PALS

• LOC
• breathing
• color

shout for help/activate emergency response then check for a pulse

• with pulse:  give breaths
• without a pulse or pulse <60:  CPR

primary assessment:  ABCDE

secondary assessment:  focused medical history & physical exam

diagnostic tests

assess scene for danger

• ABCDE
• Airway
• Breathing
• Circulation
• Disability
• Exposure

get VS, etc

if child has obstruction and is still awake

<1year old:  5 back slaps & 5 chest thrusts

</= 1 year:  abd thrusts

• 1. ET
• 2. CPAP - continuous positive airway pressure
• 3. trach
• 4. removal of foreign body:  direct laryngoscopy

• infants:  30 to 60
• toddler (1-3):  24-40
• preschooler:  (4-5):  22-34
• school age (6 to 12):  18- 30
• adolescent (13-18):  12 to 16

anything that raises metabolic demands:  anxiety, fever

normal for RR to pause for 10-15 seconds during sleep

tachypnea

cessation of breathing for 20 seconds or <20 seconds if accompanied by bradycardia, cyanosis, or pallor

sign of deterioration or respiratory distress

head bobbing:  tilt head back during I and forward during E

seesaw:  chest retracts & abd expands during inspiration & opposite during expiration

may not be enough airflow to cause sounds

usually heard on I:  indicates upper airway obstruction that may be critical

heard during E usually

caused by partially closed glottis

usually r/t alevolar collapse/lung problems

may indicate respiratory failure or may be response to pain from abd probs

upper airway obstruction with liquid:  vomit, blood, secretions, etc

usually during E

usually means lower airway obstruction:; bronchiolitis, asthma, obstruction

• AKA rales
•  I sounds

alveolar fluid

dry crackles:  atelectasis

finger, toe, or earlobe

low H&H/RBC's:  inadequate HgB but all is saturated:  shows normal O2 sat

inadequate circulation:  may have adequate O2 but it can't circulate

carbon monoxide:  shows high O2 sat

• newborn - 3 months:  85 - 205
• 3 mo to 2 years:  100 to 190
• 2 yrs to 10 years:  60 - 140
• <10:  60 -100

hypoxia

normal for HR to fluctuate with breathing in children:  increase with I and decrease with E

fluctuation in pulse voume with respiratory cycle

severe asthma & pericardial tamponade

< 2 seconds

mm, lips, palms, and soles

may be hypoxemia, hypovolemia, or shock that cause intense vasoconstriction from irregular supply of O2 blood

cyanosis of mm and mouth

usually an emergency

may be more apparent in mm and nail beds, soles of feet, tip of nose, and earlobes

• neonate (1 day):  60-75/30-45
• neonate (4 days):  65-85/35-55
• infant up to 1 year:  75-95/35-55
• 1 -2 years old:  85-105/45-65
• 7 years:  95-115/55-75
• 15 years:  similar to adults

• 1. decreased LOC
• 2. loss of muscular tone
• 3. seizures
• 4. pupil dilation

can be caused by decreased circulating volume:  blood loss, dehydration

may be caused by vasodilation:  septic shock

development of bradycardia

increasing UO

• AVPU pediatric response scale
• Alert:  awake, active, responsive
• Voice:  responds only to voice calling name or speaking loudly
• Painful:  responds only to painful stimulus
• Unresponsive:  none

motor response

• Eye Opening:
• 4 - spontaneous
• 3 - to speech
• 2 - to pain
• 1 - none

• Best verbal response:
• 5 - oriented
• 4 - confused
• 3 - inappropriate words
• 2 - incomprehensible speech
• 1 - none

• Best motor response
• 6 - obeys
• 5 - localizes
• 4 - withdraws
• 3 - abnormal flexion/flexion in response to pain
• 2 - extensor response/extension in response to pain
• 1 - none

• Eye Opening:
• 4 - spontaneous
• 3 - to speech
• 2 - to pain
• 1 - none

• Best verbal response
• 5 - coos & babbles
• 4 - irritable, cries
• 3 - cries in response to pain
• 2 - moans in response to pain
• 1 - none

