PALS Study Guide Part 5

MANAGEMENT OF SHOCK FOLLOWING SUCCESSFUL RESUSCITATION After cardiac arrest, manage shock using the following algorithm: FIGURE 23: PALS POST ARREST SHOCK MANAGEMENT ALGORITHM PATIENT TRANSPORT Use the following guide to arrange the safe transport of the pediatric patient to definitive care.        Prepare for transport: o Find the nearest tertiary pediatric facility o Know and follow the protocol for inter-hospital transport o Anticipate medications, fluids or blood products that might be needed during transport o Prepare them to go with the team. Coordinate with the receiving facility: o Identify the specific receiving provider in the facility o The resuscitation team leader should communicate directly with the receiving provider o Communicate any changes in the child’s condition during transport. Use all appropriate precautions: o Universal precautions o Obtain cultures if infection suspected o Do not delay antibiotics if infection suspected o Use appropriate isolation techniques if needed. Prepare the child and family: o Communicate all implemented treatments to the family o Communicate information about where the child will go and additional capabilities at that facility o Obtain consent for transport o Answer questions and provide comfort to the child and family. Prepare the documentation: o Send a copy of chart with the child o Send copies of all lab tests and x-rays with the child o Send laboratory contact information for all pending tests with the child. Determine the most appropriate mode of transportation: o Ground ambulance: Inexpensive and available in most weather conditions but may involve increased time for distant transports o Helicopter: Faster than ground ambulance for long-distance transports, but more expensive than ground ambulance and may not be able to fly in all weather o Fixed wing aircraft: The best mode of transport for long distances or for very unstable child, but expensive and typically requires interim ground ambulance to reach the aircraft. Select the transport team: o Trained in pediatric care and the pediatric transport equipment o Trained in the selected mode of transportation. UNIT TWELVE: MEDICATIONS USED IN PALS Medications change quickly. It is highly recommended that a pharmacist be included on the resuscitation team to manage all drugs and dosages for pediatric patients. Drug Adenosine Classification Antiarrhythmic Indications SVT Amiodarone Antiarrhythmic SVT, VT with pulses, VF, VT without pulse Atropine Anticholinergic Symptomatic bradycardia, toxins and overdoses Epinephrine Catecholamine vasopressor, Inotrope Anaphylaxis, asthma, symptomatic bradycardia, croup, shock, cardiac arrest, toxins or overdose Dose/Administration 1st dose = 0.1 mg/kg rapid IV push to max of 6 mg. 2nd dose = 0.2 mg/kg rapid IV push to max of 12 mg SVT or VT with pulse 5mg/kg load over 2060 minutes to 300 mg max VF or VT without pulse: 5mg/kg rapid bolus to 300 mg max Bradycardia: 0.02 mg/kg IV with 0.5 mg max dose may repeat one time By ET tube: 0.04-0.06 mg/kg Toxins/overdose: 0.02-0.05 mg/kg repeated every 20-30 minutes until symptoms reverse Anaphylaxis: 0.01 mg/kg every 15 minutes to max of 0.3 mg Asthma: (1:1000) 0.01 mg/kg subcutaneous every 15 minutes to max 0.3 mg Symptomatic bradycardia: 0.01 mg/kg IV every 3-5 minutes to max dose of 1 mg Croup: 0.25 ml Racemic epi solution via nebulizer Cardiac arrest: 0.01 mg/kg (1:10000) IV or 0.1 mg/kg (1:1000) per ET tube every 3-5 minutes Shock: 0.1-1 mcg/kg/ minute IV infusion Toxins/ODs: 0.01 mg/kg (1:10000) IV to max dose of 1 mg Possible Side effects Dizziness, headache, metallic taste, shortness of breath, hypotension, slow or fast heart rate, nausea, flushing, sweating Headache, dizziness, tremors, syncope, hypotension, bradycardia, CHF, nausea, vomiting, diarrhea, rash, skin discoloration, hair loss, flushing, coagulation problems Headache, dizziness, confusion, anxiety, flushing, visual difficulties, pupil dilation, dry mouth, tachycardia, high or low blood pressure, nausea, vomiting, constipation, urinary retention, painful urination, rash, dry skin Considerations Cardiac monitoring during administration; administer through central line if available; flush with saline following administration Tremors, anxiety, headaches, dizziness, confusion, hallucinations, dyspnea, SVT, VT, palpitations, hypertension, nausea, vomiting, hyperglycemia, hypokalemia, vasoconstriction