Pediatric Advanced Life Support

1. Pediatric Advanced Life Support • Guidelines established in 1983 by the American heart Association. • Pediatric Advanced Life Support: A Review of the AHA Recommendations, American Family Physician, October 15, 1999. • Http://www.aafp.org/afp/991015ap/1743.html

2. Cardiopulmonary Arrest • In most infants and small children respiratory arrest proceed cardiac arrest. • 92% of children with respiratory arrest only have no subsequent neurologic impairment.

3. Respiratory Arrest • Early recognition and intervention prevents deterioration to cardiopulmonary arrest and probable death. • Only 10% of children who progress to cardiopulmonary arrest are successfully resuscitated.

4. Assessment • 30 second rapid cardiopulmonary assessment is structured around ABC’s. • Airway • Breathing • Circulation

5. Airway • Airway must be clear and patent for successful ventilation. • Position • Clear of foreign body • Free from injury • Intubate if needed.

6. Breathing • Breathing is assessed to determine the child’s ability to oxygenate. • Assessment: • Respiratory rate • Respiratory effort • Breath sounds • Skin color

7. Impending Respiratory Failure • Respiratory rate less than 10 or greater than 60 is an ominous sign of impending respiratory failure.

8. Circulation • Circulation reflects perfusion. • Shock is a physiologic state where delivery of oxygen and substrates are inadequate to meet tissue metabolic needs.

9. Circulatory Assessment • Heart rate is the most sensitive parameter for determining perfusion and oxygenation in children. • Heart rate needs to be at least 60 beats per minute to provide adequate perfusion. • Heart rate greater than 140 beats per minute needs to be evaluated.

10. Circulatory Assessment • Pulse quality reflects cardiac output. • Capillary refill measure peripheral perfusion. • Temperature and color of extremities proximal versus distal.

11. Circulatory Assessment • Urinary output • Adequate kidney perfusion • 1- 2 ml of urine per kg / hour • Level of Consciousness / LOC

12. Blood Pressure • 25% of blood volume must be lost before a drop in blood pressure occurs. • Minimal changes in blood pressure in children may indicate shock.

13. Management • Oxygen • Cardiac Monitoring • Pulse oximetry • Inaccurate when peripheral perfusion is impaired.

14. Airway Management • Bag-valve-mask with bradypenia or apnea • Intubation as needed • Suctioning to remove secretions

15. Vascular Access • After airway and oxygenation needs met. • Crystalloid solution • Normal saline • Lactated ringers • 20ml/kg bolus over 20 minutes

16. Gastric Decompression • Gastric decompression with a nasogastric or oral gastric tube is necessary to ensure maximum ventilation. • Air trapped in stomach can put pressure on the diaphragm impeding adequate ventilation. • Undigested food can lead to aspiration.

17. Cardiopulmonary Failure • Child’s response to ventilation and oxygenation guides further interventions. • If signs of shock persists: • Inotropic agents such as epinepherine are given.

18. Epinepherine • Indications: • Bradycardia • Shock (cardiogenic, septic, or anaphylactic) • Hypotension • IV or through the endotracheal tube

19. Bradycardia • Bradycardia is the most common dysrhythmia in the pediatric population. • Epinephrine is drug of choice. • Atropine if epinephrine is ineffective.

20. Sodium Bicarbonate • In instances where the child is acidotic, sodium bicarbonate is administered IV. • The drug is not as stable in the pediatric population but is often used during the resuscitative phase of CPR.

21. Glucose Levels • Monitor serum glucose levels • Replace with 10 % dextrose in the neonate • 25% glucose in the child

22. Ventricular Tachycardia • Ventricular tachycardia is usually secondary to structural cardiac disease. • Lidocaine • Cardioversion

23. Post-resuscitation Care • Re-assessment of status in ongoing. • Laboratory and radiologic information is obtained. • Etiology of respiratory failure or shock is determined. • Transfer to facility where child can get maximum care.