1. PEDIATRIC Advanced Life Support
Neva Batayola, MD
Pediatric Critical Care

2. What is PALS all about?
Evaluating and recognizing an infant or child with respiratory compromise, circulatory compromise, or cardiac arrest
Giving timely and appropriate treatment or interventions
Applying effective team dynamics, observing individual roles and responsibilities during pediatric resuscitation
Providing optimal post resuscitation management

3. Pediatric Chain of Survival
For best survival and quality of life, pediatric life support includes prevention, early cardiopulmonary resuscitation (CPR), prompt access to the emergency response system, and rapid pediatric advanced life support (PALS), followed by integrated post–cardiac arrest care. These 5 links form the American Heart Association (AHA) pediatric Chain of Survival (Figure 1), the first 3 links of which constitute pediatric BLS.
Early CPR
EMS
Rapid PALS
Intergrated
Post-cardiac
Arrest care
prevention
Berg, M. D. et al. Circulation 2010;122:S862-S875

4. BLS: foundation of saving lives
Fundamental aspects:
immediate recognition of sudden cardiac arrest ( unconsciousness)
activation of emergency response system ( call 911 )
early performance of CPR (C A B steps)
rapid defibrillation (AED) when appropriate
BLS or early administration of CPR is the foundation of saving lives following cardiac arrest.

5. CPR: ABC IS FOR BABIES. NOW IT’S C-A-B!
NEW
OLD

6. High quality CPR…
Chest compressions of appropriate rate and depth. "Push fast": push at a rate of at least 100 compressions per minute. "Push hard": push with sufficient force to depress the chest (at least 1/3 of the AP diameter of the chest or approximately 1½ in. = 4 cm in infants and approximately 2 in. = 5 cm in children)
allowing complete recoil of the chest after each compression
minimizing interruptions in compressions
avoiding excessive ventilation

7. High quality CPR = Effective PALS
the cornerstone of a system of care that can optimize outcomes beyond return of spontaneous circulation (ROSC).
Return to a prior quality of life and functional state of health is the ultimate goal of a resuscitation system of care.

8. Pathway to pediatric cardiac arrest
In infants and children, cardiac arrest most commonly results from progressive respiratory failure, shock or both. Less commonly, it can occur suddenly, secondary to either a VF or VT.
AHA Pediatric Advanced Life Support

9. Assessment: Key to Pediatric Management
Life threatening
Not life threatening
Life threatening
Once cardiac arrest occurs, even with optimal resuscitation efforts, the outcome is generally poor. For this reason, one needs to know the important concepts of pediatric assessment, as it is the key to pediatric management. Assessment identifies life threatening situations which need rapid systematic intervention to prevent progression to cardiac arrest.
Not life threatening
AHA Pediatric Advanced Life Support Manual 2006 9

10. What We Had… General Assessment ( P A T ) Primary Assessment
Secondary Assessment
Tertiary Assessment
The Assess-Categorize-Decide-Act model was used to evaluate and treat pediatric patients, especially those who were seriously ill or injured. Initial and repeated assessment allowed one to determine the best treatment or intervention at any point in time. From the information gathered during assessment, one categorized the clinical condition of the child by type and severity, decided what needed to be done and acted to implement appropriate treatment. The whole process is repeated until patient stabilization was achieved.
Assess-Categorize-Decide-Act Model
Pediatric Advanced Life Support 2006

11. The PAT & the Primary, Secondary & Tertiary Surveys
AHA Pediatric Advanced Life Support. 2006

12. What’s NEW… I n i t i a l I m p r e s s i o n E v a l u a t e
Primary assessment
Secondary assessment
Diagnostic tests
I n t e r v e n e
I d e n t i f y
Evaluate-Identify-Intervene Sequence Pediatric Advanced Life Support 2010

