PALS Course Outline 2011 Olton/Plainview EMT-P Courses I. PALS Course Overview/Registration II. PALS Science Overview Video III. Child/Infant CPR/AED Review Video IV. Management of Respiratory Emergencies Video V. Review of Respiratory Emergencies Flow Charts Recognition of Respiratory Problems Flow Chart Management of Respiratory Emergencies Flow Chart VI. Review of Rhythm Disturbances/Electrical Therapy Procedures Handouts VII. Vascular Access Video VIII. Resuscitation Team Concept Video IX. Overview of Pediatric Assessment Video X. Review of Pediatric Assessment Algorithm XI. Review of Shock Handouts Recognition of Shock Flow Chart Management of Shock Flow Chart XII. Review of PALS Cardiac Arrest Priorities CPR Defibrillation IV Access/Medications Advanced Airway Management XIII. Review of Rhythm Treatment Priorities Rate Rhythm Blood Pressure XIV. Review of Cardiac Treatment Algorithms AHA Pulseless Arrest Algorithm SPEMS Algorithms a. VF/Pulseless V-Tach (Pediatric) b. Asystole/PEA (Pediatric) AHA Bradycardia Algorithm SPEMS Pediatric Bradycardia Algorithm AHA Tachycardia Algorithm SPEMS Algorithms a. SVTs b. V-Tach with a Pulse XV. Putting it all Together Core Case Studies a. Respiratory Cases 1, 2, 3, 4 b. Cardiac Cases 3, 4 c. Shock Cases 1, 2, 3, 4 Pediatric Megacodes (Class) XVI. Written Exam 25 Questions Minimum Passing Grade: 84% XVII. Retesting (As Needed) 1
Introduction Management of any seriously ill or injured patient requires assessment of heart rate and rhythm (cardiac monitoring).
Procedure Follow these steps to perform cardiac monitoring. Modify for your specific device.
Step Action 1 Power on monitor/defibrillator. 2 Attach ECG leads to patient:
• White lead-to right shoulder • Red lead-to left flank or abdomen • Ground (black, green, brown) lead-to left shoulder
Note: In units with cardiovascular patients, 5-lead monitoring may be used. For 5-lead monitoring the green lead is placed under the white, lower on the torso. The brown lead is placed in the middle of the chest.
Placement of electrodes for ECG monitorin . 3 Adjust device to manual ECG monitoring mode
(not AED mode or paddles) to display rhythm in standard limb leads I, II, III .
4 Visually check monitor screen and assess heart rate and rhythm.
Introduction Specific emergency interventions for tachyarrhythmias include
• vagal maneuvers • synchronized cardioversion
Vagal Maneuvers
Vagal In normal infants and children the heart rate falls with stimulation of the vagus Maneuvers nerve. In patients with supraventricular tachycardia (SVT), vagal stimulation may
terminate the tachycardia. Several maneuvers stimulate vagal activity. The success rates of these maneuvers in terminating tachyarrhythmias vary, depending on the child's age, level of cooperation, and underlyill9 condition.
If possible, obtain a 12-lead EGG before and after the maneuver; record and monitor the EGG continuously during the maneuver. If the patient is stable and the rhythm does not convert, you may repeat the attempt. If the second attempt fails, select another method or provide pharmacologic therapy. If the patient is unstable, attempt vagal maneuvers only while making preparations for pharmacologic or electrical cardioversion. Do not delay definitive treatment with vagal maneuvers.
Maneuver Description Application of ice to the face
This is the most effective vagal maneuver in infants and young children.
Method One method is to mix crushed ice with water in a plastic bag or glove (Figure 1). While recording the EGG, apply the ice water mixture to the infant's face for only 10 to 15 seconds. Do not obstruct ventilation (ie, cover only the forehead, the eyes, and the bridge of the nose). If this method is successful, SVT will terminate in seconds.
Figure 1. Ice water is applied to the infant's face for vagal stimulation in an attempt to terminate SVT. Note that the bag of ice water does not cover the nares or mouth and does not obstruct ventilation.
Val salva Other vagal maneuvers may be effective and appear to be safe, maneuver based on data obtained largely in older children, adolescents,
and adults. Older children can be taught to use these maneuvers on their own.
