PALS - Pediatric advanced life support
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PALS - Pediatric advanced life support
- 1. PEDIATRIC ADVANCED LIFE SUPPORT Dr. Vinaykumar S Appannavar
- 2. SESSION 01 – BLS pearls – Introduction to PALS – How to recognize the sick child – a structured approach
- 3. Basic life support – BLS refers to care healthcare providers and public safety professionals provide to patients who are experiencing respiratory or cardiac arrest Steps of BLS: 1. Ensure safety 2. Assess response 3. Activate EMS 4. C-A-B 5. Defibrillation 6. Continuation or recovery from resuscitation BLS
- 5. AIRWAY
- 6. BREATHING
- 11. PRINCIPLES OF PALS – ALS refers to constellation of interventions needed to support the vital physiological processes during critical illness ,while we await for definite therapy – Taking care of respiratory, circulatory and neurological insufficiencies is called as ADVANCED LIFE SUPPORT – The format of identifying a sick child involves a structured approach .
- 12. HOW TO RECOGNIZE THE SICK CHILD – A STRUCTURED APPROACH 3 year old Riya, presented with fever and cough since 2 days and rapid breathing since 1 day. At presentation RR – 56cpm Pallor + recession ++ Spo2 – 86% @RA CASE 01
- 14. EVALUATE – For recognition of sick child using structured approach – INITIAL IMPRESSION – PRIMARY ASSESSMENT – SECONDARY ASSESSMENT – DIAGNOSTIC TESTS EVALUATE
- 15. 1. INITIAL IMPRESSION APPEARENCE BREATHING PEDIATRIC ASSESMENT TRAINGLE COLOR EVALUATE 3 year old Riya, presented with fever and cough since 2 days and rapid breathing since 1 day. At presentation Pallor + RR – 56cpm recession ++ Spo2 – 86% @RA
- 16. CONCIOUSNESS - HMF –Tone – Interactive – Consolable – Look – SpeechAPPEARENCE EVALUATE TICLS INITIAL IMPRESSION
- 17. BRAIN DYSFUNCTION – Primary hypoxia – Secondary hypoxia IDENTIFY
- 18. EVALUATE 3 year old Riya, presented with fever and cough since 2 days and rapid breathing since 1 day. At presentation Pallor + RR – 56cpm recession ++ Spo2 – 86% @RA BREATHING – Whether the child is not breathing at all ? – Whether the breathing is too fast or too slow ? – Are there any audible sounds during respiration? – Is breathing regular and smooth or asynchronous/ jerky / paradoxical ? – Is there use of accessory muscles : flaring of ala nasi, head bobbing ? BREATHING INITIAL IMPRESSION
- 19. RESPIRATORY DYSFUNCTION – ABNORMALITIES in any of previously mentioned parameters IDENTIFY
- 20. EVALUATE 3 year old Riya, presented with fever and cough since 2 days and rapid breathing since 1 day. At presentation Pallor + RR – 56cpm recession ++ Spo2 – 86% @RA BREATING – A pale child – Bruises, ecchymosis or petechial rashes – Mottling or dusky or blue hue – Cyanosis – Evidence of active bleeding COLOR INITIAL IMPRESSION COLOR
- 21. CIRCULATORY DYSFUNCTION – ABNORMALITIES in any of previously mentioned parameters IDENTIFY
- 23. IDENTIFY – severity of the insufficiency and classify the typesIDENTIFY RESPIRATORY CIRCULATORY NUEROLOGICAL STABLE LIFE THREATENING SITUATION CARDIAC ARREST DISTRESS FAILURE COMPENSATED HYPOTENSIVE CORTICAL BRAINSTEM
