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PALS: Pediatric advanced life support

Pediatric advanced life support

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PALS: Pediatric advanced life support

  2. 2. PEDIATRIC ADVANCED LIFE SUPPORT “Assessment and maintenance of pulmonary and circulatory function in the period before, during and after an instance of cardiopulmonary arrest in a seriously ill or injured child, by a system of critical care procedures and facilities.” AHA 2014 Timely intervention in seriously ill or injured children is the key to preventing progression toward cardiac arrest and to saving lives.
  3. 3. INTRODUCTION In contrast to adults, cardiac arrest in infants and children does not usually result from a primary cardiac cause. More often it is the terminal result of progressive respiratory failure or shock, also called an asphyxial arrest. Asphyxia begins with a variable period of systemic hypoxemia, hypercapnea, and acidosis, progresses to bradycardia and hypotension, and culminates with cardiac arrest.
  4. 4. BASIC CONSIDERATIONS FOR PALS Paediatric advanced life support (PALS) usually takes place in the setting of an organized response in an advanced healthcare environment. In these circumstances, multiple responders are rapidly mobilized and are capable of simultaneous coordinated action.
  5. 5. ASPHYXIAL CARDIAC ARREST Cardiac arrest caused by asphyxiation (lack of oxygen in blood) Carbon dioxide accumulates in the lungs while oxygen in the lungs is depleted resulting in cardiac arrest. Causes: drowning, choking, airway obstruction, sepsis, shock
  6. 6. ASPHYXIAL CARDIAC ARREST “One large pediatric study demonstrated that CPR with chest compression and mouth-to-mouth rescue breathing is more effective than compression alone when the arrest was from a noncardiac etiology.” “Ventilations are more important during resuscitation from asphysia-induced arrest, than during resuscitation from VF or pulseless VT.”
  7. 7. SHOCK Shock results from inadequate blood flow and oxygen delivery to meet tissue metabolic demands. The most common type of shock in children is hypovolemic, including shock due to hemorrhage. Distributive, cardiogenic, and obstructive shock occur less frequently. Shock progresses over a continuum of severity, from a compensated to a decompensated state. Compensatory mechanisms include tachycardia and increased systemic vascular resistance (vasoconstriction) in an effort to maintain cardiac output and perfusion pressure respectively. Decompensation occurs when compensatory mechanisms fail and results in hypotensive shock.
  8. 8. Typical signs of compensated shock include ● Tachycardia ● Cool and pale distal extremities ● Prolonged (2 seconds) capillary refill (despite warm ambient temperature) ● Weak peripheral pulses compared with central pulses ● Normal systolic blood pressure As compensatory mechanisms fail, signs of inadequate end-organ perfusion develop. In addition to the above, these signs include ● Depressed mental status ● Decreased urine output ● Metabolic acidosis ● Tachypnea ● Weak central pulses ● Deterioration in color
  9. 9. ● Tachycardia is a common sign of shock, but it can also result from other causes, such as pain, anxiety, and fever. ● Pulses are weak in hypovolemic and cardiogenic shock, but may be bounding in anaphylactic, neurogenic, and septic shock. ● Blood pressure may be normal in a child with compensated shock but may decline rapidly when the child decompensates. Like the other signs, hypotension must be interpreted within the context of the entire clinical picture.
  10. 10. HYPO/HYPERTHERMI A Potential complications of hypothermia include diminished cardiac output, arrhythmia, pancreatitis, coagulopathy, thrombocytopenia, hypophosphatemia, hypovolemia from cold diuresis, hypokalemia, and hypomagnesemia. ● Monitor temperature continuously, if possible, and treat fever (38°C) aggressively with antipyretics and cooling devices because fever adversely influences recovery from ischemic brain injury ● Treat post ischemic seizures aggressively; search for a correctable metabolic cause such as hypoglycemia or electrolyte imbalance. ● Avoid rewarming from 32 to 34°C faster than 0.5°C per 2 hours unless the patient requires rapid rewarming for clinical reasons.
