PALS Scenario Review

  1. Anatomy and Physiology Review
    1. Respiratory System
      1. Passageway for fresh oxygen to enter the lungs and blood supply
      2. Respiratory waste products to leave the blood and lungs
    2. Cardiovascular System
      1. Heart
        1. Four chambers
        2. Pumps blood to the lungs to pick up oxygen
        3. Pumps blood around the body
          1. to deliver oxygen and nutrients to the tissues
          2. to remove waste products from the tissues
      2. Vascular System
        1. Arteries carry blood to tissues
          1. carotid pulse
          2. femoral pulse
          3. radial pulse
          4. brachial pulse
        2. Veins carry blood to heart
  2. Respiratory Failure
    1. Pathophysiology
      1. Constrictive
      2. Obstructive
      3. Destructive
    2. Assessment
      1. Pulmonary symptoms
      2. Cardiovascular symptoms
      3. Neurological symptoms
      4. Other symptoms
    3. Treatment
      1. Oxygen therapy
      2. Ventilatory support
        1. Carbon dioxide clearance
        2. Pharmacological therapy
  3. Respiratory Arrest
    1. Assessment
    2. Treatment
      1. Oxygen therapy
      2. Ventilatory support
        1. Carbon dioxide clearance
        2. Advanced airways
  4. Cardiac Arrest
    1. Pathophysiology
      1. If the heart stops contracting, no blood will flow
      2. The body cannot survive when the heart stops
        1. Organ damage begins quickly after the heart stops
        2. Brain damage begins 4-6 minutes after the patient suffers cardiac arrest — damage becomes irreversible in 8-10 minutes
      3. Cardio-pulmonary resuscitation (CPR)
        1. Artificial ventilation — oxygenates the blood
        2. External chest compressions — pushing on the chest squeezes the heart and simulates a contraction
        3. Oxygenated blood is circulated to the brain and other vital organs
    2. General Reasons for the Heart to Stop Beating
      1. Sudden death and heart disease
      2. Breathing stops, especially in infants and children
      3. Medical emergencies
      4. Trauma
  5. Resuscitation
    1. System Components to Maximize Survival
      1. Early access
        1. Public education and awareness
          1. rapid recognition of a cardiac emergency
          2. rapid notification before CPR starts — "phone first"
        2. 911-pre-arrival instructions and dispatcher directed CPR
      2. Early CPR
        1. Lay public
          1. family
          2. bystanders
        2. Emergency Medical Responders
      3. Early Defibrillation
      4. Early Advanced Care
    2. Basic Cardiac Life Support (Refer to the Current American Heart Association Guidelines)
      1. Adult CPR and foreign body airway obstruction
      2. Child CPR and foreign body airway obstruction
      3. Infant CPR and foreign body airway obstruction
    3. Airway Control and Ventilation
      1. Basic Airway adjuncts
      2. Ventilation
        1. Delivery of excessive rate or depth of ventilation reduces blood return to the right side of the hear
        2. Reduces the overall blood flow that can be generated with CPR
    4. Chest Compressions
      1. Factors which decrease effectiveness
        1. Compression that are too shallow
        2. Slow compression rate
        3. Sub-maximum recoil
        4. Frequent interruptions
      2. Devices to assist circulation
        1. Impedance Threshold Device
        2. Mechanical Piston Device
        3. Load-Distributing Band or Vest CPR
  6. Automated External Defibrillation (AED) (Refer to the current American Heart Association guidelines)
    1. Adult AED Use
    2. Child AED Use
    3. Infant AED Use
    4. Special AED situations
      1. Pacemaker
      2. Wet patients
      3. Transdermal medication patches
  7. Shock (Poor Perfusion)
    1. Definition
      1. Perfusion is the passage of blood and oxygen and other essential nutrients to the body’s cells
      2. While delivering these essentials to the body’s cells, the circulatory system is also removing waste such as carbon dioxide from the cells
      3. Shock is a state of hypoperfusion, or inadequate perfusion of blood through body tissues
      4. Hypoperfusion can lead to death if not corrected
    2. Anatomy and Physiology Review
      1. Heart/Blood vessels
      2. Physiology of respiration
        1. Gas exchange
          1. alveolar level
          2. tissue level
        2. Circulation
          1. pulmonary
          2. systemic
      3. Essential components for normal perfusion
        1. Functioning pump/heart
          1. pump delivers blood to the tissue
          2. pump collects blood from the body
          3. controlled by the autonomic nervous system during shock
        2. Adequate volume
          1. blood contains formed elements
            1. RBCs transport oxygen
            2. WBCs fight infection
            3. platelets form blood clots
            4. clots are very unstable and prone to rupture
          2. plasma is the fluid that transports the formed elements
        3. Intact container/vessels
          1. arteries surrounded by smooth muscle contract and dilate to deliver blood to tissue
          2. capillary beds are the site where perfusion occurs
          3. veins are low pressure vessels responsible for returning blood to the heart
          4. smooth muscle and sphincters controlled by the autonomic nervous system to constrict or dilate
          5. blood flow controlled by cellular tissue demands
    3. Disruptions That Can Cause Shock
      1. Inadequate fluid/blood – blood/water loss
      2. Failing pump/heart
        1. Disease or injury to conduction system
        2. Damage to cardiac muscle
      3. Leaky or dilated container/vessels
        1. Loss of nervous control
        2. Severe allergic reactions
        3. Massive infection
        4. Hypothermia
    4. Categories of Shock
      1. Compensated shock
      2. Decompensated shock
      3. Irreversible shock
    5. Shock Due to Fluid Loss
      1. Hypovolemic
        1. Examples
        2. Signs and symptoms
    6. Shock Due to Pump Failure
      1. Cardiogenic
        1. Examples
        2. Signs and symptoms
    7. Shock Due to Container Failure
      1. Anaphylaxis
        1. Examples
        2. Signs and symptoms
      2. Neurogenic
        1. Examples
        2. Signs and symptoms
      3. Sepsis
        1. Examples
        2. Signs and symptoms
    8. Patient Assessment
      1. Complete a scene size-up
      2. Perform a primary assessment
      3. Obtains a relevant history
      4. Perform secondary assessment
      5. Perform a reassessment

