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Pediatric Advanced Life Support 2005 Update

www.nursesed.net Toll Free 866.266.2229

Copyright 2005 2

PALS Course Agenda

Day One - Recertifying Student and Certifying Student returns for Day Two 8:00 Welcome 8:15 AHA Overview Video 8:45 2005 BLS Presentation/Practice/Skills Check-off 9:30 AHA Video of anatomical differences of child/adult 10:00 Break 10:15 Instructor presentation of oxygen administration and airway

adjuncts and skills 10:45 ECG Interpretation and skills 11:00 AHA IO Video and skills 11:30 AHA Video of cardiac arrest 12:00 Lunch 13:00 Instructor presentation of Team Roles and Team Dynamics in

cardiac arrest, bradycardia and SVT 13:30 Student skills return of cardiac arrest, bradycardia and SVT 14:30 AHA Video of Pediatric Assessment 14:45 Instructor presentation of Pediatric Assessment 15:30 AHA Video with student management of core cases 16:00 Written evaluation and remediation Day Two - Return of Certifying Student 8:00 AAP Video of Assessing a child with Appearance WOB Circulation 8:30 Mega-code of Ventricular Fibrillation/PEA Bradycardia/Asystole SVT/Stable and Unstable 9:00 Management of Core Cases 9:30 Written Evaluation and remediation

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PALS Course Overview

The PALS Provider Course is designed to aid the pediatric healthcare provider:

♥♥ Recognize an infant or child requiring Advanced Life Support

♥♥ Learn to apply the “Assess, Categorize, Decide, Act” model

♥♥ Learn the importance of effective CPR for cardiac arrest

♥♥ Learn the importance of effective team interaction

The cognitive skills to be accomplished in this class are as follows:

♥♥ Recognition and management of circulatory and respiratory emergencies

♥♥ Identification and treatment of rhythm disturbances

♥♥ Drug administration ♥♥ Use of PALS algorithms and flow charts

The psychomotor skills to be accomplished in this class are as follows:

♥♥ BLS ♥♥ Airway management ♥♥ Intraosseous access ♥♥ Fluid and drug delivery ♥♥ Team performance

A team resuscitation approach promotes successful outcomes

♥♥ The team leader is responsible for insuring things are done right.

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♥♥ The team members are proficient in their skills within their scope of practice.

♥♥ Effective team work and communication increases resuscitation success.

To help you achieve these objective the PALS Provider Course includes Skills Stations and Learning Stations. There are three Skills Stations:

♥♥ Management of Respiratory Emergencies ♥♥ Management of Circulatory Emergencies ♥♥ Vascular Access (optional)

The Learning Stations you will actively participate in are as follows:

♥♥ Pulseless Arrest Ventricular Fibrillation Pulseless Ventricular Tachycardia Asystole Pulesess Electrical Activity

♥♥ Tachyarrthythmias ♥♥ Bradyarrhythmias ♥♥ Respiratory Emergencies

Upper airway obstruction Lower airway obstruction Lung tissue disease Disordered control of breathing

♥♥ Shock Hypovolemic Obstructive Distributive/Septic Cardiogenic

Make sure you are proficient in BLS skills before attending the course. The following skills will be tested:

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♥♥ Child one rescuer CPR/AED ♥♥ Infant one and two rescuer CPR

You must past the written test with a minimum score of 84%. You must perform effectively as a team leader for two core case testing stations:

♥♥ One cardiorespiratory arrest or rhythm disturbance case

♥♥ One respiratory or shock case

Scientific Evidence Based

The American Heart Association updates their scientific materials every 5 years and all materials are evidenced based. The following data was collecting:

♥♥ Survival from out-of-hospital cardiac arrest are as follows:

6.4% for adult 5-12% for children

♥♥ Survival from in hospital cardiac arrest are as follows:

20% for adults 27% for children

“High Quality CPR” does make a difference. Continuous effective CPR is the foundation of successful Pediatric Advanced Life Support and must never be compromised. The core principles are as follows:

♥♥ Push hard the distance from the anterior to posterior chest by 1/3

♥♥ Push fast at a rate of 100 X minute ♥♥ Allow the chest to recoil ♥♥ Avoid hyperventilation

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Effective chest compressions increases Coronary Perfusion Pressure

♥♥ The greater the coronary perfusion pressure accomplished during chest compressions - the better the chances of survival.

♥♥ When chest compressions are interrupted coronary perfusion pressure drops.

Ventilation may be harmful if:

♥♥ Given with too much tidal volume ♥♥ Given to forcefully ♥♥ Given with hyperventilation

Advanced Resuscitation Management

Skills require OPA, NPA, suction tubing, ET tubes, CO2, laryngoscopes demonstration. One out of every four children who arrest in the hospital have a shockable rhythm. The longer the interval between arrest and defibrillation the lower the chance of survival. By-stander CPR in the first few minutes of arrest increases the chance of survival. Defibrillation in the hospital can be accomplished with the AED or manual defibrillation. The new 2005 guidelines indicate only a single shock rather than escalating shock as indicated in the past. Biphasic defibrillation has a greater success rate than monophasic defibrillation. The post-shock rhythm is typically a non perfusing rhythm and therefore, CPR is needed until a perfusing rhythm is accomplished. The heart is ischemic and hi-quality CPR is needed before attempting another shock. No pulse checks are done after defibrillation No rhythm checks are done after defibrillation

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CPR must be initiated promptly after defibrillation Pulseless arrest is organized around 2 minutes of CPR then pulse checks and rhythm checks are done. Limit interruption.

♥♥ Shock as needed ♥♥ Rotate compressors ♥♥ Establish IV/IO access ♥♥ Give drugs ♥♥ Consider advanced airway

Pulseless Arrest with a Shockable Rhythm begins with CPR until the AED/defibrillator arrives. When the AED/defibrillator arrives:

♥♥ Check the rhythm ♥♥ If VF or pulseless VT give 1 shock

Manual 2 j/kg AED >1year

♥♥ Resume CPR for 2 minutes. During these 2 minutes establish IV/IO access and prepare epinephrine dose.

IV/IO = 0.01 mg/kg of a 1:10;000 solution which will be 0.1 ml/kg ET = 0.1 mg/kg of a 1:1:000 solution which will be 0.1 ml/kg

May repeat every 3-5 minutes ♥♥ CPR in only interrupted for advanced airway and

shock ♥♥ Keep safe!

I’m clear You’re clear Oxygen clear

Asystole and PEA are not shockable rhythms.

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♥♥ Give high-quality CPR ♥♥ Obtain a vascular access ♥♥ Prepare and give Epinephrine

IV/IO = 0.01 mg/kg of a 1:10:000 solution which will be 0.1 ml/kg ET = 0.1 mg/kg of a 1:1:000 solution which will be 0.1 ml/kg

May repeat every 3-5 minutes ♥♥ Continue CPR for 2 minutes ♥♥ Recheck the rhythm ♥♥ Recheck the pulse ♥♥ Look for reversible causes

Advanced Airway placement.

♥♥ Team leaders need to determine appropriate time for advanced airway.

♥♥ Cuffed tubes are as safe as uncuffed. Cuffed ET tubes require cuff pressures to be monitored.

♥♥ Verify tube placement clinically Mist or fog present in the tube No epigastric sounds during BMV Bilateral breath sounds heard

♥♥ Verify tube placement with the CO2 detector “gold is good.”

♥♥ Verify tube placement during and after transport. Drug Administration

♥♥ IV/IO is preferred ♥♥ ET administration results in unpredictable drug

absorption and effect. ♥♥ Us ET only if IV/IO access is unattainable.

Optimal doses are unknown but you may increase the IV/IO dose by 2-3 times.

