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PALS - WRITTEN TEST AND CASE STUDY REVIEW
MATERIAL QUESTIONS & ANSWERS
1. CPR Sequence: C-A-B
Circulation-Airway-Breathing
2. Algorithm: Pediatric Septic Shock
First hour...: Oxygen & support ventilation Establish IV, draw labs (glucose, blood cultures) Begin resuscitation Push repeated 20 mL/kg isotonic crystalloid (3-4) unless rales, resp distress, hepatomegaly Correct hypo-glycemia/calcemia Admin 1st dose antibiotics STAT STAT vasopressor drip/stress-dose hydrocortisone Establish 2nd IV
3. Algorithm: Pediatric Septic Shock
Fluid Responsive?: Yes - ICU No - Vasoactive drug & titrate for normotension Normo: begin dopamine Hypo/warm: norepi Hypo/cold: epi
4. Adenosine (slows HR): SVT
0.1 mg/kg - dose 1
0.2 mg/kg - dose 2
max = 6 mg RAPID push
5. Amiodarone (antiarrythmic): VF/VT (pulseless)
5 mg/kg Bolus max = 300 mg SVT, VT (with pulses) 5 mg/kg over 20-60 mins max = 300 mg
H's (G,K,T,V,X,DRO): 1. Hypo-Glycemia
2. Hypo/hyper-Kalemia
3. Hypo-Thermia
4. Hypo-Volemia
5. Hypo-Xia
6. HyDROgen ion (acidosis)
- Reversible Causes of Pediatric Cardiac Arrest (H&T's) 5 T's (A,E,HC,HP,O): 1. Tamponade, cardiac
2. Tension pneumothorax
3. Thrombosis, coronary
4. Thrombosis, pulmonary
5. Toxins
12. Rescue Breaths: 1 every 6-8 secs
8-10 per min
13. CBC
(Assessment part 1): Consciousness Breathing Color
14. ABCDE
(Assessment part 2): Airway Breathing Circulation Disability Exposure
15. SAMPLE (Assessment
part 3): S/Sx Allergies Medications Past medical hx Last meal/drink Events leading to situation
16. DOPE
(Pediatric with airway, deteriorates rapidly): Displacement Obstruction Pneumothorax Equipment
19. Algorithm: Pediatric Tachycardia, Pulse Present, Poor Perfusion: Airway,
assess with breathing if needed, oxygen Cardiac monitor, BP, oximetry, IV access ECG, evaluate QRS --Wide: Possible VT If Cardiopulmonary Compromise: Sync Cardioversion If not: Adenosine, Amiodarone --Narrow: If Sinus Tachy: search for and treat cause If SVT: Vagal, Adenosine, Sync Cardioversion
20. Core Case Action Order
(A,I,I): Assess Identify Intervene
21. To end the case...: Therapeutic end
Compensated or uncompensated Prepare to intubate Call pediatrics, other specialist needed Begin post resuscitation care
22. UAO: Presentation, Causes, TX: Stridor on inspiration, High pitched inspira-
tion (Anaphylaxis, Croup, Foreign Body) Humid Oxygen, Neb Epi, Removal
23. LAO: Presentation, Causes, TX: Wheezing on expiration
(Asthma, Bronchiolitis) Neb Albuterol, SQ Epi, Mag Sulf, Steroids
24. Lung Tissue Disease: Presentation, Causes, TX: Grunting, stiff lungs, in-
creased breathing effort (I, E), tachypnea, crackles (Pneumonia) Antibiotics, Albuterol
25. Disordered Breathing: Presentation, Causes, TX: Irreg breathing pattern
(Drug OD, Injury) Antidote, DOPE, MASK AND BAG
26. For Bradycardia: O
CPR
Epi
33. What should I do for a pneumothorax?: Needle decompression
Chest tube placement
