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From PALS guideline 2005, 2006, 2009 AHA :

Emergency Medicine Conference : Future of Pre-hospital and Emergency Care

Illustrated by Chodchanok Vijarnsorn MD.

Division of Pediatric Cardiology, Department of Pediatrics,

Faculty of Medicine, Siriraj Hospital

21/6/2010

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Agenda

Two parts

Call fast

Look-listen-feel and airway maintain and check pulse

Chest compression (new guideline)

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Etiologies:

Out of hospital cardiac arrest : Respiratory failure & Shock By standBasic life support alone

In hospital cardiac arrest Multiple etiologies Poor outcomeEffective CPR better survival *

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Many etiologies

Cardiopulmonary failure

Cardiopulmonary arrest

Death Cardiopulmonary recovery

Impaired Unimpaired

neurologic neurologic

recovery recovery

Respiratory failure Shock

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Pre – cardiopulmonary failure

Respiratory distress shock

4 steps : Assessment

1. General assessment

2. Primary assessment

3. Secondary assessment

4. Tertiary assessment

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General assessment

Pediatric assessment triangle (PAT)

Appearance- restless?,

-not interactive?

-muscle tone-Cry/speech

Breathing-increase effort?

-noise on respiration

-nasalflaring-retraction

Circulation-pale? mottling?-bleeding

First few seconds

Life threatening?

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First few seconds

Life threatening?

General assessment

Respiratory distress

Respiratory failure

Shock

Compensated/

decompensated

ACTION

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Primary assessment

Primary assessment : ABCDE

- A : airway

- B : breathing

- C : circulation

- D : disability

- E : exposure

( PE, look listen feel, include V/S & oxygen saturation)

ACTION

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A : Airway

Chest movement

Breath sound

Feel : air passes through nose and mouth

Upper airway : clear/ maintainable, not maintainable

Increase respiratory effort, inspiratory force/absent?

Snoring, stridor?

Retraction?

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Breathing

RR

Respiratory effort

Tidal volume

Airway and lung sound

Pulse oximetry

94% = adequate oxygenation

< 94% airway intervention

< 90% in 100% oxygen ( non rebreathing mask advanced intervention : assisted ventilation

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Circulatory

Cardiovascular function

- skin color : mottling

- HR

- BP

-Pulse

(peripheral/central)

- capillary refill

End organ

- brain perfusion

- skin perfusion

- renal perfusion ( urine output)

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Definition of hypotension

Term (0-28 day)…………… < 60 mmHg

Infant (1-12 mo)………….. < 70 mmHg

Children 1-10 y-o (5th P). < 70 + 2 (age yr)

Children > 10 y-o…………..< 90 mmHg

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Capillary refill

Normal < 2 seconds

Prolonged capillary refill > 2 sec

In case : shock, hypothermia, severe dehydration

Warm shock : capillary refill < 2 sec due to peripheral vasodilatation

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Pulse check : central pulse

Use femoral / brachial pulse : < 1 year-old

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Disability

AVPU pediatric response scale

Glasglow coma scales

Pupillary response to light

AVPU

Alert

Voice

PainfulUnresponsiveness

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Exposure

Trauma

Burn

Child abuse

Skin lesion

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Action

General management for all patients

Airway position

Oxygen

Pulse oxymetry

EKG monitor as indicated

BLS as indicated

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Secondary assessment

3. Secondary assessment

- SAMPLE

- S : Signs and symptoms

- A : Allergies

- M : medication

- P : past medical history

- L : last meal

- E : events leading to presentation

ACTION

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Tertiary assessment

Laboratory : ABG, VBG, Hb, SVO2 sat, HCO3, lactate,

Radiography : CXR, echocardiography

Exhale CO2, PEFR, CVP

Emphasize : Anytime you identify a life threatening condition, initiate appropriate

care immediately

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Assess

Categorize

Decide

Action

If you recognize a life threatening condition at any time,

immediately begin life saving intervention and activate the emergency response system

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Summary

PALS guideline AHA 2008

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Signs of life threatening condition

Airway Complete or severe AO

Breathing Apnea, significant work of breathing

Circulation Absent pulse, poor perfusion, hypotension, bradycardia

Disability Unresponsiveness, depress conscious

Exposure Significant hypothermia, bleeding, purpura, abdominal distension due to bleeding

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Life saving intervention

ABC/CPR 100% oxygen Assisted ventilation :

bag mask, ETT Cardiac and

respiratory monitoring : EKG, pulse oximetry

Intravenous / I/O Bolus isotonic

crystalloid Lab study : DTX, ABGDrugs Electrical therapy

ACTION

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New recommendation : Bag & mask

ventilation :

E-C clamp

Give 2 breath chest move?

