1. Advanced Paediatric Life Support
Welcome
Read the notes under the slides
NB check video links working and adjust sound as appropriate to environment

2. Advanced Paediatric Life Support Aims
To provide the knowledge necessary for effective treatment and stabilisation of children with life threatening emergencies
To teach the practical procedures necessary for effective management of childhood emergencies
To assess continuously the acquisition of these skills

3. Advanced Paediatric Life Support Content
Theory
Manual and VLE
Practical
Skill Stations, workshops
Simulations
Assessment
Pre-course: VLE
In course: continuous
Course
Serious illness
Serious injury
Life support
Candidates will be assessed during skill stations, workshops and simulations on their knowledge/skills as well as their performance working either within a team, or as a team leader. They will also be assessed for their potential as future instructors, based on their enthusiasm, support of colleagues, team-working, communication skills and credibility.

4. Advanced Paediatric Life Support Your role
You should:
have read the book!
completed the pre-course VLE topics and on-line assessments
attend all sessions and promptly
complete your reflective log during the course
support your faculty and fellow candidates
enjoy yourself!
Candidates should be informed that they will be assessed in simulations on both technical and non-technical skills, but also when observing and debriefing.
Reflective log:
Candidates can access electronic copy on VLE / paper copy on course
Capture reflections during the course that you can then utilise in the clinical environment
Time at end of day 2 to share your experiences and implementation of the APLS approaches in practice

5. Simulations You will play your own role
Each person will take a turn at leading, initially with a team of two
Further help will follow after the initial assessment and resuscitation is complete
You will then work as a full team, either retaining the lead or handing over
The debrief will cover technical and non-technical areas

6. Advanced Paediatric Life Support Educational support
Mentoring
Feedback
FACULTY INTRODUCTIONS
This would be a nice time to introduce (SHORT!) the faculty and they can each mention whose mentor and group they are.
Feedback here relates to that which candidates receive during the course

7. Advanced Paediatric Life Support Post course support
Access to website and VLE:
References, BestBETs, Guidelines
Updates, e-Scenarios
Online educational resource
Feedback: Post-course questionnaire on the VLE
Tweet about the APLS course on #apls
INSTRUCTOR NOTES
eScenarios for CPD are available on the ALSG web-site. Successful completion of five of these is awarded one CPD point from the RCPCH. Past e-scenarios continue to be available and instructors are encouraged to contribute to the development of new ones.

8. Advanced Paediatric Life Support
Mention any local fire regulations and to turn off mobile phones.
Introduction and house-keeping

9. Assessing and managing the seriously ill child
Advanced Paediatric Life Support
Assessing and managing the seriously ill child

10. Assessing and managing the seriously ill child: Objectives
To learn a rapid clinical assessment sequence to identify serious illness in a child
To understand the structured approach to the management of the seriously ill child
Structured approach is needed in the simulations
The rapid clinical assessment should take less than 60s (excl BP) – it follows the same order as treatment should be provided
Re-assessment using the same structure should be undertaken after any treatment
It is used as a communication tool between staff and for record keeping in the critically ill or injured child

11. Causes of cardiac arrest in children
Airway Obstruction
Respiratory Depression
Alveolar/Chest Wall Failure
Fluid Loss
Fluid Mal-distribution
Heart Failure
Foreign body, asthma, croup, bronchiolitis
Respiratory Failure
Cardiac Arrest
Circulatory Failure
Convulsions, sepsis, poisoning, ↑ICP
Pneumonia, chest trauma & myopathy
Bleeding, burns, diarrhoea, vomiting
Sepsis, anaphylaxis
Myocardial depression, congenital abnormality
Pathways to cardiac arrest
Talk about how assessment and intervention with the conditions on the left of the slide can prevent or slow progression to the serious consequences on the right of the slide. This involves rapid assessment of the seriously ill child (summarised on next slide).
Examples:
Respiratory obstruction: croup, asthma, bronchiolitis
Respiratory depression: post-ictal, meningitis, poisoning
Alveolar or chest wall failure: pulmonary contusion, flail chest, diaphragmatic hernia (traumatic or congenital)
Fluid loss: gastroenteritis, femoral / pelvic fractures
Fluid maldistribution: meningococcal shock, anaphylaxis
Heart failure: local anaesthetic toxicity, congenital heart disease

12. Advanced Paediatric Life Support Systematic approachB C D E
Primary assessment
Resuscitation
Secondary assessment – identification of key features
Emergency treatment
Stabilisation, transfer to definitive care
Stress the structured approach – reinforce:
the need to treat in order of the structured approach
the role of repeat assessments
the value of using this in record keeping and in communications between staff.

13. Rapid Assessment Airway and Breathing – Effort – Efficacy – Effects
Circulation
Heart rate
Pulse volume
Capillary refill time
Blood pressure
Skin temperature
Disability – Conscious level – Posture – Pupils
This should take less than 60s (apart from BP).
It is used for assessment, order of interventions, communication both written and verbal.

