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}Z _{Z }lZ }lZ:Z:Z _{Z }lZ _rlz_ rlz- rlz_ _rlz _{4 \1,/-:1,/- /|\ }1,,-:0,/-:1,,/l\ /l\ /l\ }0,, /l\ 7rr zs 4\ 4\ 4\ 4\ 4\ /l\ /l\ /N 4\ 4\ 4\ /l\ /l\ 4\ /l\ 4\ /N /l\ -{Z :|,/- _rlz_ /N _rlz_ _{Z _{Z :z 7rs 7N *W- Redlands 7rs -W-Hospital 7rs [-TiJ|Communirv 7N :Z :lZ 7N :le _{Z :Z Dear PALS Participant: _{,,_ 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. \Z 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 :Z \l/ :rz :le 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 :Z rlz rlt _\lZ .\l/- 71r71{ \lZ SlZ \lZ rlz \lz 7t\ \lz 7t\ -\l/- 7t-rlz- 7N /l\ }l//l\ -1!a7l\ zl\ /N /l\ -{Z -{Z Z\ -{Z }1,77t\ -{Z 7N -{Z 7l\ }l/-rlz- 7t\ 7gY -rlz- -4\ 4\ )!4 4\ 7rs zs 4\ -!a- 7|{ 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.@ Fiohling H.a.t Ois€as. end Strok6 Question Answer act, Dfd bcO Dad ocd lcd oad 2. 4. ] o. 7. o. a o ' 10. a I t. 12. oca 13. 15. 16. 1' bod bca Ccd bca bca e lcd acd b1d b.d Question 18. Answer ab ab ca ad 20. ab ao 22. ab ca 27, al ab ab ab 28. ob cd cd cl ad cl 23. 24. 25. 10- aa al 30. la cd cd 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