PALS - Written Test & Case Study Review Material with Complete Solutions, Exams of Pediatrics

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PALS - Written Test & Case Study Review Material with Complete Solutions CPR Sequence - ANSWER-C-A-B Circulation-Airway-Breathing Algorithm: Pediatric Septic Shock First hour... - ANSWER-Oxygen & support ventilation Establish IV, draw labs (glucose, blood cultures) Begin resuscitation Push repeated 20 mL/kg isotonic crystalloid (3-4) unless rales, resp distress, hepatomegaly Correct hypo-glycemia/calcemia Admin 1st dose antibiotics STAT STAT vasopressor drip/stress-dose hydrocortisone Establish 2nd IV Algorithm: Pediatric Septic Shock Fluid Responsive? - ANSWER-Yes - ICU No - Vasoactive drug & titrate for normotension Normo: begin dopamine Hypo/warm: norepi Hypo/cold: epi Adenosine (slows HR) - ANSWER-SVT 0.1 mg/kg - dose 1 0.2 mg/kg - dose 2 max = 6 mg RAPID push Amiodarone (antiarrythmic) - ANSWER-VF/VT (pulseless) 5 mg/kg Bolus max = 300 mg SVT, VT (with pulses) 5 mg/kg over 20-60 mins max = 300 mg Atropine (increases HR) - ANSWER-Bradycardia 0.02 mg/kg may repeat once Epinepherine (increases HR) - ANSWER-Bradycardia/Pulseless Arrest 0.01 mg/kg (1:10,000) every 3-5 min Hypotensive Shock 0.1-1 mcg/kg per min Anaphylaxis 0.01 mg/kg every 3-5 min Algorithm: Pediatric Cardiac Arrest - ANSWER-Shout for help CPR Oxygen, AED If no shock - CPR for 2 min, IV, Epi q 3-5 min, reassess If shock - after...CPR for 2 min, IV, reassess If 2nd shock - CPR for 2 min, Epi q 3-5 min, reassess If 3rd shock - CPR for 2 min, Amiodarone, treat cause, reassess... Post Resuscitation Care Shock Doses - ANSWER-1st shock - 2 j/kg 2nd shock - 4 j/kg Max 10 j/kg Reversible Causes of Pediatric Cardiac Arrest (H&T's) 6 H's (G,K,T,V,X,DRO) - ANSWER-1. Hypo-Glycemia 2. Hypo/hyper-Kalemia 3. Hypo-Thermia 4. Hypo-Volemia 5. Hypo-Xia 6. HyDROgen ion (acidosis) Reversible Causes of Pediatric Cardiac Arrest (H&T's) 5 T's (A,E,HC,HP,O) - ANSWER-1. Tamponade, cardiac 2. Tension pneumothorax 3. Thrombosis, coronary 4. Thrombosis, pulmonary 5. Toxins Rescue Breaths - ANSWER-1 every 6-8 secs 8-10 per min Minimum SBP calc - ANSWER-70 + 2 X age in years Endotrach Tube Size calc (and difference between 2 types) - ANSWER-Uncuffed = age / 4 + 4 Cuffed = age / 4 + 3 (prevents aspiration) IO vascular access components - ANSWER-Less than 24 hour use Leg bone below knee is best Stop when POP Cannot use same bone twice Must have pressure to flow, PUSH HARD 10 mL/kg on IVF bolus Flush with 10 mL after any drug Chest Compression Depth - ANSWER-Child 1/3 chest = 2 inches, 5 cm Infant 1/3 chest = 1.5 inches, 4 cm ET placement confirmation - ANSWER-Mist in tube Bilat lung breath sounds No gurgling in abdomen CO2 detect (capnography/capnometry) What should I do for a pneumothorax? - ANSWER-Needle decompression Chest tube placement Shockable Rhythms - ANSWER-Pulseless VT VF (v fib) Not Shockable Rhythms - ANSWER-PEA Asystole Medication Sequence (Epi/Ami) - ANSWER-Epi 0.01 mg/kg every 3-5 min Amiodarone 5 mg/kg bolus, can repeat to a total of 15 mg/kg per 24 hours For SVT with pulse - ANSWER-Vagal/Adenosine/Cardioversion For VT with pulse - ANSWER-Amiodarone/Cardioversion For Torsades de Pointes - ANSWER-Magnesium Cardioversion Doses - ANSWER-0.5-2 j/kg 1st time = 0.5 j/kg 2nd time = 1-2 j/kg Core Case Resp 1: UAO (Anaphylaxis) - ANSWER-Open airway Admin O2 100% non-rebreather, re-assess AED, Vitals (cardiac rhythm = sinus tachy) S/sx of UAO, resp distress TX: Epi IM, Steroids, CPAP Vascular access Prepare for intubation Core Case Resp 2: LAO (Bronchiolitis or Asthma) - ANSWER-Admin O2 100% non- rebreather after finishing neb tx, re-assess AED, Vitals (cardiac rhythm = sinus tachy) S/sx of LAO, resp distress Suction nose TX: Neb albuterol, Non-invasive pos press vent (NIPPV), Steroids Vascular access, labs, ABGs, chest X-ray Prep for bag-mask vent, intubation Core Case Resp 3: Lung Tissue Disease (Pneumonia or Aspiration) - ANSWER-Admin O2 100% non-rebreather after finishing