Pediatric Advanced Life Support

1. Pediatric Advanced Life Support Jan Bazner-Chandler CPNP, CNS, MSN, RN

2. American Heart Association • Pediatric Advanced Life Support • Guidelines first published in 1997 • Revisions made in 2005

3. Students Nurse Concerns • You will need to learn the basics as outlined in the PALS 2005 Guidelines • American Heart Association 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.

4. Cardiopulmonary Arrest • In most infants and small children respiratory arrest precedes cardiac arrest.

5. Causes of Respiratory Arrest in Children • Bronchospasm / respiratory infection • Burns • Drowning • Dysrhythmias • Foreign Body Aspiration • Gastroenteritis (vomiting and diarrhea) • Sepsis • Seizures • Trauma

6. Pediatric Cardiac Arrest • Pediatric cardiopulmonary arrest results when respiratory failure or shock is not identified and treated in the early stages. • Early recognition and intervention prevents deterioration to cardiopulmonary arrest and probable death.

7. 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.

8. 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

9. 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.

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

11. Assessment • 30 second rapid cardiopulmonary assessment is structured around ABC’s. • Airway • Breathing • Circulation

12. Breathing • Breathing is assessed to determine the child’s ability to oxygenate. • Assessment: • Respiratory rate • Respiratory effort • Breath sounds • Skin color

13. Airway • Airway must be clear and patent for successful ventilation. • Position • Suction • Administration of oxygen • Bag-mask ventilation

14. Bag-valve-mask

15. 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.

16. LMA –Laryngeal Mask Airway

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

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

19. Circulation Assessment • Heart rate (most accurate assessment) • Blood pressure • End organ profusion • Urine output (1-2 mL / kg / hour) • Muscle tone • Level of consciousness

20. Circulatory Assessment • Heart rateis 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.

21. 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.

22. 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 vascular access in the proximal tibia or distal femur should be initiated.

23. Intraosseous Access

26. IV Solutions • Crystalloid solution • Normal saline 20ml/kg bolus over 20 minutes

27. 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.

28. Accurate Output • Insert foley • Output 1-2 mL / kg / hour

29. Cardiopulmonary Failure • Child’s response to ventilation and oxygenation guides further interventions.

30. Arrhythmias • Bradycardia • Pulseless Arrest – ventricular fibrillation • Asystole – no pulse • Tachycardia with poor perfusion • Tachycardia with adequate perfusion

31. Bradycardia • The most common dysrhythmia in the pediatric population. • Etiology is usually hypoxemia • Initial management: ventilation and oxygenation. • If this does not work IV or IO epinephrine 0.1 mg / kg

32. Pulseless Arrest – Asystole • ABC: Start CPR • Give oxygen when available • Attach monitor / defibrillator • Check rhythm / check pulse • If asystole give epinephrine 0.01 mg / kg of 1:10,000 • Resume CPR may repeat every 3-5 minutes until shockable rhythm is seen

33. Asystole No Rhythm No rate No P wave No QRS comples

34. Pulseless Arrest – VF and Pulseless VT • ABCs: start CPR • Give oxygen as soon as available • Attach monitor / defibrillator • Check rhythm: VF / VT • Give one shock at 2 J/kg • If still VF / VT • Give 1 shock at 4 J/kg • Give Epinephrine 0.01 mg/kg of 1:10,000

36. Tachycardia with Adequate Perfusion • Sinus tachycardia: • Infants: HR < 220 bpm • Children: HR < 180 bpm • P waves present and normal • Treatment: give oxygen and treat cause

37. Tachycardia with Adequate Perfusion • Sinus Ventricular Tachycardia • Infants: HR >220 bpm • Children: HR > 180 bpm • P waves absent or abnormal • Treatment: consider vagal maneuver • Give adenosine IV 0.1mg/kg

38. Supraventricular Tachycardia Interventions Oxygen Call for code Cardioversion Vagal Maneuvers Adenosine

39. Tachycardia with poor perfusion • Ventricular tachycardia • Synchronized cardioversion • First dose: 0.5 to 1 J/kg • Next dose: 2 J/kg • Consider: amiodarone 5 mg/kg IV over 30 to 60 minutes

40. Ventricular Tachycardia

41. 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.

42. PALS Drugs

43. Epinephrine • Action: increase heart rate, peripheral vascular resistance and cardiac output; during CPR increase myocardial and cerebral blood flow. • Dosing: 0.01 mg / kg 1: 10,0000

44. Amiodarone • Used in atrial and ventricular antiarrhythmic • Action: slows AV nodal and ventricular conduction, increase the QT interval and may cause vasodilation. • Dosing: IV/IO: 5 mg / kg bolus

45. Adenosine • Drug of choice of symptomatic SVT • Action: blocks AV node conduction for a few seconds to interrupt AV node re-entry • Dosing • First dose: 0.1 mg/kg max 6 mg • Second dose: 0.2 mg/kg max 12 mg

46. Glucose • 10% to 25% strength • Action: increases glucose in hypoglycemia • Dosing: 0.5 – 1 g/kg

47. Naloxone • Opiate antagonist • Action: reverses respiratory depression effects of narcotics • Dosing: IV/IO • 0.1 mg/kg < 5 years • 0.2 mg/kg > 5 years

48. Sodium bicarbonate • pH buffer for prolonged arrest, hyperkalemia • Action: increases blood pH helping to correct metabolic acidosis

49. Dobutamine • Therapeutic classification: inotropic • Pharmacologic classification: adrenergic • Action: increases force of contraction and heart rate; causes mild peripheral dilation; may be used to treat shock • Dosing: IV/IO: 2-20 mcg/kg/min infusion

50. Dopamine • Therapeutic classification: inonotropic • May be used to treat shock; effects are dose dependent • Increases force of contraction and cardiac output, increases peripheral vascular resistance, BP and cardiac output • Dosing: IV/IO infusion: 2-20 mcg/kg/min