Course Overview

This study guide is an outline of content that will be taught in the American Heart Association Accredited Pediatric Advance Life Support (PALS) Course. It is intended to summarize important content, but since all PALS content cannot possibly be absorbed in a class given every two years, it is expected that the student will have the 2010 Updated ECC Handbook readily available for review as a reference. The student is also required to have the AHA PALS Textbook available for reference and study for more in depth content.

•Agenda

oWelcome, Introduction, Overview oVideo Review oBLS Review oSimulation Base Scenarios

§§PALS Algorithms

§§Rapid Cardiopulmonary Assessment

§§Skills Stations

§§ Skills Evaluation o Written Evaluation

Evidence Based Updates

Approximately every 5 years the AHA updates the guidelines for CPR and Emergency Cardiovascular Care. These updates are necessary to ensure that all AHA courses contain the best information and recommendations that can be supported by current scientific evidence experts from outside the United States and outside the AHA. The guidelines were then classified as to the strength of evidence that supports the recommendation.

Objectives

Upon the completion of this PALS course the participant will be able to:

• Identify lethal rhythms
• Describe Rapid Cardiopulmonary Assessment and use it as a guide while working through scenarios •Verbalize treatment algorithms for each of the following lethal rhythms: oPulseless arrest oBradycardia oTachycardia
• Verbalize steps to assess and treat shock
• Perform skills in 4 required skill stations oBag-Mas Ventilation and Advance Airway

oArrhythmia recognition and Management, Cardioversion and Defibrillation oVascular Access oBLS

BLS Review

(Primary Survey Approach to ECC)

C – A – B

C = circulation

• = Airway
• = Breathing

D = Defibrillation

Rescue Techniques – CAB and D

Unresponsiveness: After determining that the scene is safe, check to see if victim is responsive and breathing normally. If the infant or child victim is unresponsive and NOT breathing normally, send someone to activate the emergency response system (EMS) – phone 911 and get the AED.

IF IN THE HOSPITAL, CALL THE CODE!!

If alone the rescuer calls out for “HELP” immediately for infants and children and begins C-A-B CPR and then phone 911 after two minutes of rescue support. The goal of “phone fast” approach is to deliver oxygen quickly because the most common cause of cardiac arrest in infants and children is a severe airway breathing problems, respiratory arrest, or shock.

Exception: for sudden, witnessed collapse of child or infant, active EMS immediately after verifying that victim is unresponsive.

Circulation: Check for pulse for 5 – 10 seconds.

Push Hard. Push Fast. Allow for full chest recoil. Minimize interruptions. Avoid Hyperventilation

• The best location for performing a pulse check for a child is the carotid artery of the neck. On an infant up to the age of one year, check the brachial pulse
• You should start cycles of chest compression and breathing when the victim is unresponsive, is not breathing adequately, and does not have a pulse
• The compression to ventilation ratio is 30:2
• Proper compression technique requires the right rate and depth of compression, as well as full chest recoil. Take your weight off your hands and allow the chest to come back to its normal position. Full chest recoil maximizes the return of blood to the heart after each compression.
• The rate of performing chest compression for a victim of any age (adult, child and infant) is at a rate of at least 100 compressions per minute.
• Compressions on the child, two hands are placed in the center of the chest between the nipples on the lower half of the sternum.
• Compressions on an infant are performed by using the two finger technique (pressing two fingers along the sternum, just below the nipple line, and the fingers of the hand wrap around the back and press in with each compression)
• Compression depth is about 2 inches on a child and about 1 ½ inches on an infant.
• Rotation of 2 – man CPR is every 2 minutes (5 cycles of 30:2) or after 5 cycles of 15:2 for two person CPR on infant and children.
• Minimize interruptions in chest compression will increase the victim’s chance of survival.
• The jaw-thrust with cervical spine immobilization is used for opening airway without tilting the head or moving the neck if a neck injury is suspected (this includes drowning victims) – after two unsuccessful attempts, use head tilt-chin lift.
• To give breaths, pinch the victim’s nose closed, or for an infant place your mouth over the infant’s nose and mouth, and given 1 breath (blow for 1 second), watch for the chest to rise. If the chest does not rise, make a second attempt to open the airway with a health tilt-chin lift. Then give 1 breath (blow over 1 second) and watch for the chest to rise. Of course, if using mask barrier device or bag mask ventilation, there is no need to pinch the nose. Only provide enough air to see the chest rise and fall. If using a bag mask, there is no need to compress the bag completely.
• DO NOT over-inflate the lungs. The positive pressure in the chest that is created by rescue breaths will decrease venous return to the heart. This limits the refilling of the heart, so it will reduce cardiac output created by subsequent chest compressions.
• Some victims may continue to demonstrate agonal or gasping breaths for several minutes after a cardiac arrest, but these breaths are too slow or too shallow and will not maintain oxygenation. If there is a pulse, perform rescue breathing.
• The probably of successful defibrillation diminishes rapidly over time. Immediate CPR and defibrillation within no more than 3 to 5 minutes given a person in sudden cardiac arrest the best chance of survival.
• The AED is used on an adults, children and infants.
• If pediatric pads are unavailable, it is acceptable to use adult pads on an infant in cardiac arrest
• Adult or Child victim: place one pad on the victim’s upper right chest just below the collar bone and to the right of the sternum and the other pad on the left side and below the nipple, being careful that the pads do not touch. If the infant or child is small and the pads would touch, place the pads in an anterior/posterior position.
• Steps for defibrillation are: Power on the AED & Attach pads, clear the victim and allow the AED to analyze the rhythm – make sure not to touch the victim during the analyze phase, clear the victim and deliver shock, if advised.
• Make sure to clear the victim before shocking so that you and others helping do not get shocked.
• If not shock is advised, leave the AED pads on the victim and continue CPR, beginning with compressions.
• CPR alone may not save the life of sudden cardiac arrest victim. Early defibrillation is needed.