neb tx, re-assess, titrate O2 to 94-99% AED, Vitals (cardiac rhythm = sinus tachy) S/sx of LTD, resp failure Suction nasopharynx Vascular access, labs, ABGs, chest x-ray TX: Neb albuterol, antibiotics, Non-invasive vent (CPAP or NIPPV - PEEP) Prep for bag-mask vent, intubation Core Case Resp 4: Disordered Control of Breathing (Respiratory Depression after Seizure or Drugs or IICP) - ANSWER-Open airway Suction oropharynx AED, Vitals (cardiac rhythm = normal sinus) S/sx of DCB, resp failure Vascular access, labs, chest x-ray TX: Do not reverse drug, bag-mask/vent support Prepare for intubation, PEEP Core Case Shock 1: Hypovolemic (Dehydration) - ANSWER-Admin high-flow O2 non- rebreather, re-assess AED, Vitals (cardiac rhythm = sinus tachy) S/sx of hypotensive shock Vascular access, labs, ABGs, chest x-ray Admin IVFs 20 mL/kg bolus, assess Repeat bolus as needed for BP, HR, pulses Admin BP help drug if needed Core Case Shock 2: Obstructive (Tension Pneumothorax) - ANSWER-DOPE Begin manual ventilation, re-assess AED, Vitals (cardiac rhythm = sinus tachy) S/sx of cardiopulmonary failure and shock, compensated IMMEDIATE TX: Needle thoracostomy (R, 2nd intercostal, midclav line), chest tube Vascular access, labs, ABGs, chest x-ray Fluid bolus for BP Core Case Shock 3: Distributive (Sepsis) - ANSWER-Continue O2 AED, Vitals (cardiac rhythm = sinus tachy) Verify ET placement S/sx septic shock, uncompensated Verify patency of PAC, insert secondary PIV, labs, ABGs, blood cultures TX: Admin fluid bolus 20 mL/kg, Repeat fluid bolus 20 mL/kg for continued shock, Admin antibiotics, Admin vasoactive drug if needed for continued shock Transfer to PICU Core Case Shock 4: Cardiogenic (Myocarditis) - ANSWER-Admin high-flow O2, re- assess AED, Vitals (cardiac rhythm = sinus tachy) S/sx resp distress, compensated cardiac shock Vascular access, labs, ABGs, chest x-ray SLOW fluid bolus 5-10 mL/kg over 10-20 mins Inotropic/vasoactive drug if shock continues May need CPAP/PEEP to reduce work of breathing on heart Transfer to PICU Core Case Cardiac 1: SVT with pulses present - ANSWER-Admin high-flow O2, re- assess AED, Vitals (cardiac rhythm = SVT with adequate perfusion) S/sx resp distress, SVT, adequate perfusion Vascular access, labs, ABGs, chest x-ray TX: Vagal (ice on face), admin Adenosine (0.1 mg/kg) plus second dose (0.2 mg/kg) if needed, sync cardioversion (0.5-1 j/kg) if needed Monitor for heart failure Core Case Cardiac 2: Bradycardia - ANSWER-100% O2, re-assess CPR for 2 mins, re-assess AED/Vitals (cardiac rhythm = sinus brady) S/sx resp failure, arrhythmia - brady with poor perfusion Vascular access, labs, ABGs, chest x-ray, head CT, ECG TX: CPR, admin Epi (0.01 mg/kg every 3-5 min), antidotes if needed Prepare for intubation Core Case Cardiac 3: Asystole/PEA - ANSWER-CPR, re-assess every 2 mins Bag-mask ventilation with 100% O2, consider oropharyngeal airway AED/Vitals (cardiac rhythm = asystole) NO SHOCK S/sx cardiac arrest Vascular access, labs, ABGs Synchronized cardioversion at a dose of 4 J/kg Unsynchronized cardioversion at a dose of 2 J/kg Unsynchronized cardioversion at a dose of 4 J/kg You are treating a 5-month-old with a 2-day history of vomiting and diarrhea. The patient is listless. The respiratory rate is 52/min and unlabored. The heart rate is 170/min and pulses are present but weak. Capillary refill is delayed. You are administering high-flow oxygen, and intravenous access is in place. At this point the most important therapy is to: - ANSWER-Administer an epinephrine bolus Begin bag-mask ventilation *Provide a rapid 20 ml/kg isotonic crystalloid fluid bolus Administer a bolus of 0.5 g/kg of dextrose Which of the following groups of clinical findings would be most consistent with categorizing a patient with compensated shock? - ANSWER-*Normal systolic blood pressure, decreased level of consciousness, cool extremities with delayed capillary refill, and faint or nonpalpable distal pulses Decreased level of consciousness, extensor posturing in response to