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
Slide 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.
Slide 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
Slide 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 1220 breaths/minute (one breath every three to
five seconds) using the higher rate for younger children If the
pulse is
*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 child s chest
without touching, leaving about 3 cm between electrodes. Adult size
(810 cm) electrodes should be used for children >10 kg
(approximately one year). Infant size should be used for
infants
Slide 10
Slide 11
Broselow Tape
Slide 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.
Slide 13
*NEW 2011 CPR UPDATE CHANGES: PALS Upon ROSC, titrate inspired
oxygen (when oximetry is available) to maintain an arterial
oxyhemoglobin saturation >94% but Narrow complex (QRS 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.
Slide 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,
defib ASAP, CPR, Epi, after third shock Amiodarone
Slide 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 34C) may be
beneficial for adolescents who remain comatose after resuscitation
from sudden, witnessed, out-of-hospital VF cardiac arrest.
Therapeutic hypothermia (to 32 34C) 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.
Slide 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)
Slide 17
Slide 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
Slide 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 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
Slide 20
Overview of PALS CPR AED Paddle size: Use the largest
electrodes that will fit on the child s chest without touching,
leaving about 3 cm between electrodes. Adult size (810 cm)
electrodes should be used for children >10 kg (approximately one
year). Infant size should be used for infants
Tachycardia with 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.
Slide 51
Tachycardia with Pulse and Adequate Perfusion On EKG if QRS is
wide (greater than 0.12 seconds) Possible Ventricular tachycardia
Consider expert consultation Search and treat possible causes
Consider pharmacologic cardioversion with: Amiodarone 5 mg/kg IV
over 20-60 minutes or Procainamide 15 mg/kg over 30-60 minutes
(both will slow ventricular conduction and improve contractility,
thus increasing cardiac output) Do not administer Amiodarone and
Procainamide together May attempt Adenosine if not already
administered Consider electrical cardioversion for unstable
patients or if medications fail Cardiovert with 0.5 to 1 J/kg (may
increase to 2 J/kg if initial dose is ineffective) Sedate prior to
cardioversion Obtain 12 lead EKG
Slide 52
Slide 53
Pediatric Tachycardia with Pulses with Poor Perfusion Same as
previous slide; except DO NOT DELAY CARDIOVERSION FOR IV access and
consider possible causes Hs and Ts
Slide 54
Cardioversion verse Defribillation Cardioversion: 0.5 to 1 J/kg
with sync mode on (may increase to 2 J/kg if 1 st shock
unsuccessful) use sedation with analgesia when possible For
unstable SVT, VT, A-Fib, A-Flutter not controlled by Adenosine or
Vagal Manuvers. Cardiovert if vascular access is not established
(Do not delay cardioversion to establish IV/IO) Defibrillation: 2-4
J/kg, increase Joules, unsynchronized, for VT/VF, perform immediate
CPR after shock, assess rhythm every 2 minutes; epinephrine should
be given in conjunction every 3-5 minutes, 0.01 mg/kg
Slide 55
Split up into two groups Group 1: Review pulseless arrest
algorithm and drug management, review VF/VT algorithm, Review
Bradycardia and tachycardia algorithm Group 2: Review
defibrillation, cardioversion and T.C.P on defibrillator
Slide 56
Medications and administration Preferred route IV/IO because
ETT route is unreliable in dosing and absorption Prolonged use of
Epinephrine with increasing does no longer done Watch IO insertion
video
Slide 57
Medications Adenosine 0.1 mg/kg (up to 6 mg) 0.2 mg/kg for
second dose Rapid IV push, max single dose 12 mg. For SVT (after
vagal manuevars) Amiodarone 5 mg/kg rapid IV/IO Max 15 mg/kg/day
for refractory pulseless VT/VF
Slide 58
Medications Atropine Sulfate 0.02 mg/kg IV/IO/TT Min dose 0.1
mg, max single dose 0.5 mg, 1 mg adolescent, may double second
dose. For bradycardia after epinephrine Epinephrine 0.01 mg/kg
(1:10,000) IV/IO 0.1 mg/kg (1:1000) ETT Repeat every 3-5 minutes
during CPR Consider a higher dose (0.1mg/kg) for special
conditions, given for VT/VF, aystole, PEA, bradycardia
Slide 59
Medications Glucose 0.5-1 g/kg IV/IO max dose 2-4 mL/kg of 25%
soln 5%= 10-20 mL/kg, 10%= 5-10 mLkg, 25%= 2-4 ml/kg in large vein
Dobutamine 2-20 ug/kg/min Titrate to desired effect Dopamine 2-20
ug/kg/min Presser effects at higher doses>15 ug/kg/min
Slide 60
Medications Lidocain 1 mg/kg IV/IO/TT (with TT dilute with NS
to a volume of 3-5 ml and follow with positive pressure
ventilations. Given as a alternative to Amiodarone Magnesium
Sulfate 25-50 mg/kg IV/IO over 10-20 min Max dose 2 g, given for
Torsades De Pointes Naloxone If 5 yr old or 20 kg, 2 mg Titrate to
desired effect, for barbituate overdose Sodium Bicarb 1 mEq/kg per
dose Infuse slowly and only if ventilation is adequate
Slide 61
Management of Shock 1.Give Oxygen 2.Monitor Pulse Ox 3.ECG
monitor 4.Blood Pressure 5.IV/IO access 6.BLS as indicated
7.Bedside Glucose
Slide 62
Management of Shock Shock results from inadequate blood flow
and oxygen delivery to meet tissue metabolic demands. Shock
progresses over a continuum of severity, from a compensated to a
decompensated state. Attempts to compensate include tachycardia and
increased systemic vascular resistance (vasoconstriction) in an
effort to maintain cardiac output and blood pressure. Although
decompensation can occur rapidly, it is usually preceded by a
period of inadequate end-organ perfusion. Signs of compensated
shock include: Tachycardia Cool extremities Prolonged capillary
refill (despite warm ambient temperature) Weak peripheral pulses
compared with central pulses Normal blood pressure. As compensatory
mechanisms fail, signs of inadequate end-organ perfusion develop.
In addition to the above, these signs include Depressed mental
status Decreased urine output Metabolic acidosis Tachypnea Weak
central pulses
Slide 63
Management of Shock Signs of decompensated shock include the
signs listed above plus hypotension. In the absence of blood
pressure measurement, decompensated shock is indicated by the
nondetectable distal pulses with weak central pulses in an infant
or child with other signs and symptoms consistent with inadequate
tissue oxygen delivery. The most common cause of shock is
hypovolemia, one form of which is hemorrhagic shock. Distributive
and cardiogenic shock are seen less often. Learn to integrate the
signs of shock because no single sign confirms the diagnosis. For
example: Capillary refill time alone is not a good indicator of
circulatory volume, but a capillary refill time of >2 seconds is
a useful indicator of moderate dehydration when combined with a
decreased urine output, absent tears, dry mucous membranes, and a
generally ill appearance. It is influenced by ambient temperature,
lighting, site, and age.
Slide 64
Management of Shock Tachycardia also results from other causes
(eg, pain, anxiety, fever). Pulses may be bounding in anaphylactic,
neurogenic, and septic shock. In compensated shock, blood pressure
remains normal; it is low in decompensated shock. Hypotension is a
systolic blood pressure less than the 5th percentile of normal for
age, namely:
