0'&) · EMERGENCY MEDICAL CONSULTANTS INC. FloridaÕs Premier Provider Of Quality Medical Traini ng...

EMERGENCY MEDICAL CONSULTANTS INC.

Florida’s Premier Provider Of Quality Medical Training Programs

Nationally Accredited and OSHA Programs

CEU Provider

Since 1988

PEDIATRICADVANCEDLIFESUPPORT

ParticipantPreparationPacket2017–2020

Thisinformationisderivedfromthe2015ECCguidelines

ThispacketcontainsprepinformationforthePALSCourseaswellasEKGandBLSreviews.

Westronglyrecommendcompletingtheseexamspriortothecourse.

-MANDATORYREQUIREMENTS-

YoumustbringtheAHAPALStextbooktoclasswithyourcompletesonlineAHASelfAssessment.

InstructionscanbefoundonpageiiofyourpurplePALStextbook.Passingscore=70%

(Ifascoreof70%isnotachievedineachsection,pleasereviewthetextandretestthesection).

★!IfyouareattendingtheBLSsectionfollowing,refertopage42foradditionalinstructions.(ThereismandatorypretestifyouarechoosingtodoBLS)

CourseDate/Time:____________________________________Location:__________________________________________

Name:__________________________________________________________________________________________________

©2017EmergencyMedicalConsultants

ThismaterialprotectedbyCopyrightandmaynotbereproducedwithoutwrittenconsent

(772) 878-3085 * Fax: (772) 878-7909 * Email: [email protected]

597 SE Port Saint Lucie Blvd * Port Saint Lucie, Florida 34984

Visit Our Website- www.medicaltraining.cc

2017B

2

3

EMERGENCY MEDICAL CONSULTANTS INC.

Florida’s Premier Provider Of Quality Medical Training Programs


CEU Provider

Since 1988

ThiscopyrightedpreppacketisasupplementforthosestudentstakingPALSwithEMC.

WelcometothelatestAmericanHeartAssociationPediatricAdvancedLifeSupportcoursesponsoredbyEmergencyMedical

ConsultantsInc.TheFulltrainingcourseistwodays.Therefreshercourseisonedayonly.NOTALL2DAYCOURSESHAVEAONE

DAYREFRESHERCOMPONENT–PLEASEVERIFYWITHOUROFFICEIFWEAREOFFERINGAONEDAYCOURSEANDWHICHDAYIT

WILLBE.

ThePALScoursestressesearlyrecognitionandmanagementofpre-terminaleventsratherthanmerely“runningapedicode”.We

usenostress,smallgroupinteractiveskillsandscenariostationstopresenttheinformationinafun,relaxedatmosphere.Weare

pleasedyouhavechosenourprogramandaresureyouwillfindthecourseinformativeandworthwhile.

Inordertokeepourprograms“StressFree”andassureallparticipantsmeettheAHArequirementsforproficiency,acertainamount

ofhomestudyisrequiredpriortotheactualclass.TheAHAmandatesparticipantshaveaccesstothelatesttextbook,reviewit,and

suggestcompletingthepretestpriortoenteringtheprogram.Ifyoudonothaveaccesstoatextbook,pleasecallLaerdalat1-888-

562-4242.Or,youmaypurchasethetextbookthroughouroffice.

The evaluation process consists of a written exam, on which participants are required to score at least 84% and two patient

managementscenariosrequiringappropriatetreatment.Again,thesestationsaredesignedtobeuserfriendlyandlowstress.

Weworkveryhardtokeepourprogramsupbeat,relevantandata levelALLparticipantswhohavepreparedwillpasswithease.

Ourfacultyisalwaysavailabletoexplaininformationorprocedures,justask.

All information is based on the American Heart Association PALS standards at the time of printing and thought to be correct.

Providers are encouraged to review the PALS textbook and their specific policies prior to implementing any procedures or

administeringanymedicationbasedonthisstudypacket.

Thispacketcontainsprepinformationandapretest.TheAHAtextprovidesinformationtoaccesstheironlinepre-testinformation

atwww.heart.org/eccstudent.Onpage6ofyourtextwillgiveyouacode/password.

FormoreEKGpractice,logontowww.Skillstat.com

Ifyouhaveanyquestionsorcommentsfeelfreetocallourofficeat772-878-3085.

WelookforwardtoseeingyouinthePALSprogram.

ShaunFix

President,EmergencyMedicalConsultantsInc.



Visit Our Website… EMCmedicaltraining.com

4

PALS2015-AHAGuidelineUpdates

ThelatestPALSguidelinesfromtheAmericanHeartAssociation2015ECCCommitteewerepublishedinlate

2015andimplementationbeganinearly2016.Theseguidelineswillbeutilizedfrom2016through2020.

Thissectioncontainsabriefsynopsisoftheguidelinesthatwerenewin2015,aswellasarationale.

CPRChanges-Children&Infants

Aswithadults-Callfornearbyhelpassoonasthevictimisfoundunconscious.Simultaneousassessmentof

pulseandrespirationsisalsoindicatedforinfantsandchildren.Ifnotpresent,activatetheemergencyresponse

systemorcallforbackup.

New Change: Infant/ Child Chest Compression Depth—Rescuers should provide chest compressions that

depress the chest at least 1/3rd of the anteroposterior diameter of the chest in pediatric patients

(approximately1.5”ininfantsuptooneyear-to2”inchildrenuptotheonsetofpuberty.)Oncechildrenhave

reachedpuberty–the recommendeddepthof compression is, again, sameas theadult, at least2’ butnot

over2.4”.

Rationale:Apediatricstudyobservedimproved24hoursurvivalwhencompressiondepthisatleast2inches.

Judgmentofcompressiondepthisdifficultatthebedside,andtheuseofafeedbackdevicethatprovidessuch

informationmaybeuseful,ifavailable.

NewChange:Infant/ChildCompressionRate—theadult,childandinfantcompressionrateisnowthesame,

100-120.

Rationale: To maximize educational consistency and retention, pediatric experts have adopted the same

compressionrateasrecommendedforadultBLS.

NewChange:CompressiononlyCPR—ConventionalCPR (rescuebreathandchest compressions) shouldbe

providedforinfantsandchildrenincardiacarrest.“Compressiononly”istheleastpreferredmethod.

Rationale: Theasphyxial natureofmostpediatricpatientsnecessitates ventilationaspartof effectiveCPR.

Large registry studies have demonstratedworse outcomes for presumed asphyxial pediatric cardiac arrest

patients,whichcompromisethevastmajorityofout-of-hospitalpediatricarreststhatweretreatedonlywith

compressiononlyCPR.

NewChange:CPRwithanAdvancedAirway inPlace—Withanadvancedairway inplace,deliver1breath

every6seconds(10breathsperminute)whilecontinuouschestcompressionsarebeingperformed.

Rationale:Thissimplesinglerateforadults,childrenandinfants-ratherthanarangeofbreathsperminute-

shouldbeeasiertolearn,rememberandperform.

Asalways-withadults,infantsandchildren,makeeveryefforttominimizeinterruptionsinCPRtolessthan10

seconds.

AllaboveBLSchangesapplytothepediatric/infantpatientinadditiontothePALSspecificnew

recommendations:

5

PALSSpecificChanges

NewChange:FluidResuscitation—Forchildreninshock,aninitialfluidbolusof20ml/kgisreasonable.

However,ifthechildhasafebrileillness-administrationofIVfluidsshouldbeundertakenwithcautionasit

mayactuallybeharmful.Thisisespeciallytrueinclinicalsettingswhereaccesstocriticalcareresources

(ventilatorsandinotropicdrugs)arelimited.

Rationale:ThecurrentrecommendationcontinuestoemphasizetheadministrationofIVfluidsforchildren

withsepticshock.However,incertainresourcelimitedsettings,excessivefluidbolusesgiventofebrilechildren

mayleadtocomplicationswhenappropriateequipmentandexpertisearenotavailabletoeffectivelyaddress

them.

NewChange:AtropineforEndotrachealIntubation—Thereisnoevidencetosupporttheroutineuseof

atropineasapremedicationtopreventbradycardiainemergencypediatricintubations.

Rationale:Recentevidenceisconflictingastowhetheratropinepreventsbradycardiaandotherarrhythmias

duringemergencyintubationinchildren.

NewChange:AntiarrhythmicMedicationsforshockrefractoryVForpulselessVT-AmiodaroneorLidocaineis

equallyacceptablefortreatmentofshockrefractoryventricularfibrillation(VF)orpulselessventricular

tachycardia(pVT).

Rationale:Recentstudieshaveindicatedthatlidocainewasassociatedwithhigherratesofsurvival,returnof

spontaneouscirculation(ROSC)andincreased24hoursurvivalratethatamiodarone.However,neither

lidocainenoramiodaroneadministrationwasassociatedwithimprovedsurvivaltohospitaldischarge.

NewChange:TargetedTemperatureManagement—Forcomatosechildrenwhoarecomatoseinthefirstfew

daysfollowingcardiacarrest(inoroutofhospital),temperatureshouldbemonitoredcloselyandfevershould

betreatedaggressively.

Ifthearrestoccurredoutofhospital,thecomatosechildcanmaintaineither5daysofnormothermia(36-

37.5C)or2daysofinitialcontinuoushypothermia(32-34C)followedby3daysofnormothermia.Forchildren

whoremaincomatoseafterin-hospitalcardiacarrest,thereisinsufficientdatatorecommendhypothermia

overnormothermia.

Rationale:Astudycomparinghypothermiavsnormothermiashowednodifferenceinfunctionaloutcomeat1

yearbetweenthe2groups.Therewasalsonoadditionalcomplicationsinthegroupthatwastreatedwith

therapeutichypothermia.

