Pals 2017 part 1
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The document outlines the 2017 Pediatric Advanced Life Support (PALS) guidelines emphasizing the initial and secondary assessments of pediatric patients in life-threatening situations. It details the continuous evaluation and intervention process, focusing on respiratory and circulatory issues, and highlights the importance of advanced techniques such as intubation and emergency medications. The assessment concludes with an emphasis on ongoing monitoring and definitive management of identified conditions.
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Pals 2017 part 1
- 1. PEDIATRIC ADVANCED LIFE SUPPORT 2017 GUIDELINES- PART 1 DR. SAYED ISMAIL,MD PROFESSOR AND CONSULTANT OF PEDIATRIC ALSALAMA HOSPITAL
- 2. Objectives • Pediatric advanced life support 2017 guidelines are presented in 4 parts presentations • To provide up to date management of life threatening conditions • To help the pediatricians and emergency physicians to pass the PALS examination
- 4. Pediatric Assessment Initial assessment Primary assessment Secondary assessment Diagnostic tests
- 5. Initial Assessment (1st look ) aim : to detect life threatening conditions
- 6. Based on initial assessment If the patient Unresponsive , Critical conditions identify intervene Evaluate Activate CPR SSS Connect to monitors SSS = safety , stimulate , shout
- 7. IF PATIENT UNRESPONSIVE NO BREATHING , NO PULSE START CAB GO TO CARDIAC ARREST ALGORITHM YES identify intervene Evaluate No breathing , pulse present OPEN AIRWAY , GIVE PPV IF PULSE LESS THAN 60YES NO SSS Safety ,stimulate , shout
- 8. identify intervene Evaluate •Evaluate by primary , secondary ass. and diagnostic test •Identify the problem either respiratory or circulatory •Then intervene according to problems Continuous process
- 9. Evaluate by Primary assessment Secondary assessment Diagnostic tests identify intervene Evaluate
- 10. Identify TYPE SEVERITY 1-Respiratory Upper airway obstruction Lower airway obstruction lung tissues Disordered control of breathing Respiratory distress Respiratory failure 2-Circulatory = Shock Hypovolemic shock Distributive Cardiogenic Obstrutctive Compensated Hypotensive 3-Cardiopulmonary failure e.g. SVT , VT, 4- Cardiac arrest (asystole , pulseless VT, VF) All exam cases
- 11. Intervene • Open air way • Suction • intubations • Ppv • Iv line • Iv bolus • inotropes • Cardiac Consultations identify intervene Evaluate The evalaute –identify – intervene is continous : process after each intervension and when the child condition changes ABCD
- 13. Evaluate Identify Intervene Initial assessment • Appearance • Breathing • circulation Life threatening critical disease SSS , CPR Help, call team ,connect TO cardiac monitor , PULSE O2, assess.. Primary assessment A: patent , maintainable B : R rate , effort ,sounds , air entry, o2 sat C : HR, PULSE( P, C) , BP, CRT, skin T, Color , Level of consciousness D: AVPU , pupil , b glucose E: skin , temperature • RESPIRATORY : • RD or • RF • CARDIAC CASE : • STABLE • OR UNSTABLE (Poor perfusion,lowBP….) • SHOCK • compensated • or hypotensive Resuscitative measures : High flow O2 for RD , but bagging for RF OPEN AIR WAY METHODS intubation, IV adenosine Cardio version IV LINE , Bolus Fluids Dextrose for hypoglycemia N.B The primary assessment also takes place once life‐threatening conditions have been treated (the pulse >60 , )
