Pediatric Advanced Life Support

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Pediatric Advanced Life Support

• Jan Bazner-Chandler
• CPNP, CNS, MSN, RN

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Pediatric Advanced Life Support

• Guidelines established in 1983 by the American
  heart Association.
• Pediatric Advanced Life Support A Review of the
  AHA Recommendations, American Family Physician,
  October 15, 1999.
• Http//www.aafp.org/afp/991015ap/1743.html

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American Heart Association

• Pediatric Advanced Life Support
• Published online November 28, 2005
• Article can be found at

http//circ.ahajournals.org/cgi/content/full/112/2
4_suppl/IV-167
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JAOA

• Review of guidelines for Pediatric Advanced Life
  Support short version of AHA
• www.jaoa.org/cgi/reprint/104/1/22.pdf
• Quick review of AHA guidelines

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Students Nurse Concerns

• You will need to learn the basics as outlined in
  the PALS article 1999 and review 2005 standards.
• AHA guidelines are expected standards of a
  practicing pediatric nurse.
• You will need to know basic CPR guidelines and
  have a current CPR card prior to starting the
  clinical rotation.

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Cardiopulmonary Arrest

• In most infants and small children respiratory
  arrest precedes cardiac arrest.
• 92 of children with respiratory arrest only have
  no subsequent neurologic impairment.

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Cardiac Arrest

• Pediatric cardiac arrest is
• Uncommon
• Rarely sudden cardiac arrest caused by primary
  cardiac arrhythmias.
• Most often asphyxial, resulting from the
  progression of respiratory failure or shock or
  both.

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Upper airway obstruction Lower airway
obstruction Lung tissue disease /
infection Disorders of breathing
Hypovolemic (most common) Distributive septic,
anaphylactic Cardiogenic Obstructive
Respiratory Failure
Hypotensive Shock
Cardiopulmonary Failure
Asphyxial Arrest
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Respiratory Arrest

• Early recognition and intervention prevents
  deterioration to cardiopulmonary arrest and
  probable death.
• Only 10 of children who progress to
  cardiopulmonary arrest are successfully
  resuscitated.

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Assessment

• 30 second rapid cardiopulmonary assessment is
  structured around ABCs.
• Airway
• Breathing
• Circulation

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Airway

• Airway must be clear and patent for successful
  ventilation.
• Position
• Clear of foreign body
• Free from injury
• Intubate if needed.

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Breathing

• Breathing is assessed to determine the childs
  ability to oxygenate.
• Assessment
• Respiratory rate
• Respiratory effort
• Breath sounds
• Skin color

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Impending Respiratory Failure

• Respiratory rate less than 10 or greater than
• 60 is an ominous sign of impending
• respiratory failure.

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Circulation

• Circulation reflects perfusion.
• Shock is a physiologic state where delivery of
  oxygen and substrates are inadequate to meet
  tissue metabolic needs.

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Circulation Assessment

• Heart rate
• Pulse
• Blood pressure
• End organ profusion
• Urine output
• Level of consciousness
• Muscle tone

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Circulatory Assessment

• Heart rate is the most sensitive parameter for
  determining perfusion and oxygenation in
  children.
• Heart rate needs to be at least 60 beats per
  minute to provide adequate perfusion.
• Heart rate greater than 140 beats per minute at
  rest needs to be evaluated.

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Circulatory Assessment

• Pulse quality reflects cardiac output.
• Capillary refill measures peripheral perfusion.
• Temperature and color of extremities proximal
  versus distal.

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Circulatory Assessment

• Urinary output
• Adequate kidney perfusion
• 1- 2 ml of urine per kg / hour
• Level of Consciousness / LOC

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Blood Pressure

• 25 of blood volume must be lost before a drop in
  blood pressure occurs.
• Minimal changes in blood pressure in children may
  indicate shock.

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Management

• Oxygen
• Cardiac Monitoring
• Pulse oximetry
• May be inaccurate when peripheral perfusion is
  impaired.