6

PediatricAdvancedLifeSupport

Syllabus

Approx14hours

TwoDayFullTrainingProgram

DayOne

ProgramIntroduction

OverviewofPALSScience

ManagementofRespiratoryFailure

Break

OverviewofRhythms/Algorithms

SkillsReview–RespiratoryManagement,VascularAccess,ReviewCPRstandards

Lunch

Skillsstations

1. RespiratoryEmergencies,Airwaymanagement

2. Shock,VascularAccessIV&IOSkills,medication&broselowreview

3. BLS–ChildandInfantCPRandAED

DayTwo

Puttingscenariomanagementtogether/TeamConcept

GroupReviewofPatientCases

Break

PatientCasemanagementScenarios/Simulations

1.ShockandTrauma

2.RespiratoryEmergencies

3.CardiacCases

Lunch

Evaluations

1.WrittenExam

2.ScenarioManagementEvaluations

7

PediatricAdvancedLifeSupport

Syllabus

OneDay-RefresherProgram

Approx7hours

GENERALLYPRESENTEDTHEFIRSTDAYOF2DAYPROGRAM

ProgramIntroduction

OverviewofPALSscience

PediatricAssessment,RecognitionofRespiratoryFailureandShockReview

Break

OverviewofRhythms/Algorithms

SkillsReview,RespiratoryManagement,VascularAccess,ReviewCPRStandards

Lunch

GroupReviewofCaseManagement

1. CardiacCases

2. RespiratoryCases

3. ShockCases

BLSChild&InfantSkillsCheck-off

Evaluations

1.WrittenExam

2.ScenarioManagementEvaluations

8

ASSESSINGKIDS

ThinkliketheChild

“Agiantstrangeriscomingafterme”

“Momsaysdon’ttalktostrangers”

“IfIsayI’mOKthey’llleave”

Uniqueissueswhendealingwithchildren

Theydon’tthinkweareheroeswhenwearetheretotreatthem

Medically,they“hide”illnessandinjurybymaintainingnormalvitalsigns

Headinjuriesandliverbleedsare2culpritsthatcancauseaslowdeterioration

Tipsfordealingwithchildren

UnderstandMOSTofusdon’tgettoregularlyevaluatesignsandsymptomsinkids

Remembertheymaypresentalittledifferently

Assesstheconsciouschildfromacrosstheroominitially

Ifappropriate,usetheparentsforpsychologicalfirstaid

Talktothechildabouthimselfandhistoystogainarapport

Unlikeadults,stablekidswillgenerallystaythatwayifwesupporttheirABC’s

*Continuallyreviewtheuniquepresentationofrespiratoryandcirculatorycompromiseinchildrensinceit

differsfromtheadultpatientsweareusedtodealingwith

Goodresourcesforpediatricinformation

AmericanAcademyofPediatrics847-434-4000 www.aap.org

AmericanCollegeofEmergencyPhysicians800-798-1822 www.ACEP.org

EMSC202-844-4927 www.ems-c.org

NationalSafeKidsCampaign202-662-0600 www.safekids.org

NationalCenterforInjuryPreventionandControl770-488-1506 [email protected]

HeartRate RespRate Lowestacceptable(systolic)BPInfant(<1yr) 100-180 Infant(<1yr) 30-53Infant(1mo-1yr) 70

Toddler(1-3yrs) 98-140 Toddler(1-3yrs)22-37Children1-10yrs 70+(ageinyearsx2)

Preschool(3-5yrs) 80-120 Preschool(3-5yrs)20-28>10yrs 90

SchoolAges(5-10yrs)75-118 SchoolAges(5-10yrs)18-25

Adolescent(>10yrs) 60-100 Adolescent(>10yrs)12-20

*Heartrateandrespratemaybelowerwhileasleep

9

PEDIATRICASSESSMENTSEQUENCE

*INITIALIMPRESSION“Sickornotsick”

*EVALUATE

TertiaryAssessment/Management

Initial Pediatric Assessment

General Appearance Most Crucial

Appearance Work of Breathing

Degree of interactivity Tripod or sniffing position

Muscle tone Retractions

Verbal response or cry Audible breath sounds

Circulation to Skin

Pale

Mottled

Cynotic Obvious bleeding/ Petechia purpura

Assessment

Triangle

Primary Assessment

Airway Breathing Circulation Disability Exposure Patent? Present? Present? Level of expose body

Noiseless? Rate extremities consciousness and

Effort cap refill exposure control

Sounds

Secondary Assessment

Physical Exam SAMPLE History Bedside Tests

Head *Symptoms *Past history *Vital signs

to toe *Allergies *Last intake *Glucose

as needed *Meds *Events causing incident *Monitors (O2,EKG)

*IDENTIFY

Respiratory Problem Circulatory Problem Cardiac Problem

(Shock) (Tachy, Brady or CP Failure)

*INTERVENE Manage

C – support Circulation = from EKG to vascular access, fluids or meds as needed

A – position Airway if needed

B – manage Breathing = blow by O2 to BVM, intubation or meds as needed

10

*Labs*Cultures*X-rays*Medications*CardiacTx*SpecialtyConsult

RESPIRATORYDISTRESS/RESPIRATORYFAILURE

Thekeytopediatricresuscitationistorecognizeearlyandtreataggressivelybeforethechilddecompensates.

Respiratorydistress

Potentialrespiratoryfailure:Increasedworkofbreathing

• Tachypnea

• Tachycardia

• Anxiety/Agitation/Irritability

• Retractions

• Nasalflaring

Probablerespiratoryfailure:

• Lethargy

• Headbobbing

• Grunting

• Cyanosis/Pallor

Respiratoryfailure:Inadequateventilationoroxygenation

• Slowrespirations

• ↓SaO2

Cardiopulmonaryfailure:

• Agonalbreathing-inadequaterespiratoryeffort

• Bradycardia

RespiratoryManagement

Maintainairway

• Usuallydonebypatientifawake

• Fordecreasedlevelofconsciousnessplacein“sniffingposition”

(supinewithneckandheadslightlyelevated)

Assistwithoxygen–onlyenoughtomaintainsaturationbetween94-99%

• Blow-by,ifalertandapprehensive

• Directmaskifthechildwillacceptandneedsit

• Bagvalvemaskforlowrateortidalvolume

• Intubation-seeindicationsbelow

Considerintubationbyaskilledprofessionalforthefollowing:

• Unconsciousinprofoundshock

• Anypatientrequiringbagvalvemaskventilationsformorethanoneminute

o respiratoryarrest

o respiratorydepressionnotrespondingtobag-valve-maskventilations

o bradycardianotrespondingtobagvalvemaskventilations

o tachypneawithpoortidalvolumenotrespondingtobag-valve-mask

Ifanintubatedpatientsuddenlydeterioratesthink“DOPE”

• Displacedtube

• Obstructedtube

• Pneumothorax

• Equipmentfailure(i.e.ventilatorfailure,ambufailure,O2empty,etc.)

(notnecessarilyinthatorder)

FourtypesofRespiratoryProblems

Upperairwayobstruction

Stridor

Voicechange/drooling

↑inspiratoryeffort

Lowerairwayobstruction

Asthma,bronchiolitis

↑expiratoryeffort

Prolongedexpiratoryphase

Cough

Wheezing

Possible↓airmovement

Lungtissuedisease

Pneumonia

Pulmonaryedema

Grunting

Crackes(rales)

Decreasedairmovement

Hypoxia

Disorderedcontrolofbreathing

Irregularrate&pattern

Variableeffort/Inadequateeffort

Centralapnea

11

SHOCK

Shock:inadequateperfusiontomeetthemetabolicdemandsofthetissues.

Question#1:Isthereareasonforthischildtobeinshock?

Earlysigns

• Tachycardia

• Decreasedperfusionofskin–cool,paleormottled,delayedcapillaryrefill

• Alteredmentation

• Discrepancyinvolumebetweenperipheralandcentralpulses

Septicshockmayhavebriskcapillaryrefillwithboundingcentralpulses

Hypotensionisalatesignofshock

Compensatedshock–patientshowingsignsofshockwithanormalB/P

Hypotensiveshock–shockwithhypotension(generallynotseenuntil30%fluidloss)

Treatment:

• AssessCAB’s

• MaintainAirway

• AdministerhighflowO2

• MaintainBodyTemperature

• MonitorEKGandPulseoximetry

• Obtainvascularaccess(IVorIO)

• AdministerFluidBolus’s20ml/kgNSORLRinunder20min.RepeatPRN

• Considervasopressorsforrefractory,cardiac,orsepticshock

• Reduceoxygendemand

o supportbreathing

o controlpainandanxiety

o managefever

12

IfIVaccessisnotreadilyaccessibleinapatientinarrest,neararrestorprofoundshock,proceedwith

intraosseousinfusion.

IVtips:

• Don’ttiethetourniquettootight

• Usetransilluminatorifavailable

• Immobilizethechildifnecessaryflushtheangiocathwithheparinflushsolutionorsaline

• Leavetheplugofftheendoftheangiocath

• Beveldownforsmallorsuperficialveins

• Useskinprep(i.e.benzoin)andlotsoftape

• SecuretoIVboardifnecessary

Inthetraumapatientwithshockgivetwofluidboluses;ifsymptomsarestillpresentconsiderpackedcellsor

blood.

ThelatestguidelinesrecommendCO2WaveformCapnography

• RemembernormalCO2is35-45

• CO2isacid

• HighCO2-denotesrespiratoryacidosis

-Ventilatemoreeffectivelyandmorefrequently

• LowCO2-duringcardiacarrestindicateslowperfusion

• MaybecommonduringarrestduetoCPRbeingtheonlyperfusion

• (compressionsareonlyabout20%aseffectiveasnormalbloodflow)

• GoalistomaintainCO2above10mmHg

IfCO2remainsbelow10mmhgthroughoutcode,survivalisvirtually“0”

• CO2waveformsprovideamoresensitiveandrapidevaluationofrespiratoryfunctionthanpulseoximetry

• SpecificallyevaluatingPERFUSION

UseEndtidalCO2(afterintubation)toevaluate:

• ETtubeplacement(IsthereanyCo2?)

• EffectivenessofCompressions,istheCo2levelabove20mmhg?

-ifnot,evaluatecompressions

13

CARDIOPULMONARYFAILUREBradycardia(below60/min)withAgonalBreathing

AssessCAB’s

Ventilate

Administer100%Oxygen

Intubatewhenappropriate

AssessVitalSigns

Obtainvascularaccess

CardiorespiratoryCompromise?

Poorperfusion

Hypotension

Respiratorydistress

No Yes

Observe Performchestcompressionsifdespite

SupportCAB’s oxygenation&ventilation:

Transportpedsfacility Heartrate<60/min

ContinueCPRuntilratesustainsatgreaterthan60min,ideallyover80-100

Epinephrine

IV/IO:0.01mg/kg1:10,000

RepeatEpinephrineevery3-5minutesatsamedose

Atropine

0.02mg/kg(usuallynotusedinchildren<1year)

Min.dose:0.1mg

Maxsingledose:0.5mgforchild

1.0mgforadolescent

Mayberepeatedonce

Considerpacemaker

Considertreatablecauses

Hypoxia

Hypoglycemia

Hypothermia

Herniationofbrainstem

14

Ingeneral,childrenrequiredefibrillationmuchlessfrequentlythanadults,howevermorerecentstudies

confirmventricularfibrillationismoreprevalentthanpreviouslythoughtandmaybemissedduetothefact

thatEKG’smaynotbeinitiatedasrapidlyasinadults.

