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Pediatric Advanced Life Support Jan Bazner-Chandler CPNP, CNS, MSN, RN.

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Presentation on theme: "Pediatric Advanced Life Support Jan Bazner-Chandler CPNP, CNS, MSN, RN."— Presentation transcript:

1 Pediatric Advanced Life Support Jan Bazner-Chandler CPNP, CNS, MSN, RN

2 American Heart Association Pediatric Advanced Life Support Guidelines first published in 1997 Revisions made in 2005

3 Students Nurse Concerns You will need to learn the basics as outlined in the PALS 2005 Guidelines AHA guidelines are expected standards of a practicing pediatric nurse. You will need to know basic CPR guidelines and have a current CPR card prior to starting the clinical rotation.

4 Cardiopulmonary Arrest In most infants and small children respiratory arrest precedes cardiac arrest.

5 Causes of Cardiac Arrest in Children Bronchospasm / respiratory infection Burns Drowning Dysrhythmias Foreign Body Aspiration Gastroenteritis (vomiting and diarrhea) Sepsis Seizures Trauma

6 Pediatric Cardiac Arrest Pediatric cardiopulmonary arrest results when respiratory failure or shock is not identified and treated in the early stages. Early recognition and intervention prevents deterioration to cardiopulmonary arrest and probable death.

7 Cardiac Arrest Pediatric cardiac arrest is: Uncommon Rarely sudden cardiac arrest caused by primary cardiac arrhythmias. Most often asphyxial, resulting from the progression of respiratory failure or shock or both.

8 Respiratory Failure Hypotensive Shock Cardiopulmonary Failure Asphyxial Arrest Upper airway obstruction Lower airway obstruction Lung tissue disease / infection Disorders of breathing Hypovolemic (most common) Distributive: septic, anaphylactic Cardiogenic Obstructive

9 Respiratory Arrest Early recognition and intervention prevents deterioration to cardiopulmonary arrest and probable death. Only 10% of children who progress to cardiopulmonary arrest are successfully resuscitated.

10 Respiratory Failure A respiratory rate of less than 10 or greater than 60 is an ominous sign of impending respiratory failure in children.

11 Assessment 30 second rapid cardiopulmonary assessment is structured around ABCs. Airway Breathing Circulation

12 Breathing Breathing is assessed to determine the childs ability to oxygenate. Assessment: Respiratory rate Respiratory effort Breath sounds Skin color

13 Airway Airway must be clear and patent for successful ventilation. Position Suction Administration of oxygen Bag-mask ventilation

14 Bag-valve-mask

15 New Guidelines – Airway Management Failure to maintain the airway is leading cause of preventable death in children. New PALS focuses on basic airway techniques. Laryngeal mask airway.

16 LMA –Laryngeal Mask Airway

17 Endotracheal Tube Intubation New guidelines: Secondary confirmation of tracheal tube placement. Use of end-tidal carbon dioxide monitor or colorimetric device

18 Circulation Circulation reflects perfusion. Shock is a physiologic state where delivery of oxygen and substrates are inadequate to meet tissue metabolic needs.

19 Circulation Assessment Heart rate (most accurate assessment) Blood pressure End organ profusion Urine output (1-2 mL / kg / hour) Muscle tone Level of consciousness

20 Circulatory Assessment Heart rate is the most sensitive parameter for determining perfusion and oxygenation in children. Heart rate needs to be at least 60 beats per minute to provide adequate perfusion. Heart rate greater than 140 beats per minute at rest needs to be evaluated.

21 Blood Pressure 25% of blood volume must be lost before a drop in blood pressure occurs. Minimal changes in blood pressure in children may indicate shock.

22 Vascular Access – New Guidelines New guidelines: in children who are six years or younger after 90 seconds or 3 attempts at peripheral intravenous access – Intraosseous vascular access in the proximal tibia or distal femur should be initiated.

23 Intraosseous Access



26 IV Solutions Crystalloid solution Normal saline 20ml/kg bolus over 20 minutes Lactated ringers

27 Gastric Decompression Gastric decompression with a nasogastric or oral gastric tube is necessary to ensure maximum ventilation. Air trapped in stomach can put pressure on the diaphragm impeding adequate ventilation. Undigested food can lead to aspiration.

