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Most popular medical Questions
What risks are associated with administering an inappropriately low dose of atropine?If the dose of atropine is too small, paradoxically worsening bradycardia may result. This is as a result of atropine's central stimulating effect on the medullary vagal nerve at lower doses, which slows atrioventricular conduction and heart rate. Standard dosing of atropine in a setting of bradycardia is 0.02 mg/kg intravenously. However, at least 0.1 mg should be used, even in the youngest patient.
When is the use of calcium indicated during a resuscitation?
Routine use of calcium is no longer recommended during a resuscitation. There is evidence that calcium may increase postischemic injury in the intracranial reperfusion phase that follows resuscitation. However, calcium use may be justified in three settings of resuscitation: (1) an overdose of a calcium-channel blocker; (2) hyperkalemia resulting in cardiac dysrhythmia; and (3) infants and children with low serum calcium.
What are the indications for the placement of an intraosseous line?
Because of the difficulty and delays with establishing intravenous access in pediatric resuscitations, intraosseous infusions have become the very early second line of therapy in emergency settings. Failure to achieve intravenous access in three attempts or 90 seconds (whichever is shorter) is an indication for intraosseous access. An intraosseous line is a rapid means of vascular access and uses the marrow cavity of bone, which drains into the central venous system. All medications and fluids that can be given intravenously can be given by the intraosseous route, at the same rate and dosages, with comparable distribution. The technique involves placing a needle, a bone marrow needle, or an intraosseous needle into the proximal tibia approximately 1-3 cm below and medial to the tibial tuberosity. Distal tibial and proximal femoral sites are less commonly used.
What signs indicate that an intraosseous needle has been correctly placed?
A soft pop should be felt as you break through the cortex.
The needle should be very stable.
There should be free flow of intravenous fluids without infiltration of the subcutaneous tissues.
Bone marrow aspiration-although it does confirm placement-may not always be possible, even when needle placement is correct. Therefore, if you cannot aspirate marrow, you should rely on signs 1-3 for determination of placement.
Is capillary refill still a useful clinical sign?
Capillary refill is the return to normal color of the pulp of the finger or fingernail after it has been compressed. In healthy children, a normal value is approximately 2 seconds. In theory, a normal refill time is a measure of adequate peripheral perfusion and thus normal cardiac output and peripheral vascular resistance. It has been used as a measure of perfusion in the settings of trauma and possible dehydration. However, it must be used in conjunction with other clinical features, because studies of its usefulness as a sole indicator of dehydration have shown it to have a low sensitivity and specificity. In one study of children with 5-10% dehydration, only 50% had prolonged capillary refill. In addition, lower ambient temperature has a significant effect on delaying capillary refill. Capillary refill should be measured in the upper extremity.
When should a failing resuscitation be stopped?
Studies have suggested that, when more than two rounds of medication (i.e., epinephrine and bicarbonate) have been given and/or more than 20 minutes have elapsed since the initiation of resuscitation without clinical cardiovascular or neurologic improvement, the likelihood of death or survival with neurologic devastation greatly increases. Unwitnessed out-of-hospital arrests are nearly always associated with a poor outcome. In settings of hypothermia, asystolic patients should be rewarmed to 36C before resuscitation is discontinued.
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