pediatric advanced life support pediatric advanced life support pediatric advanced life support (pals) is a course offered by the american heart association (aha) for health care providers who take care of children and infants in the emergency room, critical care and intensive care units in the hospital, and out of hospital (emergency medical services (ems)). the course teaches healthcare providers how to assess injured and sick children and recognize and treat respiratory distress/failure, shock, cardiac arrest, and arrhythmias. basic life support (bls) two-finger technique for infant chest compressions (single rescuer) two-thumb encircling hands technique for infant chest compressions (two rescuers) pals builds upon aha's pediatric basic life support (bls). providers should follow the aha's pediatric bls algorithms for single and ≥ 2 person rescuer. the most essential component of bls and pals cardiac arrest care is high quality cardiopulmonary resuscitation (cpr). cpr should begin with a check for responsiveness, getting help, and activating the emergency response system. after this, the provider should assess for breathing and a pulse (brachial pulse in infant and carotid pulse in child) - all within 10 seconds. if no pulse and no breathing or only gasping, start cpr. cpr consists of chest compressions followed by rescue breaths - for single rescuer do 30 compressions and 2 breaths (30:2), for > 2 rescuers do 15 compressions and 2 breaths (15:2). the rate of chest compressions should be 100-120 compressions/min and depth should be 1.5 inches for infants and 2 inches for children. chest compressions differ between infants and children. for infants, chest compressions can be done with the two-fingers technique (single rescuer) or two-thumbs encircling hands technique (2 rescuer). in the two-fingers technique, the provider uses their index and middle finger to press down on the infant's sternum, below the nipples. in the two-thumb encircling hands technique, the provider's hands should wrap around the chest with both thumbs pressing down on the infant's sternum. for children, chest compressions should be done with the provider placing the heel of one hand over the child's lower chest and pressing down while keeping their arms straightened at the elbow. child chest compressions if help hasn't arrived after 2 minutes, the provider should call for help again and get an automated external defibrillator (aed). once help and the aed arrives, the provider should place the aed pads on the child, making sure to not disrupt chest compressions. the aed will let the provider know if the child has a shockable heart rhythm. if shockable, give a shock and then immediately resume cpr. assessment pals teaches a systematic assessment approach so that the health care provider can quickly identify any life-threatening conditions and treat them. the pals systematic approach algorithm begins with a quick initial assessment followed by checking for responsiveness, pulse, and breathing. if the child has no pulse and isn't breathing, start cpr. if the child has a pulse but isn't breathing, provide ventilation and give oxygen (when possible). once it has been established that the child has a pulse, is breathing, and doesn't require immediate life saving treatment, the provider will begin their primary assessment followed by a secondary assessment and further diagnostic workup. continuous reassessments should be done to reassess for life-threatening conditions. initial assessment the initial assessment is meant to be a very quick assessment performed within the first few seconds of interacting with a child and it utilizes the acronym abc - appearance, breathing, and color. the provider will assess appearance (level of consciousness and responsiveness, speaking or crying), breathing (breathing or not breathing, increased work of breathing, abnormal breath sounds), and color (pale, mottled, cyanotic, bleeding). primary assessment the primary assessment uses the acronym abcde - airway, breathing, circulation, disability, exposure. airway - assess airway patency (open/patent, unobstructed vs obstructed) and if the patient will need assistance maintaining their airway breathing - assess respiratory rate, respiratory effort, lung sounds, airway sounds, chest movement, oxygen saturation via pulse oximetry circulation - assess heart rate, heart rhythm, pulses, skin color, skin temperature, capillary refill time, blood pressure disability - assess neurological function with avpu pediatric response scale (alert, voice, painful, unresponsive), pediatric glasgow coma scale (eye opening, motor response, verbal response), pupil response to light (normal, pinpoint, dilated, unilateral dilated), blood glucose test (low blood sugar / hypoglycemia can cause altered mental status) exposure - assess temperature/ fever, signs of trauma (cuts, bleeding, bruises, burns, etc.), skin (petechiae, purpura, etc.) secondary assessment once the primary assessment is completed, the provider can do a secondary assessment which consists of a complete physical exam and focused medical history. the information asked in the medical history uses the acronym sample - signs and symptoms, allergies, medications (prescribed, over the counter, vitamins, herbal), past medical history (any medical problems, prior surgeries), last meal (helpful information to know because it can affect when a child can have surgery or receive anesthesia), events (onset of illness and events leading up to illness). parts of the history that are especially important for children include asking about medications that the child could have gotten into (e.g., if a pill fell on the floor or an unlocked medicine cabinet), history of prematurity, birth history, and immunizations. respiratory distress and failure providers must be able to identify respiratory problems that are easily treatable (e.g., treated with oxygen, suctioning/ clearing airway, albuterol, etc.) and those that can rapidly progress to life-threatening conditions. respiratory distress can progress to respiratory failure which can progress to cardiac arrest. once respiratory complaints have progressed to cardiac arrest, death and neurological damage are more likely to occur. for this reason, providers should aim to identify and treat respiratory conditions before they progress and worsen. signs and symptoms common signs of respiratory distress increased work of breathing nasal flaring (nostrils widening during breathing) accessory muscle use (using muscles other than the diaphragm and intercostal muscles during breathing (e.g., sternocleidomastoid)) retractions (collapse of parts of the chest during breathing) (e.g., suprasternal, substernal, sternal, intercostal, subcostal, supraclavicular) head bobbing (in infants) grunting tachypnea (too fast breathing) pallor (pale skin) tachycardia (fast heart rate) agitation and anxiety respiratory distress