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PALS update 2005 to 2010
The document summarizes key points from PALS guidelines regarding the assessment and management of pediatric emergencies. It discusses the primary, secondary, and tertiary assessments using ABCDE/SAMPLE approaches. Signs of life-threatening conditions like airway obstruction, respiratory distress, and shock are outlined. The document also reviews recent PALS recommendations for compressions-to-ventilations ratios, use of cuffed endotracheal tubes, laryngeal mask airways, and exhaled CO2 detectors for confirming endotracheal tube placement.
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PALS update 2005 to 2010
- 1. From PALS guideline2005, 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 1
- 2. Agenda Two parts Call fast Look-listen-feeland airway maintain and check pulse Chest compression (new guideline) 2
- 3. Etiologies: Out of hospitalcardiac arrest : Respiratory failure & Shock By stand Basic life support alone In hospital cardiac arrest Multiple etiologies Poor outcome Effective CPR better survival * 3
- 4. Many etiologies Respiratory failure Shock Cardiopulmonary failure Cardiopulmonary arrest Death Cardiopulmonary recovery Impaired Unimpaired neurologic neurologic recovery recovery 4
- 5. Pre – cardiopulmonaryfailure Respiratory distress shock 4 steps : Assessment 1. General assessment 2. Primary assessment 3. Secondary assessment 4. Tertiary assessment 5
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- 7. General assessment Pediatric assessment triangle (PAT) Appearance Breathing - restless?, -increase effort? -not interactive? -noise on respiration -muscle tone -nasalflaring -Cry/speech -retraction Circulation First few seconds -pale? mottling? Life threatening? -bleeding 7
- 8. General assessment First few seconds Life threatening? Shock Respiratory distress Compensated/ Respiratory failure decompensated ACTION 8
- 9. Primary assessment Primaryassessment : ABCDE - A : airway - B : breathing - C : circulation - D : disability - E : exposure ( PE, look listen feel, include V/S & oxygen saturation) ACTION 9
- 10. A : Airway Chestmovement Breath sound Feel : air passes through nose and mouth Upper airway : clear/ maintainable, not maintainable Increase respiratory effort, inspiratory force/absent? Snoring, stridor? Retraction? 10
- 11. Breathing RR Respiratory effort Tidal volume Airwayand lung sound Pulse oximetry 94% = adequate oxygenation < 94% airway intervention < 90% in 100% oxygen ( non rebreathing mask advanced intervention : assisted ventilation 11
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- 13. Circulatory Cardiovascular End organ function - brain perfusion - skin color : mottling - skin perfusion - HR - renal perfusion ( - BP urine output) -Pulse (peripheral/central) - capillary refill 13
- 14. 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 14
- 15. 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 15
- 16. Pulse check :central pulse Use femoral / brachial pulse : < 1 year-old 16
- 17. Disability AVPU pediatric responsescale Glasglow coma scales Pupillary response to light AVPU Alert Voice Painful Unresponsiveness 17
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- 19. Action General management forall patients Airway position Oxygen Pulse oxymetry EKG monitor as indicated BLS as indicated 19
- 20. Secondary assessment 3. Secondaryassessment - SAMPLE - S : Signs and symptoms - A : Allergies - M : medication - P : past medical history - L : last meal - E : events leading to presentation ACTION 20
- 21. 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 21
- 22. Assess Action Categorize Decide If you recognize a life threatening condition at any time, immediately begin life saving intervention and activate the emergency response system 22
- 23. Summary PALS guideline AHA 2008 23
- 24. Signs of lifethreatening 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 24
- 25. Life saving intervention ACTION 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, ABG Drugs Electrical therapy 25
- 26. New recommendation :Bag & mask ventilation : E-C clamp Give 2 breath chest move? (12-20 breath/min for child) 26
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- 28. PALS and neonatalupdate 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 28
- 29. Chest compression Nipple linefor child Below nipple line in infant 29
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- 32. Coronary Perfusion PressureImproves With Sequential Compressions CPP at 5:1 ratio Survival with 15:2 CPP at 15:2 ratio 32
- 33. “Continue CPR asmuch as possible except rhythm check” 33
- 34. Key change inBLS 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 34
- 35. Categorize Determine thetype and severity Type Severity Respiratory - Upper airway obstruction -Respiratory - Lower airway obstruction distress - lung parenchymal disease -Respiratory failure - Disorder control of breathing Circulatory - Hypovolemic shock -Compensated - Obstructive shock shock - Distributive shock -Hypotensive shock - Cardiogenic shock 35
- 36. Recognition of respiratory distress and failure 36
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- 43. Prehospital Tracheal Intubationvs 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 43
- 44. Use of CuffedEndotracheal 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) + 3 Uncuff size (mm): (age (yr) /4) + 4 Depth : age (yr)/2 + 12 44
- 45. Insertion of theLaryngeal 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. 45
- 46. Verification of EndotrachealTube 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 46
- 47. Colorimetric Exhaled CO2Detector Colorimetric exhaled CO2 detector device changes color (from purple to yellow) with detection of exhaled CO2 “additional” confirmation with clinical assessment 47
- 48. Recognition of shock in pediatric patient PALS update 2008-2009 48
- 49. Myocardial contractility Heart rate CaO2, Hb Cardiac output preload Stroke volume Tissue perfusion Blood pressure afterload ปัจจัยที่มีผลต่อ tissue perfusion 49
- 50. 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 50
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- 52. Recognition of shockflow chart 52
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- 60. Medications : MaintainCO postresuscitation Stabilization 60
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- 62. Potentially Reversible Causes ofArrest: 6 H’s Hypovolemia Hypoxemia Hydrogen ion (acidosis) Hypo-/hyperkalemia hypoglycemia Hypothermia 62
- 63. Potentially Reversible Causes ofArrest: 5 T’s Toxins Tamponade, cardiac Tension pneumothorax Thrombosis (coronary or pulmonary) Trauma (hypovolemia) 63
- 64. PALS guideline Tachycardiaalgorithm PALS Tachycardia Algorithm 64
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- 66. Trend of PALS2010 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 66
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