pediatric advanced life support -...
TRANSCRIPT
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Pediatric Advanced Life Support
AHA 2010
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American Heart Association
Pediatric Advanced Life Support
Guidelines first published in 1997
Revisions made in 2005
Revisions made in 2010
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ABC or CAB
2010 AHA for CPR recommend a CAB sequence
Chest compression
Airway
Breathing
Ventilation
Critical thinking: WHY?
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CAB Guidelines
Infant BSL guidelines apply to infants < approximately one
year of age.
Child BSL guidelines apply to children > 1 year until
puberty (breast development in girls and axillary hair in
males)
Adult BSL for puberty and above.
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Chest compression
Rate of 100 compression per minute
Push hard: sufficient force to depress at least one third
the anterior-posterior diameter of the chest.
1 ½ inches in infants 4cm
2 inches in children 5cm
Allow chest recoil after each compression to allow the
heart to refill with blood
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Hand placement Infant: compress the sternum with 2 fingers placed just below the inter-
mammary line
Child: compress the lower half of the sternum at least one third of the AP
diameter of the chest (2 inches) with one or two hands
Note: do not compress over the xiphoid or ribs
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Ventilation / Compression
One rescuer: 30 compression to 2 ventilation
After initial 30 compression, open airway using a head tilt-
chin lift and give 2 breaths using mouth-to-mouth-and
nose.
Note: if you use mouth to mouth, pinch off the nose.
calling for EMS and AED.
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CABS Sequence
Assess need for CPR
If health care provider take 10 seconds to check for pulse
Brachial in infant
Carotid or femoral in a child
“ARE YOU OKAY?”
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Breathing child
If child is breathing, put in recovery position, call
emergency response system, return quickly and re-assess
child’s condition
Turn child on-side (recovery position)
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Inadequate Breathing With Pulse
If pulse > 60 per minutes but there is inadequate
breathing give rescue breathing at a rate of about 12 to
20 breathes per minute.
Reassess pulse about every 2 minutes
Carotid or femoral for child
Brachial for infant
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Unresponsive and not breathing
If the child is unresponsive and not breathing (or only
gasping) begin CPR.
Start with high-quality chest compression. (30 chest
compressions)
After one cycle 2 minutes check for pulses
Call for help when able
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Bradycardia with Poor Perfusion
If pulse is less than 60 per minutes and there
are signs of poor perfusion Pallor
Mottling
cyanosis
despite support of oxygenation and ventilation – start
CHEST COMPRESSION
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Defibrillation
“Children with sudden witnessed collapse (eg, a child
collapsing during an athletic event) are likely to VF or
pulseless VT and need immediate CPR and rapid
defibrillation. “
VF and pulseless VT are referred to as “shockable
rhythms” because they respond to electric shocks.
VT – ventricular tachycardia
VF – ventricular fibrillation
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Defibrillation Dosing
The recommended first energy dose for defibrillation is 2
J/kg.
If second dose is required, it should be doubled to 4 J/kg.
AED with pediatric attenuator is preferred for children <
1years of age.
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Defibrillation Sequence
Turn AED on
Follow the AED prompts
End CPR cycle (for analysis and shock)
Resume chest compressions immediately after the shock.
Minimize interruptions in chest compression
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Asphyxial Cardiac Arrest
Cardiac arrest caused by asphyxiation (lack of oxygen in
blood)
Carbon dioxide accumulates in the lungs while oxygen in
the lungs is depleted resulting in cardiac arrest.
Causes: drowning, choking, airway obstruction, sepsis,
shock
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Asphyxial Cardiac Arrest
“One large pediatric study demonstrated that CPR with
chest compression and mouth-to-mouth rescue breathing
is more effective than compression alone when the arrest
was from a noncardiac etiology.”
“Ventilations are more important during resuscitation
from asphyxia-induced arrest, than during resuscitation
from VF or pulseless VT.”
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Foreign-body Airway Obstruction
90% of childhood deaths from foreign body aspiration
occur in children < 5 years of age; 65% are infants.
Balloons, small objects, foods (hot dogs, round candies,
nuts and grapes) are the most common causes of foreign-
body airway obstruction
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FBAO
If FBAO is mild, do not interfere.
Allow the victim to clear the airway by coughing.
If the FBAO is severe (victim unable to make a sound)
you must act the relieve the obstruction.
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FBAO
For a child perform subdiaphragmatic abdominal thrusts
until the object is expelled or the victim becomes
unresponsive.