  11. 11. FOREIGN-BODY AIRWAY OBSTRUCTION 90% of childhood deaths from foreign body aspiration occur in children < 5 years of age; 65% are infants. Balloons, small objects, foods (hot dogs, round candies, nuts and grapes) are the most common causes of foreign- body airway obstruction
  12. 12. FBAO If FBAO is mild, do not interfere. • Allow the victim to clear the airway by coughing. If the FBAO is severe (victim unable to make a sound) you must act the relieve the obstruction.
  13. 13. FBAO For a child perform subdiaphragmatic abdominal thrusts until the object is expelled or the victim becomes unresponsive. For an infant, deliver repeated cycles of 5 back blows followed by 5 chest compressions until the object is expelled or the victim becomes unresponsive.
  14. 14. FBAO – UNRESPONSIVE Start Chest Compression After 30 chest compressions open airway If you see a foreign body remove it DO NOT perform a blind finger sweep Give 2 breaths Followed by 30 chest compressions
  15. 15. DROWNING Outcomes after drowning is determined by the duration of submersion, the water temperature, and how promptly and effectively CPR is provided.
  16. 16. PEDIATRIC CARDIAC ARREST Pediatric cardiopulmonary arrest results when respiratory failure or shock is not identified and treated in the early stages. Early recognition and intervention prevents deterioration to cardiopulmonary arrest and probable death.
  17. 17. 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.
  18. 18. RESPIRATORY FAILURE A respiratory rate of less than 10 or greater than 60 is an ominous sign of impending respiratory failure in children.
  19. 19. RESPIRATORY FAILURE Respiratory failure is characterized by inadequate ventilation, insufficient oxygenation, or both. Anticipate respiratory failure if any of the following signs is present: ● An increased respiratory rate, particularly with signs of distress (eg, increased respiratory effort including nasal flaring, retractions, seesaw breathing, or grunting) ● An 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.
  20. 20. BREATHING Breathing is assessed to determine the child’s ability to oxygenate. Assessment: • Respiratory rate • Respiratory effort • Breath sounds • Skin color
  21. 21. BREATHING CHILD If child is breathing, put in recovery position, call emergency response system, return quickly and re-assess child’s condition Turn child on-side (recovery position)
  22. 22. INADEQUATE BREATHING WITH PULSE If pulse > 60 per minutes but there is inadequate breathing give rescue breathing at a rate of about 12 to 20 breathes per minute. Reassess pulse about every 2 minutes • Carotid or femoral for child • Brachial for infant
  23. 23. UNRESPONSIVE AND NOT BREATHING If the child is unresponsive and not breathing (or only gasping) begin CPR. Start with high-quality chest compression. (30 chest compressions) After one cycle 2 minutes check for pulses Call for help when able
  24. 24. AIRWAY Airway must be clear and patent for successful ventilation. • Position • Suction • Administration of oxygen • Bag-mask ventilation • Note: suctioning is helpful if secretions, blood or debris is present. Use with caution if upper airway swelling is edema (eg. croup, epiglottitis)
  25. 25. BAG-VALVE-MASK
  28. 28. CUFFED ET TUBE
  29. 29. ET TUBE
  30. 30. RAPID SEQUENCE INTUBATION (RSI) To facilitate emergency intubation and reduce the incidence of complications, skilled, experienced providers may use sedatives, neuromuscular blocking agents, and other medications to rapidly sedate and neuromuscularly block the pediatric patient. Use RSI only if you are trained, and have experience using these medications and are proficient in the evaluation and management of the pediatric airway. If you use RSI you must have a secondary plan to manage the airway in the event that you cannot achieve intubation.
  31. 31. CRICOID PRESSURE DURING INTUBATION There is insufficient evidence to recommend routine cricoid pressure application to prevent aspiration during endotracheal intubation in children. Do not continue cricoid pressure if it interferes with ventilation or the speed or ease of intubation.