Airway: Open the Airway The head tilt-chin lift is the best way to open unresponsive victim’s airway when you do NOT suspect cervical spine injury.

Breathing: Given two breaths

Defibrillation: Attach the Automated External Defibrillator (AED)

Primary Assessment: ABCDE

• – Airway
  • Look for movement of the chest or abdomen
  • Listen for air movement and breath sounds
• – Breathing
  • Respiratory Rate
  • Respiratory Effort
  • Chest expansion and air movement
  • Lung and airway sounds
  • Oxygen saturation by pulse oximetry
  • A consistent respiratory rate of less than 10 or more than 60 breaths/min in a child of any age is abnormal and suggests the presence of a potentially serious problem.
  • Caused by the use of neck muscles to assist breathing
  • Most frequently seen in infants and can be a sign of respiratory failure
  • A child may be in respiratory distress yet maintain normal oxygen saturation by increasing respiratory rate and effort, especially if supplementary oxygen is administered.
• – Circulation
  • Heart rate and rhythm
  • Pulses (both peripheral and central)
  • Capillary refill time
  • Skin color and temperature
  • Blood Pressure
• – Disability
  • Decrease level of consciousness
  • Loss of muscular tone
  • Generalized seizures
  • Pupil dilation
• – Exposure
  • Undress the seriously ill or injured child as necessary to perform a focused physical examination •Maintain cervical spine precaution when turning any child with a suspected neck or spine injury.
  • Look for evidence of trauma such as bleeding, burns, or unusual markings that suggest nonaccidental trauma
  • Respiratory Distress: tachypnea, increased respiratory effort, grunting, stridor, wheezing, seesawing or “abdominal” breathing, head bobbing
  • Respiratory Failure: bradypnea, periodic apnea, falling heart rate/bradycardia, diminished air movement, low oxyhemoglobin saturation, stupor, coma, poor muscle tone, cyanosis
  • Characterized by the accumulation of air under pressure in the pleural space
  • Treatment – immediate needle decompression (18 to 20 gauge) over the top of the child’s third rib •A gush of air is a sign that needle decompression has been successful.
  • Compensated Shock: Normal systolic BP, decreased level of consciousness, cool extremities with delayed capillary refill, and faint or non-palpable distal pulses
  • Hypotensive Shock: Hypotension with signs of shock
  • Steps for defibrillation:
    • When the AED or defibrillator arrives, turn it on
    • Select energy level
    • Position appropriate pads or electrodes (apply conductive paste if using paddles)

Status	Description
Clear	Airway is open and unobstructed for normal breathing
Maintainable	Airway is obstructed but can be maintained by simple measures (eg, head tilt-chin lift)
Not Maintainable	Airway is obstructed and cannot be maintained without advanced interventions (eg, intubation)