Method I nstruct the child to • blow through an obstructed straw • blow on his thumb as if it were a trumpet without letting any air
out while blowing , • bear down as if passing a bowel movement • hold his breath while ice is laced to the face
Do not use the following methods to induce vagal activity:
• Application of external ocular pressure • Carotid massage
Introduction Synchronized cardioversion is used for children with tachyarrhythmias (SVT, ventricular tachycardia [VT] with pulses, atrial flutter, atrial fibrillation) that are
• unstable (ie, associated with evidence of cardiovascular compromise, such as poor perfusion, hypotension, or heart failure)requiring immediate cardioversion by an appropriately skilled provider
• stable-permitting elective cardioversion at the direction of a pediatric cardiologist
During synchronized cardioversion electrical therapy is administered through adhesive electrode pads or handheld paddles. You will need to place the defibrillator/monitor in synchronized (sync) mode. The sync mode is designed to deliver energy just after the R wave of the QRS complex.
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Technique Follow these steps to perform synchronized cardioversion. Modify for your specific device.
Step Action 1 Consider sedation but do not delay cardioversion in an
unstable patient. 2 Power on the monitor/defibrillator (monophasic or
biphasic). i
3 Attach monitor leads to the child ("white to right, red to ribs, what's left over to the left shoulder") and ensure proper display of the child's rhythm.
4 Interpret the heart rhythm. Confirm indication for synchronized cardioversion.
5 Press the SYNC control button to engage synchronization mode.
6 Look for markers on the R wave indicating sync mode. Adjust monitor gain if necessary until sync markers occur with each R wave.
7 Select the appropriate energy level. The initial energy dose for synchronized cardioversion is 0.5 to 1 J/kg. If tachyarrhythmia persists after the first attempt, double the dose to 1 to 2 J/kg.
8 Select the largest paddles or pads that will fit on the chest wall without touching. Prepare paddles and (
conducting surface for placement. Place paddles/pads correctly. (See steps 2, 3, and 4 in the Procedure for Manual Defibrillation on the student CD.)
9 Announce to team members: "Charging cardioverterstand clear!"
10 Press the CHARGE button. 11
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When the cardioverter is fully charged, clear the patient. To ensure the safety of cardioversion, always announce when you are about to deliver a shock (eg, "I am going to shock on three. One, I'm clear. Two, you're clear, oxygen's clear. Three, everybody's clear." Direct oxygen flow away from the patient's chest and consider temporarily disconnecting the bag or the ventilation circuit from the endotracheal tube during shock delivery.
12 Press the DISCHARGE buttons simultaneously on the paddles or the SHOCK button on the cardioverter.
13 Check the monitor to evaluate the rhythm. If the tachyarrhythmia persists, increase the energy level Goules) according to the appropriate algorithm.
14 Activate the sync mode after delivery of each synchronized shock if the patient remains in a tachycardic rhythm. Most defibrillators default back to the unsynchronized mode after delivery of a synchronized shock. This default allows an immediate shock if cardioversion produces VF.
Introduction Defibrillation shocks are indicated for ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). To treat VF/pulseless VT effectively, you need to know how to operate a manual defibrillator and perform manual defibrillation.
Procedure Follow these steps to operate a manual monitor/defibrillator (either biphasic or monophasic) and attempt manual defibrillation. Modify for your specific device.
Step Action 1 Power on monitor/defibrillator. 2 Select the proper pads or paddles. Attach adhesive
electrode pads. Select largest paddles or pads that will fit on the chest wall without touching.
Weight/Age Paddle/Pad Size 10 kg
( approximately 1 year old)
• Large adult paddles (8 to 13 cm) • Adult pads
<10 kg «1 year old)
• Small infant paddles (4.5 cm) • Pediatric pads
3 Prepare paddles/pads for rhythm identification and shock delivery . • If using paddles, apply electrode cream or paste to them.
Placing paddles directly on the child's bare skin decreases the delivered current. Note: Do not use saline-soaked gauze pads or sonographic gels. Do not use alcohol pads because they may pose a fire hazard and produce chest burns.
• If using adhesive electrode pads, peel the backing away . 4 Position paddles or pads so that the heart is between
them. Place one paddle or pad on the upper right side of the chest below the clavicle, along the patient's right upper sternal border. Place the other paddle/pad lateral to the left nipple in the anterior axillary line (positioned under and to the left of the nipple and between the nipple and the axilla). Make sure paddles do not touch. Do not overlap pads.
