PALS update 2005 to 2010

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PALS update 2005 to 2010

  1. 1. From PALS guideline 2005, 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 1
  2. 2. Agenda Two parts Call fast Look-listen-feel and airway maintain and check pulse Chest compression (new guideline) 2
  3. 3. Etiologies: Out of hospital cardiac arrest : Respiratory failure & Shock By stand Basic life support alone In hospital cardiac arrest Multiple etiologies Poor outcome Effective CPR better survival * 3
  4. 4. Many etiologies Respiratory failure Shock Cardiopulmonary failure Cardiopulmonary arrest Death Cardiopulmonary recovery Impaired Unimpaired neurologic neurologic recovery recovery 4
  5. 5. Pre – cardiopulmonary failure  Respiratory distress  shock 4 steps : Assessment 1. General assessment 2. Primary assessment 3. Secondary assessment 4. Tertiary assessment 5
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  7. 7. General assessment  Pediatric assessment triangle (PAT) Appearance Breathing - restless?, -increase effort? -not interactive? -noise on respiration -muscle tone -nasalflaring -Cry/speech -retraction Circulation First few seconds -pale? mottling? Life threatening? -bleeding 7
  8. 8. General assessment First few seconds Life threatening? Shock Respiratory distress Compensated/ Respiratory failure decompensated ACTION 8
  9. 9. Primary assessment  Primary assessment : ABCDE  - A : airway  - B : breathing  - C : circulation  - D : disability  - E : exposure  ( PE, look listen feel, include V/S & oxygen saturation) ACTION 9
  10. 10. A : Airway Chest movement Breath sound Feel : air passes through nose and mouth Upper airway : clear/ maintainable, not maintainable Increase respiratory effort, inspiratory force/absent? Snoring, stridor? Retraction? 10
  11. 11. Breathing RR Respiratory effort Tidal volume Airway and lung sound Pulse oximetry  94% = adequate oxygenation  < 94% airway intervention  < 90% in 100% oxygen ( non rebreathing mask  advanced intervention : assisted ventilation 11
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  13. 13. Circulatory  Cardiovascular  End organ function - brain perfusion - skin color : mottling - skin perfusion - HR - renal perfusion ( - BP urine output) -Pulse (peripheral/central) - capillary refill 13
  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 14
  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 15
  16. 16. Pulse check : central pulse Use femoral / brachial pulse : < 1 year-old 16
  17. 17. Disability AVPU pediatric response scale Glasglow coma scales Pupillary response to light AVPU Alert Voice Painful Unresponsiveness 17
  18. 18. Exposure Trauma Burn Child abuse Skin lesion 18
  19. 19. Action General management for all patients Airway position Oxygen Pulse oxymetry EKG monitor as indicated BLS as indicated 19
  20. 20. Secondary assessment 3. Secondary assessment - SAMPLE - S : Signs and symptoms - A : Allergies - M : medication - P : past medical history - L : last meal - E : events leading to presentation ACTION 20
  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 21
  22. 22. Assess Action Categorize Decide If you recognize a life threatening condition at any time, immediately begin life saving intervention and activate the emergency response system 22
  23. 23. Summary PALS guideline AHA 2008 23
  24. 24. Signs of life threatening 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 24
  25. 25. Life saving intervention ACTION  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 25
  26. 26. New recommendation : Bag & mask ventilation : E-C clamp Give 2 breath chest move? (12-20 breath/min for child) 26
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  28. 28. PALS 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 28
  29. 29. Chest compression Nipple line for child Below nipple line in infant 29
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  32. 32. Coronary Perfusion Pressure Improves With Sequential Compressions CPP at 5:1 ratio Survival with 15:2 CPP at 15:2 ratio 32
  33. 33. “Continue CPR as much as possible except rhythm check” 33
  34. 34. Key change in BLS 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 34
  35. 35. Categorize  Determine the type and severity Type Severity Respiratory - Upper airway obstruction -Respiratory - Lower airway obstruction distress - lung parenchymal disease -Respiratory failure - Disorder control of breathing Circulatory - Hypovolemic shock -Compensated - Obstructive shock shock - Distributive shock -Hypotensive shock - Cardiogenic shock 35
  36. 36. Recognition of respiratory distress and failure 36
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  43. 43. Prehospital Tracheal Intubation vs 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 43
  44. 44. Use of Cuffed Endotracheal 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 44
  45. 45. Insertion of the Laryngeal 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. 45
  46. 46. Verification of Endotracheal Tube 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 46
  47. 47. Colorimetric Exhaled CO2 Detector Colorimetric exhaled CO2 detector device changes color (from purple to yellow) with detection of exhaled CO2 “additional” confirmation with clinical assessment 47
  48. 48. Recognition of shock in pediatric patient PALS update 2008-2009 48
  49. 49. Myocardial contractility Heart rate CaO2, Hb Cardiac output preload Stroke volume Tissue perfusion Blood pressure afterload ปัจจัยที่มีผลต่อ tissue perfusion 49
  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 50
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  52. 52. Recognition of shock flow chart 52
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  55. 55. Intraosseous canulation 55
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  57. 57. PALS shock algorithm 57
  58. 58. PALS shock algorithm 58
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  60. 60. Medications : Maintain CO postresuscitation Stabilization 60
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  62. 62. Potentially Reversible Causes of Arrest: 6 H’s Hypovolemia Hypoxemia Hydrogen ion (acidosis) Hypo-/hyperkalemia hypoglycemia Hypothermia 62
  63. 63. Potentially Reversible Causes of Arrest: 5 T’s Toxins Tamponade, cardiac Tension pneumothorax Thrombosis (coronary or pulmonary) Trauma (hypovolemia) 63
  64. 64. PALS guideline Tachycardia algorithm PALS Tachycardia Algorithm 64
  65. 65. PALS Bradycardia Algorithm 65
  66. 66. Trend of PALS 2010 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 66
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