34. Shockable Rhythms: Pulseless VT
VF (v fib)
35. Not Shockable Rhythms: PEA
Asystole
36. Medication Sequence (Epi/Ami): Epi 0.01 mg/kg every 3-5 min
Amiodarone 5 mg/kg bolus, can repeat to a total of 15 mg/kg per 24 hours
37. For SVT with pulse: Vagal/Adenosine/Cardioversion
38. For VT with pulse: Amiodarone/Cardioversion
39. For Torsades de Pointes: Magnesium
40. Cardioversion Doses: 0.5-2 j/kg
1st time = 0.5 j/kg 2nd time = 1-2 j/kg
41. Core Case Resp 1: UAO (Anaphylaxis): Open airway
Admin O2 100% non-rebreather, re-assess AED, Vitals (cardiac rhythm = sinus tachy) S/sx of UAO, resp distress TX: Epi IM, Steroids, CPAP Vascular access Prepare for intubation
42. Core Case Resp 2: LAO (Bronchiolitis or Asthma): Admin O2 100% non-re-
breather after finishing neb tx, re-assess AED, Vitals (cardiac rhythm = sinus tachy) S/sx of LAO, resp distress Suction nose TX: Neb albuterol, Non-invasive pos press vent (NIPPV), Steroids Vascular access, labs, ABGs, chest X-ray Prep for bag-mask vent, intubation
43. Core Case Resp 3: Lung Tissue Disease (Pneumonia or Aspiration): Ad- min
O2 100% non-rebreather after finishing neb tx, re-assess, titrate O2 to 94-99% AED, Vitals (cardiac rhythm = sinus tachy) S/sx of LTD, resp failure Suction nasopharynx Vascular access, labs, ABGs, chest x-ray
Vascular access, labs, ABGs, chest x-ray Admin IVFs 20 mL/kg bolus, assess Repeat bolus as needed for BP, HR, pulses Admin BP help drug if needed
46. Core Case Shock 2: Obstructive (Tension Pneumothorax): DOPE
Begin manual ventilation, re-assess AED, Vitals (cardiac rhythm = sinus tachy) S/sx of cardiopulmonary failure and shock, compensated IMMEDIATE TX: Needle thoracostomy (R, 2nd intercostal, midclav line), chest tube Vascular access, labs, ABGs, chest x-ray Fluid bolus for BP
47. Core Case Shock 3: Distributive (Sepsis): Continue O
AED, Vitals (cardiac rhythm = sinus tachy) Verify ET placement S/sx septic shock, uncompensated Verify patency of PAC, insert secondary PIV, labs, ABGs, blood cultures TX: Admin fluid bolus 20 mL/kg, Repeat fluid bolus 20 mL/kg for continued shock, Admin antibiotics, Admin vasoactive drug if needed for continued shock Transfer to PICU
48. Core Case Shock 4: Cardiogenic (Myocarditis): Admin high-flow O2, re-as-
sess AED, Vitals (cardiac rhythm = sinus tachy) S/sx resp distress, compensated cardiac shock Vascular access, labs, ABGs, chest x-ray SLOW fluid bolus 5-10 mL/kg over 10-20 mins
Inotropic/vasoactive drug if shock continues May need CPAP/PEEP to reduce work of breathing on heart Transfer to PICU
49. Core Case Cardiac 1: SVT with pulses present: Admin high-flow O2, re-as-
sess AED, Vitals (cardiac rhythm = SVT with adequate perfusion) S/sx resp distress, SVT, adequate perfusion Vascular access, labs, ABGs, chest x-ray TX: Vagal (ice on face), admin Adenosine (0.1 mg/kg) plus second dose (0. mg/kg) if needed, sync cardioversion (0.5-1 j/kg) if needed Monitor for heart failure
