1. Respiratory Arrest Versus Cardiac Arrest (PALS)
Presented by Danyel Dorn RN, MSN, CPN, Clinical Nurse Educator-Pediatric Service Line

2. Purpose
Nurses must recognize deterioration and shock in the pediatric patient and identify priorities in assessment and management of the ill or injured child. The Nurse caring for the pediatric patient must also demonstrate cardiopulmonary resuscitation using PALS guidelines. Completion of this chapter does not indicate completion of the AHA PALS certification program.

3. Competency Statement
The perianesthesia registered nurse will be able to identify and provide appropriate emergency care in the perianesthesia setting for the deteriorating pediatric patient.

4. Priorities
Requires rapid recognition of deterioration and systematic intervention
Cardiopulmonary arrest in pediatric PACU patients occurs most commonly in children less than 5 years old (especially infants) and pediatric patients with comorbidities
The cause of most arrests is respiratory

5. Primary Assessment
Airway
Breathing
Circulation
Disability

6. AVPU Scale A = alert V = voice P = pain U = unresponsive
Pediatric response scale, pupil reaction and blood glucose
The AVPU scale has four possible outcomes

7. AVPU Outcomes
Alert: The patient is fully awake (although not necessarily oriented). This patient will have spontaneously open eyes, will respond to voice (although may be confused) and will have bodily motor function
Voice: The patient makes some kind of response when spoken to, which could be in any of the three component measures of eyes, voice or motor (ex: patient’s eyes open on being asked “are you ok?”) The response could be as little as a grunt, moan or slight move of a limb when prompted by the voice of the rescuer

8. AVPU Outcomes
Pain: The patient makes a response on any of the three component measures as a response to painful stimulus (squeezing fingers)
A patient with some level of consciousness (a fully conscious patient would not require a pain stimulus) may respond by using his/her voice, moving their eyes, or moving part of their body (including posturing)

9. AVPU Outcomes
Unresponsive: This outcome is recorded if the patient does not give any eye, voice or motor response to voice or pain

10. Pediatric Information
PALS defines hypoglycemia as a blood glucose < mg/dl in preterm and term neonates and < 60 mg/dl for all other infants, children, and adolescents (See your institutional policy on definition of hypoglycemia)
Prolonged environmental exposure
assess skin and core temperature
Decrease in core temperature could lead to bradycardia and/or asystole

11. Pals Information Activate an emergency response
Provide high quality CPR when indicated
Compressions at least 100/minute, depth 1/3 AP diameter, allow complete chest recoil after each compression, minimize interruptions in compressions, avoid excessive ventilation
Two rescuer CPR in pals = 15:2
Monitor etCO2 for quality of CPR, should be greater than 15mm Hg

12. Pals Information
Ensure early use of defibrillator for shockable rhythms (VF/VT) at 2-4 J/kg
Adult AEDs should ideally be used only in children over 8 years or over 25 kg
For children less than 8 years or less than 25 kg, use manual defibrillation, an AED with attenuated dose or, if nothing else is available, an adult AED

13. Secondary Assessment S = signs and symptoms A = allergies
M = medications
P = past medical history, injuries, illnesses
L = last meal/intake
E = events leading up to the situation or illness

14. Respiratory Distress Vs. Failure
Increased work of breathing, irregular breathing and inadequate respiratory effort
Resp. Failure include one or more of the following: very rapid or inadequate respiratory rate, significant or inadequate respiratory effort, low oxygen saturation despite high flow oxygen, bradycardia (ominous sign), cyanosis, and decreased level of consciousness

15. Upper Airway Obstruction
Increased respiratory rate and effort
Decreased air movement
Stridor, barking cough
Snoring or gurgling
Hoarseness
Tx: 100% O2, position for comfort, anticipate IM epinephrine for anaphylaxis and additional interventions as indicated including racemic epinephrine and IV dexamethasone, CPAP, CXR

16. Lower Airway Obstruction
Increased respiratory rate and effort
Decreased air movement
Prolonged expiration
Wheezing
TX: albuterol nebulizer, CPAP, Steroids, CXR

17. Lung Tissue Disease Increased respiratory rate and effort
Decreased air movement
Grunting, crackles
Ex: pneumonia
TX: 100% O2, antibiotics, albuterol, CPAP

18. Disordered Control of Breathing
Irregular respiratory pattern
Inadequate or irregular respiratory depth and effort
Normal or decreased air movement, signs of upper airway obstruction
Ex: poison ingestion
TX: Support ventilation as needed, treat underlying cause

19. Shock
Hypovolemic or obstructive shock (tension pneumothorax, cardiac tamponade, massive pulmonary embolism, ductal dependent congenital heart lesion)