An alternative method is to place the paddles/pads in an anterior-posterior position with one just to the left of the sternum and the other over the back. Anterior-posterior placement may be necessary if the child is an infant and only large paddles or pads are available. In dextrocardia, position pads in a mirror image of the standard placement. Adjust device to manual mode (not AED mode). If necessary, adjust LEAD button to display rhythm in • standard limb leads I, II, or III (if EGG leads are used) • paddles (if paddles are used instead of pads) Interpret heart rhythm. Confirm indication for defibrillation. Adjust ENERGY button to select appropriate energy dose. An initial dose of 2 J/kg (biphasic or monophasic waveform) is recommended. If this dose does not terminate VF or pulseless VT, deliver subsequent doses of 4 J/kg. Apply firm pressure to paddles to create good contact between the paddle and the skin. Ensure good contact between the skin and the adhesive electrode pad. If a large amount of hair on the chest prevents good skin-electrode contact, quickly shave the area and reapply the paddle/pad.
Modifications may be required in special situations.
Special Situation Modification Standing water Remove the victim 'from the
water and quickly wipe the chest.
Implanted defibrillator or Do not place an electrode pacemaker pad directly over the
implanted device because the device may reduce delivery of current to the heart. Place the pad at
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least 1 inch (2.5 cm) to the side of the implanted device.
Transdermal medication Do not place an electrode patch pad directly over a
medication patch. If the patch is in the way, remove it and wipe the child's skin before attaching the pad.
Press the CHARGE button to charge the defibrillator. The CHARGE button is located either on the defibrillator or
on one or both paddles. If the device requires more that 10 seconds to charge, rescuers may resume chest compression until the device is charged and ready for shock delivery.
11 "Clear" the patient when the defibrillator is fully charged. To ensure the safety of defibrillation, always announce when you are about to deliver a shock. State a "warning" firmly and in a forceful voice before delivering each shock (this entire sequence should take less than 5 seconds). You may use a warning like this:
• "I am going to shock on three. One, I'm clear." Check to make sure you are clear of contact with the patient, the stretcher, or other equipment.
• "Two, you're clear." Make a visual check to ensure that no one is touching the patient or stretcher. In particular, check the person providing ventilations. That person's hands should not be touching the ventilatory adjuncts, including an advanced airway. Be sure oxygen is not flowing across the patient's chest. Direct flow away from the patient's chest and consider temporarily disconnecting the bag or the ventilation circuit from the endotracheal tube during shock delivery.
• "Three, everybody is clear." Check yourself one more time before pressing the SHOCK button(s).
You need not use these exact words, but you must warn others that you are about to deliver shocks and that everyone must stand clear.
12 Press SHOCK button(s) to deliver current. Press either • a Single SHOCK button located on the defibrillator • both SHOCK buttons on paddles simultaneously
13 Immediately resume CPR starting with chest compressions for about 2 minutes.
** Ideally chest compressions should be interrupted only for rhythm checks and actualdefibrillations. The 2005 guidelines state that when CPR is indicated the provider shouldperform 5 cycles (2 Minutes) of chest compressions. Continue CPR while drugs areprepared/administered and the defibrillator is charging. Providers must organize care toensure that chest compressions, initial and subsequent defibrillations are not delayed inorder to administer drugs, place advanced airways or obtain vascular access.
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1. Resume CPR2. Amiodarone, 5mg/kg to a max of 300mg. May repeat once in 3-5
minutes at 2.5mg/kg to a max of 150mg.****3. Defibrillate @ 4 Joules/kg, to a max of 360 Joules or Biphasic Equivalent4. Resume CPR
NO
Rhythm Change? YES
1. Resume CPR2. IV, NS, TKO***3. Intubate Patient4. Epinephrine: Repeat Every 3 to 5 Minutes
•IV/IO: 0.01mg/kg to a max of 1mgper single dose(1:10,000, 0.1mL/kg)
•ET: 0.1mg/kg (1:1,000, 0.1mL/kg) toa max of 1mg per single dose.
5. Defibrillate @ 4 Joules/kg, to a max of 360 Joulesor Biphasic Equivalent
6. Resume CPR
NO
Rhythm Change? YES
*Patients > 1 YOAIn all witnessed or known short duration
(<4-5 minutes) cardiac arrest wheredefibrillation is indicated immediatedefibrillation should be performed.
In all other arrest situations wheredefibrillation is indicated the provider
should perform 5 cycles (2 minutes) ofCPR prior to defibrillation.
***A Fluid Challange of 20cc/kgShould be Administered Over 10
Minutes in All Cardiac ArrestSituations. May Repeat Once.
