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PALS

  1. Heart rate: Awake & sleeping
    Newborn to 3 months
    • Awake: 85 to 205
    • sleeping: 80 to 160
  2. Heart rate: Awake & sleeping
    3 months to 2 yr
    • Awake: 100 - 190
    • Sleeping: 75 - 160
  3. Heart rate: Awake & sleeping
    2 - 10 yr
    • Awake: 60 - 140
    • Sleeping: 60 - 90
  4. Heart rate: awake & sleeping
    >10 yr
    • Awake: 60 - 100
    • Sleeping: 50 - 90
  5. RR: Infant
    30 - 60
  6. RR: Toddler
    24 - 40
  7. RR: Preschooler
    22 - 34
  8. RR: School-aged child
    18 - 30
  9. RR: Adolescent
    12 - 16
  10. Hypotension in Term neonates (0-28 days)
    <60 systolic BP
  11. Hypotension in Infants (1 to 12 months)
    <70 Systolic BP
  12. Hypotension in 1-10 yrs (5th BP percentile)
    <70 + (age in years x 2) systolic BP
  13. Hypotension in children >10 yrs
    <90 systolic BP
  14. Pediatric drugs used in cardiac arrest
    • Epi
    • Amiodarone - antiarrhythmic
  15. Pediatric cardiac arrest algorithm
    • Shout for help, activate emergency response
    • 1.Start CPR
    • Give O2
    • Attach monitor/defib
    • Rhythm shockable?
    • 2. Yes (VT/VF) or No (Asystole/PEA)
  16. Pediatric cardiac arrest: You just finished first round of CPR, Monitor shows non-shockable rhythm
    • Asystole/PEA
    • Continue CPR for 2 mins
    • IV/IO access
    • Give Epi 3-5 mins
    • Consider advanced airway
  17. Pediatric cardiac arrest: First round of CPR & monitor check showed non-shockable rhythm. You continue CPR, get IO/IV & give epi, and put in advanced airway. Monitor reassesses rhythm, it's shockable. what do you do
    • shock... duh
    • Continue CPR 2 min
    • give epi
    • reassess rhythm after 2 mins.
    • IF NOT SHOCKABLE, repeat above.
    • IF SHOCKABLE, SHOCK.. then give Amiodarone, treat reversible causes
  18. Pediatric cardiac arrest: First round of CPR & monitor check showed non-shockable rhythm. You continue CPR, get IO/IV & give epi, and put in advanced airway. Monitor reassesses rhythm, it's not shockable. what do you do
    • Continue CPR for 2 mins
    • Treat reversible causes
    • Reassess rhythm
    • IF NOT SHOCKABLE... repeat CPR 2 mins, another epi dose if time
    • IF SHOCKABLE... Shock, continue CPR, give epi
  19. Pediatric cardiac arrest: You just finished first round of CPR, Monitor shows shockable rhythm...
    • VT/VF
    • SHOCK
    • Continue 2 mins CPR, get IO/IV access
    • Reassess rhythm
    • IF IT'S SHOCKABLE... shock, continue 2 min EPR, give epi, consider advanced airway
    • IF NOT SHOCKABLE... Same
  20. Pediatric cardiac arrest: you finished first round CPR, you shocked, Continued CPR 2 mins, obtained IO/IV access, shocked again, continued CPR 2 min, gave epi, considered airway. Monitor still shows shockable rhythm. What do you do
    • Shock!
    • Continue CPR 2 min
    • Give amiodarone
    • Treat reversible causes
    • Continue algorithm..
  21. Pediatric Cardiac arrest: CPR quality
    • Push hard (≥ 1/3 of anterior-posterior diameter of chest)
    • Minimize interruptions
    • Avoid excessive ventilation
    • If no advanced airway, 15:2 compression-ventilation ratio.
    • If advanced airway, 8-10 breaths per min w continuous chest compressions
  22. Pediatric cardiac arrest: Shock energy for defib
    • First shock: 2 J/kg
    • Second shock: 4 J/kg
    • Subsequent shocks: ≥ 4 J/kg
    • Max 10 J/kg or adult dose
  23. Pediatric cardiac arrest: dose for epi
    • IO/IV: 0.01 mg/kg (0.1 mL/kg of 1:10,000) 
    • May repeat every 3-5 mins

    If no IO/IV access, may give endotracheal dose: 0.1 mg/kg (0.1 mL/kg or 1:1,000)
  24. Pediatric cardiac arrest: dose for Amiodarone
    • *is an antirrhythmic med
    • 5 mg/kg bolus during cardiac arrest
    • May repeat 2 times for refractory VF/Pulseless VT
  25. Recall H's
    • Hypovolemia
    • Hypoxia
    • Hydrogen ion (acidosis)
    • Hypoglycemia
    • Hypo/Hyperkalemia
    • Hypothermia
  26. Recall T's
    • Tension pneumothorax
    • Tamponade, cardiac
    • Toxins
    • Thrombosis, pulmonary
    • Thrombosis, cardiac
  27. Pediatric drugs used in bradycardia
    • Epi
    • Atropine - increases HR
  28. Pediatric bradycardia w pulse & poor perfusion: first step
    • Identify and treat underlying causes
    • Maintain airway, O2
    • Cardiac monitor to ID rhythm, BP & oximetry
    • IO/IV access
    • 12 lead
  29. Pediatric bradycardia w pulse & poor perfusion: what is meant by cardiopulmonary compromise?
    • hypotension
    • acutely altered mental status
    • signs of shock
  30. Pediatric bradycardia w pulse & poor perfusion: Next steps after baseline assessment
    • Is cardiopulmonary compromise continuing even after maintaining airway & providing O2?
    • NO... Support ABC, Continue O2, Observe, consider expert consult
    • YES.. CPR if HR <60/min, with poor perfusion despite oxygenation and ventilation
  31. Pediatric bradycardia w pulse & poor perfusion:You've given CPR due to HR <60/min, with poor perfusion despite oxygenation and ventilation. Bradycardia persists?
    • If no... support ABC, give O2, Observe, expert
    • If YES:
    • Give Epi
    • Give Atropine for increased vagal tone or primary AV block
    • Consider transthoracic pacing/transvenous pacing
    • Treat underlying causes
    • *If pulseless, go to cardiac arrest algorithm
  32. Atropine Dose
    • Increases heart rate
    • 0.02 mg/kg. May repeat once.
    • Min dose 0.1 mg and max single dose 0.5 mg.
  33. Drugs used in tachycardia
    Adenosine - treats abnormal arrhythmias