• Best motor response
• 6 - moves spontaneouly & purposely
• 5 - withdraws in response to touch
• 4 - withdraws in response to pain
• 3 - decorticate posturing - abnormal flexion in response to pain
• 2 - decerebrate posturing:  abnormal extension in response to pain
• 1 - none

brainstem injury

ocular trauma, ICP

remove clothing one item and a time

look for trauma

check temp/temp differences on body

• SAMPLE
• S - s/s at onset
• A - allergies
• M - meds
• Past medical Hx
• Last meal
• Events leading to current illness & Tx done

only indicates O2 dissolved in blood plasma - if HgB is low PaO2 may be normal anyway

high lactate shows hypoxia of tissues and anaerobic respiration

• hypotension
• hypo/hyperthermia
• hypoxia
• hypovolemia
• hyper/hypo electrolytes
• hypoglycemia
• tamponade
• toxin
• tension pneumothorax
• thrombosis
• trauma

higher metabolic rate

increased RR and depth

• 1. first sign = tachycardia
• 2. tachypnea
• 3. s/s of resp distress

cyanosis, decreased LOC, bradypnea,/apnea, bradycardia

high CO2 - inadequate ventilation

. anything that depresses resp system:  drugs, CNS probs

decreased/decreasing LOC:  even if O2 sat is normal suspect ventilation is inadequate & hypercarbia & resp acidosis may be present

• 1. increased airway resistance
• 2. decreased lung compliance
• 3. use of accessory muscles
• 4. disordered CNS control of breathing

Airway:  positioning open, clear with suctioning, oropharyngeal or nasopharyngeal airway

Breathing:  O2 sat, auscultate breath sounds, give O2, sit up, albuterol/epi, vent with bag, ET

Circulation:  color, pulses, cap refill, HR & rhythm, BP, IV for fluid therapy & meds as indicated

ABC's for respiratory distress/failure AND

• 1. remove foreign body if possible
• 2. suction nose/moouth
• 3. reduce airway swelling with meds
• 4. minimize agitation - can make swelling worse
• 5.  may need surgery
• 6. CPAP

s/s of upper airway obstruction and barking cough

mild:  dexamethasone

mod-sever:  humidified O2, NPO, nebulized epi, dexamethasone, heliox

• 1. O2 with nonrebreather
• 2. bag vent
• 3. dexamethasone
• 4. ET
• 5. surgical airway prn

• 1. ABC interventions for resp failure and give IM injection of EPI q10-15 min prn
• 2. albuterol
• 3. ET
• 4. Tx hypotension:  trendelenburg, isotonic solution 20mL/kg bolus, may give IV epi,     5. diphenhydramine & an H2 blocker             6. methylprednisolone/corticosteroids

if it is not complete obstructions:  do not do anything, get help and let child try to cough it up

• if complete & child is conscious:
• 1year:  5 back slaps & 5 chest thrusts
• over 1 year:  abd thrusts

if child becomes unresponsive:  start CPR even if pulse is palpable starting with chest compressions  - before giveing breaths see if there is a foreign body that can be removed

• 1. humidified O2
• 2. albuterol
• 3. oral/IV corticosteroids
• 4. ipratropium bromide
• 5. IV access & fluids
• 6. Mg sulfate IV slow (15 to 30 min):  monitor HR & BP
• 7. DX tests:  ABG, CXR
• 8. terbutaline SQ or by cont IV:  relaxes and opens airways
• 9. positive airway pressure
• 10. ET

• 1. Dx tests:  ABG, CXR, viral studies, CBC, blood culture, sputum gram stain & culture
• 2. admin ABX
• 3. albuterol for wheezing
• 4. CPAP or ET with vent prn
• 5. reduce metabolic demand by normalizing tem p & reducing WOB

• 1. hear problems especially involving L ventricle
• 2. hypoxia
• 3. cardiac-depressant drugs:  beta blockers, tricyclic antidepressants, Ca channel blockers

