PALS REVIEW

Anna Duran, MDJanelle Aragon, MD

Objectives

Have better understanding of Pediatric BLS

Understand presentation of shock and treatment

Be able to identify Algorithm to initiate and steps involved

Be able to successfully place an IO

PEDIATRIC SHOCK REVIEW

Definition

ShockCirculatory system failure

to supply oxygen and

nutrients to meet cellular

metabolic demands

Goal of therapy is to recognize, evaluate, and treat shock in its earliest stage

Initial priorities are ABC’s Fluid resuscitation - 20cc/kg of crystalloid. Subsequent treatment depends on the

etiology of shock and the patient’s hemodynamic condition

Successful resuscitation depends on early and appropriate intervention

Remember These?

Blood PressureBP = CO x SVR

Cardiac OutputCO = SV X HR

Vascular Tone (SVR)Regulated by several mechanisms

Oxygen Delivery (Crowley’s Fav Equations)

DO2 = CO x CaO2 x 10 CO depends on HR, preload, afterload, and

contractility

CaO2 = Hgb x 1.34 x SaO2 + (PaO2 x 0.003) Ca0₂ = arterial oxygen content

Hemoglobin carries more than 99% of oxygen in the blood under standard conditions

But this is not a PICU lecture…so we move on

Hemodynamics

Myocardial

Contractility

Preload

Stroke Volume

Cardiac Afterload

Output

Heart Rate

Blood

Pressure

Systemic Vasc. Resistance

Cardiovascular Function

Cardiac OutputClinical Assessment

○ Perfusion: capillary refill, urine output, LOC ○ acid-base status○ temperature

CO = HR x SV○ HR responds the quickest○ SV is a function of preload, afterload, and

myocardial contractility, any of these can affect SV

○ A noncompliant heart cannot increase SV

SXS of Shock Early Signs of Shock

sinus tachycardiahypoxiadelayed capillary refillfussy, irritable

Late Signs of Shockbradycardiaaltered mental status (lethargy, coma)Decreased tonehypotension is a very late sign (remember to get

baseline BP)

Assessment/Tx

ABC’s

First assess airway patency, ventilation, then circulatory system

Respiratory PerformanceRespiratory rate, effort, and pattern, WOB,

oxygenation Circulation

Heart rate, BP, perfusion, and pulses, liver size

Level of Responsiveness

Secondary Survey

Once ABCs addressed Head to toe-

Don’t forget fontanelle/pupils

Classification of Shock• COMPENSATED

– normal or increased blood flow however may be maldistributed-delayed cap refill; vital organ function is maintained

• UNCOMPENSATED– Reduction in effective circulating volume-

hypotension

• IRREVERSIBLE– inadequate perfusion of vital organs; irreversible

damage; death cannot be prevented

Types of Shock

Hypovolemic Hemorrhagic Cardiogenic Obstructive Distributive

Hypovolemic Shock Worldwide # 1 cause of death in children Causes

○ Water Loss (vomiting or diarrhea with poor PO intake, diabetes, severe burns)

○ Blood Loss-hemorrhagic shock- (trauma to include abusive trauma)

Low preload leads to decreased SV and decreased CO.

Compensation occurs with increased HR and SVR

Hemodynamics

Myocardial

Contractility

Preload

Stroke Volume

Cardiac Afterload

Output

Heart Rate

Blood

Pressure

Systemic Vasc. Resistance

Hypovolemia Tx Fluid! 20cc/kg isotonic fluid with repeat bolus UNTIL

shock is corrected Goals

Restore intravascular volumeCorrect metabolic acidosisTreat the cause

Reassess perfusion, urine output, vital signs... NS can cause a hyperchloremic acidosis-

how?

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Cardiogenic Shock Low CO and high systemic vascular

resistance Result of primary cardiac dysfunction:

-A compensatory increase in SVR occurs to maintain vital organ function

-Subsequent increase in LV afterload, LV work, and cardiac oxygen consumption

-CO decreases and ultimately results in volume retention, pulmonary edema, and RV failure

Hemodynamics

Myocardial Contractility

Stroke Volume Preload

Cardiac

Output Afterload

Blood Heart Rate

Pressure

Systemic Vasc. Resistance

Cardiogenic Etiologies Congenital heart disease Arrhythmias Myocarditis Myocardial injury Drug toxicity Septic shock Infiltrative diseases

mucopolysaccharidosesglycogen storage diseases

Thyrotoxicosis Pheochromocytoma

Cardiogenic Shock Tx Initial clinical presentation can be identical

to hypovolemic shock Fluid, but… If worsens after giving volume, suspect

cardiogenic shock Usually need invasive monitoring, further

evaluation, pharmacologic therapy , PICU and Cardiologist.

