Download Study Guide - Redlands Community Hospital

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Dear PALS Participant:
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Thank you for choosir.rg Redlands Community Hospital to further your clinical education through
our Pediatric Advanced Life Supporl course. This is a tr.vo-day course for those u'ho have never
taken a PALS course or r.vho u'ish a complete review. For those rvishing recertification only
(without extensive revierv) attending just day two is permissible. Check-in will be at 8:,15 a.nr.
on both dates u'ith course time being 0900-1600. Course is held in the Weisser Education
Pavilion Conference Rooms. Continental breakfast rvill be provided, and lunch rvill be on your
own.
It cannot be emphasized er.rough that for maximum benefit and the greatest success in this course,
pafticipants should be u'ell prepared for the first day of class. The AHA's P,4ZS Provider
Msnual is the required reference for this course. This book is available through the Education
Depafiment for $35 and at various clinical bookstores. Included in this packet are materials to
assist you in preparing for this course. Although this packet is meant to assist you in studying for
the course testing session, it is not intended to replace the textbook.
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After revierving the n.raterial, rve advise you to complete the pre-test r.vhich is included rvith tl.re
packet alor.rg rvith an answer key. Thus, any problems )'ou may encounter in this proccss may be
addressed by the instructor during the coursc.
Please bring these materials rvith you to class. Meeting your needs is our
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priority. Wc look
fonvard to working with you and hope you find this a valuable learning experience. Ifyou l.ravc
any questions, please feel lree to contact the RCH Education Depafiment (909/335-5530).
2012
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Upon completion of the course $e parncipant wilJ:
I.
Be familiar with and able to implement the algorithms of the Arnerican
Heart Association guidelines for Pediatric BLS and PALS.
iI.
List the signs and symptoms ofrespiratory distress.
IIL Explain the signs and symptoms of compensated versus decompensated
shock.
IV.
Describe the pharfilacology of the resuciration drugs of choice and their
appropnate application to a given situation.
V.
,nnr^nrrelp
1rp
Recognize potential and actual letbal dysrhyhmias and choose the
rimpnt
\4.
Demonstrale correct and safe procedure with placement ofan IO line.
\.{1. Demonstrate proficiency wtth
the airway adjuncrs thal
fbll withrn
therr scope of praclice.
VIII.
Successfully function as a team member in an emergency event, which
includes. dysrhythmia recognilion and treatment, patient assessment and problem solving.
D(
Pass
tie wnfien
exam by 84Vo
or greater.
,{MEzuCAN HEART ASSOCIATION IS A NONPROFIT ENTITY
AND RECEWES NO MONEY COLLECTED
IN CONJLI},ICTION W]TH THIS CLASS
30
A.
B,
RAPID qRDIOPULIO{ARY ASSESSMEM
NXI{AY PAIENCY
RBTT{ING
18 YR
Newborn 1 YR
18
40
24
Chest rise, breath sourxls, stridor,
Rate:
Air Ehtrlz:
l,bctErlics:
6lor:
C.
smID
CTRCUIAtIC}I
tibnnals
Abnormal-s:
I{eart Rate
- 3 rp140
<sY:R
>5t:R
{
wheezing
Retractions, grunting
Nelborn
U
> 50 Ahays abnornal
2-10YR
3rnc. -2YR
130
> 180
\60
>
>10yR
AO
75
> 210 &nsider SVI
160
PBTPIERAI/cENTRAL pur,sEs:
hesent/Absent, Vo1ume :PerlpheralV3 Oentral
s,r" perfirsicn
EPfLIARY
REILL: nl
Te{rperature,
< 2 sEc
@Ior cyanotic, pa.llor, mottfing)
(
3) ow Perfusj.on
Recognition
of lErerts,
Reaction to pain, Muscle tone, Pupil size
I{)
,, il@d kessure (Distingruishes
Nevdcorn
Systolic
>
60
ccnrpensated
lYR
>70
vs deccnpensated
shock )
>lYR
>
70+ (2XAge)
PALS STUDY GUTDE
Calt lor hclp
Responsive?/Breathing?
No>
'AED
Pulse?
r\o )
START CPR
+
VF
PULSELESS VT
Check pulse
CPR til Defib avail
t
CPPJAirway Adjuncts/lv Access
I
Shock 2J,&g
I
Epinephrine 0.1ccikg IVP
I
CPR
(repeat q 3 mins)
X 2 mins
I
I
Consider and give specifrc Tx for.
Pulse \//Shock 4J,&g
I
CPR
X 2 mins
PulseVShock 4 or5J 0J/kg
I
IV Access/Airway Adjuncts
Epinephrine 0.1cc,&g IVP
I
CPR X 2 mins
(repeat q 3 mins)
I
Pulse
VShock 4 or 5J 0J/kg
I
CPR X 2 mins
I
Altemelive drue c hoices :
Amiodarone 5rng/kg IVP
Magnesium 25-50mg/kg
IV over 10+ mlns
Pulmonary,/coronary thrombosis
Acidosis
Tension Pneumothora,r
Cardiac Tamponade
Hypoxia
Hypovolemia
Hypothermia
Hypoglycemia
Hyper./}lypo electrolytes
Drug OD
Lidocaine l mg/kg IVP
(repeatq5minsto
max dose 3mg,&g)
palsstdl
8,/1 1
Copyrlght 1994 Susan Mi
--.l
r-- "' BRADYCARDIA
I
llsnsroin
'".-.'-- t -'---'
'
't-- -
I
Check pulse (< 60 beats/min start CpR)
Check oulse/Check Flat Line Protocol
I
Airway AdjunctsAV Aocess
I
? Signs
CPfu Airway Adjuttcts/IV Ascess
I
Epinephrine 0.lcc/kg IVP
(repeat q 3 mins)
I
PdseV
I
Consider heatable causes:
Hypoxia
Hlperi HYPo K+
Hypoglycemia
Hypothermia
Pre-existing acidosis
NO
I
Observe
I
or S),mptoms
I
I
?
