PALS Study Course

The Pediatric Advanced Life Support (PALS) course is designed to polish the resuscitation skills of healthcare professionals to more accurately identify and treat infant, child and adolescent cardiopulmonary emergencies. Once this course is completed, healthcare providers should be able to use the pediatric assessment and other tools to aid in the recognition and management of the following situations:

  • Respiratory Distress and Respiratory Failure
  • Bradyarrhythmias and Tachyarrhythmias
  • Cardiac Arrest
  • Stroke
  • Postresuscitation

» Chapter 1: Pediatric Assessment: A Systematic Approach

Chapter 1 - Pediatric Assessment: A Systematic Approach

Pediatric assessment is a systematic process consisting of four stages: general, primary, secondary, and tertiary, and is completed to evaluate the clinical condition of a severely ill or injured child. Each stage is approached using the Assess-Categorize-Decide-Act model as a guide for completing a thorough assessment. The patient's condition is periodically reassessed and monitored to determine the best treatment at any given time. The four stages of pediatric assessment are outlined below.

  • GENERAL : The general assessment utilizes the Pediatric Assessment Triangle as a guide to assess the patient’s auditory and visual condition, looking for clues such as interaction, eye contact, increased breathing effort, or cyanosis, that would indicate respiratory issues.
  • PRIMARY : The primary hands-on assessment evaluates the patient's cardiopulmonary and neurologic function. The ABCDE approach used during this assessment is described in detail below and is also illustrated in the Pediatric Assessment Flow Chart located at the end of this chapter.
  • Repositioning the child to a more comfortable position, suctioning his or her nose and oropharynx or implementing a head tilt-chin lift establishes an open airway. If these basic maneuvers are ineffective, advanced techniques such as endotracheal intubation, CPAP, or cricothyrotomy may be necessary.
  • The child's breathing is assessed by evaluating respiratory rate, respiratory effort, tidal volume, airway and lung sounds, and pulse oximetry. Assessment may determine that more advanced measures or life-saving techniques need to be implemented. The chart below details the indicators of normal and abnormal breathing.

Assessment

Normal

Abnormal

Respiratory Rate

Depends on age* (12-60bpm)

*see chart in reference guide

Tachypnea (faster than normal),

Bradypnea (slower than normal) or

Apnea (ceased breathing >20 seconds; 3 types: Central, Obstructive and Mixed)

Respiratory Effort

Normal breathing efforts

Nasal flaring, chest retractions, head bobbing/seesaw respirations

Tidal Volume

5 to 7 mL/kg of body weight, symmetrical chest expansion, soft quiet inspiratory sounds

Decreased or asymmetric chest expansion

Distal air movement

Airway & Lung Sounds

Inspiratory: soft, quiet sounds occur simultaneously with effort

Expiratory: short, quieter sounds, sometimes absent

Stridor, grunting, wheezing, gurgling or crackle sounds

Pulse Oximetry

Oxygen saturation > 94%

Oxygen saturation < 94%

  • The circulation assessment focuses on the patient's cardiovascular function (skin color, heart rate, blood pressure, pulse, etc) and end-organ function (brain, skin and renal perfusion). The chart below addresses the indications of normal and abnormal circulation.

Assessment

Normal

Abnormal

Skin Color & Temperature

Consistent over trunk & extremities; nail beds, palms & soles of feet should be pink

Hands & feet are affected first then trunk & extremities turn pale, cool & mottled

Heart Rate

Depends on age*

*see chart in reference guide

Tachycardia (faster than normal)

Bradycardia (slower than normal)

Heart Rhythm

Regular with small fluctuations in rate

Irregular rhythm, arrhythmia

Blood Pressure

Depends on age & gender*

*see chart in reference guide

Outside of normal range indicated in chart, hypotension

Pulses

Easy palpitation of central & peripheral pulses

Loss of peripheral pulses then weakening central pulses

Capillary Refill Time

< 2 seconds

> 2 seconds, caused by dehydration, hypothermia and shock

Brain

Normal results from AVPU scale

Cerebral hypoxia indentified by loss of muscular tone, generalized seizures, papillary dilation, unconsciousness

Skin

Pink & consistent over trunk & extremities

Petechia, pupura (bleeding from capillaries), Cyanosis, pallor & mottling (inadequate oxygen to the tissues)

Renal Perfusion

Adequate urine output (varies by age)

  • Infants/young children: 1.5-2 mL/kg per hour
  • Older children/adolescents: 1 mL/kg per hour

Low urine output over time based on normal levels by age

  • The cerebral cortex and the brainstem are assessed during the disability stage. This assessment is performed at the end of the primary assessment and again during the secondary. Level of consciousness is assessed using the AVPU Pediatric Response Scale and Glasgow Coma Scale (GCS), and by establishing pupillary response to light.
  • The final assessment is exposure, wherein the patient's body is evaluated for trauma, tested for tenderness, and core body temperature is measured.
  • SECONDARY : Once the patient is stabilized, the physical examination is completed and medical history is obtained. The SAMPLE mnemonic is a guide to key assessments that need to be completed during the physical examination. The details of the mnemonic are located in the Pediatric Assessment Flow Chart at the end of this chapter.
  • TERTIARY : Laboratory and non-laboratory ancillary studies are completed to identify the presence and severity of respiratory and circulatory abnormalities. Studies include: arterial blood gas (ABG), venous blood gas (VBG), hemoglobin concentration, pulse oximetry, exhaled CO 2 monitoring, capnography, chest x-ray and peak expiratory flow rate. This assessment should be completed in conjunction with all other stages of the pediatric assessment.

The following Pediatric Assessment Flow Chart is an illustrative representation of the assessment steps used during pediatric evaluations.

PEDIATRIC ASSESSMENT FLOW CHART

If the following life-threatening signs occur during the pediatric assessment, then the Emergency Response System (ERS) needs to be activated.

  • Absolute obstruction of airflow
  • Work of breathing is laborious, signs of bradypnea
  • Undetected pulse, hypotension
  • Unconsciousness
  • Severe hypothermia and/or bleeding

The following are life-saving measures that can be taken to prevent digression to cardiac arrest.

  • ABCs
  • Provide oxygen
  • Provide ventilation
  • Monitor cardiac & respiratory functions
  • Establish IV/IO access

» Chapter 2: Recognizing and Managing Respiratory Distress and Respiratory Failure

Chapter 2 - Recognizing and Managing Respiratory Distress and Respiratory Failure

Airway resistance, decreased lung compliance, strength and coordination of respiratory muscles, and central nervous system's control of breathing are mechanisms that affect the patient's work of breathing. Increased work of breathing indicates respiratory illness, because traditionally breathing is a subconscious action.

Recognizing and treating respiratory distress and respiratory failure in early stages will decrease the chance of progression to cardiac arrest. Respiratory distress is characterized by increased respiratory effort and rate, and is associated with changes in airway sounds, skin color and mental status, and by the presence of tachypnea or tachycardia. The digression to respiratory failure occurs when the child can no longer maintain adequate gas exchange. Thus, failure results from inadequate oxygenation, ventilation or both, and is indicated by marked tachypnea, bradypnea, tachycardia, bradycardia, changes in or no respiratory effort, cyanosis, inadequate or absent distal air movement and coma.