Distributive Shock

High CO and low SVR (opposite of hypovolemic and cardiogenic shock)

Maldistribution of blood flow causing inadequate tissue perfusion

Due to release of endotoxin, vasoactive substances, complement cascade activation, and anaphylaxis and spinal cord trauma)

Early septic shock is the most common form

Hemodynamics

Myocardial Contractility

Stroke Volume Preload

Cardiac Afterload

Output

Blood Heart Rate

Pressure

Systemic Vasc. Resistance

Distributive Etiologies

Anaphylaxis – IgE mediated Anaphylactoid reactions- IgE

independent Spinal cord injury/spinal shock Early sepsis Drug intoxication

Barbiturates, Phenothiazines, Antihypertensives

Distributive Shock Tx Goal is to maintain intravascular volume

and minimize increases in interstitial fluid (the primary problem is a decrease in SVR)FluidsVasoactive/Cardiotonic agents

often necessaryTreat the cause (i.e.. Anaphylaxis,

antibiotic therapy)

Anaphylaxis Treatment Airway/Breathing- 100%Fi02 Circulation- epi 1:1000 (0.01mg/kg) IM

Can repeat dose every 3-5minutes IV attempt Can give epi IV/IO BUT 1:10,000 (0.01mg/kg) slow

push over 1-2 minutes and on monitor. IVF Diphenhydramine 1mg/kg IV Ranitadine 1mg/kg IV Methylprednisolone 2mg/kg (up to 60mg) IV β-agonist via neb Intubation considerations

The Extras Metabolic acidosis develops secondary to tissue

hypoperfusion-depresses myocardial contractility and impairs the effectiveness of catecholamines

Congenital adrenal hyperplasia ○ Infant presents in shock, usually in the second week of life,

typically a boy, with metabolic acidosis, hyponatremia, hypoglycemia, and hyperkalemia, hypotension

Hyperammonemia○ mild elevations are common with shock○ levels > 1000 are consistent with inborn errors of metabolism ○ Other DD: consider Reye Syndrome, toxins, hepatic failure

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BLS REVIEW

Who’s Who in BLS

Infant BLS guidelines apply to infants<approximately 1 year of age.

Child BLS guidelines apply to children approximately 1 year of age until puberty. For teaching purposes puberty is defined as breast development in females and the presence of axillary hair in males.

Adult BLS guidelines (see Part 5) apply at and beyond puberty.

Pediatric BLS Algorithm.

Berg M D et al. Circulation 2010;122:S862-S875

Copyright © American Heart Association

AirwayPositioning/

Opening

Sniffing Position/Jaw Thrust

Maintaining

Suction

Airway Adjunts

NPA

OPA

LMA

ETT

Size Matters

Nasopharyngeal Airway (NPA)

Edge of the nose to tip of the ear

Oropharyngeal

Airway (OPA)

Not to be used with patient who has intact gag reflex

Lips to the edge of the mandible

Breathing

Children/Infants = 1 breath every 3-5 seconds

Adults = 1 breath every 5-6 seconds

Bag for gentle chest rise

Remember to NG decompression to prevent abdominal distention

Inadequate breathing: give rescue breaths at a rate of about 12 to 20 breaths per minute

The EC clamp technique of bag-mask ventilations.

Berg M D et al. Circulation 2010;122:S862-S875

Copyright © American Heart Association

Circulation

Pulse

Absent or <60 per minute AND there are signs of poor perfusion (ie, delayed cap refill, mottling) despite support of oxygenation and ventilation, begin chest compressions.

Push Hard, Push Fast and Allow Full Chest Recoil.