DEFIBRILLATOR–REQUIREDKNOWLEDGE

JOULE(WATTSECONDS)SETTINGS:

DEFIBRILLATION:2J/kgFirstattempt,4J/kglaterattempts(higherdosesmaybeconsideredupto10J/kg)

CARDIOVERSION:0.5-1.0J/kg.Mayincreaseto2J/kg

1.KnowshowtoturnmonitorANDdefibrillatoron

2.Knowshowtosetcurrent(joules)

3.Knowshowtosetsyncbuttonforperfusingrhythms

4.Knowshowtodischargepaddlestopatient

5.KnowshowtoQUICKLOOK/Paddlefunctionvs.leadselect

6.Knowswheretopositionpaddles/pads

7.Knowshowtochangetopediatricpaddlesize

8.Knowsindicationsforuse:

Ventricularfibrillation

VentricularTachycardia

Supraventriculartachycardia

9.Knowstoclearthepatientarea

10.Knowswhatinterfacemediatouse–jellorpads

11.Knowscurrenttouseinchildrenandinfants

AED–(Automaticdefibrillator)canbeusedonallchildrenandinfants.Ideally,usepediatric

padsbecausetheyreducetheenergyasitcomesfromthedefibrillator.Ifpediatricpadsare

notavailable,adultpadsmaybeused,astheriskofallowingventricularfibrillationto

deteriorateintoasystoleisgreaterthantheriskposedbythehigherenergyoftheAEDusing

adultdefibrillationdoses.

AutomatedExternalDefibrillator

Shocksatpresetenergylevels

PhysioControlLifepakModel:ManualDefibrillator

Operatorchoosesenergylevel

15

SkillsReviewforHealthcareProviders

TheCAB'sofCPR

SimultaneouslyDetermineunresponsivenessandcheckforeffectivebreathing

Ifunresponsive:calla“code”or911

C=Circulation-CheckforapulseMax-10seconds.Ifpulseisnotdefinite,begincompressions.

A=Airway-Openairway(headtilt/chinlift)

B=Breaths-Give2breathsthenbacktocompressions

D=Defibrillator-AttachamanualdefibrillatororAED

CPRReference

Adults(>puberty) Children(1-puberty) Infants(<1yr)

Rescuebreathing,Victimdefinitelyhas

apulse

10-12breaths/min

recheckpulseevery2minutes

12-20breaths/min


12-20breaths/min


Compressionlandmark

Nopulse

(orpulse<60ininfantorchildwith

poorperfusion)

Middleofthechest,

betweenthenipples

Middleofthechest,

betweenthenipples

1fingerbelownippleline

Compressionsareperformedwith Heelof2hands Heelof1or2hands

2fingersOR

2thumbswhenusing

encirclinghandstechnique

Rateofcompressionsperminute 100-120/min 100-120/min 100-120/min

Compressiondepth 2-2.4inches Atleast1/3depthofchest

2inches

Atleast1/3depthofchest

1½inches

Ratioofcompressionstobreaths

*Onceanadvancedairwayisplaced

ventilationswillbe1every6sec.with

continualcompressions.

30:2

Changecompressorsand

reevaluateevery2min

30:2

15:2if2rescuer


reevaluateevery2min

30:2

15:2if2rescuer


reevaluateevery2min

ForeignBodyAirwayObstruction*IfnotrapidlyremovedcallEmergencyMedicalService*

Consciouschoking

Adult Child Infant

AbdominalThrusts

AbdominalThrusts

5BackBlows/5ChestThrusts

Unconsciouschoking

Adult Child Infant

Calla“code”

orcall911

BeginCAB’sofCPR

Beforegivingbreaths:

lookinmouthforforeignbody,

removeobjectifitisseen.

RepeatcyclesofCPRifneeded

BeginCPR

Ifsecondrescuerispresent,

sendthemtocalla“code”or911,

otherwise,callafter2minofCPR





BeginCPR








16

CardiacRhythmDisturbances

Mostchildrendonothavesignificantcardiacdysrhythmiascausinginstability(donottakethistomeanthatchildrenneverhave

cardiacdysrhythmias).Ingeneralrhythmdisturbancesinchildrenaretreatedemergentlywhenthepatientissymptomaticorifthe

rhythmislikelytodeteriorate.

Inchildren,rhythmsareclassifiedas:

Tachy(Fast):

Firstsignofstress

Lookforcausesotherthancardiac(i.e.fever,pain,hypovolemia)

NotconsideredSVTunless220ininfant,180inchild.

SignsofSVT–nopwave,HRdoesnotvarywithactivity,abruptonset,narrowcomplex

Widecomplex(>.09secor2boxes)maybev-tach

Brady(Slow)Causes:

Hypoxia

Hypothermia

Hypoglycemia

Collapse(Absent):

Frequentlytheendresultofprolongedhypoxiaand/oracidosis

MaybeAgonal/Asystole,pulselesselectricalactivity(PEA)orv-fib/pulselessv-tach

NewbornResuscitation

QuickHistory: Multiplebirth?Prematurity?Meconium?NarcoticUse?

QuickAssessment: Termofgestation?Amnioticfluidclear?Breathingorcrying?Goodmuscletone?

TermNewbornVitalSigns

Heartrate(awake):100to180bpm

Respiratoryrate:30to60breaths/min

Systolicbloodpressure:55to90mmHg

Diastolicbloodpressure:25to55mmHg

APGARSCORESign 0 1 2

Heartrate(bpm) Absent Slow(<100beats/min>100beats/min

Respirations Absent Slow,irregular Good,crying

Muscletone Limp Someflexion Activemotion

Reflexirritability NoresponseGrimace Cough,sneeze,cry

(toacatheterin

thenares,tactile

stimulation)

Color BlueorpalePinkbodywith Completelypink

Blueextremities

7–10Normal

4–6ModeratelydepressedrequiresO2andstimulation

0–3Severelydepressedrequiresresuscitation

Meconium• SuctionMouthandnose,onlyifobstructed

• Intubateandsuctionusingmeconiumaspirator,onlyindepressedneonateswiththickmeconiumpresent.

• RepeatwithnewETTuntilclear

• Thenstartpyramid

Initial Assessment and

Stabilization Outside the Delivery Room

Assessandsupport*: Airway(positionandclear)

Breathing(stimulatetobreathe)

Circulation(assessheartrateandcolor)

Temperature(warmanddry)

Alwaysneeded

bynewborns

Neededless

Frequently

Rarelyneededbynewborns

*NoteABCisstillusedinnewborns

Drying,warm,position,stimulate

Oxygen

BagValveMask

Compressions

Intubation

Medication

17

InitialManagementofthePediatricArrest

“ThePanicZone”ShaunFix

I. Introduction

Perhapsthegreateststressorforthemedicalproviderisdealingwithandmanagingtheuncommon

cardiacarrestinthepediatricpopulation.Whileadult“codes”areroutine,“pedicodes”becomehectic,

frantic,adchaotic-thus,the“loadandgo”responsetakesover.Thissessionisdesignedtogive

participantsabriefoverviewofthepediatricarrestpathophysiology,expectedoutcomesandasimple

formattoeffectivelyapplyBLSandALSproceduresinordertogiveyourpatienttheirbestchancefor

survival.

II. Learningobjectives

Attheendofthisprogramtheparticipantwillbeableto:

1.Discussthepathophysiologyofthepediatricarrestincontrasttotheadult.

2.Discussexpectedoutcomesforthepediatricpatientwhoarrests

3.Explaintheuseofoxygenandbagvalvemaskinthepediatricpatient

4.Describeintubationdifferencesinthepediatricpopulation

5.Statewhichmedicationscanbegivenviatheendotrachealtube.

6.DiscusstheimportanceofproperBLSprocedures-CPR,immobilization,O2andtemperatureregulation

7.Statetheindicationsandproceduresforintraosseousaccess

8.Explaintheconceptofaprecalculatedpharmacologysystem

III.Discussion/Summary

Theprognosisforthepediatricpatientwhosufferscardiacorrespiratoryarrestispoor;theonlyrealway

toreducechilddeathsistostressprevention.Themostcommoncausesarerespiratoryinnature,thus,in

thenontraumatizedpatientitisimperativethatprovidersmanagethevictimwithexcellentCPR,

appropriateairwayproceduresandoxygenation,shockcontrol,andinitialmedicationswherethepatient

liestogivethechildthegreatestchanceofsurvival.

Thingstokeepinmind:

Ø Childrenmaynotbesmalladults-buttheprinciplesofcareareunchanged.Circulation,Airway,and

Breathingsupportcanbeaccomplishedrapidlyandwithlittledifficultybytheinitialresponding

providers.

Ø ExcellentACLSwithpoorBLSisofnovalue.ImmediateBLSmanagementandCPRareofparamount

importance.

Ø MedicalcodesshouldreceiveALStreatmentwherethepatientlies-AlongwithgoodCPR,oxygen,

upgradedairway,intraosseousinfusion,andinitialpharmacologyifpossiblewithinareasonabletime.

Ø Traumaisstilltreatedintheoperatingroom.SecureC-spineandairway“LoadandGo”with

secondarytreatment,IV’sandmedsenroute.

Ø Coolistherule!Asourstresslevelsincrease,ourpatientcarelevelsdecrease.

18

MedicationsforPediatricCardiacArrest&SymptomaticArrhythmiasNote:Thestandardrecommendationistohavesometypeofprecalculateddrugchartorlengthbasedtapefordosing.