Inadequate oxygenation (hypoxemia) and inadequate ventilation (hypercarbia) are results of restricted airflow that lead to respiratory distress and/or respiratory failure. It is important to recognize these two impairments early on. A SpO2 <94% indicates hypoxemia, decreased oxyhemoglobin saturation in the blood. The presence or development of tissue hypoxia is also a possibility, although the two conditions are not mutually exclusive. Identifying the following signs of tissue hypoxia can be life saving for a child. A pulse oximetry can be used to detect hypoxemia.

  • Tachypnea
  • Tachycardia (early)
  • Bradycardia (late)
  • Bradypnea, apnea (late)
  • Cyanosis (late)
  • Nasal flaring
  • Agitation
  • Altered mental status
  • Pallor
  • Fatigue

Both a decrease in respiratory function and presence of airway or lung tissue disease can result in hypercarbia. Inadequate ventilation produces respiratory acidosis as a result of reduced CO2 output. The signs of hypercarbia are difficult to differentiate from those of hypoxia; therefore, an arterial blood gas (ABG) test is recommended to verify diagnosis.

  • Tachypnea
  • Nasal flaring
  • Agitation
  • Altered mental status
  • Fatigue

Categorizing Respiratory Distress and Failure by Type

Respiratory distress and failure are categorized by severity (respiratory failure being more severe than respiratory distress) and type (upper or lower airway obstruction, lung tissue disease or disordered control of breathing). The chart below is an overview of the types of respiratory distress and failure; these can occur in isolation or simultaneously with another type.

Types of Respiratory Distress and Respiratory Failure

Type

Location of Obstruction

Causes

Indicators

Upper Airway

Nose, Pharynx or Larynx

  • Food, small object or a mass obstruction
  • Swelling of tissue
  • Croup
  • Anaphylaxis
  • Tachypnea
  • Increased inspiratory respiratory effort
  • Crying, change in voice
  • Stridor (usually inspiratory)
  • Poor chest rise & air entry on auscultation

Lower Airway

Lower Trachea, Bronchi or Bronchioles

  • Asthma
  • Bronchiolitis
  • Tachypnea
  • Wheezing (usually expiratory)
  • Increased respiratory effort
  • Prolonged expiratory phase
  • Coughing

Lung Tissue Disease

Lungs

  • Pneumonia
  • Pulmonary edema
  • Pulmonary trauma
  • ARDS (acute onset, PaO2/FiO2 <300, bilateral infiltrates on chest x-ray & no evidence of cardiogenic cause of pulmonary edema)
  • Tachypnea (usually marked)
  • Tachycardia
  • Increased respiratory effort
  • Grunting, crackles
  • Hypoxemia
  • Diminished breath sounds

Disordered Control of Breathing

Respiratory system

  • Seizures
  • CNS infections
  • Hydrocephalus
  • Head injury
  • Brain tumor
  • Neuromuscular disease
  • Variable/irregular respiratory rate
  • Central apnea
  • Variable respiratory effort
  • Shallow breathing

Respiratory Disease and Failure Management

Identifying the severity and type of respiratory illness will aid in achieving the management goals of supporting and/or restoring adequate oxygenation and ventilation. Initial management efforts begin with the ABC assessment (Airway - Breathing - Circulation).

  • Airway - support and/or open airway, clear if obstructed, insert OPA or NPA device as needed
  • Breathing - provide oxygen, ventilation assistance or administer medicine if necessary, continue monitoring oxygen saturation, prepare for ET tube as needed
  • Circulation - monitor heart rate and rhythm, establish vascular access as needed

Once the initial assessment is completed and the patient is stable, the type of respiratory illness should to be identified. The following charts cover the general and specific management goals and techniques for upper airway obstruction, lower airway obstruction, lung disease, and disordered control of breathing.

Upper Airway Obstruction

General Management

The focus is on relieving obstruction by suctioning, reducing airway swelling, removing object, and deciding if advanced airway management or surgery is needed

Specific Causes

Specific Management

Croup

Mild: administer a dose of dexamethasone, provide cool mist

Moderate to Severe: administer oxygen, nebulized epinephrine & dexamethasone, provide cool mist, keep NPO

Severe: assist ventilation, provide high concentration of oxygen, place ET tube

Anaphylaxis

Administer IM epinephrine, prepare for ET tube, administer diphenhydramine and H2 blocker, administer methylprednisolone;

If wheezing: administer albuterol and continuous nebulization if severe

If hypotensive: place in Trendelenburg position, administer epinephrine by small boluses, & administer isotonic crystalloid

Lower Airway Obstruction

General Management

Provide assisted ventilation using bag-mask at slow respiratory rates; if respiratory failure or severe respiratory disease is present, the focus is on providing adequate oxygenation first. Children can usually tolerate hypercarbia without adverse effects

Specific Causes

Specific Management

Bronchiolitis

Oral or nasal suctioning as needed

Run ancillary testing as needed, possibly viral studies, chest x-ray, ABG test

Acute Asthma

Mild: administer humidified oxygen, albuterol by MDI/nebulizer, corticosteroids PO

Moderate to Severe: same as in mild asthma, and administer ipratropium bromide by MDI/nebulizer, possibly administer magnesium sulfate & establishing vascular access, run ancillary tests as needed

Severe: same as above, and assist ventilation, consider BiPAP, place ET tube, and administer IV methylprednisolone, terbutaline SQ or IV

Lung Tissue Disease

General Management

Use positive expiratory pressure (if hypoxemic), administer bronchodilators (if wheezing), monitor cardiac output and tissue perfusion

Specific Causes

Specific Management

Infectious Pneumonia

Administer antimicrobial therapy, albuterol by MDI/nebulizer, consider BiPAP, run ancillary testing as needed

Chemical Pneumonitis

Administer nebulized bronchodilators (if wheezing), consider BiPAP, if child’s symptoms are severe, refer to specialized center

Aspiration Pneumonitis

Consider BiPAP and administration of antibiotics if chest x-ray shows an infiltrate and fever is present

Cardiogenic Pulmonary Edema

Provide positive-pressure ventilation or mechanical ventilation with PEEP, administer therapy to support cardiovascular function, consider expert consultation, reduce temperature and work of breathing to reduce metabolic rate

Noncardiogenic Pulmonary Edema (ARDS)

Monitor cardiac, pulse oximetry and end-tidal CO2, run ABG, VBG and total blood count tests, support ventilation via noninvasive pressure support ventilation or mechanical ventilation with PEEP

Disordered Control of Breathing

General Management

Complete ABC assessment

Specific Causes

Specific Management

Increased Intracranial Pressure (ICP)

Use jaw thrust maneuver, verify open airway, administer 20 mL/kg IV isotonic crystalloid (if poor perfusion), administer hypertonic saline, avoid hypothermia, and once airway is secure & ventilation adequate, treat agitation

Poisoning or Toxicity

Administer antidote, contact poison control, suction airway (if vomiting), run ancillary tests as needed

Neuromuscular Disease

Complete ABC assessment

» Chapter 3: Recognizing and Managing Bradyarrhythmias and Tachyarrhythmias

Chapter 3: Recognizing and Managing Bradyarrhythmias and Tachyarrhythmias

Arrhythmias indicate deviation from the normal sequence of electrical cardiac impulses. Normal heart rates, such as typical heart rate and baseline rhythm, are dependent upon the child’s age and physical and clinical conditions. Arrhythmias are classified into two broad categories and further delineated into more specific categories based on what is considered normal for each child.

