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Resp rate for:

infant
toddler
preschooler
school-age
infant = 30-60
toddler = 24-40
preschooler = 22-34
school-age = 18-30
Heart rate sleeping/awake for:

< 3months
3months-2years
2-10years
10+ years
< 3months = 80/205
3months-2years = 75/190
2-10years = 60/140
10+ years = 50/100
Hypotension by SBP for:

< 1month
1month-1year
1-10years
10+years
< 1month = < 60
1month-1year = < 70
1-10years = < 70 + (2 x yo)
10+years = < 90
decompensated shock = ?
hypotension + signs of poor perfusion
How many H's are there for possible cause of dysrthmias?
and What are they?
6 H's

1.hypoxia
2.hypovolemia
3.hypothermia
4.hypoglycemia
5.hypo/hyperkalemia
6.hydrogen ions (acidosis)
How many T's are there for possible cause of dysrthmias?
and What are they?
5 T's
1.Tamponade
2.Tension pneumothorax
3.Toxins (poisons, drugs)
4.Thrombosis (coronary = AMI; pulmonary = PE)
5.Trauma
Give the highpoints of the rapid cardiopulmonary assessment for an infant or child?
1.general appearance
2.ABC's
3.perfusion
4.BP & UOP
5.physiological status
6.treatment algorithm
Important points for general appearance.
1. level of consciousness - a.awake, b.responds to verbal, c.responds to pain, d.unresponsive

2.overall color - a.good, b.bad

3.muscle tone - a.good, b.floppy

3.mus
Cardiopulmonary assessment: important point about A of ABC's.
A refers to airway

open and hold with head tilt-chin lift
Cardiopulmonary assessment: important point(s) about B of ABC's. (6)
B = breathing

1.present/absent
2.rate: normal/too slow/too fast
3.pattern: regular/irregular/gasping
4.depth: normal/shallow/deep
5.nasal flaring/sternal retractions/accessory muscle use
6.stridor/grunting/wheezing
Cardiopulmonary assessment: important point(s) about C of ABC's. (4)
C = circulation

1.central pulse: present/absent
2.rate: normal/too slow/too fast
3.rhythm: regular/irregular
4.QRS: narrow/wide
Cardiopulmonary assessment: important point(s) about perfusion (4)
1.central pulse vs peripheral pulse: equal/unequal
2.skin color, pattern, temp: normal/abnormal
3.capillary refill: normal/abnormal (>2seconds)
4.liver edge palpated: at costal margin (normal or dry)/below costal margin (fluid overload)
Cardiopulmonary assessment: important point(s) about SBP.
acceptable for age - normal/compensated

or

hypotensive
Cardiopulmonary assessment: important point(s) about UOP.
adequate for age: infants & children (1-2cc/kg/hr)/ adolescents (30ml/hr)
Cardiopulmonary assessment: important point(s) about physiologic status.
1.stable/unstable

2.respiratory distress/failure

3.compensated shock/decompensated shock
what does stable physiologic status mean?
- needs little support, reassess frequently
what does unstable physiologic status mean?
- needs immediate support and intervention
what does physiologic status resp distress mean?
- increased rate; effort & noice of breathing; requires much energy
what does physiologic status resp failure mean?
- slow or absent rate; weak or no effort; very quiet
what does physiologic status compensated shock mean?
1.SBP acceptable

2.perfusion poor
a.central vs peripheral pulse strength is unequal
b.peripheral color poor
d.skin is cool
f.capillary refill prolonged
what does physiologic status decompensated shock mean?
1.systolic hypotension
2.poor or absent pulses
3.poor color
4.weak compensatory effort
Cardiopulmonary assessment: what are the treatment algorithms?
1.bradycardia w/ pulse

2.tachycardia w/ adeq perfusion

3.tachycardia w/ poor perfusion

4.pulseless arrest
a.VF/PVt & asystole/PEA
how can you estimate endotracheal tube for infants and children?
uncuffed = (age in yrs/4) + 4

cuffed = (age in yrs/4) + 3
2 methods for confirming tube placement.
clinical assessment
devices
clinical assessment for tube placement
1.bilateral chest rise/fall
2.listen for breath sounds over stomach & 4 lung fields (left & right anterior and midaxillary)
3.water vaopr in tube (helpful but not definitive)
devices to check tube placement
end-tidal CO2 detector
esophageal detector
what does ETD stand for?
end-tidal CO2 detector
weight for ETD
> 2 kg
how to use ETD
attach b/t ET and Ambu bag
give 6 breaths w/ ambu bag
what changes color in ETD? what do color changes mean?
litmus paper in center of device

original color during inhalation from O2 inhaled into trachea

color change during exhalation from CO2 exhaled from trachea
what does it mean when you get original color with exhalation on a ETD?
-litmus paper wet so replace ETD
-tube not in trachea so remove ET
-cardiac output low during CPR
when can you use esophageal detector?
weight > 20 kg
perfusing rhythm
what does the esophageal detector resemble?
turkey baster
how do you use esophageal detector? and what do findings mean?
compress bulb and place ate end of ET

bulb inflates quickly = tube in trachea

bulb inflates poorly = tube in esophagus
when are esophageal detectors not recommended for use?
during cardiac arrest
when sudden deterioration of an intubated patient occurs, immdiately check?
DOPE

