PALS – 2010 Guidelines Helpful Information Life Support Education

Pediatric Assessment Triangle P A T Appearance Work of Breathing Circulation

Pediatric assessment triangle

Pediatric Chain of Survival Prevention Early CPR Prompt Access to EMS Rapid Pediatric Advanced Life Support (PALS) Integrated Post-Cardiac Arrest Care

SYSTEMATIC APPROACH Evaluate Identify Intervene Primary Assessment Secondary Assessment Focused Exam SAMPLE History Intervene Diagnostic Tests Tertiary Assessment

assessment

Airway & Respiratory Considerations OPA – NPA – When do we use them Signs of progressive Respiratory Failure - Respirations decreasing and more lethargic Following Breathing Treatments – ABC’s Indications for needle decompression Treatment options for allergic reactions

AIRWAY MANAGEMENT Rescue Breathing One (1) Rescue Breath every 3 – 5 Seconds Pediatric Patient with a pulse but not breathing BVM = 1 Breath every 3 – 5 seconds Has an ET Tube = 1 Breath every 3 – 5 seconds CPR with advanced airway – Continuous Compressions and 1 breath every 6 – 8 seconds (8 – 10/minute)

ET Tube Sizes UN-Cuffed Age/4 + 4 Cuffed Age/4 + 3.5 Listen------- Epigastric AXilla Lungs

breathing Diminished breath sounds Diminished rise of the chest on one side Respiratory distress with stridor (possible allergic reaction (Epi IM) Barking cough (moderate stridor & retractions) (Nebulized Epi)

Airway & Respiratory Considerations Oxygen should be administered to patients with low O2 saturations and increased work of breathing Nebulized Epinephrine is for stridor, mild to moderate retractions, barking cough

Additional Information Tracheal deviation – absence of breath sounds - Needle decompression Following a seizure – ABC’s manage airway/breathing Equipment Treat patient

Blood Pressure- Lower 5th percentile Estimate of Minimum Systolic Blood Pressure Age Minimum systolic blood pressure 0 to 1 month 60 mm Hg >1 month to 1 year 70 mm Hg 1 to 10 years of age 70 mm Hg + (2 x age in years) >10 years of age 90 mm Hg

Rhythm disturbances Hypovolemic – Fluid boluses SVT- Vagal Maneuvers – Adenosine 0.1 mg/kg Adenosine 0.2 mg/kg Synchronized Cardioversion - 0.5 - 1 joules Synchronized Cardioversion – 2 joules/kg

Bradycardia in Pediatrics Initial thoughts - Oxygenation and Ventilation CPR if HR <60/min with poor perfusion despite oxygenation and ventilation Expert Consultation Epinephrine - .01 mg/kg every 3 – 5 minutes May consider Atropine 0.02 mg/kg if vagal response Consider pacing if not responding or heart blocks Treat underlying cause (H’s & T’s)

Narrow Complex Tachycardia in Pediatrics SVT (Supraventricular tachycardia) Children - > 180 Infants - > 220 History – Level of Consciousness Vagal Maneuvers IV/IO Access Adenosine 0.1 mg/kg (max 6mg) 0.2 mg/kg (max 12 mg) [second dose] No Access or condition deteriorates – Synchronized Cardioversion 0.5 – 1 joule/kg If condition continues – 2 joules/kg

Wide Complex Tachycardia in Pediatrics History – Level of Consciousness Consider Adenosine if time Stable Patient – Amiodarone 5 mg/kg over 20 to 60 min. Expert Consultation Unstable Patient – Synchronized Cardioversion 0.5 – 1 joule/kg

Cardiac Arrest Scene Safety PPE Establish Unresponsiveness and Lack of Normal Breathing Sudden Collapse - Activate Emergency System Get AED/Defibrillator Check Pulse Begin Chest Compressions C – A – B Activate EMS after 2 minutes of CPR if not already done For victims of Sudden Collapse = Use AED as soon as it arrives ! If there are no Pediatric Pads – Use the Adult Pads

Cardiac Arrest Shockable Rhythm (VF/Pulseless VT) Deliver 1 shock – 2-4 joules/kg Resume CPR immediately (Chest Compressions) IV/IO Access Epinephrine 0.01 mg/kg every 3 – 5 minutes Consider advanced airway Defibrillate at 4 joules/kg Amiodarone – 5 mg/kg May repeat 1 or 2 times Consider Reversible Causes

Cardiac Arrest Non-Shockable Rhythm CPR – starting with Chest Compressions IV/IO Access Epinephrine 0.01 mg/kg every 3 – 5 minutes Consider advanced airway CPR Consider Reversible Causes

H’s & T’s Hypovolemia Hypoxia Hypoglycemia Hydrogen Ions (Acidosis) Hypo/Hyperkalemia Hypothermia TRAUMA Tension Pneumothorax Tamponade – Cardiac Toxins Thrombosis – Pulmonary Thrombosis – Coronary

IO Access DO NOT USE if: Fracture Crush injury Bone disease Previous attempts

Ventilations during cpr Compression to Ventilation Ratio 30:2 – 1 Rescuer CPR 15:2 – 2 Rescuer CPR CPR with ETT in place Continuous Chest Compressions Ventilations – 1 Breath every 6 to 8 seconds (8 – 10 breaths/minute)

Post Arrest Care Goals – Preserve neurologic function Prevent secondary organ injury Diagnose & Treat cause of illness Enable patient to arrive at Pediatric Tertiary-Care facility in optimal physiologic state Frequent assessment is necessary because of risk of deterioration Maintain Oxygen saturation between 94 and 99% following ROSC

Capnography for ROSC Capnography is used for verification of advance airway and for indication of return of spontaneous circulation (ROSC) during CPR. [1 Minute Interval] 50 37.5 25 12.5 mm Hg Capnography tracing displaying the PETCO2 in mm Hg on the vertical axis over time. This patient is intubated and receiving CPR. Note that the ventilation rate is approximately 8 to 10 breaths per minute. The initial PETCO2 is less than 12.5 mm Hg during the first minute, indicating very low blood fl ow. The PETCO2 increases to between 12.5 and 25 mm Hg during the second and third minutes, consistent with the increase in blood flow with ongoing resuscitation. Return of spontaneous circulation (ROSC) occurs during the fourth minute. ROSC is recognized by the abrupt increase in the PETCO2 (visible just after the fourth vertical line) to over 40 mm Hg, which is consistent with a substantial improvement in blood fl ow.

Defibrillation Example VF/Pulseless VT 2 – 4 Joules/kg CPR Epinephrine 0.01mg/kg every 3 – 5 minutes Defibrillate 4 joules/kg Epinephrine OR Amiodarone 5 mg/kg Defibrillate 4 joules/kg up to 10 joules/kg or max adult dose Consider Causes (H’s & T’s)

Why Adenosine may be helpful VT vs Pre-excited Atrial Fibrillation in a 9 year old

Two Major Causes of Death in Pediatric Trauma……. ____ I ____ W ____ ____ ____ O ____ P ____ ____ M ____ ____ ____ AND U ____ ____ ____ C ____ ____ NI ____ ____ D ____ E ____ O ____ ____ H ____ ____ E