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Questions and Answers
What characterizes the compensated stage of shock?
What characterizes the compensated stage of shock?
Which type of shock is most commonly associated with a decrease in blood volume?
Which type of shock is most commonly associated with a decrease in blood volume?
What is the primary feature that distinguishes decompensated shock from compensated shock?
What is the primary feature that distinguishes decompensated shock from compensated shock?
In assessing circulation during shock, what is the normal capillary refill time (CRT)?
In assessing circulation during shock, what is the normal capillary refill time (CRT)?
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Which of the following is NOT a feature of compensated shock?
Which of the following is NOT a feature of compensated shock?
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What clinical feature is commonly associated with bleeding disorders like von Willebrand Disease?
What clinical feature is commonly associated with bleeding disorders like von Willebrand Disease?
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Which investigation is primarily used to assess the structure and functioning of von Willebrand factor?
Which investigation is primarily used to assess the structure and functioning of von Willebrand factor?
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What is the primary treatment used to induce the release of von Willebrand factor from endothelial cells?
What is the primary treatment used to induce the release of von Willebrand factor from endothelial cells?
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Which of the following characterizes the APTT results in bleeding disorders like von Willebrand Disease?
Which of the following characterizes the APTT results in bleeding disorders like von Willebrand Disease?
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Which factor is specifically assessed with the vWF ristocetin cofactor assay?
Which factor is specifically assessed with the vWF ristocetin cofactor assay?
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What is the correct rate for performing chest compressions during pediatric resuscitation?
What is the correct rate for performing chest compressions during pediatric resuscitation?
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Which method is preferred for airway management during prolonged pediatric CPR?
Which method is preferred for airway management during prolonged pediatric CPR?
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Where should chest compressions be performed on a pediatric patient?
Where should chest compressions be performed on a pediatric patient?
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Which pulse check site is appropriate for infants during resuscitation?
Which pulse check site is appropriate for infants during resuscitation?
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What should be ensured after performing chest compressions for effective resuscitation?
What should be ensured after performing chest compressions for effective resuscitation?
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What is the primary cause of cardiopulmonary arrest in a child?
What is the primary cause of cardiopulmonary arrest in a child?
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What is the compression-to-ventilation ratio when two rescuers are performing CPR on a child?
What is the compression-to-ventilation ratio when two rescuers are performing CPR on a child?
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What should be done immediately after confirming a non-shockable rhythm during pediatric resuscitation?
What should be done immediately after confirming a non-shockable rhythm during pediatric resuscitation?
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How often should reassessment occur during CPR for a child?
How often should reassessment occur during CPR for a child?
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What is the maximum energy dose for a repeat shock in pediatric resuscitation?
What is the maximum energy dose for a repeat shock in pediatric resuscitation?
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What is the primary purpose of using vasopressors in treatment?
What is the primary purpose of using vasopressors in treatment?
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What fluid type is preferred due to its low price and easy availability for initial fluid therapy?
What fluid type is preferred due to its low price and easy availability for initial fluid therapy?
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According to the rules of 60, how long should vasoactive drugs be started after initiating fluid therapy?
According to the rules of 60, how long should vasoactive drugs be started after initiating fluid therapy?
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Which of the following is a suitable initial fluid bolus for a patient in the first 60 minutes?
Which of the following is a suitable initial fluid bolus for a patient in the first 60 minutes?
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Which drug is classified as a phosphodiesterase III inhibitor used as an inotropic agent?
Which drug is classified as a phosphodiesterase III inhibitor used as an inotropic agent?
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What is the recommended initial fluid bolus for a patient in shock?
What is the recommended initial fluid bolus for a patient in shock?
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In the context of cold shock, when should norepinephrine be administered?
In the context of cold shock, when should norepinephrine be administered?
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What action should be taken if a patient shows no response after initial fluid therapy for 60 minutes?
What action should be taken if a patient shows no response after initial fluid therapy for 60 minutes?
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Which medication is recommended for a patient showing cold shock with a normal blood pressure?
Which medication is recommended for a patient showing cold shock with a normal blood pressure?
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What is the primary treatment for warm shock requiring vasoconstriction?