100 compressions/min

Depth compression

Infant 1/3 AP diameter (1.5cm)

Child 1/3 AP diameter (2cm)

CPR Ratios 1 Rescuer – (all ages) = 30:2 (one cycle) 2 Rescuers –Adults = 30:2

Children/Infants = 15:2

CPR when Advanced Airway is in place (all ages) = No pause for breaths. Continuous chest compressions while breaths are done 1 breath every 6-8 seconds.

Reassess after five cycles or two minutes

Foreign BodiesResponsive Infant Position infant facedown, resting on forearm, head slightly lower than

chest, supporting head and jaw with hand. 5 back blows (middle of back btwn shoulder blades w/ heel of hand) Carefully turn infant over as a unit, supporting head. Support infant

on forearm. 5 chest thrusts (2 finger position just below the nipple line). Repeat back blows & chest thrusts until object is expelled or the

infant becomes unresponsive.

Unresponsive Infant: Open the airway, look for an object. If an object is visible, remove it.

DO NOT perform a blind finger sweep. Begin CPR** with one extra step: each time you open the airway,

look for the object in the back of the throat. If you see an object, remove it.

Foreign BodyResponsive Child/Adult Perform abdominal thrusts (Heimlich Maneuver) Continue abdominal thrusts until the object is expelled or

the victim becomes unresponsive.

Unresponsive Child/Adult Open the airway, look for an object. If an object is visible,

remove it. DO NOT perform a blind finger sweep. 2. Begin CPR with one extra step: each time you open the

airway, look for the object in the back of the throat. If you see an object, remove it.

Remember

In PALS, as you know, doses are weight dependent.

Think about this when you are looking up doses. Our code sheets are WEIGHT DEPENDENT.

Adenosine Peds: 0.01mg/kg

Adults 3mg

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REVIEW OF PALS ALGORITHMS

Algorithms Bradycardia with a Pulse

Stable Cardiopulmonary statusCardiopulmonary Compromise

Tachycardia with Pulses and Poor PerfusionSinus TachycardiaSupraventricular TachycardiaVentricular Tachycardia

Pulseless ArrestVentricular Fibrillation vs. Ventricular TachycardiaAsystole vs. PEA

Septic Shock

Steps involved when called to evaluate a patient Help can be called for at any time!!! The sooner the better! #1

LOOK AT YOUR PATIENT!! Sick or not sick

#2 Examine

#3 Cardiac Monitor

#4 Check wires/tubing

#5 Call for help and Establish Roles

#6 Identify Algorithm

#7 Resuscitation Supplies/Meds

Sick or Not Sick?

Sick or Not Sick

Sick or Not Sick

http://www.youtube.com/watch?v=XJ-ON24aO9s&feature=BFa&list=PLF7E5E6EAB1933606

Examine

Get history (RN/family concerns, HPI, hospital course)

Vital signs (trends and current) Physical Exam (ABC’s)

AirwayBreathingCardiovascular

Physical Exam

AirwayCan patient speak or cry?Look: for respiratory distress (i.e. grunting,

flaring retractions), choking, cyanosisListen: air movement in neck and chest,

quality (stridor, wheeze, etc..), I:E, RRFeel: movement from mouth, nose, chest

rise, crepitusAssess: can airway be maintained with

basic maneuvers/positioning, suction

Physical Exam Breathing

Is patient moving sufficient air in and out to maintain effective oxygenation and ventilation?

Look: RR, trachea position, symmetry of chest rise, accessory muscles, skin color

Listen: symmetry and quality, adequacy of air movement, intrathoracic sounds (stridor, crackles, wheeze)

Feel: subcutaneous air, tenderness, instability of chest wall

Assess: stable or not? Respiratory failure? BMV? Intubate? Trumpets?

Physical Exam Cardiovascular

Adequate circulation to support end-organ function?Look:

○ poor perfusion: cyanosis, mottling, pallor, altered mental status

○ Chest trauma: asymmetry of chest expansion○ Jugular Venous Distention

Listen○ Heart rate: tachycardic vs. bradycardic vs. normal○ Heart tones: murmur, rub, gallop○ Breath sounds: rales vs. wheeze○ Diminished Breath sounds