Rhythm Change?NOContinue to Treat,
Monitor & TransportYES
Refer to AppropriateAlgorithm
Check Pulse
EMT-Paramedic
1. ABCs2. CPR (2005 Guidelines)**3. Ventilate with Oxygen (Insert OPA/NPA)4. Use ResQPOD if the patient has reached puberty5. Attach Defibrillator6. Defibrillate @ 2 Joules/kg or Biphasic Equivalent7. Resume CPR
***• If IV or IO access unavailable administer Lidocaine 2mg/kg, ET.• If V-Tach not suppressed repeat Lidocaine 2mg/kg, ET, every
3-5 minutes to a max of 6mg/kg, ET• Once an antiarrhythmic is administered DO NOT administer a
different antiarrhythmic.• If IV or IO access is obtained after ET Lidocaine was administered,
administer Lidocaine 1mg/kg, IV, may repeat every 3-5 minutesto a max of 3mg/kg, IV (Should not administer more than 3 totaldoses whether IV/IO or ET)
• The Administration of Lidocaine during IO placement for paincontrol ONLY does not contraindicate the administration ofAmiodarone if indicated
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EMT-Paramedic
Refer to AppropriateAlgorithm
Rhythm Change or Pulse Present? YES
NO
1. Resume CPR2. Epinephrine: Repeat Every 3 to 5 Minutes
•IV/IO: 0.01mg/kg up to a max of 1mgper single dose. (1:10,000, 0.1mL/kg)
or•ET: 0.1mg/kg up to a max of 1mg
per single dose. (1:1,000, 0.1mL/kg)
Rhythm Change or Pulse Present?
NO
Resume CPR
Treat Possible ContributingFactors****
Continue to Treat,Monitor & Transport
YES
***IV Fluids Should be Infusedat a Rate to Obtain a FluidBolus of 20cc/kg Over 10
Minutes. May Repeat Onceif Needed.
Page 8
ASYSTOLE or PULSELESSELECTRICAL ACTIVITY -
PEDIATRIC
****Consider Whether One of the Followingmay be Involved and Treat Appropriately:•Hypovolemia (Infuse Volume)
* Ideally chest compressions should be interrupted only for rhythm check. The 2005 guidelines statethat when CPR is indicated the provider should perform 5 cycles (2 minutes) of chest compressions.Continue CPR while drugs are prepared/administered. Providers must organize care to minimizeinterruption in chest compressions for rhythm checks, advance airway insertion, or vascular access.
**Asystole should be confirmed in 2 leads. Ifrhythm is unclear and possibly Ventricular
Fibrillation, go to Ventricular Fibrillation Algorithm.
1. ABCs2. CPR (2005 Guidelines)*3. Ventilate with Oxygen (Insert OPA/NPA)4. Use ResQPOD if the patient has reached puberty5. Attach Defibrillator**6. IV, NS***7. Intubate Patient8. Resume CPR
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Pulse >60 (>80 in Infant), orSigns/Symptoms Resolve?
BRADYARRHYTHMIA -PEDIATRIC
Pulse >60 (>80 in Infant), orSigns/Symptoms Resolve?
NO
YES
YES
NO
YES
NO
Patient has any of the Following:•Signs/Symptoms of Hypoperfusion?•Hypotension?•Respiratory Difficulty?
EMT-Paramedic
Continue to Treat,Monitor & Transport
Page 10
1. ABCs2. Oxygen3. Assist Ventilations if Respirations Inadequate
(Insert OPA/NPA if needed)4. Intubate Patient if Unable to Maintain Airway5. IV, NS, TKO (Use IO Access if Necessary)6. Assess Vital Signs & Perfusion
Perform Chest Compressions if, DespiteOxygenation & Ventilation, Heart Rate:•<80/min in an Infant (<1 year old)•<60/min in a Child (1-12 years old)
Epinephrine:•IV/IO: 0.01mg/kg (1:10,000, 0.1mL/kg) to a max of 5cc per
single dose.or
•ET: 0.1mg/kg (1:1,000, 0.1mL/kg) to a max of 0.5cc persingle dose.