pain, hypertension, and apnea Normal blood pressure, normal level of consciousness, bounding distal pulses, hypercarbia, hypoxemia, and normal urine output Unresponsiveness, normal breathing, and good distal pulses You are treating a 10-year-old patient after a motor vehicle crash. The patient is unresponsive and flexes his arms at the elbow in response to a painful stimulus. An endotracheal tube is in place with position confirmed. You are ventilating using a resuscitation bag with oxygen, and the child has an SPO2 of 95% and good chest excursion bilaterally. The blood pressure is 130/70 mm Hg, and the heart rate is 90/min with good perfusion. You have established intravenous access. Which of the following actions would be most appropriate at this time? - ANSWER-*Obtain a CT scan of the head and neck Begin manual hyperventilation Provide continuous positive airway pressure Give an intravenous bolus of mannitol You arrive on the scene of a 12-year-old child who suddenly collapsed on the playground. The child is unresponsive, apneic, and pulseless and CPR is in progress. A lay rescuer just brought the school AED, turned it on, and attached it. The AED recommends a shock. Which of the following should be done next? - ANSWER-Obtain intravenous access *Attempt defibrillation Change compressions:ventilations from 30:2 to 15:2 Attempt endotracheal intubation You are caring for a child in persistent ventricular fibrillation. Which of the following would best describe the child's cardiac condition? - ANSWER-*The heart is not pumping blood at all The heart is beating too slowly to maintain circulation There is no electrical activity in the heart The heart is pumping so fast that it cannot fill completely between beats You are called to treat a 5-year-old with a 3-day history of worsening respiratory distress. The child responds only to pain. The heart rate is initially 45/min and regular with poor capillary refill. You provide bag-mask ventilations (BMV) with high-flow oxygen that produces good chest rise with full and clear bilateral breath sounds. The heart rate rises in response to ventilation, but after you suction the posterior pharynx, bradycardia recurs (40/min). Which of the following interventions would be most appropriate for you to do first? - ANSWER-Perform transcutaneous pacing Administer epinephrine IV Administer atropine IV *Resume bag-mask ventilation You are caring for an 8-month-old with bradycardia and very poor perfusion that has persisted despite effective ventilations with high-flow oxygen. You should begin chest compressions if the heart rate is: - ANSWER-More than 200/min More than 150/min Less than 100/min *Less than 60/min You are caring for a 2-year-old with a 1-day history of respiratory distress and stridor. The patient is alert. The child's respiratory rate is 32/min with good chest rise. SPO2 is 98% in room air. The heart rate is 128/min and capillary refill is normal. Skin is warm, pink, and dry. At this point you should: - ANSWER-Assist ventilations with bag-mask device Use a nonrebreathing mask with tight mask seal *Keep the patient calm and comfortable Give IV methylprednisolone (Solumedrol) You are caring for a 7-year-old with respiratory distress that has worsened over the past few hours. The child is alert and in moderate respiratory distress with prolonged exhalation time. The respiratory rate is 28/min with bilateral expiratory wheezes. The heart rate is 112/min with good capillary refill. The wheezing in this patient indicates: - ANSWER-Lung tissue (parenchymal) lung disease Disordered control of breathing Upper airway obstruction *Lower airway obstruction Which of the following assessments is most useful in evaluating the effectiveness of bag-mask ventilations? - ANSWER-Hearing an air leak around the mask when the bag is fully compressed Seeing the abdomen rise during ventilation *Observation of visible chest rise A normal systolic, diastolic, and mean arterial pressure You are assessing a 6-year-old child who appears unconscious