13. The Initial Impression
A modification of the PAT, the goal of which is to help one quickly recognize a child at risk for deterioration and prioritize actions and interventions
The first quick (within seconds) “from the doorway” visual and auditory observation of the child’s consciousness, breathing and color

14. C – B - C Initial Impression Consciousness
Unresponsive, irritable, alert
Breathing
Increased work of breathing, absent or decreased respiratory effort, or abnormal sounds heard without ausculation
Color
Pallor, mottling, cyanosis

15. Initial Impression: DECISION & ACTION POINTS
Unresponsive and not breathing or only gasping
Call for help
Check pulse
(-) pulse, start CPR beginning with compressions
if with ROSC begin E-I-I sequence
(+) pulse rescue breathing
HR<60 & poor perfusion despite adequate oxygenation/ventilation chest compressions & ventilations
HR> begin EII sequence

16. Initial Impression: DECISION & ACTION POINTS
Findings normal or non-urgent, child breathing adequately
begin E-I-I sequence
Always be alert to a life-threatening situation. If at any point you identify
a life-threatening problem, call for help and begin lifesaving interventions.

17. The E-I-I Sequence: Evaluate
Clinical Assessment
What It Is
Primary Assessment
Rapid, hands-on ABCDE approach evaluating respiratory, cardiac & neurologic function; includes vital signs & pulse oximetry
Secondary Assessment
Focused medical history & physical exam
Diagnostic Tests
Laboratory, radiographic & other advanced tests that help to identify the child’s physiologic condition & diagnosis
EVALUATE… to gather information about the child’s condition or status

18. Pediatric Primary Assessment
Airway, Breathing, Circulation, Disability, Exposure
rapid ordered, stepwise hands-on evaluation of cardiopulmonary and neurologic function to prioritize treatment
Includes vital signs & O2 saturation by pulse oximetry

19. Pediatric Primary Assessment
AIRWAY
open?
movement of the chest/abdomen?
air movement and breath sounds?
Decide if:
Clear – open / unobstructed
Maintainable – simple measures
not maintainable - advanced interventions
Simple Measures: positioning, head tilt-chin lift / modified jaw thrust, FBAO relief, airway adjuncts (NPA, OPA)
ADVANCED interventions: endotracheal intubation, LMA, CPAP, cricothyrotomy
AHA Pediatric Advanced Life Support.2010

20. Pediatric Primary Assessment
BREATHING
Respiratory rate (RR)
Normal, Irregular, Fast, Slow, Apnea
Respiratory effort
Normal, Increased, Inadequate
Chest expansion & air movement (TV)
Normal, Decreased, Unequal, Prolonged expiration
Lung and airway sounds
Pulse oximetry (SaO2)
Normal, Hypoxemic
Evaluate RR before hands on assessment SaO2 normal 95% and higher % = Pa02 60mmHg
Count no of times the chest rises in 30sec and multiply by 2
A consistent RR <10 or >60 in a child of any age is abnormal and suggests the presence of a potentially serious problem.
RATE: tachypnea, bradypnea, apnea (central, obstructive, mixed)
RESPIRATORY EFFORT: nasal flaring, retractions (mild to mod = subcostal, substernal, intercostal; severe = retractions as in mild to mod plus supraclavicular, suprasternal, sternal) , head bobbing (use of neck muscles), seesaw respirations
Retractions + stridor or inspiratory snoring sound = upper airway obstruction
Retractions + expiratory wheeze = marked lower airway obstruction (asthma, bronshiolitis)
Retractions + grunting or labored respirations = lung tissue disease
Lung/airway sounds: stridor(inspiratory or inspiratory/expiratory), grunting (expiratory; sign of severe respiratory distress or failure), gurgling (inspiratory or expiratory), wheezing (mostly expiratory), crackes (sharp, crackling ispiratory sounds)
AHA Pediatric Advanced Life Support.2010