- 14. Evaluate Identify Intervene Secondary assessment 1. SAMPLE • S/s , • Allergy, • Medication , • Past h, • Last meal • Events 2. Reassessment Repeat Vital signs 3. Head to toe examination differential diagnosis. • Type of respiratory problems e.g • URTO, • LRTO • Lung D , • disorderd breath control Type of shock • hypovolemic , • cardiogenic , • Distrubutive • Obstructive To Give Emergency Treatment A B C D E D-Treat the undelaying causes E- Expert consultation Diagnostic tests Blood gases Hb concentration , blood chemistry CXR ….. Identify the type of problem as respiratory or circulatory or both , and deterimine the severity
- 15. Identify TYPE SEVERITY 1-Respiratory Upper airway obstruction Lower airway obstruction lung tissues Disordered control of breathing Respiratory distress Respiratory failure 2-Circulatory = Shock Hypovolemic shock Distributive Cardiogenic Obstrutctive Compensated Hypotensive 3-Cardiopulmonary failure e.g. SVT , VT, 4- Cardiac arrest All exam Cases will be one of theses Problems
- 16. Primary assessment ABCDE Airway Breathing Circulation Disability Exposure Intervene Resuscitations MEASURES Suction , air way , bag positive breathing , intubation, IV FLUIDS Anticonvulsive drugs AIM Idetify the problems: • Respiratory • Cardiac • shock Secondary assessment
- 17. Airway Assessment • The airway must be clear and patent for successful ventilation • Maintainable or unmaintainable A Evaluate
- 18. Measures to maintain airway • Use head tilt , chin left • jaw thrust In cervical injury (most useful) • Suctions • Use oral or nasopharyngeal airway • Intubations • Laryngeal mask • Cricothyrotomy • Remove the foreign body : – <1 yr give 5 back slaps and 5 chest thrusts – >1yr give 5 abdominal thrusts – If the patient become unresponsive activate emergency , and start CPR = Intervene
- 19. Breathing Assessment 1. Respiratory rate ˂ 10 or > 60 is sign of impending respiratory failure 2. Respiratory effort ,retractions, 3. Sounds wheezing, grunting , rales 4. Air entry 5. Pulse oximetry B
- 20. Respiratory distress RD is clinical state characterized by ↑RR Nasal flaring Retraction Grunting ,wheezing or stridor Cyanosis Change in mental status GRUNTING IS SIGN OF SEVERE RESP DISTRESS
- 21. Breathing difficulty Location of retraction Mild to moderate Subcostal Sub sternal Intercostal Severe Supraclavicular Suprasternal sternal HEAD BOBBING SEESAW SAW UPPER AIR WAY OBSTRUCTION Chest retractions Stridor LOWER AIRWAY OBSTRUCTIONS Chest retractions WHEEZING
- 22. FOUNDATIONAL FACTS • SEESAW BREATHING : – Is present when chest retract and abdomen expand – Caused by strong contraction of diaphragm that dominate the chest wall muscles – Seen in infant and children with neuromuscular weakness – Is inefficient form of ventilation can quickly lead to fatigue
- 23. Apnea • Apnea = cessation of breathing more than 15 seconds • Types : – Central apnea , no respiratory efforts – Obstructive : there is respiratory effort without airflow – Mixed apnea MINUTE VENTILATION = Respiratory rate X tidal volume
- 24. O2 SATURATION • Is the % of total HB that is fully saturated with O2 • IF 94 % or more in room air indicate adequate oxygenation • Less than 94% indicate hypoxia and need o2 administration • Keep the o2 sat 94 - 99% to avoid hypoxia or hyperoxia • O2 sat less than 90% while receiving 100% o2 is an indication (RF) for further intervention
- 25. Respiratory failure It Is inadequate ventilation or oxygenation, or both, that leads to an ↑ (paco2) and/or ↓ (pao2), resulting in acidosis. Clinical findings Marked ↑RR (early) or ↓RR (late) Tachycardia early or Bradycardia late Low O2 sat despite high O2 Cyanosis Decreased consciousness + Abnormal blood gases
