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You may have seen this already…funny but sadly all too true (sorry about the language)
Great page here
Our remake of an old mnemonic (Not performed in this order)
MOIST N DAMP
Morphine Oxygen Intubation Sit-up Twelve lead Nitrates Dangle legs Ativan (lorazepam) Monitor Q 3-5 Pulmonary Congestion (CPAP)
Your comments are welcome!
Updated in this post – See here http://www.rhmedicclass.com/index.php/12-lead-ekg-in-acs/
(From Tim Phalen’s lecture)
March 29, 2009, Dr Cooper Pediatric Circulatory Emergencies PAT Is he in shock? Volume or Cardiogenic, assess vitals, mentation, etc, (BP last indicator) Peds, who present with dysrhythmias, present like they are in shock. They won’t tell you that they have palpitations, etc, do not presume that if a child is in shock you always give fluid…must rule out cardiogenic causes. Shock- failure of circulation to meet the metabolic demands of the tissues (energy) Hypoperfusion – inability of circulation to deliver blood to tissues, results in hypoxia Hypotension – not enough pressure to deliver blood to core organs Compensated shock – inability to meet needs of peripheral tissues Decompensated shock – inability to meet metabolic demands of core organs Cardiopulmonary failure – moribund state resulting in from total respiratory and/or circulatory collapse Preload – tension in ventricle wall at end diastole – corresponds with RAP/LAP (potential amount of force that can be generated by the ventricle based upon the amount of stretching by the muscle fibers – determined by end diastolic volume Afterload- tension in ventricular wall at end systole (covaries with PVR peripheral vascular resistance) (pressure head against which the heart has to squeeze) Contractility – force developed by the ventricular wall during systole Pediatric Hemodynamic changes Blood Loss Heart rate immediately increases and only drops at around 45% loss BP maintains until about 30% loss and then drops severely (soft arteries can constrict much better than adults) CO starts dropping immediately and also drops severely of at 30% loss Shock – A Hydraulic Solution Pump Failure (cardiogenic) Electrical dysrhythmias (defib cardiovert) Mechanical – cardiomyopathy (inotrope, vasopressor) Pipe Failure Distributive –(anaphylaxis, neurogenic – decreased vascular tone) (volume resuscitation MAST, Epi, contain the spread) Obstructive (Pneumothorax, Tamponade) (decompress tension pneumo) Prime Failure Hypovolmic dehydration, hemorrhage, GI Dissociative –CO poisoning (o2 specific antidote) Kids have proportionally larger blood volume but absolute volume is smaller Softer more compliant vessels – capable of intense vasoconstriction Smaller heart ventricles less compliant – less stretch per Starling’s Law – cannot really increase contractility – more dependent on rate to increase CO Pulse higher than 150 – (5x age in years) is tachycardia, BP <70 +2 x age is lowest BP Hypovolemic shock most common is peds, then septic, then cardiogenic Hypovolemic – mostly dehydration, then hemorrhagic, GI Septic –more common endotoxin vs extotoxin – (results in inability for cells to extract o2) Cardiogenic – usually electrical (SVT VFIB) Kids don’t usually get clammy unless cardiogenic, mottled in Hypovolemic Simultaneous palpation of proximal and distal pulses (eg. femoral vs Pedal) big diff indicates compensated shock Fluid Doses 20ml/kg of NS or LR – does it help? See study…Bottom line – maybe not be effective in short transport times. Focus on maintaining airway. 2 attempts or 90 sec, AC or saphenous at ankle. Then try IO. IO must be injected under pressure, gravity drip will not work Pediatric Trauma Immature anatomy Different mechanisms Long term sequela Age specific equipment Larger heads, softer skulls – will fall head first, will decompensate quickly due to head trauma, soft tissue obstruction due to decrease tone leading to hypoxemia, ICP, cerebral edema, Proportionally smaller torso yet larger organs Impact – smaller total body mass More often hit by cars than unrestrained passengers (abdomen and L spine from improper seat belt position) Waddell’s Triad 1. Femur fracture2. Intra-abdominal or intrathoracic injury3. Head injury Falls from height Fall from bike – head – unhelmeted bike riders 2nd leading cause of head injury death in US kids (#1 MVA) Normoventilate(30) for resp failure, decomp shock, traumatic coma Hyperventilate (35)– single dilated pupil, fixed dilated, apneic spells SCIWORA Syndrome: (Spinal Cord Injury w/o Radiologic Abnormality) Head Trauma – …. Neck Trauma …… Chest Trauma – soft bone structure – Abdominal Trauma – upper organs are lower, lower organs are higher (liver not well protected), thinner walled, abdominal viscera less protected MSK Trauma, lose less blood, growth plate involvement, incomplete fractures, vascular injury common ABCDEF – Airway Breathing Circulation Disability (pupils and GCS), E exposure, (but keep warm) F (focused physical on stable patient) El Physiocontrol Lifepak 12, así como muchos otros tipos de equipos médicos usados se pueden comprar en línea por mucho más barato que comprar nuevos.