Available in 1:1000 and 1:10000 concentrations so the team must be aware of which concentration is being used; monitor BP, oxygen, and ECG; give via central line if possible; do not give in cocaine induced ventricular tachycardia Monitor ECG and BP; use with caution in patients with a perfusing rhythm, hepatic failure; contraindicated for 2nd or 3rd degree heart block Monitor ECG, oxygen, and BP; administer before intubation if bradycardic; contraindicated in glaucoma and tachyarrhythmias Drug Oxygen Classification Elemental gas Indications Hypoxia, respiratory distress or failure, shock, trauma, cardiac arrest Albumin Plasma volume expander Shock, trauma, burns Dose/Administration In resuscitation, administer at 100% via high flow system and titrate to response to maintain oxygen saturation >94% 0.5-1 g/kg by rapid infusion Albuterol Bronchodilator Asthma, bronchospasm, hyperkalemia 2.5 mg if weight <20 kg 5 mg if weight >20 kg Alprostadil Prostaglandin vasodilator Maintain patency of ductus arteriosus in congenital heart disease Initial: 0.05-0.1 mcg/kg/ minute In cardiac arrest: 20 mg/kg IV bolus into central line In non-arrest: infuse over 30-60 minutes 0.5-1 g/kg Calcium chloride Electrolyte Dexamethasone Corticosteroid Hypocalcemia, hyperkalemia; consider for calcium channel blocker overdose Croup asthma Dextrose Carbohydrate Hypoglycemia Maintenance: 0.01-0.05 mcg/kg/ minute 0.6 mg/kg for one dose (max dose 16 mg) Possible Side effects Headache, dry nose/ mouth, airway obstruction if secretions become dry Considerations Monitor oxygen saturation; insufficient flow rates may cause carbon dioxide retention Fluid overload, increased respiratory rate, flushing, rash, hypocalcemia Tremors, anxiety, headaches, bad taste, dry nose/throat, dyspnea, wheezing, tachycardia, hypotension, nausea, vomiting, flushing Seizures, apnea, vasodilation, hypotension, bradycardia, cardiac arrest, diarrhea, renal failure, flushing, hypoglycemia, DIC, hypocalcemia, fever Hypotension, cardiac arrhythmias, cardiac arrest, burn or sclerosis of peripheral veins, hypercalcemia Use within 4 hours of opening vial Headache, insomnia, seizures, psychosis, visual difficulties, hypertension, edema, tachycardia, osteoporosis, diarrhea, nausea ,GI bleeding, flushing, sweating, poor wound healing, hyperglycemia, sodium and fluid retention, hemorrhage, hypokalemia Sclerosis of veins, hyperglycemia Can be given PO, IM or IV Should not be used with tachyarrhythmias May cause tissue sloughing should be refrigerated until administered Monitor ECG and BP; contraindicated in digitoxicity or hypercalcemia; flush IV tubing before and after administration Do not administer during resuscitation unless hypoglycemia is documented; use point of care glucose monitoring Drug Diphenhydramine Classification Antihistamine Indications Anaphylaxis after epinephrine Dose/Administration 1 -2 mg/kg every 4 to 6 hours to a max dose of 50 mg Dobutamine Beta adrenergic Ventricular dysfunction 2-20 mcg/kg/ minute infusion Dopamine Catecholamine vasopressor, inotrope 2-20 mcg/kg per minute infusion titrated to response Etomidate Short acting sedative with no analgesic properties Furosemide Loop diuretic Ventricular dysfunction, cardiogenic or distributive shock Sedation for intubation or for patients with hypotension or multiple trauma Pulmonary edema, fluid overload Hydrocortisone Corticosteroid Adrenal insufficiency associated with septic shock 2 mg/kg IV bolus to max dose of 100 mg Inamrinone Inodilator Myocardial dysfunction, cardiogenic shock, CHF Loading dose 0.751 mg/kg bolus over 5-10 minutes may repeat twice to max dose of 3mg/kg Infusion at 510 mcg/kg/minute Possible Side effects Dizziness, drowsiness, CNS symptoms, blurred vision, pupil dilation, dry nose/mouth/throat, hypotension, tachycardia, nausea, vomiting, urinary retention or frequency photosensitivity Headache, dizziness, hypotension, palpitations, angina, nausea, vomiting thrombocytopenia Headache, dyspnea, palpitations, PVCs, SVT, VT, nausea, vomiting, acute renal failure 0.2-0.4 mg/kg IV over 30 to 60 seconds with max dose of 20 mg Fast or slow respiratory rate, high or low blood pressure, tachycardia nausea, vomiting, cough 1 mg/kg IV or IM to max dose of 20 mg Headache, weakness, vertigo, hearing and vision problems, dry mouth, ECG changes, nausea, vomiting, diarrhea, abdominal cramping, polyuria, glycosuria, muscle