Evaluate Identify Intervene

1. INITIAL IMPRESSION
o Appearance
o Breathing
Work of breathing
o Circulation
Pallor?
Mottling?
2. PRIMARY SURVEY
a. Airway
i. Maneuvers
ii. Insertion of adjuncts
b. Breathing
i. Pattern
ii. Rate
iii. Effort
iv. Grossly audible sounds
v. Chest expansion
vi. Auscultation
vii. O2 sats
*BRADYCARDIA: impending arrest
c. Circulation
i. If <60 BPM: CPR
ii. Carotid/femoral: child
iii. Capillary refill: normal is 2 seconds
iv. Skin color
v. Temp
vi. Cyanosis
vii. Pulses
viii. Trunk vs. extremities
ix. Normal SBP: 90 mmHg +2x age
1. Hypotension: 70 +2x age
x. Intraarterial monitoring
d. Disability
i. AVPU
1. Awake
2. Responds to Verbal stimulus? Pain? Unresponsive?
ii. Glucose
1. Neonates: 45 mg/dL
2. Child/infants: 60 mg/dL
e. Exposure
i. Signs of trauma
ii. Rashes/discolorations
iii. Temperature
*a patient in respiratory distress: manage: O2 by nonrebreather mask FiO2 100%
*Respiratory failure: O2 sats of <94%; do bag valve mask ventilation
3. SECONDARY SURVEY
a. SAMPLE
i. Signs/Sx
ii. Allergies
iii. Meds
iv. Past Med Hx
v. Last Meal
vi. Events Prior
b. Respiratory Emergencies
i. Anatomy of childs airway
1. Funnel shaped larynx
2. Narrowest point: cricoid
3. Tongue and epiglottis are large
4. Superior and anterior
ii. 4 possible etiologies
1. Upper airway obstruction
2. Lower airway obstruction
3. Lung tissue disease
4. Disordered control of breathing
iii. Management
1. Positioning
a. Comfortable position
2. Nebulizer
3. O2
a. Low flow: Nasal Cannula and Face Mask
b. High flow: nonrebreather mask at 10-15 lpm
i. Patient should have spontaneous breathing
c. High flow NC
d. Positive Pressure Ventilation
i. Bag Valve Mask
1. Ready suctioning (10 seconds max)
2. Insert OPA
4. Monitor: HR; O2 Sats; appearance
5. OPA: in patients with no gag and unconscious
a. Measure: mouth to angle of jaw
6. Advanced airway
a. Confirm: end tidal CO2
b. ET sizes
i. Cuffed: Age/4 + 3.25
ii. Uncuffed Age/4 + 4
c. LMA
d. Troubleshooting
i. Displacement
ii. Obstruction
iii. Pneumothorax
iv. Equipment Failure
c. SHOCK
i. TYPES OF SHOCK
1. Hypovolemic shock
a. Tachycardia
b. Poor perfusion
c. BP MAY be initially high
2. Distributive shock
a. May have warm, flushed skin
b. Septic Shock
c. Anaphylaxis
3. Cardiogenic shock
a. Congenital heart disease
b. Myocarditis
c. Cardiomyopathies
4. Obstructive shock
a. Pulmonary Embolism
 b. Tension Pneumothorax
c. Tamponade
d. Ductal dependent lesions
ii. Compensated shock: may have normal BP
iii. Hypotensive shock
1. <5 % percentile / age
2. Ominous finding
iv. Management
1. Compensated shock: peripheral line
2. Hypotensive shock: IO MAY be needed
3. Fluid resuscitation
a. Non-Cardiogenic Shock: 20cc/kg in 5-10 minutes
b. Cardiogenic Shock: 5-10 cc/kg over 10-20 mins
c. ISOTONIC solution
d. Signs of congestion after fluid bolus
i. Hepatomegaly
ii. Respiratory distress
iii. Crackles
4. Fever with NO shock
a. No bolus needed
5. Sepsis
a. Antibiotics within 1 hr
b. Vasopressors
6. Cardiogenic shock
a. Small fluid bolus
b. Inotropes
7. Obstructive shock
a. Disease-specific management
b. Prostaglandin infusion for ductal dependent lesions
8. INTRAOSSEOUS ACCESS
a. After 2 peripheral line attempts within 90 seconds
b. Sites
i. Proximal tibia
ii. Distal tibia: medial malleolus
iii. Distal femur
iv. ASIS
c. Contraindications
i. Fractures
ii. Fragile bones; e.g. osteogenesis imperfecta
iii. Previous attempt in same bone
iv. Overlying infection
4. Post-Cardiac Arrest Care
a. Priorities: Oxygenation, Ventilation, Perfusion
b. Airway and Breathing
i. ET tube placement
1. ETCO
ii. CXR
iii. O2 sats: goal is 94-99%
iv. ABGs
c. Circulation
i. HR: ensure adequate ventilation and oxygenation
ii. Stroke volume
1. Fluid boluses
iii. Electrolyte imbalance (e.g. hypocalcemia)
 iv. Hypoglycemia
v. Inotropes
vi. Hypertension no immediate Treatment
d. Neurologic outcome
i. Hypothermia
1. 5 days of normothermia (36-37.6)
OR
2. 2 days of hypothermia (32-34 deg C) PLUS 3 days of normothermia