- 24. – 6yr old Sameer, presented with early morning pain abdomen and vomiting since 2 hours, drooping of eyelids and weekness of all 4 limbs since 1 hour, At presentation RR – 16cpm, shallow Secretions ++ Ptosis + Quadriparesis + Spo2 – 86% @ RA CASE 02
- 25. PRIMARY ASSESSMENT EVALUATE 3 year old Riya, presented with fever and cough since 2 days and rapid breathing since 1 day. At presentation Pallor + RR – 56cpm recession ++ Spo2 – 86% @RA 6yr old Sameer, presented with early morning pain abdomen and vomiting since 2 hours, drooping of eyelids and weakness of all 4 limbs since 1 hour, At presentation RR – 16cpm, shallow Secretions ++, Ptosis +, Quadriparesis +, Spo2 – 86% @ RA ASSESSMENT PENTAGON AIRWAY BREATHING CIRCULATIONDISABILITY EXPOSURE
- 26. AIRWAY OPEN MAINTAINABLE – Some assistance NON MAINTAINABLE – Advanced assistance EVALUATE PRIMARY ASSESSMENT AIRWAY 3 year old Riya, presented with fever and cough since 2 days and rapid breathing since 1 day. At presentation Pallor + RR – 56cpm recession ++ Spo2 – 86% @RA 6yr old Sameer, presented with early morning pain abdomen and vomiting since 2 hours, drooping of eyelids and weakness of all 4 limbs since 1 hour, At presentation RR – 16cpm, shallow Secretions ++, Ptosis +, Quadriparesis +, Spo2 – 86% @ RA
- 27. BREATHING Respiratory rate Work of breathing Chest wall movements and tidal volume Auscultation for air entry and adventitious sounds Pulse oximetry EVALUATE PRIMARY ASSESSMENT BREATHING 3 year old Riya, presented with fever and cough since 2 days and rapid breathing since 1 day. At presentation Pallor + RR – 56cpm recession ++ Spo2 – 86% @RA 6yr old Sameer, presented with early morning pain abdomen and vomiting since 2 hours, drooping of eyelids and weakness of all 4 limbs since 1 hour, At presentation RR – 16cpm, shallow Secretions ++, Ptosis +, Quadriparesis +, Spo2 – 86% @ RA
- 28. BREATH SOUNDSEVALUATE PRIMARY ASSESSMENT BREATHING AIRWAY ADDED SOUNDS LOCATION Snuffles Nasal Snoring Naso-pharyngeal Stridor Upper airway Wheeze Lower airway Crackles Lungs - alveoli Grunting Parenchyma
- 29. Severity of Respiratory insufficiency IDENTIFY
- 30. Type of Respiratory insufficiencyIDENTIFY
- 31. INTERVENE TYPE EXAMPLE ER INTERVENTIONS Medical Upper airway obstruction Viral croup Humidified oxygen, nebulised budesonide or injectable steroid Mechanical Upper airway obstruction Foreign body Diphtheria Black slap/ chest thrust – infant Heimlich Manoeuvre - Children ADS & Tracheostomy Lower airway obstruction Acute severe asthma Bronchiolitis Inhaled short acting beta agonist Lung parenchymal disease Bacterial Pneumonia Antibiotics Disordered control of breathing Seizures / Coma Anticonvulsants Bag-mask ventilation Advanced airway management
- 32. CIRCULATION Heart rate and rhythm Central and peripheral pulses Capillary refill time Skin color and temperature Blood pressure Urine output EVALUATE PRIMARY ASSESSMENT 3 year old Riya, presented with fever and cough since 2 days and rapid breathing since 1 day. At presentation Pallor + RR – 56cpm recession ++ Spo2 – 86% @RA 6yr old Sameer, presented with early morning pain abdomen and vomiting since 2 hours, drooping of eyelids and weakness of all 4 limbs since 1 hour, At presentation RR – 16cpm, shallow Secretions ++, Ptosis +, Quadriparesis +, Spo2 – 86% @ RA CIRCULATION