March 29, 2009, Dr Cooper
Pediatric Circulatory Emergencies
PAT
Is he in shock? Volume or Cardiogenic, assess vitals, mentation, etc, (BP last indicator)
Peds, who present with dysrhythmias, present like they are in shock. They won’t tell you that they have palpitations, etc, do not presume that if a child is in shock you always give fluid…must rule out cardiogenic causes.
Shock- failure of circulation to meet the metabolic demands of the tissues (energy)
Preload – tension in ventricle wall at end diastole – corresponds with RAP/LAP (potential amount of force that can be generated by the ventricle based upon the amount of stretching by the muscle fibers – determined by end diastolic volume
Afterload- tension in ventricular wall at end systole (covaries with PVR peripheral vascular resistance) (pressure head against which the heart has to squeeze)
Contractility – force developed by the ventricular wall during systole
Pediatric Hemodynamic changes
Shock – A Hydraulic Solution
Pump Failure (cardiogenic)
Pipe Failure
Prime Failure
Kids have proportionally larger blood volume but absolute volume is smaller
Softer more compliant vessels – capable of intense vasoconstriction
Smaller heart ventricles less compliant – less stretch per Starling’s Law – cannot really increase contractility – more dependent on rate to increase CO
Pulse higher than 150 – (5x age in years) is tachycardia, BP <70 +2 x age is lowest BP
Hypovolemic shock most common is peds, then septic, then cardiogenic
Hypovolemic – mostly dehydration, then hemorrhagic, GI
Septic –more common endotoxin vs extotoxin – (results in inability for cells to extract o2)
Cardiogenic – usually electrical (SVT VFIB)
Kids don’t usually get clammy unless cardiogenic, mottled in Hypovolemic
Simultaneous palpation of proximal and distal pulses (eg. femoral vs Pedal) big diff indicates compensated shock
Fluid Doses 20ml/kg of NS or LR – does it help? See study…Bottom line – maybe not be effective in short transport times. Focus on maintaining airway.
2 attempts or 90 sec, AC or saphenous at ankle. Then try IO. IO must be injected under pressure, gravity drip will not work
Pediatric Trauma
Normoventilate(30) for resp failure, decomp shock, traumatic coma
Hyperventilate (35)– single dilated pupil, fixed dilated, apneic spells
SCIWORA Syndrome: (Spinal Cord Injury w/o Radiologic Abnormality)
Head Trauma – ….
Neck Trauma ……
Chest Trauma – soft bone structure –
Abdominal Trauma – upper organs are lower, lower organs are higher (liver not well protected), thinner walled, abdominal viscera less protected
MSK Trauma, lose less blood, growth plate involvement, incomplete fractures, vascular injury common
ABCDEF – Airway Breathing Circulation Disability (pupils and GCS), E exposure, (but keep warm) F (focused physical on stable patient)
El Physiocontrol Lifepak 12, así como muchos otros tipos de equipos médicos usados se pueden comprar en línea por mucho más barato que comprar nuevos.
