PALS approach to management of common pediatric resipatory emergencies.

1. Pediatric Emergencies Mx
Approach
By Fatima Farid
Ped Resident Yr 4

2. Objectives
• Identify children that require immediate intervention
• Recognize & differentiate between respiratory distress vs failure
• Perform early interventions for respiratory distress & failure
• Learn how to apply team dynamics
Let’s practice together as a team!
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3. Do you know how to identify a sick child?
3

4. PALS Systematic
Approach Algorithm
1. Initial
impression
2. Evaluate
3. Identify
4. Intervene
4
(1)
Evaluate
(2)
Identify
(3)
Intervene
Constantly!!
Remember!!

5. Initial Impression
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• Your first QUICK
observation of the
child’s situation
• It is accomplished
within the first few
seconds of seeing the
child

6. PAT - Our tool for initial impression
• The pediatric assessment
triangle (PAT) is used to:
1. Identify the general type of
physiological problem
2. Recognize urgency for
treatment & transport
• Appearance, breathing & colour
are concentrated upon
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7. Appearance - TICLS
• Indicates the overall
physiologic status
• T – tone
• I – interactiveness
• C – consolability
• L – look/ gaze/ stare
• S – speech/ cry
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8. Breathing
• Position/ posture
• Tripod/ sniffing
• Work of breathing:
• Nasal flaring
• Retractions
• Use of accessory muscles
• Increased, inadequate or absent
respiratory effort
• Breath sounds:
• Wheezing/ stridor/ grunting/ gurgling/
etc
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9. Colour
• Helps assess the overall circulatory status
• Expose the child enough to appreciate:
• Pallor
• Mottling
• Cyanosis
• Flushing
• Bruising
• Petechiae/ purpura
• Bleeding
• Look at the skin and mucus membranes
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10. PALS Systematic
Approach Algorithm
1. Initial
impression
2. Evaluate
3. Identify
4. Intervene
10
(1)
Evaluate
(2)
Identify
(3)
Intervene
Constantly!!
Remember!!

11. Evaluate- Identify- Intervene
• Evaluate:
• Primary assessment
• Secondary assessment
• Diagnostic assessment
• Identify:
• Respiratory vs circulatory vs combined
• Severity (distress/ failure/ shock/ arrest)
• Intervene
• Continue sequence after each intervention or change in patient condition
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(1)
Evaluate
(2)
Identify
(3)
Intervene

12. Evaluate - Primary assessment (ABCDE)
Airway
1. Clear
2. Maintainable
3. Non- maintainable
Breathing
1. Rate & pattern
2. Effort
3. Chest expansion & air movement
4. Lung & airway sounds
5. O2 saturation by pulse oximetry
Circulation
1. Heart rate & rhythm
2. Pulses (peripheral and central)
3. Capillary refill time
4. Skin colour and temperature
5. Blood pressure
Disability
1. AVPU
2. GCS
3. Pupil response to light
4. Blood glucose test
Exposure
1. Temperature
2. Trauma
3. Skin rash
4. Extremities
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(1)
Evaluate
(2)
Identify
(3)
Intervene

13. Evaluate continued
Secondary assessment
• Focused history: (SAMPLE)
• S- Signs and symptoms
• A- Allergies
• M- Medications
• P- Past medical Hx
• L- Last meal
• E- Event leading up to current
situation
• Focused physical examination
Diagnostics assessments
• ABG/ VBG/ CBG
• Hemoglobin
concentration
• Central venous
O2 saturation
• Arterial lactate
• Central venous
pressure monitor
• Invasive arterial
pressure monitor
• Chest x- ray
• ECG
• Echocardiogram
• Peak expiratory
flow rate
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14. PALS Systematic
Approach Algorithm
1. Initial
impression
2. Evaluate
3. Identify
4. Intervene
14
(1)
Evaluate
(2)
Identify
(3)
Intervene
Constantly!!
Remember!!

