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From PALS guideline 2005, 2006, 2009 AHA :
Emergency Medicine Conference : Future of Pre-hospital and Emergency Care
Illustrated by Chodchanok Vijarnsorn MD.
Division of Pediatric Cardiology, Department of Pediatrics,
Faculty of Medicine, Siriraj Hospital
21/6/2010
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Agenda
Two parts
Call fast
Look-listen-feel and airway maintain and check pulse
Chest compression (new guideline)
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Etiologies:
Out of hospital cardiac arrest : Respiratory failure & Shock By standBasic life support alone
In hospital cardiac arrest Multiple etiologies Poor outcomeEffective CPR better survival *
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Many etiologies
Cardiopulmonary failure
Cardiopulmonary arrest
Death Cardiopulmonary recovery
Impaired Unimpaired
neurologic neurologic
recovery recovery
Respiratory failure Shock
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Pre – cardiopulmonary failure
Respiratory distress shock
4 steps : Assessment
1. General assessment
2. Primary assessment
3. Secondary assessment
4. Tertiary assessment
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General assessment
Pediatric assessment triangle (PAT)
Appearance- restless?,
-not interactive?
-muscle tone-Cry/speech
Breathing-increase effort?
-noise on respiration
-nasalflaring-retraction
Circulation-pale? mottling?-bleeding
First few seconds
Life threatening?
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First few seconds
Life threatening?
General assessment
Respiratory distress
Respiratory failure
Shock
Compensated/
decompensated
ACTION
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Primary assessment
Primary assessment : ABCDE
- A : airway
- B : breathing
- C : circulation
- D : disability
- E : exposure
( PE, look listen feel, include V/S & oxygen saturation)
ACTION
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A : Airway
Chest movement
Breath sound
Feel : air passes through nose and mouth
Upper airway : clear/ maintainable, not maintainable
Increase respiratory effort, inspiratory force/absent?
Snoring, stridor?
Retraction?
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Breathing
RR
Respiratory effort
Tidal volume
Airway and lung sound
Pulse oximetry
94% = adequate oxygenation
< 94% airway intervention
< 90% in 100% oxygen ( non rebreathing mask advanced intervention : assisted ventilation
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Circulatory
Cardiovascular function
- skin color : mottling
- HR
- BP
-Pulse
(peripheral/central)
- capillary refill
End organ
- brain perfusion
- skin perfusion
- renal perfusion ( urine output)
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Definition of hypotension
Term (0-28 day)…………… < 60 mmHg
Infant (1-12 mo)………….. < 70 mmHg
Children 1-10 y-o (5th P). < 70 + 2 (age yr)
Children > 10 y-o…………..< 90 mmHg
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Capillary refill
Normal < 2 seconds
Prolonged capillary refill > 2 sec
In case : shock, hypothermia, severe dehydration
Warm shock : capillary refill < 2 sec due to peripheral vasodilatation
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Pulse check : central pulse
Use femoral / brachial pulse : < 1 year-old
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Disability
AVPU pediatric response scale
Glasglow coma scales
Pupillary response to light
AVPU
Alert
Voice
PainfulUnresponsiveness
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Exposure
Trauma
Burn
Child abuse
Skin lesion
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Action
General management for all patients
Airway position
Oxygen
Pulse oxymetry
EKG monitor as indicated
BLS as indicated
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Secondary assessment
3. Secondary assessment
- SAMPLE
- S : Signs and symptoms
- A : Allergies
- M : medication
- P : past medical history
- L : last meal
- E : events leading to presentation
ACTION
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Tertiary assessment
Laboratory : ABG, VBG, Hb, SVO2 sat, HCO3, lactate,
Radiography : CXR, echocardiography
Exhale CO2, PEFR, CVP
Emphasize : Anytime you identify a life threatening condition, initiate appropriate
care immediately
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Assess
Categorize
Decide
Action
If you recognize a life threatening condition at any time,
immediately begin life saving intervention and activate the emergency response system
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Summary
PALS guideline AHA 2008
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Signs of life threatening condition
Airway Complete or severe AO
Breathing Apnea, significant work of breathing
Circulation Absent pulse, poor perfusion, hypotension, bradycardia
Disability Unresponsiveness, depress conscious
Exposure Significant hypothermia, bleeding, purpura, abdominal distension due to bleeding
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Life saving intervention
ABC/CPR 100% oxygen Assisted ventilation :
bag mask, ETT Cardiac and
respiratory monitoring : EKG, pulse oximetry
Intravenous / I/O Bolus isotonic
crystalloid Lab study : DTX, ABGDrugs Electrical therapy
ACTION
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New recommendation : Bag & mask
ventilation :
E-C clamp
Give 2 breath chest move?