21. Pediatric Primary Assessment
CIRCULATION
Heart Rate (HR) & rhythm
Pulses (central & peripheral)
CRT
Skin color and temperature
Blood Pressure (BP); in children <3 yrs, attempt only once
Level of consciousness
Urine output
CENTRAL pulses: femoral, brachial (infants), carotid (older children), axillary
PERIPHERAL pulses: radial, dorsalis, posterior tibial
CRT ≤ 2 sec is normal
COLOR: pallor, mottling, cyanosis
URINE OUTPUT: 1 cc/kg/hr adult: 1ml/min or 60ml/hr

22. Pediatric Primary Assessment
EXPOSURE
Hypo/hyperthermia
Evidence of trauma
or injury
Rash
DISABILITY
AVPU Pediatric Response Scale (cerebral cortex fxn)
GCS
Pupillary response
Blood sugar
BLOOD SUGAR: good range mg/dl hypoglycemia: <55 in children <35-45 in neonates
Decreased LOC
Loss of muscle tone
Irritability, lethargy, agitation
Generalized seizures
Pupil dilatation

23. Pediatric Secondary Assessment
Focused history
Signs and symptoms
Allergies
Medications
Past Medical History
Last Meal
Events
Detailed PE S E A L M P
Focused medical hx using SAMPLE mnemonic and a
thorough head-to-toe P.E.
AHA Pediatric Advanced Life Support. 2010

24. Diagnostic Tests
Assessment of respiratory and circulatory abnormalities
ABG, VBG, Hb, Blood sugar
Pulse oximetry, CXR
Capnography (ETC02), exhaled C02
Sv02 saturation, arterial lactate
CVP, 2DEcho, ECG, PEFR
Invasive arterial pressure monitoring

25. The E-I-I Sequence: IDENTIFY
Type Severity
Respiratory Upper Airway Obstruction Respiratory Distress
Lower Airway Obstruction Respiratory Failure
Lung Tissue Disease
Disordered Control of
Breathing
Circulatory Hypovolemic Shock Compensated Shock
Distributive Shock Hypotensive Shock
Cardiogenic Shock
Obstructive Shock
Cardiopulmonary Failure
Cardiac Arrest
IDENTIFY… any problem by type and severity

26. The E-I-I Sequence: INTERVENE
Positioning to maintain a patent airway
Activating ERS or calling a code
Starting CPR
Obtaining the code cart & monitor
Placing the pt on a cardiac monitor & pulse oximeter
Administering oxygen
Supporting ventilation
Starting medications & fluids (e.g., nebulizer treatment, IV/IO fluid bolus)
INTERVENE… with appropriate actions to treat the problem

27. Let’s look at a scenario…
You are on duty at the ER and the nurse asks you evaluate a 10-yr-old with difficulty breathing 15 min after eating.
Initial impression: anxious, with increased inspiratory effort and stridor, with pale skin

28. IDENTIFY the problem
Respiratory distress or respiratory failure
INTERVENE
Open airway if needed, give 100% O2 via non-rebreathing mask in tolerated, attach to monitor, apply pulse oximeter

29. EVALUATE – Primary Assessment
Airway: inspiratory stridor
Breathing: RR 30/min, deep suprasternal retractions, nasal flaring, poor aeration on auscultation, SP02 90% room air
Circulation: HR 130/min, peripheral pulses normal, CRT 2 sec, BP 115/75 mmHg
Disability: somewhat anxious
Exposure: T 37ºC
INTERVENE… with appropriate actions to treat the problem

30. Respiratory distress vs respiratory failure; Upper Airway Obstruction
IDENTIFY
Respiratory distress vs respiratory failure;
Upper Airway Obstruction
INTERVENE
INTERVENE… with appropriate actions to treat the problem
Assess response to 02; analyze cardiac rhythm

31. EVALUATE – Secondary Assessment: SAMPLE History
Signs and symptoms: difficulty breathing 15 min after eating a cookie
Allergies: Peanuts
Medications: None
Past medical history: previously healthy
Last meal: had only a cookie since breakfast
Events: difficulty of breathing began within several min of eating a cookie
INTERVENE… with appropriate actions to treat the problem