  • Bradyarrhythmia - a slower than normal heart rate.
  • Relative Bradycardia - heart rate too slow for child's level of activity and clinical condition.
  • Significant Bradycardia - heart rate slower than normal for child's age, typically associated with shock and/or respiratory distress or failure. Tissue hypoxia is the leading cause.
  • Tachyarrhythmia - a faster than normal heart rate that typically originates in the heart's atria or ventricles.
  • Relative Tachycardia - heart rate too fast for child's level of activity and clinical condition.

Bradyarrhythmias

Signs & Symptoms of Bradycardia

Examples of Bradyarrhythmia

  • Sinus Node Arrest/Sick Sinus Syndrome presents as abnormal heart rhythms such as atrial, junctional and idioventricular escape rhythms, caused by a malfunction of the sinus node, the heart's primary pacemaker.
  • Sinus Bradycardia develops as result of reduced metabolic demand or increased stroke volume. Sinus bradycardia is most commonly caused by hypoxia, but may also be triggered by poisoning, hypoglycemia, or hypothyroidism. This arrhythmia is usually an accidental finding in healthy young adults and athletes.
  • AV Block is the impairment of conduction between the heart's atria and ventricles. There are four types:

Type

Characteristics

Symptoms

1st Degree

PR interval lengthened beyond 0.20 seconds, impulse conducting from atria to ventricles through the AV node is delayed

Usually no symptoms

2nd Degree - Mobitz Type 1 (aka Wenckebach phenomenon)

Progressive prolongation of the PR interval on ECG on consecutive beats followed by a blocked P wave

Sometimes dizziness occurs

2nd Degree - Mobitz Type 2

Sporadically non-conducted P waves not preceded by PR prolongation and not followed by PR shortening on ECG, may rapidly progress to complete heart block

Could possibly cause sensed irregularities of heart beat, presyncope or syncope

3rd Degree

(complete heart block)

Impulse generated in the SA node in the atrium does not propagate to the ventricles. Ventricles are activated by the accessory pacemaker (aka escape rhythms)

Symptomatic; fatigue, presyncope or syncope

Bradycardia Management

The Bradycardia Algorithm below is the preferred guide to recommended management techniques specific to bradyarrhythmia cases.

BRADYCARDIA ALGORITHM

Tachyarrhythmias

Signs & Symptoms of Tachycardia

Examples of Tachyarrhythmia

Tachyarrhythmias are categorized based on the demonstrated width of the QRS complex. The following chart will identify the examples of tachycardia, and how to identify each arrhythmia.

Type

Characteristics

Causes

Narrow Complex

Sinus Tachycardia (ST)

  • Sinus node discharge faster than normal for age
  • Develops when the body needs increased oxygen delivery
  • Heart rate varies with activity
  • Heart rate <200bpm (infants), <180bpm (children), P wave normal, PR interval constant, R-R interval variable
  • Hypoxia
  • Hypovolemia
  • Fever
  • Metabolic stress
  • Trauma/Pain/Anxiety
  • Toxicity
  • Anemia

Supraventricular Tachycardia (SVT)

  • Abnormally fast rhythm, originates above ventricles
  • Most common tachyarrhythmia causing cardiovascular compromise (infants)
  • Heart rate >200bpm (infants), >180bpm (children), P wave abnormal, R-R interval usually constant
  • Accessory pathway reentry
  • Ectopic atrial focus
  • AV nodal reentry

Atrial Flutter

  • Occurs in the atria of the heart, and mostly in individuals with cardiovascular disease
  • Uncommon in children
  • Variable AV conduction & irregular ventricular rate
  • Hypertension
  • Ischemia
  • Cardiomyopathy
  • Abnormal heart valve

Wide Complex

Ventricular Tachycardia (VT)

(assume this arrhythmia unless child is known to have aberrant conduction, then may be SVT)

  • Occurs in the ventricles
  • Uncommon in children,
  • VT with pulses can cause heart rate to vary from normal to 200bpm
  • Compromises stroke volume and cardiac output
  • Can deteriorate into VF or pulseless VT
  • Ventricular rate 120bpm & regular, P wave usually unidentifiable, T waves opposite in polarity to QRS
  • Disturbance to electrolytes
  • Drug toxicity
  • Prolonged QT syndrome
  • Myocarditis
  • Underlying heart disease

Polymorphic VT - Torsades de Pointes

  • Ventricular rate varies from 150 to 250bpm
  • QRS complex vary in appearance
  • Associated with conditions with prolonged baseline QT interval (identified during sinus rhythm)
  • Diarrhea
  • Hypomagnesaemia
  • Hypokalemia

Tachycardia Management

Initial management approach is directed by the answers provided to the following questions:

Question

Answer

Management

Is a pulse present or absent?

Present

Proceed to Tachycardia Algorithms

Absent

Begin Pediatric Pulseless Arrest Algorithm

Is perfusion adequate or poor?

Adequate

Begin Pediatric Tachycardia with Adequate Perfusion Algorithm, consider expert consultation

Poor

Begin Pediatric Tachycardia with Pulses and Poor Perfusion Algorithm (emergency interventions)

Is rhythm narrow or wide complex?

Narrow

Refer to ST vs. SVT differential

Wide

Refer to ST vs. SVT differential (treat as presumed VT unless child has known aberrant conduction)

The management priorities once an arrhythmia is identified are as follows:

  • Supporting ABCs
  • Monitor pulse oximetry
  • Attach defibrillator
  • Establish vascular access
  • Perform lab studies
  • Assess neurological status
  • Treat hypothermia
  • Be prepared to administer appropriate drugs

Emergency interventions include vagal maneuvers, synchronized cardioversion, pharmacologic therapy and expert consultation. The Tachycardia with Adequate Perfusion Algorithm below outlines the recommended management approach for children presenting with symptomatic tachycardia and adequate perfusion.

Tachycardia with Adequate Perfusion Algorithm

The following Tachycardia with Pulses and Poor Perfusion Algorithm defines the recommended assessment and management protocol for children presenting with symptomatic tachycardia and poor perfusion.