YES
I
* Epinephrine 0.lcclkg IVP
(ifneeded, repeat q 3 mins)
Support ABCs
* Atropine 0.2cc,&g I\rP
(Use fot tx of vagal-induced
bradys or "fine-tuning" HR
If needed, repeat q 5 mins
to max dose: lmg chitd
2mg teen)
Drug OD
nols*dr
y'tt
eourlllt
1001 8u8on lNordcl
Fffiffiffi;,il;]
.--....,. ---"-**"
r,. ."-
1
PULSE PRESENT
I
STABLE
LTNSTABLE
(rapid HR, resp distress,
LoC, s/s poor perfusion)
t
I
Ah'way Adjuncts, iV Access
Sedation whenever possible
Or, IV Access
I
I
SVT or
Narrow QRS Tachy
S;'nchronized Cardioversion
Vagal Maneuvers
I
Lidocaine 0lmg/kg IVP
(may repeat q 5 mins up
to max dose of 100mg)
Adenosine 0.lmgikg rapid IVP
,ld"no.in"lo.ztg,&g rapid IVP
f;H> _
o.sras
of
lJ/kg
I
puts./
Possible TX's:
Amiodatone Smg/kg IV over 20-60 mins
Cardioversion
I
ZJkg
l.
pulse
V
I
Consider adding an antianhythmic
before 3'" shock
I
4Jkg
t-r/
pulse
lstrslds 0/ | |
cop$lonl
1004
gusrn tilador
Not Shockable
Shockable
Give 5 cycl€s
of cpR*
Shockable
Dunns CPR
Shockable
(1oo/man) '
.
Push hard and fast
.
Ensure tull chest recoll'
.
Minimize intenuptions in chest
.
One cycle of CPR: 15 comPressions
then 2 breaths; 5 cycles -1 to 2 min
.
.
*
Avoid hyperventilation
Secure airway and confirm placement.
.
Rotate cornpressors every 2 minutes
wit! rl')4hr che.t<
Search for and treat posslble
contributing factors:
- Hypovolemia
- Hypoxia
- Hydrogen io. (acidosis)
- Hypo /hyperkalemia
- Hypoglycemia
- Hypothermia
- Toxins
praced,
"cycles" - I3ly."lXt"?,"f:1,iX?*
- Thrombosls (coronary or
pulmonary)
oreatns - rrauma
d'';k
;iiidJ'i"i".
After an advanced airway is
tescuers no longer deliver
of CPR. Give coniinous chesl com_
oressions wilhout pauses lor
6ii
e
i"
i
rhythm every 2 mindes.
Figure 6.
164
Pedlatrjc Pulseless Arrest Algonthm
I
FOR PRE-COURSE PRACTICE
PEDIATR]C ADVANCED LIFE SUPPORT
TIERAPEUT1C MODAIITIES
Directlons:
Labei the rh)Ihm and list the course oftreatment in appropriate order'
I
baby was pu! in his crib for a nap with a pacifier hanging around his neck
on a ribbon. His aunt finds him blue, unresponsive and not breathing. Paramedics are called
and arrive to this scene:
A l2 month old
RH YTHM:
TREATMENT PLAN:
2
A 7 year old boy ls playing at a construction sile with two fnends. They're digging tunnels
in a huge din piie. A worker yells at the two he sees to leave the site. Ten minutes later, the
rvorker finds the third with his head and chest buried in the din. He calls 91 I and paramedics
find no respirations, a puise of 42 bpm, B/P 50.P, blue lips and mottled legs:
RHYTHM:
TREATMENT PLAN:
3.
A 5 year old girl was bathing her new puppy in the bathtub. She lifted him out and started
to dry the puppy with the hairdryer but he ran away. She placed the hairdryer on the tub's edge,
retrieved the puppy from the bedroom, and then retrieved the hairdryer from the bathtub srill
filled rvith water. She now anives in the ER with CPR in progress by EMTS:
RHYTHM:
TREATMENT PLAN:
4.
A 5 month old male is being brought to your ER, at 2:00AM, by his parents. They're verv
worried because he's worse now than when he first woke up this morning with a temp of 99 ,
refusing to nurse, fussy and barely wening a diaper. Their doctor told them to give him
Pedialyte and Tylenol. Now he's very sleepy, has dusky lips, cool and mottled lilnbs and veri,
rapid respirations with intercostal retractions. The cardiac monitor shows:
1,.
|'j
''t':
RHYTHM:
TREATMENT PLAN:
5.
A 2 year old boy is being brought into the urgenl care center by his grandparenrs because
ill. They repon his mother told them he has had "a lor ofdianhea the past
lhree days and won't eat much". You find him lethargic, has cold and mottled arms and legs, a
respiratory rate of64 with nasal flaring and a pulse rate at 200 bpm:
he appears severely
RHYTIM:
TREATMENT PLAN:
9: _ EYJS
are bringing in a 3 year old boy who fell down a flight ofcement srairs while ridrng
his Big wheel outside his family's apartment. cpR is in progress. your initial assessmenl find;
him with a right flail-chest when ventilated, abdominal rigidity, a compound fracture ofthe right
ankle and no B/P or pulse:
RHYTHM:
TREATMENT PLAN:
rt
*TffiffiH"tl
Fighling Heart Dis€ase and Stroke
Pediatric Advanced Life Support Course
Which of the following statements about poisoning and overdose in the pediatric
population is true?
a.
b.
c.
d.
2"
whenever a poison or toxin is ingested, you should induce vomiting to eliminate it from
the body
poisoning and overdose cause a significant number of deaths in the 15- to 24-year-old
age group
poisoning and overdose do not occur in the pediatric population
the first priority of management for the child with poisoning or a drug overdose is to "get
the antidote"
A 3-year-old unresponsive, apneic child is broughtto the Emergency Department. The
EMTs transporting the child tell you the child became pulseless as they pulled up to
the hospital. The child is receiving CPR, including positive-pressu re ventilation with
bag and mask and 100% oxygen and chest compressions. You confirm that apnea is
present and that ventilation is producing bilateral breath sounds and chest expansion
while a colleague confirms absence of spontaneous central pulses and other signs of
circulation. A third colleague attaches the ECG monitor and reports that ventricular
fibrillation is present. Which of the following therapies is most appropriate for this
child at this time?
establish lV/lO access and administer amiodarone 5 mg/kg
b. establish lV/lO access and administer lidocaine 1 mg/kg
c. attempt defibrillation at 2 J/kg
d. establish lV/lO access and administer epinephrine 0.01 mg/kg
3.