1.Displacement
a.tube not in trachea
b.tube moved down into bronchus (right mainstem most common)

2.Obstruction
a.secretions
b.kinking of tube

3.Pneumothorax
a.chest trauma
b.barotrauma
c.non-compliant lung disease

4.Equipment
a.check oxygen source
b.check Ambu bag
c.check ventilator
Cardiac arrest drug(s)
epinephrine
Antiarrhythmic drug(s)
amiodarone
lidocaine
magnesium
procainamide
PALS Bradycardia drug(s)
epinephrine
atropine
PALS Tachycardia drug(s)
adenosine
PALS Vasopressor drug(s)
dobutamine
dopamine
PALS miscellaneous drug(s)
glucose
naloxone
sodium bicarbonate
Epinephrine drug class
catecholamine
Epinephrine MOA
increases:
-HR
-peripheral vascular resistance
-cardiac output

during CPR, increases
-myocardial BF
-cerebral BF
Epinephrine IV/IO dose
0.01 mg/kg (0.1 ml/kg) of 1:10,000 solution q3-5min
what routes can epinephrine be given?
IV
IO
ET
Epinephrine ET dose
0.1 mg/kg (0.1 ml/kg) of 1:1,000 solution q3-5 min
Amiodarone drug class and indications
Class: atrial and ventricular antiarrhythmic

Indications:
a.VF/PVT
b.perfusing VT
c.perfusing SVT
Amiodarone MOA
1.slows AV node and ventricular conduction
2.increases QT interval
3.vasodilation possible
amiodarone routes
IV
IO
Amiodarone route & dose for a.VF/PVT
b.perfusing VT
c.perfusing SVT
d.max
a.IV/IO 5mg/kg bolus
b.IV/IO 5mg/kg over 20-60 min
c.IV/IO 5mg/kg over 20-60 min
d.15mg per 24 hrs
Amiodarone side effects
hypotension
torsades
half-life 40 days
ventricular antiarrhythmic to consider when amiodarone unavailable
lidocaine
lidocaine class & indications
ventricular antiarrhythmic (considered when amiodarone unavailable)
1.VF/PVT
2.perfusing VT
lidocaine MOA
decreases ventricular automaticity, conduction, and repolarization
lidocaine routes and doses:
a.VF/PVT
b.Perfusing VT
c.infusion
a.IV/IO: 1mg/kg bolus q5-15m
ET: 2-3 mg/kg

b.IV/IO: same

c.20-50mcg/kg/min
which PALS drugs listed as possible infusion?
lidocaine
dobutamine
dopamine
lidocaine caution
neurotoxicity & seizures
Magnesium class & indications (related to PALS)
1.ventricular antiarrhythmic for Torsade
2.hypomagnesemia
Magnesium MOA
shortens ventricular depolarization & repolarization (decreases QT interval)
Magnesium routes & doses? and Max dose?
IV/IO: 25-50 mg/kg over 10-20min; give faster in Torsades

max: 2gm
magnesium side effects?
hypotension
bradycardia
procainamide class & indications
atrial and ventricular antiarrhythmic for perfusing rhythms
1.perfusing recurrent VT
2.recurrent SVT
procainamide MOA
1.slows conduction speed
2.prolongs ventricular de- adn repolarization (increases QT interval)
procainamide route & dose for:
a.perfusing recurrent VT
b.recurrent SVT
a.IV/IO: 15mg/kg infused over 30-60 min

b.IV/IO: same
procainamide side effects
1.hypotension
2.use w/ extreme caution w/ amiodarone b/c can cause AV block or Torsades
which drug is the drug of chose for pediatric bradycardia AFTER oxygen & ventilation?
epinephrine
epinephrine dose for bradycardia?
sames as for arrest
atropine class & indication
vagolytic

bradycardia (after O2, ventilation, & epi)
which drug should be considered after O2, ventilation, and epi?
atropine
atropine MOA
blocks vagal input therefore increases SA node activity and improves AV conduction
atropine routes, doses, and maxes
IV/IO: 0.02mg/kg (may double amt for 2nd dose)