3/25/09 Dr Cooper Pediatric Airway Management Bag and drag, get control of lungs and heart will follow – get control of airway and move Start with PAT – Appearance – example, seesaw respirations – upper airway obstruction. Snoring; soft tissue, gurgling; secretions, stridor; croup FBAO, epiglottis. Hoarseness; laryngeal trauma Mandibular block, needs to be moved forward– use OPA or Jaw thrust Larynx, higher and more forward in the throat, airway is funnel shaped, particulate matter can get wedged below cords but above cricoid ring. Size of Infant airway= drinking straw. Adult=Garden hose Management Non- rebreather Pulse Oximeter of 90-95%, GCS 14, AVPU of V , compensated shcok – SBP 70-90 + 2x age BVM, Spo2 <90%, SBP <70 + 2x age (decompensated shock), Traumatic Coma, AVPU P or U, GCS 8 or less – disable pop-off valve, watch the chest just rise, Size the mask, completely cover nose and mouth, face mask cannot press against eye, causes profound vagal response in baby EC Clamp OPA – teeth to angle of mandible NPA – nares to tip of earlobe Positioning Medical – Sniffing plus Trauma – Neutral airway position Squeeze – relax, 20 times per minute Do not hyperextend neck in either case Infant – pad entire body (or use a backboard with a hole for head). Head is too high and padding aligns plane of face to be parallel with stretcher. Disproportion ends around 8 years of age. Older child may need a shoulder roll. Steeles rule of three, spinal cord is only one third of spinal canal. Hard to add further injury as long as you keep some degree of caution, a little movement won’t injure, May have to remove C collar in order to intubate Technique for high pressure ventilation- Sniff plus, jaw thrust up into mask, two thumbs on side of mask ETT – respiratory failure decompensated shock, traumatic coma Miller Blade to lift floppy epiglottis (less than 8 years) Uncuffed tube – allows for larger diameter tube, and cuff pressure may cause pressure on tracheal mucosa Pass tube just below where black mark disappears 4 Ps Prepare – suction o2 scope and tube Position patent and operator – eye level of airway – Preoxygenate Perform intubation _ don’t persist longer than you can hold your own breath Smaller mouth, developing dentition, etc avoid levering, suction avoid prying RSI where used – GCS 5-9 Confirm placement primarily and secondary (wave form capnography) Neonatal Intubation – very delicate maneuver DOPE for common ETT problems Displacement – re-auscultate Obstruction – suction Pneumothorax – absent sounds on one side Equipment failure – Don’t screw around, bad tube – remove Nasogastric Intubation Straight back into nares will follow curve of throat, measure from nares, around ears down to xyphoid process ETT vs BVM – No significant mortality differences, true for medical and trauma patients. BVM the single most important skill to master (TUBE TOOLS – CD Rom) The Physiocontrol Lifepak 12 as well as many other types of used medical equipment can be purchased online for much cheaper than buying new. ___________________ Respiratory Problems Respiratory distress – increased effort but enough to compensate for tissue hypoxia – due to mild hypoxemia (days) Respiratory failure increased or decreased effort not enough to compensate for tissue hypoxia – due to sever hypoxemia (hours) Respiratory arrest – if uncorrected leads to cardiopulmonary arrest (2 minutes) Upper airway obstruction – extrathoracic Lower airway disease – intrathoracic Grunting = PEEPing Peripheral mottling – circulatory problem; central mottling- respiratory problem Sniffing and tripod – severe distress, head bobbing or grunting – respiratory failure Oxyhemoglobin dissociation curve – kid won’t turn blue until o2 is dangerously low Pediatric Respiratory volumes -Kids have smaller oxygen cushion than adults, will deteriorate more quickly. Higher o2 requiements Upper Airway Obstructions Croup FBAO Bacterial Tracheitis Least common.epiglottitis rare due to vaccine Lower Airway Asthma –reactive airway disease Bronchiolitis – caused by RSV Pneumonia – lung tissue disease FB – small FB lodged in lower airway – generally caused resorbtion atelectasis Pediatric Airway Assessment – determine degree of problem – altered mental status very worrying sign, indicates respiratory failure – BVM – if the baby accepts the mask he needs the mask. Treatment – o2 always primary – everything else is adjunct
3/25/09 Dr Cooper
Pediatric Airway Management
Bag and drag, get control of lungs and heart will follow – get control of airway and move
Start with PAT – Appearance – example, seesaw respirations – upper airway obstruction. Snoring; soft tissue, gurgling; secretions, stridor; croup FBAO, epiglottis. Hoarseness; laryngeal trauma
Management
Technique for high pressure ventilation- Sniff plus, jaw thrust up into mask, two thumbs on side of mask
ETT – respiratory failure decompensated shock, traumatic coma
ETT vs BVM – No significant mortality differences, true for medical and trauma patients.