♥♥ Flush with 5 ml of NS

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♥♥ Follow with 5 breaths ♥♥ High-dose epinephrine is no longer

recommended. High-dose epinephrine can be harmful and unlikely to be helpful. Consider high dose epinephrine for beta blocker overdose.

Post Resuscitation Care

♥♥ Children of postresuscitation will have poor cardiac function.

♥♥ Monitor temperature and treat fever aggressively ♥♥ Consider hypothermia for infants that are

hymodynamically stable.

Skills Stations for Child and Infant CPR/AED You are at a children’s camp picnic and you see a 7 year old suddenly collapse. You have and AED in the camp office and you have a pocket mask with you. Respond appropriately. You are in the hospital when you notice a child in his mother’s arms that suddenly stiffens. Mother cries out “My baby stopped breathing!” There is no evidence of trauma.

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1. Child: 1 rescuer CPR and AED __Checks for response __Activates emergency response __Opens the airway & Checks for breathing __Gives 2 breaths with chest rise __Checks for carotid pulse __Delivers chest compressions 30:2 __Gives 2 breaths with chest rise __Powers on AED when arrives __Selects proper pads and placement __Clears and delivers shock __Begins chest compressions 100/min __[ ] Pass __ [NR] _____Instructor signature 2. Infant 1- and 2-rescuer CPR __Checks for response __Activates emergency response __Opens the airway & checks for breathing __Gives 2 breaths with chest rise with bag/mask __Checks for brachial pulse __Delivers chest compressions 30:2 with fingers __Gives 2 breaths with chest rise __Second rescuer takes over bag/mask and first rescuer continues chest compressions at 15:2 __15:2 chest compressions with pause for ventilations

[ ] Pass [NR] Instructor signature

Clear the victim to allow AED to analyze rhythm. If the AED recommends a shock, attempt to defibrillate using the AED* Check for brachial pulse. An infant with a heart rate less than 60/min despite high flow oxygen requires chest compressions.* The effectiveness of bag/mask ventilation can be evaluated by visible chest rise.]

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Anatomical Differences of Children and Adults The following are the unique attributes of a child’s airway:

♥♥ Airways for children and infants are considerable smaller than adults.

♥♥ Adult larynx is cylindrical with narrowest opening is at the vocal cords. In contrast, the larynx of infant and children taper into a funnel shape.

♥♥ The child’s airway continues to narrow below the vocal cords to the cricoid cartilage.

♥♥ With infants and toddlers the larynx is positioned more superior compared to adults.

♥♥ In addition, the tongue and epiglottis are relatively large.

♥♥ Prominate vagal tone predisposes to bradycardia. ♥♥ Note the airway is always anterior to the

esophagus and the cricoid cartilage is the only complete cartilage ring located below the vocal cords of all ages.

♥♥ High-flow and low-flow oxygen delivery systems This part is not on the video but appears in the skills stations and needs to be verbalized

In your “Management of Respiratory Emergencies Skills Station” you must verbalize the difference between high-flow and low-flow oxygen delivery systems.

♥♥ High flow (>10 L/min). O2 flow exceeds patient inspiratory flow, preventing entrainment of room air if system is tight-fitting; delivers up to 95% FIO2 can be achieved with a nonrebreather with a reservoir.

♥♥ Low flow (< 10 L/min). Patient inspiratory flow exceeds O2 flow, allowing entrainment of room

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air; delivers up to 0.23 FIO2 and can be achieved with a nasal cannula or simple mask.

♥♥ Maximum nasal cannula flow rate is 4 L/min.

Advanced Airways

The following techniques for maintaining airways will be discussed:

♥♥ Bag/Mask Ventilation ♥♥ Oral Airway Insertion ♥♥ Endotracheal Intubation ♥♥ Laryngeal mask airway insertion

Bag/Mask ventilation is an essential life support intervention. One rescuer bag/mask ventilation is accomplished with the following techniques:

♥♥ Open the airway and seal mask to the face. ♥♥ Appropriate size mask extends from bridge of

the nose to the base of the chin. ♥♥ The E-C technique uses the 3rd, 4th, and 5th

fingers to represent the “E” to lift the jaw upward. The thumb and forefinger represents the “C” to seal mask to the face.

♥♥ Lift jaw toward the mask rather than pushing the mask to the face.

♥♥ Take care not to push on the soft tissue under the chin.

♥♥ Ventilate 1 breath over 1 second and assuring that there is adequate chest rise.

♥♥ Suspected trauma patients require a jaw thrust maneuver to open the airway while maintaining cervical spine immobilization and provide rescue breathing.

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Endotracheal Intubation When endotracheal intubation is preformed reliable oxygen is delivered to the lungs with less risk for gastric distention.

If trauma is suspected cervical spine immobilization must be maintained during intubation. To select the proper ET tube size and proper drug dose administration a length based tape is used to measure from the top of the head to the heel. Test suction equipment prior to intubation. Place the child in the “sniffing position”

♥♥ Alignment for infants can be achieved by placing a folded towel or pad under the shoulders and torso.

♥♥ The opening of the ear shoulder be even with the height of the shoulder.

♥♥ For older children, place a folded towel or pad beneath the head.

Preoxygenate should be provided prior to intubation. Suction the oropharynx if necessary. Laryngoscope blades can be straight or curved.

♥♥ Hold handle in left hand. ♥♥ Open mouth with right hand. ♥♥ Insert blade into mouth and follow the natural

curvature of the pharynx. ♥♥ Sweep the tongue to the left as you reach the

base of the tongue. ♥♥ When the epiglottis is visualized, the tip of the

blade may be used to lift the epiglottis. ♥♥ Do not rock.

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♥♥ Avoid pressure on upper lip and gum. ♥♥ An assistant may apply cricoid pressure to bring

the glottic opening into view. ♥♥ Assistant may apply pressure on right corner of

mouth. ♥♥ Insert tracheal tube from right corner of the

mouth. ♥♥ Do not insert ET tube down the barrel of the

laryngoscope because it will obstruct your view. ♥♥ Note epiglottic marker on the ET tube that

designates the correct depth of the ET. The marker should be at the level of the vocal cords.

♥♥ Begin PPV when ET tube is place. ♥♥ Watch for symmetrical chest rise. ♥♥ Listen for bilateral breath sounds. Breath sounds

heard only on the right side indicates that right mainstem intubation has occurred. Withdraw the ET tube until bilateral breath sounds are heard.

♥♥ Confirmation to assure proper placement can be accomplished with a CO2 detector after 6 ventilations.

♥♥ Secure the tube with tape and liquid adhesive.

Trouble Shooting

The ET tube will be hooked up to a mechanical ventilator for continuous ventilations with preset pressures. If the mechanical ventilator alarms you must “trouble shoot” to intervene. Always begin with bag/mask ventilation with 100% oxygen while determining the reason for the alarm.* Use the DOPE pneumonic to assist you in this process.

♥♥ D = Displacement. The tracheal tube can migrate into the right mainstem or displace out of the trachea.

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♥♥ O = Obstruction. The ET can become kinked or become blocked by secretions.

♥♥ P = Pneumothorax. Check for bilateral chest wall movement and changes in exhaled CO2. Keep in mind that children may not show tracheal deviations like seen with adults. Breath sounds absent on one side without chest rise plus a SpO2 that is falling is an indication of tension pneumothorax.*

♥♥ E = Equipment failure. To check for equipment failure, disconnect from the mechanical ventilator and begin bagging. If the patient improves the problem is probably equipment failure.

Oral Airway Insertion

If your child is unconscious and does not have an ET tube in place, you should maintain the airway with an OPA (orophyarngeal airway). The following guidelines will be helpful to insert an OPA.

