PALS CERTIFICATION COURSE QUESTIONS WITH CORRECT ANSWERS GRADED TO PASS

Which topics are included in the PALS course ? - PALS includes the following: (1) Overview of assessment (2) Recognition and management of respiratory distress and failure (3) Recognition and management of shock (4) Recognition and management of cardiac arrhythmias (5) Recognition and management of cardiac arrest (6) Postresuscitation management of patients with pulmonary and cardiac arrest (7) Review of pharmacology What should be the primary focus of the clinician on prevention of cardiopulmonary failure - The clinician should primarily focus on prevention of cardiopulmonary failure through early recognition and management of respiratory distress, respiratory failure, and shock that can lead to cardiac arrest from hypoxia, acidosis, and ischemia. What is the main cause of cardiac arrests in children? - In infants and children, most cardiac arrests result from progressive respiratory failure and/or shock, thus one of the aims of PALS rapid assessment model is to prevent progression to cardiac arrest. What is the pediatric assessment triangle? - Brief visual and auditory observation of child's overall (1) appearance, (2) work of breathing, (3) circulation What are the components of the primary assessment? What signs should the clinician look for? - The clinician should in rapid sequence assess: (1) Airway (patent, patent with maneuvers/adjuncts, partially or completely obstructed) (2) Breathing (respiratory rate, effort, tidal volume, lung sounds, pulse oximetry) (3) Circulation (skin color and temperature, heart rate and rhythm, blood pressure, peripheral and central pulses, capillary refill time) (4) Disability: (a)AVPU pediatric response scale: Alert, Voice, Pain, Unresponsive; (b) Pupillary response to light (c) Presence of hypoglycemia (rapid bedside glucose or response to empiric administration of dextrose) (d) Glasgow Coma Scale What are the components of the secondary assessment? For what should the clinician look for during the secondary assessment? - This portion of the evaluation includes a thorough head to toe physical examination, as well as a focused medical history that consists of the "SAMPLE" history: (S) Signs and Symptoms (A) Allergies (M) Medications (P) Past medical history (L) Last meal (E) Events leading to current illness What are the components of the tertiary assessment? - Injury and infection are common causes of life-threatening illness in children. Thus, for this stage, ancillary studies are frequently directed towards identifying the extent of trauma or an infectious focus. There are many causes of acute respiratory compromise in children. The clinician should strive to categorize respiratory distress or failure into one or more of the following: - (1) Upper airway obstruction (eg, croup, epiglottitis) (2) Lower airway obstruction (eg, bronchiolitis, status asthmaticus) (3) Lung tissue (parenchymal) disease (eg, bronchopneumonia) (4) Disordered control of breathing (eg, seizure, coma, muscle weakness) What is the focus of initial management - The main focus of initial management is to support airway, breathing, and circulation How can the clinician support the airway? - (1) Provide 100 percent inspired oxygen (2) Allow child to assume position of comfort or manually open airway (3) Clear airway (suction) (4) Insert an airway adjunct if consciousness is impaired (eg, nasopharyngeal airway or, if gag reflex absent, oropharyngeal airway) How can the clinician support breathing? - For supporting breathing, the clinician should: (1) Assist ventilation manually in patients not responding to basic airway maneuvers or with inadequate or ineffective respiratory effort (2) Monitor oxygenation by pulse oximetry (3) Monitor ventilation by end-tidal carbon dioxide (EtCO2) if available (4) Administer medications as needed (eg, albuterol, epinephrine) T of F: in preparation for intubation, the patient should receive 100 percent oxygen? - True! In preparation for intubation, the patient should receive 100 percent oxygen via a high-concentration mask, or if indicated, positive pressure ventilation with a bag-valve-mask to preoxygenate and improve ventilation. What should be done if the patient cannot maintain their airway, oxygenation, or ventilatory requirements? - In such cases, the patient should undergo placement of an artificial airway, usually via endotracheal intubation and less commonly with a laryngeal mask airway or alternative device. T or F some patients with upper airway obstruction and/or respiratory failure may respond to noninvasive ventilation if airway reflexes are preserved. - True! Certain populations of patients with upper airway obstruction and/or respiratory failure may respond to noninvasive ventilation (CPAP or BiPAP) if airway reflexes are preserved. When a patient appears to be in shock, what should be the goal of the next action taken? - The goal should be to recognize and categorize the type of shock in order to prioritize treatment options Why is the early management of shock so critical for patient survival? - Early treatment of shock may prevent the progression to cardiopulmonary