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As we learn more about resuscitation science and medicine, physicians and researchers realize what works best and what works fastest in a critical, life-saving situation. Therefore, it is necessary to periodically update life-support techniques and algorithms. If you have previously certified in pediatric advanced life support, then you will probably be most interested in what has changed since the latest update in The table below also includes changes proposed since the last AHA manual was published.
The PALS systematic approach is an algorithm that can be applied to every injured or critically ill child. The first step is to determine if the child is in imminent danger of death, specifically cardiac arrest or respiratory failure. The PALS systematic assessment starts with a quick, first impression. Is the child in imminent danger of death? Is there time to evaluate the child to identify and treat possible causes for the current illness?
Is the child conscious? Is she breathing? What is her color? The evaluation of breathing include several signs including breathing rate, breathing effort, motion of the chest and abdomen, breath sounds, and blood oxygenation levels. Normal breathing rates vary by age and are shown in the table.
The breathing rate higher or lower than the normal range indicates the need for intervention. Nasal flaring, head bobbing, seesawing, and chest retractions are all signs of increased effort of breathing. The chest may show labored movement e. Stridor is a high-pitched breath sounds, usually heard on inspiration, that usually indicates a blockage in the upper airway. Rales or crackles often indicate fluid in the lower airway. Rhonchi are coarse rattling sounds usually caused by fluid in the bronchi.
A heart rate that is either too fast or too slow can be problematic. In children, heart rate less than 60 bpm is equivalent to cardiac arrest.
Diminished central pulses, such as in the carotid, brachial, or femoral arteries, indicate shock. Bradycardia and tachycardia that are interfering with circulation and causing a loss of consciousness should be treated as cardiac arrest or shock, rather than as a bradycardia or tachycardia. Exposure is included in the primary assessment to remind the provider to look for causes of injury or illness that may not be readily apparent.
During the removal, the provider should look for signs of discomfort or distress that may point to an injury in that region. The Secondary Assessment includes a focus history and focused physical examination looking for things that might cause respiratory or cardiovascular compromise. The focused physical examination may be quite similar to the Exposure phase of the Primary Assessment, but will be guided by the data that the provider collects during the focused history.
The focused history will also help determine which diagnostic tests should be ordered. Cardiac arrest in children can occur secondary to respiratory failure, hypotensive shock, or sudden ventricular arrhythmia. In most pediatric cases, however, respiratory failure, shock, and even ventricular arrhythmia are preceded by a milder form of cardiovascular compromise. For example, respiratory failure is usually preceded by some sort of respiratory distress.
In fact, respiratory distress is the most common cause of respiratory failure and cardiac arrest in children. As you may expect, outcomes are better if one can intervene during respiratory distress rather than respiratory failure. Cardiac arrest occurs when the heart does not supply blood to the tissues. Strictly speaking, cardiac arrest occurs because of an electrical problem i. Shock i. Many different disease processes and traumatic events can cause cardiac arrest, but in an emergency, it is important to be able to rapidly consider and eliminate or treat the most typical causes of cardiac arrest.
To facilitate remembering the main, reversible causes of cardiac arrest, they can be organized as the Hs and the Ts. Fluid resuscitation in PALS depends on the weight of the child and the severity of the situation. While dehydration and shock are separate entities, the symptoms of dehydration can help the provider to assess the level of fluid deficit and to track the effects of fluid resuscitation. In the current guidelines, the clinician must fully evaluate the child with febrile illness since aggressive fluid resuscitation with isotonic crystalloid solution may not be indicated.
The child is still in a delicate condition. All major organ systems should be assessed and supported. Maintenance fluids should be given. If the child has been resuscitated in the community or at a hospital without pediatric intensive care facilities, arrange to have the child moved to an appropriate pediatric hospital.