Drug Dose(pediatric) Remarks

Adensine 0.1mg/kgIV/IO(max6mg) RapidIV/IObolus

Repeatdose0.2mg/kg(max12mg) Rapidflush

Amiodarone 5mg/kgIV/IO IVbolus

(pulselessVT/VF) Mayrepeatdoseupto2times

Amiodarone Loading:5mg/kgIV/IO Repeattomax

(perfusingtachyrhythms) over20-60min 15mg/kg/dayIV

Ativan(Lorazepam) 0.05-0.1mg/kgIV/IO/IM Maxsingledose4mg

Atropinesulfate 0.02mg/kgIV/IO Mindose:0.1mg

Maydoublefor2nddose Maxsingledose

0.5mgchild

Ca2+chloride10% 20mg/kgIV/IO(0.2ml/kg) Giveslowly

Dopamine 2-20mcg/kg/min 1600mcg/mlconcentration

Dobutamine 2-20mcg/kg/min 2000mcg/mlconcentration

Epinephrineforarrest 0.01mg/kgIV/IO Repeatevery3–5min

Orbradycardia *ETT:0.1mg/kg(10X’stheIVdose)

Epinephrineinfusion 0.1-1mcg/kg/min Concentrations:0.1mg/ml(100mcg/ml)

For3-7kgpts:0.05mg/ml(50mcg/ml)

Glucose 0.5-1g/kgIV/IO 10%=5-10ml/kg

25%=2-4ml/kg

50%=1–2ml/kg

Lidocaine 1mg/kgIV/IOEquallyacceptableasAmiodaroneinvf/pvt

Lidocaineinfusion 20-50mcg/kg/min Concentrations:4000mcg/ml

After1mg/kgloadingdose For3-7kgpts:8000mcg/ml

Magnesiumsulfate 25-50mg/minIV/IOover Maxdose2g

10-20min

Naloxone 0.1mg/kgupto2.0mg Titratetodesiredeffect

IV/IO/IM

Procainamide 15mg/kgIV/IO Giveover30–60min

Sodium 1mEq/kgperdose Pushslowly&only

Bicarbonate Ifventilationisadequate

Valium(Diazepam) 0.1-0.3mg/kgIV/IOor Maxsingledose5mg

0.5mg/kgrectal(rectalmaxsingledose10mg)

*EndotrachealTubedoses(ETT)orLido,Epi,Atropine&Narcanareacceptablebutdiscouraged

19

PediatricAsystole

“CircleofLife”

CoreConceptsofResuscitation

AssessCAB’s&BeginCPR

Attachmonitor/defibrillator

AdministerOxygen

ContinuallyprovideCPRin2mincycles

30compressions/2breaths1rescuer

15compressions/2breaths2rescuerStopbrieflyevery2mintoassess

[Secondaryprocedures]

SecureAirwaywhenappropriate/MonitorCO2

ObtainVascularAccess

ContinuallyprovideCPRin2mincyclesthenstopbrieflytoreassessrhythm

Epinephrine(giveassoonaspossible)

IV/IO:0.01mg/kg1:10,000

RepeatEpinephrineQ3-5minutes

Identify&treatcauses:

H’s

Hypovolemia

Hypoxia

Hydrogenions(acidosis)

Hypothermia

Hypo/hyperkalemia.

Hypoglycemia

T’s

Toxins

Trauma

Tamponade(cardiac)

Tensionpneumothorax

Thrombosis(pulmonaryorcoronary)

Tooslowortoofast

Anytime

in the

sequence

20

PulselessElectricalActivityCouldbeanyrhythmotherthanpulselessVForVT

“CircleofLife”




AdministerOxygen


30compressions/2breaths1rescuer

15compressions/2breaths2rescuerStopbrieflyevery2mintoassess




Epinephrine(giveassoonaspossible)

IV/IO:0.01mg/kg1:10,000

RepeatEpinephrineQ3-5minutes

Identifyandtreatcauses:

H’s

Hypovolemia

Hypoxia

Hydrogenions(acidosis)

Hypothermia

Hypo/hyperkalemia.

Hypoglycemia

T’s

Toxins

Trauma

Tamponade(cardiac)

Tensionpneumothorax

Thrombosis(pulmonaryorcoronary)

Tooslowortoofast

Anytime

in the

sequence

21

PediatricVentricularFibrillation/PulselessVentricularTachycardia

“CircleofLife”




Defibrillate2J/kg

AdministerOxygen


Stopbrieflyevery2mintoassessanddefibrillate




Defibrillate4J/kg2minutesafterfirstdefibrillation

Epinephrine

IV/IO:0.01mg/kg1:10,000

Defibrillate4J/kgifVForpulselessVT

Amiodarone5mg/kgIVorIO

Defibrillate4J/kgifVForpulselessVT

RepeatEpinephrineevery3-5minatthesamedose

Continue2minofCPRaftereachdose

Defibrillate4J/kg

MayrepeatAmiodaroneevery5minupto15mg/kg

Defibrillate4J/kg

IdentifyandTreatcausesbetweendefibrillationAnytimeinthesequence:

H’s-Hypovolemia,Hypoxia,Hydrogenions(acidosis),Hypothermia,Hypo/hyperkalemia,Hypoglycemia

T’s-Toxins,Trauma,Tamponade,TensionPneumo,Thrombus(pulmorcoronary),Toofastortooslow.

Mayconsider:

Lidocaine1mg/kg

(equallyeffective

asAmiodarone)

or

Magnesiumsulfate

25-50mg/kgONLY

ifTorsades

or

hypomagnesemia

issuspected

22

Bradycardia

CardiopulmonaryFailure

Bradycardia(below60/min)withAgonalBreathing

AssessCAB’s

Ventilate

Administeroxygenasneeded

Intubatewhenappropriate

Obtainvascularaccess

Assessvitalsigns

Cardio-respiratorycompromise?

Poorperfusion

Hypotension

Respiratorydistress

No Yes

Observe Performchestcompressionsifdespite

SupportCAB’s oxygenation&ventilation:Heartrate<60/min

Transportpedsfacility

ContinueCPRuntilratesustainsatgreaterthan60min,ideallyover80-100

Epinephrine

IV/IO:0.01mg/kg1:10,000

RepeatEpinephrineevery3-5minutesatsamedose

Atropine

0.02mg/kg(usuallynotusedinchildren<1year)

Min.dose:0.1mg

Maxsingledose:0.5mgforchild

1.0mgforadolescent

Mayberepeatedonce

Considerpacemaker

Considertreatablecauses

Hypoxia

Hypoglycemia

Hypothermia

Herniationofbrainstem

Anytime

in the

sequence

23

WideComplexTachycardia(>.09sec)

Assumedtobe

VentricularTachycardia,Stable

(nosignsofshock)

AssesCAB’s

Maintainairway

Oxygen,asneeded

EKGandpulseoximeter

Assessvitalsigns

Consider12leadECGandexpertconsultespeciallyifstable

Establishvascularaccess

Amiodarone5mg/kgover20-60min

Successfulconversion?

Yes No

Synchronizedcardioversion0.5J/kgto1J/kg

(mayincreaseto2J/kg)

ConsiderExpertConsult

*Maychoosetotryonedoseofadenosine0.1mg/kgtodetermineiftherhythmisSVTwith

aberrancy.

May consider:

Procainamide 15mg/kg

over 30-60 min

or

Lidocaine 1mg/kg

(do not routinely

administer multiple

antiarrhythmic meds)

Consider Expert

Consult

24

WideComplex(>.09sec)

Assumedtobe

VentricularTachycardia,Unstable(signsofpoorperfusion/shock)

AssessCAB’s

Maintainairway

Oxygen,asneeded

EKG&pulseoximeter

Assessvitalsigns

Codeequipmentprepared

ExpertConsult&12leadECGwhenappropriate

Immediatesynchronizedcardioversion

0.5-1.0J/kg(considersedation,donotdelaycardioversion)

Attempt2ndsynchronizedcardioversionupto2J/kg

Ifunsuccessfulorrapidreoccurrence

Thena3rdsynchronizedcardioversionupto2J/kg

Rate:over180forchildren;over220forinfants

Mayconsider:

Amiodarone5mg/kgIV

over20-60min

or

Procainamide15mg/kgIV

over30-60min

(donotroutinely

administermultiple

antiarrhythmicmeds)

25

NarrowComplexTachycardia

Assumedtobe

SupraventricularTachycardia,Stable

AssessCAB’s

Maintainairway

Oxygen,asneeded

EKG&pulseoximeter

Assessvitalsigns

Consider12leadECG&expertconsult

Vagalmaneuvers

(iceorstraw)

Establishvascularaccess

Adenosine0.1mg/kgIVrapidly

Followedbyrapidflush

(maydoubledoseandrepeatx1)

Expertpediatricconsult

Rate:over180forchildren;over220forinfants

26

NarrowComplexTachycardia

SupraventricularTachycardia,Unstable(signsofpoorperfusion/shock)

AssessCAB’s

MaintainAirway

Oxygen,asneeded

Assessvitalsigns

Codeequipmentprepared

Consider12leadECG&expertconsultwhenappropriate

Considervagalmaneuvers

ifnotcriticallyunstable

(iceorstraw)

IfIV/IOisalreadyinplace&ptisnotcritical

Adenosine0.1mg/kgIVrapidly

followedbyrapidflush

OR

Synchronizedcardioversion

0.5-1.0J/kgSedateifpossible(mustnotdelaycardioversion)

Ifunsuccessful

2ndsynchronizedcardioversionupto2joules/kg

Thena3rdsynchronizedcardioversionupto2J/kg

May consider:

Amiodarone 5mg/kg IV

over 20-60 min

or

Procainamide 15mg/kg

IV over 30-60 min

(do not routinely

administer multiple

antiarrhythmic meds)

27

PediatricShock

PoorperfusionpreorpostresuscitationHypoperfusionfromanycause

AssessCAB’s

MaintainAirway

AdministerOxygen,asneeded

Maintainbodytemperature

MonitorEKG&Pulseoximetry

EmergencyVascularAccess(IVorIO)Alwaysassessforandtreathypoglycemia,hypocalcemia,andacidosis

ASSESSFORANDMAINTAINANADEQUATEHEARTRATEANDRHYTHM

ShockfromTrauma

20ml/kgNSorLRRapidly

Continuedsignsofpoorperfusion

20ml/kgNSorLRRapidly


3rdinfusionof20ml/kgNS/LR

or

10ml/kgpackedRBC’smixedwith

NS

RepeatQ20-30minasneeded

Addresstheproblem(surgery?)

andadministerwholeblood

CardiacRelatedShock

5-ml/kgNSorLR

(providedlungsareclear)


Alongwith2ndfluidbolus

consider:

Dopamineat10–20mcg/kg/min

or

Epinephrine0.1–1mcg/kg/min

NorEpi0.1–2mcg/kg/min

↓

Considerexpertconsultation

SepticShock

20ml/kgNSorLR(administer

fluidscarefullyinafebrileillness)

3–4x’sinthefirsthour

CorrectGlucoseandCalciumlevel

Givebroadspectrumantibiotic

within1hour

Contact/Transferto

specializedICU

Consider:

Dopamine10-20mcg/kg/min

or

Epinephrine0.1–1mcg/kg/min

NorEpi0.1–2mcg/kg/min

ICUoptionsbasedScv02

&B/P

*Norepinephrine/vasopresson

*Hgbtransfusion

*Dobutamine

PostCardiacArrest-InducedTargetedTemperatureManagement(TTM):

Fortheresuscitatedchildwhoremainscomatose,TTMmaybebeneficial.(32–34°C/low90’sF)

Forcomatosechildrenresuscitatedoutofhospital,itisreasonabletomaintaineither5daysof

normothermia(36-37°C)or2daysofcontinuoushypothermia(32–34°C),followedby3daysof

normothermia.Currentstudiesshowednodifferenceinoutcomeafter1yearbetweenrandomized

groupsthatreceivedeitherhypothermiaornormothermia.Forchildrenwhowereresuscitatedin-

hospital,thereisinsufficientdatatorecommendhypothermiaovernormothermia.