failure In children, does shock present with low or high cardiac output? - Shock in children usually presents with low cardiac output, but some patients may have high cardiac output, such as with sepsis or severe anemia. How can shock be classified? - Shock severity is usually classified based on its effect on systolic blood pressure at presentation (i.e. compensated vs. decompensated) or based on its pathophysiology (i.e hypovolemic; distributive; cardiogenic; obstructive shock) What is the meaning of "compensated" shock, when does it occur? - Compensated shock occurs when compensatory mechanisms (including tachycardia, increased systemic vascular resistance, increased inotropy, and increased venous tone) maintain a systolic blood pressure within a normal range What is the meaning of hypovolemic "decompensated" shock? When does it occur? - Hypotensive shock occurs when compensatory mechanisms fail to maintain systolic blood pressure. Define hypotension in term infants? - In term infants 0 to 1 month of age, systolic pressure 60 mmHg Define hypotension in infants 1 to 12 months of age? - For infants 1 to 12 months of age, hypotension is defined by systolic pressure 70 mmHg Define hypotension in infants 1 to 10 years of age? - In children 1 to 10 years of age, hypotension is defined as: Systolic pressure (5th percentile) (70 mmHg + [child's age in years x 2]) Define hypotension in children over 10 years of age? - In children over 10 years of age, systolic blood pressure 90 mmHg What is key to know about hypotensive "decompensated" shock in contrast to compensated shock? - Hypotensive shock may rapidly progress to cardiopulmonary failure. How can shock be classified according to its pathophysiology? - Shock can be classified as being hypotensive, distributive; cardiogenic or obstructive What is hypovolemic shock? - Shock that is characterized by inadequate circulating blood volume (from fluid loss). Common causes include diarrhea, hemorrhage (internal and external), vomiting, inadequate fluid intake, osmotic diuresis (eg, diabetic ketoacidosis), third-space losses, and burns. What is distributive shock? - A form of shock arising from inappropriately distributed blood volume typically associated with decreased systemic vascular resistance. Common causes include septic shock, anaphylactic shock, and neurogenic shock (eg, head injury, spinal injury). What is cardiogenic shock? - A form of shock arising from impaired heart contractility. Common causes include congenital heart disease, myocarditis, cardiomyopathy, arrhythmias, sepsis, poisoning or drug toxicity, and myocardial injury (trauma). What is obstructive shock? - A form of shock that arises from obstructed blood flow to the heart or great vessels. Common causes include cardiac tamponade, tension pneumothorax, ductal-dependent congenital heart lesions, and massive pulmonary embolism. Can patients suffer from more than one type of shock? - Yes, any given patient may suffer from more than one type of shock. For example, a child in septic shock may develop hypovolemia during the prodrome phase, distributive shock during the early phase of sepsis, and cardiogenic shock later in the course. What is the definition of cardiopulmonary failure? - Respiratory failure + hypotensive shock Which are the "airway" physical findings preceding cardiopulmonary failure that a clinician should look for? - Stridor, stertor, drooling, and/or severe retractions Which are the "breathing" physical findings preceding cardiopulmonary failure that a clinician should look for? - Bradypnea, irregular, ineffective respiration, gasping, and/or cyanosis • What are the "circulation" physical findings preceding cardiopulmonary failure that a clinician should look for? - Bradycardia, capillary refill 5 seconds, weak central pulses, no peripheral pulses, hypotension, cool extremities, and/or mottled/cyanotic skin What are the "disability" physical findings preceding cardiopulmonary failure that a calinician should look for? - Signs suggesting the presence of diminished level of consciousness What interventions should be performed in all patients with cardiopulmonary failure? - Positive pressure ventilations with 100 percent inspired oxygen, chest compressions for heart rate 60 beats per minute in patients with poor perfusion, and administration of intravenous fluids and medications tailored to treat the underlying cause are indicated How is the heart rate status classified in children? - In children, the heart rate is classified as bradycardia, tachycardia, and pulseless arrest. Why is being able to detect the presence of a bradyarrythmia in children so important? What is usually the primary cause? - Bradyarrhythmias are common pre-arrest rhythms in children and are often due to hypoxia. In general terms, in children, what is the definition of bradycardia? - A heart rate that is slow compared with normal heart rates for the patient's age (can be classified into primary or secondary based on etiology) What is a bradyarrthymia? - Slow abnormal rhythm originating in the atria or the ventricles. What is primary bradycardia? - Primary bradycardia is the result of congenital and acquired heart