ET: 0.03mg/kg

child max: 1mg
adolescent max: 2mg
what PALS drugs can be given ET?
epi
lidocaine
atropine
naloxene
atropine side effects
worsened bradycardia with dose < 0.1 mg
adenosine indication
symtomatic SVT
what is the drug of choice for symptomatic SVT?
adenosine
adenosine MOA
blocks AV node conduction for a few seconds to interrupt AV node re-entry
adenosine routes & doses
IV/IO:
1st dose 0.1mg/kg (max 6mg)
2nd dose 0.2mg/kg (max 12mg)
adenosine side effects
1.transient AV block or asystole
2.very short half-life
dobutamine class & indications
synthetic catecholamine

1.decreases cardiac contractility
2.shock
dobutamine MOA
1.increases force of contraction & HR
2.mild peripheral dilation
3.shock treatment
dobutamine route & doses
IV/IO: 2-20mcg/kg/min infusion
dobutamine side effects
tachycardia
dopamine class & indications
catecholamine

1.hypotension
2.shock
3.increases cardiac contract & CO
what doses low dose dopamine do?
1.increases force of contraction
2.increased CO
what does moderate dose dopamine do?
1.increased peripheral vascular resistance
2.increased BP
3.increased CO
what does high dose dopamine do?
1.higher increased peripheral vascular resistance
2.higher increased BP
3.increased cardiac work & O2 demand
dopamine route & dose
IV/IO: 2-20 mcg/kg/min
dopamine side effect
tachycardia
glucose MOA
1.increases blood glucose in hypoglycemia
2.prevents hypoglycemia when insulin used to treat hyperkalemia
glucose route & dose
IV/IO:
0.5-1g/kg = 2-4 ml/kg D25
-or-
5-10ml/kg D10
-or-
10-20ml/kg D5
glucose caution
max recommendated concentration should not exceed D25%; hyperglycemia may worsen neuro outcome
naloxone class & indication
opiate antagonist

reverses resp depression effects of narcotics
naloxone routes & doses
<5yr or 20kg, IV/IO: 0.1mg/kg

>5yr or 20kg, IV/IO: upto 2mg
naloxone caution
1.half-life usually less that half-life of narcotic, so repeat dose is often required
2.ET dose can be given but NOT preferred
what other routes can naloxone be given?
IM
SQ
sodium bicarbonate class & indication
pH buffer

1.prolonged arrest
2.hyperkalemia
3.tricyclic overdose
sodium bicarbonate MOA
increases blood pH to correct metabolic acidosis
sodium bicarbonate route & dose
IV/IO: 1mEq/kg slow bolus; give ONLY after effective ventilation is established
sodium bicarbonate caution
causes other drugs to precipitate so flush IV tubing before and after
what is important to note with ET drug administration?
-distribution is unpredictable
-use this route when there is no IV/IO access
-give down ET and flush with 5ml NS, followed w/ 5 ventilations to disperse drug
Child CPR sequence MAIN steps
1.tap and ask: are you ok?
2.open airway w/ head tilt/chin lift
3.check carotid or femoral pulse for no more than 10 seconds
4.use AED when it arrives
explain child CPR step 1
Tap and ask: Are you ok?

a.send someone to call 911 and bring an AED
how many main steps to child CPR?
4
who are AEDs approved for?
children 1-8 yrs old
explain child CPR step 2
open airway w/ head tilt/chin lift

a.assess breathing
b.if inadeq: give 2 breaths over 1 second each
c.each breath should make chest rise
explain child CPR step 3
check carotid or femoral pulse for no more than 10 seconds

a.if pulse is felt, give 12-20 breaths per minute (one every 3-5 seconds)
b.if pulse NOT DEFINITELY FELT, give 30 compressions in center of chest, b/t nipples
c. compression 1/3-1/2 depth of chest wall with one or two hands
d.one cycle of CPR in 30 compressions & 2 breaths
e.give 5 cycles of CPR w/ minimum interruptions (about 2mins)
explain child CPR step 4
use AED when it arrives

a.after 5 cycles of CPR, turn on AED and follow voice prompts
b.use child pads if age 1-8 yrs
c.after AED shocks or says "no shock advised", resume CPR
d.after 5 cycles of CPR, check rhythm/pulse
whats different with basic airway mngmt w/ 2 rescuer child CPR?
a.one rescuer gives 15 compressions and pauses
b.other rescuer gives 2 breaths during pause
c.one cycle of CPR is 15 compressions and 2 breaths (over 1 second each)
d.rescuers change "compressor" role after every 5 cycles of CPR
whats different with advanced airway mgmt w/ 2 rescuer child CPR?
a.give 100 continuous compressions per minute
b.give 8-10 breaths per minute (1 every 6-8 seconds)
what makes infant CPR different from child CPR?
1.compress sternum with 2 fingers
2.no recommendation for or against AED in infants under 1 years old
what makes infant 2-rescuer CPR different from child 2-rescuer CPR?
1.2 thumb-encircling hands technique