You are attempting resuscitation of an infant or child with severe symptomatic
bradycardia and no evidence of vagal etiology. The bradycardia persists despite
establishment of an effective airway, oxygenation, and ventilation. Which of the
folf owing is the fiTst drug you should administer?
atropine
b dopamine
c. adenosine
d. epinephrine
4.
You are preparing to use a manual external defibrillator and external paddles in the
pediatric setting. When would it be mosf appropriate to use the smaller "pediatricsized" paddles for delivery of direct-current energy?
a.
b.
c.
d.
5.
b.
c.
d.
when the patient welghs less than approximately
when ihe patient weighs less than approximately 10
whenever you can compress the victim's chest using
attempt to identify and treat reversible causes (using the 4 H's and 4 T's as a memory
aid)
attempt defibrillation at 4 Jlkg
administer escalating doses of epinephrine
administer synchronized cardioversion
Which of the following statements about the effects of epinephrine during attempted
resuscitation is true?
a-
b.
c.
d.
7.
for synchronized cardioversion but not for
A 7-year-old boy is found unresponsive, apneic, and pulseless. CPR is provided, and
tracheal intubation and vascular access are achieved. The ECG monitor reveals
pulseless electrical activity (PEA). An initial lV dose of epinephrine has been
administered, and effective ventilations and compressions continue for 1 minute.
Which of the following therapies should you pertorm nex{?
a.
6.
the smaller paddles should be used
defibrillation
the smaller paddles should be used
25 kg or is less than I years old
the smaller paddles should be used
kg or is less than 1 year old
the smaller paddles should be used
only the heel of one hand
epinephrine decreases peripheral vascular resistance and reduces myocardial afterload
so that ventricular contractions aTe more effective
epinephrine can improve coronary artery perfusion pressure and can stimulate
spontaneous contractions when asystole is present
epinephrine is not useful in ventricular fibrillation because it will increase myocardial
initability
epinephrine decreases myocardial oxygen consumption
You are participating in the elective intubation of a 4-year-old child with respiratory
failure. You must select the appropriate size of uncuffed tracheal tube. Which of the
fof f owing sizes is most appropriate for an average 4-year-old?
a.
b.
c.
d.
3-mm
4-mm
5-mm
6-mm
tube
tube
tube
tube
o"
A 9-month-old infant presents with a respiratory rate of 45 breaths/min and a heart
rate of 250 bpm with narrow (<0.08 seconds) QRS complexes. The infant is receiving
'100% oxygen by face mask, and an lV catheter is in place. The infant's systolic blood
pressure is 64 mm Hg and palpable with faint pulses, and capillary refill time is 5 to 6
seconds. The infant responds only to painful stimulation, and he has no history of
vomiting or diarrhea. Which of the following is the most appropriate initial treatment
for this infant?
a. attempt immediate defibrillation
b. administer a 20 mUkg fluid bolus of normal saline over 20 minutes or less
c. administer adenosine 0.1 mg/kg rapid bolus (2-syringe technique)
d. administerverapamil
q
You are in a restaurant when a woman at the next table cries out, "l think he's
choking." You look over and see a 3-year-old child who does appear to be choking.
You go to the table and confirm that the child is responsive, but he is cyanotic, unable
to cough or talk, and is not moving air. Which of the following is the most appropriate
initial therapy for this child"
give 5 back blows and then 5 chest thrusts
b. perform a blind finger sweep
c. do not intervene unless the child becomes unresponsive; then perform abdominal thrusts
d. tell the victim you will help and give abdominal thrusts
10.
You are evaluating a 7-month-old boy. The infant presented with a history of poor
feeding, fussiness, and sweating. He is alert and responsive, and he has a respiratory
rate of 48 breaths/min with good bilateral breath sounds. Heart rate is 250 bpm with
narrow (<0.08 seconds) QRS complexes, and the heart rate does not vary with activity
or cry. Pulses are readily palpable, and capillary refill is 2 seconds. Which of the
following therapies is mosf appropriate for this infant?
a.
b.
c.
d.
11.
make an appointment with a pediatric cardiologist for later in the week
consider vagal maneuvers (eg, ice to the face) while lV access is attempied and provide
lV adenosine once access is established
perform immediate synchronized cardioversion without awaiting establishment of lV
access
establish lV access, administer a fluid bolus of 20 ml/kg of isotonic crystalloid, and
administer antibiotics
You are evaluating a responsive 6-year-old girl. The child presented with fever,
irritability, mottled color, cool extremities, and a prolonged capillary refill time. Her
heart rate is 160 bpm, respiratory rate is 45 breaths/min, and BP is 98/56 mm Hg.
Which of the following most accurately describes this child's condition, using the
terminology taught in the PALS course?
a. decompensated
b. decompensated
shock associated with inadequate tissue perfusion
shock associated with inadequate tissue perfusion and significant
hypotension
c. compensated
d. compensated
12-
An 8-year-old child was struck by a car. He arrives in the Emergency Department alert,
anxious, and in respiratory distress. His cervical spine is immobilized, and he is
receiving a 10 L/min flow of 100% oxygen by face mask. Respirations are 60
breaths/min, heart rate is 150 bpm, and systolic blood pressure is 60 mm Hg. No
breath sounds are heard over the right chest, and the trachea is clearly deviated to the
left. Pulse oximetry reveals an oxyhemoglobin saturation of 84%. Which of the
following is the most appropriate immediate intervention for this child?
a.
b.
c.
d.
