Download PEDIATRIC Advanced Life Support

PEDIATRIC
Advanced
Life Support
Neva Batayola, MD
Pediatric Critical Care
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
Pediatric Chain of Survival
prevention
Early CPR
EMS
Rapid PALS
Intergrated
Post-cardiac
Arrest care
Berg, M. D. et al. Circulation 2010;122:S862-S875
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
CPR: ABC IS FOR BABIES. NOW IT’S C-A-B!
NEW
OLD
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
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.
Pathway to pediatric cardiac arrest
AHA Pediatric Advanced Life Support. 2006
Assessment: Key to Pediatric
Management
Life
threatening
Life threatening
Not life
Not life threatening
threatening
AHA Pediatric Advanced Life Support Manual 2006
What We
Had…
General Assessment
(PAT)
Primary Assessment
Secondary Assessment
Tertiary Assessment
Assess-Categorize-Decide-Act Model
Pediatric Advanced Life Support 2006
The PAT & the Primary, Secondary & Tertiary Surveys
AHA Pediatric Advanced Life Support. 2006
What’s
Initial Impression
NEW…
Evaluate
Primary assessment
Secondary assessment
Diagnostic tests
Intervene
Identif y
Evaluate-Identify-Intervene Sequence Pediatric Advanced Life Support 2010
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
C–B-C
Consciousness
Breathing
Color
Initial Impression
Unresponsive, irritable,
alert
Increased work of
breathing, absent or
decreased respiratory
effort, or abnormal sounds
heard without ausculation
Pallor, mottling, cyanosis
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>60
begin EII sequence
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.
The E-I-I Sequence: Evaluate
Clinical Assessment
Primary Assessment
Secondary Assessment
Diagnostic Tests
What It Is
Rapid, hands-on ABCDE approach
evaluating respiratory, cardiac &
neurologic function; includes vital
signs & pulse oximetry
Focused medical history &
physical exam
Laboratory, radiographic & other
advanced tests that help to
identify the child’s physiologic
condition & diagnosis
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
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
AHA Pediatric Advanced Life Support.2010
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
AHA Pediatric Advanced Life Support.2010
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
Pediatric Primary Assessment
DISABILITY




AVPU Pediatric Response
Scale (cerebral cortex fxn)
GCS
Pupillary response
Blood sugar
Decreased LOC
Loss of muscle tone
Irritability, lethargy, agitation
Generalized seizures
Pupil dilatation
EXPOSURE



Hypo/hyperthermia
Evidence of trauma
or injury
Rash
Pediatric Secondary Assessment
S
 Focused history
E

Signs and symptoms
Allergies
Medications
Past Medical History
Last Meal
Events

Detailed PE





L
A
M
P
Focused medical hx using
SAMPLE mnemonic and a
thorough head-to-toe P.E.
AHA Pediatric Advanced Life Support. 2010
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
The E-I-I Sequence: IDENTIFY
Type
Respiratory
Upper Airway Obstruction
Lower Airway Obstruction
Lung Tissue Disease
Disordered Control of
Breathing
Circulatory
Severity
Respiratory Distress
Respiratory Failure
Hypovolemic Shock
Compensated Shock
Distributive Shock
Cardiogenic Shock
Hypotensive Shock
Obstructive Shock
Cardiopulmonary Failure
Cardiac Arrest
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)
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
IDENTIFY the problem
Respiratory distress or respiratory failure
INTERVENE
Open airway if needed, give 100% O2 via nonrebreathing mask in tolerated, attach to monitor,
apply pulse oximeter
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
IDENTIFY
Respiratory distress vs respiratory failure;
Upper Airway Obstruction
INTERVENE
Assess response to 02; analyze cardiac rhythm
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
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
IDENTIFY
Respiratory distress vs respiratory failure; Upper Airway Obstruction
IDENTIFY
Respiratory distress vs respiratory failure; Upper Airway Obstruction
INTERVENE
Allow position of comfort; consider specific interventions for
UAO (eg. Racemic epinephrine, IV/IM dexamethasone, helium02 mixture, etc.; consider vascular access IV/IO; prepare for
endotracheal intubation
EVALUATE – Diagnostic Tests


ABG / VBG, electrolytes, BUN/creatinine, glucose, CBC
with differential
Imaging as appropriate
RE-EVALUATE – IDENTIFY – INTERVENE
after each intervention
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
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
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
Upper airway obstruction







Foreign body aspiration
Epiglottitis
Croup
Anaphylaxis
Tonsillar hypertrophy
Mass compromising the airway lumen
(abscess, tumor)
Congenital airway abnormality (congenital
subglottic stenosis)
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
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
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)
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
Bag-Mask Ventilation





Appropriate face mask (extending from
bridge of the nose to cleft of the chin)
Self inflating ventilation bag
Bag size: 400-500 ml infant/young child
1000 ml older child/adolescent
Position: neutral or sniffing
E-C clamp technique
Breathing: EC clamp technique
Bag-Mask Ventilation
Tracheal Tube- size and depth
Uncuffed tube size:
<1yr
3.5mm ID
1-2 yr
4.0mm ID
>2 yr
4 + (Age/4)
Cuffed tube size:
<1yr
3.0 mm ID
1-2 yr
3.5 mm ID
>2 yr
3.5 + (Age/4)
ETT depth (lip):
ETT size x 3
AHA, Basic Life Support Textbook,2007
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
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)
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:
70 + (age in yrs x 2 ) mmHg
>10 yrs
<90mmHg
Typical MAP: 55 + (age in yrs x 1.5) mmHg
COMPENSATED SHOCK
Possibly Hours
HYPOTENSIVE SHOCK
Potentially Minutes
CARDIAC ARREST
AHA Pediatric Advanced Life Support Manual 2011
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
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
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
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.
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%
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, dopamineresistant 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
(0.03-1.5mcg/k/min)
Phosphodiesterase inhibitors
for catecholamine-refractory low cardiac output and
high SVR
milrinone 50-75 mcg/kg iv loading 60 min
0.375-0.75 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; 6:195-199
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

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)
Vasopressin



Endogenous levels decrease in
vasodilatory shock
potent vasoactive agent in the treatment
of vasodilatory shock in adults and
children
Dose: 0.0005-0.002 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. 2009 Oct
1;180(7):632-9. Epub 2009 Jul 16.
PALS Pulseless Arrest Algorithm.
Kleinman M E et al. Pediatrics 2010;126:e1361-e1399
©2010 by American Academy of Pediatrics
PALS Bradycardia Algorithm.
Kleinman M E et al. Pediatrics 2010;126:e1361-e1399
©2010 by American Academy of Pediatrics
PALS Tachycardia Algorithm.
Kleinman M E et al. Pediatrics 2010;126:e1361-e1399
©2010 by American Academy of Pediatrics
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
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
The Resuscitation Team
airway






Team leader
Airway
Compressor
IV / IO meds
Monitor / Defibrillator
Observer/ Recorder
I
IV/IO
meds
V
/
comressor
Monitor/
defibrillator
Observer/
recorder
Team leader
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
THANK
YOU