28 Accurate Output Insert foley Output 1-2 mL / kg / hour

29 Cardiopulmonary Failure Childs response to ventilation and oxygenation guides further interventions.

30 Arrhythmias Bradycardia Pulseless Arrest – ventricular fibrillation Asystole – no pulse Tachycardia with poor perfusion Tachycardia with adequate perfusion

31 Bradycardia The most common dysrhythmia in the pediatric population. Etiology is usually hypoxemia Initial management: ventilation and oxygenation. If this does not work IV or IO epinephrine 0.1 mg / kg

32 Pulseless Arrest – Asystole ABC: Start CPR Give oxygen when available Attach monitor / defibrillator Check rhythm / check pulse If asystole give epinephrine 0.01 mg / kg of 1:10,000 Resume CPR may repeat every 3-5 minutes until shockable rhythm is seen

33 Asystole No Rhythm No rate No P wave No QRS comples

34 Pulseless Arrest – VF and Pulseless VT ABCs: start CPR Give oxygen as soon as available Attach monitor / defibrillator Check rhythm: VF / VT Give one shock at 2 J/kg If still VF / VT Give 1 shock at 4 J/kg Give Epinephrine 0.01 mg/kg of 1:10,000


36 Tachycardia with Adequate Perfusion Sinus tachycardia: Infants: HR < 220 bpm Children: HR < 180 bpm P waves present and normal Treatment: give oxygen and treat cause

37 Tachycardia with Adequate Perfusion Sinus Ventricular Tachycardia Infants: HR >220 bpm Children: HR > 180 bpm P waves absent of abnormal Treatment: consider vagal maneuver Give adenosine IV 0.1mg/kg

38 Interventions Oxygen Call for code Cardioversion Vagal Maneuvers Adenosine Supraventricular Tachycardia

39 Tachycardia with poor perfusion Ventricular tachycardia Synchronized cardioversion First dose: 0.5 to 1 J/kg Next dose: 2 J/kg Consider: amiodarone 5 mg/kg IV over 30 to 60 minutes

40 Ventricular Tachycardia

41 New Guideline Epinephrine Still remains primary drug for treating patients for cardiopulmonary arrest, escalating doses are de-emphasized. Neurologic outcomes are worse with high- dose epinephrine.

42 PALS Drugs

43 Epinephrine Action: increase heart rate, peripheral vascular resistance and cardiac output; during CPR increase myocardial and cerebral blood flow. Dosing: 0.01 mg / kg 1: 10,0000

44 Amiodarone Used in atrial and ventricular antiarrhythmic Action: slows AV nodal and ventricular conduction, increase the QT interval and may cause vasodilation. Dosing: IV/IO: 5 mg / kg bolus

45 Adenosine Drug of choice of symptomatic SVT Action: blocks AV node conduction for a few seconds to interrupt AV node re-entry Dosing First dose: 0.1 mg/kg max 6 mg Second dose: 0.2 mg/kg max 12 mg

46 Glucose 10% to 25% strength Action: increases glucose in hypoglycemia Dosing: 0.5 – 1 g/kg

47 Naloxone Opiate antagonist Action: reverses respiratory depression effects of narcotics Dosing: IV/IO 0.1 mg/kg < 5 years 0.2 mg/kg > 5 years

48 Sodium bicarbonate pH buffer for prolonged arrest, hyperkalemia Action: increases blood pH helping to correct metabolic acidosis

49 Dobutamine Synthetic catecholamine Action: increases force of contraction and heart rate; causes mild peripheral dilation; may be used to treat shock Dosing: IV/IO: 2-20 mcg/kg/min infusion

50 Dopamine Catecholamine May be used to treat shock; effects are dose dependent Increases force of contraction and cardiac output, increases peripheral vascular resistance, BP and cardiac output Dosing: IV/IO infusion: 2-20 mcg/kg/min

51 Defibrillator Guidelines AHA recommends that automatic external defibrillation be use in children with sudden collapse or presumed cardiac arrest who are older than 8 years of age or more than 25 kg and are 50 inches long. Electrical energy is delivered by a fixed amount range 150 to 200. (2-4J/kg)

52 Post-resuscitation Care Re-assessment of status is ongoing. Laboratory and radiologic information is obtained. Etiology of respiratory failure or shock is determined. Transfer to facility where child can get maximum care.

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