♥♥ To choose the appropriate size the OPA should measure from the corner of the mouth to the angle of the jaw.

♥♥ An OPA that is to large can block the airway and an OPA that is too small can cause the tongue to obstruct the airway.

♥♥ Use a tongue blade to depress the tongue. ♥♥ Never use an OPA for a conscious patient. It

may stimulate the gag reflex and the patient may vomit.

If your child is semiunconscious, you should maintain the airway with a NPA (nasopharyngeal airway). The following guidelines will be helpful to insert a NPA.

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3. Management of Respiratory Emergencies Skills Station __Verbalizes the difference of high-flow and low-flow O2 __Verbalizes the maximum flow rate for nasal cannula is 4L/min __Opens the airway with head-tilt while keeping mouth open __Verbalizes the different indications for OPA and NPA __Inserts the OPA __Looks, listens, feels for breathing with the OPA __Suctions the OPA – not to exceed 10 sec __Selects correct mask size __Performs EC technique __States equipment for ET placement __States confirmation for ET placement __Secures the ET tube __Suctions the ET tube __ Use of DOPE pneumonic

♥♥ To choose the appropriate size the NPA should measure from the tip of the nose to the tragus of the ear.

♥♥ The Outside diameter of the NPA should be less than the diameter of the nostril.

♥♥ Lubricate the NPA and advance tip along floor of nasal cavity

LMA (Laryngeal Masks Airway) may also be used to secure the airway. The following guidelines will be helpful to insert a LMA:

♥♥ Deflate the cuff ♥♥ Lubricate ♥♥ Introduce into the pharynx with the “indentation

part” directed to the tongue and advance so that it will obstruct the esophagus.

♥♥ Then inflate the LMA which seals the hypopharynix.

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ECG Interpretation

When the electricity goes through the heart it travels from the SA node to the AV node. As that occurs it causes the atrium to contract and a P wave appears on the EKG paper. When the electricity travels on through the Bundle Branches it causes the ventricles to contract and the QRS complex appears. When the heart goes through its resting phase the T wave appears. If you have a P wave, QRS complex, and a T wave – you have a Sinus Rhythm.

There are several ways to determine the rate of the rhythm. Your NEO instructor will show you the following way in class. Memorize the numbers in red on the next page. You may want to memorize them in groups of three. (300-150-100) (75-60-50) Then find a complex that lands on a bold line. Go to the next bold line and say “300,” then “150,” then “100,” then “75,” then “60.” The second complex landed between 60 and 75. In resuscitation, Approximate rates are all that you need to know.

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Practice the Rhythm

Are there P waves? _______________ Are there T waves? ______________ What is the rate? ___________________ This is a normal sinus rhythm.

Are there P waves? _______________ Are there T waves? ______________ What is the rate? ___________________ A sinus tachycardia usually does not exceed a rate of 180/ bpm for children and does not exceed 220/bpm for infants. Rates greater than 180 and 220 bpm is referred to as a supraventricular tachycardia The most important principle in managing a sinus tachycardia is identify the cause such as hypovolemia, pain, fever and/or agitation.

Are there P waves? _______________ Are there T waves? ______________ What is the rate? ___________________ A rate of less than 60 beats per minute is a Sinus Bradycardia . A Bradycardia with poor perfusion in the child is an ominous sign and requires immediate CPR with bag/mask ventilation. The drug for a sinus bradycardia of is epinephrine at 0.01 mg/kg of a 10:000 solution.

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This is a First Degree Block because the PR interval is greater than 0.20 seconds. ♥♥ Each little box measures 0.04 seconds. There are 8 little boxes from

the beginning of the P to the beginning of the Q. ♥♥ The PR interval in this strip is 8 x .04 = .32 seconds. ♥♥ This heart rate is about 40 bpm. If this patient is symptomatic and

probably is, begin chest compressions with bag/mask ventilation.

This is a Mobitz I, Second Degree Block. It is also called the Wenckebach. ♥♥ The PR interval progressively lengthens until a QRS complex is

dropped. ♥♥ The patient has a heart rate of about 60 bpm.

This is a Mobitz II, Second Degree Block. The QRS complexes are dropped following some of the P waves. ♥♥ There is no progression of PR intervals as in the Mobitz I. ♥♥ This is a serious situation!! ♥♥ This requires a Transcutaneous Pacemaker.

The drug of choice to increase the heart rate from a heart block or vagal induced bradycardia is Atropine rather than epinephrine. It is also used to assist in rapid sequence intubation. The dose varies depending of the indications. 20

This is an Asystole. It is also referred to as an agonal rhythm. You must not call this a Flat Line. A Flat Line occurs when the leads come off your patient. An Asystole occurs when the heart dies. To confirm the difference between asystole and flat line – turn up the gain or sensitivity on your monitor. Keep up with your CPR. Try some Epinephrine 0.01 mg/kg of a 1:10,000 solution

This a Third Degree/Complete Heart Block. The atriums are working. The ventricles are working. But they are not working together. The P wave does not cause the QRS complex to occur. There is a complete block. This is serious. Your patient will require a Transcutaneous Pacemaker.

This is a fibrillating heart and often referred to as a Ventricular Fibrillation *– sometimes called a VF There is no pumping action with a fibrillating heart.*. To defibrillate a fibrillating heart - shock it to stop it. Like rebooting your computer!!! There would be no value of shocking an Asystole because an asystole is a heart that is already stopped. This rhythm is appropriate to defibrillate.

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This is a Torsades de Pointes. This is a rhythm that is “wide and ugly.” Wide and ugly is usually ventricular in origin. Look closely at this rhythm – it appears in groups. That indicates it is “jumping its focus.” Magnesium is the drug of choice.

This is a rhythm strip showing defibrillation.

This is artifact and 60 cycle. ♥♥ Artifact occurs with leads that become loose on the

chest. ♥♥ 60 cycle occurs with interference with electrical tooth

brushes or razors. Do not defibrillate this patient!! Artifact can look like ventricular fibrillation!!!

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Most children who develop VT have an underlying heart disease, electrolyte disturbances and/or drug toxicity. Therefore, if a child has a VT and cardioversion is unsuccessful, you should consider the metabolic or toxic causes. Toxic exposures resulting in injury death are significant problems for healthcare providers of the Emergency Department or critical care. The following are toxic exposures that may cause ventricular tachyarrhythmias:

Cocaine Toxicity – symptoms of ACS Antidepressant Toxicity – from adult presciption Calcium Channel Blocker Toxicity – from Diltiazem Beta-Adrenergic Blocker Toxicity –from the “lol’s” Opiate Toxicity – from codeine, hydrocodone, oxycodone

This is called a polymorphic tachycardia. This is another tachycardia that is “wide and ugly!!” Wide and ugly is usually ventricular in origin. The complexes are irregular.

This is called a monomorphic tachycardia. This is another tachycardia that is “wide and ugly!!” This may or may not be ventricular in origin. The complexes here are uniform. There are two rules about wide complex tachycardias.

Rule #1 – Always assume they are ventricular in origin until proven otherwise.

Rule #2 – Don’t forget Rule #1

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Combination of sodium channel blockers beta blockers.

This is an atrial tachycardia that originates in the atria and also called a Supraventricular Tachycardia (SVT), The rate is about 300 bpm. There are no P waves or T waves. It is the sinus tachycardias that have Ps and Ts but not the SVTs

Manage the patient with SVTs by determining if the child is stable or unstable. Stable = vagel and consider Adenosine Adenosine = 0.1 mg/kg rapidly

repeat if needed at 0.2mg/kg Unstable = consider Adenosine and/or cardiovert.