28

PediatricPostResuscitationCareReturnofSpontaneousCirculation(ROSC)

Optimizeoxygenationandventilation

AppropriateETTplacement

endtidalCO2orcapnography–tubeisinairway

CXR–depthofinsertion

MaintainO2sat94-99%

ensuresadequateoxygenation

preventsriskofreperfusioninjuryrelatedtoexcessiveoxygen

VentilatetomaintainCO2levelsappropriatetopatient’scondition

monitorindirectlybycapnography

monitordirectlybyABG

Optimizecardiacoutput-Cardiacoutput=strokevolumexheartrate

Strokevolumeisdeterminedbypreload,contractility,andafterload

Increasepreloadbyadministeringfluidboluses

Maynottolerate20mL/kgduetopoormyocardialfunctionpostarrest;try5-10mL/kgover10-20min

Improvecontractilitybycorrectinghypoglycemiaand/orelectrolyteimbalancesincludinghypocalcemia

Inotropes(dopamine)and/orinodilators(milranone)maybeneeded

Avoidhypotension–treatwithfluidsand/orvasopressors

MaintainHRappropriateforage–aggressivelytreatanytachyorbradyarrhythmias

Maintainadequatehemoglobinconcentrations

Optimizeneurologicoutcome

Aggressivelytreathyperthermia,hypotension,hypoglycemia,andhypoxiaallofwhichcancause

secondarybraininjury.

Aggressivelytreatseizureswhichmayresultfrom:hypoglycemia,electrolyteimbalance,or

underlyingbraininjury.Seizuresincreasethemetabolicdemand;correctthecauseifpossible.

Mildhypothermiaiscommonpostarrestandshouldnotbeaggressivelytreated.

Childrenresuscitatedfromoutofhospitalarrestshouldbemaintainedateither5daysofnormothermia

(96.8-99.5oF)or2daysofinitialcontinuoushypothermia(89.6-93.2oF)then3daysofnormothermia.

Transportasneededformostappropriatelevelofcare.

29

SupplementalInfo

SpecialNeedsChildren

Medicalandtechnologicaladvanceshaveallowedcriticallyillorinjuredchildrentolivelongerlives.Manyofthese12million

childrenwillbeencounteredathome,inschools,orinnon-medicalcarefacilities.

Thesepatientspresentspecialchallengesinassessmentandmanagement.Thecaretakercanbeagreathelpindetermining

whatis“normal”andwhatisuniqueforthisparticularpatient.

Commontechnologicalsupportincludestracheostomies,ventilators,CSFshuntsandgastrostomytubes.Troubleshooting

complicationswiththesedevicescanbeaccomplishedusingamodifiedversionoftheDOPEmnemonicforevaluatingET

tubes.

TracheostomyTubes

Thepatientmayormaynothaveapatentupperairwayallowingventilationororalintubationintheemergencysetting.

AnothertrachtubeorastandardETtubecanbeplacedinthestomaifneeded.Possiblecomplications:

• D–dislodgedtube

• O–obstructedtube

• P–pneumothorax

• E–equipmentfailure

HomeVentilators

Thecaregivershouldbefamiliarwiththeventilatortype,functionandsettingsforthechild.Identifyingandtreatingthe

causesofacuterespiratorydistressintheventilatordependentpatientmustbedoneimmediately.Possiblecausesofthe

deterioratingchildwhoisventilatordependentmayinclude:

• D–displacedordisconnectedtubingorETortrachtube

• O–obstructionofairflow–ventilatorortrachtube

• P–pneumothoraxorpatientcondition(i.e.–respiratorydiseases)

• E–equipmentfailure–trytomanuallyventilatethepatient

CentralVenusCatheters

Thesesitesmayhaveexternalportsrequiringregular“flushing”orbeplacedundertheskinshowingavisible“port”which

mustbeaccessedthroughtheskinandrequiremonthly“flushing”.

CommoncausesofCVCrelatedcomplicationsinclude:• D–displacementordisconnectioncausingseriousbleeding

• O–obstruction–clotsorkinkingofthecatheter

• P–pulmonaryembolus,pneumothorax,pericardialtamponade

• E–equipmentfailure–leaking,crackingorinfection

FeedingTubes

Usedfornutritionormedicationsinchildrenwhohavenutritional,developmentalorswallowingproblems.

Potentialcomplicationsforfeedingcathetersinclude:

• D–displacement

• O–obstructed

• P–peritonitis,perforation,pneumoperitoneum

• E–equipmentfailure–thetubingorthefeedingpump

CSFShunts

UsedinpatientswhoareunabletodrainorreabsorbCSFfromtheventriclesinthebrain.Thismaybeduetomedical

conditions,traumaorneoplasms.Theshuntisacatheterplacedinthebrain,whichdrainsfluidtotheabdominalorthoracic

cavityforreabsorbtion.EmergenciesinvolvingCSFshuntsmayinclude:

• D–displacement–patientmayshowsignsof↑ ICP

• O–obstruction–SI/SXincludeheadacheirritability,N/V,bulgingfontanellearesignsof↑ ICP

• P–peritonitis,perforation,pseudocyst–allpresentingasacuteabdomenorshock

• E–equipmentfailure–leaking,kinkingorcrackingoftheshuntcausingsignsofinfectionor↑ ICP

30

SupplementalInfo

CommonPediatricEmergencies

SeizuresMostcommonpediatricmedicalemergency

Feveristhemostcommoncause

• Febrileseizuresalonearenotlifethreatening(buthowdoyouknowfeveristrulythecause?)

• Noalcoholorcoolbaths–thesecanleadtoshiveringandincreasetemp.

StatusEpilepticus–2ormoreseizureswithoutregaininconsciousnessor1continuousseizurelasting

morethan15-20minutes.

TreatmentCAB’s

PreventInjury,Lateralrecumbnantposition(forairwaymaintenance)

Vascularaccessifunstableorinstatusseizures

AtivanIMorIV,IO(0.1mg/kg)

MidazolamIV,IN,IM,IO(0.1mg/kg)

ValiumIV,IO(0.1-0.2mg/kg)orrectal(0.5mg/kg)or

Mostseizureslastlessthan5minutesandneednotreatmentexceptopeningtheairway,suction,andO2

FeverRemoveclothing

Tylenol(15mg/kg)orMotrin(10mg/kg)

SepsisInitiallymanageshockandfever

Appropriateantibiotics

Considersepsisspecificfacility

MeningitisWatchforS/SofincreasedICP

Maybelifethreateningifnotcaughtearly

SymptomsFever(maybeonlypresentingsymptomininfant)

Bulgingfontanel

Irritability

Lethargy

Nuchalrigidity

S/SincreasedICP

TreatmentInitiallymanageshock,ICP,andfever

Appropriatelabs

Appropriateantibiotics

31

HeadInjuriesCommoninPediatrics–largeheadcomparedtobody

ConcussionPathophysiology

Swelling–noactualdamagetobraintissue

AssessmentVomiting

Sleepiness

NeurochecksWNL

ManagementCAB’s

Observefor:

• S/SincreasedICP

• S/Shemorrhage/contusion

IntracranialHemorrhage/ContusionPathophysiology-Bleedingwithinthebraintissue

AssessmentS/Sofconcussion+neurodeficits

Lethargyorlossofconsciousness

Seizures

Unequalorsluggishpupils

Hemiparesis,hemiparalysis

ManagementCAB’s

Closeobservation

Surgicalintervention

IncreasedIntracranialPressure

Assessment(Cushing’sTriad)

Hypertension

Bradycardia

Irregularrespirations

ManagementCAB’s

Considerelevatinghead

Maintainadequateventilations(pCO2approx.30)

Hyperventilationreservedforrapidlydeterioratingpatients(mayneedrapidsurgicalintervention)

Corticosteroids

Mannitolmaybeconsideredbysomeifnobleed

32

RespiratoryDistress

“Noisybreathingisobstructedbreathing”

Managingtherespiratorydistressismoreimportantthandiagnosing

Croup Epiglottitis

Usually<3yrsold Usually3-6yrsold

“Sick”foracoupleofdays Suddenonset

Lowgradefever Highfever

Not“toxic”appearing “Toxic”appearing

Drooling–dysphagia

“Tripod”

Both

Stridor

“Barky”cough

Asthma

RAD(reactiveairwaydisease)–bronchoconstriction

Tightnessreducesairflowandthusmaydecreasewheezing

Pneumonia/Bronchiolitis

Infiltrates

Respiratorydistresswithcoarsebreathsounds,rales,rhonchi,andpossiblywheezing

Generalmanagement

Psychologicalfirstaid

Airwayasappropriate–positionofcomfortsniffingposition

O2astolerated–blowbyBVMETT

Pulseoximeter,cardiorespiratorymonitor

InitialIVtherapymaybedelayed

Nebulizertreatments

• Bronchodilators,forasthma,andpossiblypneumoniaandbronchiolitis

§ (Albuterol1.25-2.5mg/dose)

• Racemicepinephrine0.05mL/kg/doseforcroup(notusedforepiglottitis)

Steroidsforcroup

33

SIDS

SuddenInfantDeathSyndrome(SIDS)isthesuddenandunexplaineddeathofaninfantunderoneyear

ofage.