BVM the single most important skill to master
(TUBE TOOLS – CD Rom)
The Physiocontrol Lifepak 12 as well as many other types of used medical equipment can be purchased online for much cheaper than buying new.
___________________
Respiratory Problems
Grunting = PEEPing
Peripheral mottling – circulatory problem; central mottling- respiratory problem
Sniffing and tripod – severe distress, head bobbing or grunting – respiratory failure
Oxyhemoglobin dissociation curve – kid won’t turn blue until o2 is dangerously low
Pediatric Respiratory volumes -Kids have smaller oxygen cushion than adults, will deteriorate more quickly. Higher o2 requiements
Upper Airway Obstructions
Lower Airway
Pediatric Airway Assessment – determine degree of problem – altered mental status very worrying sign, indicates respiratory failure – BVM – if the baby accepts the mask he needs the mask.
Treatment – o2 always primary – everything else is adjunct
Pediatric Assessment, Dr Cooper 3/23/09 See www.cpem.org Planning: Triage & transport – Needs vs. resources – enroute, review and plan Arrival: General Impression: Pediatric Assessment Triangle (PAT) – Hands off assessment – ABC Appearance, Work of Breathing, Circulation to skin Initial Assessment: Rapid cardiopulmonary assessment – Hands on Focused History: pertinent negatives, relevant findings Pediatric Assessment Triangle Appearance Alertness Distractibility Consolibility Eye contact Quality of cry Spontaneous movement (All critical to whether brain is perfused properly) Work of Breathing Chest rise Rocking motions Retractions Nasal flailing Head bobbing Grunting Snoring Stridor (C)Circulation Pallor Mottled Blue Grey Initial Assessment: Rapid cardiopulmonary assessment – Hands on Airway –clear? Maintainable?, stable? Breathing – ventilation, oxygenating, stable? In peds rates and effort are not necessarily related like adults, effort much more important! Circulation: Shock? Cardiogenic?, stable? Shock: inability of blood to meet metabolic needs of the tissues- Mental status, pulse rate and character; distal vs. proximal, skin color, BP. Cardiogenic shock: Dysrhythmias, other , compensated, decompensated, cardiopulmonary failure (cardiogenic shock not initially treated with fluid) Focused History: pertinent negatives, relevant findings Why peds don’t have heart attacks: no CAD, atherosclerosis, etc –congenital heart diseases are rare. Adults drop dead, kids droop dead (secondary to respiratory arrest, etc) Anatomic & Physiologic differences Child airway – funnel shaped, narrowest part is at crichoid ring- adult s cylinder, narrowest at glottis Small jaw, large tongue, prone t soft tissue obstruction – reposition Immature immune system. lack of specific antibodies, protective mucus layer Infants are nasal breathers, keep clear Floppy omega shaped epiglottis Narrow subglottic area Remember if suspected C spine injury, stabilize c spine before/while maintaining airway Breathing anatomy Adult – diagonal ribs, stiff cartilage, stronger muscles Ped – horizontal ribs, soft cartilage, weaker muscles – diaphragmatic breathers, much less alveoli – faster o2 depletion. Susceptible to barotraumas, high risk of Pneumothorax, bag until chest rise, no more. (head bobbing grunting – near end resp failure)young tissue – high elastin content– shift mediastinum -easily Breathing assessment requires an open Airway! – ASSESS A, THEN FIX A! THEN GO ON TO B! Is ventilation adequate – inspect chest rise – capability Auscultation – air entry (Missed slide) Always consider hypoxia first as cause for AMS Auscultate in armpits, small chest, sounds travel ETT only of BVM ineffective Consider NG/OG if abdominal distention Circulation Adults, big hearts large chambers and thin walls, Starlings Law (like a spring, recoil helps CO) peds – small