A child with a delayed cap refill without distal pulses would be unstable.* The initial dose for cardioversion is 0.5 J/kg to 1 J/kg and the subsequent dose is 2 J/kg.*

This is a “wide-complex” tachycardia. Assume it is ventricular in origin until you prove otherwise. Therefore, this is a ventricular tachycardia.. ♥♥ If the patient is stable you should consider Amiodarone for

treatment. ♥♥ If the patient is unstable you should check his pulse.

♥♥ If he is unstable with a pulse you would need to cardiovert. ♥♥ If there is no pulse this is a pulseless ventricular tachycardia and

you need to defibrillate.

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Defibrillation

For an unwitnessed child with no pulse, perform 2 minutes of high-quality CPR first. Then proceed with the following steps to defibrillate: ♥♥ Apply sticky pads or paddles on the chest – one on the

right and one on the left. If the chest is small and you are using sticky pads, you may place one on the chest and one on the back.

♥♥ Put the defibrillator in the defibrillating mode. ♥♥ Choose your joules – 2 j/kg initially and 4 j/kg

subsequently. ♥♥ Charge the defibrillator.. ♥♥ Keep yourself safe – “I’m clear, You’re clear, Oxygen

clear” ♥♥ Defibrillate by pushing the shock button ♥♥ Return to CPR without checking for pulse or reanalyzing

Cardioversion

If you have decided to cardiovert – let’s get ready.

♥♥ Airway – airway – airway!! Always secure the airway. ♥♥ Oropharyngeal for the unconscious ♥♥ Nasophayrngeal for the semiconscious ♥♥ BMV ready with oxygen source. ♥♥ Make sure your suction is ready for use ♥♥ Better have an IV ♥♥ Automatic blood pressure cuff would be cool ♥♥ Surely your patient is being monitored ♥♥ Better have the crash cart available ♥♥ Do you have time for a 12-lead and a chest film?

Let’s get set ♥♥ Premedicate with a sedative plus analgesic. Versed is cool.

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♥♥ Turn on the defibrillator ♥♥ Attach monitor leads on the patient “white on right”

“smoke (black) over fire (red)” ♥♥ Put the defibrillator in the sync mode ♥♥ Look for markers on the R wave indicating sync mode ♥♥ Adjust monitor gain if necessary until sync markers occur

with each R wave. ♥♥ Are the conductor pads in place? Usually cardioversion is

not done with hand held paddles. ♥♥ Make sure the lead select switch is in the lead I, II, III

position and not the “paddle” position. ♥♥ Select the energy dose for the specific type of rhythm. ♥♥ An initial energy dose is 0.5 j/kg – 1 j/kg initially and

2 j/kg subsequently.

Go ♥♥ Charge the defibrillator and announce what you are doing.

I’m clear – You’re clear - Oxygen clear ♥♥ Depress the discharge button.. ♥♥ Check the monitor. - Check the patient. ♥♥ You may have to up the joules and reattempt.

Intraosseous Access

IO skills station is optional. Intraosseous (IO) access is a life saving technique that provides a raped vascular access and recognized as safe and effective for use in resuscitation attempts for all ages.

♥♥ Medications injected via IO can rapidly reach the central circulation.

5. Rhythm Disturbance/Electrical Therapy Skills Station __Applies ECG electrodes correctly (white on right, smoke over fire) __Turns on __Manual mode to display rhythm in standard limb leads (I, II, III) or

quick look paddles __Verbalizes defibrillation mode for VF and Pulseless VT __Verbalizes correct joules for defibrillation = 2-4 j/kg __Verbalizes sync mode for unstable SVT, VT with pulse __Verbalizes correct joules of cardioversion = 0.5-1 j/kg __Places pads or paddles correctly __Verbalizes how to keep safe

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Intraosseous Access

Intraosseous (IO) access is a life saving technique that provides a rapid vascular access and recognized as safe and effective for use in resuscitation attempts for all ages.

♥♥ Medications injected via IO can rapidly reach the central circulation.

The Sites that may be appropriate for IO infusions are:

♥♥ The proximal tibia just below the growth plate is the most commonly used site.

♥♥ The distal tibia just below the medial maleolus is another acceptable site.

♥♥ The anterior aspect of the distal femur above the knee.

♥♥ The anterior superior iliac spine. For severe shock or pre-arrest

♥♥ Establish IO if unable to rapidly access an IV site.

For Cardiac Arrest

♥♥ It is appropriate to attempt IO access immediately.

For Responsive patients

♥♥ Consider local anesthesia or sedation. The Contraindications of IO access are as follows:

♥♥ Fractures near or proximal to the site ♥♥ Crush injuries near or proximal to the site ♥♥ Fragile bones, such as osteogenesis imperfecta ♥♥ Previous attempts to obtain access in the same

bone

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♥♥ Avoid infected sites if possible. The Equipment needed for IO insertion is as follows:

♥♥ Gloves ♥♥ Skin disinfectant ♥♥ IO or bone marrow needle ♥♥ Tape ♥♥ Syringe ♥♥ Isotonic IV fluids and IV tubing ♥♥ Short extension tubing ♥♥ 3-way stop-cock

The Preparation for IO insertion is as follows:

♥♥ Position the leg with slight external rotation ♥♥ Use universal precautions ♥♥ Clean with skin disinfectant ♥♥ Identify the tibial tuberosity below the knee

joint. Insertion site is the first flat part of the tibia, 1-2 fingers width below this medial prominence not to injure the growth plate.

The Placement of the IO needle has the following guidelines

♥♥ Select an IO needle length that is appropriate. ♥♥ The flange may need to be removed t o allow

successful placement particularly in using the distal femur.

♥♥ The stylet should remain in place during insertion to prevent needle from becoming clogged with bone or tissue.

♥♥ Stabilize the leg on a firm surface to facilitate needle insertion.

♥♥ Do not place hand behind the leg. ♥♥ Insert needle so it is perpendicular to the tibia.

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♥♥ Use a twisting motion with gently but firm pressure.

♥♥ Continue inserting the needle until sudden lack of resistance is felt.

♥♥ If the needle is placed correctly it should stand without support.

♥♥ Remove the stylet. ♥♥ Attach empty syringe. Aspiration may reveal

pink tinged fluid or blood. But if no fluid returns it does not necessarily mean that the IO is incorrectly placed. Blood withdrawn from syringe may be used for glucose determination.

♥♥ Attach a saline syringe and infuse a small volume while observing the insertion site for swelling. Also assess the posterior site in case the needle has penetrated the other side of bone.

♥♥ Fluid should easily infuse with saline injection To Secure the IO needle:

♥♥ Screw the flange down so flush with skin. ♥♥ Tape over the flange of the needle. ♥♥ Use gauze padding to support the needle. ♥♥ Attach extension tubing and tape the extension

tubing to the skin. Volume and drug resuscitation can be manually delivered via syringe attached to stopcock attached to the extension tubing.

♥♥ Fluids given under pressure needs to be monitored closely to avoid air embolism.

♥♥ Any medication that can be administered IV can be given IO.

♥♥ All medications should be followed with a saline flush of 5-10 ml.