    Amiodarone - antiarrhythmic med used for tachy

    Procainamide - treats abnormal arrhythmias
  34. Pediatric tachycardia w pulse and poor perfusion: first steps
    • Id and treat underlying cause
    • Maintain patent airway, assist breathing as necessary
    • Oxygen
    • Cardiac monitor to id rhythm, monitor BP & oximetry
    • 12 lead
  35. Pediatric tachycardia w pulse and poor perfusion: You got cardiac monitor hooked up and evaluating rhythm.  When looking to QRS, what are you looking for?
    • The duration. 
    • Is it wide (≥0.09 sec) possible Vtach

    Is it narrow (≤0.09 sec). Need to evaluate rhythm with 12 lead or monitor. Probable sinus tach or SVT
  36. Pediatric tachycardia w pulse and poor perfusion: Rhythm is possibly VTach...
    • Cardiopulmonary compromise? (hypotension, altered mental status, signs of shock)
    • If YES... do synchronized cardioversion, then reassess
    • If NO... consider adenosine if rhythm reg and QRS monomorphic. Consider consult. Consider giving Amiodarone or Procainamide
    • Give amiodarone & procainamide
  37. Pediatric tachycardia w pulse and poor perfusion: You got cardiac monitor hooked up and evaluating rhythm. QRS is narrow, Probable sinus tach. What do you do...
    • Sinus tach... P waves present/normal. Variable R-R; constant PR
    • Infants: rate usually <220/min
    • Children: rate usually <180/min

    Search for and treat cause
  38. Pediatric tachycardia w pulse and poor perfusion: You got cardiac monitor hooked up and evaluating rhythm. QRS is narrow, Probable SVT. What do you do...
    • P waves present/absent
    • HR not variable
    • Infants: rates usually ≥220/min
    • Children: rates usually ≥180/min

    • Consider vagal maneuvers
    • Give adenosine, consider cardioversion
  39. Pediatric synchronized cardioversion
    • Begin with 0.5 - 1 J/kg; if not effective increase to 2 J/kg
    • Sedate if needed, but don't delay cardioversion
  40. Adenosine dose
    • STOPS HEART, ALLOWS IT TO RESTART
    • IV/IO
    • First dose: 0.1 mg/kg rapid bolus (max 6 mg)
    • Second: 0.2 mg/kg rabid bolus (max 2nd dose 12 mg)
  41. Amiodarone dose
    • IV/IO dose
    • 5 mg/kg over 20-60 mins 

    OR can give procainamide
  42. Procainamide dose
    • 15mg/kg over 30-60 min
    • Do not routinely administer amiodarone and procainamide together
  43. How to assess for and treat persistent shock
    • ID, treat contributing factors
    • Consider 20 mL/kg IV/IO boluses of isotonic crystalloid
  44. V TACH
    • HR is >150 & regular
    • NO P WAVE
    • So no P-QRS relationship
    • may or may not have pulse, falls into PEA
  45. V-FIB
    • No HR at all... irregular
    • No P
    • No QRS
    • So No P-QRS complex
    • Shockable, must be shocked!
  46. SVT
    • Also called A-TACH
    • HR >150, regular
    • Is relationship btwn P-QRS, but moving WAY too fast
    • P goes off before T calms down
    • Tx w vagal
    • Give adenosine (the stop your heart drug)
  47. Atrial flutter
    • HR can fall in too slow, reg, or too fast
    • Reg rate
    • No P wave
    • Present or not present QRS
    • Prob is not perfusing
  48. A fib
    • Rate can fall into too slow, reg, or too fast
    • Reg rate
    • No P wave
    • QRS present
    • Narrow QRS
  49. 1st degree block
    • HR can be either normal or too slow
    • reg rate
    • P wave present
    • QRS present
    • Is a relationship
    • Problem is relationship is distant. Don't want to break up, but don't want to be close
  50. 2nd degree block type I (Winkie)
    • HR can be either normal or too slow 
    • Rate is regular
    • Irregular P wave, QRS wave
    • Both are present, but bad relationship
  51. 2nd degree block type 2
    • HR is too slow, but regular & weird
    • P & QRS is present, but are together, and then apart, then together, apart
  52. 3rd degree block
    • complete heart block
    • HR is too slow, regular
    • P present, QRS present
    • No relationship btwn P & QRS. Are individually regular but not reg together
Author
jskunz
ID
321160
Card Set
PALS
Description
pals
Updated

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