13.
shock requiring no intervention
shock associated with inadequate tissue perfusion
perform tracheal intubation and call for a STAT chest x-ray
obtain a chest x'ray and provide bag-mask ventilation until the x-ray is read
establish lV access and administer a 20 ml/kg bolus of normal saline
perform needle decompression of the right chest and assist ventilation with a bag and
mask if necessary
A 2-year-old child presents with mild difficulty breathing of gradual onset. She is alert,
but she has a sore throat and is making coarse, high-pitched inspiratory sounds (mild
stridor). Her oxyhemoglobin saturation is 94% in room air, and her lung sounds are
clear with adequate breath sounds bilaterally. Which of the following is the most
appropriate indial intervention for this child?
a. immediate tracheal intubation
b. immediate radiologic evaluation of the soft tissues of the neck
c. evaluation of oxyhemoglobin saturation with pulse oximetry and analysis
d.
14.
of arterial blood
gases to determrne if hypercarbia is present
administration of humidified supplemental oxygen as tolerated and continued evaluation
An 18-month-old child presents with a 1-week history of a cough and runny nose. He
is cyanotic and responds only to painful stimulation. His heart rate is 160 bpm;
respirations have dropped from 65 to 10 per minute with severe intercostal retractions
and a capillary refill time of less than 2 seconds. Which of the following is the most
appropriate immediate treatment for this toddler?
a.
b.
c.
d.
establish vascular access and admrnister a 20 mL/kg bolus of isotonic fluids
open the aiMay and provide positive-pressure ventilation using 100% oxygen and a bagmask device
administer 100% oxygen by face mask, establish vascular access, and obtain a STAT
chest x-ray
administer 100% oxygen by face mask, obtain blood for arterial blood gas analysis, and
establish vascular access
15.
You are supervising another healthcare provider in the insertion of an intraosseous
needle into an infant's tibia. Which of the following signs should you tell the provider
will best indicate successful insertion of a needle into the bone marrow cavity?
a. pulsatile blood flow will be present in the needle hub
b. fluids or drugs can be administered freely without local soft tissue swelling
c.
d.
15.
An anxious but alert 7-year-old child is brought to the Emergency Department. The
child has a heart rate of 260 bpm with narrow QRS complexes and no variability in
heart rate with activity, Respirations are 30 breaths/min and unlabored. Extremities are
warm, and capillary refill time is less than 2 seconds. He is awake and alert, and he
denies chest pain or shortness of breath. Which of the following is the r.rost
appropriate initial treatment for this child?
a.
b.
c.
d.
1
7.
perform immediate synchronized cardioversion (0.5 to 1 J/kg)
establish vascular access and administer a 20 mUkg bolus of normal saline
attempt vagal maneuvers by having the child blow into an occluded straw, and esiablish
vascular access to deliver adenosine if needed
begin immediate transcutaneous overdrive pacing
A pale and obtunded 3-year-old child with a h istory of diarrhea is brought to the
hospital. Respirations are 45 breaths/min with no distress and good breath sounds
bilaterally. Heart rate is 150 bpm, and BP is 88i64 mm Hg. Capillary refill time is 5
seconds, and peripheral pulses are weak. After placing the child on a 10 Umin flow of
100% oxygen and obtaining vascular access, which of the following is the mosl
appropriate immediate treatment for this child?
a.
b.
c.
d.
18.
resistance to tnsertion suddenly rncreases as the tip of the needle passes through the
bony cortex into the marrow
once inserted the shaft of the needle moves easily in all directions within the bone
obtain a chest x-ray
administer a maintenance crystalloid infusion
administer a 20 mUkg bolus of lV or lO isotonic fluids
administer a dopamine infusion at a rate of 2 to 5 pglkg per minute
An infant with a history of vomiting and diarrhea arrives by ambulance. The infant
responds only to painful stimulation. The upper airway is patent, respiratory rate is 40
breaths/min with good bilateral breath sounds, and 100% oxygen is being
administered. She has cool extremities, weak pulses, and a capillary refill time of more
than 5 seconds. Blood pressure is 85/55 mm Hg, and glucose concentration
(measured by bedside test) is 100 mg/dL. Which of the following is the mosf
appropriate treatment for this infant?
a.
b.
c.
d.
19.
Which of the following devices will most reliably deliver a high (90% or greater)
concentration of inspired oxygen?
a.
b.
c.
d.
20"
establish lV or lO access and administer 20 mUkg 5% dextrose and 0.45% sodium
chloride over 5 minutes
establish lV or lO access and administer 20 mUkg lactated Ringer's solution over 60
minutes
perform tracheal intubation and administer 0.1 mg/kg epinephrine (0.1 ml/kg of 1.1000
solution) by tracheal tube
administer 20 mUkg isotoriic crystalloid over 10 to 20 minutes
a nasal cannula with oxygen flow of 4 L/min
a simple oxygen mask
a non-rebreathing face mask with an oxygen reservoir
a partial rebreathing mask
You are transporting a 6-year-old tracheally intubated patient who is receiving
positive-pressure mechanical ventilation. The child begins to move his head and
suddenly becomes cyanotic and bradycardic. You remove the child from the
mechanical ventilator circuit and provide manual assisted ventilation with a bag via
the tracheal tube. During manual ventilation with 100% oxygen, the child's color and
heart rate improve slightly and his blood pressure remains adequate. Breath sounds
and chest expansion are present and adequate on the right side, but they are
consistently diminished on the left side, The trachea is not deviated, and the neck
veins are not distended. A suction catheter passes easily beyond the tip of the
tracheal tube. Which of the following is the mosf fikely cause of this child's acute
deterioration?
a.
b.
c.
d.
21.
tracheal tube disDlacement
tracheal tube obstruction
tensionpneumothorax
equipment failure
An 11-year-old skateboarder suffered multiple system trauma with no obvious midface
injury" He is obtunded and apneic. After bag-mask ventilation with 100% oxygen and
appropriate cervical spine immobilization, which of the following is the preferred
method for tracheal intubation?
a.
b.
c.
d.
nasotracheal route
orotracheal route
cricothyrotomy
nasogastric tube
22.