- 26. Breathing - Primary assessment intervene Resuscitation ● Give high‐flow oxygen (flow rate 15 l/min) through a mask with a reservoir bag to any child with respiratory difficulty or hypoxia. ● In the child with inadequate respiratory effort, this should be supported either with bag–valve–mask ventilation or intubation and intermittent positive pressure ventilation
- 27. Circulation Assessment Circulation is assessed by 1. Heart rate, 2. heart rhythm (cardiac monitor , or ECG recording ) 3. Pulse ( both peripheral and central ) 4. Capillary refill time 5. Blood pressure 6. Skin ,color and temperature 7. Brain ,Level of consciousness 8. Renal ,Urine output End organ perfusion C
- 28. Bradycardia • Hypoxia is the most common cause of bradycardia • Bradycardia + signs of poor perfusion ( decreased responsiveness , weak peripheral pulse ,cool mottled skin) needs immediate support with bag ventilation with O2 , if HR LESS THAN 60 , DO CHEST COMPRESSION + epinephrine • Bradycardia + no signs of poor perfusion , suggest heart block or drug overdose
- 29. Tachycardia Warrant further assessment HR > 180 infant or toddler HR >160 in child older than 2 yr Tachycardia + hypotension , or depressed consciousness, or poor perfusion = Shock require immediate evaluation and intervention
- 30. PULSE CENTRAL PULSE PERIPHERAL PULSE • Carotid • Axillary • Brachial • Femoral • Radial • Dorsalis pedis • Posterior TIBIAL Weak central pulse need rapid intervention it indicates ( shock ) DECREASED COP WEAK CENTRAL PULSE
- 31. Capillary refill time • Is the time to blood takes to return to tissue blanched by pressure • Normal = 2 seconds • More than 2 sec in poor tissue perfusion ( dehydration , shock , hypothermia ) • Brisky as in septic shock
- 32. Skin findings Skin color Location Causes Pallor Skin , mucous membranes • Anemia • Poor perfusion (cold, stress, shock) Mottling Skin Vasoconstriction Cyanosis Skin , mm Decreased O2 sat Skin temperature Cool skin with decreased perfusion
- 33. Blood pressure Minimal acceptable systolic BP more than 60 in neonate , more than 70 in infant in children = 70 + ( AGE X 2) Hypotension indicates decompensated shock 25% of the blood volume must be lost before a drop in blood pressure occurs.
- 34. Renal perfusion Urine Output • 1.5 To 2 ml/ Kg / Hour in infant and young children • 1ml/kg per hour in older children
- 35. Circulation assessment followed by appropriate intervention Primary assessment of circulation as before Resuscitation In every child with an inadequate circulation: ● Give high‐flow oxygen through either a mask with a reservoir bag or an endotracheal tube if intubation has been necessary for airway control or inadequate breathing. 1. Provide IV or intraosseous access should be gained 2. Immediate infusion of crystalloid (20 ml/kg) given. 3. Vasoactive drugs
- 36. • IV access- Don’t forget intraosseous access in emergencies • To place an intraosseous cannula: use sterile technique, identify the tibial tuberosity, insert the intraosseous cannula 1 - 3 cm below (distal) to the tuberosity on the medial side of the tibia, direct the needle perpendicular to the long axis of the bone or slightly caudal (toward the toes) to avoid the epiphysial plate, use a firm twisting motion. • Do NOT use an IO in a fractured bone.
- 37. • Stop advancing the needle when you feel a sudden decrease in resistance as the needle enters the marrow cavity. The needle is in the marrow cavity if: • You felt the decrease in resistance as you entered the marrow cavity. • The needle can remain upright without support. • Marrow can be aspirated (looks red and grainy) - not always achievable. • Fluid flows freely without subcutaneous infiltration.
