PALS Study Guide Part 1

UNIT ONE: GENERAL CONCEPTS In the pediatric population, cardiac arrest usually results from one of three problems:    Progressive respiratory distress and failure (the most common cause) Progressive shock (second most common) Sudden cardiac death from ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) (5-15% of all pediatric cardiac arrest cases). The Pediatric Advanced Life Support (PALS) course stresses identification and early intervention in each of these problems. PALS PREPARATION If attending a PALS course, the student must know the key concepts that will be used during the course:     ECG rhythm recognition Infant and child basic life support (BLS) Pediatric pharmacology PALS algorithms and treatments. ORGANIZATION OF THE PALS COURSE In the PALS course, the student will demonstrate competency in four key skills stations that include simulations that stress the role of the team in the pediatric resuscitation process:     One- and two-rescuer BLS for both infants and children Management of respiratory emergencies Rhythm disturbances and electrical therapies Vascular access. The student will be asked to participate as team leader and team member in the skills stations. After successful completion of the skills, the student must successfully complete and pass a written exam testing the cognitive skills associated with pediatric resuscitation. 2015 PALS GUIDELINE CHANGES Guideline Old Guideline 2015 Guideline Sequence CAB (compressions, airway, breathing) Confirmed in the 2015 guidelines Compression depth Used “at least” without a maximum depth Infants to children up to puberty: compress the chest up to 1/3 of the chest diameter; Puberty and adolescence: use adult compression depth between 2 and 2.4 inches (5 to 6 cm) Frequency At least 100 compressions per minute Between 100 and 120 compressions per minute Compression-only CPR Infants and children require compressions and respirations, but compressions are better than nothing Infants and children still require compressions and respirations for optimal CPR since most pediatric emergencies affect respiration primarily; Compression-only CPR is useful in infants/children in cardiac arrest Fluid resuscitation Aggressive fluids Treat septic shock with isotonic IV fluids at a dose of 20 mL/kg, though use with caution in resource-limited settings (i.e. no critical care) Atropine premedication Use a minimum atropine dose of 0.1 mg to prevent paradoxical bradycardia Do not routinely use atropine as premedication for endotracheal intubation; atropine can be used in patients at increased risk of bradycardia Vasopressors Use epinephrine for cardiac arrest Consider using epinephrine during cardiac arrest Extracorporeal CPR Consider extracorporeal CPR only for children in standard resuscitationrefractory cardiac arrest Extracorporeal CPR may be considered in at-risk children who have a cardiac arrest within a hospital with proper protocols, personnel, and equipment available Amiodarone and lidocaine Amiodarone preferred to lidocaine for pulseless VT/VF unresponsive to shock Amiodarone and lidocaine equally effective for pulseless VT or VF unresponsive to shock Post-cardiac arrest Comatose patients should be cooled to between 32°C and 34°C for 12-24 hours Comatose patients with cardiac arrest outside of the hospital should be cooled to 32°C to 34°C for 2 days followed by 3 days of normothermia or a total 5 days of normothermia; no recs for inhospital cardiac arrest; treat fever aggressively Post-cardiac arrest New recommendation for 2015 Maintain systolic BP above the fifth percentile by age, use intra-arterial pressure monitoring Post-cardiac arrest No recommendations about PaCO2 Titrate oxygen to achieve PaO2 between 94% and 99%; keep PaCO2 within normal range TABLE 1: COMPARISON OF PALS GUIDELINES CHANGES TO PEDIATRIC BLS IN 2015 Pediatric BLS was changed in 2015 to incorporate the use of cell phones into the algorithm. In an out-of-hospital arrest, the lone rescuer may call 911 before providing CPR if that rescuer has a cell phone is available. When others are nearby, they should be instructed to call 911 using an available cell phone, then get an AED. When a lone rescuer finds an infant or child up to the age of puberty who is the victim of an unwitnessed collapse, the rescuer should give 2 minutes