- 33. Hypotension cut off AGE FORMULA Term neonate < 60mmHg Upto 1 year < 70 mmHg 1-10 year 70 + age (years) * 2 10 years < 90 EVALUATE PRIMARY ASSESSMENT CIRCULATION Compensated shock will have normal BP with poor perfusion Hypotension is a late sign : Shock will be decompensated once hypotension sets in Fall of systolic pressure of >10mmhg is worrisome even if hypotension is absent Recognized and must be intervened in the compensated stage
- 34. Severity of Circulatory insufficiency COMPENSATED HYPOTENSIVE IDENTIFY
- 35. Type of Circulatory insufficiencyIDENTIFY HYPOVOLEMIC SHOCK DISTRUTIVE SHOCK CARDIOGENIC SHOCK OBSTRUCTIVE SHOCK
- 36. TYPE EXAMPLE ER INTERVENTIONS HYPOVEMIC SHOCK Diarrhoea and dehydration Humidified oxygen, IO/IV access, Crystalloid bolus DISTRUTIVE SHOCK Septic shock Humidified oxygen, IO/IV access, Crystalloid bolus, ANTIBIOTICS, vasoactives CARDIOGENIC SHOCK Acute myocarditis Humidified oxygen, IO/IV access, inotropes OBSTRUCTIVE SHOCK Tension pnuemothorax Assisted ventilation, IO/IV access, needle thoracocentesis INTERVENE
- 37. PRIMARY ASSESSMENT EVALUATE 3 year old Riya, presented with fever and cough since 2 days and rapid breathing since 1 day. At presentation Pallor + RR – 56cpm recession ++ Spo2 – 86% @RA 6yr old Sameer, presented with early morning pain abdomen and vomiting since 2 hours, drooping of eyelids and weekness of all 4 limbs since 1 hour, At presentation RR – 16cpm, shallow Secretions ++, Ptosis +, Quadriparesis +, Spo2 – 86% @ RA ASSESSMENT PENTAGON AIRWAY BREATHING CIRCULATIONDISABILITY EXPOSURE
- 38. DISABILTYEVALUATE PRIMARY ASSESSMENT DISABILITY 2 STEP process Cortical assessment : By GCS and AVPU scale Brain stem assessment : Pupillary responses and movements
- 39. EXPOSUREEVALUATE PRIMARY ASSESSMENT EXPOSURE – The child is appropriately exposed and examined for bleeds, injuries, swelling, distension, deformity and rashes
- 41. SECONDARY ASSESSMENT FOCUSED HISTORY FOCUSED EXAMINATION EVALUATE Sings and symptoms Allergies Medication received Past medical history Last meal taken Event that bought the child to ER
- 42. DIAGNOSTIC TESTSEVALUATE – Blood glucose – Hematological profile – Acid – base balances – CT scan – MRI
- 43. IDENTIFY – severity of the insufficiency and classify the typesIDENTIFY RESPIRATORY CIRCULATORY NUEROLOGICAL STABLE LIFE THREATENING SITUATION CARDIAC ARREST DISTRESS FAILURE COMPENSATED HYPOTENSIVE CORTICAL BRAINSTEM
- 44. At the end of INITIAL IMPRESSION 3 year old Riya, presented with fever and cough since 2 days and rapid breathing since 1 day. At presentation RR – 56cpm recession ++ Spo2 – 86% @RA 6yr old Sameer, presented with early morning pain abdomen and vomiting since 2 hours, drooping of eyelids and weakness of all 4 limbs since 1 hour, At presentation RR – 16cpm, shallow Secretions ++, Ptosis +, Quadriparesis +, Spo2 – 86% @ RA SEVERITY Respiratory distress Compensated Shock Respiratory Failure Hypotensive shock TYPE UAO Hypovolemic Shock LAO Distributive Shock Lung parenchymal disease Cardiogenic shock Disordered control of breathing Obstructive shock APPEARENCE BREATHING PEDIATRIC ASSESMENT TRAINGLE COLOR APPEARENCE BREATHING PEDIATRIC ASSESMENT TRAINGLE COLOR