What is the primary treatment for warm shock requiring vasoconstriction?
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What is the preferred route for vascular access in medication administration?
What is the preferred route for vascular access in medication administration?
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Which of the following rhythms is classified as a shockable rhythm?
Which of the following rhythms is classified as a shockable rhythm?
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Which potential cause of cardiac arrest is associated with an imbalance of potassium levels?
Which potential cause of cardiac arrest is associated with an imbalance of potassium levels?
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Which large accessible vein is primarily used for vascular access?
Which large accessible vein is primarily used for vascular access?
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What effect does an Automated External Defibrillator (AED) have on the myocardium?
What effect does an Automated External Defibrillator (AED) have on the myocardium?
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What is a common finding in hypovolemic shock?
What is a common finding in hypovolemic shock?
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Which characteristic is associated with cardiogenic shock?
Which characteristic is associated with cardiogenic shock?
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In distributive shock, which of the following findings is typically observed?
In distributive shock, which of the following findings is typically observed?
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What classification is also known as warm shock?
What classification is also known as warm shock?
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Which condition might lead to venous pooling of blood?
Which condition might lead to venous pooling of blood?
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What feature distinguishes hypovolemic shock from cardiogenic shock?
What feature distinguishes hypovolemic shock from cardiogenic shock?
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Which of the following is a sign of effective renal perfusion?
Which of the following is a sign of effective renal perfusion?
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In distributive shock, what is the expected capillary refill time (CRT)?
In distributive shock, what is the expected capillary refill time (CRT)?
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Study Notes
Bleeding Disorders
-
Clinical Features:
- Mucocutaneous bleeds (nosebleeds, bleeding gums)
- Heavy menstrual bleeding in females
- Severe cases are similar to Hemophilia A (Factor VIII deficiency)
-
Investigation:
- Coagulation Profile - Increased APTT: Indicates a problem with Factor VIII activity.
- vWF Antigen Levels: Used to diagnose vWD types 1 and 3.
- vWF Multimer Testing: Assesses the structure and function of the protein.
- vWF Ristocetin Cofactor Assay: Measures how well vWF binds to platelets. Lower binding indicates vWD.
-
Management:
- Desmopressin: Stimulates the release of stored vWF from endothelial cells. Used for Type 1 vWD.
- vWF-containing Concentrates: Available as plasma-derived or recombinant products. Used for Type 2 and Type 3 vWD.
Pediatric Resuscitation - Initial Assessment
-
Verify scene safety
- Position patient supine on a firm surface.
- Immobilize if fracture suspected (e.g., traffic accident).
-
Check responsiveness:
- Look for any body movements.
- Shout for help and activate emergency services if unresponsive.
-
Check breathing:
- Observe chest movements.
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Check pulse:
- Brachial artery (infants)
- Carotid or femoral artery (over 1 year old)
Pediatric Resuscitation - Circulation
-
Chest Compressions:
- Location: Lower third of the breastbone (sternum).
- Rate: 100 to 120 compressions per minute.
- Depth: One-third of the chest's anteroposterior diameter. Ensure full recoil to allow heart filling.
Pediatric Resuscitation - Airway
- Head tilt-chin lift:
- Jaw thrust:
Pediatric Resuscitation - Breathing
- Non-invasive: Bag-valve-mask ventilation.
-
Invasive: Endotracheal intubation.
- Preferred in: In-hospital CPR, prolonged CPR.
- Cuff pressure: Monitor carefully.
Shock
- Condition of circulatory dysfunction:
-
Types of Shock:
- Hypovolemic (most common): Decreased blood volume due to hemorrhage or dehydration.
- Cardiogenic: Caused by problems with the heart's ability to pump (congenital heart disease, myocarditis, cardiomyopathy).
- Distributive: Abnormal blood vessel dilation (anaphylactic shock, neurogenic shock).
- Septic: Includes features of all other shock types.
Stages of Shock
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Compensated Stage: Vital organ functions are maintained (brain, heart, kidneys). The body compensates with:
- Sympathetic activation leading to increased systemic vascular resistance (SVR) and increased heart contractility.
- Blood is diverted away from non-essential areas (e.g., skin).
