An Overview

Objectives:To present the course objective of PALSTo briefly review BLSTo give an overview of Rhythm DisturbancesTo review types of vascular accessTo know team dynamics in resuscitationTo present the pediatric assessment overview

Pediatric Advanced Life Support2006 American Heart AssociationDesigned for healthcare providers who

initiate and direct advanced life support beyond BLS through the stabilization or transport phases of a pediatric emergency, either in or out of hospital.

Enhance skills in the evaluation & management of an infant or child with respiratory compromise, circulatory compromise, or cardiac arrest.

PALSActive participation in simulated core cases,

designed to reinforce important concepts, including:Identification & treatment medical conditions that

place a child at risk for cardiac arrestThe systematic approach to pediatric assessmentThe assess-categorize-decide-act approach to

assessment and management of a seriously ill infant or child

PALS algorithms & flow chartsEffective resuscitation team dynamics

The goal of the PALS Provider Course is to improve the quality of care provided to seriously ill or injured children, resulting in improved outcome.

Rhythm DisturbancesI. Parts of the defibrillator

1. Power button2. Energy selector3. Paddles4. Charge button (machine & paddles)5. Shock button (machine & paddles)6. Sync

Rhythm DisturbancesII. Identifying rhythm

Non-shockable

Asystole

PEA

Rhythm DisturbancesII. Identifying rhythm

Shockable Rhythm(1) Defibrillate: 2 to 4 J/kg

Ventricular Tachycardia

Ventricular Fibrillation

Rhythm DisturbancesII. Identifying Rhythm

Shockable Rhythm(2) Synchronized Cardioversion: 0.5 to 1 J/kg

Supraventricular Tachycardia

Rhythm DisturbancesIII. Steps:

1. Identify rhythm2. Select energy3. Clear

(1) I’m clear(2) You’re clear(3) Everybody clear(4) Oxygen away(5) Verify rhythm

4. Deliver shock

Vascular AccessIntravenous routeIntraosseous route

Use IO needle w/ stylet or rigid needleSites: anterior tibia, distal femur, medial malleolus, ASISFor drugs and fluidsCan be established in all age groupsCan be achieved in 30 to 60 secondsPreferred over the ET route for medicationsAny drug that can be administered IV can be given

through IOContraindications:

Fracture in extremity Previous insertion attempt in extremity that entered the

marrow space Infection overlying bone Osteogenesis imperfecta

Team DynamicsElements:

1. Closed-loop communication2. Clear messages3. Clear roles and responsibilities4. Knowing one’s limitations5. Knowledge sharing6. Constructive intervention7. Reevaluation and summarizing8. Mutual respect

Team DynamicsRole Responsibilities

Team Leader Directs the resuscitationMonitors performance of tasksModels excellent team behavior

Airway Checks O2 setupAdminister oxygenInserts OPA or NPAPerforms BMVInserts NG / OG tubePrepares / performs ET intubation

IV / IO Gains IV / IO accessPrepares drugs & fluidsAdministers drugs & fluids

Compressor Performs chest compressionIf chest compressions are not needed during a case, team member may obtain equipment, fluids and drugs or assist the observer

Monitor / defibrillator Establishes ECG monitoring, checks pulse, operates monitor/defibrillator

Observer / recorder Monitors performance of the team

Pediatric AssessmentObjectives:

To be familiar with the systematic assessment of a seriously ill or injured child;

To review the recognition of the signs of respiratory distress, respiratory failure, and shock & to know when to refer in these instances.

Pediatric AssessmentGeneral AssessmentPrimary AssessmentSecondary AssessmentTertiary Assessment

General AssessmentPrimary AssessmentSecondary AssessmentTertiary Assessment

Pediatric Assessment

General AssessmentPediatric Assessment Triangle (PAT)

Appearance

Work of Breathing

Circulation

General AssessmentAppearance

Muscle toneInteractionConsolabilityLook / gazeSpeech / cry

General AssessmentWork of Breathing

Increased work of breathing nasal flaring retractions

Decreased or absent respiratory effortAbnormal sounds

wheezing grunting stridor

General AssessmentCirculation

Abnormal skin color pallor mottling

Bleeding

Pediatric AssessmentGeneral AssessmentPrimary AssessmentSecondary AssessmentTertiary Assessment

Primary Assessment

Airway Breathing

Exposure Circulation

Disability

Primary AssessmentAirway

Look for movement of the chest or abdomenListen for breath sounds and air movementFeel for the movement of air at the nose and

mouth

Primary AssessmentBreathing

Respiratory raterespiratory effortTidal volumeAirway and lung soundsPulse oximetry

Primary AssessmentCirculation

Assess cardiovascular function by: Skin color and temperature Heart rate Heart rhythm Blood pressure Pulses (peripheral and central) Capillary refill time

Primary AssessmentCirculation

Assess end-organ function by: Brain perfusion (mental status) Skin perfusion Renal perfusion (urine output)

Primary AssessmentDisability

AVPU Pediatric Response ScaleGlasgow Coma Scale (GCS)Pupillary response to light

Primary AssessmentExposure

RashTemperatureEvidence of trauma

Pediatric AssessmentGeneral AssessmentPrimary AssessmentSecondary AssessmentTertiary Assessment

Secondary AssessmentSigns &

Symptoms

Allergy

Medications

Past Medical History

Last Food/Fluid intake

Events

Secondary AssessmentSigns & Symptoms

Breathing difficultyFeverDiarrhea, vomitingBleedingFatigueTime course of symptoms

Secondary AssessmentAllergy

MedicationsFoodLatex

Secondary AssessmentMedications

Last dose and time

Secondary AssessmentPast Medical History

Birth historyUnderlying problemsPast surgeriesImmunization status

Secondary AssessmentLast Meal

Time and nature of food / drinks

Secondary AssessmentEvents

Leading to current illnessTreatment during interval from onset

Pediatric AssessmentGeneral AssessmentPrimary AssessmentSecondary AssessmentTertiary Assessment

Tertiary AssessmentRespiratory abnormalities

ABG / VBG Pulse Oximetry, CXR, PEFR

Circulatory abnormalities ABG / VBG Serum lactate CVP Monitoring CXR Echocardiography