For an infant, deliver repeated cycles of 5 back blows
followed by 5 chest compressions until the object is
expelled or the victim becomes unresponsive.
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Five quick back blows
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Five quick chest thrusts
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Five quick upward thrusts
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Five quick upward thrusts
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FBAO – unresponsive
Start Chest Compression
After 30 chest compressions open airway
If you see a foreign body remove it
DO NOT perform a blind finger sweep
Give 2 breaths
Followed by 30 chest compressions
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Drowning
Outcomes after drowning is determined by the duration
of submersion, the water temperature, and how promptly
and effectively CPR is provided.
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Pediatric Advanced Life Support
Timely intervention in seriously ill or injured children is
the key to preventing progression toward cardiac arrest
and to saving lives.
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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.
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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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Respiratory Failure
A respiratory rate of less than 10 or greater than 60 is an
ominous sign of impending respiratory failure in children.
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Breathing
Breathing is assessed to determine the child’s ability to
oxygenate.
Assessment:
Respiratory rate
Respiratory effort
Breath sounds
Skin color
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Airway
Airway must be clear and patent for successful ventilation.
Position
Suction
Administration of oxygen
Bag-mask ventilation
Note: suctioning is helpful if secretions, blood or debris is present. Use with caution if upper airway swelling is edema (eg. croup, epiglottitis)
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Bag-valve-mask
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LMA –Laryngeal Mask Airway
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Uncuffed tube size:
<1yr 3.5mm ID
1-2 yr 4.0mm ID
>2 yr 4 + (Age/4)
Cuffed tube size: <1yr 3.0 mm ID 1-2 yr 3.5 mm ID >2 yr 3.5 + (Age/4)
ETT depth (lip):
ETT size x 3
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Uncuffed ET tubes
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Cuffed ET Tube
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ET Tube
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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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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 (most accurate assessment)
Blood pressure
End organ profusion
Urine output (1-2 mL / kg / hour)
Muscle tone
Level of consciousness
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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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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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Blood Pressure Guidelines
Hypotension is defined as systolic blood pressure
Neonates: < 60 mm Hg
Infants: <70 mm Hg
Child (1 to 10): < 70 mm Hg
Child (>10): < 90 mm Hg
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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 vascular access in the proximal tibia
or distal femur should be initiated.
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Intraosseous Access
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IV Solutions
Crystalloid solution for fluid loss (hypovolemia)
Normal saline 20ml/kg bolus over 20 minutes
Ringers Lactate
Blood loss:
Colloid: 5% albumin
Blood
Fresh-frozen plasma
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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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Arrhythmias
Bradycardia with pulse
Tachycardia with pulses and adequate perfusion
Pulseless arrest
VF/VT
Asystole
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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 0.01 mg / kg
(1:10,000)
ET tube (not recommended) 0.1 mg / kg
Search for and treat possible contributing factors
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Tachycardia with pulses
Supraventricular tachycardia
History: vague, non-specific, history of abrupt rate change
P waves absent or normal
HR not variable with activity
Infants: rate > 220/min
Children: rate > 180/min
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Management
Consider vagal maneuvers
Establish vascular access
Adenosine
First dose 0.1 mg/kg IV (maximum of 6 mg)
Second dose 0.2 mg/kg IV (maximum of 12 mg)
Synchronized cardioversion: 0.5 to 1 J / kg
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Pulseless Arrest
Ventricular fibrillation / ventricular tachycardia
Asystole
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Asystole
No Rhythm
No rate
No P wave
No QRS comples
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Pulseless Arrest – Asystole
CAB: 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 epinephrine every 3-5 minutes
until shockable rhythm is seen
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Pulseless Arrest – VF and VT
Start CAB
Give oxygen
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
Consider: amiodarone at 5 mg / kg
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New Guideline Epinephrine
Still remains primary drug for treating patients for
cardiopulmonary arrest
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PALS Drugs
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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
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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
Used in pulseless arrest
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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
Used in tachycardia with pulses after synchronized
cardioversion
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Glucose
10% to 25% strength
Action: increases glucose in hypoglycemia
Dosing: 0.5 – 1 g/kg
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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
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Sodium bicarbonate
pH buffer for prolonged arrest, hyperkalemia
Action: increases blood pH helping to correct metabolic
acidosis
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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
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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
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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 1 years of age .
Electrical energy is delivered by a fixed amount range 150
to 200. (2-4J/kg)
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