• 1. ventilatory suppoet:  CPAP, PEEP with vent
• 2. diuretics
• 3. inotropic drugs
• 4. reduce metabloic demand by normalizing temp and decreasing WOB

low BP

• 1. irregular breathing or apnea
• 2. increase in mean arterial pressure
• 3. bradycardia

indicates impending brain herniation

• 1. get neurosurgical consult
• 2. open airway with jaw-thrust
• 3. O2 - may hyperventilate if brain herniation is impending
• 4. poor perfusion or organ dysfunction r/t poor perfusion:  IV with isotonic fluids
• 5. hypertonic & osmotic agents
• 6. Tx agitation & pain
• 7. Avoid hyperthermia

• 1. irregular respirations/apnea
• 2. bradycardia
• 3. hypertension
• 4. unequal or dilated pupils not responsive to light
• 5. decerebrate or decorticate posturing

• 1. call poison control center
• 2. suction airway with vomiting
• 3. admin antidote as indicated
• 4. Dx tests:  ABG, ECG, CXR, electrolytes, glucose, serum osmolality, & drug screen

ineffective cough and secretions build up

airway obstruction, pneumothorax

deliver each breath over 1 second

metabolic demands of body are not met by BF/oxygenation

may be r/t loss of BV, maldistribution of blood, BV dilation, increased metabolic demands, heart malfunction

CO = HR x stroke volume (amnt pumped out)

infants need HR to maintain CO b/c they are unable to adjust their stroke volume to compensate for low HR

• preload - amnt in heart before it pumps
• contractility
• afterload - vascular resistance

• 1. tachycardia
• 2. vasoconstriction to nonvital organs:  decreased UO, decreased extremity perfusion, pulse, cap refill, paleness, etc
• 3. increased contractility

• increase in SVR = increased diastolic pressure
• decrease in SVR - decrease in diastolic pressure

will usually be maintained by increased SVR

narrowed pulse pressure r/t increase SVR = increase diastolic pressure

• 1. hypotension
• 2. lactic acidosis
• 3. end-organ dysfunction:"  altered mental status, decreased UO
• 4. myocardial dysfunction & cardiac arrest

compensated - systolic BP maintained at normal

decompensated:  low systolic BP

children are at risk even with compensated b/c they may have very low CO with high SVR keeping BP normal

automated BP readings may be inaccurate if taken when there is no distal perfusion:  weak pulses, cap refill, pale, etc

decreasing LOC

septic shock - sepsis can cause vasodilation & decreased SVR

may still have warm extremities, brisk cap refill, and full peripheral pulses despite hypotension

if child's BP is <

70 + (child's age X2)

• 1. s/s of decreasing profusion:  decreasing pulse, cap refill, coloring
• 2. decreasing BP
• 3. increasing HR & RR
• 4. decreasing LOC

diarrhea

• 1. diarrhea/vomiting
• 2. hemorerhage
• 3. inadequate fluid intake
• 4. osmotic diuresis:  DKA
• 5. third-space losses
• 6. large burns

metabolic acidosis occurs with hypovolemic shock - hyperventilation compensates for this

• 1. increased RR & HR
• 2. decreased BP & narrowed pulse pressure
• 3. metabolic acidosis
• 4. weak or absent peripheral pulses
• 5. delayed cap refill
• 6. cool, pale, diaphoretic skin
• 7. changes in LOC
• 8. oliguria

septic, neurogenic, anaphylactic

vasodilation & increased vascular permeability cause relative hypovolemia and decreased perfusion

high cervical spine injury:  hypotension and vasodilation occur r/t no CNS stimulation

not able to compensate with tacfhycardia so HR and BP will both be low

same as hypovolemic except neurogenic shock will have decreased HR

in initial stages will have adequate CO with low SVR then progresses to same as hypovolemic with low CO & BP with high SVR

• 1. fever/hypothermia
• 2. low/high WBC

DIC

can cause ischemia to adrenal gland -> decreased cortisol -> low SVR & myocardial dysfunction

• 1. anxiety or agitation
• 2. NV
• 3. urticaria
• 4. angioedema
• 5. respiratory distress with stridor or wheezing
• 6. hypotension
• 7. tachycardia

• 1. s/s of hypovolemic shock
• 2. s/s of resp distress r/t pulm edema
• 3. s/s of CHF
• 4. cyanosis

rapid fluids can worsen pulm edema

PEA

• 1. respiratory distress
• 2. tachycardia
• 3. poor peripheral perfusion
• 4. muffled or diminished heart sounds
• 5. narrowed pulse pressure
• 6. pulsus paradoxus ( increase in systolic BP by >10 during inspiration)
• 7. distended neck veins
• 8. changes in LOC

small QRS complexes

use echo to Dx

air accumulates in pleural space -> presses on surrounding areas -> PEA

trauma

person with positive-pressure ventilation who suddenly deteriorates

• 1. tracheal deviation toward contralateral side
• 2. hyperresonance of affected side
• 3. diminished breath sounds on affected

other s/s are similar to cardiac tamponade

similar to hypovolemic shock

s/s of congestion & R heart failure distinguish it

may also complain of chest pain from ischemia to area

• 1. O2 admin, ventilation
• 2. may need blood admin
• 3. rapid admin of isotonic fluids

• 1. rapid fluid admid
• 2. vasopressors to combat low  SVR

• increase CO while decreasing cardiac demands
• 1. positive-pressure ventilation to reduce WOB
• 2. slow infusion ov IV fluid
• 3. inotropics and vasodilators

acidosis = K+ increase r/t K+ forced out of cells by H+

shock pt may have hyperkalemia

does not respond well to bicarb/buffer Tx unless solely due to buffer loss

must correct tissue perfusion to correct acidosis

still may give bicarb for severe acidosis

• 1. stable - leave in position of comfort / hypotensive - trendelnburg
• 2. O2 admin
• 3. may need blood
• 4. may need vent
• 5. vascular access
• 6. fluid resuscitation:  isotonic bolus 20mL/kg over 5 to 20 min & repeat (except in cardiogenic) / blood for hemorrhage
• 7. Monitor & assess SpO2, HR, BP, LOC, temp, & UO
• 8. labs
• 9. meds prn

• 1.  sepsis
• 2. blood transfusions

• 1. EPI
• 2. dopamine
• 3. dobutamine

increase contractility & HR

milrinone & inamrinone

decrease SVR, improve contractility & cornonary artery BF

• nitro drugs:
• nitroglycerin, nitroprusside/nipride

• 1. EPI in doses >0.3mcg/kg per minute
• 2. NE
• 3. dopamine in doses >10mcg/kg per minute
• 4. vasopressin

ventilation with PEEP

• 1. DKA - high blood osmolality r/t increased glucose -> cerebral edema can occur
• 2. ingestion of Ca channel blockers or beta blockers

• preterm & term neonates:  <45
• infants, children, and adolescents:  <60

• 1. oral ingestion of glucose if possible
• 2. IV glucose 0.5 to 1g/kg (D5W)

• 1. lactate
• 2. glucose
• 3. calcium
• 4. ABG
• 5. CBC
• 6. cultures

give vasopressors & stress-dose hydrocortisone

evaluate pt for improvement:  BP, HR, peripheral perfusion to determine next intervention

improvement:  take to ICU

• 1. O2 and vent prn
• 2. IV access X2
• 3. fluid bolus 20mL/kg repeatedly
• 4. Testing:  lactate, glucose, Ca, ABG, cultures, CBC
• 5. Correct any metabolic problems:  hypoglycemia, hypocalcemia
• 6. first dose of broad spectrum ABX STAT
• 7. may give vasopressor or stress hydrocortisone
• 8. monitor for fluid overload