An unresponsive 7-month-old infant presents with cold extremities and a capillary
refill time of more than 5 seconds. His heart rate is 260 bpm with weak pulses and
narrow QRS complexes. lV access is established with difficulty. The infant is receiving
100% oxygen by non-rebreathing face mask, and oxygenation and ventilation are
adequate, Pediatric monitor/defibrillation/pacing electrode pads are in correct position
on the infant's chest. You attempt to flush the lV line with normal saline and note that
it is no longer patent. Which of the following is the most appropriate initial treatment
for this infant?
a.
b.
c.
d.
23.
A pulseless 'l1-month-old infant with ventricular fibrillation arrives in the Emergency
Department. CPR is in progress. You ensure that bag-mask ventilation with 100%
oxygen is producing effective chest expansion and breath sounds bilaterally,
establish an lV with a large catheter, attempt defibrillation atimes, and administer a
first dose of epinephrine. The child remains in ventricular fibrillation after 2
minutes of CPR. Which of the following actions should you perform nexf?
a.
b.
c.
d.
24.
provicie lidocaine 1 mg/kg lV or amiodarone 5 mg/kg bolus lV After defibrillation
attempt defibrillation al4 Jlkg
provide second dose of epinephrine 0.1 mg/kg lV (1:1000 solution, 0.'1 mUkg)
consider adenosine 0.1 to 0.2 mg/kg
You are preparing to attempt synchronized cardioversion for a child with
supraventricu lar tachycardia. What is the recommended initial energy <iose for
synchronized cardioversion for infants and children?
a.
b.
0.05 to 0. 1 J/kg
0.5 to '1 J/kg
d.
6 to 10 J/kg
c.
25.
perform immediate tracheal intubation
reattempt vascular access to enable administration of lV adenosine
establish {O access and administer a 20 mL/kg bolus of isotonic crystalloid followed by
adenosine
perform immediate synchronized cardioversion
2to 4 Jlkg
You are participating in the attempted resuscitation of a 3-year-old child in pulseless
ventricular tachycardia. You have attempted defibrillation 3 times without converting
the VT to a perfusing rhythm. The airway is secure and ventilation is effective.
Attempts at lV access have been unsuccessful, but lO access has been established,
You have been unable to identify any reversible cause of the VT. You administer
epinephrine, circulate it for
aminutet and attempt defibrillation a fourth time,
but VT persists. Which of the following drugs should you administer nexf?
a.
b.
c.
d.
epinephrine 0.1 mg/kg by tracheal tube (1:1000 solution, 0-1 mUkg)
adenosine 0.1 mg/kg lV push
epinephrine 0.1 mg/kg lO (1 :1000 solution, 0.1 ml/kg)
lidocaine 1 mg/kg lO or amiodarone 5 mg/kg lO
26.
An 18-month-old submersion (near-drowning) victim is currently stable in a
community hospital ED. A tracheal tube is in place with proper position confirmed.
The toddler is receiving mechanical ventilation and a low-dose dopamine infusion to
support blood pressure and perfusion. Which of the following options is most
appropriate for transporting this child from the community hospital to a tertiary care
center?
a. a helicopter team with no pediatric experience that is 20 minutes away
b. the local EMS service with a Basic EMT
c.
d.
27.
the local basic EMS service with a pediatric nurse along to help
A 3-year-old boy presents with multiple system trauma. The child was an unrestrained
passenger in a motor vehicle crash. He is unresponsive to voice or painful stimulation, and his right pupil is dilated and responds sluggishly to light. His respiratory rate
is less than 6 breaths/min, heart rate is 170 bpm, systolic blood pressure is 60 mm Hg,
and capillary refill time is 5 seconds. What are the frTst actions you should take to
support this child?
a.
b.
c.
d.
28.
a pediatric critical care transport team from the receiving tertiary care center that is 30
mrnutes away
provide 100% oxygen by simple mask, immobilize the cervical spine, establish vascular
access, and provide maintenance lV fluids
provide 100% oxygen by simple mask and perform a head{o{oe survey to identify the
extent of all injuries; begin an epinephrine infusion and titrate to maintain a systolic blood
pressure of at least 76 mm Hg
establish immediate vascular access, administer 20 mUkg of isotonic crystalloid, and
reassess the patient; if the child's systemic perfusion does not improve, administer 10 to
20 mUkg of packed red blood cells
open the airway (iaw thrust technique) while immobilizing the cervical spine, administer
positive-Dressure ventilation
You are caring for a 7-year-old boy. The child was a pedestrian struck by a car. He is
breathing spontaneously with oxygen supplementation, and he has good central
pulses. He has an open mid-shaft fracture of the right femur; his right thigh is swollen
and bleeding heavily. The child arrives in your medical facility with adequate
ventilation and perfusion, and his spine is immobilized. Which of the following are the
best initial steps for you to take to treat this child's leg injury?
a.
b.
c.
d.
apply drrect pressure to the wound and continue to evaluate and support systemic
perfusion, including perfusion of the leg
call the orthopedic surgeon and do not touch the leg
attempt to align the fracture and apply a tourniquet above the wound
attempt to control bleeding with hemostatic clamps, apply a tourniquet, and then attempt
to aliqn the fracture
29. Which of the following statements about pediatric injury in the United States is frue?
a.
b.
c.
d.
38.
motor vehicle-related trauma accounts for less than 10% of all pediatric injuries resulting
in death
injuries are the leading cause of death in children older than 6 months
bicycle helmets will not reduce the severity of most bicycle-related head injuries
most fire-related deaths occur in schools
You are assisting ata statowide tnck and field event in a professional sports facility.
You witness a ioung teenage gld collapse while running, She is unresponsive when
you arrive at her side, Othol byFtanders have calted for EMS suppoft and are
performing w€ll-coordlnatsd CPR. They report tfiat the to€n has no known health
problems, butshe ls now apneic and pulseless: Which of the following actions would
most Iikely improve tft's teen's chance of survival?
a. take over mouth-tGmouth resuscitation
b. attach and oporate an AED as soon as one is retrieved
c.
d.
provide crowd control
get a blanket to keep the patient warm
10
*T:fllliri.@
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Answer
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13.
15.
16.
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18.
Answer
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ab
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22.