SIDS,sometimesknownas“cribdeath”,isthemajorcauseofdeathinbabiesfrom1monthto2yearof

age.Thedeathissuddenandunpredictable,mostofteninaseeminglyhealthybaby,andusuallyduring

sleep.MostSIDSdeathsoccurbetweenages1and4months,affectingmoreboysthangirls,and

occurringmoreofteninthefall,winterandearlyspringmonths.

ReducingtheRiskofSIDS

Sleepposition

• Unlesscontraindicated,healthybabiesshouldsleepontheirbacks

• Ifthesidelyingsleeppositionischosen,thebaby’slowerarmshouldbepositionedforwardto

preventhimfromrollingintoaproneposition

Sleepsurface

• Thebabyshouldsleeponafirmmattress.Fluffyblankets,waterbeds,sheepskin,orpillows

shouldnotbeusedasasleepsurface

Temperature

• Roomtemperatureshouldbemoderate;notcold,butnotwarmerthaniscomfortableforadults

Smokefreeenvironment

• Babiesandyoungchildrenexposedtosmokehavehigherincidenceofcoldsandother

respiratoryinfections,aswellasincreasedriskforSIDS

Routinehealthcare

• RoutinewellandsickbabyvisitsaswellasreceivingvaccinationsontimereducetheriskofSIDS

Prenatalcare

• EarlyandregularprenatalcarecanhelpreducetheriskofSIDS

• TheriskofSIDSishigherforbabieswhosemotherssmokedduringpregnancy

Breastfeeding

• Breastfeedingprovidesenhancedimmuneprotectionforinfants

34

WrittenPreCourseExamination

1.Youarecalledtoevaluatea9montholdinfant.Youhaveassessedthattheinfantisunresponsiveandarenow

simultaneouslycheckingforbreathingandpulse.Whereareyoupalpatingforapulseandhowlongshouldittake?

A.Carotid,notmorethan10seconds

B.Brachial,notmorethan20seconds

C.Carotid,notmorethan15seconds

D.Brachial,notmorethan10seconds

2.A2yearoldisbroughtintotheemergencyroomfollowingafallfromhishighchair.Thechildisunresponsiveandhasslow,

irregularrespirations.Whatisthemostlikelycauseofthischild’srespiratoryfailure?

A.Upperairwayobstruction

B.Disorderedcontrolofbreathing

C.Bluntchesttrauma

D.Lowerairwayobstruction

Usethefollowingscenariotoanswerthenext2questions:

A4yearoldchildwitha3dayhistoryofvomiting,diarrhea,andpoorPOintakeisbroughtintotheERbyherdad.Sheis

afebrile,heartrateis132,respirationsare22andunlabored,capillaryrefillis5,centralpulsesarepresent,peripheralpulses

areweak,bloodpressureis80/52.

3.Youdeterminethatthischildisin:

A.Hypovolemicshock

B.Obstructiveshock

C.Distributive,septicshock

D.Cardiogenicshock

4.Shehasreceived4normalsalinebolusesof20mL/kg.Herheartrateis90/minandcapillaryrefillis<2seconds,butshe

remainsverylethargic.Whichdiagnostictestshouldbedonefirst?

A.CTscanofthebrain

B.EEG

C.Bloodglucose

D.ABG


Duetoaclusterofseizuresathome,a6yearoldgirlisgivenDiastat(rectaldiazepamgel)byherdad.HecalledEMSbecause

herseizurescontinued.ThechildreceivedIVlorazepamenrouteandisnolongerseizingonarrivaltotheER.Sheis

unresponsivewithsnoringrespirations,rateof6/minandpoorchestrise.

5.Yourbestinitialinterventionis:

A.Repositionandinsertandoralairway

B.Administerflumazenil

C.Administernaloxone

D.ApplyO2vianonrebreathermask

6.Postresuscitativecareincludesmonitoringthepatient’sO2saturation.Whichofthefollowingsaturationisbest

recommended?

A.94-99%

B:95-100%

C.>94%

D.>97%

35

7.Youareamemberofthecodeteamrespondingtoacodeinpediatrics.Onarrival,highqualityonepersonCPRisbeing

correctlyperformedona3yearoldboywitharatioof_____.Nowthattheteamhasarrived,2personCPRwillbeginwitha

ratioof_____.

A.15:2,30:2

B.30:2,15:2

C.15:2,5:1

D.30:2forboth

8.Inspiteofpositioningandoralairwayinsertionanunresponsivepatient’srespirationsareslowandirregular.Whatshould

beyournextintervention?

A.ApplyO2vianonrebreathermask

B.Performendotrachealintubation

C.Providebag-maskventilation

D.administeralbuterolsulfatevianebulizer

9.Youaretheteamleaderduringaresuscitationattemptona7yearoldchild.Themonitorisjustappliedandshowsthe

followingrhythm.Thereisnopulse.

Youinstructtheteamtodefibrillateat_____.Yournextinstructionshouldbe_____.

A.2J/kg,Rechecktherhythm

B.1J/kg,AdministerAmioderone

C.4J/kg,Checkforapulse

D.2J/kg,Resumecompressions

10.WhichofthefollowingisnotanelementofhighqualitypediatricCPR?

A.Compressionrateof100-120/min

B.Compressiondepthof1/4–1/3thedepthofthechest

C.Allowingcompleterecoilbetweencompressions

D.Pulsechecksevery2minutes


An8yearoldoncologypatientpresentstotheERwithafeverthatstartedthismorning.Thechildislethargic.Axillarytempis

102.7,heartrate144,respiratoryrate26withincreasedworkofbreathing,bloodpressure80/52,pulsesareboundingwith

capillaryrefill<2.Chemistrydrawnonarrivalshowslacticacidosis.

11.Youaccuratelyassess_____because_____.

A.Hypotensiveshock,systolicbloodpressureis<86

B.Compensatedshock,systolicbloodpressureis>70

C.Noshock,thecapillaryrefillis<2

D.Cardiogenicshock,theheartrateis>140

12.Thischildismostlylikelyin:

A.Hypovolemicshock

B.Distributive,neurogenicshock

C.Distributive,Septicshock

D.Obstructiveshock

36

13.Whichofthefollowingisthebestindicatoroftheseverityoftheshock?

A.Bloodpressure

B.Heartrate

C.Temperature

D.Capillaryrefill

14.Youhavedecidedtogivethischildafluidbolus.Whichofthefollowingwouldyougive?

A.20mL/kg5%dextrosein0.45%normalsalineover1hour

B.20mL/kgnormalsalineover<20min

C.10mL/kglactatedringersover30min

D.15mL/kg5%dextroseinwaterover1hour

15.WhatelseshouldthischildreceivewithinashorttimeofarrivaltotheER?

A.Cardiologyconsult

B.Chestx-ray

C.Neurologyconsult

D.Broadspectrumantibiotic

16.Youareaskedtoperforminarolethatisoutsideyourscopeofpracticeandthereforeaskforadifferentrole.Thisisan

exampleof:

A.Knowingyourlimitations

B.Expectingspecialtreatment

C.Notbeingateamplayer

D.Beingtoolazytolearnnewroles

17.Youareassessingachildwithincreasedrespiratoryeffort.Onauscultationyouhearcrackles(rales).Thishelpsyou

identifythatthischildhas:

A.Lowerairwayobstruction

B.Upperairwayobstruction

C.Disorderedcontrolofbreathing

D.Lungtissuedisease

18.Whichofthefollowingwouldindicateupperairwayobstruction?

A.Crackles(rales)

B.Increasedinspiratoryeffortandstridor

C.Prolongedexpiratoryphaseandwheezing

D.Slow,irregularrespirations

19.A1yearoldchildisincardiacarrestanddoesnothaveanIVsite.Whatisyourbestintervention?

A.ImmediatelyinsertanIO

B.GiveepinephrineviatheETT

C.Have2peopletryrepeatedlytostartanIV

D.Askthedoctortoinsertacentralline

20.Whileprovidingcareatacamp,youdiscovera6yearoldchildunresponsivewithnopulse.Youshoutforhelpbutnoone

comes.Youshould:

A.LeavethechildtoactivateEMS,thenreturnandperformCPR

B.DoCPRwhilecontinuingtoshoutforhelphopingsomeonehearsyou

C.DoCPRfor2minutes,leavetoactivateEMS,restartCPR

D.ActivateEMSafterdoingCPRfor10minutes

37


AGrandmotherbringsanunresponsive10montholdtotheER.Thebaby’sskiniscoolandpale,capillaryrefillis6seconds,

respirationsarelaboredwithretractionsandinspcrackles(rales)auscultatedinthebases,bloodpressureis64/40.The

monitorshowsthefollowingwithaheartrateof260/min.

21.Thisconditiondescribes:

A.Unstablesupraventriculartachycardia

B.Stablesupraventriculartachycardia

C.Ventriculartachycardia

D.Sinustachycardia

22.Immediatetreatmentis:

A.StartanIV,giveadenosineslowIVpush

B.20mL/kgnormalsalinebolus

C.Defibrillationat2J/kg

D.Synchronizedcardioversionat0.5-1J/kg

23.Whichofthefollowingchildrenneedsimmediateattention?

A.2yearoldwithatemperatureof99.9oF

B.5yearoldwithnasalcongestionandO2sat95%onroomair

C.4yearoldwithbloodpressure88/50

D.10montholdwithheadbobbingandgrunting

24.Youareassessinga1yearoldwiththefollowingvitalsigns:

heartrate120,respiratoryrate30,bloodpressure84/56.Whichoftheseindicatesaproblem?

A.None,theseareallnormalvalues

B.Heartrate

C.Respiratoryrate

D.Bloodpressure

25.UsingtheAVPUscale,howwouldyoudocumentLOCforan18montholdsittingonmom’slaplookingaround,whocries

whenyouapproachandiseasilyconsoledbymom?

A.Awake

B.Voice

C.Pain

D.Unresponsive

38


Anunresponsive7yearoldgirlisbroughtintotheERbymom.Herskiniscoolandcyanotic,respiratoryrateis6,herO2sat

is86%onroomairandherbloodpressureis74/38.Centralpulsesareweak,peripheralpulsesareabsent.Themonitor

displaysthefollowingrhythm:

26.Whatrhythmismostconsistentwiththeabovestripandclinicalpresentation?