Tachycardia with Pulses and Poor Perfusion Algorithm

» Chapter 4: Recognizing and Managing Cardiac Arrest

Chapter 4: Recognizing and Managing Cardiac Arrest

Cardiac arrest is the cessation of normal circulation of the blood due to the heart's failure to contract effectively. Rapid recognition and management of respiratory distress, respiratory failure and shock are paramount to differing the occurrence of cardiac arrest. In children, cardiac arrest presents as either hypoxic/asphyxial arrest or sudden cardiac arrest (SCA).

  • Hypoxic/Asphyxial Arrest - result of inadequate oxygen flow to the tissues, most common pathophysiologic mechanism of cardiac arrest, preceded by cardiopulmonary failure.
  • Sudden Cardiac Arrest (SCA) - uncommon in children, associated with VF or pulseless VT, caused by anomalous coronary artery, hypertrophic cardiomyopathy, long QT syndrome, commotio cordis and myocarditis. Cardiovascular screening can sometimes prevent cardiac arrest; early and effective resuscitation is also a preventative of death.

Causes of Cardiac Arrest

The context, physical location of the cardiac arrest, the child's age and health are factors used to determine the underlying cause of the arrest. The most common corollaries are respiratory failure and hypotension. The following chart illustrates the common causes of cardiac arrest categorized by respiratory, shock or sudden cardiac etiologies.

Identifying Cardiac Arrest

Before a child digresses to cardiac arrest, he or she develops cardiopulmonary failure. Identifying cardiopulmonary failure promptly could alleviate the chances of cardiac arrest occurring. The primary assessment identifies signs indicating cardiopulmonary failure:

  • Airway - upper airway obstruction caused by a decrease in consciousness
  • Breathing - ineffective respirations and bradypnea
  • Circulation - delayed capillary refill time, weak central pulses, no peripheral pulses, cool extremities, bradycardia, hypotension and cyanosis
  • Disability - diminished level of consciousness
  • Exposure - address life-threatening conditions first

Looking for signs of cardiac arrest will also aid in rapid treatment and, hopefully, life saving measures. The primary assessment could reveal the following clinical signs of cardiac arrest:

  • Breathing - apnea or agonal gasps
  • Circulation - no pulses (less reliable of an assessment, rely on other signs as well)
  • Disability - unresponsiveness

One of the arrest rhythms (asystole, PEA, VF, pulseless VT, or torsades de pointes) will be present during cardiac arrest. Asystole and PEA are the most common initial rhythms, especially in children younger than 12 years old. VF/pulseless VT are more commonly associated with sudden collapse victims. The following chart summarizes the characteristics of each arrest rhythm:

Arrest Rhythm

Characteristics

Asystole

  • ECG: flat line
  • Unresponsive
  • No breathing
  • No pulse

PEA (organized electrical activity w/no palpable pulse)

  • ECG: low/high-amplitude T waves, prolonged PR & QT intervals, AV dissociation or complete heart block
  • Width of QRS complex can indicate etiology

VF ( pulseless arrest of ventricular rhythm)

  • No organized rhythm & no coordinated contractions
  • Heart does not pump blood
  • Primary VF is uncommon in children
  • Chaotic electrical activity

Pulseless VT ( pulseless arrest of ventricular rhythm)

  • Organized, wide QRS complexes

Torsades de Pointes ( polymorphic VT)

  • QRS complexes changes in polarity & amplitude
  • Ventricular rate ranges from 150-250bpm

Cardiac Arrest Management

The return of spontaneous circulation (ROSC), indicated by adequate perfusion and the presence of organized cardiac electrical activity, is the objective of cardiac arrest management. Successful management starts with effective CPR and is tailored to the cause of the cardiac arrest. The following chart is an overview of the appropriate responses to a pediatric cardiac arrest, depending on the situation of the occurrence.

Situation

Response Sequence

Unwitnessed, Lone Rescuer, Out-of-Hospital

1. Treat as asphyxial

2. Begin CPR with cycles of chest compressions & ventilations (2 minutes)

3. Activate ERS & get AED (if available)

4. Use AED after 5 cycles/2 minutes of CPR

Witnessed, Lone Rescuer, Out-of-Hospital

1. Treat as primary cardiac rhythm disturbance

2. Activate ERS & get AED (if available)

3. Provide 5 cycles/2 minutes of CPR, use AED if no pulse

In-Hospital

1. Send someone to active ERS & get code cart, simultaneously begin CPR

2. Attach and use defibrillator

Basic Life Support (BLS)

High-quality BLS techniques are the foundation of effective advanced life support measures. The chart below is a detailed review of the BLS ABCD maneuvers by age (some maneuvers are recommended to be completed only by healthcare providers, denoted by HCP).

Basic Life Support Maneuvers

Rescuer

Maneuver

Adult

≥ 8 years old

Child

1 to 8 years old

Infant

< 1 years old

ACTIVATE ERS

Activate when victim is found unresponsive

HCP: if asphyxial arrest likely, activate ERS after 5 cycles

Activate after performing 5 cycles of CPR.

For sudden, witnessed collapse, activate ERS after verifying child is unresponsive.

A IRWAY

Use head tilt-chin lift (HCP: suspected trauma use jaw thrust)

B REATHING

Check breathing; if absent or agonal, then:

Give 2 breaths about 1 second each

Rescue breathing w/o chest compressions (HCP)

10-12bpm

(about 1 breath every 5-6 seconds)

12-20bpm

(about 1 breath every 3-5 seconds)

Rescue breaths for CPR w/ advanced airway (HCP)

8-10 breaths/min

(about 1 breath every 6-8 seconds)

Foreign-body airway obstruction

Abdominal thrusts

Back slaps and chest thrusts

C IRCULATION

Check carotid pulse

Check brachial or femoral pulses

Compression Location

Center of chest, between nipples

Just below nipple line

Compression Method

2 Hands: Heel of 1 hand, other on top with fingers interlaced & elbows locked

2 Hands: Heel of 1 hand, other on top

1 Hand: Heel of 1 hand

1 rescuer: 2 fingers

2 rescuers (HCP): 2 thumbs-encircling hands

Compression Depth

1.5 to 2 inches

About 1/3 to 1/2 the depth of the chest

Compression Rate

Roughly 100/minute

Compression-to-Ventilation Ratio

30:2

(1 or 2 rescuers)

30:2 (1 rescuer)

HCP: 15:2 (2 rescuers)

D EFIBRILLATION (AED)

Use adult pads

For HCP: give 5 cycles of CPR before shock if arrest is not witnessed, & out-of-hospital

Use AED after 2 min of CPR (out-of-hospital). Use child pads if available.

For HCP: use AED asap for sudden collapses & in-hospital cases

Not Recommended






HCP = Health Care Provider

Advanced Life Support

Advanced management actions begin once a defibrillator is available; actions include rhythm assessment, shock delivery, establishing vascular access, providing pharmacologic therapy and placing advanced airways.