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Table
1
Summary of Key BLS Components for Adults, Children. and Infants*
I
Component
|
I
t
-
-Adults
I
Recognition
Chitdren-_ |
Infants
Unresponslve (for all ages)
I
i
Recommendations
_-
No breathino or |o nornta
breath ng (e onty gasplng)
No b.reathing or only gasping
i
No p:rlse pa pated w thin 10 seconds lor a I aoes (HCp on y)
CPR sequence
C-A B
Compression rate
At
At lea"r 2 ilches i5
east '100/min
rA AP dlameter
.
,z ncnes
:: cm)
15
I
I
At least
cmr
I
., ,
Aoour
.
At least 1A AP diameler
About j% inches (4 cm)
Allow complete recoij between compressions
Chest wall recoil
FlCps rotate compressors every 2 minutes
Minimlze interruptions in chest compressions
Attempt to limit nterrruptions to <10 seconds
Heacl
tilt-chln lft (HCP suspected lraumailu* tf-r|,u"q
30:2
Single rescLter
3At2
1 or 2 rescuers
15:2
2 HCP rescuers
Ventilations: when rescuer
untrained or trained and
not proficient
Compressions on y
1 breath every 6_g seconds (g 10 breaths/mjn)
Asynchronous wilh chest compressions
About 1 second per breath
Visible chest rise
Defibrillation
Altach and use AED as soon as available. Minirnlze interruplions in chest compressions before and after shock;
resume CPR beginnlng wjth compressions tmmedrately afier eacn snock.
Abbrevralio.s AEtr, altomaled orlernal de fibrir/alori AP rnterior posteror;CPF, car! opulnro.ary res!scitatoi: HCq heatth.ar. prov.ter
'Exclld n9 lhe newly born in whom the etiltoqy oi ar aresr s nearry a/ways asphvrral
Whyj Newer case repods suggest that an AED may be sale
and etfective in infants. Because survival requires defibrillation
when a shockable rh\,4hm is present during cardiac arrest,
delivery of a high-dose shock is preferable to no shock Limited
evidence supports the safety of AED use in infants.
PEDIATRIC ADVANCED
LIFE SUPPORT
Summary of Key lssues and Maior Changes
key issues in the review of the PALS literature resulted
in refinement of existing recommendations rather than
new recommendations: new information is provided for
N4any
resuscitation of infants and children with selected congenital
heart defects and pulmonary hypertension.
Monitoring capnography/capnometry is again recommended
to confirm proper endotracheal tube position and may
be useful during CPR to assess and optimlze the quality of
cnest compresstons.
.
.
The PALS cardiac arrest algorithm was simplified to
emphasize organization of care around 2-minute periods of
uninterrupted CPFI.
The initial defibrillation energy dose of 2 to 4 J/kg of either
monophasic or biphasic waveform is reasonable; for ease oi
teaching, a dose of 2 J/kg may be used (this dose is the same
as in the 2005 recommendation). For second and subsequent
doses, give at least 4 J/kg. Doses higher than 4 J/kg (not
to exceed 10 J/kg or the adult dose) may also be safe and
effective, especially if delivered with a biphasic defibrillator.
.
on the basis of increasing evidence of potential harm
from high oxygen exposure, a new recommendation has
been added to titrate inspired oxygen (when appropriate
equipment is available), once spontaneous circulation
has been restored, to maintain an afterial oxyhemoglobin
saluration >94yo bu| <1OOyo to limit the risk of hyperoxemia.
.
.
Providers are advised to seek expe:t consultation, if
possible. when administering amiodarone or procainamide
to hemodynamically stable patienis with arrhythmias
.
The definition of wlde-complex tachycardia has been
changed from >0.08 second to >0.09 second.
Recommendations for Monitoring Exhaled CO2
2O1O {New): Exhaled CO, detection (capnography or
colorimetry) is recommended in addition to clinical assessment
to confirm tracheal tube position for neonates, infants, and
children with a perfusing cardiac rhythm in all settings (eg,
prehospitar. FD. intensrve care Jnit. ward. operating roon ) and
during intrahospital or interhospitai transport (Figure 34 on
page 13). Continuous capnography or capnometry monitoring.
if available, may be beneficial durjng CPR to help guide therapy,
especially the effectiveness of chest compressions (Figure 3B
on page 13).
2oO5 (Old): ln infants and children with a perfusing rhythm,
use a colorimetric detector or capnography to detect exnaled
CO, to confirm endotracheal tube position in the prehospital
and in-hospital settings and during intrahospital and
interhospital transPon.
Why: Exhaled CO, monitoring (capnography or colorimetry)
generally confirms placement of the endotracheal tube in
the airway and may more rapidly indicate endotracheal tube
misplacemenvdisplacement than monitoring of oxyhemoglobin
saturation. Because patient transport increases the risk ior
tube displacement, continuous CO, monitoring is especially
important at these times.
Animal and adult studies show a strong correlation between
Pflco, concentration and interventions that increase cardiac
output during CPR. P co, values consistently <10 to 15 mm Hg
suggest that effofts shouid be focused on improving chest
compressions and making sure that ventilation is not
excessive. An abrupt and sustained rise in PFrco, may be
observed iust before clinical identification of FOSC, so use
of PFrco, monitoring may reduce the need to interrupt chest
compressions for a PUlse check.
New sections have been added on resuscitation of
infants and children with congenital heart defects,
Def i bri I lation E n e rgy
including single ventricle, palliated single ventricle, and
pulmonary hypertension.
2O1O
D ose s
(New): lt is acceptable to use an initial dose of 2 to 4 J/kg
.
Several recommendations for medications have been
revised. These include not administering caicium except in
very specific circumstances and limiting the use of etomidate
in septic shock.
for defibrillation, but for ease of teaching, an initial dose of 2
J/kg may be used. For refractory VE it is reasonable to Increase
the dose. Subsequent energy levels should be at leasl 4 J/kg,
and higher energy levels, nol to exceed 10 J/kg or the adult
maximum dose, may be considered.
.
Indications for postresuscitation therapeutic hypothermia
have been clarified somewhat.
2OO5 (Old): With a manual defibrillator (monophasrc or
biphasic), use a dose of 2 J/kg for the first attempt and 4 J/kg
.