after striking his head on a concrete step. You pinch the patient's chest and the patient grabs your hand. You would document this response as: - ANSWER-Decerebrate posturing Decorticate posturing Withdrawal from a painful stimulus *Localization of a painful stimulus You are caring for an 8-year-old child who was struck by a car. The child is alert, very anxious, and in respiratory distress. The child is receiving high-flow oxygen by face mask, has a respiratory rate of 60/min, the heart rate is 150/min, systolic blood pressure is 70 mm Hg, and a SpO2 of 86% and falling. Breath sounds and chest rise are absent over the right chest. Which of the following is the most likely cause of this child's distress? - ANSWER-*Tension Pneumothorax Cardiac temponade Severe hypovolemia Cardiac asthma You are treating a 10-year-old victim of multisystem trauma. The child is very anxious and confused. The respiratory rate is 44/min and unlabored. the pulse is rapid and weak. Capillary refill is delayed. High-flow oxygen and an intravenous line are in place. The most appropriate initial fluid for rapid volume expansion is: - ANSWER-10% dextrose in water 5% dextrose in Ringer's lactate 5% dextrose in normal saline *Normal saline or Ringer's lactate When monitoring the quality of chest compressions during a resuscitation, you should ensure that providers are: - ANSWER-Pushing hard - ensure that the chest is compressed 3/4 of the anterior-posterior diameter Pushing fast - compress at a rate of 150/min *Allowing complete recoil - let the chest return to its original position between compressions Minimizing interruptions - do not permit interruptions for more than 1 minute If a child has a HR more than 60 bpm, pulse is present, but they are not breathing, what should you do? - ANSWER-Rescue breaths - NOT CPR For a pediatric patient, at what HR should you start CPR? - ANSWER-< 60 bpm When is it acceptable to use the ambu bag? - ANSWER-With 2 person rescue, NOT one If a child has an allergic reaction, what should you give them? - ANSWER-normal epinephrine What dose of epi do you give kids? - ANSWER-0.01 mg/kg If a child needs AED, but there are no pediatric paddles, what do you do? - ANSWER- use adult's paddles, make sure 2 inches between the 2 paddles There should be a rescue breath every ____ seconds and ___ rescue breathes every min - ANSWER-3-5 seconds 12-20 min Child presents with diarrhea and vomiting what should you give to them? - ANSWER- Glucose! (fluids too but she said the answer will be Glucose since they will likely be hypoglycemic) What is the normal respiratory rate for an infant (less than 1 y.o.)? - ANSWER-30-60 bpm What is the normal respiratory rate for a toddler (1-3 y.o.)? - ANSWER-24-40 bpm What is the normal respiratory rate for a preschooler (4-5 y.o)? - ANSWER-22-34 bpm What is the normal respiratory rate for a school age child (6-12 y.o.)? - ANSWER-18-30 bpm What is the normal respiratory rate for an adolescent (13-18 y.o)? - ANSWER-12-16 bpm What are the three locations retractions may be seen if a child is having mild to moderate breathing difficulty? - ANSWER-subcostal (abdomen below ribs) substernal (abdomen below sternum) intercostal (between ribs) What are the three locations retractions may be seen if a child is having severe breathing difficulty? - ANSWER-supraclavicular suprasternal sternal (retraction of sternum toward spine) What does the sound of moist crackles (rales) indicate? - ANSWER-accumulation of alveolar fluid (pneumonia, pulmonary edema or interstitial lung disease) What does the sound of dry crackles (rales) indicate? - ANSWER-atelectasis (small airway/alveolar collapse) and interstitial lung disease) How can a child maintain normal SpO2 and still be in respiratory distress? - ANSWER- increased RR and increased respiratory effort What SpO2 indicates adequate oxygenation when a child is breathing room air? - ANSWER-greater than or equal to 94% What SpO2 indicates further intervention is indicated if a child is already receiving 100% O2? - ANSWER-less