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Pals%20update%202005%20to%202010 chodchanok
- 1. 1 From PALS guideline2005, 2006, 2009 AHA : Emergency Medicine Conference : Future of Pre-hospital and Emergency Care Illustrated by Chodchanok Vijarnsorn MD. Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Siriraj Hospital 21/6/2010
- 2. 2 Agenda Two parts Call fast Look-listen-feeland airway maintain and check pulse Chest compression (new guideline)
- 3. 3 Etiologies: Out of hospitalcardiac arrest : Respiratory failure & Shock By stand Basic life support alone In hospital cardiac arrest Multiple etiologies Poor outcome Effective CPR better survival *
- 4. 4 Many etiologies Cardiopulmonary failure Cardiopulmonaryarrest Death Cardiopulmonary recovery Impaired Unimpaired neurologic neurologic recovery recovery Respiratory failure Shock
- 5. 5 Pre – cardiopulmonaryfailure Respiratory distress shock 4 steps : Assessment 1. General assessment 2. Primary assessment 3. Secondary assessment 4. Tertiary assessment
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- 7. 7 General assessment Pediatricassessment triangle (PAT) Appearance - restless?, -not interactive? -muscle tone -Cry/speech Breathing -increase effort? -noise on respiration -nasalflaring -retraction Circulation -pale? mottling? -bleeding First few seconds Life threatening?
- 8. 8 First few seconds Lifethreatening? General assessment Respiratory distress Respiratory failure Shock Compensated/ decompensated ACTION
- 9. 9 Primary assessment Primaryassessment : ABCDE - A : airway - B : breathing - C : circulation - D : disability - E : exposure ( PE, look listen feel, include V/S & oxygen saturation) ACTION
- 10. 10 A : Airway Chestmovement Breath sound Feel : air passes through nose and mouth Upper airway : clear/ maintainable, not maintainable Increase respiratory effort, inspiratory force/absent? Snoring, stridor? Retraction?
- 11. 11 Breathing RR Respiratory effort Tidal volume Airwayand lung sound Pulse oximetry 94% = adequate oxygenation < 94% airway intervention < 90% in 100% oxygen ( non rebreathing mask advanced intervention : assisted ventilation
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- 13. 13 Circulatory Cardiovascular function - skincolor : mottling - HR - BP -Pulse (peripheral/central) - capillary refill End organ - brain perfusion - skin perfusion - renal perfusion ( urine output)
- 14. 14 Definition 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 Capillary refill Normal <2 seconds Prolonged capillary refill > 2 sec In case : shock, hypothermia, severe dehydration Warm shock : capillary refill < 2 sec due to peripheral vasodilatation
- 16. 16 Pulse check :central pulse Use femoral / brachial pulse : < 1 year-old
- 17. 17 Disability AVPU pediatric responsescale Glasglow coma scales Pupillary response to light AVPU Alert Voice Painful Unresponsiveness
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- 19. 19 Action General management forall patients Airway position Oxygen Pulse oxymetry EKG monitor as indicated BLS as indicated
- 20. 20 Secondary assessment 3. Secondaryassessment - SAMPLE - S : Signs and symptoms - A : Allergies - M : medication - P : past medical history - L : last meal - E : events leading to presentation ACTION
- 21. 21 Tertiary assessment Laboratory: ABG, VBG, Hb, SVO2 sat, HCO3, lactate, Radiography : CXR, echocardiography Exhale CO2, PEFR, CVP Emphasize : Anytime you identify a life threatening condition, initiate appropriate care immediately
- 22. 22 Assess Categorize Decide Action If you recognizea life threatening condition at any time, immediately begin life saving intervention and activate the emergency response system
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- 24. 24 Signs of lifethreatening condition Airway Complete or severe AO Breathing Apnea, significant work of breathing Circulation Absent pulse, poor perfusion, hypotension, bradycardia Disability Unresponsiveness, depress conscious Exposure Significant hypothermia, bleeding, purpura, abdominal distension due to bleeding
