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

Pediatric Advanced Life Support Guidelines established in 1983 by the American heart Association. Pediatric Advanced Life Support: A Review of the AHA Recommendations, American Family Physician, October 15, 1999. Http://www.aafp.org/afp/991015ap/1743.html

American Heart Association Pediatric Advanced Life Support Published online November 28, 2005 Article can be found at: http://circ.ahajournals.org/cgi/content/full/112/24_suppl/IV-167

JAOA Review of guidelines for Pediatric Advanced Life Support – short version of AHA www.jaoa.org/cgi/reprint/104/1/22.pdf Quick review of AHA guidelines

Students Nurse Concerns You will need to learn the basics as outlined in the PALS article 1999 and review 2005 standards. 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.

Cardiopulmonary Arrest In most infants and small children respiratory arrest precedes cardiac arrest. 92% of children with respiratory arrest only have no subsequent neurologic impairment.

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.

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

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.

Assessment 30 second rapid cardiopulmonary assessment is structured around ABC’s. Airway Breathing Circulation

Airway Airway must be clear and patent for successful ventilation. Position Clear of foreign body Free from injury Intubate if needed.

Breathing Breathing is assessed to determine the child’s ability to oxygenate. Assessment: Respiratory rate Respiratory effort Breath sounds Skin color

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

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

Circulation Assessment Heart rate Pulse Blood pressure End organ profusion Urine output Level of consciousness Muscle tone

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.

Circulatory Assessment Pulse quality reflects cardiac output. Capillary refill measures peripheral perfusion. Temperature and color of extremities proximal versus distal.

Circulatory Assessment Urinary output Adequate kidney perfusion 1- 2 ml of urine per kg / hour Level of Consciousness / LOC

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.

Management Oxygen Cardiac Monitoring Pulse oximetry May be inaccurate when peripheral perfusion is impaired.

Airway Management Bag-valve-mask with bradypenia or apnea Suctioning to remove secretions Intubation as needed

Bag-valve-mask

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.

LMA –Laryngeal Mask Airway

LMA Disadvantages: Inability to prevent aspiration. Inability to serve as route for administering medications.

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

Vascular Access After airway and oxygenation needs met. Crystalloid solution Normal saline 20mL/kg bolus over 20 minutes Lactated ringers – used more in adults

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 access recommended.

Intraosseous Access

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.

Cardiopulmonary Failure Child’s response to ventilation and oxygenation guides further interventions. If signs of shock persists: Inotropic agents such as epinephrine are given.

Epinephrine Indications: IV or ET through the endotracheal tube Bradycardia Shock (cardiogenic, septic, or anaphylactic) Hypotension IV or ET through the endotracheal tube

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.

2 New Medications for PALS Vasopressin – causes systemic vasoconstriction – used to increase blood flow to brain and heart during CPR. Need to be studied further. Amiodarone – antiarrhythmic agent – used in ventricular fibrillation and ventricular tachycardia. Given 5 mg/kg over 20 minutes.

Bradycardia Bradycardia is the most common dysrhythmia in the pediatric population. Epinephrine is drug of choice – dose is 0.01 to 0.03 mg/kg/dose

Sodium Bicarbonate In instances where the child is acidotic, sodium bicarbonate may be administered IV. The drug is not as stable in the pediatric population but is often used during the resuscitative phase of CPR.

Glucose Levels Monitor serum glucose levels Replace with 10 % dextrose in the neonate 25% glucose in the child

Ventricular Tachycardia Ventricular tachycardia is usually secondary to structural cardiac disease. Amiodarone – 5 mg/kg over 20 minutes Cardioversion

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. (4J/kg)

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.

BLS Updates 2006 Unresponsive infant less than 1 year and children 1 year to puberty Open airway Give 2 breaths (if not breathing) Begin compressions – 30 – (if no pulse) Activate EMS system AED after 5 cycles of CPR

Tilt Head to Sniff Position

Witnessed Collapse of Child Activate EMS AED before CPR Compression 30 to 2 breaths – hand placement at nipple line 2 rescue 15 to 2 – if infant circle chest and use thumbs

Choking Infant 5 back slaps 5 Chest thrusts

Heimlich for Infants

Clearing the Mouth