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

2. Pediatric Advanced Life Support
Guidelines established in 1983 by the American heart Association.
Pediatric Advanced Life Support: A Review of the AHA Recommendations, American Family Physician, October 15, 1999.

3. American Heart Association
Pediatric Advanced Life Support
Published online November 28, 2005
Article can be found at:

4. JAOA
Review of guidelines for Pediatric Advanced Life Support – short version of AHA
Quick review of AHA guidelines

5. Students Nurse Concerns
You will need to learn the basics as outlined in the PALS article 1999 and review 2005 standards.
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.

6. Cardiopulmonary Arrest
In most infants and small children respiratory arrest precedes cardiac arrest.
92% of children with respiratory arrest only have no subsequent neurologic impairment.

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

11. Airway Airway must be clear and patent for successful ventilation.
Position
Clear of foreign body
Free from injury
Intubate if needed.

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

13. Impending Respiratory Failure
Respiratory rate less than 10 or greater than
60 is an ominous sign of impending
respiratory failure.

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

15. Circulation Assessment
Heart rate
Pulse
Blood pressure
End organ profusion
Urine output
Level of consciousness
Muscle tone

16. 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.

17. Circulatory Assessment
Pulse quality reflects cardiac output.
Capillary refill measures peripheral perfusion.
Temperature and color of extremities proximal versus distal.

18. Circulatory Assessment
Urinary output
Adequate kidney perfusion
1- 2 ml of urine per kg / hour
Level of Consciousness / LOC

19. 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.

20. Management Oxygen Cardiac Monitoring Pulse oximetry
May be inaccurate when peripheral perfusion is impaired.

21. Airway Management Bag-valve-mask with bradypenia or apnea
Suctioning to remove secretions
Intubation as needed

22. Bag-valve-mask

23. 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.

24. LMA –Laryngeal Mask Airway

25. LMA Disadvantages: Inability to prevent aspiration.
Inability to serve as route for administering medications.

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

27. Vascular Access After airway and oxygenation needs met.
Crystalloid solution
Normal saline 20mL/kg bolus over 20 minutes
Lactated ringers – used more in adults

28. 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 access recommended.

29. Intraosseous Access

30. 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.

31. Cardiopulmonary Failure
Child’s response to ventilation and oxygenation guides further interventions.
If signs of shock persists:
Inotropic agents such as epinephrine are given.

32. Epinephrine Indications: IV or ET through the endotracheal tube
Bradycardia
Shock (cardiogenic, septic, or anaphylactic)
Hypotension
IV or ET through the endotracheal tube

33. 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.

34. 2 New Medications for PALS
Vasopressin – causes systemic vasoconstriction – used to increase blood flow to brain and heart during CPR.
Need to be studied further.
Amiodarone – antiarrhythmic agent – used in ventricular fibrillation and ventricular tachycardia. Given 5 mg/kg over 20 minutes.

35. Bradycardia
Bradycardia is the most common dysrhythmia in the pediatric population.
Epinephrine is drug of choice – dose is 0.01 to 0.03 mg/kg/dose

36. Sodium Bicarbonate
In instances where the child is acidotic, sodium bicarbonate may be administered IV.
The drug is not as stable in the pediatric population but is often used during the resuscitative phase of CPR.

37. Glucose Levels Monitor serum glucose levels
Replace with 10 % dextrose in the neonate
25% glucose in the child

38. Ventricular Tachycardia
Ventricular tachycardia is usually secondary to structural cardiac disease.
Amiodarone – 5 mg/kg over 20 minutes
Cardioversion

39. 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. (4J/kg)

40. 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.

41. BLS Updates 2006
Unresponsive infant less than 1 year and children 1 year to puberty
Open airway
Give 2 breaths (if not breathing)
Begin compressions – 30 – (if no pulse)
Activate EMS system
AED after 5 cycles of CPR

42. Tilt Head to Sniff Position

43. Witnessed Collapse of Child
Activate EMS
AED before CPR
Compression 30 to 2 breaths – hand placement at nipple line
2 rescue 15 to 2 – if infant circle chest and use thumbs

44. Choking Infant
5 back slaps
5 Chest thrusts

45. Heimlich for Infants

46. Clearing the Mouth