Pediatric Advanced Life Support

1. Pediatric Advanced Life Support

2. Make Checks available to: Life Support Education

3. Agenda DAY 1 • Course introductions and overview • Review new 2011 updates • BLS primary survey video • PALS secondary survey video • CPR and AED practice, ETCO2 monitoring (group 1) • Airway devices and intubation (group 2) • Bradycardia station (group 1) • Asystole/PEA station (group2) • Patient assessment Video • Respiratory emergencies (group 1) • VF/VT station (group 2) DAY 2 • Tachycardias • Shocks • Lead II rhythm review • Team resuscitation concept video • Algorithm review • Mega-code review/practice Testing and Megacode • Remediation

4. Introduction • PALS is designed to give the learner the ability to assess and quickly respond to pediatric emergencies including respiratory arrest and cardiac arrest. • The course is two days and encompasses a written exam and a core scenario that must be passed with at least an 84%. First hour of class we will be going over a pre-test.

5. PALS Over View: AHA guidelines Purpose of PALS • Acquire the ability to recognize an infant or child whom requires advanced life support • Learn to apply the “Assess, Categorize, Decide and Act” model of assessment • Learn the importance and technique for quality and effective CPR and advanced life support • Learn effective team coordination and team member roles in resuscitation Key Points of Importance of PALS • The first step in cardiac arrest is prevention • If cardiac arrest does occur, effective high quality CPR is the most important aspect in successful resuscitation • Studies show that poor skills by healthcare workers lead to increased incidences of death and brain death • All PALS students must perform effective and quality CPR throughout the course • WATCH PALS INTRODUCTION ON VIDEO

6. *NEW 2011 CPR UPDATE CHANGES: BLS • If there's a palpable pulse >60, but the patient shows inadequate breathing, give rescue breaths at a rate of 12–20 breaths/minute (one breath every three to five seconds) using the higher rate for younger children • If the pulse is <60 and there are signs of poor perfusion (pallor, mottling, cyanosis) despite support of oxygenation and ventilation, begin chest compressions. Beginning CPR prior to full cardiac arrest results in improved survival. • Place less emphasis on the pulse check. For an unresponsive and non-breathing child, begin CPR if a pulse cannot be detected within 10 seconds

7. *NEW 2011 CPR UPDATE CHANGES: BLS • Initiate CPR with chest compressions rather than rescue breaths (CAB rather than ABC). Asphyxial cardiac arrest is more common in infants and children, and ventilations are extremely important in pediatric resuscitation. The CAB sequence for infants and children is to simplify training. Therefore, start CPR with chest compressions immediately, while a second rescuer prepares to provide ventilation • Compress at a rate of at least 100/min. After each compression, allow the chest to recoil completely • Depth of compressions is at least one-third (1/3) the anterior-posterior diameter of the chest or approximately 1½ inches (4 cm) in infants and 2 inches (5 cm) in children. Note: Inadequate compression depth and incomplete recoil is common even among trained providers.

8. *NEW 2011 CPR UPDATE CHANGES: BLS • For the lone rescuer, a compression-ventilation ratio of 30:2 is recommended. For two rescuers, a ratio of 15:2 is recommended. • Oropharyngeal and nasopharyngeal airways help maintain an open airway. Make sure to select the correct size. • Deliver ventilations with as short a pause in compressions as possible. If an advanced airway is in place, compressions should be delivered without pauses for ventilation. Ventilations should be delivered at a rate of eight to 10 breaths/minute (every six to seven seconds) without interrupting compressions. Avoid excessive ventilation

9. *NEW 2011 CPR UPDATE CHANGES: Defibrillation • Follow package directions for placement of defibrillator pads. Place manual electrodes over the right side of upper chest and the apex of the heart (to left of nipple over left lower ribs). There is no advantage in an anterior-posterior position of the paddles. • Paddle size: Use the largest electrodes that will fit on the childʼs chest without touching, leaving about 3 cm between electrodes. “Adult” size (8–10 cm) electrodes should be used for children >10 kg (approximately one year). “Infant” size should be used for infants <10 kg. • An initial dose of 2 to 4 J/kg is acceptable. For refractory VF, itʼs reasonable to increase the dose to 4 J/kg. Higher energy levels may be considered, not to exceed 10 J/kg or the adult maximum dose • If an AED with an attenuator is not available, use an AED with standard electrodes • In infants <1 year, a manual defibrillator is preferred. If not available, an AED with an attenuator may be used. An AED without a dose attenuator may be used if neither a manual defibrillator nor a dose attenuator is available