Age	Breaths/min
Infant (<1 year)	30 to 60
Toddler (1 - 3 years)	24 to 40
Preschooler (4 - 5 years)	22 to 34
School Age (6 to 12 years)	18 to 30
Adolescent (13 - 18 years)	12 to 16

Head Bobbing – often indicate that the child has increased risk for deterioration

Pulse Oximetry Readings

Normal Heart Rate (per Minute) by Age

Age	Awake Rate	Mean	Sleeping Rate
Newborn to 3 months	85 to 205	140	80 to 160
3 months to 2 years	100 to 190	130	75 to 160
2 years to 10 years	60 to 140	80	60 to 90
> 10 years	60 to 100	75	50 to 90

Normal Blood Pressure in Children by Age

Age	Systolic Blood Pressure (mm Hg)		Diastolic Blood Pressure (mm Hg)
	Female Male		Female Male
Neonate (1 day)	60 to 76	60 to 74	31 to 45	30 to 44
Neonate (4 day)	67 to 83	68 to 84	37 to 53	35 to 53
Infant (1 month)	73 to 91	74 to 94	36 to 56	37 to 55
Infant (3 month)	78 to 100	81 to 103	44 to 64	45 to 65
Infant (6 months)	82 to 102	87 to 105	46 to 66	48 to 68
Infant (1 year)	68 to 104	67 to 103	22 to 60	20 to 58
Child (2 years)	71 to 105	70 to 106	27 to 65	25 to 63
Child (7 years)	79 to 113	79 to 115	39 to 77	38 to 78
Adolescent (15 years)	93 to 127	95 to 131	47 to 85	45 to 85

Definition of hypotension by Systolic Blood Pressure and Age

Systolic Blood Age Pressure (mm Hg)
Term Neonates (0 -­‐ 28 days)	< 60
Infants (1 to 12 months)	< 70
Children 1 to 10 years (5th blood pressure percentile)	< 70 + (age in years x2)
Children > 10 years	< 90

Glasgow Coma Scale for Adults and Modified Glasgow Coma Scale for Infants and Children
Response Adult Child Infant					Coded Value
Eye Opening	Spontaneous	Spontaneous	Spontaneous		4
	To Speech	To Speech	To Speech		3
	To Pain	To Pain	To Pain		2
	None	None	None		1
Best Verbal Response	Oriented	Oriented, appropriate	Coos and babbles		5
	Confused	Confused	Irritable, cries		4
	Inappropriate Words	Inappropriate Words	Cries in response to pain		3
	Incomprehensible Sounds	Incomprehensible words or nonspecific sounds	Moans in response to pain		2
	None	None	None		1
Best Motor Response	Obeys	Obeys commands	Moves spontaneously purposely	and	6
	Localizes	Localizes painful stimulus	Withdraws in response to touch		5
	Withdraws	Withdraws in response to pain	Withdraws in response to pain		4
	Abnormal Flexion	Flexion in response to pain	Decorticate posturing (abnormal flexion in response to pain)		3
	Extensor response	Extension in response to pain	Decelerate posturing (abnormal extension in response to pain)		2
	None	None	None		1

Management of Respiratory Emergencies

Respiratory Problems can be categorized into two categories based upon severity

Respiratory Problems are categorized into four categories based upon type: Evaluate by observing symmetric chest expansion and by listening for bilateral breath sounds. Breath sounds should be auscultated over the anterior and posterior chest wall and in the axillary areas. Listen for intensity and pitch of sounds.

Upper Airway obstruction:

Lower Airway obstruction:

Lung Tissue (Parenchymal) disease

Respiratory Distress

Respiratory Failure

Airway Devices

Nasopharyngeal Airway – semi – conscious

Oral pharyngeal Airway – unconscious

Laryngeal Mask Airway (LMA) – recommended if provider is inexperienced with E.T. tube

Endotracheal Tube – usually the ideal airway in hospitalized patients

Determine proper uncuffed size by age / 4+4 (example age 2 / 4 + 4 = 4.5 size)

Determine proper cuff size by age divided by 4 add 3.5

(Note: cuffed tubes should not be inflated to a pressure of >20 cm H2O)