- Adequacy of circulation: Assessed by capillary refill time (CRT). Normal CRT is ≤ 2 seconds. In shock, CRT is ≥ 3 seconds.
- Decompensated Stage: Occurs if shock is prolonged and multiorgan dysfunction develops.
Shock - Compensated vs. Decompensated
| Feature | Compensated Shock | Decompensated Shock |
|---|---|---|
| Mental Status | Agitation or confusion | Drowsiness |
| Heart Rate | Increased | Markedly increased |
| CRT | Increased (≤ 3 sec) | Increased (> 5 sec) |
| Urinary output | Normal | Oliguria/anuria |
| Blood pressure (BP) | Normal | Decreased |
| Respiratory rate | Increased | Increased |
Pediatric Resuscitation - Causes of Cardiopulmonary Arrest in a Child
- Respiratory causes are more common than cardiac causes.
- Respiratory failure.
- Terminal stages of shock.
Pediatric Resuscitation - Cardiopulmonary Resuscitation (CPR) - Initial Assessment
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Pulse and breathing absent:
- Start CPR (compressions and ventilation):
- Two rescuers - 15 compressions: 2 ventilations.
- One rescuer - 30 compressions: 2 ventilations (outside the hospital).
- With endotracheal intubation (two people): 100-120 compressions per minute, 20-30 breaths per minute.
- Reassess every two cycles and attach an external automated defibrillator (AED).
- Start CPR (compressions and ventilation):
-
Pulse present, breathing absent:
- Provide ventilation (PPV): 20-30 breaths per minute.
- Assess every minute.
- If pulse is absent or heart rate is less than 60 beats per minute with poor perfusion, start CPR.
Pediatric Resuscitation - CPR - Management of Shocking Rhythms
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If shockable rhythm:
- Deliver shock (2 J/kg).
- Continue CPR and reassess.
- Repeat shocks up to 10 J/kg. If there's no response, the rhythm is refractory.
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If non-shockable rhythm:
- Immediately administer epinephrine: 0.1 ml/kg of a 1:10,000 solution.
- Repeat every 3 to 5 minutes.
- Continue CPR for 2 minutes and reassess.
Pediatric Resuscitation - CPR - Drugs
- Lidocaine and amiodarone may be used in specific scenarios.
Miscellaneous
-
Sites of 10 access:
- Proximal tibia.
- Distal femur.
-
Rules of 60:
- Obtain IO access if IV access is not available within 60 seconds.
- Administer fluid boluses up to 60 ml/kg in the first hour.
- Start vasoactive drugs 60 minutes after starting fluid therapy.
-
Fluid Therapy:
- Crystalloids (e.g., normal saline, Ringer lactate) are preferred over colloids due to their lower cost and easier availability. Long-term risks of using colloids in children are unknown.
-
Management of Sepsis:
- Third-generation cephalosporin + vancomycin.
-
Vasoactive Drugs:
- Vasopressors: Alter vascular resistance (e.g., epinephrine, norepinephrine, vasopressin).
- Inotropes: Increase cardiac contractility (e.g., epinephrine, dobutamine, milrinone, levosimendan).
- Vasodilators: Dilate blood vessels (e.g., nitroglycerine, nitroprusside).
Shock Types
-
Hypovolemic Shock:
- Suspected when: History consistent with fluid loss and inadequate oral intake.
- Findings: Dehydration (dry mouth, reduced or absent tears, sunken eyes), reduced central venous pressure (CVP), decreased preload.
-
Cardiogenic Shock:
- Cause: Impaired cardiac contractility leading to blood pooling in veins.
- Findings: Increased CVP, increased jugular venous pressure, an S3 gallop sound, congestive hepatomegaly.
-
Distributive Shock (Warm Shock):
- Also known as warm shock.
- Findings: Warm extremities, bounding pulses, fast capillary refill time (CRT < 3 seconds), feeble/decreased pulses.
-
Septic Shock (Cold Shock):
- Findings: Cold extremities, slow CRT, feeble pulses.
-
Septic Shock (Warm Shock):
- Findings: Warm extremities, fast CRT, bounding pulses.