15. Identify
Type Severity
Respiratory
• Upper airway obstruction
• Lower airway obstruction
• Lung tissue disease
• Disordered control of breathing
• Respiratory distress
• Respiratory failure
Circulatory
• Hypovolemic shock
• Distributive shock
• Cardiogenic shock
• Obstructive shock
• Compensated shock
• Hypotensive shock
Cardiopulmonary failure
Cardiac arrest
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16. Types of respiratory disease
Type Causes Signs
Upper airway obstruction
(nose, pharynx, larynx)
Foreign body aspiration, anaphylaxis, tonsillar
hypertrophy, croup, epiglottitis, pharyngeal/
retropharyngeal/ peritonsillar abscess, tumours,
congenital airway anomalies, thick secretions,
traumatic intubation sequelae
• Increased resp rate & effort
• Stridor
• Change in voice, cry, cough
• Drooling, snoring, gurgling
• Poor chest rise
• Poor air entry
Lower airway obstruction
(lower trachea, bronchi, bronchioles)
Asthma, bronchiolitis
• Increased resp rate & effort
• Decreased air entry
• Prolonged expiratory phase
• Wheezing
• Cough
Lung tissue disease
(parenchyma)
Pneumonia, pulmonary edema, lung contusion,
allergic rxn, toxin, vasculitis, infiltrative dse
• Increased resp rate & effort
• Grunting
• Crackles
• Diminished air entry
• Tachycardia
• Hypoxemia despite administration of O2
Disordered control of
breathing
Seizure, CNS infections, head injury, brain tumour,
hydrocephalus, neuromuscular dse, metabolic
anomalies, drug overdose
• Variable/ irregular resp pattern & effort
• Shallow breathing with inadequate effort
• Central apnea
• Normal or decreased air movement 16

17. Severity of respiratory disease
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• Distress:
• Increased respiratory rate, effort and work of breathing
• Child is trying to maintain adequate gas exchange despite
airway obstruction, reduced lung compliance, or lung tissue
disease
• As fatigue develops, adequate gas exchange cannot be
maintained & respiratory failure ensues

18. Severity of respiratory disease
• Failure:
• Clinical state of inadequate oxygenation, ventilation or both
• Can result from any type of respiratory disease
• When respiratory effort is inadequate, failure can occur without
typical signs of respiratory distress
• Respiratory failure is a clinical state that requires intervention
to prevent deterioration to cardiac arrest
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19. Distress vs Failure
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Resp Distress
1. Awake, alert
2. Tachypneic
3. Nasal flaring
4. Chest wall retractions
5. Audible grunting
Resp Failure
1. Obtunded
2. Marked tachypnea
3. Abdominal breathing
4. Cyanosed

20. PALS Systematic
Approach Algorithm
1. Initial
impression
2. Evaluate
3. Identify
4. Intervene
20
(1)
Evaluate
(2)
Identify
(3)
Intervene
Constantly!!
Remember!!

21. Team dynamics – they key to good care
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22. Intervention
overview
• Varies according to the
underlying cause
• Oxygen therapy is a
common factor that
should be well-
understood for correct
administration!
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23. Oxygen therapy
Indications
Respiratory distress, shock, altered mentation (reduced tissue perfusion
& increased body demands)
O2 delivery to conscious child Ensure child’s comfort & minimize distress
O2 delivery to unconscious child Implement airway protection maneuvers
Types of delivery
Low- flow modes:
• Nasal cannula
• Simple oxygen mask
High- flow modes:
• Non-rebreathing mask with reservoir
• High flow nasal cannula
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24. Low- flow modes
• Not tight fitting to airway, hence FiO2 is lower & cannot be fully
controlled as room air mixes during inhalation
• Nasal cannula:
• FiO2 22- 60%
• Flow 0.25- 4 L/min
• Simple face mask:
• FiO2 35- 60%
• Flow 6- 10 L/min
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25. High- flow modes
• Reliably delivery oxygen concentration
higher than 60% & flow at minimum 10
L/min
• Non- rebreathing mask:
• FiO2 up to 95%
• Flow 10- 15 L/min
• High- flow nasal cannula:
• Flow 4- 40 L/min as per child’s need
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26. PALS Systematic
Approach Algorithm
1. Initial
impression
2. Evaluate
3. Identify
4. Intervene
26
(1)
Evaluate
(2)
Identify
(3)
Intervene
Constantly!!
Remember!!

27. 27
Thanks for
listening!