32. EVALUATE – Secondary Assessment: P.E.
Vital signs after 02: HR 120/min RR 20/min SP02 98% at 100% 02 BP 115/75 mmHg
HEENT: stridor at rest
Heart & Lungs: no murmur, breath sounds course, CRT 2 sec
Abdomen: normal
Extremities: no edema
Back: normal
Neurologic: somewhat anxious
INTERVENE… with appropriate actions to treat the problem
IDENTIFY
Respiratory distress vs respiratory failure; Upper Airway Obstruction

33. IDENTIFY
Respiratory distress vs respiratory failure; Upper Airway Obstruction
INTERVENE
INTERVENE… with appropriate actions to treat the problem
Allow position of comfort; consider specific interventions for UAO (eg. Racemic epinephrine, IV/IM dexamethasone, helium-02 mixture, etc.; consider vascular access IV/IO; prepare for endotracheal intubation

34. EVALUATE – Diagnostic Tests
ABG / VBG, electrolytes, BUN/creatinine, glucose, CBC with differential
Imaging as appropriate
INTERVENE… with appropriate actions to treat the problem
RE-EVALUATE – IDENTIFY – INTERVENE after each intervention

35. Identification of Respiratory Problems
By severity
1. respiratory distress
2. respiratory failure
By type
1. upper airway obstruction
2. lower airway obstruction
3. lung tissue disease
4. disordered control of breathing

36. Respiratory distress
Clinical state characterized by abnormal respiratory rate (tachypnea) or effort (increased or inadequate)
Ranges from mild to severe
Signs: tachypnea, increased/inadequate respiratory effort, abnormal airway sounds, tachycardia, pale cool skin, alteration in consciousness

37. Respiratory Failure
Inadequate ventilation, insufficient oxygenation, or both
Signs:
- ↑RR, signs of distress (eg, ↑respiratory effort: nasal flaring, retractions, seesaw breathing, or grunting)
- inadequate respiratory rate, effort, or chest excursion (eg, diminished breath sounds or gasping), especially if mental status is depressed
- Cyanosis with abnormal breathing despite supplementary oxygen

38. Upper airway obstruction
Foreign body aspiration
Epiglottitis
Croup
Anaphylaxis
Tonsillar hypertrophy
Mass compromising the airway lumen (abscess, tumor)
Congenital airway abnormality (congenital subglottic stenosis)

39. Lower airway obstruction
Obstruction of the lower airways (lower trachea, bronchi, bronchioles)
Asthma, bronchiolitis
Tachypnea, expiratory/inspiratory/biphasic wheezing, increased respiratory effort, prolonged expiratory phase

40. Lung tissue disease
Heterogenous group of clinical conditions affecting the lung at the level of gas exchange, characterized by alveolar and small airway collapse or fluid-filled alveoli
Pneumonia (bacterial, viral, chemical), pulmonary edema (CHF, ARDS), pulmonary contusion, toxins, vasculitis, infiltrative disease

41. Disordered control of breathing
Abnormal breathing pattern producing signs of inadequate respiratory rate, effort, or both
Neurologic disorders (seizures, CNS infections, head injury, brain tumor, hydrocephalus, neuromuscular disease)

42. Initial management of respiratory distress or failure
AIRWAY
position of comfort
open airway (head tilt-chin lift, modified jaw thrust)
clear airway (suction, remove FB)
consider OPA, NPA
BREATHING
monitor Sp02, provide 02, assist ventilation
inhaled medication as needed
endotracheal intubation if needed
CIRCULATION
monitor HR, rhythm, BP
establish vascular access as indicated