  32. 32. END-TIDAL CO2 (PETCO2) Continuous capnography or capnometry monitoring, if available, may be beneficial during CPR, to help guide therapy, especially the effectiveness of chest compressions If the PETCO2 is consistently 10 to 15 mm Hg, focus efforts on improving chest compressions and make sure that the victim does not receive excessive ventilation.
  33. 33. VENOUS ACCESS Peripheral IV access is acceptable during resuscitation if it can be placed rapidly, but placement may be difficult in a critically ill child. Although a central venous catheter can provide more secure long-term access, its placement requires training and experience, and the procedure can be time consuming. Therefore central venous access is not recommended as the initial route of vascular access during an emergency. If both central and peripheral accesses are available, administer medications into the central circulation since some medications (eg, adenosine) are more effective when administered closer to the heart, and others (eg, calcium, amiodarone, procainamide, sympathomimetics) may be irritating when infused into a peripheral vein.
  34. 34. VASCULAR ACCESS Vascular access is essential for administering medications and drawing blood samples. Obtaining peripheral venous access can be challenging in infants and children during an emergency; intraosseous (IO) access can be quickly established with minimal complications by providers with varied levels of training.
  35. 35. 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 vascular access in the proximal tibia or distal femur should be initiated.
  37. 37. INTRAOSSEOUS (IO) ACCESS IO access is a rapid, safe, effective, and acceptable route for vascular access in children and it is useful as the initial vascular access in cases of cardiac arrest. All intravenous medications can be administered intraosseously, including epinephrine, adenosine, fluids, blood products and catecholamines. Onset of action and drug levels for most drugs are comparable to venous administration.
  38. 38. ENDOTRACHEAL TUBE INTUBATION New guidelines: • Secondary confirmation of tracheal tube placement. • Use of end-tidal carbon dioxide monitor or colorimetric device
  39. 39. ENDOTRACHEAL DRUG ADMINISTRATION Vascular access (IO or IV) is the preferred method for drug delivery during CPR, but if it is not possible, lipid-soluble drugs, such as lidocaine, epinephrine, atropine, and naloxone (mnemonic “LEAN”) can be administered via an endotracheal tube. However, the effects may not be uniform with tracheal as compared with intravenous administration.
  40. 40. NEUROLOGIC SYSTEM A primary goal of resuscitation is to preserve brain function. Limit the risk of secondary neuronal injury by adhering to the following precautions: ● Do not routinely provide excessive ventilation or hyperventilation. It has no benefit and may impair neurologic outcome by adversely affecting cardiac output and cerebral perfusion. Intentional brief hyperventilation may be used as temporizing rescue therapy in response to signs of impending cerebral herniation (eg, sudden rise in measured intracranial pressure, dilated pupil not responsive to light, bradycardia, hypertension). ● Therapeutic hypothermia (32°C to 34°C) may be considered for children who remain comatose after resuscitation from cardiac arrest.
  41. 41. CIRCULATION Circulation reflects perfusion. Shock is a physiologic state where delivery of oxygen and substrates are inadequate to meet tissue metabolic needs.
  42. 42. CIRCULATION ASSESSMENT Heart rate (most accurate assessment) Blood pressure End organ profusion • Urine output (1-2 mL / kg / hour) • Muscle tone • Level of consciousness
  43. 43. 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.
  44. 44. 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.
  45. 45. BLOOD PRESSURE GUIDELINES Hypotension is defined as systolic blood pressure Neonates: < 60 mm Hg Infants: <70 mm Hg Child (1 to 10): < 70 mm Hg Child (>10): < 90 mm Hg
  46. 46. IV SOLUTIONS Crystalloid solution for fluid loss (hypovolemia) • Normal saline 20ml/kg bolus over 20 minutes • Ringers Lactate Blood loss: Colloid: 5% albumin Blood Fresh-frozen plasma
  47. 47. 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.
  48. 48. ELECTROCARDIOGRAPHY Monitor cardiac rhythm as soon as possible so both normal and abnormal cardiac rhythms are identified and followed. Continuous monitoring is helpful in tracking responses to treatment and changes in clinical condition.