11. Broselow Tape

12. *NEW 2011 CPR UPDATE CHANGES: PALS • The PALS cardiac arrest algorithm is simplified and organized around two-minute periods of uninterrupted CPR. • Exhaled CO2 detection is recommended as confirmation of tracheal tube position with a perfusing rhythm in all settings and during intra- or inter-hospital transport. Capnography/capnometry, used for confirming proper endotracheal tube position, may also be useful to assess and optimize the quality of chest compressions during CPR • It may also spare the rescuer from interrupting chest compressions for a pulse check because an abrupt and sustained rise in PetCO2 is observed just prior to clinical identification of ROSC.

13. *NEW 2011 CPR UPDATE CHANGES: PALS • Upon ROSC, titrate inspired oxygen (when oximetry is available) to maintain an arterial oxyhemoglobin saturation >94% but <100% to limit the risk of hyperoxemia. • Bradycardia with pulse and poor perfusion: epinephrine, atropine and pacing may be used. • Tachycardia with pulse and poor perfusion: > Narrow complex (QRS <0.09) SVT: Attempt vagal stimulation. Adenosine is the drug of choice. If hemodynamically unstable or adenosine are ineffective, perform synch cardioversion, starting at a dose of 0.5 to 1 J/kg, increasing to 2 J/kg. > Wide complex (QRS>0.09) tachycardia, hemodynamically stable: Adenosine may be considered if the rhythm is regular and monomorphic and is useful to differentiate SVT from VT. Consider cardioversion using energy described for SVT. Expert consultation is strongly recommended prior to administration of amiodarone or procainamide. If hemodynamically unstable, cardioversion is recommended.

14. SVT • Stable: Vagals first, then Adenosine 0.1, 0.2mg/kg, Then cardiovert as last resort 0.5-1J/kg • Unstable: Cardiovert VT with pulse: Stable: Adenosine .1, .2, Amiodarone 5mg/kg over 60 min, then cardioversion if needed. Unstable: Cardioversion VT/VF: no pulse , defibASAP, CPR, Epi, after third shock Amiodarone

15. *NEW 2011 CPR UPDATE CHANGES: PALS • Routine calcium administration is not recommended for pediatric cardiopulmonary arrest in the absence of documented hypocalcemia, calcium channel blocker overdose, hypermagnesemia or hyperkalemia. • Etomidate has been shown to facilitate endotracheal intubation in infants and children with minimal hemodynamic effect but is not recommended for routine use in pediatric patients with evidence of septic shock. • Although there have been no published results of prospective randomized pediatric trials of therapeutic hypothermia, based on adult evidence, therapeutic hypothermia (to 32–34°C) may be beneficial for adolescents who remain comatose after resuscitation from sudden, witnessed, out-of-hospital VF cardiac arrest. Therapeutic hypothermia (to 32–34°C) may also be considered for infants and children who remain comatose after resuscitation from cardiac arrest. • Whenever possible, provide family members with the option of being present during resuscitation of an infant or child.

16. CPR Practice and Competency Testing • Single person resuscitation (30:2 ratio, 100 compressions a minute, 2 minute cycles) • Two person resuscitation (15:2 ratio) • Use of Bag/Mask (remember, always bag a patient whom becomes distressed and cyanotic on the ventilatior)

18. CPR Practice and Competency Testing • Compression techniques (one hand method, two hand, two finger or encircling thumb technique) Watch video on CPR practice, we will be practicing CPR soon

19. Overview of PALS CPR • High Quality CPR • Compression rate of at least 100 per minute • Push hard and fast • Compression depth 1/3 AP diameter of the chest, 1 ½ inches in infants and 2 inches in pediatrics • Allow proper chest recoil after each compression to allow for proper cardiac output • Minimize interruptions for continuous brain and organ perfusion • Avoid excessive ventilation to prevent impendence of venous return back to the heart and gastric insufflation