43. Bag-Mask Ventilation
Appropriate face mask (extending from bridge of the nose to cleft of the chin)
Self inflating ventilation bag
Bag size: ml infant/young child
1000 ml older child/adolescent
Position: neutral or sniffing
E-C clamp technique

44. Bag-Mask Ventilation Breathing: EC clamp technique
No advanced airway: 1 breath every 3-5 sec
Advanced airway: I breath every 6-8 sec 44

45. Tracheal Tube- size and depth
Uncuffed tube size:
<1yr 3.5mm ID
1-2 yr 4.0mm ID
>2 yr (Age/4)
Cuffed tube size:
<1yr 3.0 mm ID
1-2 yr 3.5 mm ID
>2 yr (Age/4)
ETT depth (lip):
ETT size x 3
AHA, Basic Life Support Textbook,2007 45

46. Shock
Results from inadequate blood flow and oxygen delivery to meet tissue metabolic demands
Typical signs of compensated shock include
Tachycardia
Cool and pale distal extremities
CRT >2 sec despite warm ambient temp
Weak peripheral vs central pulses
Normal systolic blood pressure

47. Identification of Shock
By severity (effect on BP)
Compensated shock
Hypotensive
By type
Hypovolemic (diarrhea, vomiting, hge, burns)
Distributive (septic, anaphylactic, neurogenic)
Cardiogenic (CHD, myocarditis, arrhythmias, sepsis)
Obstructive (cardiac tamponade, tension pneumothorax, ductal-dependent lesions, massive PE)

48. Blood Pressure Typical SBP 1-10 y.o. (50th percentile)
90 + (age in yrs x 2) mmHg
Hypotension (5th percentile)
term neonates <60mmHg
up to 12 months <70mmHg
1-10 yrs: (age in yrs x 2 ) mmHg
>10 yrs <90mmHg
Typical MAP: 55 + (age in yrs x 1.5) mmHg

49. COMPENSATED SHOCK Possibly Hours HYPOTENSIVE SHOCK Potentially Minutes
Compensated shock needs to be recognized as soon as it occurs as it can go on for hours, progress into hypotensive shock which can in minutes lead to cardiac arrest.
CARDIAC ARREST
AHA Pediatric Advanced Life Support Manual 2011

50. Shock management Optimizing 02 content of the blood
Improving volume & distribution of cardiac output
Reducing 02 demand
Correcting metabolic derangements
Identifying and reversing the underlying cause of shock
High flow O2, invasive or noninvasive MV, blood transfusion if low Hb
Rapid volume resuscitation with crystalloid/colloid
Noninvasive ventilation, endotracheal intubation and assisted ventilation
Correct hypoglycemia, hypocalcemia, hypo-hyperkalemia, metabolic acidosis

51. 10 steps of goal-directed management of pediatric shock
1. Recognize shock at time of triage
2. Transfer pt immediately to shock/trauma room and amass resuscitation team
3. Begin Oxygen and establish IV access using 90 sec for peripheral attempts
4. If unsuccessful after 2 peripheral attempts, consider IO
5. Palpate for hepatomegaly; auscultate for rales

52. 10 steps of goal-directed management of pediatric shock
6. If liver is up and if no rales are present, push 20ml/kg boluses of isotonic saline up to 60ml in 5-10min until improved perfusion or liver comes down or patient develops crackles. Give blood if with unresponsive hemorrhagic shock
If liver is down, beware of cardiogenic shock. Consider inotropic support ( PGE1 to maintain ductus arteriosus in all neonates).
7. If CRT>2 sec and/or hypotension persists during fluid resuscitation, begin IO / peripheral Epinephrine

53. 10 steps of goal-directed management of pediatric shock
8. If at risk for adrenal insufficiency give hydrocortisone as bolus (50mg/kg) and then as infusion titrating between 2-50 mg/kg/day
9. If continued shock, intubate and support ventilation mechanically.
10. Direct therapy to goals: CRT < 3sec, normal BP for age, improving shock index.

