory condition of the patient as either respiratory _________ or respiratory _______.
Describe the difference between those two situations. |
-distress: abnormal respiratory rate or effort; may be increased or inadequate; ranges from mild to severe.
-failure: inadequate oxygenation, ventilation, or both; often end stage of distress. |
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PALS categorizes the cardiovascular condition of the patient as either _______ shock or ________ shock.
Describe the difference between those two situations. |
-compensated: open/maintained airway, normal/inc. breathing rate; normal sounds (may/not have crackles); Pulse may/not weak; skin pale/warm/cool
-hypotensive: non-maintainable airway; labored breathing rate; crackles/grunting; pulse weak; skin pale/cool |
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PALS suggests that the proper positioning of the patient is helpful to manage the airway. In cases where you are not required to perform a head tilt-chin lift or jaw thrust, how should you position the child?
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-Allow ped pt to assume a position of comfor or position the child to improve airway patency.
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What are the five parts of the PALS breathing assessment?
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-Respiratory rate
-Respiratory effort -Chest expansion & air movement -Lung & airway sounds -O2 saturation by pulse oximetry |
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PALS suggests that you evaluate the child's respiratory rate ______ you perform other assessments.
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-before
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PALS suggests that you count the child's respiratory rate for _____ seconds.
Why? |
-30
-In the case of sleeping infants, the pattern is irregular and the rate itself might not be as helpful as the actual assessment of effort to breath. |
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If you have a child patient who was tachypneic but has now slowed their breathing rate, how do you know if that patient is improving or getting worse?
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-Improvement only if level of consciousness & reduced signs of working to breath are associated with the slowing of breathing rate.
-Worse if the level of consciousness also deteroriates. |
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PALS talks about "quiet tachypnea" as opposed to tachypnea with respiratory distress. What are some conditions that could cause quiet tachypnea?
Why is this true? |
-high fever, pain, dehydration, DKA, sepsis, early CHF, severe anemia, some congenital heart defects
-because its the body's way of attempting to fix metabolic acidosis rather than address hypoxia |
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We usually don't use the term "bradypnea". PALS mentions it as a key assessment point and notes several causes. List them.
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-respiratory muscle fatigue; central nervous system injury or infection; hypothermia; medication related
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List as many signs of increased respiratory effort as you can.
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-nasal flaring; retractions; head bobbing; seesaw breathing; open-mouth breathing; gasping; use of accessory muscles; grunting; prolonged expiratory phase
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What are retractions and why are they important to detect?
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-inward movements of the chest wall or tissues, neck or sternum during inspiration
-important as a sign that air movement is impaired and that the child is having to use chest muscle to move air into the lungs. |
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What is grunting and why is it important to detect?
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-short, low-pitched sound heard during expiration; occurs when exhaling against a partially closed glottis and meant to keep the alveolar sacs open.
-often a sign of lung tissue disease resulting from small airway collapse, alveolar collapse or both; may mean progression from distress to failure. |
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What is head bobbing and why is it important to detect?
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-chin lifts and neck extends during inspiration in attempt to get accessory muscles involved in inspiration; usually seen in infants; can be a sign of failure.
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What is see-saw breathing and why is it important to detect?
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-chest retracts and abdomen extends during inspiration (accessory muscles attempting to help) likely related to upper airway obstruction or bad lower airway obstruction.
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What is stridor and why is it important to detect?
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-severe distress sign; high pitched sound on inspiration and sometimes also on expiration; upper airway obstruction from swelling or foreign body.
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When auscultating to detect the effectiveness of air movement, where does PALS suggest that you listen?
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-over the anterior and posterior chest because the chest is so small that sounds are transmitted easily from side to side.
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In a patient with bronchiolar obstruction, what abnormal lung sound should you suspect and why?
Will all patients with bronchiolar obstruction produce that sound Which ones may not? |
-wheezes caused by narrowed bronchioles that act to make a whistle when air movement occurs.
-If the child is not moving any air throught the obstructed bronchiole, then no whistle, thus no wheezes. |
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What conditions cause stridor?
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-upper airway obstruction from swelling or foreign body
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What conditions cause grunting?
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-small airway collapse, alveolar collapse due to atelectasis or both
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What conditions cause gurgling?
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-secretions in the upper airway
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What conditions cause crackles?
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-fluid in the alveoli or the alveoli opening
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What conditions cause wheezing?
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-lower airway obstruction (asthma, bronchiolitis)
-isolated inspiratory: foreign body or other cause of partial obstruction of trachea or upper airway. -bronchiolar obstruction "essentially" |
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PALS lists two types of crackles---what are they and what do they suggest?