20. Overview of PALS CPR AED • Paddle size: Use the largest electrodes that will fit on the childʼs chest without touching, leaving about 3 cm between electrodes. “Adult” size (8–10 cm) electrodes should be used for children >10 kg (approximately one year). “Infant” size should be used for infants <10 kg. • If an AED with an attenuator is not available, use an AED with standard electrodes • In infants <1 year, a manual defibrillator is preferred. If not available, an AED with an attenuator may be used. An AED without a dose attenuator may be used if neither a manual defibrillator nor a dose attenuator is available

22. Airway Management • Upper airway obstruction: • Note presence of stridor (typically inspiratory) • Note cough (seal like, dull, muffled) • Note Conciousness • Note breath sounds (decreased?), note HR (typically tachycardic) • Note color, retractions, grunting, tachypnea and WOB • If in distress causing compromise: open airway and determine if an advanced airway is needed. Support ventilations and begin CPR as needed • Possible causes: Croup, Epiglotitis, Apiration, inhaled toxins, anaphylaxis • Administer nebulized epinephrine/racemic for moderate stridor/barking cough • Treat underlying problem: airway, cool mist, racemic epinephrine, decadron, steroids

23. Airway Management Lower Airway Obstruction • Note presence of Wheezing (typically expiratory), prolonged expiratory phase and airtrapping • Note decreased aeration in lungs, desaturation • Note color (cyanosis is a late sign) • Causes: Asthma, Pneumonia, Bronchiolitis, aspiration that has migrated passed trachea (unilateral wheezing) • Treat with bronchodilators, bronchial hygein and bronchoscopy

24. Advanced Airways • Airway problems in the pediatric population is especially critical as it typically is the precipitating cause of pediatric arrest

25. Advanced Airways • Cuffed ETT now considered as safe or more safe than a non cuffed for small children • Verify placement with exhaled CO2 detector (turns yellow for correct placement); check chest rise, breath sounds then CXR • Exhaled CO2 may not be detected in prolonged arrest • May use a EDD • USE DOPE mnemonic when determining deterioration of an intubated patient; D: displacement of ETT, O: obstruction of the tube; P: pneumothorax; E: equipment failure

26. Support of Ventilation The method of advanced airway support (endotracheal intubation versus laryngeal mask versus bag-mask) provided to the patient should be selected on the basis of the training and skill level of providers in a given advanced life support (ALS) system and on the arrest characteristics and circumstances (eg, transport time and perhaps the cause of the arrest).

27. Split up into two groups • Group 1. • CPR practice • Bag and mask practice • AED practice • Oxygen management • Group 2. • Intubation practice • LMA overview 20 minutes per group then switch

28. Airway Management Watch Airway Management Video Rapid Sequence Intubation • To facilitate emergency intubation and reduce the incidence of complications, skilled, experienced providers may use sedatives, neuromuscular blocking agents, and other medications to rapidly sedate and paralyze the victim. Use RSI only if you are trained and have experience using these medications and are proficient in the evaluation and management of the pediatric airway. If you use RSI you must have a secondary plan to manage the airway in the event that you cannot achieve intubation.

29. Airway Management Cuffed Versus Uncuffed Tubes • In the in-hospital setting a cuffed endotracheal tube is as safe as an uncuffed tube for infants beyond the newborn period and in children.In certain circumstances (eg, poor lung compliance, high airway resistance, or a large glottic air leak) a cuffed tube may be preferable provided that attention is paid to endotracheal tube size, position, and cuff inflation pressure Disordered control of breathing • Occurs often after a head injury or as a result of aneurysm or infection in brain. Normal rhythmic breathing is altered, requires protection of airway with artificial airways. Endotracheal Tube Size • Length-based resuscitation tapes are helpful and more accurate than age-based formula estimates of endotracheal tube size for children up to approximately 35 kg,even for children with short stature. • In preparation for intubation with either a cuffed or an uncuffedendotracheal tube, confirm that tubes with an internal diameter (ID) 0.5 mm smaller and 0.5 mm larger than the estimated size are available. During intubation, if the endotracheal tube meets resistance, place a tube 0.5 mm smaller instead. Following intubation, if there is a large glottic air leak that interferes with oxygenation or ventilation, consider replacing the tube with one that is 0.5 mm larger, or place a cuffed tube of the same size if an uncuffed tube was used originally. Note that replacement of a functional endotracheal tube is associated with risk; the procedure should be undertaken in an appropriate setting by experienced personnel.