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4. Vascular Access Skills Station __Verbalizes indications __Verbalizes sites ( anterior tibia, distal femur, medial malleolus,

anterior superior iliac spine) __Verbalizes contraindications for IO placement (fracture, previous

insertion attempt, infection) __Inserts IO safely __Verbalizes how to confirm correct placement __Attaches IV line to IO __Demonstrates giving fluids using 3-way stopcock and syringe __Demonstrates correct drug dosage using the length-based tape

Assess for Complications

♥♥ Swelling ♥♥ Needle displacement

Displaced Needles can cause

♥♥ Tissue necrosis ♥♥ Compartment syndrome

Removal of the IO needle should be accomplished is less than 24 hours. IO needles are intended for short term use. Alternative Needles for IO insertion are as follows:

♥♥ Large-bore hypodermic needle ♥♥ Spinal needle

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Cardiac Arrest

The child weighed 30 kg Joules for defibrillation should be initially 2 j/kg Therefore, 30 kg X 2 j/kg = 60 joules were delivered Epinephrine dose should be 0.01 mg/kg Therefore, 0.01 mg/kg X 30 kg = 0.3 mg Joules for defibrillation after the initial dose is 4j/kg Therefore, 4 j/kg X 30 kg = 120 joules were delivered Amiodarone dose of 5mg/kg was ordered Therefore 5 mg X 30 kg = 150 mg Effective Communication is essential in resuscitation. The Team Leader has the following responsibilities:

♥♥ Directs resuscitation ♥♥ Monitors performance of task ♥♥ Models excellent team behaviors ♥♥ Must be proficient in all skills.

Pause and discuss Team Roles and Team Dynamics A Team Member should be proficient in his/her scope of practice. The areas of responsibility may be:

♥♥ Airway ♥♥ IV/IO ♥♥ Compressor ♥♥ Monitor/Defibrillator ♥♥ Observer/Recorder/Timer

Note the reenactment for Effective Team Dynamics: ♥♥ Closed-loop communication

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6. Cardiac VF/Pulseless VT Skills Station __Assigns roles __Uses effective communication __Recognizes arrest & directs initiation of CPR __Directs activation of monitor __Recognizes VF or Pulseless VT __Directs defibrillation at 2j/kg safely __Directs resumption of CPR __Calls for intubation __Directs IV/IO access __Directs appropriate epi dose __Directs defibrillation at 4 j/kg __Directs resumption of CPR __Directs appropriate epi dose __Considers amiodarone or lidocaine __[ ] Pass __ [NR] ____Instructor signature 7. Cardiac Asystole/PEA Skills Station __Assigns roles __Uses effective communication __Recognizes arrest & directs initiation of CPR __Directs activation of monitor __Recognizes asystole or PEA __Directs IV/IO access __Directs appropriate epi dose __Directs 2nd epi dose at appropriate interval __Directs rhythm check every 2 minutes __Verbalizes 3 causes of asystole or PEA __[ ] Pass __ [NR] ____Instructor signature

♥♥ Clear messages ♥♥ Clear roles and responsibilities ♥♥ Knowledge sharing ♥♥ Constructive interventions ♥♥ Reevaluation and summarizing ♥♥ Mutual respect

Three separate mega codes will be presented by the instructor and then a return demonstration will be given by the student. They will be as follows:

♥♥ Unresponsive and CPR to VF and end with PEA ♥♥ Unresponsive to Bradycardia to Asystole ♥♥ Stable SVT to Unstable SVT

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Pediatric Assessment Pediatric Assessment must have a systematic approach

♥♥ Assess ♥♥ Categorize ♥♥ Decide ♥♥ Act

Assess ♥♥ Appearance to dictate how aggressively to

respond ♥♥ WOB to dictate how aggressively to provide

oxygen ♥♥ Circulation with assessing cap refill to dictate

how aggressively to establish IV access. Categorize

♥♥ Respiratory ♥♥ Circulatory ♥♥ Both Further categorize the Respiratory into four groups

♥♥ Upper airway obstruction ♥♥ Lower airway obstruction ♥♥ Tissue disease ♥♥ Disordered control of breathing

Further categorize the Respiratory condition into severity

♥♥ Respiratory Distress (a child in respiratory distress is the child that is compensating for his condition)

♥♥ Respiratory Failure with or without respiratory distress.( a child in respiratory failure is the child that is decompensating from his condition)

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Categorize the Circulatory Problems ♥♥ Caused by shock ♥♥ Caused by arrhythmia

Further categorize the shock ♥♥ Hypovolemic ♥♥ Obstructive ♥♥ Distributive ♥♥ Cardiogenic

If the shock is causes by an arrhythmia, determine if it is caused by a rhythm that is

♥♥ too slow ♥♥ to fast ♥♥ absent.

Decide if the patient has life-threatening condition and Act accordingly.

The Primary Assessment follows the general assessment.

♥♥ A = assess and respond to airway problems Look, listen, and feel for air movement and

chest movement Open the airway with positioning Suction

CPR for FBAO

♥♥ B = assess and respond to breathing problems Is the RR rate too fast or too slow? Is there increase effort? Are there abnormal breath sounds? Is the O2 sat within normal limits?

♥♥ C = assess and respond the circulation problems Is the heart rate too fast or too slow?

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Check both the peripheral and central pulses Check the cap refill (should be < 2 seconds) Check the skin color and temperature Check the blood pressure – double the age

of the child, add 70 to arrive at a normal blood pressure for a child

Altered LOC indicates poor brain perfusion <UO indicates poor kidney perfusion

♥♥ D = assess and respond to disability The AVPU may be used to rate the level of consciousness based on the child’s age and setting or situation

Is the patient “alert?” Does the patient respond to “voice?” Does the patient respond to “pain?” Is the patient “unresponsive?”

The Glasgo Coma Scale can also be used to define a child’s LOC and neurologic status.

The best eye opening response The best verbal response The best motor response

The response to pain is an important component of critical neurologic function. To evaluate response to a central painful pinch to patient’s sternum, if the patient grabs for you hand, he/she localized the painful stimulus. The child would get a score of 5 out of a possible 6. PERRL – are the pupils equal, round, react to light? If the response is abnormal, the child needs advance life support

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Blood Glucose – low blood sugar can cause altered level of consciousness which in turn causes brain injury. Children are unable to holds their glycogen stores well.

♥♥ E = Exposure (remove the clothes to assess) Look for petechiae (tiny spots to indicated low platelet count)or purpura (larger spots to indicate septic shock) Look for signs of trauma and note the child’s response to your touch

Obtain a child’s core temperature and rewarm if the child is cold

♥♥ F = full set of vitals Include O2 saturations

Include Blood Sugar

Head-to-toe assessment may be deferred. For the kids a “toe-to-head” assessment may more advantageous. The Secondary Assessment follows the primary assessment which is a focused history from the caregiver or family using the SAMPLE pneumonic may be helpful if you suspect metabolic or toxic causes*

♥♥ S = signs and symptoms ♥♥ A = allergies ♥♥ M = medication ♥♥ P = past medical history ♥♥ L = last meal ♥♥ E = events leading to assessment

The Tertiary Assessment follows the primary assessment. It encompasses lab studies, x-rays, ECGs, and ect.