• 1. Establish central venous access
• 2. vasoactive drug
• 3. additional fluids & consider colliod fluids
• 4. may give transfusion if HgB<10
• 5. may vent with PEEP

NE:    vasoconstrictor, increase contractility

vasopressin

dopamine

EPI - inotropic effects

>/= 0.3mcg/kg per minute

can produce lactate

• hydrocortisone 2mg/kg IV bolus
• max dose 100 mg

• 1. normal Tx of any shock
• 2. EPI:  IM:  1:1000, may give infusion after 10-15min 1:10,000
• 3. isotonic solution
• 4. albuterol
• antihistamines:  diphenhydramine, H2 blockers (tidines)
• 5. corticosteroids:  methylprednisolone
• 6. may use vasopressors

hypotension, bradycardia, hypothermia

• other shock Tx AND
• 1. position flat or head-down for venous return
• 2. trial of isotonic fluid
• 3. for fluid-refractory hypotension:  vasopressors:  EPI, NE
• 4. warming or cooling prn

improve cardiac function & decrease metabolic demand

• 1. cautious fluids (5-10 mL/kg over 10-20min)
• 2. O2
• 3. assist with ventilation prn
• 4. may est. central venous access for measureing CVP
• 5. Tests:  ABG, HgB, lactate, cardiac enzymes, thyroid, CXR, ECG, echo
• 6. Meds:  vasodilators, diuretics, inotropes
• 7. reduce metabolic demand:  assist with vent, antipyretics, analgesics, sedatives,

• 1. fluid bolus may help perfusion at first
• 2. pericardial drainage with radiology guide or emergency pericardiocentesis

1. immediate needle decompression followed by thoracostomy for chest tube

• 1. O2 & vent assistance
• 2. fluid therapy prn
• 3. echo, CT, or angiography; ABG, CBC, Ddimer, ECG, CXR, VQ lung scan
• 4. anticoagulatns:  heparin, lovenox
• 5. consider fibrinolytics

• 1. proximal or distal tibia
• 2. distal femur
• 3. anterior-superior iliac spine

• 1. hypotension(can't increase SV)
• 2. decreased LOC
• 3. shock

• 1. hypoxia
• 2. hypotension
• 3. hydrogen - acidosis
• 4. hypothermia
• 5. heart block
• 6. toxins/poisons/drugs

adenosine

• 1. vagal maneuvers
• 2. adenosine
• 3. synchronized cardioversion

• 1. adenosine - stops AV conduction for 10 seconds
• 2. amiodarone - atrial and vent tachy
•      stable SVT refractory to adenosine
•      unstable VT
•      prolongs QT
• 3. procainamide:  same as amiodarone
•      use if amiodarone not working
• 4. lidocaine:  alternative to amiodarone for stable VT
•      not for SVT
• 5. MgSo:  torsades

• 1. SVT
• 2. atrial flutter
• 3. VT with pulse

• >220 for infant
• >180 for child

give rapid bolus with rapid flush r/t 10 second half life

• 0.1mg/kg first dose up to 6mg
• 02.mg/kg second dose up to 12 mg

• 1. give analgesic/sedative
• 2. start with 0.5 to 1 J/kg then increase to 2J/kg if needed
• 3. record and monitor ECG after each cardioversion attempt

5mg/kg over 20-60 minutes

15mg/kg over 30 to 60 minutes

• 1. VF
• 2. VT with no pulse
• 3. asystole
• 4. PEA

slow wide QRS complex rhythms that immediatly preced asystole

• adults - 2 inches
• children & infants:  at least 1/3 A/P diameter

2

1 breath q 6-8 seconds lasting 1 second

EP, vasopressin

amiodarone, lidocaine, Mg

hypocalcemia, hyperkalemia, hypermagnesemia, Ca channel blocker OD

• 1. hyperkalemia
• 2. tricyclic antidepressants OD
• 3. Na channel blocking drugs

• first shock:  2J/kg
• all others:  4J/kg

Max 10J/kg or adult dose

0.01mg/kg

Repeat q 3-5 min

5mg/kg bolus

repeat up to 2 times

• >10kg/1 yr or older = adult pads
• <10kg/<1yr = infant pads

• 1. continue manual ventilation/ET insertion
• 2. make sure ET in proper position & document position in mouth & get CXR for correct postion
• 3. assessment of cardiopulmonary
• 4. PEEP prn:  O2<90 while receiving 100% inspired O2
• 5. sedation & analgesia:  all ET pt get this
• 6. UO with catheter
• 7. Admin fluids, blood prn
• 8. Hang amiodarone/procainamide if used?