30. Airway Management • If an uncuffedendotracheal tube is used for emergency intubation, it is reasonable to select a • 3.5-mm ID tube for infants up to one year of age and a • 4.0-mm ID tube for patients between 1 and 2 years of age. • After age 2, uncuffedendotracheal tube size can be estimated by the • following formula: • If a cuffed tube is used for emergency intubation of an infant less than 1 year of age, it is reasonable to select a 3.0 mm ID tube. For children between 1 and 2 years of age, it is reasonable to use a cuffed endotracheal tube with an internal diameter of 3.5 mm After age 2 it is reasonable to estimate tube size with the following formula

31. Respiratory Compromise • Be vigilant for signs of respiratory compromise. Often, symptoms of shock or cardiac distress are treated without regard to respiratory status, but in many cases a cardiac dysrhythmia or compensated shock can be completely resolved by aggressive oxygenation. • Whenever a pediatric patient’s heart rate is too slow, or is slowing, the first and primary treatment is to give assisted ventilations if the child’s airway is not maintained or their work of breathing is not effective. • For pediatric patients with any symptoms, always provide oxygen, the exact flow rate depending on patient needs. Stable patients with a cardiac dysrhythmia but no respiratory distress can receive low-flow oxygen (up to 4 L/min.) via nasal cannula. Unstable cardiac patients, patients in shock (compensated or hypovolemic), or patients with respiratory distress should receive oxygen via non-rebreather mask, if they tolerate it. Patients in respiratory failure should receive assisted ventilations via bag-mask valve.

32. Respiratory Compromise • It is critical that students correctly categorize the degree of respiratory compromise and provide appropriate oxygenation. • In Respiratory Distress, the patient will have an increased respiratory rate and effort. Be alert for patient position, nasal flaring, retractions, and accessory muscle use. Skin color may be normal or pale, and the patient may exhibit the beginnings of an Altered Level of Consciousness (ALOC). Adventitious breath sounds may or may not be present. Any patient in respiratory distress should receive high-flow oxygen via non-rebreather mask, if they tolerate it.

33. Respiratory Compromise • In Respiratory Failure, the patient may have an increase in respiratory effort with increased or decreased respiratory rate. Be alert for patient position, nasal flaring, retractions, and accessory muscle use. Head bobbing, decreased respiratory effort, “seesaw” respiratory pattern, shallow respirations, cyanosis, difficulty speaking, and poor air movement (diminished or absent breath sounds) are signs of respiratory failure. For any child in respiratory failure or severe respiratory distress, you should consider the following interventions: Assisted Ventilations (provide ventilations via Bag-valve Mask); Advanced Airway (consider Endotracheal Intubation); or Mechanical Ventilations (such as CPAP or BiPAP). When providing assisted ventilations, students should remember that hyperventilation (ventilating too often, too rapidly, or with too much volume) will diminish the effectiveness of circulation.

34. Exhaled or End-Tidal CO2 Monitoring • When available, exhaled CO2 detection (capnography or colorimetry) is recommended as confirmation of tracheal tube position for neonates, infants, and children with a perfusing cardiac rhythm in all settings (eg, prehospital, emergency department [ED], ICU, ward, operating room) and during intrahospital or interhospital transport. • Remember that a color change or the presence of a capnography waveform confirms tube position in the airway but does not rule out right mainstem bronchus intubation. During cardiac arrest, if exhaled CO2 is not detected, confirm tube position with direct laryngoscopy because the absence of CO2 may reflect very low pulmonary blood flow rather than tube misplacement.

35. Exhaled or End-Tidal CO2 Monitoring • Confirmation of endotracheal tube position by colorimetric end-tidal CO2 detector may be altered by the following: • If the detector is contaminated with gastric contents or acidic drugs (eg, endotracheally administered epinephrine), a consistent color rather than a breath-to-breath color change may be seen. • An intravenous (IV) bolus of epinephrinemay transiently reduce pulmonary blood flow and exhaled CO2 below the limits of detection. • Severe airway obstruction (eg, status asthmaticus) and pulmonary edema may impair CO2 elimination below the limits of detection. • A large glottic air leak may reduce exhaled tidal volume through the tube and dilute CO2 concentration.

