PEDIATRIC Advanced

Life Support

Neva Batayola, MDPediatric 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

Berg, M. D. et al. Circulation 2010;122:S862-S875

prevention Early CPR EMS Rapid PALS IntergratedPost-cardiacArrest care

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

NEW OLD

CPR: ABC IS FOR BABIES. NOW IT’S C-A-B!

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 Pathway to pediatric cardiac pediatric cardiac arrestarrest

AHA Pediatric Advanced Life Support. 2006AHA Pediatric Advanced Life Support. 2006

Assessment: Key to Pediatric Management

AHA Pediatric Advanced Life Support AHA Pediatric Advanced Life Support Manual 2006Manual 2006

Life threatening

Not life threatening

What WeWhat WeHad…Had…

Assess-Categorize-Decide-Act Model Assess-Categorize-Decide-Act Model

Pediatric Advanced Life Support 2006Pediatric Advanced Life Support 2006

General Assessment ( P A T )Primary AssessmentSecondary AssessmentTertiary Assessment

The PAT & the Primary, Secondary & Tertiary Surveys

AHA Pediatric Advanced Life Support. 2006AHA Pediatric Advanced Life Support. 2006

WhatWhat’s ’s NEWNEW

……

Evaluate-Identify-Intervene Sequence Pediatric Advanced Life Support 2010Evaluate-Identify-Intervene Sequence Pediatric Advanced Life Support 2010

E v a l u a t e Primary assessment Secondary assessment Diagnostic tests

I d e n t i f y

I n t e r v e n e

I n i t i a l I m p r e s s i o n

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 Initial Impression

Consciousness Unresponsive, irritable, alert

Breathing

Increased work of breathing, absent or decreased respiratory effort, or abnormal sounds heard without ausculation

Color Pallor, mottling, cyanosis

Initial Impression: DECISION & ACTION POINTS

Unresponsive and not breathing or only gaspingCall for helpCheck 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 identifya life-threatening problem, call for

help and begin lifesaving interventions.

The E-I-I Sequence: Evaluate

Clinical Assessment What It Is

Primary Assessment Rapid, hands-on ABCDE approach evaluating respiratory, cardiac & neurologic function; includes vital signs & pulse oximetry

Secondary AssessmentFocused medical history & physical exam

Diagnostic TestsLaboratory, radiographic & other advanced tests that help to identify the child’s physiologic condition & diagnosis

Pediatric Primary Assessment

rapid ordered, stepwise hands-on evaluation of cardiopulmonary and neurologic function to prioritize treatment

Includes vital signs & O2 saturation by pulse oximetry

Airway, Breathing, Airway, Breathing, Circulation, Disability, Circulation, Disability, ExposureExposure

Pediatric Primary Assessment

AIRWAYopen?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.2010AHA Pediatric Advanced Life Support.2010

Pediatric Primary Assessment

BREATHING

Respiratory rate (RR)Normal, Irregular, Fast, Slow, Apnea

Respiratory effortNormal, Increased, Inadequate

Chest expansion & air movement (TV)Normal, Decreased, Unequal, Prolonged expiration

Lung and airway sounds Pulse oximetry (SaO2)

Normal, HypoxemicAHA Pediatric Advanced Life Support.2010AHA Pediatric Advanced Life Support.2010

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 AssessmentPediatric Primary Assessment

DISABILITY AVPU Pediatric Response

Scale (cerebral cortex fxn) GCS Pupillary response Blood sugar

EXPOSURE

Hypo/hyperthermia Evidence of trauma

or injury Rash

Pediatric Primary AssessmentPediatric Primary Assessment

Decreased LOCLoss of muscle toneIrritability, lethargy, agitationGeneralized seizuresPupil dilatation

Pediatric Secondary Assessment

Focused history Signs and symptoms Allergies Medications Past Medical History Last Meal Events

Detailed PE

SS

AA

MMPP

LL

EE

Focused medical hx Focused medical hx using SAMPLE using SAMPLE mnemonic and a mnemonic and a thorough head-to-toe thorough head-to-toe P.E.P.E.AHA Pediatric Advanced Life Support. AHA Pediatric Advanced Life Support.

20102010

Diagnostic Tests Assessment of respiratory and circulatory

abnormalities

ABG, VBG, Hb, Blood sugarPulse oximetry, CXRCapnography (ETC02), exhaled C02 Sv02 saturation, arterial lactateCVP, 2DEcho, ECG, PEFRInvasive arterial pressure monitoring

The E-I-I Sequence: IDENTIFY Type Severity

Respiratory Upper Airway Obstruction Respiratory Distress

Lower Airway Obstruction Respiratory Failure

Lung Tissue Disease

Disordered Control of

Breathing

Circulatory Hypovolemic Shock Compensated Shock

Distributive Shock Hypotensive Shock

Cardiogenic 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 non-rebreathing 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

Assess response to 02; analyze cardiac rhythm

INTERVENE

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

Allow position of comfort; consider specific interventions for UAO (eg. Racemic epinephrine, IV/IM dexamethasone, helium-02 mixture, etc.; consider vascular access IV/IO; prepare for

endotracheal intubation

INTERVENE

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 comfortopen airway (head tilt-chin lift, modified jaw thrust)clear airway (suction, remove FB)consider OPA, NPA

BREATHINGmonitor Sp02, provide 02, assist ventilationinhaled medication as neededendotracheal intubation if needed

CIRCULATIONmonitor HR, rhythm, BPestablish 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

Bag-Mask Ventilation

Breathing: EC clamp technique

Tracheal Tube- size and depth

Uncuffed tube size:<1yr 3.5mm ID1-2 yr 4.0mm ID>2 yr 4 + (Age/4)

Cuffed tube size:<1yr 3.0 mm ID1-2 yr 3.5 mm ID>2 yr 3.5 + (Age/4)

ETT depth (lip):

ETT size x 3

Uncuffed tube size:<1yr 3.5mm ID1-2 yr 4.0mm ID>2 yr 4 + (Age/4)

Cuffed tube size:<1yr 3.0 mm ID1-2 yr 3.5 mm ID>2 yr 3.5 + (Age/4)

ETT depth (lip):

ETT size x 3AHA, 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 TachycardiaCool and pale distal extremitiesCRT >2 sec despite warm ambient tempWeak peripheral vs central pulsesNormal systolic blood pressure

Identification of Shock

By severity (effect on BP)Compensated shockHypotensive

By typeHypovolemic (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

HYPOTENSIVE SHOCK

CARDIAC ARREST

Possibly Hours

Potentially Minutes

AHA Pediatric Advanced Life Support Manual 2011AHA 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, dopamine-resistant 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 min0.375-0.75 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

Pediatric Critical Care Medicine 2001, 2:24-28

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

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/minvarying 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

Team leader Airway Compressor IV / IO meds Monitor / Defibrillator Observer/ Recorder

Team leader

airway

comressor

Observer/ recorder

IV/IV/IO meds

Monitor/

defibrillator

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