  49. 49. ARRHYTHMIAS Bradycardia with pulse Tachycardia with pulses and adequate perfusion Pulseless arrest • VF/VT • Asystole
  50. 50. DEFIBRILLATORS Defibrillators are either manual or automated (AED), with monophasic or biphasic waveforms. AEDs in institutions caring for children at risk for arrhythmias and cardiac arrest (eg, hospitals, EDs) must be capable of recognizing pediatric cardiac rhythms and should ideally have a method of adjusting the energy level for children.
  51. 51. DEFIBRILLATION “Children with sudden witnessed collapse (eg, a child collapsing during an athletic event) are likely to VF or pulseless VT and need immediate CPR and rapid defibrillation. “ VF and pulseless VT are referred to as “shockable rhythms” because they respond to electric shocks. VT – ventricular tachycardia VF – ventricular fibrillation
  52. 52. DEFIBRILLATION DOSING The recommended first energy dose for defibrillation is 2 J/kg. If second dose is required, it should be doubled to 4 J/kg. AED with pediatric attenuator is preferred for children < 8 years of age.
  53. 53. DEFIBRILLATION SEQUENCE Turn AED on Follow the AED prompts End CPR cycle (for analysis and shock) Resume chest compressions immediately after the shock. Minimize interruptions in chest compressions. State CLEAR when giving the shock and have visual / verbal communication with any other rescue personal
  54. 54. 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 tall. Electrical energy is delivered by a fixed amount range 150 to 200. (2-4J/kg)
  55. 55. TACHYCARDIA WITH PULSES Supraventricular tachycardia History: vague, non-specific, history of abrupt rate change P waves absent or normal HR not variable with activity Infants: rate > 220/min Children: rate > 180/min
  56. 56. BRADYCARDIA WITH POOR PERFUSION •If pulse is less than 60 per minutes and there are signs of poor perfusion • Pallor • Mottling • cyanosis despite support of oxygenation and ventilation – start CHEST COMPRESSION
  57. 57. BRADYCARDIA The most common dysrhythmia in the pediatric population. Etiology is usually hypoxemia Initial management: ventilation and oxygenation. If this does not work IV or IO epinephrine 0.01 mg / kg (1:10,000) ET tube (not recommended) 0.1 mg / kg Search for and treat possible contributing factors
  58. 58. PULSELESS ARREST Ventricular fibrillation / ventricular tachycardia Asystole
  59. 59. PULSELESS ARREST ● As soon as the child is found to be unresponsive with no breathing, call for help, send for a defibrillator, and start CPR (with supplementary oxygen if available). Attach ECG monitor or AED pads as soon as available. Throughout resuscitation, emphasis should be placed on provision of high-quality CPR ● While CPR is being given, determine the child’s cardiac rhythm from the ECG or, if you are using an AED, the device will tell you whether the rhythm is “shockable” (eg VF or rapid VT) or “not shockable” (eg, asystole or PEA). It may be necessary to temporarily interrupt chest compressions to determine the child’s rhythm. Asystole and bradycardia with a wide QRS are most common in asphyxial arrest. VF and PEA are less common but VF is more likely to be present in older children with sudden witnessed arrest.
  60. 60. MANAGEMENT Consider vagal maneuvers Establish vascular access Adenosine • First dose 0.1 mg/kg IV (maximum of 6 mg) • Second dose 0.2 mg/kg IV (maximum of 12 mg) Synchronized cardioversion: 0.5 to 1 J / kg
  61. 61. ASYSTOLE      No Rhythm No rate No P wave No QRS comples
  62. 62. PULSELESS ARREST – ASYSTOLE CAB: Start CPR Give oxygen when available Attach monitor / defibrillator Check rhythm / check pulse If asystole give epinephrine 0.01 mg / kg of 1:10,000 Resume CPR may repeat epinephrine every 3-5 minutes until shockable rhythm is seen
  63. 63. PULSELESS ARREST – VF AND VT Start CAB Give oxygen Attach monitor / defibrillator Check rhythm: VF / VT Give one shock at 2 J/kg If still VF / VT Give 1 shock at 4 J/kg Give Epinephrine 0.01 mg/kg of 1:10,000 Consider: amiodarone at 5 mg / kg
  64. 64. 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.