  • Rhythm Assessment - The child's rhythm will be either shockable or unshockable. Upon determination, the appropriate course of treatment can be administered (either the left or right side of the Pulseless Arrest Algorithm will direct management protocol).
  • Defibrillation - Once shock is delivered, CPR can begin immediately, starting with chest compressions. Patient should be cleared via a 3-part warning before a shock is delivered. Paddles are placed 3cm apart with the heart in between, one on upper right side of chest, below clavicle and the other on the left side of the left nipple over heart. Defibrillator should not be used around water, in oxygen-enriched environments, or directly over pacemaker or medication patch.
  • Establishing Vascular Access - access routes are established by priority and availability: IV, IO, ET tube.
  • Pharmacologic Therapy - the chart below outlines the applicable pharmacologic agents for cardiac arrest.

Category

Drug

Indications of Use

Vasopressors

Epinephrine

Resuscitation: increases coronary perfusion pressure

Vasopressin

Insufficient evidence to recommend for children during cardiac arrest

Antiarrhythmics

Amiodarone

Possible contributor to the treatment of shock-refractory or recurrent VF/VT; efficacy in pediatric cardiac arrest unknown

Lidocaine

Ventricular arrhythmias; efficacy in pediatric cardiac arrest unknown

Magnesium Sulfate

Torsades de Pointes; Hypomagnesemia; efficacy in pediatric cardiac arrest unknown

Other

Atropine

Bradyarrhythmias; efficacy in pediatric cardiac arrest unknown

Calcium

Ionized Hypocalcemia and Hyperkalemia; not recommended in pediatric cardiac arrest

Sodium Bicarbonate

Hyperkalemia, tricyclic antidepressant or other sodium blocking agent overdose; consider for prolonged cardiac arrest

  • Advanced Airway Placement - airways can be placed during CPR, and, once in place, 8-10 breaths should be provided per minute (1 breath every 6-8 seconds) without pauses for chest compressions and avoiding excessive ventilation. Direct laryngoscopy can be used to confirm tube placement if exhaled CO2 is not detectable with a colorimetric exhaled CO2 device.

The Pediatric Pulseless Arrest Algorithm is divided into two pathways, one for shockable rhythms (VF and pulseless VT) and one for nonshockable rhythms (asystole and PEA), including a summary of the recommended management techniques for each.

Pediatric Pulseless Arrest Algorithm

Management of Special Circumstances

Cardiac arrest arising from by trauma, drowning, anaphylaxis or toxins require special treatment methods. The chart at the end of this section is an overview of the management ABCDEs of three of these special circumstances.

  • Trauma , common in children, is caused by PEA from tension pneumothorax, cardiac tamponade or massive hemorrhage, upper cervical spinal injury combined with respiratory arrest, severe head injury, injury to vital structures and hypoxia secondary to respiratory arrest.
  • Drowning victims require immediate CPR. Children need to be removed from the water and body temperature warmed to at least 30°C so to support effective resuscitation efforts.
  • Providing CPR, administering volume and adrenergic drugs, best manages anaphylactic cases. Anaphylaxis caused cardiac arrest usually occurs in healthy children; most likely they will respond positively to vasodilatation correction and low intravascular volume.
  • Poisoning can directly or indirectly lead to cardiac arrest. Refer to the Pediatric Pulseless Arrest algorithm for treatment actions. Also, consult with a poison control center or toxicologist to identify and treat the cause of poisoning.

Management Techniques

Trauma

Drowning

Anaphylaxis

A irway

  • Use jaw-thrust maneuver
  • Manually stabilize head & neck
  • Open airway
  • Use manual maneuvers to open & maintain airway

B reathing

  • Ventilate w/bag-and-mask device using 100% oxygen
  • Avoid routine hyperventilation
  • Empiric bilateral needle decompression for tension pneumothorax
  • Seal significant pneumothorax
  • Ventilate w/bag-and-mask device using 100% oxygen
  • Be prepared to suction
  • Ventilate w/bag-and-mask device using 100% oxygen
  • If ET in place, be prepared for the occurrence of airway edema

C irculation

  • Perform CPR
  • Attach monitor/defibrillator
  • Stop hemorrhaging
  • Provide fluid resuscitation
  • Empiric pericardiocentesis for cardiac tamponade
  • Vasopressor therapy if suspected spinal shock
  • Perform high-quality CPR
  • Attach monitor/defibrillator
  • Avoid pacing if hypothermic (could induce VF)
  • Perform chest compressions
  • Administer large volumes of isotonic crystalloid (IV/IO)
  • Administer epinephrine in standard doses
  • Manage according to algorithm (asystole or PEA)

D isability

  • Maintain spinal immobilization
  • Maintain cervical spinal immobilization

E xposure

  • Maintain body temperature
  • Evaluate body temperature and heat if hypothermic

Factors that Affect Resuscitation Outcomes

  • Time from collapse until CPR or arrival of emergency personnel should be as short as possible.
  • Duration of resuscitation efforts - prolonged CPR can be effective and ineffective depending on underlying condition. It is usually ineffective, however, has been successful in hypothermic children for 30-60 minutes after arrest.
  • Cause of cardiac arrest plays a role in successful outcomes. For instance, PEA patients may have reversible causes that respond well to treatment, VF/pulseless VT patients are more likely to survive than asystole patients, and trauma induced out-of-hospital arrest and shock induced in-hospital arrest victims rarely survive.
  • Quality of CPR - high-quality CPR increases the likelihood of a positive outcome

Ethics in Resuscitation

If family is present during resuscitation efforts, special accommodations should be made:

  • One healthcare provider should act as the liaison between the family and the medical staff as resuscitation efforts are performed.
  • Plenty of space should be provided for the family.
  • Healthcare providers should always be aware that the family is present when communicating with each other.

Terminating resuscitation efforts depends on available resources and the likely cause and/or contributing factors of the arrest. Prolonged resuscitation efforts should continue if the child has recurring or refractory VF/VT, drug overdose or toxicity, or primary hypothermic insult.

» Chapter 5: Recognizing & Managing Shock

Chapter 5 -Recognizing & Managing Shock

When oxygen and nutrient delivery to the tissue becomes inadequate for metabolic needs, the body goes into shock. Specifically, shock can occur from impairment in heart contractility (cardiogenic shock), obstructed blood flow (obstructed shock), inadequate blood volume (hypovolemic shock) or erroneously distributed blood volume (distributive shock). When oxygen delivery to tissues is inadequate, the body extracts oxygen from the blood and can cause tissue hypoxia, anaerobic metabolism, and lactic acid accumulation. Tissue hypoxia causes are categorized as follows:

Hypoxemic

Decrease in arterial oxygen content

Anemic

Excessive blood loss (hemorrhage), excessive red blood cell destruction (hemolysis) or deficient red blood cell production (aplastic anemia or cancer), all abnormalities in the oxygen-carrying capacity of the blood

Ischemic

Low cardiac output (inadequate oxygen delivery to tissue due to insufficient blood flow)

Histotoxic (Cytotoxic)

Impaired cellular metabolic oxygen use, regardless of normal or increased oxygen delivery

The delivery of oxygen to tissues is contingent upon the oxygen content in the blood (determined by hemoglobin concentration and SaO2 level) and optimal blood flow to the tissues (determined by tissue metabolic needs and cardiac output). When tissue perfusion is inadequate, the body's compensatory mechanisms - tachycardia, increased systemic vascular resistance, increased strength of contractility and increased venous tone - are activated to meet the demands of the body and restore oxygen.

