pals for nurses . Dr Ashok

1. PEDIATRIC ADVANCED LIFE SUPPORT
(PALS)
T P VIGNESHWARAN

2. A 3 year old boy presents with multisystem trauma. The child was
an unrestrained passenger in motor vehicle crash. On assessment
he is unresponsive to voice or painful stimulation.
His vitals : RR < 6 / min, HR – 172 /min , Systolic BP – 60mmHg ,
CRT – 5sec and SpO2 – 75%.
how will approach this child ?

3. SYSTEMATIC APPROACH – PALS

7. INITIAL IMPRESSION

8. PRIMARY ASSESSMENT
AIRWAY •Patent
•Patent with maneuvers / adjuncts
•Partially or completely obstructed
BREATHING •Respiratory rate
•Respiratory effort
•Tidal volume
•Lung sounds
•pulse oximetry
CIRCULATION Evaluate cardiovascular function by assessing
•Skin color and temperature
•Heart rate and rhythm
•Pulses ( both peripheral and central )
•Capillary refill time
•Blood pressure including pulse pressure
Evaluate end organ perfusion by assessing
mental status , Skin color , U.O
DISABILITY Establish child’s level of consciousness by
AVPU pediatric response scale , GCS ,
Pupillary responses
EXPOSURE Fever or hypothermia , Skin findings ,
Evidence of trauma

9. SECONDARY ASSESSMENT
Focused history and physical examination
• Signs & symptoms
• Allergies
• Medications
• Past medical history
• Last meal
• Events leading to current illness
TERTIARY ASSESSMENT
Laboratory , radiographic and other advanced tests to
establish child’s physiological condition and diagnosis.

10. CATEGORIZE THE CLINICAL CONDITION
Respiratory insufficiency Circulatory insufficiency
UA Obstruction
LA Obstruction
Lung Parenchymal disease
Disordered control of
breathing
Hypovolemic shock
Distributive shock
Cardiogenic Shock
Obstructive shock
Respiratory distress
Respiratory failure
Compensated shock
Hypotensive shock
Respiratory + circulatory
Cardiopulmonary failure
Cardiac arrest
Initial
Impression
Severity
Type
10/21/2022 IAP - PALS 2011 MODULE 10

11. RESPIRATORY DISTRESS RESPIRATORY FAILURE
A OPEN AND MAINTAINABLE NOT MAINTAINABLE
B •TACHYPNEA
•INCREASED RESPIRATORY EFFORT
•GOOD AIR MOVEMENT
•BRADYPNEA TO APNEA
•DECREASED RESPIRATORY
EFFORT
•POOR TO ABSENT AIR
MOVEMENT
C TACHYCARDIA
PALLOR
BRADYCARDIA
CYANOSIS
D ANXIETY AND AGITATION LETHARGY TO
UNRESPONSIVENESS
E VARIABLE TEMPERATURE VARIABLE TEMPERATURE
CATEGORIZE RESPIRATORY PROBLEMS BY SEVERITY

12. CLINICAL SIGNS HYPOVOLEMIC
SHOCK
DISTRIBUTIVE
SHOCK
CARDIOGENIC
SHOCK
OBSTRUCTIVE
SHOCK
A PATENCY AIRWAY OPEN AND MAINTAINABLE / NOT MAINTAINABLE
B RESPIRATORY
RATE
INCREASED
RESPIRATORY
EFFORT
NORMAL TO INCREASED LABORED
BREATH
SOUNDS
NORMAL NORMAL
( +/- CRACKLES)
CRACKLES , GRUNTING
C SBP COMPENSATED SHOCK HYPOTENSIVE SHOCK
PULSE PRESSURE NARROW WIDE NARROW
PERIPHERAL
PULSE QUALITY
WEAK BOUNDING OR
WEAK
WEAK
HEART RATE INCREASED
SKIN PALE , COOL WARM OR COOL PALE , COOL
CRT DELAYED VARIABLE DELAYED
URINE OUTPUT DECREASED
D LEVEL OF
CONSCIOUSN
ESS
IRRITABILITY EARLY LETHARGIC LATE
E TEMPERATURE VARIABLE

13. If you see a life threatening condition begin life saving interventions
as follows
• Support ABCs ( CPR for cardiac arrest)
• Provide supplementary 100% oxygen
• Provide assisted venilation e.g bag –mask , ET intubation
• Start cardiac and respiratory monitoring e.g ECG, Pulse oximetry , exhaled
CO2 if inubated
• Establish IV / IO access
• Give a bolus of isotonic crystalloid
• Obtain laboratory studies such as bed side glucose and arterial blood gas
• Administer drugs
• Provide electrical therapy

15. CASE SCENARIO -1
1 year old male child with incessant cry , poor feeding brought to ER.
Identify the rhythm ?
Narrow complex tachycardia with absent P wave
what is the treatment ?
vagal maneuvers / adenosine
if no response to adenosine and child is hypotensive what do want to do ?
synchronised cardioversion ( 0.5-2J/kg) +/- amiodarone

16. Case scenario -2
10 yr old male child – 30kg on ventilator has tachycardia,
hypotension with altered sensorium. Pulses felt.
• Read the ECG.
wide complex tachycardia – monomorphic VT
• Treatment ?
Synchronised cardioversion

18. CASE SCENARIO -3
8 year old child on ventilator with HR – 50/min
Identify the rhythm.
sinus bradycardia
What could be the most common cause?
hypoxia
Treatment ?
rule out DOPE ; provide 100% oxygen.
if associated with signs of poor perfusion:
CPR +/- adrenaline / atropine

20. CASE SCENARIO – 4
An 8 month old infant brought to ER for evaluation of severe diarrhoea. On
examination he is unresponsive, gasping , pulseless and BP not recordable.
Cardiac monitor shows following rhythm.
Identify the rhythm.
ventricular fibrillation
Treatment ?
CPR / Defibrillation +/- epinephrine / amiodarone

22. TAKE HOME MESSAGE
• Systematic approach to pediatric assessment
• Assess , categorize , decide and act
• Effective team dynamics
• Know your roles during resuscitation
• If you recognise life threatening condition begin life saving
interventions
• Search for and treat possible contributing factors during life
threatening situation ( H’s & T’s)
• Follow PALS algorithm based on problem identified

23. THANK YOU