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Assess Categorize Decide Act General Assessment

♥♥ Appearance – to dictate how aggressively you will respond

♥♥ WOB – to dictate how aggressively you will initiate supplemental oxygen

♥♥ Cap refill – to dictate how aggressively you will initiate IV access with NS infusion

Respiratory Problems Categorize

Respiratory Problems can cause inadequate oxygenation and inadequate ventilation and may progress without interventions. The signs and symptoms are as follows:

♥♥ Tachypnea – breathing to fast – generally speaking > 60 bpm

♥♥ Breathing to slow – generally speaking <20 bpm ♥♥ Tachycardia deteriorates to Bradycardia ♥♥ Pallor – poor skin color progresses to cyanosis ♥♥ Nasal flaring progresses to retractions ♥♥ Agitation progresses to altered LOC ♥♥ Fatigue progresses to unresponsive

If you believe the patient has a respiratory problem, try to categorize the problem in a group

♥♥ Upper airway obstruction ♥♥ Lower airway obstruction ♥♥ Tissue disease (pneumonia) ♥♥ Disordered control of breathing(funny breathing)

Further categorize severity

♥♥ Respiratory distress (compensated condition) ♥♥ Respiratory failure (decompensated condition)

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Upper airway obstructions are obstructions that occur in the nose, pharynx or larynx and range from mild to sever. Common causes are

♥♥ Foreign-body obstruction ♥♥ Croup or epiglottis from tissue swelling ♥♥ Thick secretions that obstruct the nasal passages

Clinical signs of upper airway obstructions are as follows:

♥♥ The hallmark sound of FBAO is aspiratory referred to as strider

♥♥ The hallmark sound of croup is a seal-like bark ♥♥ Drooling – a sign of epiglottis rather than croup ♥♥ The sound of snoring and/or gurgling may need

to be suctioned

Management of upper airway obstruction includes the following:

♥♥ Open the Airway, maintain Breathing and support Circulation

♥♥ Removal of foreign body obstruction Perform jaw-thrust or head-tilt chin lift Back slaps and/or chest thrust for <1 y/o Abdominal thrust for <1y/o Chest compressions may displace the object

♥♥ Suctioning the nose and mouth ♥♥ Treat croup depending on the severity

Mild croup with occasional barking cough provide cool mist

Moderate croup with frequent barking cough provide humidified O2 & nebulized epi

Severe croup with weak cough ventilate with bag/mask ventilation provide high-flow oxygen consider intubation

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8. Respiratory Upper Airway Obstruction Skills Station __Assigns roles __Uses effective communication __Directs assessment of ABCDE & Full set of vitals __Directs opening airway manually __Directs administration of 100% oxygen __Directs activation of monitor __Recognizes s/s of upper airway obstruction __Categorizes respiratory distress or failure __Verbalizes indication for BMV or CPAP __Directs IV/IO access __Directs reassessment/response __Summarizes specific treatment for UAO (racemic epi and CPAP) __Verbalizes indications for intubation (decreased mental status,

inadequate oxygenation) __[ ] Pass __ [NR] ____Instructor signature

♥♥ Treat anaphylaxis depending of the severity Mild allergic reactions with stuffy nose, itching of the skin and/or rash - call for help Severe allergic reactions with trouble breathing, swelling of the tongue and face – give epi by autoinjector, get help, give nebulized albuterol

♥♥ Allow the child to assume the position easiest to breath. General management of a child with upper airway obstruction is to avoid unnecessary agitation which may worsen upper airway obstruction. Try to keep the child calm and comfortable*

♥♥ A child’s head often drops to obstruct the airway. Do not use pillows for children, positioning the head with slight hperextention will enhance the airway,.

♥♥ Administer high flow/high concentration of O2 ♥♥ Consider an airway adjunct or advanced airway ♥♥ Consider a tracheostomy

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Lower airway obstructions are obstructions that occur in the trachea, bronchi or the bronchioles. .Common causes

♥♥ Bronchiolites ♥♥ Asthma

Clinical signs of lower airway obstruction are as follows:

♥♥ The hallmark sound is expiratory referred to as wheezing.*

Management of lower airway obstruction

♥♥ Open the Airway, maintain Breathing and support Circulation

♥♥ If assisted ventilation is required bag/mask ventilation must be done at a relatively slow rate to allow more time for expiration and reduce the risk of air trapping.

♥♥ Ventilations must be given without high pressures that cause gastric distention and run the risk of pneumothorax

♥♥ For bronchiolitis perform oral and nasal suctioning administer bronchodilators consider nebulized epinephrine or albuterol

♥♥ For asthma Mild asthma – get help administer humidified oxygen, albuterol or corticosteroids Severe asthma – get help Consider high-flow oxygen IV access for IV medications Impending respiratory failure– get help Consider endotracheal intubation

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9. Respiratory Lower Airway Obstruction Skill Station __Assigns roles __Uses effective communication __Directs assessment of ABCDE & Full set of vitals __Directs activation of monitor __Recognizes s/s of lower airway obstruction __Categorizes respiratory distress or failure __Verbalizes indications for BMV __Directs IV/IO access __Directs reassessment/response __Summarizes specific treatment for LAO (nebulized albuterol) __Verbalizes indications for intubation (decreased mental status, inadequate oxygenation) __[ ] Pass __ [NR] ____Instructor signature

Mild Asthmatics – can walk about Moderate Asthmatics – usually need to sit

Severe Asthmatics – sit in the tripod position Mild Asthmatics – talk in full sentences Moderate Asthmatics – talk in phrases Severe Asthmatics – talk in single words

Mild Asthmatics – wheezing is soft Moderate Asthmatics – wheezing is loud

Severe Asthmatics – wheezing is absent

Mild Asthmatics – O2 sat on room air =>95% Moderate Asthmatics – O2 sat = 91-95%

Severe Asthmatics – O2 sat = <90%

Mild Asthmatics – HR = normal to increased Moderate Asthmatics – HR = increased

Severe Asthmatics – HR =decreased

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10. Respiratory Lung Tissue Disease Skills Station __Assigns roles __Uses effective communication __Directs assessment of ABCDE & Full set of vitals __Directs BMV with 100% oxygen with chest rise __Directs activation of monitor and pulse ox __Recognizes s/s of lung tissue disease __Categorizes respiratory distress or failure __Directs IV/IO access __Directs reassessment/response __Summarizes specific treatment for lung disease (antibiotics) __Verbalizes indications for intubation (decreased mental status,

inadequate oxygenation) __[ ] Pass __ [NR] ____Instructor signature

Lung tissue diseases are diseases that affect the substance of the lung tissue and further affect lung ventilation.

Common causes are as follows: ♥♥ Pneumonia and pulmonary edema with fluid

filled alveoli; ♥♥ Atelictasis with collapse of alveoli (trauma) ♥♥ Toxins such as allergins

The clinical signs of tissue disease are as follows: ♥♥ Marked tachypnea ♥♥ Tachycardia ♥♥ Increase WOB ♥♥ Grunting ♥♥ Crackles ♥♥ Diminished breath sounds

Management of diseases of the lung tissue includes the following:

♥♥ Open the Airway, maintain Breathing and support Circulation

♥♥ Perform ancillary (tertiary) testing such as blood and sputum cultures, blood test and chest x-rays

♥♥ Treat for gram positive organisms ♥♥ Consider CPAP ♥♥ Reduce temperature to reduce metabolic demand

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11. Respiratory Disordered Control of Breathing Skills Station __Assigns roles __Uses effective communication __Directs assessment of ABCDE & Full set of vitals __Directs BMV of 100% oxygen with chest rise __Directs activation of monitor and pulse ox __Recognizes s/s of disordered control of breathing __Categorizes respiratory distress or failure __Directs IV/IO access __Directs reassessment/response __Summarizes specific treatment for DCB (reversal agents) __Verbalizes indications for intubation

(decreased mental status, inadequate oxygenation

Disordered control of breathing are abnormal patterns that produce symptoms of inadequate respiratory rate and/or effort. The child is said to be “breathing funny.” Common causes and interventions are as follows:

♥♥ Increased ICP Treat fever Elevate the child’s head Hyperventilate until advanced providers arrive

♥♥ Poisoning or drug overdose Contact the poison control center 1 800 222 1222 for appropriate interventions Determine

Who – are other family members exposed. What – the evidence of exposure/how much When – the time and duration of exposure Where – location of the child when found Why – self-harm, error of administration, curiosity.

