This post is basically gonna by my notes after reading the pediatric advanced life support, because I'm going in for the update tomorrow and I'm really nervous. Even though I don't really think I'll fail it or anything, it's not material I review a lot. So I've been going over it casually over the past two weeks and I did the little test on line I'm supposed to do. And I'm realizing what a crapload of information it covers, and definitely has me on my toes.
Comparatively, I'd say, Adult cardiac life support and neonatal resuscitation are a bit more straightforward in strategy: you kind of just follow the flow sheet and it tells you exactly what to do. There's a lot more to consider in the pediatric population. For one thing there's the age and size variations: some kids will need to be treated more like neonates, and others will need to be treated more like adults.
There are also medical problems that are a lot more common in the pediatric population than in other populations. For instance: if you find an unresponsive kid out of the blue, you operate under the assumption that what's causing the kid to be unresponsive is respiratory in nature. This is the total opposite of what you do in an adult cardiac arrest, because most kids don't suffer from heart disease. So unless you know the kid has some sort of congenital cardiac condition, or is being hospitalized for sepsis or something, you begin with respiration and you can call out for help but you don't want to leave the patient's side until you've done 5 cycles of CPR. If it hasn't been too long since the collapse, and the problem is respiratory in origin, ventilation support may even be sufficient, so we wanna try that first.
They also go into a lot more detail about specific respiratory problems, and the different types of shock, and none of the medications are, like, a standard dose...they're all based on the patient's weight. So you have to calculate pretty much every dose before you give it.
It's a LOT to remember, and it's so friggin deceptive because the PALS book is, like, the smallest of the AHA books that I've read.
Anyway...I'm just gonna go over my notes one more time. Please forgive the typos and misspellings, but if I'm wrong about instructions or dosages you should comment and let me know.
PALS BLS
CPR with AED and 1 or 2 rescuers:1) Ensure scene safety
2) check for response, send someone to call 911/get AED
3a) for sudden witnessed collapse and single rescuer: call 911 and get AED
3b) for unwittnessed collapse and single rescuer: activate after performing 5 cycles of CPR
4) Open airway (head-tilt-chin-lift or jaw thrust if suspected neck injury), and check breathing for less than 10 seconds
5) Give 2 breaths that cause the chest to rise and last over 1 second each.
6) check pulse for less than 10 seconds Brachial in infants carotid in kids.
7a) if pulse felt provide rescue breaths at 1 breath Q3 seconds (unless for some reason the patient has an advanced airway, then you'll wanna give them at 10-12 times per minute, which ends up being about once every 6 seconds)
7b) if pulse not felt, begin compressions at a rate of 100-120 per minute, compress to a deapth of 1/3-1/2 and allow to recoil. If there is one rescuer 30 compressions: 2 breaths, use two finger technique for infants or 1-2 hands for older kids.
If there are two rescuers 15 compressions: 2 breaths, use hands encircling technique for infants or 1-2 hands for older kids.
8) If not already done after five cycles/single rescuer: call 911/get AED
9a) If patient is <1 acls="" continue="" cpr="" move="" old="" or="" over="" p="" responders="" starts="" take="" to="" until="" victim="" year="">9b) if patient >1 year old use AED /defibrillator after 5 cycles.
10) Check rhythm if patient > 1 year old.
11) if Rhythm is shockable: give 1 shock and resume CPR x 5 cycles
12) if rhythm is not shockable: resume CPR x5 cycles and recheck rhythm until ACLS providers take over or victim starts to move.
ACLS/PALS providers will need to perform several assessments very quickly:
1) General Assessment:
Visual and auditory, taking in patient's appearance and work of breathing as well as how well blood circulation seems to be working. This one is very quick and probably the most simple.
2) Primary assessment:
A rapid hands on ABCDE, cardiopulmonary and neurologial function assessment
A=airway patency.
Positioning, suctioning, airway adjuncts (nasal airway or one of those things to keep the tongue out of the throat) or intubation.
B=breathing
Rate and effort, tidal volume, airway/lung sounds, pulse ox etc.