than 90% What is the normal awake heart rate for newborn to 3 months? - ANSWER-85-205 bpm What is the normal sleeping heart rate for newborn to 3 months? - ANSWER-80-160 bpm What is the normal awake heart rate for 3 months to 2 years? - ANSWER-100-190 bpm What is the normal sleeping heart rate for 3 months to 2 years? - ANSWER-75-160 bpm What is the normal awake heart rate for 2-10 years? - ANSWER-60-140 bpm What is the normal sleeping heart rate for 2-10 years? - ANSWER-60-90 bpm What is the normal awake heart rate for >10 years? - ANSWER-60-100 bpm What is the normal sleeping heart rate for >10 years? - ANSWER-50-90 bpm What is considered hypotension in neonates? - ANSWER-< 60 mmHg systolic BP What is considered hypotension in infants (1-12 mo.)? - ANSWER-< 70 mmHg systolic BP What is considered hypotension in peds (1-10 y.o.)? - ANSWER-< 70 mmHg + (age x 2) What is considered hypotension in peds (>10 y.o.)? - ANSWER-< 90 mmHg What is AVPU used for? What does AVPU stand for? - ANSWER-Assessment of LOC (cerebral cortex fxn) Alert, Voice, Painful, Unresponsive Which of the following rhythms is shown on this ECG rhythm strip? - ANSWER-Sinus bradycardia *Ventricular fibrillation (VF) Asystole Supraventricular tachycardia) You are caring for a 3-year-old with myocarditis and heart failure. She has become poorly responsive to a sternal rub and is difficult to rouse. She has a sinus rhythm with a heart rate of 175/min, and a blood pressure of 88/65 mm Hg. Her skin is cool and mottled, capillary refill time is 5 seconds and she has barely palpable distal pulses. Oxygen saturation is 90% on high-flow, high-concentration oxygen by face mask. Her respirations are labored at 50/min with moderate retractions, and crackles are heard at the bases. Which of the following would be the most appropriate therapy for this child? - ANSWER-Obtain a STAT echocardiogram and chest x-ray Perform synchronized cardioversion at 0.5 joules/kg *Provide assisted ventilations with 100% oxygen and prepare for endotracheal intubation Administer epinephrine 0.1 mL/kg of 1:10,000 solution IV You are treating a 5-month-old with a 2-day history of vomiting and diarrhea. The patient is listless. The respiratory rate is 52/min and unlabored. The heart rate is 170/min and pulses are present but weak. Capillary refill is delayed. You are administering high-flow oxygen and intravenous access is in place. At this point the most important therapy is to: - ANSWER-Administer an epinephrine bolus Begin bag-mask ventilation *Provide a rapid 20 mL/kg isotonic crystalloid fluid bolus Administer a bolus of 0.5 g/kg of dextrose You are treating a 10-year-old patient after a motor vehicle crash. The patient is unresponsive and flexes his arms at the elbow in response to a painful stimulus. An endotracheal tube is in place with position confirmed. You are ventilating using a resuscitation bag with oxygen, and the child has an Spot of 95% and good chest excursion bilaterally. Blood pressure is 130/70 mm Hg and heart rate is 90/min with good perfusion. You have established intravenous access. Which of the following actions would be most appropriate at this time? - ANSWER-Give an intravenous bolus of mannitol Provide continuous positive airway pressure (CPAP) *Obtain a CT scan of the head and neck Begin manual hyperventilation You arrive on the scene where a 12-year-old child has suddenly collapsed on the playground. The child is unresponsive, apneic, and pulseless, and CPR is in progress. A lay rescuer just arrived with the school AED, turned it on, and attached it. The AED recommends a shock. Which of the following should be done next? - ANSWER-Attempt endotracheal intubation Obtain intravenous access *Attempt defibrillation Change the compression-to-ventilation ratio from 30:2 to 15:2 You are caring for a child in persistent VF. Which of the following would best describe the child's cardiac condition? - ANSWER-*The heart is not pumping blood at all The heart is beating too slowly to maintain circulation