14. Interactive airway/breathing
Look at the videos
List all signs and symptoms of potential respiratory failure
Order these according to effort, efficacy and effect
Candidates are divided into their course groups
Ask them to look at the video(s) and produce a list of the signs and symptoms under the headings of effort, efficacy and effect
You may wish to write:
Effort
Efficacy
Effect
On a flipchart.
And ask the groups to feedback their list and write these up if you wish.

15. Interactive: list all signs/symptoms
Play each video and ask the candidates to list all of the signs and symptoms – you may need to adjust the sound

16. Interactive: list all signs/symptoms
No sound on this video – just visual signs

17. Potential respiratory failure
Effort of breathing
Efficacy of breathing
Effects of respiratory inadequacy
Note for instructors:
Effort: Respiratory rate, Accessory muscle use, Flaring of the nostrils, Child's position, Stridor (mostly inspiratory), Wheeze (expiratory), Grunting (end-expiratory – it may arise from alveolar / respiratory bronchiolar pathology, either primary, or secondary to peritonism or raised intracranial pathology)
Ask if there are exceptions (neuromuscular, exhaustion, central depression)
Efficacy: Look for chest expansion and symmetry, Listen in all areas, Pulse oximetry (colour), Normal SaO2 in oxygen does not rule out respiratory failure, with an elevated CO2.
Ask for imminent sign: silent chest
Effects on other systems:
Might be difficult to obtain all from the video. If necessary let them listen to what else the effects could be (Heart rate: tachycardia – bradycardia/ skin colour: Pallor, mottling secondary to endogenous epinephrine, cyanosis. Mental status: agitation, restlessness, reduced conscious level, coma
Pre terminal sign: sat <85% in air

18. Carlos’ case Carlos is three years old.
He has had a fever and been drowsy for just a few hours, but he is so unlike his usual active self that his mother is really worried about him and has brought him to the Emergency Department.
Present this case and the following slide and invite candidates to discuss in their groups the initial resuscitation and then think about the differential diagnosis of circulatory failure and the specific interventions that should be given.
Invite candidates to provide answers to next two slides, including any other key features that they can think of before moving on to Deepak’s case, e.g.:
bilious vomiting, abdominal pain and distension – surgical abdomen
pallor and splenomegaly – severe anaemia

19. Carlos’ case: Primary assessment and resuscitation
On examination
Resuscitation A
Patent
Call for help
Maintain airway (may need later intubation)
High flow oxygen
IV access and fluids (may need 2 to 3 boluses)
Bloods
Reassess B
Resp. rate 40/min
SpO2 not recordable
No significant recession C
Pale
Heart rate 170/min
Weak peripheral pulses
BP 65mmHg systolic
CRT 4 sec D
AVPU
Allow 2 minutes

20. Carlos’ case: emergency treatment?
Key Feature
Diagnosis
Treatment
Vomiting/ Diarrhoea
Gastroenteritis
IV/IO Fluid
Fever and rash
Septicaemia
Antibiotics
Allergen, urticaria
Anaphylaxis
Adrenaline
Signs of heart failure
CHD / Cardiomyopathy
Prostaglandin
Diuretics, inotropes
Abnormal rhythm on ECG
Arrhythmia
Arrhythmia algorithms
High blood glucose
Diabetes
Fluid
Insulin
Show key features and ask for diagnosis and emergency treatment.
Ask whether there are any other key features / diagnoses not listed here.
E.g. bilious vomiting, abdominal pain and distension – surgical abdomen
pallor and splenomegaly – severe anaemia
Allow 4 minutes

21. Potential circulatory failure
Cardiovascular signs
Effects of circulatory inadequacy
Ask randomly which are:
Cardiovascular signs (heart rate, pulse volume, CRT (should not be used as the sole measure of shock and is best obtained on the sternum), blood pressure)
Effects on other organs (resp rate, skin temperature and colour, mental status)

22. Deepak’s case Deepak is 13 years old.
He has been found unconscious in the local park. He has been brought by paramedics and his friend says that they haven’t been doing anything (but he smells of alcohol)
Present this case and the following slide and invite candidates to discuss in their groups the initial resuscitation and then think about the differential diagnosis of reduced conscious level and the specific interventions that should be given.
Invite candidates to provide answers to next two slides, including any other key features that they can think of before summing up. E.g.
headaches, acute onset – cerebrovascular event
headaches, high BP – hypertensive encephalopathy
vague and inconsistent history, other trauma in an infant – child abuse