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-Moist crackles: accumulation of alveolar fluid (pneumonia, pulmonary edema or interstitial lung disease)
-Dry crackles: atelectasis and interstitial lung disease |
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What is hypoxia?
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-low O2 in the tissues
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What is hypoxemia?
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-low O2 in the blood
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Does pulse oximetry detect hypoxemia or hypoxia?
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-hypoxemia
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Does pulse oximetry help you assess ventilation? Why or why not?
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-No; capnography readings are better as assessing ventilation but metabolism and perfusion must be normal before decisions are made about ventilation based on capnometry.
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Can a patient by hypoxemic but not hypoxic? How?
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-Yes; hypoxemia is a indicator that there is low O2 in the blood but if cardiac output is increased to compensate, then more blood moving past the tissues but not carrying the usual O2 load; measured by pulse oximetry.
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How can you evaluate the accuracy of a pulse oximetry reading?
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-Watch the signal strength indicator on the pulse ox and match the HR on the pulse ox w/the pts HR.
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What conditions can give you false readings on pulse oximetry?
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-Poor perfusion, cold skin, carbon monoxide, methemoglobinemai
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How do you assess capillary refill?
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-normothermic environment--raise just above the level of the heart--doesn't have to be a nailbed
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What is the value of using capillary refill for an assessment?
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-Faster than a BP; gives some qualitative info; similar to presence of peripheral pulses.
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Is capillary refill a reasonably accurate measure in infants and children?
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-If present in peds, its reasonable to consider that perfusion is not normal but its absence does NOT guarantee normal perfusion.
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What is considered a delayed capillary refill time?
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-less than or equal to 2 seconds or the time it takes you to say "capillary refill".
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What causes delayed capillary refill?
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What is mottling and what does it tell you?
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What is pallor and what does it tell you?
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What is peripheral cyanosis and what does it tell you?
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What is central cyanosis and what does that tell you?
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How do you know what a normal HR, RR or BP is for an infant or child?
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Your patient is hypovolemic. Why is she tachycardic?
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What if your hypovolemic patient who was tachycardic starts to have her HR decrease---what does that mean?
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Make a chart (from memory) of the GCS for adults. Now add children and infant to it---what is the amin difference for infants on motor response compared to other ages?
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Do children have a higher or lower need for O2 to support metabolism compared to adults in terms of ml/kg/min? How much difference is there?
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In a pediatric patient with hypoxia, what would you expect their HR and RR to do compared to normal while they are compensating?
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What about the situation in number 53 if they have now decompensated?
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Describe how the blood gets "loaded" with oxygen----include as many steps as you can. (see number 56---we ask you to name things that go wrong in each phase of this process).
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List five conditions that could lead to hypoxemia and briefly explain what is happening in each and your treatment.
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If your patient was initally agitated & anxious with a low pulse oximetry reading & you gave supplemental oxygen that has now improved the pulse oximetry reading to above 90% & it is still climbing & the child seems MUCH more calm &, actually, really seems to be pretty tired & listless, is this a problem? if so, what is the problem & how will you fix it?
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Explain why the same amount of airway edema/inflammation in an adult will have a much less significant impact than that same amount in an infant.
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What is lung compliance?
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What causes decreased lung compliance?
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How can gastric distention impact ventilation?
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What impact is there from the difference in chest wall compliance in very young patients compared to older children or adults?
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Inspiration is normally an active process (requires energy) while expiration is normally passive (simple relaxation---min energy consumed). What can cause expiration to also become active & therefore increase the work of breathing potentially leading to respiratory muscle fatigue?
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Explain how breathing rate is regulated by the nervous system.
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Pediatric patients who are working hard to exhale will generate higher than normal intrathoracic pressure which may lead to what problem?
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What are signs of an upper airway obstruction?
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What are signs of a lower airway obstruction?
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What are signs of "lung tissue disease" according to PALS?
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What are signs of "disordered control of breathing" according to PALS?
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In a pediatric patient who is not in cardiac arrest, what is your first priority in management?
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Your pediatric patient has a cough suggestive of croup & is having trouble swallowing & so they are drooling & have lots of upper airway secretions. Why is suctioning something you should do with caution?
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Upper airway edema is best treated with what?
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Your pediatric patient has an anaphylactic reaction for some reason. Describe your management of the patient in terms of any medications or fluid therapies.
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What medications and fluid therapies would you provide for a pediatric patient with lower airway obstruction from bronchiolitis or asthma?
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Your pediatric patient is drowsy, bradycardic, has quiet lung sounds, see-saw breathing and a pulse oximetry reading of 85%. Describe your management and explain what is the likely field diagnosis.
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According to PALS, what is the role oof CPAP in pneumonia?
