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Pals%20update%202005%20to%202010 chodchanok

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Pals%20update%202005%20to%202010 chodchanok

  1. 1. 1From PALS guideline 2005, 2006, 2009 AHA :Emergency Medicine Conference : Future of Pre-hospital and Emergency CareIllustrated by Chodchanok Vijarnsorn MD.Division of Pediatric Cardiology, Department of Pediatrics,Faculty of Medicine, Siriraj Hospital21/6/2010
  2. 2. 2AgendaTwo partsCall fastLook-listen-feel and airway maintain andcheck pulseChest compression (new guideline)
  3. 3. 3Etiologies:Out of hospital cardiac arrest :Respiratory failure & ShockBy standBasic life support aloneIn hospital cardiac arrestMultiple etiologiesPoor outcomeEffective CPR better survival *
  4. 4. 4Many etiologiesCardiopulmonary failureCardiopulmonary arrestDeath Cardiopulmonary recoveryImpaired Unimpairedneurologic neurologicrecovery recoveryRespiratory failure Shock
  5. 5. 5Pre – cardiopulmonary failure Respiratory distress  shock4 steps : Assessment1. General assessment2. Primary assessment3. Secondary assessment4. Tertiary assessment
  6. 6. 6
  7. 7. 7General assessment Pediatric assessment triangle (PAT)Appearance- restless?,-not interactive?-muscle tone-Cry/speechBreathing-increase effort?-noise on respiration-nasalflaring-retractionCirculation-pale? mottling?-bleedingFirst few secondsLife threatening?
  8. 8. 8First few secondsLife threatening?General assessmentRespiratory distressRespiratory failureShockCompensated/decompensatedACTION
  9. 9. 9Primary assessment Primary assessment : ABCDE - A : airway - B : breathing - C : circulation - D : disability - E : exposure ( PE, look listen feel, include V/S &oxygen saturation)ACTION
  10. 10. 10A : AirwayChest movementBreath soundFeel : air passes through nose andmouthUpper airway : clear/ maintainable,not maintainableIncrease respiratory effort, inspiratory force/absent?Snoring, stridor?Retraction?
  11. 11. 11BreathingRRRespiratory effortTidal volumeAirway and lung soundPulse oximetry 94% = adequate oxygenation < 94% airway intervention < 90% in 100% oxygen ( nonrebreathing mask  advancedintervention : assisted ventilation
  12. 12. 12
  13. 13. 13Circulatory Cardiovascularfunction- skin color : mottling- HR- BP-Pulse(peripheral/central)- capillary refill End organ- brain perfusion- skin perfusion- renal perfusion (urine output)
  14. 14. 14Definition 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
  15. 15. 15Capillary refillNormal < 2 secondsProlonged capillary refill > 2 secIn case : shock, hypothermia, severedehydrationWarm shock :capillary refill < 2 sec due to peripheral vasodilatation
  16. 16. 16Pulse check : central pulseUse femoral / brachialpulse : < 1 year-old
  17. 17. 17DisabilityAVPU pediatric response scaleGlasglow coma scalesPupillary response to lightAVPUAlertVoicePainfulUnresponsiveness
  18. 18. 18ExposureTraumaBurnChild abuseSkin lesion
  19. 19. 19ActionGeneral management for all patientsAirway positionOxygenPulse oxymetryEKG monitor as indicatedBLS as indicated
  20. 20. 20Secondary assessment3. Secondary assessment- SAMPLE- S : Signs and symptoms- A : Allergies- M : medication- P : past medical history- L : last meal- E : events leading topresentationACTION
  21. 21. 21Tertiary assessment Laboratory : ABG, VBG, Hb, SVO2 sat,HCO3, lactate, Radiography : CXR, echocardiography Exhale CO2, PEFR, CVP Emphasize : Anytime you identify a lifethreatening condition, initiate appropriatecare immediately
  22. 22. 22AssessCategorizeDecideActionIf you recognize a life threatening condition at any time,immediately begin life saving intervention andactivate the emergency response system
  23. 23. 23SummaryPALS guideline AHA 2008
  24. 24. 24Signs of life threatening conditionAirway Complete or severe AOBreathing Apnea, significant work ofbreathingCirculation Absent pulse, poorperfusion, hypotension,bradycardiaDisability Unresponsiveness, depressconsciousExposure Significant hypothermia,bleeding, purpura,abdominal distension dueto bleeding