I. Chain of survival

      a. There are 5 links in the adult Chain of Survival

            i. Immediate recognition of cardiac arrest and activation of the emergency response system

            ii. Early cardiopulmonary resuscitation (CPR) emphasizing chest compressions

            iii. Rapid defibrillation

            iv. Effective advanced life support

            v. Integrated post-cardiac arrest care

      b. Appropriate chain reactions can improve chances of survival and recovery for heart attack and stroke patients

II. Optimal chest compressions

      a. Compress at a rate of 100 – 120/min

      b. The number of compressions per minute is an important determinant of return of spontaneous circulation and good neurological outcomes

      c. Heel of one hand over the center of the patient’s chest (lower half of the sternum) and the heel of the other hand over the first so the hands are overlapped and parallel

      d. Compress at least 2 inches (5 cm)

            i. Shallow compressions are associated with lower cardiac arrest survival

      e. Do not compress more than 2.4 inches (6 cm)

            i. Non-life threatening injuries may occur

      f. Allow complete recoil of chest between compressions

      g. Minimize interruption

            i. Ventilation/Compression Ratio

                  1. 2 breaths after every 30 compressions if no advanced airway is in place

                  2. 1 breath every 6 seconds with continuous compressions if an advanced airway is present

                  3. Each breath should take about 1 second

                  4. Ventilate with only enough volume to observe chest rise

      h. High performance CPR

      i. Coordinated manner with other practitioners (e.g., pit crew CPR)

Neonatal resuscitation

      a. Assessment

            i. If “yes” is answered to these three questions, the infant stays with the mother and standard care continues, including maintaining the newborn’s temperature.

                  1. Full term gestation?

                  2. Good muscle tone?

                  3. Breathing or crying adequately?

            ii. If “no” is answered to ANY of the above assessment questions, resuscitation efforts should be attempted in this sequence:

                  1. First 30 seconds postpartum

                        a. Dry the infant, then, warm and maintain normal temperature

                        b. Position airway

                        c. Clear secretions

                        d. Stimulate

                  2. 30-60 seconds postpartum

                        a. Heart rate below 100/min or gasping/apnea

                              i. Initiate positive pressure ventilation and monitor SpO2

                        b. Labored breathing or persistent cyanosis

                              i. Position and clear the airway, monitor SpO2, supplementary O2 as needed

                  3. After one (1) minute postpartum

                        a. Heart rate >100/min

                              i. Provide post resuscitation care

                        b. Heart rate <100/min

                              i. Check chest movement

                              ii. Correct ventilations as needed

                                    1. ETT, laryngeal mask, or appropriate supraglottic airway

                        c. Heart rate >60/min

                              i. Begin chest compressions coordinated with PPV and 100% O2

                              ii. Place on ECG monitor

                              iii. Considerations

                                    1. Intubation

                                    2. IO or emergency umbilical vein cannulation (UVC)

                                    3. Epinephrine

Content Creator: Madison Browning
CAPCE Course Number: 21-EMTP-F3-6202
Total CE Hours: 1
Level: Advanced
EMT-CE uses the NEMSES guidelines as the foundation for every course outline.