Transcript Pediatric Advanced Life Support

Pediatric Advanced Life
Support
Jan Bazner-Chandler
CPNP, CNS, MSN, RN
Pediatric Advanced Life Support
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Guidelines established in 1983 by the American
heart Association.
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Pediatric Advanced Life Support: A Review of the
AHA Recommendations, American Family
Physician, October 15, 1999.
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Http://www.aafp.org/afp/991015ap/1743.html
American Heart Association
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Pediatric Advanced Life Support
Published online November 28, 2005
Article can be found at:
http://circ.ahajournals.org/cgi/content/full/112/24_suppl/IV-167
JAOA
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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
Students Nurse Concerns
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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.
Cardiopulmonary Arrest
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In most infants and small children respiratory
arrest precedes cardiac arrest.
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92% of children with respiratory arrest only
have no subsequent neurologic impairment.
Cardiac Arrest
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Pediatric cardiac arrest is:
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Uncommon
Rarely sudden cardiac arrest caused by primary
cardiac arrhythmias.
Most often asphyxial, resulting from the
progression of respiratory failure or shock or both.
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
Respiratory Arrest
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Early recognition and intervention prevents
deterioration to cardiopulmonary arrest and
probable death.
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Only 10% of children who progress to
cardiopulmonary arrest are successfully
resuscitated.
Assessment
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30 second rapid cardiopulmonary
assessment is structured around ABC’s.
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Airway
Breathing
Circulation
Airway
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Airway must be clear and patent for
successful ventilation.
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Position
Clear of foreign body
Free from injury
Intubate if needed.
Breathing
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Breathing is assessed to determine the
child’s ability to oxygenate.
Assessment:
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Respiratory rate
Respiratory effort
Breath sounds
Skin color
Impending Respiratory Failure
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Respiratory rate less than 10 or greater than
60 is an ominous sign of impending
respiratory failure.
Circulation
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Circulation reflects perfusion.
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Shock is a physiologic state where delivery of
oxygen and substrates are inadequate to
meet tissue metabolic needs.
Circulation Assessment
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Heart rate
Pulse
Blood pressure
End organ profusion
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Urine output
Level of consciousness
Muscle tone
Circulatory Assessment
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Heart rate is the most sensitive parameter for
determining perfusion and oxygenation in children.
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Heart rate needs to be at least 60 beats per minute to
provide adequate perfusion.
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Heart rate greater than 140 beats per minute at rest needs
to be evaluated.
Circulatory Assessment
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Pulse quality reflects cardiac output.
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Capillary refill measures peripheral perfusion.
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Temperature and color of extremities
proximal versus distal.
Circulatory Assessment
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Urinary output
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Adequate kidney perfusion
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1- 2 ml of urine per kg / hour
Level of Consciousness / LOC
Blood Pressure
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25% of blood volume must be lost before a
drop in blood pressure occurs.
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Minimal changes in blood pressure in
children may indicate shock.
Management
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Oxygen
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Cardiac Monitoring
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Pulse oximetry
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May be inaccurate when peripheral perfusion is
impaired.
Airway Management
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Bag-valve-mask with bradypenia or apnea
Suctioning to remove secretions
Intubation as needed
Bag-valve-mask
New Guidelines – Airway Management
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Failure to maintain the airway is leading
cause of preventable death in children.
New PALS focuses on basic airway
techniques.
Laryngeal mask airway.
LMA –Laryngeal Mask Airway
LMA
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Disadvantages:
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Inability to prevent aspiration.
Inability to serve as route for administering
medications.
Endotracheal Tube Intubation
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New guidelines:
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Secondary confirmation of tracheal tube
placement.
Use of end-tidal carbon dioxide monitor or
colorimetric device
Vascular Access
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After airway and oxygenation needs met.
Crystalloid solution
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Normal saline 20mL/kg bolus over 20 minutes
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Lactated ringers – used more in adults
Vascular Access – New Guidelines
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New guidelines: in children who are six years
or younger after 90 seconds or 3 attempts at
peripheral intravenous access – Intraosseous
access recommended.
Intraosseous Access
Gastric Decompression
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Gastric decompression with a nasogastric or
oral gastric tube is necessary to ensure
maximum ventilation.
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Air trapped in stomach can put pressure on the
diaphragm impeding adequate ventilation.
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Undigested food can lead to aspiration.
Cardiopulmonary Failure
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Child’s response to ventilation and
oxygenation guides further interventions.
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If signs of shock persists:
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Inotropic agents such as epinephrine are given.
Epinephrine
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Indications:
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Bradycardia
Shock (cardiogenic, septic, or anaphylactic)
Hypotension
IV or ET through the endotracheal tube
New Guideline Epinephrine
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Still remains primary drug for treating patients
for cardiopulmonary arrest, escalating doses
are de-emphasized.
Neurologic outcomes are worse with highdose epinephrine.
2 New Medications for PALS
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Vasopressin – causes systemic
vasoconstriction – used to increase blood
flow to brain and heart during CPR.
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Need to be studied further.
Amiodarone – antiarrhythmic agent – used in
ventricular fibrillation and ventricular
tachycardia. Given 5 mg/kg over 20 minutes.
Bradycardia
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Bradycardia is the most common dysrhythmia
in the pediatric population.
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Epinephrine is drug of choice – dose is 0.01 to
0.03 mg/kg/dose
Sodium Bicarbonate
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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.
Glucose Levels
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Monitor serum glucose levels
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Replace with 10 % dextrose in the neonate
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25% glucose in the child
Ventricular Tachycardia
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Ventricular tachycardia is usually secondary
to structural cardiac disease.
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Amiodarone – 5 mg/kg over 20 minutes
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Cardioversion
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)
Post-resuscitation Care
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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.
BLS Updates 2006
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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
Tilt Head to Sniff Position
Witnessed Collapse of Child
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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
Choking Infant
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5 back slaps
5 Chest thrusts
Heimlich for Infants
Clearing the Mouth