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What is the difference between CPAP and BiPAP?
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Your pediatric patient has crackles in his lungs and is very drowsy. You decide that CPAP is not indicated because of his decreased level of consciousness. What should you do?
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What is PEEP?
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What does PEEP do for your patient?
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How do you deliver PEEP w/non-invasive ventilation?
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How do you deliver PEEP w/invasive ventilation (after ET intubation)?
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When would you use PEEP?
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What is Cushing's Triad and what does it suggest?
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When is intentional hyperventilation appropriate and why and how do you do it?
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In a patient w/elevated ICP, you MUST prevent any episode of _______ OR _______.
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What is the impact of hyperthermia on ICP?
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What is the role of agitation on ICP?
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Name two bronchodilators for delivery by nebulizer and explain their action.
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Your asthma patient has not responded to nebulized bronchodilators, what are some other possible interventions?
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What tools or techniques are useful to place your patient in the sniffing position for airway management?
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How do you assess whether you have achieved sniffing position when doing airway management?
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Is hypotension the same as hypoperfusion? Why or why not? Give examples or explain.
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Name some conditions that would contribute to shock even when the patient has not lost volume, has no pump malfunction and the container is the appropriate size? Why is this the case?
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What is anaerobic metabolism and why do we need aerobic metabolism?
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Adequate delivery of O2 to the tissues requires three main things according to PALS. What are they?
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Explain preload and the impact of reduced or increased preload on cardiac output.
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Explain afterload and the impact of reduced or increased afterload on cardiac output.
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How can cardiac output be increased?
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As shock develops, list four things that your body does to try to maintain O2 delivery to the tissues of the vital organs.
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What signs and symptoms do each of those three things produce usually?
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Tachycardia has its limits as a compensatory mechanism. As the rate increases past some point, cardiac output actually decreases. Why is this the case? (consider 103 & 104)
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When do the ventricles fill?
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When does the myocardium get perfused?
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How do you tell if a patient is in compensated or uncompensated shock?
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What is the most common cause of distributive (container) shock in pediatrics?
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In terms of cardiac output and systemic vascular resistance, how is distributive shock different from the other three types of shock?
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Why does volume replacement help in distributive shock?
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Explain "warm shock" and "cold shock" as PALS describes it.
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What is pulse pressure?
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How can pulse pressure be used to help determine the type of shock?
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Explain how the compensatory mechanisms of the body tend to work to make cardiogenic shock worse.
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Initially, tachycardia can increase cardiac output & compensate for loss of blood volume or inappropriate vasodilation. Eventually, bradycardia occurs which usually leads rapidly to cardiac arrest. Why does this happen?
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Most shock types are initially treated w/volume replacement. For hypovolemia & distributive shock, the fluid bolus for pediatrics is ________ml/kg.
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For pediatric patients in _________ shock, the volume replacement fluid bolus amount is 25% of the amount in number 114.
Why is that true? |
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How can you assess the difference between cardiogenic & hypovolemic shock? (think tachypnea)
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List 3 things that can cause obstructive shock in adults (not counting supine hypotensive syndrome) & pediatrics. Then list a fourth cause that is peculiar to infants.
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What is pulsus paradoxus and how would you measure it?
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In which pediatric patients might you suspect cardiac tamponade?
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In tension pneumothorax, list the two main things that lead to hypoxia and hypoperfusion.
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How does a pulmonary embolism lead to heart failure?
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In terms of assessment of breathing rate, breathing effor, lung sounds, pulse pressure, heart rate, skin condition & capillary refill, make a chart that shows how hypovolemic shock, cardiogenic shock & obstructive shock differ greatly from distributive shock.
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Of all the metabolic issues that can compound shock, hypoglycemia is probably the only one that we can really deal with in the field. Describe how treatment of hypoglycemia in peds is different from adults.
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Regardless of the type of shock, PALS suggests that fluid therapy is key for all types. Describe how you would administer fluids for each of the types of shock (hypovolemia, distributive, cardiogenic, obstructive).
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As you begin to treat shock, how will you know when you have achieved a "therapeutic end point" according to PALS?
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In adults, we treat shock by "lay them down, keep them warm, give high flow O2, control ext. bleeding & transport rapidly." Which of those is potentially different for peds & why?
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In adults, when we have patients in shock, most medics give a minimal "radio report" that consists of basically an alert rather than a full patient description & rarely is a physician consult involved. How is that different for peds or is it the same?
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After about one hour, approx. how much of the normal saline fluid bolus that you gave your patient is still in the intravascular space?
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Other than cardiogenic shock, PALS suggests that there is one other group of peds patients in shock who should receive less than the usual fluid bolus volume. Who are they?