of CPR before leaving the victim to go get help/call 911/get AED. If the lone rescuer has a working cell phone, 911 should be called first. When a lone rescuer finds an infant or child up to the age of puberty who is the victim of a witnessed collapse, the rescuer should leave the victim to go get help/call 911/get AED. If the lone rescuer has a cell phone, call 911 first. When a lone rescuer finds an adolescent (puberty and older) who is the victim of a witnessed or unwitnessed collapse, the rescuer should leave the victim to go get help/call 911/get AED. If the lone rescuer has a cell phone, call 911 first. PEDIATRIC CHAIN OF SURVIVAL FIGURE 1: PEDIATRIC CHAIN OF SURVIVAL In infants and children, it is better to monitor for signs of respiratory distress before overt respiratory failure occurs, requiring resuscitation. If resuscitation is required, it should include high-quality CPR and activation of EMS (e.g., call 911). Qualified providers should perform PALS followed by post-arrest care following return of spontaneous circulation (ROSC). FIGURE 2: BLS INFANT AND CHILD ALGORITHM UNIT TWO: PEDIATRIC EVALUATION In the pediatric population, respiratory and circulatory problems lead to cardiopulmonary failure while arrhythmias can lead directly to cardiac arrest. Rapidly evaluate and intervene using the PALS Sequence Algorithm (Figure 3): FIGURE 3: PALS SEQUENCE ALGORITHM When evaluating the child’s level of consciousness, breathing and color, note:    Level of consciousness: Is the child awake and alert, irritable and crying, or unresponsive? Breathing: Is the child’s respiratory pattern normal for his age, diminished or absent, or extremely labored? Color: Is the child’s color mottled, cyanotic or pale, and/or normal for his ethnicity? This initial assessment will guide the next steps of the PALS sequence. Begin the primary and secondary assessments using the Evaluate-Identify-Intervene sequence if the child is breathing, has a good pulse and color, and is responsive. EVALUATE-IDENTIFY-INTERVENE The Evaluate-Identify-Intervene sequence will enable identification of the most appropriate intervention. Use this sequence until the child is stabilized or until the child’s condition deteriorates and other treatment is indicated. • Primary Assessment • Secondary Assessment • Diagnostic Tests Evaluate Identify • Respiratory • Circulatory • Traumatic • Appropriate to Cause Intervene FIGURE 4: EVALUATE-IDENTIFY-INTERVENE SEQUENCE EVALUATE THE CHILD During evaluation, conduct the primary assessment, secondary assessment, and diagnostic tests. At all times, be aware of whether or not a condition is life-threatening and be ready to move to the appropriate intervention immediately. Assessment A  Airway B  Breathing C  Circulation Primary Assessment Assessment Techniques Abnormal Findings Observe for movement of the Obstructed but maintainable chest or abdomen Listen to the chest for breath Obstructed and cannot be opened sounds with simple interventions Rate <10 or >60 = Abnormal (Apnea, bradypnea, tachypnea) Effort Nasal flaring, head bobbing, seesaw respirations, retractions Chest or abdominal expansion Asymmetrical or no chest movement Breath sounds Stridor, grunting, wheezing, rales, rhonchi Oxygen saturation (O2 sat) <94% on room air <90% at any time Heart rate Bradycardia Tachycardia Absent Peripheral pulses (radial, posterior tibial, dorsalis pedis) Central pulses (femoral, brachial, carotid, and axillary) Capillary refill Diminished or absent Close monitoring Diminished or absent Skin color/temperature Pale mucous membranes Management of Pediatric Shock Management of Pediatric Shock Management of Pediatric Shock Immediate respiratory intervention required Management of Pediatric Shock Management of Pediatric Shock >2 seconds Central cyanosis Peripheral cyanosis Blood pressure D  Disability E  Exposure Interventions Keep airway open by head tilt/chin lift Keep airway open using advanced interventions Immediate respiratory intervention required Immediate respiratory intervention required Immediate respiratory intervention required Immediate respiratory intervention required Supplemental oxygen Advanced airway Bradycardia Algorithm Tachycardia Algorithm Cardiac Arrest Algorithm Outside of the normal range for age Alert – Awake, active, responsive to parents (normal) Voice – Responds