•Repeat Every 3-5 Minutes at Same Dose
Atropine, 0.02mg/kg, IV•Minimum Dose 0.1mg•Maximum Single Dose 0.5mg•May Repeat every 3-5 Minutes(In children 0-8 years of age to a max of 1mg)(In Adolescence 9-15 years of age to a max of 2mg)
** The Administration of Lidocaine during IO placementfor pain control ONLY does not contraindicatethe administration of Amiodarone if indicated
PEDIATRIC SVTRATES
In Infants Heart rate > 220In Children Heart Rate > 180
PEDIATRIC DOSES• Sync. Cardiovert @ 1Joule/kg to a max of 100 J
Sync. Cardiovert @ 2Joules/kg to a max of 360 J*•Adenosine, 0.1mg/kg to a max of 12mg•Versed, 0.1mg/kg, IV, to a max of 2.5mg•Amiodarone 5mg/kg, IV, over 20 minutes, to a maxsingle dose of 150mg. May be repeated X 2(Do not mix into 100cc of D5W)
**Amiodarone, 150mg IV Over 10 minutes.May Repeat Once if Needed.(may mix into 100cc of D5W)
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EMT-Paramedic
1. Oxygen2. IV, NS, TKO
VENTRICULAR TACHYCARDIAWITH A PULSE
NOYES
NO
Ventricular Tachycardia Suppressed? YES
YES
NO
NO
Patient Experiencing Any of the Following:•Systolic BP <90mmHG?•Chest Pain?•Dyspnea?•Signs/Symptoms of CHF?•Other Signs/Symptoms of Hypoperfusion?
YESContinued on
Following Page C
Continue to Treat,Monitor & Transport
Continue to Treat,Monitor & Transport *
Page 19
* If at any time the patientstarts to experience anyof the signs and symptomsnoted above, go directlyto Cardioversion.( Pg 20)
Refer to AppropriateAlgorithm
Does Patient Have anySigns and Symptoms
Listed Above?
Amiodarone 150mg, IV, over 10 minutes.If patient remains without above signs andsymptoms. Amiodarone may be repeatedevery 10 minutes as needed to a maxof 450mg. (May mix into 100cc of D5W)
PEDIATRIC DOSE•Amiodarone 5mg/kg, IV, over 20 minutes,to a max single dose of 150mg. May berepeated X 2 (Do not mix into 100cc of D5W)
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Class I or II Cardiac Rhythm (P-11)with stable vital signs?
**Repeated CardioversionsAre Done Only if There is
NO Rhythm Change.
Intubate Patient If Needed***
Continue to Treat,Monitor & Transport
NO
Continue to Treat,Monitor & Transport
Page 20
If systolic BP >90mmHg consider Versed,5 mg, IV (2.5 mg if >60 years old)
Refer to Post ResuscitationManagement (pg-13)
1. Amiodarone 150mg, IV, over 10 minutes.Amiodarone may be repeated every
10 minutes as needed to max of 450mg.(May mix into 100cc of D5W)
2. Synchronized Cardiovert @ 360 Joules,**or Energy Setting Previously Successful,Following Each Dose of Amiodarone.
PEDIATRIC CARDIOVERSIONInfant- 1J/kg up to a max of 100JChild- 2J/kg up to a max of 360J
***• If IV or IO access unavailable administer Lidocaine 2mg/kg, ET.• If V-Tach not suppressed repeat Lidocaine 2mg/kg, ET, every
3-5 minutes to a max of 6mg/kg, ET• Once an antiarrhythmic is administered DO NOT administer a
different antiarrhythmic.• If IV or IO access is obtained after ET Lidocaine was administered,
administer Lidocaine 1mg/kg, IV, may repeat every 3-5 minutesto a max of 3mg/kg, IV (Should not administer more than 3 totaldoses whether IV/IO or ET)
• The Administration of Lidocaine during IO placement for paincontrol ONLY does not contraindicate the administration ofAmiodarone if indicated
PEDIATRIC DOSE• Amiodarone 5mg/kg, IV, over 20 minutes,
to a max single dose of 150mg. May berepeated X 2 (Do not mix into 100cc of D5W)
• Versed, 0.1mg/kg, IV, to a max of 2.5mg• Lidocaine 2mg/kg, ET, every 3-5 minutes,
to max of 6mg/kg.• If IV or IO access is obtained after ET Lidocaine
was administered, administer Lidocaine 1mg/kg, IV,may repeat every 3-5 minutes to a max of 3mg/kg, IV(Should not administer more than 3 total doseswhether IV/IO or ET)
• Once an antiarrhythmic is administeredDO NOT administer a different antiarrhythmic.
02/01/2011
Class I or II Cardiac Rhythm (P-11)with stable vital signs?
Class I or II Cardiac Rhythm (P-11)with stable vital signs?
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