  65. 65. PALS DRUGS
  66. 66. If CPR is in progress, stop chest compressions briefly, administer the medications, and follow with a flush of at least 5 mL of normal saline and 5 consecutive positive-pressure ventilations. Optimal endotracheal doses of medications are unknown; in general expert consensus recommends doubling or tripling the dose of lidocaine, atropine or naloxone given via the ETT. For epinephrine, a dose ten times the intravenous dose (0.1 mg/kg or 0.1 mL/kg of 1:1000 concentration) is recommended
  67. 67. EPINEPHRINE Action: increase heart rate, peripheral vascular resistance and cardiac output; during CPR increase myocardial and cerebral blood flow. Dosing: 0.01 mg / kg 1: 10,0000
  68. 68. AMIODARONE Used in atrial and ventricular antiarrhythmic Action: slows AV nodal and ventricular conduction, increase the QT interval and may cause vasodilation. Dosing: IV/IO: 5 mg / kg bolus Used in pulseless arrest
  69. 69. ADENOSINE Drug of choice of symptomatic SVT Action: blocks AV node conduction for a few seconds to interrupt AV node re-entry Dosing • First dose: 0.1 mg/kg max 6 mg • Second dose: 0.2 mg/kg max 12 mg • Used in tachycardia with pulses after synchronized cardioversion
  70. 70. GLUCOSE 10% to 25% strength Action: increases glucose in hypoglycemia Dosing: 0.5 – 1 g/kg
  71. 71. NALOXONE Opiate antagonist Action: reverses respiratory depression effects of narcotics Dosing: IV/IO • 0.1 mg/kg < 5 years • 0.2 mg/kg > 5 years
  72. 72. SODIUM BICARBONATE pH buffer for prolonged arrest, hyperkalemia Action: increases blood pH helping to correct metabolic acidosis
  73. 73. DOBUTAMINE Therapeutic classification: inotropic Pharmacologic classification: adrenergic Action: increases force of contraction and heart rate; causes mild peripheral dilation; may be used to treat shock Dosing: IV/IO: 2-20 mcg/kg/min infusion
  74. 74. DOPAMINE Therapeutic classification: inonotropic May be used to treat shock; effects are dose dependent Increases force of contraction and cardiac output, increases peripheral vascular resistance, BP and cardiac output Dosing: IV/IO infusion: 2-20 mcg/kg/min
  75. 75. 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.
  76. 76. REFERENCES  Duncan BW, Ibrahim AE, Hraska V, del Nido PJ, Laussen PC, Wessel DL, Mayer JE, Jr., Bower LK, Jonas RA. Use of rapid-deployment extracorporeal membrane oxygenation for the resuscitation of pediatric patients with heart disease after cardiac arrest. J Thorac Cardiovasc Surg. 1998;116:305–311.  Hoskote A, Bohn D, Gruenwald C, Edgell D, Cai S, Adatia I, Van Arsdell G. Extracorporeal life support after staged palliation of a functional single ventricle: subsequent morbidity and survival. J Thorac Cardiovasc Surg. 2006;131:1114 – 1121.  Ibrahim AE, Duncan BW, Blume ED, Jonas RA. Long-term follow-up of pediatric cardiac patients requiring mechanical circulatory support. Ann Thorac Surg. 2000;69:186 –192.  Prodhan P, Fiser RT, Dyamenahalli U, Gossett J, Imamura M, Jaquiss RD, Bhutta AT. Outcomes after extracorporeal cardiopulmonary resuscitation (ECPR) following refractory pediatric cardiac arrest in the intensive care unit. Resuscitation. 2009;80:1124 –1129.  Pediatric Advanced Life Support2010,2014 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
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Pediatric advanced life support


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