A.PEA

B.Sinusbradycardia

C.Normalsinusrhythm

D.Thirddegreeheartblock

27.Whatisthemostcommoncauseofthisrhythmininfantsandchildren?

A.Drugoverdose

B.Hyperglycemia

C.Dehydration

D.Hypoxia

28.Whatshouldyourinitialactionbe?

A.Fluidboluswith20mL/kgnormalsaline

B.Cardioversionwith0.5-1J/kg

C.Providebag-maskventilationwith100%O2

D.Administernarcan

29.Whichofthefollowingisindicativeofrespiratoryfailureina9yearoldchild?

A.Productivecoughwithinspiratorycrackes(rales)heardonausculation

B.O2satof68%onroomairand84%onO2vianonrebreather

C.Prolongedexpiratoryphasewithendexpiratorywheezingheardonauscultation

D.Respiratoryrateof32withaccessorymuscleuse

30.A3yearoldboyisbroughtintotheERbydadwitha2dayhistoryoflowgradefeversandbarkycough.Asyouenterthe

roomyouseethatthechildisalert,skinispink,andhisrespirationsarelaboredwithsuprasternalretractionsandstridor.

Whatmedicationwouldyougivefirst?

A.Nebulizedalbuterol

B.Broadspectrumantibiotic

C.Nebulizedepinephrine

D.Tylenol

31.Whatwouldyouexpecttoassessinachildwithlowerairwayobstruction?

A.Increasedinspiratoryeffortandstridor

B.Slow,irregularrespiratorypattern

C.Retractionsandcrackles(rales)onauscultation

D.Prolongedexpiratoryphaseandwheezing

32.Duringacodetheteamleaderinstructsyoutogiveamedicationdosethatyoubelievetobeincorrect.Howwouldyou

respond?

A.Givethedoseyouaretoldtogive;theteamleaderisincharge.

B.Refusesaying,“Ican’tgivethat.It’sthewrongdose”.

C.Givethemedinthedoseyoubelievetobecorrect.

D.Tactfullyclarifybysaying,“didyoumeantosay___________”

39

33.Anunresponsive5yearoldisbroughtintotheemergencyroom.Skiniscoolandcyanotic.Therearenopalpablepulses.

Themonitorshowsthefollowingrhythm.

Whatisthiscondition?

A.Normalsinusrhythm

B.PEA

C.Sinusbradycardia

D.Firstdegreeheartblock

34.Youareassessinga10yearoldboybroughttotheERafterfallingoutofatree.Whatfindingwouldindicatetoyouthat

immediateinterventionisneeded?

A.Sytolicbloodpressureof94

B.Heartrateof88

C.Warm,moistskin

D.Decreasedlevelofconsciousness

35.Alethargic2yearoldisbroughtintotheERbyhermom.Shehasarespiratoryrateof76withdeepretractionsandnasal

flaring.O2satis94%onroomair.Sheisafebrile,herskiniswarmanddry,capillaryrefillisbrisk.Asyoubringherbacktoa

roomyounoticethatherrespirationshavebecomelesslaboredandherrespiratoryratehasdroppedto20.Thisisan

indicationthat:

A.Thechildisgoingintorespiratoryfailure

B.Thechildisimproving

C.Thechildisgoingintoshock

D.Thechildisfeelinglessanxioussincesheisatthehospital

36.Whichofthefollowingchildrenisinrespiratorydistress?

A.4yearoldwithaudibleinspiratorystridor

B.2yearoldwithaheadinjurydecreasedrespiratoryeffortandarespiratoryrateof10

C.7yearoldwithanO2satof97%

D.2montholdwitharespiratoryrateof50

37.Youareevaluatingan11yearoldwithaknownallergytobeestingswhowasbroughtinafterencounteringaswarmof

beesandbeingstungseveraltimes.Whichofthefollowingwouldyoubelikelytosee?

A.Lungtissuedisease

B.Hypovolemicshock

C.Upperairwayandpossiblylowerairwayobstruction

D.Disorderedcontrolofbreathing

40


Yourpatientisanunresponsive3yearoldgirl.Herskiniscoolandcyanotic.Sheisnotbreathingandhasnopalpablepulses.

YourteambeginshighqualityCPR.Youattachamonitorandthefollowingrhythmisdisplayed:

38.Whatisthisrhythm?

A.Ventriculartachycardia

B.Supraventriculartachycardia

C.Asystole

D.VentricularFibrillation

39.Yourpriorityis:

A.Defibrillateat2J/kg

B.Fluidbolusof20mL/kgover5-10min

C.Synchronizedcardiovertat0.5-1J/kg

D.Administeradenosine0.1mg/kg

40.Thereisnochange.YourteamcontinueshighqualityCPR.Whatwouldyoudonext?

A.Defibrillateat4J/kg

B.Fluidbolusof20mL/kgover5-10min

C.Synchronizedcardiovertat0.5-1J/kg

D.Administeradenosine0.1mg/kg

41

ANSWERSHEETPRETEST

PALSWrittenEvaluation

1. D

2. B

3. A

4. C

5. A

6. A

7. B

8. C

9. D

10. B

11. A

12. C

13. A

14. B

15. D

16. A

17. D

18. B

19. A

20. C

21. A

22. D

23. D

24. A

25. A

26. B

27. D

28. C

29. B

30. C

31. D

32. D

33. B

34. D

35. A

36. A

37. C

38. D

39. A

40. A

42

EMERGENCY MEDICAL CONSULTANTS INC. Florida’s Premier Provider Of Quality Medical Training Programs


CEU Provider

Since 1988

ThefollowingpagescontainaPretestforanyone

choosingtocompletetheBLScourse

afterACLSorPALS.

Thisinformationinthispacketcomesfromthe

2015BLStextbook;Pleaseusethebooktoreview.

Youmustscorea76%(-7)Inordertotakethisprogram

Completingthesetestquestionspriortothecourse

ismandatoryifyouplanonattendingtheCPRsection

afterthePALSprogram.



Visit Our Website- www.medicaltraining.cc

43

44

SkillsReviewforHealthcareProviders

TheCAB'sofCPR

SimultaneouslyDetermineunresponsivenessandcheckforeffectivebreathing

Ifunresponsive:calla“code”or911

C=Circulation-CheckforapulseMax-10seconds.Ifpulseisnotdefinite,begincompressions.

A=Airway-Openairway(headtilt/chinlift)

B=Breaths-Give2breathsthenbacktocompressions

D=Defibrillator-AttachamanualdefibrillatororAED

CPRReference

Adults(>puberty) Children(1-puberty) Infants(<1yr)

Rescuebreathing,Victimdefinitelyhas

apulse

10-12breaths/min


12-20breaths/min


12-20breaths/min


Compressionlandmark

Nopulse

(orpulse<60ininfantorchildwith

poorperfusion)

Middleofthechest,

betweenthenipples

Middleofthechest,

betweenthenipples

1fingerbelownippleline

Compressionsareperformedwith Heelof2hands Heelof1or2hands

2fingersOR

2thumbswhenusingencircling

handstechnique

Rateofcompressionsperminute 100-120/min 100-120/min 100-120/min

Compressiondepth 2-2.4inches Atleast1/3depthofchest

2inches

Atleast1/3depthofchest

1½inches

Ratioofcompressionstobreaths

*Onceanadvancedairwayisplaced

ventilationswillbe1every6sec.with

continualcompressions.

30:2


reevaluateevery2min

30:2

15:2if2rescuer


reevaluateevery2min

30:2

15:2if2rescuer


reevaluateevery2min

ForeignBodyAirwayObstruction*IfnotrapidlyremovedcallEmergencyMedicalService*

Consciouschoking

Adult Child Infant

AbdominalThrusts

AbdominalThrusts

5BackBlows/5ChestThrusts

Unconsciouschoking

Adult Child Infant

Calla“code”

orcall911

BeginCAB’sofCPR





BeginCPR








BeginCPR








45

INFORMATIONTOKEEPINMIND:

1. Knowthemaximumtimethatshouldbespentcheckingforthepresenceofapulse.

2. Knowthepreferredtechniques/devicesforprovidingventilationsifyouareasingle

rescuerversushavingmultipleresourcesintheprofessionalsetting.

3. Knowtheconceptofscenesafety/awarenessbeforeprovidingcare.

4. Knowwhichpatientsrequireventilationsandwhichrequireventilationsplus

compressions.

5. KnowthebestwaytoopentheairwayforanAdult,Child,Infantorspinallyinjured

patient.

6. Knowthelocation,depthandrateofcompressionsforanAdult,ChildandInfant.

7. KnowwhentostartcompressionsforanAdult,ChildandInfant,beabletoexplainchest

recoil(release)andhighqualityCPR.

8. Knowthecompressiontoventilationratioforboth1and2-rescuerforAdult,Childand

Infant.

9. Knowhowtoreducetheincidenceofairbeingintroducedintothepatient’sstomach

versustheirlungs.

10. UnderstandhowanAEDaffectstheheart(shocktoorganizetherhythm),andknowthe

stepsforusinganAEDonanAdult,ChildorInfant;pediatricuseandplacement.

11. KnowhowtoincorporateCPRbefore,duringandafterAEDuse.

12. KnowthechangesinCPR,whichareincorporatedonceavictimhasanadvancedairway

“tube”placedbyamedicalprofessional.

13. Knowthesequence,proceduresandrolesfor1rescuerversus2-rescuerCPR.

14. KnowtheproceduresforconsciousandunconsciouschokingforAdult,ChildandInfant.

15. Knowhowtodetermineeffectivenessofventilationsandcompressionsbeingprovided

duringCPR

16. Knowtheelementsofeffectiveteamdynamicsandcommunicatingduringan

emergency.

46

47

MANDATORYBLSPre-CourseExam

1.Anelderlywomancollapsestothefloorinabingohall.Yourfirstactionshouldbe:

A. Opentheairwayandgive2breaths.

B. Gograbthedefibrillatoroffthewallinthehallway.

C. Yellout/callforhelpwhilesimultaneouslyassessingforpulseandrespirations.

D. Checkforacarotidpulse.

2.Youareperforming1rescuerCPRona75-year-oldfemalewithahistoryofchestpainanddiabetes.An

AEDhasjustbeenmadeavailabletoyou.Whatisthefirstactionthatyoushouldtakeatthistime?