Feel○ Central pulses, temperature of skin, capillary refill

Assess○ Adequate vs. inadequate vs. absent

Cardiac Monitor Know what the numbers on the monitor mean Make sure connections are correct and

wires/leads actually attached to the patientLead placement: White is right, Smoke (black)

over fire (red)WaveformHeart rate from leads and pulse oximeter should

correlate If patient on oxygen, make sure connected

appropriately to wall with no kinks and cannula/mask placed appropriately

Establish Roles

Code TeamTeam LeaderAirway PhysicianFloat PhysicianMedication NurseBedside NurseCirculating NurseDocumenterAssistants

Identify Algorithm

Pulse vs. No Pulse

Pulse No Pulse

Shockable

Ventricular Fibrillation

Ventricular Tachycardia

Not Shockable

AsystolePulseless Electrical Activity

What makes a Rhythm Shockable? The heart is active, but in a life-threatening

and dysfunctional pattern. In Ventricular Tachycardia, the heart is unable to pump blood effectively as it is beating too quickly to fill. This will ultimately lead to ventricular fibrillation. At this point the electrical activity in the heart becomes chaotic – again preventing the heart from pumping effectively. Over time, the fibrillation will decrease and the heart will become asystolic from lack of appropriate oxygenation.

What makes a Rhythm Shockable? Defibrillation – for UNORGANIZED

rhythmsTherapeutic delivery of an unsynchronized

electrical current through the myocardium over a brief period to terminate the dysrhythmia

Does not jump start the heartPurpose is to depolarize the ventricular cells

simultaneously (including fibrillating cells) asystole natural pacemakers will resume normal activity

What makes a Rhythm Shockable? Synchronized Cardioversion – for

ORGANIZEDDelivery of a shock to the heart to terminate

a rapid dysrhythmia that is times to avoid vulnerable periods in the cardiac cycle (peak to end of T wave)

Heart cells will contract simultaneously interrupting and terminating the abnormal electrical rhythm without damaging the heart allowing the sinus node to resume normal pacemaker activity

Identify AlgorithmPulse vs. No

Pulse

Bradycardia

Cardiopulmonary system stable?

Yes

ABC’s

Compromise

CPR

Tachycardia

Pulse

Identify AlgorithmPulse vs. No

Pulse

Bradycardia Tachycardia

Narrow QRS (<.0.8 seconds)

Sinus Tachycardia

Supraventricular Tachycardia

Wide QRS (>0.08 seconds)

Ventricular Tachycardia

Pulse

Rhythms

Rhythm

Rhythm

Rhythm

Rhythm

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IO PLACEMENT

Sites of Placement

Proximal Tibia Distal Tibia Distal Femur Proximal Humerus Sternum

Contraindications

Fracture of the extremity Cellulitis Previous attempt on same extremity Osteogenesis Imperfecta

Risks and Complications Benefits are outweigh risk in a child who is in

need of emergent medications or fluids. Few Risks and Complications

-Infiltration most common

complication

-Compartment syndrome

with infiltration

-Muscle necrosis with infiltration

-Infection and osteomyelitis – aseptic tech.

-Hematoma, fx, growth plate injuries

Procedure

Support the flexed knee by placing a towel under the calf. Palpate tibial tuberosity and move 2 cm distal and slightly medial

to the tibial tuberosity. (Identifying this landmark helps avoid hitting the growth plate.)

Clean the area with an iodine solution and drape it. Perform insertion using sterile gloves and technique.

Insert the IO needle through the skin and subcutaneous tissue. Upon reaching the bone, hold the needle with the index finger and thumb as close to the entry point as possible and, with constant pressure on the needle with the palm of the same hand, use a twisting motion to advance the needle through the cortex until reaching the marrow. A 10-15° caudal angulation may be used to further decrease the risk of hitting the growth plate, but direct entry parallel to the bone is acceptable.

Advance the needle from the cortex into the marrow space, at which point a popping sensation or lack of resistance is felt. Do not advance the needle any farther.

The first indication of proper placement occurs when the needle stands up on its own. At this point, remove the inner trocar, attach a syringe to the needle, and aspirate bone marrow. Obtaining marrow confirms placement.

If marrow is not aspirated, push a 5-mL to 10-mL bolus of NS through the syringe. Resistance to flow should be minimal, and extravasation should not be evident. Observing the calf area is important.

If flow is good and extravasation is not evident, connect the intravenous (IV) line with a 3-way stopcock at the needle, and secure the needle with gauze pads and tape.

Pictures and procedure courtesy of emedicine: Interosseous Cannulation

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