C=circulation (both cardiac & end organ)
Skin color, temp, HR, Rhythm, pulses (peripheral and central), capilary refill time, BP and pulse pressure, mental status, skin perfusion, renal output.
D=disability
AVPU pediatric response, glascow coma scale, response to voice/touch/pain, pupil response
E=Exposure
remove clothing and examine s/s hypothermia, burns etc. check temp
3) Secondary assessement
identify S/S, allergies, medications, past medical history, last meal, events leading to presentation. This usually involves asking a lot of questions for the parents if they are present.4) Tertiary Assessment:
Laboratory tests, radiography tests, and other advance tests that take a lot of time to do so order them stat
Cardiac Arrest Algorithm
If the patient is having cardiac arrest, regardless of whatever else might be going on, you definately will want to treat that fast. I'm not saying if, say, the caradiac arrest is being caused by sepsis that you won't want to treat that too. You'll need a lot of people to kinda do both at the same time. But we're just gonna talk about the cardiac arrest right now.
You'll wanna start with BLS, attach oxygen to the thing giving respiratory support, but once you get the equiptment put on all the electrodes and the defibrilation pads and do a rhythm check.
1) if the rhythim is shockable (VF/VT): give 1 shock manually at 2 J/KG or AED if patient is > 1 year old. Use a pediatric system for 1-8 years old. then restart CPR x5 cycles and give epinephrine 0.01mg/KG IV/IO or 0.1mg/kg ET and repeat this dose every 3-5 minutes.
Recheck Rhythim after the five cycles and if it is still shockable give another shock, but this time at 4J/kg, or AED for 1-8 Y/O, and resume CPR x5 cycles.You will probably give epinephrine again about this time.
At the next rhythm check, if it is still shock-able deliver 4J/kg or pediatric AED and also consider amiodarone 5mg/kg IV/IO or lidocane 1mg/kg IV/IO.
Consider magnesium 25-50mg/kg IV/IO max 2grams for torsades de pointes.
After 5 more cycles do another rhythm check and continue defibrillation with the 4J/kg if indicated.
2) if at any point the rhythim is not shockable (asystole/PEA): Resume CPR x5 cycles, give epinephrine 0.01mg/kg IV or IO or 0.1mg/kg ET. Repeat Q3-5 minutes. and Recheck rhythm after the five cycles. If rhythm is now shock-able: start with the 2J/kg dose.
You will also want to consider the Hs and Ts while you're doing all of this (which I did a whole other series of posts about a few years ago)
Bradycardia (with cardiovascular compromise) Algorithm
1 Support ABCs-give O2, attach monitor/defib. and get 12 lead EKG
2a) if compromise resolved, continue to support Airway, Breathing, Circulation and consider expert consultation
2b) if symptoms persistent and HR <60 cpr="" p="" start="">
3) give epinephrine 0.01mg/kg iv or 0.1mg/kg et. if elvated vagale tone or primary AV block is noted give atropine 0.02mg/kg, may repeat to max dose 1mg.
Tachycardia with pulsses and poor perfusion
1) 12 lead EKG
2a) If narrow QRS (<0 .08="" a="" and="" causes.="" constant="" correlate="" for="" history="" in="" infants="" interval="" is="" normal="" p="" pr="" present="" probable="" r-r="" search="" sec="" sinus="" st="" tacycardia="" treat="" usually="" variable="" waves="" with="">220, and in children it's >180.
2b) If narrow QRS and probable SVT (correlate history: vague nonsepcific h/o abrupt heart rate changes, P waves present/abnormal, HR not variable) consider vagal manuver. if ineffective establish IV access and give adenosine 0.1mg/kg to a max of 6 mg rapid IVP, may administer a second time with twice the amount of drug dose (max 12mg).
If ineffective, perform syncronized cardioversion at 0.5J/kg. if not effective may increase to 2J/kg please sedate pateint if possible but dont delay cardioversion.
Obtain expert consultation and administer amiodarine 5mg/kg IV over 20-60 minutes or procainamide 15mg/kg over 30-60 minute BUT DO NOT ADMINISTER THEM TOGETHER....