♥♥ Brain injuries from trauma Immobilize the neck Obtain a CT scan of the head and neck

♥♥ Brain tumors or infection ♥♥ Neuromuscular disease

Keep the airway open with suctioning These children have a weak cough

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Decide the severity of the respiratory failure as ♥♥ Respiratory distress ♥♥ Respiratory failure

Respiratory Distress is a clinical state characterized by the following signs and symptoms:

♥♥ Tachypnea ♥♥ Tachycardia ♥♥ Increase WOB ♥♥ Abnormal airway sounds (stridor, wheezing,

grunting) ♥♥ Decreased LOC

Respiratory Failure is characterized by inadequate oxygenation, ventilation or both.

♥♥ Tachypnea becomes bradypnea (brad-ip-nea) ♥♥ Tachycardia becomes bradycardia ♥♥ Increased WOB becomes decreased WOB ♥♥ Poor air movement sounds become absent distal

air movement ♥♥ Stupor and coma occurs ♥♥ When respiratory effort is inadequate, respiratory

failure may occur without typical signs of respiratory distress.

♥♥ For a child that you may be caring for with high-flow oxygen using a nonrebreather with pronounced respiratory distress suddenly drops his/her respiratory rate to 6/min you must begin bag/mask ventilations*

ABG results for respiratory failure: ♥♥ A decrease in pH indicates a worsening of the cellular oxygen debt (inadequate oxygenation). ♥♥ An elevated PaCO2 indicates impaired ventilation (inadequate ventilation)

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Circulatory Problems Circulatory problems occur with inadequate circulating blood volume (low cardiac output) and inadequate tissue perfusion (hypoventilation). This is referred to as shock. The treatment goal of shock is to prevent end-organ injury and halt the progression of cardiopulomonary failure and arrest. Shock is categorized into four groups:

♥♥ Hypovolemic shock ♥♥ Distributive shock ♥♥ Cardiogenic shock ♥♥ Obstructive shock

Hypovolemic shock is the most common cause of shock in children. It occurs with fluid loss from

♥♥ Diarrhea ♥♥ Hemorrhage ♥♥ Vomiting ♥♥ Inadequate fluid volume

The signs and symptoms of hypovolemic shock include

♥♥ Tachycardia to compensate for the lack of circulating blood volume

♥♥ Tachypnea to compensate for the lack of tissue perfusion

♥♥ Pallor and diminished cap refill because the body is shunting blood from the skin tovital organs

♥♥ Changes in mental status because of lack of brain perfusion

♥♥ Diminished urinary output ♥♥ The arterial pressure (systolic) begins to fall and

the venous pressure (diastolic) compensates the volume depletion and begins to rise. (narrowing of pulse pressure).

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12. Circulatory Hypovolemic Shock Skills Station __Assigns roles __Uses effective communication __Directs assessment of ABCDE & Full set of vitals __Directs administration of 100% oxygen __Directs activation of monitor and pulse ox __Recognizes s/s of hypovolemic shock __Categorizes compensated or hypotensive __Directs IV/IO access __Directs rapid administration of NS fluid bolus __Directs reassessment/response __Verbalizes therapeutic end points during shock management (HR, BP, Cap Refill, UO, Pulses,LOC) __[ ] Pass __ [NR] ____Instructor signature

The management of hypovolemic shock include ♥♥ Rapid administration of fluids over 10-20

minutes ♥♥ 20 ml/kg of Normal Saline or Ringers Lactate

which is a crystalloid isotonic solution* ♥♥ You may have to repeat the fluid bolus. ♥♥ You may have to consider blood transfusion. ♥♥ Don’t forget to warm the fluids to prevent

hypothermia!! ♥♥ Don’t forget the oxygen for all kids with

respiratory distress!! ♥♥ Don’t overlook using the IO access if you cannot

get an IV access!! ♥♥ Don’t overlook the possibility of internal

hemorrhage for the trauma patient.

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Distributive shock is the maldistribution of circulating blood volume which can be septic or anaphylactic. “There is plenty of blood but is ‘pooling’ in the vascular bed”.

♥♥ Septic shock occurs from infectious organisms that activate inflammatory mediators that lead to organ failure. Early recognition and treatment of septic shock are important for good outcome. The signs of septic shock are as follows:

Petechiae: Tiny dots suggestive of low platelet count Purpura: Larger spots suggestive of septic shock Fever Changes in level of consciousness

The management for septic shock is aimed at expanding intravascular volume 20 mL/kg NS or RL bolus up to 3-4 times based on patient response. The key is repeated fluid boluses of crystalloid isotonic solutions.* Support hypotension with Dopamine or epinephrine infusion Rapid administration of antibiotics after cultures have been obtained. Consider mechanical ventilation with

supplemental oxygen. The septic cascade:

1. Sepsis causes an inflammatory response 2. Inflammatory substances (cytokines)

become active. 3. Cytokines cause blood vessels to relax

and fluids to leak into the tissue 4. Cytokines reduces the pumping action of th

heart.

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♥♥ Anaphylactic shock is the result of severe reaction to a drug, food, toxin, plant, or venom.

The signs and symptoms of anaphylactic shock are Anxiety and/or agitation Nausea and vomiting. Hives Swelling of the face, lips and tongue Respiratory distress Tachycardia Hypotension The treatments for anaphylactic shock are

Epinephrine autoinjector and/or epinephrine infusion

Albuterol for bronchospasms Antihistamines Corticoidsteroids

♥♥ Neurogenic shock also called spinal shock results from head or spine injury. The loss of nervous system signals results in uncontrolled vasodilation and hypotension. A child that has suffered a traumatic brain injury is an example of neurogenic shock and would require a CT of the head and neck.*

The signs and symptoms of neurogenic shock are Hypotension Bradycardia In contrast the signs of symptoms of hypotensive shock are Hypotension Tachycardia

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13. Circulatory Distributive (Septic) Shock Skills Station __Assigns roles __Uses effective communication __Directs assessment of ABCDE & Full set of vitals __Directs administration of 100% oxygen __Directs activation of monitor and pulse ox __Recognizes s/s of distributive (septic) shock __Directs IV/IO access __Directs rapid administration of NS bolus __Directs reassessment/response __Recalls that early administration of antibiotics is essential __Verbalizes need for vasoactive drug support

(fluid refractory septic shock) __Verbalizes the therapeutic end points of shock management

(HR, BP, Cap Refill, UO, Pulses, LOC) __[ ] Pass __ [NR] ____Instructor signature

The treatment of neurogenic shock Position the child flat or head down to improve venous return

Fluids for hypotension Supplementary warming

Cardiogenic shock results from decreased cardiac output seen in the following

♥♥ Congenital abnormalities ♥♥ Myocarditis ♥♥ Arrhythmias ♥♥ Sepsis ♥♥ Trauma

The signs and symptoms of cardiac shock ♥♥ Tachypnea with increased respiratory effort ♥♥ Tachycardia with normal blood pressure ♥♥ Weak pulses ♥♥ Delayed cap refill

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14. Circulatory Cardiogenic Shock Skills Station __Assigns roles __Uses effective communication __Directs assessment of ABCDE & Full set of vitals __Directs administration of 100% oxygen __Directs activation of monitor and pulse ox __Recognizes s/s of cardiogenic shock __Categorizes compensated or hypotensive __Verbalizes indication for BMV or CPAP __Directs IV/IO access __Directs slow administration of NS (10cc/kg) __Directs reassessment/response __Recalls indications for vasoactive drugs for CS

(poor response to fluid therapy, persistent hypotension) __Verbalizes therapeutic end points during shock management

(HR, BP, Cap Refill, UO, Pulses, LOC) __[ ] Pass __ [NR] ____Instructor signature

♥♥ Cyanosis ♥♥ Changes in mental status ♥♥ Cold, pale, diaphoretic skin color

The treatment of cardiogenic shock ♥♥ Cautious fluid administration = 10 mL/kg of NS

delivered slowly ♥♥ Supplemental oxygen ♥♥ Obtain expert consultation ♥♥ Consider Milrinone that will improve myocardial

contractility and reduce cardiac preload and afterload.* Infants and children with cardiogenic shock often require drug therapy to increase and redistribute cardiac output to improve myocardial function and reduce systemic vascular resistance. Loading dose is 50-75 ug/kg over 10-60 min. Infusing dose is 0.5 to 0.75 ug/kg per minute The dose is not a test question!

