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PEDIATRIC Advanced Life Support

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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


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