54. Therapeutic End Points
RESUSCITATION TO CLINICAL GOALS IS THE FIRST PRIORITY!
Normal mental status
Normal pulses (no differential between peripheral & central)
Equal central and peripheral temperatures/warm extremities
CRT < 2 sec
Normal HR & BP for age
Urine output > 1cc/kg/hr
↓ serum lactate (<2mmol/L)
Reduced base deficit
Central venous 02 sat (SvO2) > 70%

55. Hemodynamic Support
Dopamine – 1st line vasopressor for fluid-refractory hypotensive shock with low SVR (10-20mcg/k/min); increase myocardial contractility after preload restoration.
Epinephrine – 1st line inotrope for fluid refractory, dopamine-resistant nonvasodilatory shock (0.02-1mcg/k/min, to as high as 2-3 mcg/kg/min in severe cases)
Norepinephrine – 1st line pressor agent for fluid refractory, dopamine-resistant vasodilatory (“warm”, hyperdynamic) shock ( mcg/k/min)

56. Phosphodiesterase inhibitors
for catecholamine-refractory low cardiac output and high SVR
milrinone mcg/kg iv loading 60 min
mcg/kg/min continuous infusion
increases contractility & improves diastolic function by decreased degradation of cAMP and increased intracellular calcium release
Pediatric Critical Care Medicine 2005; 6:

57. Phosphodiesterase inhibitors
Amiodarone (inodilator)
5 mg/kg iv 30 min
5-10 mcg/kg/min infusion
improves myocardial depression and does not increase SVR or the metabolic demands of the heart
Pediatric Critical Care Medicine 2001, 2:24-28

58. Dobutamine (2-20mcg/kg/min)
not to be used alone in severe shock
increases cardiac contractility and decreases PVR (afterload)
Vasodilator therapy (Nitroprusside/NTG) for epinephrine-resistant low CO and elevated SVR, normal blood pressure (afterload unloader)
may need simultaneous inotropic support
always augment volume (preload)

59. Vasopressin Endogenous levels decrease in vasodilatory shock
potent vasoactive agent in the treatment of vasodilatory shock in adults and children
Dose: U/kg/min
varying doses in studies
Pediatr Crit Care Med 2008 Vol. 9, No. 4 Vasopressin in pediatric vasodilatory shock: a multicenter randomized controlled trial. Choong K. et al., Am J Crit Care Med Oct 1;180(7): Epub 2009 Jul 16.

60. PALS Pulseless Arrest Algorithm.
Kleinman M E et al. Pediatrics 2010;126:e1361-e1399
©2010 by American Academy of Pediatrics

61. PALS Bradycardia Algorithm.
Kleinman M E et al. Pediatrics 2010;126:e1361-e1399
©2010 by American Academy of Pediatrics

62. PALS Tachycardia Algorithm.
Kleinman M E et al. Pediatrics 2010;126:e1361-e1399
©2010 by American Academy of Pediatrics

63. Teamwork divides the tasks while multiplying the chances of success
PALS means TEAMWORK
Resuscitation = medical expertise and mastery of skills = multiple tasks
Teamwork divides the tasks while multiplying the chances of success
Successful resuscitation = effective communication and team dynamics

64. If you want to be on the team & make a difference…
Learn the science of PALS and learn it well
Understand your role and the role of every member of your team in resuscitation
Understand how teamwork increases the chances of resuscitation success

65. The Resuscitation Team
airway
Team leader
Airway
Compressor
IV / IO meds
Monitor / Defibrillator
Observer/ Recorder
IV/
IV/IO meds
comressor
Monitor/
defibrillator
Observer/ recorder
Team leader

66. Elements of effective resuscitation team dynamics
Closed-loop communication
Clear messages
Clear roles and responsibilities
Knowing limitations
Knowledge sharing
Constructive intervention
Reevaluation and summarizing
Mutual respect

67. THANK YOU