Pediatric Advanced Life Support

Pediatric Advanced Life Support

Pediatric Chain of Survival Berg M D et al. Circulation 2010;122:S862-S875

Prevention Early cardiopulmonary resuscitation (CPR) Prompt access to the emergency response system Rapid pediatric advanced life support (PALS) Post cardiac arrest care

Infant - 1 month to 1 year of age Child 1 year of age until puberty Puberty is defined as Female - breast development Males - the presence of axillary hair

Cardiopulmonary arrest in children

Cardiopulmonary arrest in children Respiratory Shock Cardiac

Pediatric Assessment

The purposes of assessment Quickly recognize progressive respiratory failure and/or shock cardiac arrests Facilitate rapid evaluation and intervention for life-threatening conditions Prevent progression to cardiac arrest

Assessments Initial impression Primary assessment Secondary assessment Tertiary assessment

Evaluate-identify-intervene Evaluate Initial impression Primary assessment Secondary assessment Diagnostic test Intervene Identify

PALS systematic approach algorithm

Initial impression First few seconds Determine the next best steps Appearance Work of Breathing Circulation

Initial impression First few seconds Identify the general type of physiologic problem (ie, respiratory, circulatory, or neurologic) and ugency for treatment and transport

Initial impression Appearance Indicator of overall physiologic status, including degree of interactivity, muscle tone and verbal response or cry Level of consciousness, ability to interact Work of Breathing Circulation

Initial impression Appearance TICLS (tone, interactiveness, consolability, look/gaze, speech/cry) Work of Breathing Circulation

Initial impression Appearance Work of Breathing Evaluate the child s work of breathing, position and any audible breath sounds Circulation

Initial impression Appearance Work of Breathing Circulation (color) Skin color Pattern or obvious significant bleeding

Determine if life threatening Determine if life threatening Based on this initial crucial information, determine if the condition is Life threatening Start life-saving interventions and activate the ERS Not life threatening next step: primary assessment

Primary assessment Primary assessment is an hand-on evaluation of Respiratory function Cardiac function Neurological function

Primary assessment Airway Breathing Circulation Disability Exposure

Airway Patent or patent with maneuvers Partial or complete obstruction Look for movement of the chest and abdomen Listen for air movement and breath sounds

Airway Status Clear Maintainable Not maintainable Description Open, not obstructed Obstructed but can be maintained by head tilt chin lift Obstructed and need definite airway

Head tilt- chin lift Jaw thrust: trauma Open airway

Breathing Respiratory rate Respiratory effort Chest expansion and air movement Lung and airway sounds O 2 saturation by pulse oximetry

Breathing Chest expansion: Symmetrical chest rise during inspiration Air movement: evaluate distal air entry at area below both axillae Adventitious sounds: stridor, wheezing, grunting, gurgling, crackles

Normal respiratory rates by age Age Breath/min Infant (<1yr) 30-60 Toddler (1-3yr) 24-40 Preschooler (4-5yr) 22-34 School age (6-12yr) 18-30 Adolescent (13-18yr) 12-16 RR<10 or > 60/min at any age potential serious problem

Respiratory effort Breathing difficulty Location of retraction Description Mild to moderate Subcostal Abdomen, just below the rib cage Substernal Intercostal Abdomen at the bottom of the breastbone Between the ribs Severe Supraclavicular The neck just above the collar bone Suprasternal Sternal Chest just above the breast bone Sternum toward the spine

Categorize respiratory illness by type and severity Type of respiratory illness Upper airway obstruction Lower airway obstruction lung tissue disease disordered control of respiration respiratory distress respiratory failure Severity

Circulation Heart rate and rhythm Pulses (both central and peripheral) Capillary refill time Skin color and temperature Blood pressure

Normal heart rate by age Age Awake rate Mean Sleeping rate 0-3 mo 85-205 140 80-160 3 mo- 2 yr 100-190 130 75-160 2-10 yr 60-140 80 60-90 > 10 yr 60-100 75 50-90

Pulses Central pulses Femoral Brachial (infant) Carotid (older child) Axillary Peripheral pulses Radilal Dorsalis pedis Posterior tibial

Capillary refill time Evaluate in room temperature Lift the extremity slightly above the level of the heart and press on the skin Time from release pressure to skin color return to baseline Normal 2 sec

Hypotension Age Systolic blood pressure (mmhg) Term neonate (0-28 days) < 60 Infant (1-12 mo) < 70 Children 1-10 yr < 70 + (age in year x 2) Children > 10 yr < 90

Shock Early sign of shock: tachycardia Late sign of shock: hypotension

Categorized circulatory illness by type and severity Type of circulatory illness Hypovolemic shock Obstructive shock Distributive/septic shock Cardiogenic shock Severity Compensated shock Hypotensive shock

Disability Standard evaluation AVPU (Alert, Response to Voice, Response to Pain, Unresponsive) pediatric response scale Glasgow Coma Scale (GCS) Pupil response to light

Modified GCS for infant and children Child Infant Score Eye opening Spontaneous Spontaneous 4 To speech To speech 3 To pain To pain 2 None None 1 Best verbal response Oriented appropriate Coos and babbles 5 Confused Irritable, cries 4 In appropriate words Cries in response to pain 3 Incomprehensible sounds Moans in response to pain 2 None None 1 Best motor response Obeys commands Move spontaneously and purposely 6 Localized painful stimulus Withdrawals in response to touch 5 Withdraws in response to pain Withdrawals in response to pain 4 Flexion in response to pain Abnormal flexion posture to pain 3 Extension in response to pain Abnormal extension posture to pain 2 None None 1

Level of head injury Mild head injury: GCS score 13-15 Moderate head injury: GCS score 9-12 Severe head injury: GCS score 3-8

Exposure Undress the child as necessary to perform a focused physical examination Face, head, trunk (front and back), extremities and skin Evidences of trauma, bleeding, burn, deformity, petechiae, ecchymosis Keep the child comfortable and warm Core temperature

Life threatening problems A B C D E Complete and severe airway obstruction Apnea, significant increase work of breathing, bradypnea Absence of palpable pulse, poor perfusion, hypotension, bradycardia Unresponsiveness, decrease level of consciousness Significant hypothermia, significant bleeding, petechiae, or purpura consistent with septic shock

PALS systematic approach algorithm

Secondary assessment After primary survey The child was stabilized Focus on history and physical examination

Secondary assessment Signs and symptoms Allergies Medications Past medical history Last meal Event

Signs and symptoms at the onset of illness Breathing difficulty Level of consciousness Fever Oral intake Diarrhea, vomiting Bleeding Fatigue Time course of illness

Allergies Medication Food Latex etc

Medications Medications Last dose and time of recent medications

Past medical history Health history (eg, prematurity) Significant underlying medical problem (eg, asthma, chronic lung disease, arrhythmia, seizure, DM) Past surgeries Immunization status

Last meal Time and nature of last intake of liquid or food (including breast or bottle feeding in infant)

Events Event leading to current illness or injury (eg, onset sudden or gradual, type of injury) Hazard at scene Treatment during interval from onset of disease or injury until evaluation Estimated time of arrival (if out of hospital onset)

Focus on physical examination Careful assessment of the primary area of concern of the illness or injury Brief head to toe evaluation

PALS systematic approach algorithm

Tertiary assessment (diagnostic tests) Respiratory and circulatory problems ABG VBG Hemoglobin concentration Central venous oxygen saturation Arterial lactate CVP monitoring Invasive arterial pressure monitoring CXR ECG Echocardiogram Peak expiratory flow rate

PALS systematic approach algorithm