cramps, sweating, hives, hyperglycemia, anemia, hypokalemia, hyponatremia, metabolic alkalosis Psychological signs, infections, blurred vision, hypertension, diarrhea, nausea, vomiting, osteoporosis, flushing, sweating, slow wound healing, hyperglycemia Hypoxemia, hypotension, angina, arrhythmias nausea, vomiting, abdominal pain, jaundice, allergic reactions, thrombocytopenia Considerations Monitor oxygen saturations and BP; use with caution in presence of glaucoma, ulcer, hyperthyroidism Monitor ECG and BP; do not mix with sodium bicarbonate or alkaline solutions Monitor ECG and BP; avoid high infusion rates; do not mix in alkaline solutions or with sodium bicarbonate Sedation will last 10-15 minutes; monitor oxygen, BP and respiratory function; avoid use in septic shock Monitor BP, BUN, serum creatinine and electrolytes (especially potassium) Watch for signs of infection Monitor ECG, oxygen, and BP Drug Ipratropium Classification Anticholinergic bronchodilator Indications Asthma Dose/Administration 250-500 mcg every 20 minutes via nebulizer for 3 doses Lidocaine Antiarrhythmic VF, pulseless VT, wide complex tachycardia, RSI Magnesium sulfate Electrolyte bronchodilator Asthma; torsades de pointes; hypomagnesemia Methylprednisolone Corticosteroid Asthma, anaphylactic shock Tachyarrhythmias and VF: 1 mg/kg IV bolus followed by infusion of 2050 mcg/kg/ minute infusion RSI: 1-2 mg/kg IV Asthma: 25-50 mg/kg over 15-30 minutes IV Pulseless torsades: 25-50 mg/kg bolus VT with pulses and torsades: 25-50 mg/kg over 10-20 minutes 2 mg/kg to max of 60 mg IV as load dose; 0.5 mg/kg every 6 hours as maintenance dose Milrinone Inodilator Cardiogenic shock or postsurgery CHF Naloxone Opioid antagonist Narcotic reversal Nitroglycerine Vasodilator antihypertensive CHF, cardiogenic shock Nitroprusside Vasodilator antihypertensive Cardiogenic shock Hypertension 50 mcg/kg IV over 10-60 minutes as loading dose 0.25-0.75 mcg/kg/ minute IV infusion as maintenance dose For total reversal: 0.1 mg/kg IV bolus every 2 minutes to max dose of 2 mg Total reversal not needed: 1-5 mcg/kg IV (titrate to response required) Begin infusion at 0.25-0.5 mcg/kg/ minute and titrate every 15-20 minutes to max dose of 10 mcg/kg/minute 0.3-1 mcg/kg/minute for initial dose then titrate to max 8 mcg/kg/minute Possible Side effects Anxiety, dizziness, headache, dry mouth, blurred vision, cough, bronchospasm, palpitations, nausea, vomiting, rash CNS symptoms, tinnitus, blurred vision, hypotension, heart block, bradycardia, cardiac arrest, dyspnea, respiratory depression, nausea, vomiting, rash Confusion, sedation, weakness, respiratory depression, hypotension, heart block, bradycardia, cardiac arrest, nausea, vomiting, muscle cramps, flushing, sweating Depression, headache, weakness, hypertension, diarrhea, nausea, pancreatitis, ulcer, osteoporosis, hyperglycemia Headache, tremor, hypotension, ventricular arrhythmias, angina, nausea, vomiting, jaundice, hypokalemia Seizures, drowsiness, rapid respiratory rate, pulmonary edema, VF, VT, tachycardia, asystole, hypertension nausea, vomiting Considerations Monitor oxygen; if medication gets in eyes, will cause pupil dilation Headache, dizziness, hypoxemia, hypotension, cardiac arrest, tachycardia, flushing, pallor Monitor ECG and BP; watch for hypotension in hypovolemic children Seizures, dizziness, headache, agitation, hypotension, slow or fast heart rate, nausea, vomiting Monitor ECG and BP If used for prolonged times; thiocyanate and cyanide levels should be monitored. Monitor ECG and BP; May cause seizures; contraindicated for wide complex bradycardia Monitor ECG, oxygen and BP; rapid bolus may cause hypotension and bradycardia; calcium chloride can be used if needed to reverse hypermagnesemia Watch for rare anaphylaxis Monitor ECG, BP and platelet count; hypovolemia may make hypotension worse; use longer infusion time Monitor ECG, oxygen and BP; repeat doses often needed; establish assisted ventilation before administration; monitor newborn of addicted mother Drug Norepinephrine Classification Inotrope vasopressor Indications Hypotensive shock Dose/Administration 0.1-2 mcg/kg/m titrated to desired BP Possible Side effects Headache respiratory distress hypertension arrhythmias renal failure Procainamide Antiarrhythmic SVT, atrial flutter, VT with pulse 15 mg/kg as loading dose over 30-60 minutes Sodium bicarbonate Electrolyte to produce alkalinity