New diagnostic considerations have been developed for
sudden cardiac death of unknown etiology.
@ n-..,cdn
Herrt
Associatio'1
for subsequenl ailempts.
Arnerican Heflrt
Association
2010 Interim Materials
PALS Provider Manuul
Comparison Chart
Based on 2010 AHA Guidelines
GUIDELINES
ECC
ECC
BLS Changes
CPR and
otd
New
CPR
Chest compressions, Airway, Breathing
Airway, Breathing, Chest compressions
(A-B-C)
(c-A-B)
New science indicates the following order for
healthcare providers:
l. Check the patient lor responsivencss
and pr€sencdabsence of breathing or
2.
Sasprng.
4.
5.
6.
Previously, after responsiven€sg rvas
assessed, a oall for help lvas made, thc
airway was opened, the patient was checked
for breathing, and 2 breaths were given,
followed by a pulse check and compressions.
AED/
Chcck the pulse for no more than
l0
seconds.
Compressio!!s werc to be given after alrway
end breathing wore assessed, ventllations
were given, and pulscs were checked.
Compressions should be given qt a rate ofat
leasr 100/min. Each ser of J0 compressions
should take approxlmately 18 seconds or less.
Compresslons were to be given at a rate of
about 100/min. Esch cycle of30
compressions was to be completed in 23
Compression depths are as follows:
Adults: rt lstst 2 inches (5 cm)
Compresslon depth were as follows:
Adulb: l% to 2 inches
Children: one third to one halfthe
diameter ofthe chest
lnfsnts: one third to onc halfthe
diameter oflhe chest
seconds
.
compressions are ollen dclayed. Changing
to CAB will delay ventilalions by only -20
seconds for the pediatric patient,
defibrillator.
Give 30 compressions.
Open the airway and giv€ 2 breaths,
Resumecompressions.
Compressions should be initiated within l0
seconds ofrecognition of the Brrest.
.
.
Rstionsle
Although v€ntilations are an important parl
o f resusc itation, evidence shows that
compressiols are tho critical €lement in
adult resuscitation. [n ihe A-B-C sequence,
Call for help, activate emefgency
r€sponse system, get
3.
6
Children: st lcasa one third the depth
ofthe chest, apprcximately 2 inches
(5 cm)
Infants: al loost one third the depth
ofthe chest, apprcximalely t %
inches (4 cm)
.
r
.
Providers' ability to accurately deiermine
presence or absence of a pulse is limitcd.
a pulse is not detected
within l0
If
seconds, do
start comDressions without further deloy.
Faster compressions are requir€d to
generate the prossur€s neccssary to perfuse
the coronary and cerebral arteries,
or less.
Deeper compressions are required to
generate the pressures neccssary lo perfuse
the cororory end cerebral arteri€s.
Airway
and
Breathing
Cricoid pressure is not routinely
recommended during intubation,
Ifan adequale number ofrescuers were
available, one could apply fficoid pressure.
"Look, listen, and feel for breathing" has been
"Look, listen, and feel for breathing" was
used to ass€ss breathing after the airway was
removed ftom the sequence for assessmcnt of
breathing after opening the airway. Healthcare
providers briefly check for breathing when
checklng responsiveness to detect slgns of
cafdiac arrest, Aft€r d€livery of30
compressions, lone rescuers open the viotim's
airway and deliver 2 bre8ths.
AED Use
For children from I to 8 years ofage, an AED
a pedialric dose-att€nuator system should
with
be used
ifavallable. If an AED with a dose
altenuatot is not avallable, a standard AED
may b€ used,
opened.
This does not rcpresent a ahanSe for
children, ln 2005 there was not sufficicnt
evidence to r€commend for or ageingt the use
ofan AED in infants,
Randomized studies showed that cricoid
pressure can delay or prevent the placement
ofan advanced airway and that some
aspiration can still occur despite cricoid
pressure. It ls also dil{icult to prop$ly train
providers to perform lhe maneuver
corfec y,
With the new chest compf€sslon-Iirst
sequen0€, CPR is performed ifthc adult
victim is unresponsive and not brcathitlg or
not breathing normslly (ie, not bfesthing or
only gasping) and begins with compressions
(C-A-B sequenco). Therefore, bresthlng i3
briofly checked as part ofa check for
cardiac arrest. Aller the lirst set ofchesl
compressions, the airrvay is opened and the
rescuer delivols 2 breaths,
The lowest energy dose for effectiv€
defibriltation in inlbnts and chlldren is not
known. The upper limit for safe
defibrillation is also not known, but doses
>4 J/kg (as high as 9 J/kg) havo provlded
€ffective defibrillation in children and
animal models ofpediatric arrest, with no
significant adverse effects.
For infants (<1 year of age), a manual
dafrbritlator is prelbfied, [fa msnual
defibrillstor b fiot available, an AED with a
psdiatric dose Bttenuetor is dosimble lf
neither is available, qn AED without a dose
AEDS with relatively high energy doses
havc been used successluliy in inl'ants in
cardiac artegt, wilh no clear adverse effects.
attenuatof mav be used,
Pediatric ALS Changes
ord
New
Dofibrillation
It is acceptable to use an initial dost ofz to 4
J/kg for defrbrillation, but fof eas€ ofteaahing,
an initial dose of2 J/kg may be used. For
refractory VF, it is feasohable to inclease the
dose to 4 J/tg. Subsequent energy levels
should be at least 4 JAg, and higher energy
levels (not to exceed 10 J&g ot the sdult
@ 2010 American Heart Association.
With . manual deflbrillBtor (monophasic or
biphasic), a dose of2 J/kg was used for the
first att€mpt and 4 J/kg for subsequent
sttemDls.
Rationale
More data are i€€ded to identiry the optimal
energy dose for pediatric defibrillatlon.
Limited evidence is available about
et'l'ective ol maximum energy doses lor
pediahic defibrillation, but some data
suggest that higher doses may be safe and
potentially more effective. Glven the
PALS Interim Materials. Use for AHA PALS Courses until 201 I PALS materials are released. R l2- 15- 10
ftaximum dose) mav be considered,
limiled evidence to support a change, the
new recommendation is a minof
modification that allows higher doses up to
the maximum dosc most experts believe is
safe.