- 25. 25 Life saving intervention ABC/CPR 100% oxygen Assisted ventilation : bag mask, ETT Cardiac and respiratory monitoring : EKG, pulse oximetry Intravenous / I/O Bolus isotonic crystalloid Lab study : DTX, ABG Drugs Electrical therapy ACTION
- 26. 26 New recommendation :Bag & mask ventilation : E-C clamp Give 2 breath chest move? (12-20 breath/min for child)
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- 28. 28 PALS and neonatalupdate 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 Chest compression Nipple linefor child Below nipple line in infant
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- 32. 32 Coronary Perfusion PressureImproves With Sequential Compressions CPP at 5:1 ratio CPP at 15:2 ratio Survival with 15:2
- 33. 33 “Continue CPR asmuch as possible except rhythm check”
- 34. 34 Key change inBLS Effective rescue breath and visualization of 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 Categorize Determine thetype and severity Type Severity Respiratory - Upper airway obstruction - Lower airway obstruction - lung parenchymal disease - Disorder control of breathing -Respiratory distress -Respiratory failure Circulatory - Hypovolemic shock - Obstructive shock - Distributive shock - Cardiogenic shock -Compensated shock -Hypotensive shock
- 36. 36 Recognition of respiratory distressand failure
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- 43. 43 Prehospital Tracheal Intubationvs Bag-Mask Ventilation Bag-mask ventilation : as effective as intubation if transport time is short Need training and experience Must confirmation of tube position Monitoring
- 44. 44 Use of CuffedEndotracheal Tubes In-hospital setting, a cuffed ETT : as safe as an uncuffed tube for infants (except the newborn) and children Keep cuff inflation pressure <20 cm H2O Cuffed ETT size (mm) = (age (yr) /4) + 3 Uncuff size (mm): (age (yr) /4) + 4 Depth : age (yr)/2 + 12
- 45. 45 Insertion of theLaryngeal Mask Airway in Children The LMA consists of a tube with a cuffed mask at the distal end. The LMA is blindly introduced into the pharynx until resistance is met; the cuff is then inflated and ventilation assessed.
- 46. 46 Verification of EndotrachealTube Placement bilateral chest movement and listen for equal breath sounds over both lung fields gastric insufflation sounds exhaled CO2 pulse oximeter direct laryngoscopy chest x-ray
- 47. 47 Colorimetric Exhaled CO2Detector Colorimetric exhaled CO2 detector device changes color (from purple to yellow) with detection of exhaled CO2 “additional” confirmation with clinical assessment
- 48. 48 Recognition of shock inpediatric patient PALS update 2008-2009
- 49. 49 Myocardial contractility preload afterload Stroke volume Heartrate Cardiac output Tissue perfusion Blood pressure ปัจจัยที่มีผลต่อ tissue perfusion CaO2, Hb
- 50. 50 Etiology 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
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- 52. 52 Recognition of shockflow chart
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- 60. 60 Medications : MaintainCO postresuscitation Stabilization
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- 62. 62 Potentially Reversible Causes ofArrest: 6 H’s Hypovolemia Hypoxemia Hydrogen ion (acidosis) Hypo-/hyperkalemia hypoglycemia Hypothermia
- 63. 63 Potentially Reversible Causes ofArrest: 5 T’s Toxins Tamponade, cardiac Tension pneumothorax Thrombosis (coronary or pulmonary) Trauma (hypovolemia)
- 64. 64 PALS Tachycardia Algorithm PALSguideline Tachycardia algorithm
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- 66. 66 Trend of PALS2010 Pediatric assessment ( PAT )novel approach for the rapid evaluation Pediatric Emergency Care - Vol 26 Number 4, April 2010 Cardiocerebral resuscitation Hypothermia Practice skills learned in formal curricula Pediatrics 2009; 124; 610-619
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