Cardiac output (CO) is determined by stroke volume (SV) and heart rate (HR). Preload, contractility and afterload comprise stroke volume and are defined in the chart below (CO = SV x HR).

Type of Shock

Preload

(volume of blood in ventricle before contraction)

Contractility

(strength behind contraction)

Afterload

(pressure generated by heart chambers to eject blood)

Hypovolemic

Decreased

Normal or Increased

Increased

Distributive

Normal or Decreased

Normal or Decreased

Variable

Septic

Decreased

Normal to Decreased

Variable

Cardiogenic

Variable

Decreased

Increased

Effects on Blood Pressure

Cardiac output and systemic vascular resistance determine blood pressure. Shock severity can be categorized based on the body's ability to maintain or inability to maintain normal systolic blood pressure. Compensated shock occurs when body is able to maintain normal systolic blood pressure by activating its compensatory mechanisms, increased heart rate, systemic vascular resistance and splanchnic vascular resistance, but still presents with poor tissue perfusion.

Marked tachycardia, nonexistent peripheral pulses, weakened central pulses, cold extremities, altered mental status or hypotension indicate that the patient is declining from compensated shock to hypotensive shock; this transition can occur over a few hours but further decline rapidly to cardiac arrest. Hypotensive shock occurs when the body is not able to maintain normal systolic blood pressure and presents with poor tissue perfusion and high SBP.

Types of Shock

The primary assessment of the pediatric assessment is used to help identify the type of shock.

  • Hypovolemic Shock - a decrease in blood or fluid volume caused by internal bleeding, diarrhea, vomiting, dehydration or severe burns. It is the most common cause of shock among children worldwide, and characterized by a decrease in preloading, resulting in reduced stroke volume and low cardiac output.
  • Distributive Shock - inadequate organ and tissue perfusion and incorrect distribution of blood volume, categorized into the most common forms: septic, anaphylactic and neurogenic.
  • Septic Shock - is defined as sepsis or cardiovascular dysfunction, characterized by hypotension or need for vasoactive drugs to maintain normal BP or inadequate organ perfusion. Signs of septic shock include those listed in the chart below in addition to metabolic acidosis, leucopenia, leukocytosis, respiratory alkalosis or increased bands.
  • Anaphylactic Shock - occurs from a hypersensitive reaction to drugs, food, poisons or plants. Signs include hypotension, anxiety, angiodema, nausea or vomiting, urticaria and tachycardia.
  • Neurogenic Shock - results from a head or spine injury that disrupts the sympathetic nervous system signal and causes uncontrolled vasodilation. Signs include hypotension with a wide pulse pressure, normal heart rate and bradycardia.
  • Cardiogenic Shock - inadequate tissue perfusion caused by myocardial dysfunction as a result of poor contractility, abnormal rhythms or congenital heart disease.
  • Obstructive Shock - blood flow obstruction that results in impaired cardiac output, categorized into 4 types below:
  • Cardiac Tamponade - accumulation of fluid in the pericardium. The heart's ventricles will not properly fill if fluid significantly elevates the pressure of the heart. If left untreated, cardiac tamponade results in low stroke volume and possible cardiac arrest presenting with PEA rhythm. Signs specific to cardiac tamponade include decrease in SBP by more than 10 mm Hg, distended neck vein and muffled heart sounds.
  • Tension Pneumothorax - occurs when air enters the pleural space; if this continues it creates positive intrathoracic pressure, which can lead to respiratory failure and cardiac arrest if not treated immediately and properly. Signs include diminished breath sounds, tracheal deviation toward contralateral side, rapid deterioration into perfusion and hyperresonance on affected side.
  • Ductal-Dependent Lesions - cardiac abnormalities that develop in the fetus, either as forms of cyanotic congenital heart disease or left ventricular outflow tract obstructive lesions, which present in obstructive shock in the first 2 weeks of life. Specific signs of left ventricular outflow tract obstructive lesions include congestive heart failure (CHF), preductal blood pressure and cyanosis, no femoral pulses, mental status deterioration, respiratory failure and rapid deterioration in systemic perfusion.
  • Massive Pulmonary Embolism - the complete or partial obstruction of the pulmonary artery or its branches. Subtle and nonspecific signs include tachycardia, CHF signs, cyanosis, and hypotension

The chart below summarizes the causes, signs and compensatory mechanisms for each type of shock.

Types of Shock

Causes

Type Specific Signs

Compensatory Mechanisms

Hypovolemic

(Blood or fluid loss)

Dehydration, third-space losses, diarrhea, vomiting, lack of fluid consumption, hemorrhaging & burns

Normal BP, weak peripheral & central pulses, tachypnea, tachycardia, diaphoretic skin, delayed capillary refill, changes in mental status & oliguria

Increased contractility, systemic vascular resistance and tachycardia

Distributive

(Vasogenic)

Infection activates inflammatory mediators (septic), hypersensitivity reaction (anaphylactic) & spine or head injury (neurogenic)

Hypotension with wide pulse pressure or narrow pulse pressure, quick or delayed capillary refill, flushed or pale skin with vasoconstriction & bounding peripheral pulses

Tachycardia and increased end-diastolic volume of the heart

Cardiogenic

(Failure of heart to pump adequately)

Myocarditis, arrhythmias,

myocardial injury, sepsis, congenital heart disease, cardiomyopathy & poisoning

Increased respiratory effort, cyanosis & congestive heart failure

Renal fluid retention, decreased stroke volume, & increased venous tone, heart rate, left ventricular afterload & systemic vascular resistance

Obstructive

(Impaired cardiac output)

Cardiac tamponade, tension pneumothorax, ductal-dependant lesions & massive pulmonary embolism

Increased respiratory effort, systemic or pulmonary venous congestion, cyanosis & vascular congestion

Shock Management

The trajectory of shock management is to restore oxygen delivery and improve tissue metabolic balance. Treatment focuses on optimizing blood oxygen content, reducing oxygen demand, fixing metabolic imbalances and improving cardiac output.

General shock management includes the following actions:

  • Administering oxygen
  • Monitoring
  • Attach defibrillator
  • Establish vascular access
  • Positioning
  • Fluid resuscitation
  • Reoccurring assessments
  • Pharmacologic administration
  • Expert consultation

Advanced shock management leverages invasive hemodynamic monitoring such as mean arterial pressure (MAP), central venous pressure (CVP) and mixed venous oxygen saturation (SMVO2) or central venous oxygen saturation (SVO2) to evaluate cardiac output and systemic vascular resistance.

The general goals of shock management are to reverse abnormalities, improve perfusion and tissue metabolic demand balance, restore organ function, and prevent cardiac arrest. These goals apply to all types of shock, however there are specific management recommendations for each type.