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15. Circulatory Obstructive Shock Skills Station __Assigns roles __Uses effective communication __Directs assessment of ABCDE & Full set of vitals __Directs activation of monitor and pulse ox __Verbalizes need to DOPE for deterioration of intubated child __Recognizes s/s of obstructive shock __Categorizes as compensated or hypotensive __Directs IV/IO access __Directs rapid administration of NS bolus __Directs reassessment/response __Summarizes the treatment for tension pneumothorax (decompression 2nd midclavicular space) __Verbalizes the therapeutic end points during shock management

(HR, BP, Cap Refill, UO, Pulses, LOC) __[ ] Pass __ [NR] ____Instructor signature

Obstructive shock is caused by the physical obstruction of blood flow such as

♥♥ Cardiac Tamponade Signs and symptoms include muffled or diminished heart sounds and distended neck veins and the blood pressure drops during inspiration (pulsus paradoxus) The management of cardiac shock is removing the accumulation of blood with pericardiocentesis

♥♥ Tensions pneumothorax Signs and symptoms include diminished breath sounds of the affected side, distended neck veins and tracheal deviation but may be difficult to observe in small children The management of tension pneumothorax is needle decompressions by insertion of 16-20 gauge needle just above the third rib.*

♥♥ Pulmonary embolism PEs are difficult to diagnose because the subtle signs and symptoms including cyanosis, tachycardia and hypotension. The management of pulmonary embolism is surgical embolectomy.

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Decide the Severity of the shock. The severity classifying the shock to be either compensated or hypotensive (formerly called decompensated. (The effect on the blood pressure) Compensated shock is characterized by the SYSTOLIC blood pressure that is within normal limits. There may be signs of inadequate tissue perfusion but the body is able to compensate and maintain a normal blood pressure. Hypotensive shock is characterized by a drop in SYSTOLIC blood pressure with signs of poor perfusion. A key sign that a child is decompensating with diminished blood pressure in decreased mental status. To determine the normal SYSOLIC blood pressure of a child 1 -10 years of age

Double the age and add 70. A nine year old doubles to 18 and add 70 = 88

Shock caused by Circulatory Problems Cardiac rhythms are broadly classified according to the heart rate

♥♥ Too Slow ♥♥ Too Fast ♥♥ Arrest

Too Slow Bradycardia is a heat rate that is less than 60 bmp with poor perfusion and requires urgent treatment. The most common cause of bradycardia in children is hypoxia. ♥♥ Begin chest compressions interposed with

bag/mask ventilation with 100% oxygen*

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16. Cardiac Bradycardia Skills Station __Assigns roles __Uses effective communication __Directs assessment of ABCDE & Full set of vitals __Directs administration of oxygen __Directs activation of monitor __Recognizes bradycardia with compromise __Directs initiation of CPR __Directs IV/IO access __Directs appropriate epi dose __Directs response to eip __Verbalizes 3 causes of bradycardia __[ ] Pass __ [NR] ____Instructor signature

♥♥ Epinephrine is the drug of choice = 0.01 mg/kg 1:10:000 IV (0.1 mL/kg) 0.1 mg/kg 1:1000 ET (0.l mL/kg)

♥♥ Atropine for increase vagal tone or AV blocks = 0.02 mg/kg with a minimum dose of 0.1 mg and a maximum dose of 0.5 mg for a child and 1 mg for an adolescent. Small doses of atropine may produce paradoxical bradycardia. Therefore, a minimum dose of 0.1 mg is recommended.

Too Fast

Tachycardia is a heart rate that is fast for the patient’s age. Sinus tachycardias originate in the sinus node and start slow and then speed up. The causes may be:

♥♥ Increase temperature ♥♥ Pain ♥♥ Agitation/fever/pain may cause a sinus tach ♥♥ Rate is usually less than 220/min in infant and

less than 180/min in children

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7. Cardiac Asystole/PEA Skills Station – Refer to page 31

17. Cardiac SVT Skills Station __Assigns roles __Uses effective communication __Directs assessment of ABCDE & Full set of vitals __Directs administration of oxygen __Directs activation of monitor __Recognizes SVT versus ST __Categorizes as compensated or hypotensive __Directs performances of vagal maneuver __Directs IV/IO access __Directs appropriate adenosine dose and administration __Directs assessment of response __Verbalizes indication and dose of cardioversion __[ ] Pass __ [NR] ____Instructor signature

Supraventricular tachycardis begin abruptly causes by aberrant conduction.

♥♥ Rate is usually greater than 220/min in infants and greater than 180 bpm in children.

Arrest

Cardiac Arrest is associated with one of the following rhythms: ♥♥ Asystole ♥♥ PEA ♥♥ VF ♥♥ Pulsless VT

Asystole is a cardiac standstill. No electrical activity is seen PEA is an organized rhythm with no pumping action. The following rhythm without a pulse would be a PEA.

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6. Cardiac VF/Pulseless VT Skills Station – Refer to page 31

Ventricular fibrillation is a “fibrillating” heart. There is no pumping action.* It appears chaotic. You will need to identify a Ventricular Fibrillation for your test*. Pulseless Ventricular Tachycardia is a wide complex tachycardia without a pulse Management of the pulseless rhythms:

♥♥ Begin CPR ♥♥ Epinephrine IV ♥♥ Advanced Airway placement ♥♥ Defibrillation for VFib and Pulseless

VTachycardia ♥♥ Consider antiarrhythmics of Amiodarone or

Lidocaine

Core Cases In class we will observe sick children on a video and

♥♥ Decide the general appearance of the child ♥♥ Decide any aggressive approach to be initiated ♥♥ Categorize the child as respiratory or circulatory ♥♥ Further categorize the respiratory child as

Upper airway obstruction Lower airway obstruction Lung tissue disease Disordered control of breathing

♥♥ Further categorize the circulatory child as Hypovolemic shock Obstructive shock Distributive shock Cardiogenic shock

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♥♥ Decide the primary assessment with the SAMPLE history

♥♥ Decide the course of action ♥♥ Act accordingly

Manage the Core Cases

You will be asked to manage 2 of these core cases. Your management will begin with

♥♥ Assigning roles to team members. RT’s– provides a patent airway and oxygen RN #1 – establishes an IV access/hangs NS RN #2 – attaches the cardiac monitor RN #3 – determines the weight of the child RN #4 – obtains a full set of vitals

♥♥ Determines the assessment Airway – determine if the airway is patent Breathing – describe the WOB Circulation – determine the cap refill Disability – determine the mental status Exposure – is the patient exposed Full set of vitals – evaluate the vital signs

and determine the weight ♥♥ For the respiratory case - Is the child in

respiratory distress or failure? What type of airway obstruction is the child in?

♥♥ For the circulatory case - Is the child compensating or hypotensive? What type of shock is the child in?

♥♥ What would you do for the child? ♥♥ Reevaluate your interventions

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56,1,2,55,54,3,4,53,52,5,6,51,50,7,8,49,48,9,10,47,46,11,12,45,44,13,14,43,42,15,16,41,40,17,18,39,38,19,20,37,36,21,

22,35,34,23,24,33,32,25,26,31,30,27,28,