20. Poor Perfusion Tachycardia Weak peripheral pulses
Delayed capillary refill time-mottling
Pallor or cyanosis
Cool skin
Changes in level of consciousness
Decreased urine output

21. Distributive Shock Signs of poor perfusion
Potential warm flushed skin with brisk capillary refill and bounding pulses
Potential weak pulses (warm shock)
Petechial or purpuric rash (septic shock)

22. Cardiogenic/Compensated Shock
Signs of poor perfusion
Signs of congestive heart failure (shortness of breath, weakness, fatigue, edema)
Compensated Shock = signs of poor perfusion and normal blood pressure

23. Hypotensive Shock Signs of poor perfusion and low blood pressure
Tachycardia is an early sign of shock in children
Hypotension is a late and ominous sign of shock in children whose vasomotor tone and the ability to vasoconstrict allows them to maintain a normal BP in the early stages of shock

24. Treatment of Shock
Hypovolemic Shock = provide high flow oxygen as indicated, initiate 20ml/kg isotonic crystalloid rapid IV bolus, repeat as necessary until improved BP, heart rate and distal pulses
Obstructive Shock = 100% Oxygen, consider DOPE (displacement, obstruction, pneumothorax, equipment failure), thoracostomy, chest tube placement, fluid resuscitation

25. Treatment of Shock
Distributive Shock (sepsis or anaphylaxis) = 20ml/kg isotonic crystalloid rapid bolus-> repeat as necessary until improved BP, heart rate and distal pulses, obtain blood cultures if stable and administer antibiotics for sepsis, administer epinephrine and steroids for anaphylaxis, anticipate vasoactive infusion if shock is fluid refractory.
Cardiogenic Shock = high flow oxygen, 5-10ml/kg isotonic crystalloid IV bolus over minutes, prepare vasoactive or inotropic infusions for persistent shock.

26. Cardiac Rhythm Disturbances
Bradycardia (symptomatic): heart rate slower than normal for child’s age or baseline (usually < 60bpm, with cardiopulmonary compromise (shock combined with respiratory distress or failure) despite oxygenation and ventilation.
In children, bradycardia is usually the result of hypoxia

27. Cardiac Rhythm Disturbances
Tachycardia: heart rate that is fast compared with the normal heart rate for a child’s age
Tachyarrhythmia's: fast abnormal rhythms originating either in the atria or the ventricles of the heart
Stable: normal BP, perfusion and mental status
Unstable: altered mental status, respiratory distress/failure, hypotension and signs of shock

28. Cardiac Rhythm Disturbances
Asystole/PEA: No palpable pulse when assessed for 10 seconds
V Fib/Pulseless V Tach: no organized rhythm or contractions (v fib) organized, wide QRS complexes, no pulse (pulseless v tach)

29. Management of Cardiac Rhythm Disturbances
Bradycardia: 100% O2, ventilation, 12 lead ECG, CPR for symptomatic bradycardia, IV Epinephrine 0.01mg/g (0.1ml/kg of 1:10,000)
Tachyarrhythmia: SVT-Stable: initiate vagal maneuver, rapid push adenosine 0.1mg/kg, may repeat adenosine at 0.2mg/kg. Unstable: immediate cardioversion J/kg

30. Management of Cardiac Rhythm Disturbance
Asystole/PEA: high quality CPR, reassess rhythm every 2 minutes, IV/IO Epinephrine 0.01mg/kg (0.1ml/kg of 1:10,000) repeat every 3-5 minutes
Attempt to identify H’s & T’s (hypovolemia, hypoxia, hypothermia… …Toxins, tamponade, tension pneumothorax…)

31. Management of Cardiac Rhythm Disturbance
V Fib/Pulseless V Tach: CPR, reassess rhythm every 2 minutes, defibrillate at 2-4 J/kg, repeat every 2 minutes as necessary, IV/IO Epinephrine 0.01 mg/kg (0.1ml/kg of 1:10,000), administer first dose after second rhythm check and repeat every 3-5 minutes
Consider IV/IO Amiodarone 5mg/kg bolus, may repeat up to two times

32. Care Post-Resuscitation
Aim for oxygen saturation 94-99%; avoid hypoxemia and hyperoxemia, monitor etCO2,
Avoid hyperventilation which can cause cerebral vasodilation and increased intracranial pressure
Maintain aggressive hemodynamic support after return of spontaneous circulation
Treat hyperthermia, avoid hyperglycemia and hypoglycemia, monitor for seizures and treat aggressively, EEG may be used as seizures can be clinical or subclinical.

33. Reference
ASPAN (2016). A Competency Based Orientation and Credentialing Program for the Registered Nurse Caring for the Pediatric Patient in the Perianesthesia Setting.

34. Answers C B A