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The usual fluid bolus is given over how many minutes?
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You have a 15kg patient ("white area" on Broselow). The patient has signs of hypovolemic shock & you decided to give a fluid bolus. Describe how you will do that including what size IV bag, IV set, drip rate & any other info that you would use.
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You have a 5yr old pt who was struck by a car & initially was anxious, crying, HR 130, PP 90/50, RR 30. You rapidly pkg the pt, lay him supine on a backboard & cover him w/blankets, give him a NRBM at 15lpm w/good mask seal even though you have to keep him from taking it off, control the minor bleeding from his lower leg & begin rapid transport. You had a 7min scene time & 25min ETA to trauma center. During transport, you attempt and get an 18g IV w/little fight. BP 80/60, HR 150, RR 16. What can you determine from this repeat assessment?
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PALS recommends fluid therapy as first line for all types of shock. Although rarely needed in our system in the field, if fluids are not successful in improving the pts condition, vasopressors are the next step. PALS describes warm shock, normotensive shock & cold shock & suggest different vasopressors for each. What meds do they suggest for each type?
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First line treatment of anaphylactic shock is medication or fluid therapy?
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PALS suggests 2 different types of histamine blockers for anaphylaxis. What are they, what are examples & why would we need to use both?
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List the treatments for anaphylatic shock in order--include steroids, histamine blockers, epinephrine, fluids, bronchodilators & O2 in your list.
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Does PALS ever suggest the use of CPAP in the mgmt of shock? If so, when? If not, why not?
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Describe the indications, contraindications & insertion procedure for an IO in a peds pt. Include landmarks, flush or no flush, pressure on IV bag or not & any special tubing or procedures you would use.
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Why does PALS differentiate primary from secondary bradycardia?
What is the difference? |
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Symptomatic bradycardia in a peds pt is treated by:
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Specifically, explain when to use epinephrine & when to use atropine for peds symptomatic bradycardia.
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What is the rate of chest compressions for various ages of patients?
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What is the ratio of chest compressions to ventilations for various ages of patients?
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What is the depth of chest compressions for various ages of patients?
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Would you ever do chest compressions on a patient w/a pulse & why or why not?
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Names 3 ways to differentiate ST from SVT in peds pts?
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In peds pts, a wide-complex tachycardia should be treated by:
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List the vagal maneuvers suggested by PALS.
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List the add'l vagal maneuver suggested by Dr. Womack.
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List the initial & repeat synchronized cardioversion energy levels suggested by PALS.
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List the initial & repeat unsynchronized cardioversion energy levels suggested by PALS.
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Describe how you would administer adenosine to a pt w/SVT who measures in the Blue area on the Broselow. Be specific on how much volume of the medication you would give.
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List the indications for the use of magnesium sulfate according to PALS.
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How does peds cardiac arrest differ from adult cardiac arres in terms of the usual causes?
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List the 6 H's & T's according to PALS. Include the "unofficial 6th T".
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When you are doing CPR by yourself, what is always the ratio of compressions to breaths?
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When you are doing CPR on an adult, regardless of how many of you are working it, what is always the ratio of compressions to breaths?
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When you have an advanced airway in place, what is always the rate of ventilations?
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What counts for an "advanced airway"?
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What are rescue breaths & what is the rate for them in the various age groups?
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What does PALS say about Lidocaine vs Amiodarone for peds cardiac care?
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What does PALS say about when to use peds pacing/defib electrodes & when to use adult?
What does ZOLL say? |
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What does PALS say about the use of the ET tube for drug administration?
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If you have to use the ET tube route for drug administration, how is the dose modified for various drugs?
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What is the dose of Amiodarone for a pt measured in the Yellow area on the Broselow for cardiac arrest?
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What does PALS suggest for resuscitation of the drowning pt?
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What does PALS suggest about needle decompression in traumatic arrest for peds pts?
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What does PALS suggest for ET intubation for pts w/anaphylaxis?
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Describe PALS recommendations for family presence during resuscitation?
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Would you consider termination of a peds cardiac arrest in the field? Why or why not?
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What is ROSC?
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PALS suggests that peds pts who have achieved ROSC may have elevated EtCO2 readings & they give instructions on how to manage that situation. What are their recommendations & explain why they suggest that practice?
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When your intubated patient suddenly deteriorates, you should check for 4 things & the Mnemonic for that is DOPE. What are the things you should immediately check?
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PALS suggests an albuterol dose that is a bit different from what we have discussed in class. What is it?
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According to PALS, in order to reduce preload, Nitroglycerin may be given to peds pts using what dose & route?
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PALS dosing for sodium bicarbonate includes differences from the dose for adults. What is their recommendation?
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