A. Finishthe5cyclesofchestcompressionsthatyouhavestarted.

B. PlacetheAEDpadsonthechest.

C. SecureanelectricaloutlettoplugtheAEDinto.

D. TurntheAEDon.

3.Youareattendingyournephew’sbirthdaypartywhena5yearoldchildsuddenlystartschokingonahotdog.

Whatshouldyoudo?

A. Administer2rescuebreaths.

B. Performablindsweepofthevictim’smouth.

C. Deliver5back-slaps.

D. Positionyourselfbehindthechildandadministerabdominalthrusts(HeimlichManeuver).

4.Opioidsaremedicationsthatareusedtotreatpainbuthaveahighpotentialforabuse.Addictionratetothe

medicationsisagrowingproblemandtheycancauserespiratoryandorcardiacarrests.Currently,moreadults

dieeveryyearfromopioidoverdosesthancaraccidents.Whatisthenameofthemedicationthatisutilizedto

reversetheeffectsofrespiratorydepression?

A. Naloxone.

B. Ativan.

C. Lasix.

D. MagnesiumSulfate.

5.Yourmiddleageneighborismowinghisgrasswhenheclutcheshischestanddropstotheground.Hehasno

pulseorrespirations.Yoursoncalls911whileyouinitiatechestCPR.Howfastshouldthecompressionratebe?

A. 100compressionsperminute.

B. 100-120compressionsperminute.

C. 80-100compressionsperminute

D. 120-150compressionsperminute.

48

6.Bystandershavepulledayoungwomanwithapulsebutnorespirationsoutofalake.Oneofthemis

administeringrescuebreathsatarateofoneevery5-6secondswhilewaitingforEMStoarrive.Whichofthe

followingistrueaboutrescuebreaths?

A. Eachbreathshouldresultinvisiblechestrise.

B. Giveeachbreathover1second.

C. Thepulseshouldbecheckedevery2minutes..

D. Alloftheabove

7.WhichofthefollowingsituationswillslightlydelayAEDusagewhilethesituationismadesafeforAED

application?

A. Apersonfoundlyingonametalfloorinsideameatcooler.

B. Apersonfoundsubmergedinabathtub.

C. Apersonwhocollapsedinsnow.

D. Apersonwhohasatransdermalnitropatchontheirarm.

8.Whenutilizingabagvalvemaskdeviceitisimportanttoremember:

A. Thatthisdevicerequirestrainingandisbestsuitedfora2-rescuersituation.

B. TheE-Cclamptechniqueshouldbeusedwhileliftingthejawtoprovideagoodseal.

C. Tosqueezethebagfor1secondwhilewatchingthechestrise.

D. Alloftheabove.

9.WhatisthecorrectratioforcompressionstoventilationsininfantCPRwith2rescuerspresent?

A. 20compressionsto4breaths.

B. 15compressionsto2breaths.

C. Therateremains30compressionsto2breaths.

D. 15compressionsto1breath.

10.Themaximumamountoftimethatshouldbetakentocheckforapulseonanadult,infantorchildis:

A. 15seconds

B. 10seconds

C. 30seconds

D. 5seconds

11.Youarethesecondrescuerprovidingventilationstoanadultvictimincardiacarrest.Youobservethehand

placementofthepersonwhoisprovidingcompressionstobeincorrect.Youadvisethemtorepositiontheir

hands.Thisisanexampleofwhattypeofteamdynamiccommunication?

A. KnowledgeSharing.

B. ClosedLoopCommunication.

C. ConstructiveIntervention.

D. OpenCommunication

49

12.WhileprovidingCPRtoavictim,anAEDbecomesavailableandashockisindicatedandadministered.

Whatshouldyoudonext?

A. Administer2moreshocks;tototal3.

B. ImmediatelyrestartCPR,startingwithcompressions.

C. Give2breathsfirstthenresumeCPR.

D. Checkthecarotidpulsefornolongerthan10seconds.

13.Whatisthepurposeofdefibrillation?

A. Tostopachaoticrhythmandrestoretheheart’snormalrhythm.

B. Toincreasetherateofcompleteheartblock.

C. Toprovideabloodpressure.

D. Totreatcardiacstandstill.

14.Currentguidelinessuggestthatadultcompressionsshouldbeadministeredatadepthof2-2.4inches.Which

ofthefollowingisnottrueregardingchestcompressiondepth?

A. Compressionsareoftendeliveredtoohardratherthantooshallow.

B. Itmaybedifficulttoaccuratelyjudgecompressiondepthwithouttheuseofafeedbackdevice.

C. Consistentcompressiondepthofatleast2inchesisassociatedwithbetteroutcomes.

D. Potentialcomplicationscanoccuratdepthsofgreaterthan2.4inches.

15.Whatisthecorrectrateofventilationstoprovidewhenanadvancedairwayisinplace?

A. 1breathevery3-5seconds.

B. 1breathevery6-8seconds.

C. 1breathevery10seconds.

D. 1breathevery6seconds.

16.Youbeginyourshiftonthemed/surgfloor.Youbeginyourroundsandwhenyouwalkintoapatient’sroom,

younoticethepatienthasagonalrespirations.Whatshouldyoudofirst?

A. Givethepatientoxygen

B. Checkapulse,andbegincompressionsifindicated

C. Donothing,thepatientisasleep

D. BegintheHeimlichmaneuver

17.Whenisthetwothumbencirclingtechniqueisused?

A. Onaninfantwhentworescuersareavailable

B. Whentheinfantischoking

C. WhenperformingCPRonapediatricvictim

D. WhenperformingonerescuerCPRonaninfantandyoubecometired

50

18. Atthebeginningofyourworkshift,youareassignedtheroleofcompressorduringacardiacarrest.Thisis

knownas:

A. Mutualrespect

B. Closedloopcommunications

C. Clearrolesandresponsibilities

D. Constructiveintervention

19.Whileassistingwithacardiacarrest,youareinstructedtotakeoverbagvalvemaskventilations.Yourepeat

back“youwouldlikeformetotakeoverbagvalvemaskventilations.”Inteamdynamics,whatisthiscalled?

A. Closedloopcommunications

B. Knowingyourlimitations

C. Knowledgesharing

D. Mutualrespect

20.Inrelationtothe“Teamconcept”ofresuscitation,ifadequatemedicalstaffisavailable,inordertoreduce

fatigueandincreaseeffectivenessofcompressionstheteamshould?

A. Assignseveralpeopletoswitchoffoncompressionsevery2min

B. Haveeachcompressorworkuntiltheystatetheyneedrelief

C. Putarescueroneachsideofthevictimandrotateeachsetof30compressions

D. Alwaysassignthelargest,strongestpersontocompressions

21.Youarrivetofindahospitalmaintenanceworkerlyingontheground,nexttoaladder.Heappears

unconscious,yourfirstactionshouldbe?

A. Checkforbreathingandapulse

B. Shakeandshout,checkunresponsiveness

C. Begincompressionsat30:2

D. Assuretheareaissafeforyoutobein

22.Afterperformingthechokingprocedureforaconsciousvictimwhobecomesunconscious,thenext

procedureisto?

A. Performafingersweep

B. Attemptventilations

C. Straddlethevictim

D. BeginCPRcompressions

23.HighqualityCPRisthecriticalcomponenttoresuscitation,especiallycompressions;whichconceptis

correct?

A. Compressiondepthhasahigherprioritythanrecoilorrelaxation

B. Compressionandrecoil(refill)areequallyimportant

C. Ventilationisthepriorityforallvictims

D. 30ventilationsperminuteareoptimumforthebestoutcome

51

24.WhenperformingcompressionsonachildforCPRorunconsciousforeignbodyairwayproceduresthe

properdepthis?

A. ½"or½thedepthofthechest

B. 1½"to21½"inches

C. Variesbasedonageandweight

D. 2"or1/3thedepthofthechest

25.Whileataschoolevent,ateacherchokesongum.Herunstowardstheofficebeforefallingunconscious.

Immediatelyafterperforming30compressions,thenextstepis?

A. Opentheairwayandlookintothemouthbeforeventilating

B. Performafingersweepandattemptbreaths

C. Readjusttheairwaywithajawthrustmaneuver

D. Checkpulsefornomorethan10seconds

26.Theresuscitationteamismadeupofvariousprofessionalswithdifferentlevelsoflicenseandskillsets.In

ordertofunctionefficientlytheteammembersmust?

A. WaitforaphysiciantoorderCPRanddefibrillation

B. Alwaysbepreparedtoperformanyskills,evenifnotlicensedto

C. Realizetheirstrengths,abilitiesandlimitations

D. DecideiftheyfeelCPRisworththephysicaleffort

27.Avictimbeginstochoke,andyoufindthemgrabbingtheirthroatandcoughinguncontrollably,youshould?

A. PerformtheHeimlichmaneuver

B. PerformthemodifiedHeimlichmaneuver

C. Performchestthrustiftheyarepregnantorobese

D. Allowthemtocontinuecoughing

28.Youareassistingwithacardiacarrestatasurgi-center.SomeonebringsinanAEDthatyouarenotfamiliar

with,inrelationtoutilizingthis:

A. Haveanoverheadpageputoutforsomeonefamiliarwiththeunit

B. Perform2minutesofCPR,thenapplythepads

C. WaitforEMSorsomeonefamiliarwiththeAEDbeforeusing

D. Turnontheunitandfollowthedirections

29.Theacceptedratioofcompressionstoventilationsfora6yearolddrowningvictimwhenonly1rescueris

availableis?

A. 15:1

B. 30:1

C. 30:2

D. 15:2

52

30.AEDPadsrequirefirmcontacttotheskintobemosteffective,whichofthefollowingwillnegativelyeffect

thatcontact?

A. Wateronthepatientschest

B. Suntanoilontheskin

C. Haironthechest

D. Alloftheabove

53

NAME:

COURSE: Mandatory Pre Test Questions for those completing BLS after ACLS or PALS

# MISSED: GRADE:

1. A B C D

2. A B C D

3. A B C D

4. A B C D

5. A B C D

6. A B C D

7. A B C D

8. A B C D

9. A B C D

10. A B C D

11. A B C D

12. A B C D

13. A B C D

14. A B C D

15. A B C D

16. A B C D

17. A B C D

18. A B C D

19. A B C D

20. A B C D

21. A B C D

22. A B C D

23. A B C D

24. A B C D

25. A B C D

26. A B C D

27. A B C D

28. A B C D

29. A B C D

30. A B C D

REMINDER:

You must score a 76% to be

eligible for the BLS Completion

section after ACLS or PALS

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