Methods of Oxygen Delivery

OXYGEN IS THE #1 DRUG - GIVE OXYGEN AS SOON AS IT IS AVAILABLE

Provide oxygen – Room air has 21% oxygen

Low flow Oxygen (<10 L/min) patient inspiratory flow exceeds 02 flow

Nasal Cannula (1 to 4 liters) = increases oxygen by 4% for each liter

Face Mask without reservoirs = increases oxygen by 10% for each liter not recommended to give more than 40 – 60% without reservoir

High flow oxygen (>10 min) O2 flow exceeds patient inspiratory flow Face Mask with reservoir = ability to provide 100% oxygen Bag Mask

Confirming E.T. Tube placement:

Once an advanced airway is in place, there is no need to pause chest compression for ventilations.Provide 100 compressions per minute and 1 breath every 6 – 8 seconds.

If deterioration in respiratory status occurs in an intubated child, use the DOPE mnemonic

Specific Management of Tension Pneumothorax

Recognition of Shock

	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	Systolic Blood Pressure	Compensated Shock → Hypotensive Shock
	Pulse Pressure	Narrow	Variable	Narrow
	Heart Rate	Increased
	Peripheral Pulse Quality	Weak	Bounding or Weak	Weak
	Skin	Pale, cool	Warm or Cool	Pale, Cool
	Capillary Refill	Delayed	Variable	Delayed
	Urine Output	Decreased
D	Level of Consciousness	Irritable (early) Lethargic (Late)
E	Temperature	Variable

Key Points:

Capillary refill, if prolonged (>2 seconds), may indicate shock, measure blood pressure early. Shock is defined as inadequate delivery of oxygen and nutrients to the tissues relative to tissue metabolic demand. Shock can be categorized into two categories based upon severity:

*** For children ages 1 to 10 years of age, hypotension is defined as systolic BP <70 mm Hg + (child’s age in years x2) mm Hg ***

Types of Shock	Volume of Fluid	Approximate Rate of Delivery
Hypovolemic Shock (non-­‐DKA)Distributive Shock	20 ml/kg bolus (repeat PRN)	Over 5 to 10 minutes
Cardiogenic Shock (nonpoisoning)	5 to 10 ml/kg bolus (repeat PRN)	Over 10 to 20 minutes
DKA with compensated shock	10 to 20 ml/kg	Over 1 hour
Poisonings (eg, calcium channel blocker or B-­‐adrenergic blocker)	5 to 10 ml/kg bolus (repeat PRN)	Over 10 to 20 minutes

Resuscitation Team Concept

Eight Elements of Effective Team Dynamics

Six Resuscitation Team Roles

Algorithms

In contrast with cardiac arrest in adults, cardiopulmonary arrest in infants and children is rarely sudden and is more often caused by progression respiratory distress and failure or shock than by primary cardiac arrhythmias. Therefore, oxygen is the number one treatment of most pediatric conditions.

Most (not all) algorithms can be treated by following the ONE mnemonic – and then adding special considerations:

O – Oxygen

N – Normal Saline

E – Epinephrine

Differential Diagnosis – H’s and T’s

“Thinking it Through” Unless the cause of an arrhythmia is correctly identified, it will be impossible to treat. A hypovolemic person in PEA will not be helped by all of the epinephrine in the world. H’s and T’s are essential to nearly every Algorithm.

o Hypovolemia – give fluids o Hypoxia – given oxygen, check E.T. tube o Hydrogen ion (acidosis) – Sodium bicarbonate o Hypo-/Hyperkalemia – potassium or sodium bicarb o Hypoglycemia – Glucose o Toxins – Drug overdose = given Narcan o Tamponade, cardiac – pericardiocentesis o Tension Pneumothorax – needle decompression o Thrombosis, Coronary o Thrombosis, Pulmonary

Pulseless Arrest

Pulseless Arrest includes:

V-Fib and Pulseless VT are shockable

Asystole and PEA ARE NOT shockable If shockable (v-fib and pulseless VT):

Defibrillation can be performed using either monophasic or biphasic technology. Biphasic, the newer technology uses about ½ the energy of a monophasic shock.