  • Hypovolemic Shock - Fluids need to be administered within the first hour and reassessed after the introduction of each new fluid. Type of volume loss categorization as nonhemorrhagic or hemorrhagic, preventing future losses and restoring acid-base balance are subsequent management actions. Isotonic crystalloid bolus infusion of 20 mL/kg (3 dose max) is recommended for both nonhemorrhagic and hemorrhagic shock. Hemorrhagic shock victims may warrant blood transfusion if they present with crystalloid-refractory hypotension or poor perfusion.
  • Distributive Shock - Focus is on restoring intravascular volume. Vasoconstrictors are recommended for low systemic vascular resistance and inotropic agents for contractility.
  • Septic Shock - the Septic Shock Algorithm is a thorough illustration of the recommended management protocol.

SEPTIC SHOCK ALGORITHM

  • Anaphylactic Shock - Reversing the blockage caused by the allergic reaction is the main focus of management. Pharmacologic treatments include epinephrine, albuterol, antihistamines and corticosteroids.
  • Neurogenic Shock - Specific management options are positioning the patient flat or head-down, regulating body temperature and administering vasopressors for fluid-refractory hypotension patients.
  • Cardiogenic Shock - Focus is on restoring adequate cardiac output and reducing metabolic demand. BiPAP and mechanical ventilation are treatment options to help reduce work of breathing. Fluids can also be administered, but slowly and carefully. Specifically, isotonic crystalloid infusions at 5-10 mL/kg are recommended as well as seeking an expert consultation.
  • Obstructive Shock - Focus is on identifying and treating the causes while supporting cardiovascular function, and restoring tissue perfusion. More specific management recommendations are tailored to the cause.
  • Cardiac Tamponade - pericardial drainage
  • Tension Pneumothorax - immediate needle decompression, then thoracostomy for chest tube placement
  • Ductal-Dependent Lesions - administering prostaglandin E1
  • Massive Pulmonary Embolism - expert consultation for echocardiography, CT or angiography, anticoagulants are the preferred pharmacologic agent

» Chapter 6: Postresuscitation Management

Chapter 6: Postresuscitation Management

Postresuscitation management monitors and supports patients post cardiac arrest, shock or respiratory failure resuscitation. Once ROSC is achieved, healthcare providers shift their focus to supporting ABCs, primarily applying tertiary assessment tools, and supporting multiple organ systems. The charts below detail each organ system, their goals, required assessments and management protocol.

Cardiovascular System Management

Postresuscitation management for the cardiovascular system is summarized in the chart below.

Cardiovascular System Goals, Assessment & Management

Priorities

  • Reduce metabolic demand
  • Control arrhythmias
  • Maintain adequate SpO2, PaO2, hemoglobin concentration, preload, normotension & systemic perfusion
  • Manage myocardial dysfunction

Assessment

Monitor

  • Heart rate & rhythm, blood & pulse pressure, SpO2 & urine output
  • If in critical care, monitor: CVP, SvO2 & cardiac function

Physical Exam

  • Repeat examination
  • Monitor end-organ function

Laboratory Tests

  • ABG, hemoglobin & hematocrit, serum glucose, electrolytes, BUN/creatinine, calcium
  • Consider lactate & central venous oxygen saturation

Non-Lab Tests

  • Get chest x-ray to evaluate heart size & ET tube depth
  • Evaluate 12-lead ECG (if arrhythmias or myocardial ischemia)
  • Consider echocardiogram if pericardial tamponade or myocardial dysfunction are concerns

Management Protocol

Intravascular Volume

  • Establish vascular access (2 if possible)
  • Administer fluid boluses (10-20 mL/kg of isotonic crystalloid, over 5-20 minutes)
  • Consider administering blood or colloid
  • Maintain fluid requirements

Blood Pressure

  • Treat hypotension, it could lead to multisystem injury
  • If hypotension is due to arrhythmia treat arrhythmia
  • If hypotension is due to sepsis use vasopressor

Tissue Oxygenation

  • Obtain & maintain adequate SpO2 levels with supplementary oxygen
  • Maintain hemoglobin concentration
  • Support adequate perfusion

Metabolic Demand

  • Use analgesia for pain & sedation for agitation
  • Use antipyretics for fever
  • Consider ET intubation to control work of breathing

Arrhythmias

  • Use cardioversion or medical therapy to control tachyarrhythmias or bradyarrhythmias
  • Expert consultation

Postarrest Myocardial Dysfunction

  • Maintain blood pressure and perfusion
  • Be aware of possible dysfunction 4-24 hours after ROSC
  • Consider administering vasoactive drugs to aid in hemodynamic function

Shock Postresuscitation Management

Shock postresuscitation management requires a specific set of assessment steps, which is illustrated in the Postarrest Shock Algorithm below.

POST ARREST SHOCK ALGORITHM HERE

Respiratory System Management

Postresuscitation management for the respiratory system is summarized in the chart below.

Respiratory System Goals, Assessment & Management

Priorities

  • Maintain ventilation (PaCO2 levels depend on clinical circumstances)
  • Maintain oxygenation (PaO2 >60mm Hg; SpO2 >90%)

Assessment

Monitor

  • Rhythm, Spo2 & heart rate (pulse oximetry)
  • Exhaled CO2 (colorimetric device) & end-tidal CO2 (capnography)
  • If intubated: check tube position, patency, and security

Physical Exam

  • Observe chest rise
  • Look for abnormal breath sounds & signs of respiratory compromise

Laboratory Tests

  • ABG (following ROSC or 10-15 minutes after ventilated)

Non-Lab Tests

  • Get chest x-ray to evaluate pulmonary issues & ET tube depth

Management Protocol

Oxygenation

  • Use non-breathing mask to provide oxygen until child's Spo2 level is obtained
  • Maintain SpO2 ≥ 90%; if level < 90% & on 100% inspired oxygen, consider ventilation
  • Adjust oxygen saturation if child has a cyanotic cardiac lesion

Ventilation

  • Target normal PaCO2 levels (not applicable in all situations)

Respiratory Failure

  • ET intubation if oxygen administration and ventilation efforts are not effective
  • Ventilator settings : 100% oxygen, 6-15 mL/kg tidal volume, 0.6-1 sec. inspiratory time, 20-35 cm H2O peak respiratory pressure, respiratory rate of 20-30 breaths/min (infants); 16-20 breaths/min (children); 8-10 breaths/min (adolescents), 2-5 cm H2O PEEP
  • Use "DOPE" mnemonic when a ventilated patient is deteriorating
  • Check for glottic air leak
  • Check ET tube position, patency & security
  • Use a gastric tube to help with gastric inflation

Analgesia & Sedation

  • Use analgesics & sedatives to control pain
  • Consider sedating responsive intubated patients

Neuromuscular Blockade

  • Administer neuromuscular blocking agents if patient has high peak or mean airway pressure, ventilator asynchrony or difficult airway, but only after ruling out DOPE

Neurologic System Management

Postresuscitation management for the neurologic system is summarized in the chart below.