23. Deepak’s case: Primary assessment and resuscitation
On examination
Resuscitation A
Snoring
Call for help
Open and protect airway
High flow oxygen
IV/IO access and fluids
Blood tests
Start to warm
Reassess B
Resp rate 12/min
No recession
SpO2 not recordable C
Heart rate 100/min
Pale
Cold peripheries
BP 100 mmHg systolic D
AVPU
Pupils: sluggish, equal and reactive E
Hypothermic - temperature 32oC
Allow 2 minutes

24. Deepak’s case: What emergency treatment?
Key Feature
Diagnosis
Treatment
History of epilepsy
Post ictal state
Supportive monitoring
Recent trauma
Head injury
Trauma algorithm
Known chronic condition
Diabetes
Metabolic condition
DKA algorithm
Acute onset and fever
Meningitis Encephalitis
Antibiotics
Possibility of poisoning
Drugs
Alcohol
Supportive
Antidotes
Show key features and ask for diagnosis and emergency treatment.
Ask whether there are any other key features / diagnoses not listed here.
E.g.
headaches, acute onset – cerebrovascular event
headaches, high BP – hypertensive encephalopathy
vague and inconsistent history, other trauma in an infant – child abuse
The use of the structured approach in these cases will help ensure early and appropriate treatment. Candidates may practice this in the illness simulations which follow.
Allow 4 minutes

25. Potential central neurological failure
Conscious level
Posture
Pupillary signs
For a full AVPU assessment, a response to pain must be undertaken (unless there is a response to voice). Discuss assessing pain – methods of producing a painful stimulus, and what response might be seen: motor, verbal, eyes. This can be used to introduce the fuller assessment with GCS or CCS.
Posture Certain postures will not be obvious and may only show themselves when a painful stimulus is given. Discuss difference decorticate/decerebrate
Pupils: Mention unilateral fixed dilated pupil and pin-point pupils as useful examples but that details of pupillary abnormalities will be described in the decreased conscious level interactive session.

26. Advanced Paediatric Life Support
Assessing and managing the seriously ill child

27. Rapid Assessment Airway and Breathing – Effort – Efficacy – Effects
Circulation
Heart rate
Pulse volume
Capillary refill time
Blood pressure
Skin temperature
Disability – Conscious level – Posture – Pupils
This should take less than 60 seconds (apart from BP). It is used for assessment, order of interventions, communication both written and verbal.

28. Cases in full for instructor use only

29. Carlos’ case: Primary assessment and resuscitation
On examination
Resuscitation A
Patent
Call for help
Maintain airway (may need later intubation)
High flow oxygen
IV access and fluids (may need 2 to 3 boluses)
Bloods
Reassess B
Resp rate 40/min
SpO2 not recordable
No significant recession C
Pale
Heart rate 170/min
Weak peripheral pulses
BP 65 mmHg systolic
CRT 4 sec D
AVPU
Allow 2 minutes

30. Carlos’ case: What emergency treatment?
Key Feature
Diagnosis
Treatment
Vomiting/ Diarrhoea
Gastroenteritis
IV/IO Fluid
Fever and rash
Septicaemia
Antibiotics
Allergen, urticaria
Anaphylaxis
Adrenaline
Signs of heart failure
CHD / Cardiomyopathy
Prostaglandin
Diuretics, inotropes
Abnormal rhythm on ECG
Arrhythmia
Arrhythmia algorithms
High blood glucose
Diabetes
Fluid
Insulin
Show key features and ask for diagnosis and emergency treatment.
Ask whether there are any other key features / diagnoses not listed here.
E.g.
bilious vomiting, abdominal pain and distension – surgical abdomen
pallor and splenomegaly – severe anaemia
Allow 4 minutes

31. Deepak’s case: Primary assessment and resuscitation
On examination
Resuscitation A
Snoring
Call for help
Open and protect airway
High flow oxygen
IV/IO access and fluids
Blood tests
Start to warm
Reassess B
Resp rate 12/min
No recession
SpO2 not recordable C
Heart rate 100/min
Pale
Cold peripheries
BP 100 mmHg systolic D
AVPU
Pupils: sluggish, equal and reactive E
Hypothermic - temperature 32oC
Allow 2 minutes

32. Deepak’s case: What emergency treatment?
Key Feature
Diagnosis
Treatment
History of epilepsy
Post ictal state
Supportive monitoring
Recent trauma
Head injury
Trauma algorithm
Known chronic condition
Diabetes
Metabolic condition
DKA algorithm
Acute onset and fever
Meningitis Encephalitis
Antibiotics
Possibility of poisoning
Drugs
Alcohol
Supportive
Antidotes
Show key features and ask for diagnosis and emergency treatment.
Ask whether there are any other key features / diagnoses not listed here.
E.g.
headaches, acute onset – cerebrovascular event
headaches, high BP – hypertensive encephalopathy
vague and inconsistent history, other trauma in an infant – child abuse
The use of the structured approach in these cases will help ensure early and appropriate treatment. Candidates may practice this in the illness simulations which follow.
Allow 4 minutes