chambers thick walls – can’t vary CO well with heart walls, CO depends only on HR Adults – stiff vessels – vigorous response to hypovolemia and hypothermia Peds – soft vessels – more compliant vessels Smaller blood volume, lose lager percentage compared to adult Smaller fat mass – larger relative blood volume Bleeding control – direct pressure – retain systemic o2 Shock assessment – cause assessment – cardiogenic etc – Simultaneous palpation of central and peripheral pulses – strong central weak peripheral – compensated – everything weak; decompensated shock Tachycardia = 150 – 5x age in year Kids get mottled – not clammy Cap refill – use warm extremities Minimum systolic BP: 80 + 2x age Adrenaline makes you stupid – use a Broselow Tape
Pediatric Assessment, Dr Cooper
3/23/09
See www.cpem.org
Pediatric Assessment Triangle
(C)Circulation
Initial Assessment: Rapid cardiopulmonary assessment – Hands on
Focused History: pertinent negatives, relevant findings
Why peds don’t have heart attacks: no CAD, atherosclerosis, etc –congenital heart diseases are rare. Adults drop dead, kids droop dead (secondary to respiratory arrest, etc)
Anatomic & Physiologic differences
Child airway – funnel shaped, narrowest part is at crichoid ring- adult s cylinder, narrowest at glottis
Remember if suspected C spine injury, stabilize c spine before/while maintaining airway
Breathing anatomy
Breathing assessment requires an open Airway! – ASSESS A, THEN FIX A! THEN GO ON TO B!
Always consider hypoxia first as cause for AMS
Circulation
Bleeding control – direct pressure – retain systemic o2
Shock assessment – cause assessment – cardiogenic etc – Simultaneous palpation of central and peripheral pulses – strong central weak peripheral – compensated – everything weak; decompensated shock
Adrenaline makes you stupid – use a Broselow Tape
Random topics of interest, not in lectures yet 1/11/09 ACE inhibitor (ACEI) blocks conversion of angiotensin I to angiotensin 2 – results in lowering of BP, used to treat HTN & CHF.(Mechanism of Action: inhibits angiotensin converting enzyme, interfering w/ conversion of angiotensin I to angiotensin II) RAAS Vasopressin Calcium Channel Blocker (CCB) Most calcium channel blockers decrease the force of contraction of the myocardium (muscle of the heart). This is known as the negative inotropic effect of calcium channel blockers. Pituitary Krebs cycle Diuretic Fremitus Uremiais a term used to loosely describe the illness accompanying kidney failure (also called renal failure), in particular the nitrogenous waste products associated with the failure of this organ. In kidney failure, urea and other waste products, which are normally excreted into the urine, are retained in the blood. Early symptoms include anorexia and lethargy, and late symptoms can include decreased mental acuity and coma. It is usually diagnosed in kidney dialysis patients when the glomerular filtration rate, a measure of kidney function, is below 50% of normal.[2] Tetany – is a medical sign, the involuntary contraction of muscles, caused by diseases and other conditions that increase the action potential frequency. The muscle cramps caused by the disease tetanus are not classified as tetany; rather, they are due to a blocking of the inhibition to the neurons that supply muscles. Motor_end_plate Cushing’s Triad Pnuemonia Pulmonary embolism (PE)
Random topics of interest, not in lectures yet
1/11/09
In kidney failure, urea and other waste products, which are normally excreted into the urine, are retained in the blood. Early symptoms include anorexia and lethargy, and late symptoms can include decreased mental acuity and coma. It is usually diagnosed in kidney dialysis patients when the glomerular filtration rate, a measure of kidney function, is below 50% of normal.[2]
