1. Pediatric Advanced Life Support
Jan Bazner-Chandler
CPNP, CNS, MSN, RN

2. American Heart Association
Pediatric Advanced Life Support
Guidelines first published in 1997
Revisions made in 2005

3. Students Nurse Concerns
You will need to learn the basics as outlined in the PALS 2005 Guidelines
AHA guidelines are expected standards of a practicing pediatric nurse.
You will need to know basic CPR guidelines and have a current CPR card prior to starting the clinical rotation.

4. Cardiopulmonary Arrest
In most infants and small children respiratory arrest precedes cardiac arrest.

5. Causes of Cardiac Arrest in Children
Bronchospasm / respiratory infection
Burns
Drowning
Dysrhythmias
Foreign Body Aspiration
Gastroenteritis (vomiting and diarrhea)
Sepsis
Seizures
Trauma

6. Pediatric Cardiac Arrest
Pediatric cardiopulmonary arrest results when respiratory failure or shock is not identified and treated in the early stages.
Early recognition and intervention prevents deterioration to cardiopulmonary arrest and probable death.

7. Cardiac Arrest Pediatric cardiac arrest is: Uncommon
Rarely sudden cardiac arrest caused by primary cardiac arrhythmias.
Most often asphyxial, resulting from the progression of respiratory failure or shock or both.

8. Hypovolemic (most common) Distributive: septic, anaphylactic
Upper airway obstruction
Lower airway obstruction
Lung tissue disease / infection
Disorders of breathing
Hypovolemic (most common)
Distributive: septic, anaphylactic
Cardiogenic
Obstructive
Respiratory
Failure
Hypotensive
Shock
Cardiopulmonary
Failure
Asphyxial Arrest

9. Respiratory Arrest
Early recognition and intervention prevents deterioration to cardiopulmonary arrest and probable death.
Only 10% of children who progress to cardiopulmonary arrest are successfully resuscitated.

10. Respiratory Failure
A respiratory rate of less than 10 or greater than 60 is an ominous sign of impending respiratory failure in children.

11. Assessment
30 second rapid cardiopulmonary assessment is structured around ABC’s.
Airway
Breathing
Circulation

12. Breathing
Breathing is assessed to determine the child’s ability to oxygenate.
Assessment:
Respiratory rate
Respiratory effort
Breath sounds
Skin color

13. Airway Airway must be clear and patent for successful ventilation.
Position
Suction
Administration of oxygen
Bag-mask ventilation

14. Bag-valve-mask

15. New Guidelines – Airway Management
Failure to maintain the airway is leading cause of preventable death in children.
New PALS focuses on basic airway techniques.
Laryngeal mask airway.

16. LMA –Laryngeal Mask Airway

17. Endotracheal Tube Intubation
New guidelines:
Secondary confirmation of tracheal tube placement.
Use of end-tidal carbon dioxide monitor or colorimetric device

18. Circulation Circulation reflects perfusion.
Shock is a physiologic state where delivery of oxygen and substrates are inadequate to meet tissue metabolic needs.

19. Circulation Assessment
Heart rate (most accurate assessment)
Blood pressure
End organ profusion
Urine output (1-2 mL / kg / hour)
Muscle tone
Level of consciousness

20. Circulatory Assessment
Heart rate is the most sensitive parameter for determining perfusion and oxygenation in children.
Heart rate needs to be at least 60 beats per minute to provide adequate perfusion.
Heart rate greater than 140 beats per minute at rest needs to be evaluated.

21. Blood Pressure
25% of blood volume must be lost before a drop in blood pressure occurs.
Minimal changes in blood pressure in children may indicate shock.

22. Vascular Access – New Guidelines
New guidelines: in children who are six years or younger after 90 seconds or 3 attempts at peripheral intravenous access – Intraosseous vascular access in the proximal tibia or distal femur should be initiated.

23. Intraosseous Access

26. IV Solutions Crystalloid solution
Normal saline 20ml/kg bolus over 20 minutes
Lactated ringers

27. Gastric Decompression
Gastric decompression with a nasogastric or oral gastric tube is necessary to ensure maximum ventilation.
Air trapped in stomach can put pressure on the diaphragm impeding adequate ventilation.
Undigested food can lead to aspiration.