36. Capnography-Show video

37. Oxygen • Ventilate with 100% oxygen during CPR because there is insufficient information on the optimal inspired oxygen concentration once the circulation is restored, monitor systemic oxygen saturation. • Titrate oxygen administration to maintain the oxyhemoglobin saturation ≥94%-99%

38. If resuscitation efforts are unsuccessful, note possible causes for the arrest: 6 H’s and 5 T’s H’s • 1. Hypovolemia (look for signs of fluid/blood loss. Give fluid blolus’s and reassess) • 2. Hypoxia (confirm chest rise and bilateral breath sounds with ventilation, check o2 source) • 3. Hydrogen Ion Acidosis (Resp acidosis; provide adequate ventilation but do not hyperventilate, metabolic acidosis; give sodium bicarb) • 4. Hyper/Hypokalemia (for hyper give calcium chloride 10 ml of 10% over 5 minutes, for hypo give potassium or magnesium 5ml of 50% solution) • 5. Hyper/hypothermia • 6. Hypo/hyperglycemia (check glucose with Accu-check) T’s • 1. Tablets (Drug OD); find antidote or reverse drug, poison control. Always ask the family for metabolic or toxic causes during resuscitation • 2. Tamponade (look for chest trauma, malignancy, central line insertion, JVD) • 3. Tension Pneumothorax- desreased BS, deviated trachea, high peak pressures or difficult to bag, chest tube with needle decompression OVER THE THIRD RIB AT THE MIDCLAVICULAR LINE • 4. Thrombosis- give thrombolytics for suspected embolus • 5. Trauma- inspect body completely, remove clothing, secure airway, control bleeding and give volume with isotonic crystalloids and blood products

40. Arrhythmia Review

41. Ventricular Tachycardia without Pulse and Ventricular Fibrillation Pulseless V-Tach • VT- series of wide bizarre QRS that produce little to no cardiac output; rate above 100 • Requires immediate defibrillation with 2J/kg followed by immediate CPR • If after 2 minutes still in VT or VF, shock again at 4J/kg • Establish IV and give Epinephrine 0.01mg/kg

42. Ventricular Tachycardia without Pulse and Ventricular Fibrillation V-Fib • Chaotic; no defined rhythm, never a HR/pulse • Requires immediate defibrillation with 2J/kg followed by immediate CPR • If after 2 minutes still in VT or VF, shock again at 4J/kg • Establish IV and give Epinephrine 0.01mg/kg • Both of these arrhythmias will require emergent CPR, Defibrillation and Drugs!

43. Bradycardia • Bradycardia occurs when the heart beats slower than 60 beats per minute; occurs as a result of heart block or increased vagal tone. What do you do: • Support ABC’s as necessary • Give Oxygen • Attach Monitor and prepare defibrillator • Determine if bradycardia is causing cardiopulmonary compromise • IF YES: Perform CPR if despite oxygenation and ventilation with bagging; the heart rate remains below 60/min with poor perfusion • If bradycardia persists when rhythm is checked after 2 minutes; Give EPINEPHRINE and repeat every 3-5 minutes as necessary • If patient has increased vagal tone (Physiological causes of increased vagal tone include bradycardia seen in athletes; pathologic causes include MI, toxic or environmental exposure, electrolyte disorders, infection, sleep apnea, drug effects, hypoglycemia, hypothryroidism, and increased intracranial pressure) or primary AV BLOCK; give ATROPINE first dose 0.02 mg/kg, may repeat (minimum dose is 0.1mg to maximum total dose of 1 mg) • Consider pacing if drugs fail • Watch for asystole and ne prepared to perform CPR • If bradycardia is not causing any compromise; monitor patient, supply oxygen and aquire expert consultation. Also note possible causes H’s and T’s.