Bradycardia is a common cause of hypoxemia and respiratory failure in infants and children. Bradycardia is a slower than normal heart rate. A heart rate less than 60 beats per minute in a child under 11 years old is worrisome for cardiac arrest unless congenital bradycardia is present. In fact, pulseless bradycardia defines cardiac arrest. Tachycardia is a faster than normal heart rate. Pulseless tachycardia is cardiac arrest.
It is important to determine if the tachycardia is narrow complex or wide complex. This should be considered possible ventricular tachycardia. If the child is not hemodynamically stable then provide cardioversion immediately. Again, it is important to determine if the tachycardia is narrow complex or wide complex.
The most commonly used system for correlating tools to the size of a child is the Broselow Pediatric Emergency Tape System. The medication cart or crash cart is stocked using the color coding system. Basic airways do not require specialist training; however, some proficiency is needed for oropharyngeal and nasopharyngeal airway placement.
ACLS in the hospital will be performed by several providers. These individuals must provide coordinated, organized care. Providers must organize themselves rapidly and efficiently. Resuscitation demands mutual respect, knowledge sharing, and constructive criticism, after the code.
When performing a resuscitation, the Team Leader and Team Members should assort themselves around the patient so they can be maximally effective and have sufficient room to perform the tasks of their role. There are four main types of atrioventricular block: first degree, second degree type I, second degree type II, and third degree heart block. Second degree heart block Mobitz type I is also known as the Wenckebach phenomenon. Heart block is important because it can cause hemodynamic instability and can evolve into cardiac arrest.
The PR interval is a consistent size, but longer or larger than it should be in first degree heart block. Complete dissociation between P waves and the QRS complex. No atrial impulses reach the ventricle. Pulseless electrical activity or PEA is a cardiac rhythm that does not create a palpable pulse is even though it should. A PEA rhythm can be almost any rhythm except ventricular fibrillation incl.
It represents a lack of electrical activity in the heart. It is critically important not to confuse true asystole with disconnected leads or an inappropriate gain setting on an in-hospital defibrillator. Asystole may also masquerade as a very fine ventricular fibrillation.
If the ECG device is optimized and is functioning properly, a flatline rhythm is diagnosed as asystole. Note that asystole is also the rhythm one would expect from a person who has died. Consider halting PALS efforts in people who have had prolonged asystole. It is inappropriate to provide a shock to pulseless electrical activity or asystole. Cardiac function can only be recovered in PEA or asystole through the administration of medications.
This energy may come in the form of an automated external defibrillator AED defibrillator paddles, or defibrillator pads. VFib and VTach are treated with unsynchronized cardioversion, since there is no way for the defibrillator to decipher the disordered waveform. In fact, it is important not to provide synchronized shock for these rhythms. Ventricular fibrillation is recognized by a disordered waveform, appearing as rapid peaks and valleys as shown in this ECG rhythm strip:. Ventricular tachycardia may provide waveform similar to any other tachycardia; however, the biggest difference in cardiac arrest is that the patient will not have a pulse and, consequently, will be unconscious and unresponsive.
Two examples of ventricular tachycardia are shown in this ECG rhythm strips. The first is narrow complex tachycardia and the second is wide complex tachycardia:. Atrial fibrillation is the most common arrhythmia. It is diagnosed by electrocardiogram, specifically the RR intervals follow no repetitive pattern.
Some leads may show P waves while most leads do not. Atrial contraction rates may exceed bpm. The ventricular rate often range is between to bpm. Atrial flutter is a cardiac arrhythmia that generates rapid, regular atrial depolarizations at a rate of about bpm. This often translates to a regular ventricular rate of bpm, but may be far less if there is a or conduction. By electrocardiogram, or atrial flutter is recognized by a sawtooth pattern sometimes called F waves. Narrow QRS complex tachycardias include several different tachyarrhythmias.
One of the more common narrow complex tachycardias is supraventricular tachycardia, shown below. The heart rate can exceed bpm in infants and bpm in children. Wide complex tachycardias are difficult to distinguish from ventricular tachycardia.
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