• protaglandin E:  vasodilator
• maintain patency of ductus arteriosus fo rductal dependent heart disease

sedative-hypnotic with no anlgesic properties

sedation for rapid sequnce ET

• asthma/broncodilator
• hyperkalemia - moves K into cells

high flow = >10L/min

low flow <10L/m

4L/min

• OPA - unconscous victim without gag reflex
• NPA _ conscious or semiconscious

10 seconds

• 1. bone disorders
• 2. previous attempt in same bone
• 3. infection over bone

0.12 - 0.20

0.42

<0.12

T waves are very large and peaked and may even be taller than QRS

• 1. team leader ID self and assign roles
• 2. assessment:  responsiveness, breathing, & pulse, ABCDE, VS
• 3. airway maneuver & admin of 100% O2
• 4. s/s of upper airway obstruction stated
• 5. caegorize as resp distress or failure
• 6. IV/IO access
• 7. reassessment in response to Tx
• 8. Tell specific Tx for upper airway obstruction:  EPI, CPAP, etc
• 9.  Say indications for ET tube & need for smaller size than predicted for age:  unable to maintain airway, O2 or vent despite interventions

• 1. team leader ID self and assign roles
• 2. assessment:  ABCDE, responsiveness, VS
• 3. provide 100% O2
• 4. state s/s of lower airway obstruction
• 5. categorize as resp distress or failure
• 6. state indications for assisted ventilations:  ineffective ventilations or poor oxygenation
• 7. IV/IO access
• 8. reassessment after Tx:  ABC's
• state specific Tx for lower airway obstruction
• 9. state indications for ET tube

• 1. team leader intro self and assign roles
• 2. ABCDE assessment, responsiveness, & VS
• 3. assisted ventilations with 100% O2
• 4. Ensure that bag ventilations are effective:  chest rise & breath sounds
• 5. pads/leads placed properly & monitor turned on & pulse ox used
• 6. s/s of lung tissue disease
• 7. resp distress or failure?
• 8. Iv/IO
• 9. reassess ABC's after Tx
• 10. specific Tx for lung tissue disease?
• indications for ET tube?

exactly the same as lung tissue disorder except know s/s of disordered control of breathing & specific Tx

• 1. tema member intro & assign roles
• 2. ABCDE assessment, responsiveness, VS
• 3. 100% O2
• 4. pads/leads placed & pulse ox monitor
• 5. verbalize features of Hx & exam that indicate hypovolemic shock
• 6. verbalize whether pt is compensated or hypotensive
• 7. IV/IO
• 8. admin 20mL/kg isotonic fluids rapidly (over 5-20 min)
• 9. reassess ABC;s
• 10. ID parameters that indicate response to thearpy:  HR, BP, distal pulses, cap refill, UO, mental status

• 1. team leader intro & assign roles
• 2. assessment:  ABCDE, responsiveness, VS
• 3. pads/leads & pulse ox placed
• 4. verbalize DOPE mneumonic for intubated patient who deteriorates:  displacement, obstruction, pneumothorax, equipment failure)
• 5. verbalize features of Hx & exam that indicate obstructive shock
• 6. State at least 2 common causes of obstructive shock:  tension pneumo, cardiac tamponade, PE
• 7. state compensated or hypotensive
• 8. IV/IO
• 8. 10-20mL/kg rapid isotonic fluids
• 9. reassess ABC's
• 10.State Tx for tension pneumo:  second intercostal space at midclavicular line
• 11. verbalize therapeutic endpoints:  HR, BP, perfusion, UO, mental status