only to voice Pain – Responds only to pain Unresponsive – Not responsive Glasgow Coma Scale Pediatric Glasgow Coma Scale (see Table 6) Pupils Unequal or non-reactive General evaluation Signs of bleeding, burns, trauma, petechiae, and purpura TABLE 2: PRIMARY ASSESSMENT MODEL AVPU Scale Monitor and consult neurologist Management of Pediatric Shock PRIMARY ASSESSMENT Use the Primary Assessment to evaluate the child using vital signs and an ABCDE model: A  Airway Advanced interventions for keeping the airway open may include:      Laryngeal mask airway Endotracheal (ET) intubation Continuous positive airway pressure (CPAP) Foreign body removal if one can be visualized Cricothyrotomy in which a surgical opening is made into the trachea. B  Breathing The child’s respiratory rate is an important assessment that should be made early in the primary assessment process. The clinician must be aware of normal respiratory ranges by age: Age Category Infant Toddler Preschooler School age Adolescent TABLE 3: Age Range Normal Respiratory Rate 0-12 months 30-60 per minute 1-3 years 24-40 per minute 4-5 years 22-34 per minute 6-12 years 18-30 per minute 13-18 years 12-16 per minute NORMAL RESPIRATORY RATES C  Circulation The child’s heart rate is another important assessment that should be made in the primary assessment. The normal heart rates by age are: Age Category Newborn Infant/young child Child/school age Older child/ adolescent TABLE Age Range Normal Heart Rate 0-3 months 80-205 per minute 4 months to 2 years 75-190 per minute 2-10 years 60-140 per minute Over 10 years 50-100 per minute 4: NORMAL HEART RATES The child’s blood pressure should be another part of the primary assessment. Normal blood pressures by age range are: Age Category Neonate Neonate Infant Infant Infant Infant Preschool School Age Adolescent Age Range Systolic Blood Diastolic Blood Pressure Pressure 1 Day 60-76 30-45 4 Days 67-84 35-53 To 1 month 73-94 36-56 1-3 months 78-103 44-65 4-6 months 82-105 46-68 7-12 months 67-104 20-60 2-6 years 70-106 25-65 7-14 years 79-115 38-78 15-18 years 93-131 45-85 TABLE 5: NORMAL BLOOD PRESSURE Abnormally Low Systolic Pressure <60 <60 <70 <70 <70 <70 + (age in years x 2) <70 + (age in years x 2) <70 + (age in years x 2) <90 D  Disability One of the assessments of level of consciousness in a child is the Glasgow Coma Scale. Response Eye opening Verbal response Motor response Total Possible Score Score 4 3 2 1 5 4 3 2 1 6 5 4 3 2 1 3-15 Verbal Child Spontaneously To verbal command To pain None Oriented and talking Confused but talking Inappropriate words Sounds only None Obeys commands Localizes with pain Flexion and withdrawal Abnormal flexion Abnormal extension None Preverbal Child Spontaneously To speech To pain None Cooing and babbling Crying and irritable Crying with pain only Moaning with pain only None Spontaneous movement Withdraws when touched Withdraws with pain Abnormal flexion Abnormal extension None TABLE 6: PEDIATRIC GLASGOW COMA SCALE E  Exposure If the provider finds any abnormal symptoms in this category they should assess and treat the child for shock (see Unit Seven: Management of Pediatric Shock, particularly Interventions for Initial Management of Shock). During the primary assessment, if the child is stable and does not have a potentially life-threatening problem, continue with the secondary assessment. SECONDARY ASSESSMENT During the secondary assessment, complete a more in-depth history and physical exam in an attempt to identify the cause of the child’s circulatory or respiratory symptoms. The physical exam should be focused on the specific symptoms the child is having. When conducting the history, remember the acronym ‘SAMPLE’. History Focus Areas Signs and symptoms Allergies Medications Past medical/surgical history Last Meal Events Information to Gather Changes in level of consciousness, respiratory problems, vomiting, diarrhea, fever, episodes of bleeding Environmental, food, medication and usual reactions Any recent medications including dose and time any recent changes or additions of medications Birth history Immunization history Respiratory, cardiac, neurological or surgical history Time of meal and foods eaten Time of onset Description of the events leading to this episode Treatments already performed TABLE 7: SECONDARY ASSESSMENT HISTORY