conditions that directly slow the spontaneous depolarization rate of the heart's pacemaker or slow conduction through the heart's conduction system. What is secondary bradycardia? - Secondary bradycardia is the result of conditions that alter the normal function of the heart, including hypoxia, acidosis, hypotension, hypothermia, and drug effects. What are the ECG findings of bradycardia - (1) Slow heart rate relative to normal rates (table 4) (2) P waves that may or may not be visible (3) QRS complex that is narrow (electrical conduction arising from the atrium or high nodal area) or wide (electrical conduction from low nodal or ventricular region) (4) P wave and QRS complex may be unrelated (ie, atrioventricular dissociation) or have an abnormally long period between them (atrioventricular block) What are the subtypes of bradycardia? - (1) Sinus bradycardia (2) AV block (first, second, third degree) In general terms what is the definition of tachycardia in children? - A heart rate that is too fast for the child's age, level of activity, and clinical condition What are the usual causes of sinus tachycardia? - Hypovolemia, fever, physiologic response to stress or fear, or drug effect (such as with beta agonists). What are tachyarrhythmias? - Fast abnormal rhythms originating in the atria or the ventricles. How can tachyarrhythmias present in children? - In children tachyarrythmia symptoms may include palpitations, lightheadedness, dizziness, fatigue and syncope How can prolonged tachycardia present in infants? - In infants, prolonged tachycardia may cause poor feeding, tachypnea, and irritability with signs of heart failure. What factors determine the management of tachycardia? - Treatment priorities in managing tachycardias rely on whether hemodynamic instability is present and differentiating between tachycardia with narrow QRS complex and wide QRS complex tachycardias What are the most common causes of sinus tachycardia? - Hypoxia, hypovolemia, fever, metabolic stress, injury, pain, anxiety, toxins/poisons/drugs, and anemia. What are other less common causes of sinus tachycardia in children? - Cardiac tamponade, tension pneumothorax, and thromboembolism. Frequent ECG findings of tachycardia in children include - (1) Heart rate usually 220/min in infants, 180/min in children and exhibit beat to beat variability in rate. (2) P waves are present with normal appearance. (3) Constant PR intervals and exhibit a normal duration for age. (4) Variable R-R intervals. (5) Narrow QRS complexes. What is pulseless arrest? - Pulseless arrest refers to the cessation of blood circulation caused by absent or ineffective cardiac mechanical activity What is the most common cause of pediatric cardiac arrest? - Most pediatric cardiac arrests are hypoxic/asphyxial arrests that result from a progression of respiratory distress, respiratory failure, or shock rather than from primary cardiac arrhythmias ("sudden cardiac arrest"). What is the most frequent presentation of children with pulseless arrest? - Children with pulseless arrest usually appear apneic or display a few agonal gasps. They have no palpable pulses and are unresponsive. How can we classify pulseless arrest rhythms? - (1) Shockable rhythms and (2) Asystole and Pulseless electrical activity Which are the "shockable" rhythms? - (1) Shockable rhythms: (a) V. Fib (b)Pulseless V. Tach; and (c) TDP What is asystole? What is the most common cause in children? - Patients with asystole have cardiac standstill with no discernible electrical activity. The most common cause in children is respiratory failure progressing to critical hypoxemia, bradycardia, and then cardiac standstill. Underlying conditions include airway obstruction, pneumonia, submersion, hypothermia, sepsis, and poisoning (eg, carbon monoxide poisoning, sedative-hypnotics) leading to hypoxia and acidosis. What is Pulseless electrical activity (PEA)? - PEA consists of any organized electrical activity observed on ECG in a patient with no central palpable pulse. PEA 6 H's - Hypovolemia; hypoxia, hydrogen ions, hypo/hyperkalemia, hypoglycemia and, hypothermia eat Bananas when Dry, Acidic, Hungry or Cold PEA 5 T's - Toxins, Tamponade, Tension pneumothorax, Thrombosis (coronary or pulmonary), Trauma She uses Toxic Tampons while playing the Trombone under Traumatic Tension BRADYCARDIA ALGORITHM: What is the focus of bradycardia management in children? - (1) Reestablishing or optimizing oxygenation and ventilation (2) Supporting circulation with chest compressions for patients with poor perfusion and a heart rate 60 beats per minute (3) Using medications (ie, epinephrine or atropine) to increase heart rate and cardiac output What if the above three measures fail? - If these measures fail, transcutaneous pacing can be attempted; however, the same factors that are producing refractory bradycardia (eg, hypoxia, hypothermia, electrolyte disturbance, or drug overdose) may prevent effective electrical capture. TACHYCARDIA ALGORITHM: What is the focus of tachycardia management in children? - The management of sinus tachycardia focuses on treatment of the underlying physiologic derangement and is largely supportive.