• 1. team leader intro self & assign roles
• 2. assessment:  ABCDE, responsiveness, VS
• 3. 100% O2
• 4. pads/leads placed & monitor on, pulse ox
• 5. s/s of distributive/septic shock & verbalize pt Hx & physical that indicate it
• 6. compensated or hypotensive shock?
• 7. IV/IO
• 8. rapid admin of isotonic fluids
• 9. reassessment ABC's
• 10. admin of ABX
• 11. indications for vasoactive drug support:  fluid-refractory septic shock
• 12. therapeutic end points:  HR, BP, perfusion, UO, mental status

• 1. team leader intro & assign roles
• 2. assessment:  ABCDE, responsiveness, VS
• 3. 100% O2
• 4. pads/leads, monitor on, pulse ox
• 5. verbalizes Hx & exam that indicate cardiogenic shock (s/s)
• 6. compensated or hypotensive?
• 7. IV/IO
• 8. isotonic fluid 5 to 10 mL/kg over 10 to 20 min & monitor for pulmonary edema/increased CHF
• 9. reassess ABC's
• 10. indications for use of vasoactive drugs:  persistent s/s of shock despite fluid therapy
• 11. therapeutic end points:  HR, BP, perfusion, UO, mental status, importance of reducing metabolic demand

• 1. team leader intro & assign tasks
• 2. assessment:  ABCDE, responsiveness, VS
• 3. O2 by high-flow device
• 4. pads/leads, monitor on, & pulse ox
• 5. recognize narrow complex tachycardia & state diff b/t ST and SVT
• 6. compensated or hypotensive
• 7. perform vagal maneuvers:  valsalva, blowing through straw, ice to face
• 8. IV/IO
• 9. adensoine:  first dose 0.1mg/kg then 0.2mg/kg - state need for rapid admin with rapid flush
• 10. reassess ABC
• 11. verbalize indications & appropriate energy doses for synchronized cardioversion:  0.5-1J for initial dose then 2J

• 1. leader intro self and assign roles
• 2. assessment:  ABCDE, responsiveness, VS
• 3. assisted ventilatiohns with 100% O2
• 4. pads/leads place, monitor turned on, pulse ox
• 5. recognize bradycardia with cardiorespiratory compromise & verbalize to team members
• 6. compensated or hypotensive?
• 7. recall indications for chest compressions in a bradycardic pt:  HR<60 with/without a pulse
• 8. IV/IO access
• 9. EPI:  0.01mg/kg admin & saline flush
• 10. reassessment of ABC's
• 11. verbalizes consideration of at least 3 underlying causes of bradycardia:  hypothermia, drugs, increased ICP

• 1. team leader intro & assign roles
• 2. recognize cardiopulmonary arrest:  absence of responsiveness, breathing, and pulse
• 3. CPR:  rotate role of chest compressor q2min
• 4. place pads/leads, turn on monitor
• 5. recognize asystole or PEA
• 6. IO/IV
• 7. EPI:  0.01mg/kg at appropriate intervals (q3-5min) and flush with saline
• 8. check rhythm approx q2min with change of compressors
• 9. verbalizes consideration of at least 3 reversible causes of PEA or asystole: all H's & T's

• 1. team leader intro & assign team roles
• 2. recognize cardiopulmonary arrest:  no responsiveness, breathing, or pulse
• 3. start CPR
• 4. pads/leads place, monitor on
• 5. recognize VF or pulseless VT & verbalize to team members
• 6. defibrillation:  2J then 4J after that then immediately go back to CPR
• 7. IV/IO
• 8. prepare EPI:  0.01mg/kg
• 9. defibrillation 4J/kg or higher - no more than 10J/kg then CPR again
• 10. admin EPI then saline flush
• 11. verbalizes considertion of anti-arrhythmic using appropriate dose:  amiodarone, lidocaine)