50. Core Case Cardiac 2: Bradycardia: 100% O2, re-assess
CPR for 2 mins, re-assess
53. You are caring for a child who was resuscitated after a drowning event.
The child is intubated and ventilated with 100% oxygen with equal breath sounds and exhaled CO2 detected. The heart rate is slow and the monitor shows sinus bradycardia. The skin is cool, mottled, and moist; distal pulses are not palpable and the central pulses are weak. Intravenous access has been established. The core temperature is 37.3oC. Based on the PALS brady- cardia algorithm, which of the following should be provided first?: *Epineph- rine IV Transcutaneous pacing Atropine IV Dobutamine IV infusion
54. You are caring for a 5-year-old patient with supraventricular tachycardia
(heart rate = 220/min). The child is lethargic. The skin is pale and cool with
delayed capillary refill. Distal pulses are not palpable. Which of the following would be the best treatment to provide without delay?: Place cold packs on the distal upper and lower extremities Ask the child to blow through a small straw Exert light pressure on the eyes bilaterally *Provide synchronized cardioversion at 0.5 to 1 J/kg
55. You are initiating treatment for a child with septic shock and hypotension.
While administering high-flow oxygen you determine that the child's respi- rations are adequate and SpO2 is 100%. You have just established vascular access and obtained blood samples. Which of the following is the next most appropriate therapy to support systemic perfusion?: Administer repeated fluid boluses of isotonic colloid *Administer repeated fluid boluses of isotonic crystalloid Begin immediate dopamine infusion Begin immediate dobutamine infusion
56. You are treating an 8-year-old with ventricular tachycardia with pulses
and adequate perfusion. You attempted synchronized cardioversion without success. While seeking expert consultation, it would be most appropriate to:: Administer a loading dose of milrinone *Consider possible metabolic and toxicologic causes Initiate overdrive pacing transcutaneously Deliver an unsynchronized shock
57. You are caring for a 2-year-old unconscious patient who is intubated and
receiving mechanical ventilation. The child's heart rate suddenly drops to 40/min and his color becomes mottled.You should respond to these changes
Administer magnesium sulfate IV Intubate and ventilate
59. Which of the following is likely to be the most helpful technique to iden-
tify potentially reversible metabolic and toxic causes during the attempted resuscitation of a young child in cardiac arrest?: Obtaining a urine sample for toxicology screen Obtaining chest and abdominal radiographs *Soliciting a history from the caregiver or family Obtaining a venous blood gas
60. You are caring for a patient who developed a tension pneumothorax after
several hours of positive-pressure ventilation. Which of the following would be the most appropriate site for needle decompression?: *Over the third rib at the midclavicular line (ie, second intercostal space) Under the eighth rib at the midaxillary line Over the fifth rib at the sternal border Under the sixth rib at the midclavicular line
61. You attempted synchronized cardioversion for an infant with supraven-
tricular tachycardia (SVT) and poor perfusion. The SVT persists after the initial 1 J/kg shock. Which of the following should you attempt now?: *Syn- chronized cardioversion at a dose of 2 J/kg Synchronized cardioversion at a dose of 4 J/kg Unsynchronized cardioversion at a dose of 2 J/kg Unsynchronized cardioversion at a dose of 4 J/kg
62. You are treating a 5-month-old with a 2-day history of vomiting and
diarrhea. The patient is listless. The respiratory rate is 52/min and unlabored. The heart rate is 170/min and pulses are present but weak. Capillary refill is delayed. You are administering high-flow oxygen, and intravenous access is in place. At this point the most important therapy is to:: Administer an epinephrine bolus Begin bag-mask ventilation *Provide a rapid 20 ml/kg isotonic crystalloid fluid bolus Administer a bolus of 0.5 g/kg of dextrose
63. Which of the following groups of clinical findings would be most consis-
tent with categorizing a patient with compensated shock?: *Normal systolic blood pressure, decreased level of consciousness, cool extremities with delayed capillary refill, and faint or nonpalpable distal pulses Decreased level of consciousness, extensor posturing in response to pain, hyper- tension, and apnea