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Airway Management

• Bag-valve-mask with bradypenia or apnea
• Suctioning to remove secretions
• Intubation as needed

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Bag-valve-mask
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New Guidelines Airway Management

• Failure to maintain the airway is leading cause
  of preventable death in children.
• New PALS focuses on basic airway techniques.
• Laryngeal mask airway.

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LMA Laryngeal Mask Airway
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LMA

• Disadvantages
• Inability to prevent aspiration.
• Inability to serve as route for administering
  medications.

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Endotracheal Tube Intubation

• New guidelines
• Secondary confirmation of tracheal tube
  placement.
• Use of end-tidal carbon dioxide monitor or
  colorimetric device

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Vascular Access

• After airway and oxygenation needs met.
• Crystalloid solution
• Normal saline 20mL/kg bolus over 20 minutes
• Lactated ringers used more in adults

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Vascular Access New Guidelines

• New guidelines in children who are six years or
  younger after 90 seconds or 3 attempts at
  peripheral intravenous access Intraosseous
  access recommended.

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Intraosseous Access
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Gastric Decompression

• Gastric decompression with a nasogastric or oral
  gastric tube is necessary to ensure maximum
  ventilation.
• Air trapped in stomach can put pressure on the
  diaphragm impeding adequate ventilation.
• Undigested food can lead to aspiration.

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Cardiopulmonary Failure

• Childs response to ventilation and oxygenation
  guides further interventions.
• If signs of shock persists
• Inotropic agents such as epinephrine are given.

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Epinephrine

• Indications
• Bradycardia
• Shock (cardiogenic, septic, or anaphylactic)
• Hypotension
• IV or ET through the endotracheal tube

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New Guideline Epinephrine

• Still remains primary drug for treating patients
  for cardiopulmonary arrest, escalating doses are
  de-emphasized.
• Neurologic outcomes are worse with high-dose
  epinephrine.

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2 New Medications for PALS

• Vasopressin causes systemic vasoconstriction
  used to increase blood flow to brain and heart
  during CPR.
• Need to be studied further.
• Amiodarone antiarrhythmic agent used in
  ventricular fibrillation and ventricular
  tachycardia. Given 5 mg/kg over 20 minutes.

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Bradycardia

• Bradycardia is the most common dysrhythmia in the
  pediatric population.
• Epinephrine is drug of choice dose is 0.01 to
  0.03 mg/kg/dose

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Sodium Bicarbonate

• In instances where the child is acidotic, sodium
  bicarbonate may be administered IV.
• The drug is not as stable in the pediatric
  population but is often used during the
  resuscitative phase of CPR.

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Glucose Levels

• Monitor serum glucose levels
• Replace with 10 dextrose in the neonate
• 25 glucose in the child

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Ventricular Tachycardia

• Ventricular tachycardia is usually secondary to
  structural cardiac disease.
• Amiodarone 5 mg/kg over 20 minutes
• Cardioversion

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Defibrillator Guidelines

• AHA recommends that automatic external
  defibrillation be use in children with sudden
  collapse or presumed cardiac arrest who are older
  than 8 years of age or more than 25 kg and are 50
  inches long.
• Electrical energy is delivered by a fixed amount
  range 150 to 200. (4J/kg)

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Post-resuscitation Care

• Re-assessment of status is ongoing.
• Laboratory and radiologic information is
  obtained.
• Etiology of respiratory failure or shock is
  determined.
• Transfer to facility where child can get maximum
  care.

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BLS Updates 2006

• Unresponsive infant less than 1 year and children
  1 year to puberty
• Open airway
• Give 2 breaths (if not breathing)
• Begin compressions 30 (if no pulse)
• Activate EMS system
• AED after 5 cycles of CPR

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Tilt Head to Sniff Position
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Witnessed Collapse of Child

• Activate EMS
• AED before CPR
• Compression 30 to 2 breaths hand placement at
  nipple line
• 2 rescue 15 to 2 if infant circle chest and use
  thumbs

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Choking Infant

• 5 back slaps
• 5 Chest thrusts

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Heimlich for Infants
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Clearing the Mouth