Severe metabolic acidosis, hyperkalemia, tricyclic overdose Terbutaline Bronchodilator, beta adrenergic agonist Asthma, hyperkalemia Vasopressin Antidiuretic hormone analogue Cardiac arrest, septic shock 1 mEq/kg slow IV bolus to max of 50 mEq For overdose 12 mEq/kg bolus repeating until pH >7.45 follow with infusion of sodium bicarb solution to maintain alkalosis 0.1-10 mcg/kg/ minute IV Infusion 10 mcg/kg SQ every 10-15 minutes until IV is established 0.4-1 unit/kg bolus to max of 40 units Headache, dizziness, confusion, weakness, hypotension, prolonged QT interval, heart blocks and cardiac arrest, nausea, vomiting, diarrhea, rash, edema, anemia, neutropenia CNS symptoms, arrhythmia, hypotension, cardiac arrest, renal calculi, cyanosis, edema, metabolic alkalosis and other derangements, water retention CNS symptoms, palpitations, tachycardia, nausea, vomiting, arrhythmias, hypotension Fever, vertigo, dysrhythmias, hypertension, nausea, vomiting, abdominal cramps, urticaria TABLE 22: RESUSCITATION MEDICATIONS Considerations Monitor ECG and BP; IV infiltration may lead to tissue necrosis; should be administered via central line; do not mix in alkaline solution Monitor ECG (particularly QT interval) and BP; expert consultation should be called before administration Monitor ECG, oxygen and ABGs; ensure adequate ventilatory support to reduce the chance of carbon dioxide accumulation; not recommended in cardiac arrest Monitor ECG, oxygen and BP; use cautiously in children with hypokalemia Monitor BP and distal pulses; watch for signs of water intoxication; tissue necrosis may develop from IV extravasation UNIT THIRTEEN: RHYTHM RECOGNITION SINUS RHYTHM A sinus rhythm is regular with normal P, Q-R-S, T deflections and intervals. Rate = 60-100 at rest. SINUS BRADYCARDIA Sinus bradycardia is a sinus rhythm with a rate lower than normal for a child’s age. SINUS TACHYCARDIA Sinus tachycardia is a sinus rhythm with a rate greater than normal for a child’s age. Note that the p waves are still present. SINUS RHYTHM WITH 1ST DEGREE HEART BLOCK Sinus rhythm with 1st degree heart block is a sinus rhythm with a prolonged PR interval >0.20 seconds due to a delay in transmission from the atria to the ventricles. 2ND DEGREE AV HEART BLOCK A 2nd degree AV block is usually classified as Mobitz Type I (Wenckebach) or Mobitz Type II. A Mobitz Type I heart block is characterized by progressive lengthening of the PR interval until a QRS complex is dropped. A Mobitz Type II heart block is characterized by an intermittent dropped QRS that is not in a Mobitz Type I pattern. The Mobitz Type II block must be evaluated since it can rapidly progress to a complete heart block. 3RD DEGREE HEART BLOCK A 3rd degree heart block (sometimes called a complete heart block) is a rhythm in which there is no relationship between the P and QRS waves. In this case, the P to P intervals are regular but have no relationship to the QRS complexes on the ECG. SUPRAVENTRICULAR TACHYCARDIA (SVT) Supraventricular tachycardia (SVT) is an extremely fast atrial rhythm with narrow QRS complexes when the impulse originates above the bundle branches (above the ventricles). ATRIAL FIBRILLATION (AF) Atrial fibrillation (AF) is a very common arrhythmia. This rhythm is characterized by no waves before the QRS complex and a very irregular heart rate. ATRIAL FLUTTER Atrial flutter is a supraventricular arrhythmia that is characterized by a “saw-toothed” flutter appearance on the ECG that represent multiple P waves for each QRS complex. ASYSTOLE Asystole is also commonly known as a "flat line" where there is no electrical activity seen on the cardiac monitor. Not responsive to electrical defibrillation. PULSELESS ELECTRICAL ACTIVITY Can be virtually any organized ECG rhythm in a patient who is unresponsive and lacks a palpable pulse. Thus, one cannot learn a PEA rhythm. It should not be confused, however, with specific pulseless scenarios listed previously. VENTRICULAR TACHYCARDIA (VT) Ventricular tachycardia (VT) is characterized by bizarre widened QRS complexes, no P waves and a heart rate that usually exceeds 100 beats per minute. VT may quickly degenerate to Ventricular fibrillation and death. VT may be responsive to electrical defibrillation. VENTRICULAR FIBRILLATION (VF) Ventricular fibrillation (VF) is characterized by a chaotic wave pattern and no pulse. VF may be responsive to electrical defibrillation.