28. Accurate Output
Insert foley
Output 1-2 mL / kg / hour

29. Cardiopulmonary Failure
Child’s response to ventilation and oxygenation guides further interventions.

30. Arrhythmias Bradycardia Pulseless Arrest – ventricular fibrillation
Asystole – no pulse
Tachycardia with poor perfusion
Tachycardia with adequate perfusion

31. Bradycardia The most common dysrhythmia in the pediatric population.
Etiology is usually hypoxemia
Initial management: ventilation and oxygenation.
If this does not work IV or IO epinephrine 0.1 mg / kg

32. Pulseless Arrest – Asystole
ABC: Start CPR
Give oxygen when available
Attach monitor / defibrillator
Check rhythm / check pulse
If asystole give epinephrine 0.01 mg / kg of 1:10,000
Resume CPR may repeat every 3-5 minutes until shockable rhythm is seen

33. Asystole
No Rhythm
No rate
No P wave
No QRS comples

34. Pulseless Arrest – VF and Pulseless VT
ABCs: start CPR
Give oxygen as soon as available
Attach monitor / defibrillator
Check rhythm: VF / VT
Give one shock at 2 J/kg
If still VF / VT
Give 1 shock at 4 J/kg
Give Epinephrine 0.01 mg/kg of 1:10,000

36. Tachycardia with Adequate Perfusion
Sinus tachycardia:
Infants: HR < 220 bpm
Children: HR < 180 bpm
P waves present and normal
Treatment: give oxygen and treat cause

37. Tachycardia with Adequate Perfusion
Sinus Ventricular Tachycardia
Infants: HR >220 bpm
Children: HR > 180 bpm
P waves absent of abnormal
Treatment: consider vagal maneuver
Give adenosine IV 0.1mg/kg

38. Supraventricular Tachycardia
Interventions
Oxygen
Call for code
Cardioversion
Vagal Maneuvers
Adenosine

39. Tachycardia with poor perfusion
Ventricular tachycardia
Synchronized cardioversion
First dose: 0.5 to 1 J/kg
Next dose: 2 J/kg
Consider: amiodarone 5 mg/kg IV over 30 to 60 minutes

40. Ventricular Tachycardia

41. New Guideline Epinephrine
Still remains primary drug for treating patients for cardiopulmonary arrest, escalating doses are de-emphasized.
Neurologic outcomes are worse with high-dose epinephrine.

42. PALS Drugs

43. Epinephrine
Action: increase heart rate, peripheral vascular resistance and cardiac output; during CPR increase myocardial and cerebral blood flow.
Dosing: 0.01 mg / kg 1: 10,0000

44. Amiodarone Used in atrial and ventricular antiarrhythmic
Action: slows AV nodal and ventricular conduction, increase the QT interval and may cause vasodilation.
Dosing: IV/IO: 5 mg / kg bolus

45. Adenosine Drug of choice of symptomatic SVT
Action: blocks AV node conduction for a few seconds to interrupt AV node re-entry
Dosing
First dose: 0.1 mg/kg max 6 mg
Second dose: 0.2 mg/kg max 12 mg

46. Glucose 10% to 25% strength Action: increases glucose in hypoglycemia
Dosing: 0.5 – 1 g/kg

47. Naloxone Opiate antagonist
Action: reverses respiratory depression effects of narcotics
Dosing: IV/IO
0.1 mg/kg < 5 years
0.2 mg/kg > 5 years

48. Sodium bicarbonate pH buffer for prolonged arrest, hyperkalemia
Action: increases blood pH helping to correct metabolic acidosis

49. Dobutamine Synthetic catecholamine
Action: increases force of contraction and heart rate; causes mild peripheral dilation; may be used to treat shock
Dosing: IV/IO: 2-20 mcg/kg/min infusion

50. Dopamine Catecholamine
May be used to treat shock; effects are dose dependent
Increases force of contraction and cardiac output, increases peripheral vascular resistance, BP and cardiac output
Dosing: IV/IO infusion: 2-20 mcg/kg/min

51. Defibrillator Guidelines
AHA recommends that automatic external defibrillation be use in children with sudden collapse or presumed cardiac arrest who are older than 8 years of age or more than 25 kg and are 50 inches long.
Electrical energy is delivered by a fixed amount range 150 to 200. (2-4J/kg)

52. Post-resuscitation Care
Re-assessment of status is ongoing.
Laboratory and radiologic information is obtained.
Etiology of respiratory failure or shock is determined.
Transfer to facility where child can get maximum care.