ECG
Wide-complex tachycardia is present ifthe
QRS width is >0,09 second.
Wide-complex tachycardia is present ifthe
QRS widlh is >0.08 second,
Pharma-
The recommendation regardlng caloium
admlnistralion is stronger lhan ln past AHA
Guidslines: routine calcium administration is
not recommended for pediatrlc
cardlopulmonary arrest in the absence of
documonted hypocalcemia, calcium channel
blocker overdose, hypermagnesemia, or
Although the 200J ,,1HA Guldellnesfor CPR
and ECC noted lhat routine administration of
catcium does not improve the outcome of
cardisc arr€st, the words "is not
recommended" in the 2010 AHA Ouldelinet
lor CPR and ECC provide a stronger
statement and lndicate potentlql harm.
cology
ln a recent scientific statement, QRS
duration was considered prolonged if it was
>0.09 second for a child under the age of4
years, and >0.1 3scond wos coruidered
prolongcd for a child between the ages of4
and [6 yeafs. For this reason, lhe [,ALS
Guidelines Writing Croup concluded that it
would be most 0ppropriatc to considcf a
QRS width >0.09 second 0s prolong€d fbr
pediatrlc potienb. Although the human eye
is not likely to appreciate a difference of
0.01 second, a computer intcrpretation of
the ECC can document the QRS width rn
milliseconds.
Stronger evidence sgalnst the usc of
calcium during cardiopulmonary arres.
resulted in increased emphasis on avoiding
the routine use ofthis drug except for
patients wlth documented hypocalcemia,
calcium channel blocker overdose,
hypermagnesemia, or hyperkalemia,
hyperkalemia, Routine calcium administration
in cardiac arrest provides no benefit and may
be harmful,
Special
Considerations
Etomidaie has been shown to facilitate
endotracheal Intubatlon in infants and chlldren
with minimal hemodynanlic eftbct but is not
recommended fbr routino use in pediatric
patients with evide:lce ofseDtic shock.
Specific resusultation guidanoe has been
added for management ofcardiac arrest in
infants and children with single-ventricle
anatomy, Fontan or hemi-Fontantidirectional
Clenn physiology, and pulmonsry
hypert€mion.
@ 2010 American Heart Association.
Evidence ofpotential harm from the use of
etomidate in both adults and children with
septic shock led to the recommendation to
avoid its routine use in this setting.
These topics rver€ nol addressed in the r00J
AHA Guid.elines for CPR qnd ECC.
Specilio anatomical variants with congenital
heart dlsease present unique challenges for
resuscitation. The 20l0 AHA Guldellnes fot
CPR qnd ECC ovtline recommendations ln
each ofthese clinical sc€narlos. Common lo
all sccnarios is the potenilal early use of
extracorporeal membtan€ oxygenation as
PALS Interim Materials. Use for AHA PALS Courses until 201I PALS materials are releas€d. R l2-15-10
..\
Airway
and
Breathing
Once the circulation is restored, monitor
oxyhemoglobin saturation, It may be
reasonable, when th€ appropriate equipment is
available, to titrate oxygen administration ro
mailtain the arterial oxyhemoglobin
saturation >94%; an oxyhemoglobin
saluration of 100% is generally an indication
to rvean the FIor.
Exhated CO2 detection (by capnography or
colorimetry) is lecommended in nddition to
clinlcal assessment to confirm endotracheal
tube position for neonatas, infants, and
childrcn with a perfusing cardiac rhythm in all
settings (eg, pr€hospital, ED, intensive care
unit, ward, operating room) and during
intrahospital of interhospital tr0nsport,
Hyperoxia and lhe risk for reperfusion injury
were addrcssed in the 2005 AHA Guidelines
tbr CPR and ECC in general, bul
fecommendations for titfation oI inspired
oxygen were not as specific.
ln infants and children with a perfusing
rhythm, o colorimetric d€tector or
capnography was used to detect exhaled CO2
to confirm endofacheal tube position in the
prehospital and in-hospital settings and
during intrahospital and interhospilal
transDort.
rescue therapy in centers with this advanced
capability.
ln effect, ifequipment to titfate oxygen is
avsilable, iitrate oxygen to k€ep the
oxyhemoglobin satu ntion 94o/o to 99Vo,
Data suggest that hyperoxemia (ie, a high
Pao2) enhanc€s the oxidative injury
observed allcr ischemla-repertinion, such as
occurs after resusoitation llom cardlac
srf€sl.
Exhaled CO1 monitoring (capnography or
colorimetry) g€ner6lly confi rms placement
ofthe endotracheal tube in the airway and
may more rapidly lndicate cndotrachcal
tube misplacement/displacement thsn
monitoring of oxyhemoglobin saturation.
Because patient tfansporl increases the risk
for tube displacement, continuous CO2
monitoring is especially important at these
umes.
PostCardiac
Arrest
Care
@ 2010
Although there havc been no publishcd results
of pupective randomized pedlatric trials of
therapeutic hypothermia, based on adult
evidcnce, therapeutic hypothefmi8 (to 32"C to
34"C) may bc beneflcial for adolescents who
remain comatosc after res scitation ftom
sudden witnessed out-of-hospital VF cardiac
arr€st. l'herapeutio hypothefmia (to 32oC to
34oC) may also be considered for infants and
children rvho remain comatose after
resuscitation from cardiac arrest,
On tho basis ofextrapolatlon from adult and
neonatal studies, wh€n pediatric pati€nts
remain comatosc after resuscitation, cooling
them to 32"C to 34oC for 12 to 24 hours
could be considered.
Additional adult studics have continued to
show the benefit oftherapeutic hypothermia
for comatose patients atcr cardiac arrest,
including thos€ with rhythms other thon VF.
Pediatrio data afe needed.
American Heart Association. PALS Interim Materials. Use for AHA PALS Courses until 201 I PALS materials are released. R l2-15-10