First shock is at 2J/kg, subsequent shocks are 4J/kg max 10J/kg

Monophasic – maximum 360 J

Biphasic – Maximum 150 J to 200 J

*** Note: 1st shock may be 2 – 4 J/Kg, 2nd shock 4J/kg, may continue to increase to a maximum of 10J/kg or maximum adult dose ***

The first shock eliminates VF more than 85% of the time.

a.Paddle size – Infant size for <1 yr. or <10 kg

Adult size for >1 yr. or >10 kg

• Immediately following the shock, resume CPR starting with chest compressions. (DO NOT CHECK FOR PULSE AT THIS POINT)

• Perform CPR 5 cycles 30:2 with one person or 2 minutes of CPR 15:2 with 2 people.
• After 2 minutes of CPR, stop compression just long enough to check the rhythm and check for pulse
• If another shock is needed, prepare to shock, but continue CPR while the defibrillator is charging
• Repeat this sequence until the rhythm is not shockable
• If the first shock fails, CPR will circulate the blood and bring more oxygen to the heart, making a subsequent shock more likely to be successful
• Even when a shock eliminates VF, it often takes several minutes for a normal heart rhythm to return and more time for the heart to create blood flow. Chest compressions can deliver oxygen and sources of energy to the heart, increasing the likelihood that the heart will be able to effectively pump blood after the shock.

(NEVER STOP CHEST COMPRESSION LONGER THEN 10 SECONDS)

Reason for CPR immediately after the shock:

During delivery should not interrupt CPR. The time of the drug is less important than minimizing interruptions in chest compressions.

If a patient is in sustained asystole for 15 minutes, it may be reasonable to consult the family and consider calling the code.

Bradycardia

• Oxygen first **
• CPR if HR is < 60 bpm
• Epinephrine 0.01mg/kg IV/IO (1:10,000; 0.1ml/kg) is the first drug of choice for bradycardia in children 4. Atropine 0.02 mg/kg IV/IO (Minimum dose: 0.1mg; maximum total dose for children: 1mg) may be given. Small doses of atropine may cause paradoxical bradycardia in small doses which is why epinephrine is generally used. However, atropine may be used if bradycardia is due to increased vagal tone or primary AV block.

If there is a high level of heart block (usually due to congenital condition), consider transcutaneous pacing.

Tachycardia with Pulse and Adequate or Poor Perfusion

#1 Question – Stable vs. Unstable

• Stable – Vagal and/or Medication
  • Try Vagal maneuvers
  • Adenosine 0.1mg/kg (maximum doses 6mg, 2nd dose 12mg) RAPID IVP (2 syringe technique)
• Amiodarone 5mg/kg IV over 20 to 60 minutes
• Or Procainamide 15mg/kg IV over 30 to 60 minutes
• May need synchronized Cardioversion
• Magnesium load with 25 – 50 mg/kg over 10 minutes
• Steps for cardioversion:
  • Consider sedation
  • Turn on defibrillation
  • Attach monitor leads to patient
  • Press “SYNC” mode button
  • Look for markers on R wave indicating sync mode
  • Select appropriate energy level
  • Position appropriate pads or paddles
  • Press the charge button – announce that you are doing this
  • Clear: I’m clear, you’re clear – includes making sure that the oxygen is away from the patient. Everybody’s clear
  • Press the shock button and wait for shock discharge (this may take a few seconds while the machine looks for R waves and determines where the sync the shock”
  • Analyze the rhythm again. If still in tachycardia, increase the joules and try again.

Narrow QRS Regular Rhythm

Supraventricular Tachycardia

Note: A brief period of asystole may follow the injection

WIDE QRS (VT with pulse)

WIDE QRS (torsades de points)

UNSTABLE (WITH PULSE) = SYNCRONIZED CARDIOVERSION

Prepare for IMMEDIATE cardioversion. While preparing, you may try an appropriate medication (Adenosine or Amiodarone) if there is time. Also, sedate the patient if possible.

Use 0.5 to 1J/kg up to 2J/kg monophasic, depending upon the acuity of the patient (or a clinically equivalent biphasic energy dose. Optimal biphasic doses have not yet been established with certainty.

Note: Reset the sync mode after each synchronized cardioversion because most defibrillators default back to unsynchronized mode.

Hypothermia – The 2010 guidelines emphasize that induced hypothermia (32C to 34C) for 12 to 24 hours for patients who remain comatose after resuscitation from cardiac arrest may be beneficial for adolescents and may also be considered for infants and children.