- 45. AIRWAY BREATHING CIRCULATIONDISABILITY EXPOSURE 3 year old Riya, presented with fever and cough since 2 days and rapid breathing since 1 day. At presentation RR – 56cpm recession ++ Spo2 – 86% @RA 6yr old Sameer, presented with early morning pain abdomen and vomiting since 2 hours, drooping of eyelids and weakness of all 4 limbs since 1 hour, At presentation RR – 16cpm, shallow Secretions ++, Ptosis +, Quadriparesis +, Spo2 – 86% @ RA SEVERITY Respiratory distress Compensated Shock Respiratory Failure Hypotensive shock TYPE UAO Hypovolemic Shock LAO Distributive Shock Lung parenchymal disease Cardiogenic shock Disordered control of breathing Obstructive shock At the end of PRIMARY ASSEMENET AIRWAY BREATHING CIRCULATIONDISABILITY EXPOSURE ASSESSMENT PENTAGON AIRWAY BREATHING CIRCULATIONDISABILITY EXPOSURE CIRCULATION DISABILITY Cortical Brainstem Cardiogenic shock Obstructive shock Primary Secondary
- 46. ASSESSMENT PENTAGON AIRWAY BREATHING CIRCULATIONDISABILITY EXPOSURE SEVERITY CARDIOPULMONARY ARREST CARDIAC ARREST ASSESSMENT PENTAGON AIRWAY BREATHING CIRCULATIONDISABILITY EXPOSURE
- 47. – 3 month old baby, brought with 1 day history of URI, Poor feeding and breathing difficulty. Previously well child. CASE 03
- 48. EVALUATE INITIAL IMPRESSION Irritable Tachypnea PEDIATRIC ASSESMENT TRAINGLE Pale IDENTIFY INTERVENE RESPIRATORY AND CIRCULATORY INSUFFICENCY START OXYGEN, GATHER TEAM , ATTACH MONITORS
- 49. EVALUATE PRIMARY ASSESSMENT IDENTIFY INTERVENE RESPIRATORY FAILURE COMPENSATED SHOCK ASSESSMENT PENTAGON NON- MAINTAINABLE RR- 62CPM, SCR +, Grunt +,EAE ,Spo2 – 89% HR- 190BPM,SR,CE NTRAL PULSES +, Weak peripheries, CRT>4, BP- 80/60MMHG NAD NAD IO/IV ACCESS, Check ABG, Plan for bolus START HFNC 0R CPAP
- 50. URI-1 Day, Poor feeds, Breathing difficulty Liver – 6cm below RCM, Heart sounds - muffled EVALUATE SECONDARY ASSESSMENT No volume loss, No sepsis Restrict fluid boluses to 10ml/kg Cardiogenic shock, pulmonary edema INTERVENE Stop Bolus, Start Inotropes
- 51. EVALUATE DIAGNOSTIC TESTS VIRAL MYOCARDITIS MANAGE ACCORDINGLY INTERVENE – Chest Xray – 2D ECHO – Cardiac biomarkers – Viral studies
- 52. EVALUATE IDENTIFY INTERVENE INITIAL IMPRESSION PRIMARY ASSESSMENT SECONDARY ASSESSMENT DIAGNOSTIC TESTS PAT ABCDE ABCDE SAMPLE FOCUSED EXAMINATION
- 54. THANK YOU V S A
Editor's Notes
- Auscultation – Snuffles – nasal Snoring - - stridor- wheeze- crackles - grunt
- Auscultation – Snuffles – nasal Snoring - - stridor- wheeze- crackles - grunt
- Auscultation – Snuffles – nasal Snoring - - stridor- wheeze- crackles - grunt
- Auscultation – Snuffles – nasal Snoring - - stridor- wheeze- crackles - grunt
- Auscultation – Snuffles – nasal Snoring - - stridor- wheeze- crackles - grunt
- Auscultation – Snuffles – nasal Snoring - - stridor- wheeze- crackles - grunt
- Auscultation – Snuffles – nasal Snoring - - stridor- wheeze- crackles - grunt
- Auscultation – Snuffles – nasal Snoring - - stridor- wheeze- crackles - grunt