Neurologic System Goals, Assessment & Management

Priorities

  • Treat ICP
  • Maintain brain perfusion, normoglycemia & normal body temperatures
  • Identify & treat causes of seizures

Assessment

Monitor

  • Temperature

Physical Exam

  • Perform neurological assessments
  • ID: signs of cerebral herniation, seizure activity & abnormal neurologic findings

Laboratory Tests

  • Test glucose
  • Obtain serum electrolytes & calcium concentrations (seizure)
  • Consider toxicological studies (poisoning) &/or cerebral spinal fluid test (CNS infection)

Non-Lab Tests

  • Consider CT scan (CNS dysfunction or neurologic deterioration) &/or EEG (epilepticus)

Management Protocol

Brain Perfusion

  • Optimize brain perfusion (preload, afterload and contractility)
  • Avoid hyperventilation unless signs of impending cerebral herniation present

Blood Glucose

  • Treat hypoglycemia
  • Monitor glucose concentration

Temperature Control

  • Control hypothermia
  • Control hyperthermia

Increased ICP

  • Ventilate to maintain normocarbia
  • If BP adequate, elevate head of bed to 30º; keep head midline
  • If signs of impending cerebral herniation present, use short periods of hyperventilation
  • Administer mannitol or hypertonic saline (if herniation syndrome)
  • Consider administering steroids (CNS tumor, inflammatory process)
  • Expert consultation if GCD score < 13 or rapid deterioration

Seizures

  • Possible treatment options: benzodiazepine, phenytoin or barbiturate
  • Search for possible causes (hypoglycemia, electrolyte imbalance)
  • Consider toxins & metabolic disease as etiology
  • Expert consultation

Renal System Management

Postresuscitation management for the renal system is summarized in the chart below.

Renal System Goals, Assessment & Management

Priorities

  • Correct acid-base imbalance
  • Optimize renal perfusion & function

Assessment

Monitor

  • Decreased urine output (<1 mL/kg per hour for infants & children or <30 mL/hr in adolescents) AND Increased urine output

Physical Exam

  • Abdomen for distended bladder
  • Evidence of hypovolemia & circulatory dysfunction
  • Ensure urine catheter patency

Laboratory Tests

  • BUN/creatinine, serum electrolytes (renal function), & urinalysis
  • ABG, serum glucose, anion gap & lactate concentration (metabolic state)

Management Protocol

Renal Function

  • Administer vasoactive drugs to restore intravascular volume
  • Add KCI to IV fluids (if function is poor or no urine output)
  • Administer loop diuretics (if volume overload/congestive heart failure & normal BP)
  • Avoid nephrotoxic medications

Acid-Base Balance

  • Administer fluids & vasoactive drugs to improve tissue perfusion
  • Administer sodium bicarbonate to correct non-anion gap metabolic acidosis (not indicated for hyperchloremic metabolic acidosis)

Hematologic System Management

Postresuscitation management for the hematologic system is summarized in the chart below.

Hematologic System Goals, Assessment & Management

Priorities

  • Restore adequate oxygen-carrying capacity & coagulation function
  • Treat significant hemorrhage

Assessment

Physical Exam

  • ID hemorrhaging
  • Assess skin & mucous membranes (pallor, petechiae or bruising)

Laboratory Tests

  • Hemoglobin & hematocrit platelet count, prothrombin time, partial prothrombin time, INR, fibrinogen, D-dimer & fibrin split products

Management Protocol

Blood Component Therapy

  • Transfuse with PRBCs 10 mL/kg (if hemorrhagic shock is refractory to isotonic crystalloid - 2 or 3 boluses of 20 mL/kg)
  • Type-specific blood is preferred over O-negative transfusions
  • Platelet transfusions are indicated if:
  • Severe bleeding & platelet count is <50,000 to 100,000/mm3
  • At risk of bleeding & platelet count <20,000/mm3
  • Platelets should be ABO & Rh compatible & crossmatching is not necessary,
  • One unit of donated platelets per 5 kg body weight will increase platelet count by 50,000/mm3 (fresh frozen plasma does not contain platelets)

Gastrointestinal System Management

Postresuscitation management for the gastrointestinal system is summarized in the chart below.

Gastrointestinal System Goals, Assessment & Management

Priorities

  • Correct electrolyte abnormalities
  • Support systemic perfusion
  • Relieve gastric distention
  • Support hepatic function

Assessment

Monitor

  • Type & quality of nasogastric (NG) tube drainage

Physical Exam

  • Perform abdomen exam, focus on bowel sounds, size and tightness

Laboratory Tests

  • Evaluate liver function: Transaminases (ALT/AST), Biliary function, Synthetic function (albumin, PT/PTT), Glucose & Ammonia (for liver failure concerns)
  • Evaluate pancreatic function: Amylase/lipase

Non-Lab Tests

  • Consider ultrasound &/or abdominal CT scan

Management Protocol

Ileus

  • Restore & maintain electrolyte & fluid balance
  • Place OG or NG tube, aspirate gastric contents (aspirate via NG tube regularly)

Gastric Distension

  • Place OG or NG tube, aspirate stomach air & contents

Hepatic Failure

  • Maintain normal glucose concentrations
  • Correct clotting factor deficiency

Patient Transportation

The following tasks need to be completed prior to transporting an ill or injured patient to an adjunct healthcare facility:

  • Transferring facility should coordinate with receiving facility that they have the resources available to care for the patient. Contracts, documentation, and protocol agreements need to be finalized beforehand.
  • Attending and receiving physicians should discuss the patient's needs, condition, and their concerns before transferring patient.
  • Transfer requests are made once both facilities are prepared to release and receive patient.
  • A team will accompany the patient during transfer, either EMS personnel, staff from receiving hospital, or critical care teams (pediatric specifically trained teams are preferred when available).
  • The patient will need to be prepped for transport by establishing a secure airway, taping ET tube and catheters, and stabilizing spine or fractured bones.
  • Patient charts, x-rays, and blood supplies should be exchanged; transporting personnel should be notified if patient is suspected of having an infectious disease.
  • Healthcare provider follow-up with receiving facility is protocol and those updates should then be relayed to family and other participating healthcare providers. Documentation is made throughout and after transport.

The mode of transportation is primarily determined by the patient's condition and care needs. The advantages and disadvantages of transportation options are described in the chart below.

Mode of Transportation

Advantages

Disadvantages

Ambulance

Inexpensive, spacious, can stop for emergency procedures & it operates in most weather conditions

Transport time is effected by distance & traffic

Helicopter

Good for long travel distances, quick & avoids traffic delays

Harder to monitor patient & perform emergency procedures, not pressurized, expensive, & limited by weather

Fixed-Wing Aircraft

Intervention & monitoring of patient is accessible, quick, good for long distances or remote travel, pressurized, & can land at controlled sites

Delayed take off time, interim transportation needed from healthcare facility to plane to receiving facility