45. Transcutaneous Pacing • Not commonly performed with pediatrics, however it is utilized to supplement a failing conduction system associated with high degree blocks or severe unresponsive bradycardia

46. Pediatric Pulseless Arrest Algorithm • BLS: Initiate CPR 30:2 or 15:2 ratios; avoid hyperventilation (CAB) • Bag/mask ventilate with 100% oxygen • Attach monitor and prepare defibrillator • Check rhythm once on monitor after 2 minute cycle of CPR. Determine if the rhythm is shockable (VT, VF) or not; also a IV/IO should be established and an advanced airway should be considered • If shockable (VT, VF) • Give 1 shock: manual start with 2 J/Kg; AED • Resume CPR immediately after shock • Give 5 cycles (approximately 2 minutes) and then check rhythm again and determine if its shockable or not • If it is shockable continue CPR while defibrillator is charging and administer second shock with 4 J/Kg then resume CPR • Give epinephrine at this time IV/IO 0.01 mg/kg (1:10,000 soln) or ETT; repeat every 3-5 minutes • Keep checking rhythm after every 2 minutes to determine if it is shockable or not, if after 3 shocks VF or VT remain, consider antiarrythmics; • AMIODARONE 5 mg/kg IV/IO or LIDOCAIN 1 mg/kg IV/IO’ consider Magnesium 2.5-5 mg/Kg IV/IO max dose 2g for Torsades de Pointes. If rhythm continues the same; consider H’s and T’s

47. ASYSTOLE • ASYSTOLE • Algorithm: Pulseless Arrest – Not Shockable(Course Guide, page 39) • Remember: DEAD: • • Determine whether to initiate resuscitative efforts. • • Epinephrine 0.01 mg/kg (1:10,000 solution) q 3-5 min IV/IO. Give as soon as possible after resuming CPR, circulate with chest compressions. • • Aggressive oxygenation – use compression: ventilation ratio of 15:2 consider advanced airway. Avoid hyperventilation – do not ventilate too often, too quickly, or with too much volume. • • Differential Diagnosis or Discontinue resuscitation – Are they still dead? Consider the 6 H’s and 5 T’s (see above) – check blood glucose; check • coretemperature; considerNaloxone; etc.

48. PULSELESS ELECTRICAL ACTIVITY • Algorithm: Pulseless Arrest – Not Shockable • Remember: PEA: • • Possible causes (consider the 6 H’s and 5 T’s). • • Epinephrine 0.01 mg/kg IV/IO q 3-5 minutes. Give as soon as possible after resuming CPR, circulate with chest compressions. • • Aggressive oxygenation – use compression: ventilation ratio of 15:2 consider an advanced airway. Avoid hyperventilation – do not ventilate too quickly, too often, or with too much volume. Note: In PEA, the electrical system of the heart is functioning, but there is a problem with the pump, pipes, or volume – a mechanical part of the system is not working. You can use the 6 H’s and 5 T’s to remember the most common reversible causes of PEA: • Hypovolemia Toxins • Hypoxia Tamponade, cardiac • Hydrogen Ion (acidosis) Tension Pneumothorax • Hypo-/Hyperkalemia Thrombosis (coronary or pulmonary) • Hypoglycemia Trauma • Hypothermia PEA will have the appearance of a sinus rhythm, however no pulse is present!

49. Tachycardiawith Pulse and Adequate Perfusion • Assess and support ABC’s as needed • Provide Oxygen, do not rely on SpO2 monitor, may be unreliable (mask, nasal cannula…) • Attach monitor, prepare defibrillator • Evaluate/Obtain a 12 lead EKG • On EKG if QRS is normal (0.08 to 0.12 seconds) • Probable sinus tachycardia • Compatible with history consistent with known cause (fever, pain, fear…) • P waves present/normal • Variable R-R with consistent PR • Infants: rate usually <220/min; children rate usually <180/min • Treat causes (this will return rate to normal)

50. Tachycardiawith Pulse and Adequate Perfusion • On EKG if QRS is narrow (less than 0.08 seconds) • Probable Supraventricular tachycardia • Compatible history (vague, non specific, abrupt rate changes) • P waves abnsent/abnormal • HR not variable with activity • Infants rate >220/min, children rate > 180/min • Treatment: consider vagal maneuvers first (if patient is stable), ideal vagal= ice to face in infants, establish IV and consider ADENSOSINE 0.1 mg/kg IV (maximum first dose 6 mg). Use rapid bolus technique. If patient is unstable and has no IV, cardiovert immediately.