- 38. Disability Cerebral cortex function evaluation by 1- AVPU response Or Glasgow coma score Brain stem evaluation by 2-Pupillary response Equality of pupil size 3- Blood sugar D
- 39. The level of consciousness AVPU Alert = GCS 15 Responds to verbal stimuli = GCS 13 Responds to Painful stimuli = GCS 8 Unresponsive = GCS 6 Cause of decreased level of consciousness: 1. Traumatic brain injury 2. Hypoxia , poor cerebral perfusion , shock 3. Encephalopathy : hypoglycemia, hypercarbia , uremia.. 4. Seizures : epilepsy 5. CNS infections : encephalitis , meningitis 6. Drug overdose
- 40. Severity of head injury : • Severe, with GCS less than or equal to 8 • Moderate, GCS 9 – 12 • Minor, GCS 13 or greater.
- 41. Pupil response to light Check pupil size and reaction in each eye in any patient with , depressed consciousness to evaluate brain stem function Record the size of pupil , equality of pupil and reaction to light
- 42. Disability (neurological evaluation) possible intervention needed after Primary assessment • Both hypoxia and shock can cause a decrease in conscious level. Any problem with ABC must be addressed before assuming that a decrease in conscious level is due to a primary neurological problem. • any patient with a decreased conscious level or convulsions must have an initial glucose stick test performed. Resuscitation 1. Consider intubation to stabilize the airway in any child with a conscious level recorded as P or U (only responding to painful stimuli or unresponsive). 2. treat hypoglycaemia with a bolus of glucose (2 ml/kg of 25% glucose) followed by an IV infusion of glucose, after taking blood for glucose measurement in the laboratory and a sample for further studies. 3. Intravenous lorazepam, buccal midazolam or rectal diazepam should be given for prolonged or recurrent fits . 4. Manage raised intracranial pressure if present
- 43. Glucose Level Serum glucose concentration should be determined in all ill or injured children In children Glucose replacement 25 % dextrose 2 to 4 mL/ kg IV over 20 to 30 minutes for hypoglycemia. In neonates, 10 % dextrose 2ml/kg
- 44. Signs of increased intracranial pressure • Tense fontanel • Papilledema • Depressed consciousness' • Dilated pupil • Abnormal breathing • Bradycardia • Cushing triad late • Decelerate or decorticate posture Management ( ABCDE) 1- ABC : maintain airway , ventilation to keep normaL O2 sat and CO levels 2- head in 30 degree position 3- saline 3% (3ml/kg) , keep blood osmo. Less tha 360 or give mannitol 4-neurosurgical consultation D Expert
- 45. Exposure 1-Temperature : fever suggests an infection 2- SKIN Undress the seriously ill or injured child Look for evidence of trauma, purpura , rash , bleeding , burn or unusual marking suggestive of abuse Tenderness of extremities suggests injury E
- 46. Summary: the primary assessment of an infant or child • Airway and Breathing – Effort of breathing – Respiratory rate/rhythm – Stridor/wheeze – Auscultation – Skin colour • Circulation – Heart rate – Pulse volume – BP – Capillary refill – Skin temperature Disability • Mental status/conscious level • Pupils • blood glucose Exposure • skin • temperature The whole P. assessment should take less than a minute. Once airway (A), breathing (B) and circulation (C) are clearly recognised as being stable or have been stabilised, then definitive management of the underlying condition can proceed. During definitive management reassessment of ABCDE at frequent intervals will be necessary to assess progress and detect deterioration.
- 47. Secondary Assessment Aim : To Give Emergency Treatment 1- History / SAMPLE S For Signs And Symptoms A – Allergy to foods or drugs M - Medication P - Past History L - Last Meal E Event Result To The Problem 2- focused Clinical Examination Head To Toe Examination Clue 3- Ongoing assessment of vital
- 48. Secondary assessment and emergency treatment • The secondary assessment takes place once life‐threatening conditions have been assessed and treated . • It includes a focus medical history, and a clinical examination • Time is limited and a focused approach is essential. • At the end of secondary assessment, the practitioner should have formulated a differential diagnosis.
- 49. Diagnostic tests To asses the cardiopulmonary function and determine the cause Blood gases Hb concentration Pulse oximetry CXR Exhaled CO2 monitoring Echocardiography Invasive arterial pressure monitoring CVP monitoring Arterial lactate