Respiratory Emergencies
There's no real algorithm for this one. Differental treatment is based on how bad the symptoms are and whether you determine its an upper airway, lower airway, lung tissue, or disordered control of breathing problem.
People with breathing problems are generally anxious in the early stages and lethargic in the later stages, tachycardia is an early symptom but it progresses to bradycardia as breathing function deteriorates. Infants and young kids may often have a distinctive head-bobbing or seasawing breathing pattern in the abdomen.
Upper airway problems often present with inspiratory stridor, a seal like cough, and hoarse breathing.
(ex: croup- give nebulized epinephrine and corticosteroids, anaphylaxis-give IM epinephrine, albuterol 0.5mg/kg/hr with a max of 20mg/hr, antihstamine benadryl 1-2 mg/kg iv Q4-6 hours, Corticosteroid Dexamethasone 0.6mg/g IM/IV max 16.
Lower airway problems often present with expiratory wheezing, prolnged expiratory phase breathing (ex: aspiration-position to comfort and specialty consult. Bronchoiolitis-nasal suction and brinchodilator trial. Asthma-albuterol with or without ipratropium, corticosteroid, SQ epinephrine, mag sulfate, terbuttaline.)
Lung tissue/parnecymal problems often present with Grunting, crackles, and diminished breath sounds (ex; pneumonia/pneumonitis-albuterol 0.5mg/kg/hr with a max of 20 hr. and start ABT. Pulmonary edema-ventilatory support with PEEP vasoactive support, diuretic lasix 1mg/kg max 20)
Disordered control of breathing presents with normal lung sounds but a disordered breathing pattern.
(ex: incresed inacranial pressure, avoid hypozimia, hypercarbia, hyperthermia...which makes it really hard to do things like provide ventilatory support...basically this person needs an ET tube and if possible and ICP line. Poison-antidote/poison control. neuromuscular disease-ventilation support.
PALS Septic Shock Algorithm
1) Recognize ALOC and decreased perfusion-give o2 and support venntlation, start IV, begin advanced life support if needed.2) consider VBG and ABG, lactate, glucose, ionized calcium, BC, CBC.
3) Within the first our Bolus 20ml/kg NS or LR (probably more than 1 bolus will be needed, if the patient has an underlying cardiac problem or if cardiogenic shock is suspected give 5-10ml/kg), correct hypoglycemia with D25W 2-4ml/kg or D10W 5-10mlg/kg (0.5-1g/kg) DO NOT GIVE GLUCOSE FLUID TO CORRECT HYPOVOLEMIA, correct hypocalcemia 20ml/kg slow IVP calcium chloride 10%, give first dose ABT and consider vasopressors and hydrocortisone
4) monitor response:
a) if symptoms resolve-consider transfer to IC
b) if no change or worstening begin vasoactive therapy, iv/arterial access
- if BP nrmal give dopamine 2-20ug/kg/min
- if hypotensive/warm shock-give norepinephrine 0.1-1ug/kg/min
- if hypotensive/cold shock-give epinephrine 0.1-1ug/kg/min
You will want to evaluate SCVo2:
if it is > 70% with low BP/Warm shock -NS at 20ml/kg, norepinephrine with or without vasopressin
if SCVo2 is < 70 with normal PB but poor perfusion: PRBC to HGB>10g/dl, NS or LR at 20ml/kg optimize arterial O2, consider milrione 50-75ug/kg over 10-60minutes, consider nitroprusside 1-8 ug/kg/min, consider dobutamine 2-20ug/kg/min,
if SCVo2 <70 and="" blood="" cold="" hgb="" low="" perfusion="" poor="" prbc="" pressure="" shock:="" to="" until="" with="">10g/dl, optimize SPO2, NS or LR at 20ml/kg, epinephrine 0.1-1ug/kg, or dobutamine and norepinpeprhine
Consider hydrocortisone approx 2mg/kg max 100mg if adrenal insufficiency is suspected (due to all the stimulants we've been giving)