(12-20 breath/min for child)
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PALS and neonatal update
Good PALS begin with good BLS
Lay person (1 choice) : 30:2 (8 yr)
HCP : 1 rescue : 30:2
HCP : 2 rescue : 15:2 (teenage)
Child chest compression > 1 or 2 hands
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Chest compression
Nipple line for child
Below nipple line in infant
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Coronary Perfusion Pressure Improves With Sequential Compressions
CPP at 5:1 ratio
CPP at 15:2 ratioSurvival with 15:2
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“Continue CPR as much as possible except rhythm check”
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Key change in BLS
Effective rescue breath and visualization of chest rising
Fully recoil chest
Single shock for VF (2 J/kg mono-bi phasic continue CPR, rhythm check only at 2 min)
AED 1-8 years old
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Categorize
Determine the type and severity
Type Severity
Respiratory - Upper airway obstruction
- Lower airway obstruction
- lung parenchymal disease
- Disorder control of breathing
-Respiratory distress
-Respiratory failure
Circulatory - Hypovolemic shock
- Obstructive shock
- Distributive shock
- Cardiogenic shock
-Compensated shock
-Hypotensive shock
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Recognition of respiratory distress and failure
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Prehospital Tracheal Intubation vs Bag-Mask Ventilation
Bag-mask
ventilation : as effective as intubation if transport time is short
Need training and experience
Must confirmation of
tube position
Monitoring
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Use of Cuffed Endotracheal Tubes
In-hospital setting, a cuffed ETT : as safe as an uncuffed tube for infants (except the newborn) and children
Keep cuff inflation pressure <20 cm H2O
Cuffed ETT size (mm) = (age (yr) /4) + 3Uncuff size (mm): (age (yr) /4) + 4
Depth : age (yr)/2 + 12
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Insertion of the Laryngeal Mask Airway in Children
The LMA consists of a tube with a cuffed mask at the distal end.
The LMA is blindly introduced into the pharynx until resistance is met; the cuff is then inflated and ventilation assessed.
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Verification of Endotracheal Tube Placement
bilateral chest movement and listen for equal breath sounds over both lung fields
gastric insufflation sounds
exhaled CO2
pulse oximeter
direct laryngoscopy
chest x-ray
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Colorimetric Exhaled CO2 Detector
Colorimetric exhaled CO2
detector device changes color (from purple to yellow)
with detection of exhaled CO2
“additional” confirmation with clinical assessment
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Recognition of shock in pediatric patient
PALS update 2008-2009
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Myocardial contractility
preload
afterload
Stroke volume
Heart rate
Cardiac output
Tissue perfusion
Blood pressure
ปัจจัยที่มีผลต่อ tissue perfusion
CaO2, Hb
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Etiology of shock
1.hypovolemic shock
- severe dehydration, blood loss, burn, sepsis
2.Cardiogenic shock
-congenital heart disease, acquire heart disease, myocarditis, arrhythmia
3.Distributive shock
-anaphylaxis, sepsis, spinal shock
4. Obstructive shock
- cardiac tamponade, tension pneumothorax
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Recognition of shock flow chart
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Intraosseous canulation
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PALS shock algorithm
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PALS shock algorithm
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Medications : Maintain CO postresuscitation Stabilization
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Potentially Reversible Causes of Arrest: 6 H’s
Hypovolemia
Hypoxemia
Hydrogen ion (acidosis)
Hypo-/hyperkalemia
hypoglycemia
Hypothermia
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Potentially Reversible Causes of Arrest: 5 T’s
Toxins
Tamponade, cardiac
Tension pneumothorax
Thrombosis (coronary or
pulmonary)
Trauma (hypovolemia)
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PALS Tachycardia Algorithm
PALS guideline Tachycardia algorithm
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PALS Bradycardia Algorithm
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Trend of PALS 2010
Pediatric assessment ( PAT )novel approach for the rapid evaluation
Pediatric Emergency Care - Vol 26 Number 4, April 2010
Cardiocerebral resuscitation
Hypothermia
Practice skills learned in formal curricula
Pediatrics 2009; 124; 610-619
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