  25. 25. 25Life saving intervention ABC/CPR 100% oxygen Assisted ventilation :bag mask, ETT Cardiac andrespiratory monitoring: EKG, pulse oximetry Intravenous / I/O Bolus isotoniccrystalloid Lab study : DTX, ABG Drugs Electrical therapyACTION
  26. 26. 26New recommendation : Bag & maskventilation :E-C clampGive 2 breath chest move?(12-20 breath/min for child)
  27. 27. 27
  28. 28. 28PALS and neonatal update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
  29. 29. 29Chest compressionNipple line for childBelow nipple line in infant
  30. 30. 30
  31. 31. 31
  32. 32. 32Coronary Perfusion Pressure Improves With SequentialCompressionsCPP at 5:1 ratioCPP at 15:2 ratioSurvival with 15:2
  33. 33. 33“Continue CPR as much aspossible except rhythm check”
  34. 34. 34Key change in BLSEffective rescue breath and visualizationof 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
  35. 35. 35Categorize Determine the type and severityType SeverityRespiratory - Upper airway obstruction- Lower airway obstruction- lung parenchymal disease- Disorder control of breathing-Respiratorydistress-Respiratory failureCirculatory - Hypovolemic shock- Obstructive shock- Distributive shock- Cardiogenic shock-Compensatedshock-Hypotensive shock
  36. 36. 36Recognition of respiratorydistress and failure
  37. 37. 37
  38. 38. 38
  39. 39. 39
  40. 40. 40
  41. 41. 41
  42. 42. 42
  43. 43. 43Prehospital Tracheal Intubation vs Bag-MaskVentilationBag-maskventilation : aseffective asintubation iftransport time isshortNeed training andexperienceMust confirmation oftube positionMonitoring
  44. 44. 44Use of Cuffed Endotracheal TubesIn-hospital setting, a cuffed ETT : assafe as an uncuffed tube for infants(except the newborn) and childrenKeep cuff inflation pressure <20 cmH2OCuffed ETT size (mm) = (age (yr) /4) + 3Uncuff size (mm): (age (yr) /4) + 4Depth : age (yr)/2 + 12
  45. 45. 45Insertion of the Laryngeal Mask Airway inChildren The LMA consists of a tubewith a cuffed mask at thedistal end. The LMA is blindlyintroduced into thepharynx until resistance ismet; the cuff is theninflated and ventilationassessed.
  46. 46. 46Verification of Endotracheal Tube Placementbilateral chest movement and listenfor equal breath sounds over bothlung fieldsgastric insufflation soundsexhaled CO2pulse oximeterdirect laryngoscopychest x-ray
  47. 47. 47Colorimetric Exhaled CO2 DetectorColorimetricexhaled CO2detector devicechanges color (frompurple to yellow)with detection ofexhaled CO2“additional”confirmation withclinical assessment
  48. 48. 48Recognition of shockin pediatric patientPALS update 2008-2009
  49. 49. 49Myocardial contractilitypreloadafterloadStroke volumeHeart rateCardiac outputTissue perfusionBlood pressureปัจจัยที่มีผลต่อ tissue perfusionCaO2, Hb
  50. 50. 50Etiology 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
  51. 51. 51
  52. 52. 52Recognition of shock flow chart
  53. 53. 53
  54. 54. 54
  55. 55. 55Intraosseous canulation
  56. 56. 56
  57. 57. 57PALS shock algorithm
  58. 58. 58PALS shock algorithm
  59. 59. 59
  60. 60. 60Medications : Maintain CO postresuscitation Stabilization
  61. 61. 61
  62. 62. 62Potentially ReversibleCauses of Arrest: 6 H’sHypovolemiaHypoxemiaHydrogen ion (acidosis)Hypo-/hyperkalemiahypoglycemiaHypothermia
  63. 63. 63Potentially ReversibleCauses of Arrest: 5 T’sToxinsTamponade, cardiacTension pneumothoraxThrombosis (coronary orpulmonary)Trauma (hypovolemia)
  64. 64. 64PALS Tachycardia AlgorithmPALS guideline Tachycardia algorithm
  65. 65. 65PALS Bradycardia Algorithm
  66. 66. 66Trend of PALS 2010Pediatric assessment ( PAT )novelapproach for the rapid evaluationPediatric Emergency Care - Vol 26 Number 4, April 2010Cardiocerebral resuscitationHypothermiaPractice skills learned in formalcurriculaPediatrics 2009; 124; 610-619
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