Shock Type Summary Table:
| Feature | Hypovolemic | Cardiogenic | Distributive (Warm) | Septic (Cold) | Septic (Warm) |
|---|---|---|---|---|---|
| Extremities | Dehydrated | N/A | Warm | Cold | Warm |
| CRT | N/A | N/A | Flash (< 3 sec) | Flash | Flash |
| Pulses | Weak | Weak | Bounding | Feeble | Bounding |
Management Algorithm for Shock
-
Initial Steps:
- Rapid recognition of shock (assess airway, breathing, circulation).
- Stabilize airway, breathing, and circulation.
- Administer high-flow oxygen.
- Obtain IV access. If not available within 60 seconds, use IO access.
- Initial fluid bolus: 10-20 ml/kg over 15-20 minutes. Repeat up to 60 ml/kg in the first hour.
Management Algorithm for Shock - Fluid Therapy
- If there's no response to fluid therapy after 60 minutes, the shock is considered fluid-refractory.
Management Algorithm for Shock - Cold Shock
-
Requires vasodilation:
- Start with epinephrine or dopamine: 5-9 µg/kg/min.
- Initial dose: 0.05 µg/kg/min.
- Titrate up to 3 µg/kg/min.
- If there's no response, increase the dose to norepinephrine or dopamine: ≥ 10 µg/kg/min.
- Start with epinephrine or dopamine: 5-9 µg/kg/min.
Management Algorithm for Shock - Warm Shock
-
Requires vasoconstriction:
- Norepinephrine: ≥ 10 µg/kg/min.
- Give corticosteroids if adrenal insufficiency is suspected.
- Continuous cardiac monitoring.
- Transfuse to maintain hemoglobin > 10 g/dL.
Management Algorithm for Shock - Catecholamine-Resistant Shock
-
Cold Shock + Normal Blood Pressure:
- Use vasodilators:
- Nitroprusside
- Milrinone
- Nitroglycerin
- Levosimendan
- Use vasodilators:
-
Cold Shock + Low Blood Pressure:
- Titrate epinephrine to the highest tolerable dose and add norepinephrine to normalize diastolic blood pressure.
- If there's no response, consider milrinone or levosimendan.
-
Warm Shock + Low Blood Pressure:
- Titrate fluid volume to normal.
- Consider adding vasopressin to promote vasoconstriction.
Management Algorithm for Shock - Low Cardiac Output
- Use milrinone or levosimendan.
Management Algorithm for Shock - General Measures
- Look for reversible causes (e.g., pericardial effusion, pneumothorax).
- Consider extracorporeal membrane oxygenation (ECMO) if necessary.
Medical Notes - Vascular Access
- Goal: Administer medications.
- Preferred route: IV route.
- Large accessible vein: Femoral vein.
-
Alternative route: Intraosseous (IO) route.
- Proximal tibia (below tibial tuberosity).
- Distal femur.
Medical Notes - Automated External Defibrillator (AED)
- Displays cardiac rhythm to guide management.
- Delivers a shock to cause asynchronous depolarization of the myocardium.
Shockable Rhythms (Wide QRS)
- Ventricular fibrillation (V-fib): Irregular rhythm with a wide QRS complex (ECG trace diagram).
- Pulseless ventricular tachycardia (PVT): Regular rhythm with a wide QRS complex (ECG trace diagram).
Non-Shockable Rhythms
- Asystole: Flat line ECG trace diagram.
- Pulseless electrical activity (PEA): Other abnormal heart rhythms (ECG trace diagram).
Potential Causes of Cardiac Arrest (Within 6 Hours and 4 Hours)
- Hypovolemia.
- Hypothermia.
- Hypoglycemia.
- Hydrogen ion (acidosis).
- Hypo/hyperkalemia.
- Thromboembolism.
- Toxin.
- Tamponade (pericardial).
- Tension pneumothorax.
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Description
This quiz covers key aspects of bleeding disorders and pediatric resuscitation, focusing on clinical features, investigation techniques, and management strategies. You will learn how to identify mucocutaneous bleeds, interpret coagulation profiles, and perform initial assessments for pediatric patients in emergency situations.