(12-20 breath/min for child)

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PALS and neonatal update

Good PALS begin with good BLS

Lay person (1 choice) : 30:2 (8 yr)

HCP : 1 rescue : 30:2

HCP : 2 rescue : 15:2 (teenage)

Child chest compression > 1 or 2 hands

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Chest compression

Nipple line for child

Below nipple line in infant

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Coronary Perfusion Pressure Improves With Sequential Compressions

CPP at 5:1 ratio

CPP at 15:2 ratioSurvival with 15:2

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“Continue CPR as much as possible except rhythm check”

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Key change in BLS

Effective rescue breath and visualization of chest rising

Fully recoil chest

Single shock for VF (2 J/kg mono-bi phasic continue CPR, rhythm check only at 2 min)

AED 1-8 years old

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Categorize

Determine the type and severity

Type Severity

Respiratory - Upper airway obstruction

- Lower airway obstruction

- lung parenchymal disease

- Disorder control of breathing

-Respiratory distress

-Respiratory failure

Circulatory - Hypovolemic shock

- Obstructive shock

- Distributive shock

- Cardiogenic shock

-Compensated shock

-Hypotensive shock

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Recognition of respiratory distress and failure

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Prehospital Tracheal Intubation vs Bag-Mask Ventilation

Bag-mask

ventilation : as effective as intubation if transport time is short

Need training and experience

Must confirmation of

tube position

Monitoring

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Use of Cuffed Endotracheal Tubes

In-hospital setting, a cuffed ETT : as safe as an uncuffed tube for infants (except the newborn) and children

Keep cuff inflation pressure <20 cm H2O

Cuffed ETT size (mm) = (age (yr) /4) + 3Uncuff size (mm): (age (yr) /4) + 4

Depth : age (yr)/2 + 12

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Insertion of the Laryngeal Mask Airway in Children

The LMA consists of a tube with a cuffed mask at the distal end.

The LMA is blindly introduced into the pharynx until resistance is met; the cuff is then inflated and ventilation assessed.

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Verification of Endotracheal Tube Placement

bilateral chest movement and listen for equal breath sounds over both lung fields

gastric insufflation sounds

exhaled CO2

pulse oximeter

direct laryngoscopy

chest x-ray

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Colorimetric Exhaled CO2 Detector

Colorimetric exhaled CO2

detector device changes color (from purple to yellow)

with detection of exhaled CO2

“additional” confirmation with clinical assessment

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Recognition of shock in pediatric patient

PALS update 2008-2009

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Myocardial contractility

preload

afterload

Stroke volume

Heart rate

Cardiac output

Tissue perfusion

Blood pressure

ปัจจัยที่มีผลต่อ tissue perfusion

CaO2, Hb

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Etiology of shock

1.hypovolemic shock

- severe dehydration, blood loss, burn, sepsis

2.Cardiogenic shock

-congenital heart disease, acquire heart disease, myocarditis, arrhythmia

3.Distributive shock

-anaphylaxis, sepsis, spinal shock

4. Obstructive shock

- cardiac tamponade, tension pneumothorax

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Recognition of shock flow chart

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Intraosseous canulation

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PALS shock algorithm

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PALS shock algorithm

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Medications : Maintain CO postresuscitation Stabilization

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Potentially Reversible Causes of Arrest: 6 H’s

Hypovolemia

Hypoxemia

Hydrogen ion (acidosis)

Hypo-/hyperkalemia

hypoglycemia

Hypothermia

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Potentially Reversible Causes of Arrest: 5 T’s

Toxins

Tamponade, cardiac

Tension pneumothorax

Thrombosis (coronary or

pulmonary)

Trauma (hypovolemia)

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PALS Tachycardia Algorithm

PALS guideline Tachycardia algorithm

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PALS Bradycardia Algorithm

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Trend of PALS 2010

Pediatric assessment ( PAT )novel approach for the rapid evaluation

Pediatric Emergency Care - Vol 26 Number 4, April 2010

Cardiocerebral resuscitation

Hypothermia

Practice skills learned in formal curricula

Pediatrics 2009; 124; 610-619

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