can progress and worsen to respiratory failure. signs of respiratory failure include the following decreased work of breathing eventual pauses in or altogether stopping breathing (apnea) bradypnea (too slow breathing) decreased or absent air movement abnormal breath sounds cyanosis (blue skin) exhaustion and unresponsiveness can't speak or cough types of respiratory problems upper airway obstruction - e.g., croup, epiglottitis, foreign body aspiration, anaphylaxis, retropharyngeal abscess, enlarged/swollen tonsils lower airway obstruction - e.g., asthma, bronchiolitis lung tissue disease - e.g., pneumonia, pneumonitis, pulmonary edema disordered control of breathing - often described as "breathing funny"; e.g., seizure, overdose, trauma, coma, neuromuscular diseases initial management the initial management for respiratory distress uses the acronym abc - airway, breathing, circulation. airway support the airway by making sure that it is open/patent (child can do this on their own or provider may have to open airway with head tilt-chin lift or jaw thrust (if suspected cervical spine injury)) clear the airway as needed (e.g., suctioning mucus/secretions in nose and throat, removing foreign bodies, etc.) consider adding airway adjuncts such as nasopharyngeal airway (npa) or oropharyngeal airway (opa) (if no gag reflex)bag valve mask ventilation breathing monitor oxygen saturation with a pulse ox give supplemental oxygen give inhaled medications (e.g., albuterol, epinephrine) as needed manually ventilate as needed (e.g., bag mask ventilation) prepare for advanced airway circulation monitor vitals (e.g., heart rate, blood pressure) establish vascular access (for medications and fluids) as needed advanced airways intubation of a mannequin advanced airways may be necessary if the child can't maintain their airway on their own and isn't responding to other methods of ventilation and oxygenation. advanced airways use medical equipment to allow for open airways and ease of ventilation and medication delivery. types of advanced airways include supraglottic devices (devices that lie above the glottis such as opa, npa, laryngeal mask airway), infraglottic devices (devices that lie below the glottis and go into the trachea such as endotracheal tube (intubation)), and surgery (incision below the glottis such as cricothyrotomy and tracheotomy). surgical advanced airways are typically performed when intubation and other less invasive methods fail or are contraindicated or when the child will need long term mechanical ventilation. intubation to perform an intubation, the health care provider should be able to perform the steps of rapid sequence intubation (preparation, preoxygenation, pretreatment, paralysis and sedation, positioning, placement of tube, postintubation management). further management further management should be based on the specific medical condition the child has. for example, if the child is experiencing respiratory distress secondary to asthma, management would include albuterol, inhaled corticosteroids, supplemental oxygen, and more depending upon the severity of the asthma. shock shock is defined as inadequate blood flow (perfusion) in the body, causing tissues and organs to (1) not get enough oxygen and nutrients and (2) have trouble getting rid of toxic products of metabolism (e.g., lactate). it is important to recognize and treat shock as early as possible because the body requires oxygen and nutrients to function and without them, organs can eventually shut down and people can die. common signs of shock include weak pulses, altered mental status, bradycardia or tachycardia, low urine output, hypotension, and pale, cold skin. treating shock focuses on increasing blood flow and oxygen delivery to tissues and organs before organs are permanently damaged. this section will discuss the recognition and management of shock. shock severity blood pressure measurement the severity of shock is typically based on systolic blood pressure. for this reason, measuring blood pressure is an important way to assess shock; however, blood pressure machines may not be very accurate if pulses are weak and the arms and legs (where the blood pressure is measured) are poorly perfused. compensated shock is when the body is able to compensate through various mechanisms (e.g., raising the heart rate, increasing systemic vascular resistance, and more) to keep the systolic blood pressure in a normal range. hypotensive/ decompensated shock is when the body cannot maintain systolic blood pressure in the normal range, and it becomes too low (hypotensive). definition of hypotension age systolic blood pressure 0-1 month old < 60 mmhg 1–12 months old < 70 mmhg 1–10 years old 5th percentile: < 70 mmhg + mmhg > 10 years old < 90 mmhg types of shock there are 4 main types of shock: hypovolemic, distributive, cardiogenic, and obstructive. hypovolemic shock hypovolemic shock is caused by low blood volume (hypovolemia) and is the most common cause of shock in pediatric patients. common causes of volume loss include diarrhea, vomiting, hemorrhage, not drinking enough, burns, osmotic diuresis (e.g., diabetic ketoacidosis), and third space losses. signs of hypovolemic shock are related to the low blood volume and decreased blood flow to extremities (e.g., cold extremities, slow capillary refill, and weak distal pulses). distributive shock distributive shock is caused by abnormally distributed blood throughout the body which causes some parts of the body to receive inadequate blood supply. common causes of distributive shock include sepsis, anaphylaxis, and head or spinal cord injury (neurogenic shock). septic shock is typically caused by an infection or inflammation in the body. signs of septic shock include fever or hypothermia, petechia, and purpura. lab tests might show leukocytosis or leukopenia, metabolic acidosis with high lactate, and more. anaphylactic shock is caused by an allergen and common signs include facial swelling, throat swelling, hives, wheezing, etc. cardiogenic shock cardiogenic shock is caused by abnormal heart function or problems within the heart that impair pumping of blood within the heart. common causes of cardiogenic shock include congenital heart diseases, arrhythmias, myocarditis (inflammation of the heart muscle), cardiomyopathy (impairment of the heart's ability to pump), trauma/injury of the heart, drug or poison toxicity. common signs include tachycardia, distant pulses, and worsening with giving fluids. obstructive shock obstructive shock is caused by disrupted flow of blood to the heart or flow of blood out of the heart. common causes include tension pneumothorax, cardiac tamponade, pulmonary embolism, and ductal dependent congenital heart defects (conditions that worsen when the ductus arteriosus closes after birth) (e.g., hypoplastic left heart syndrome and coarctation of the aorta). tension pneumothorax: a build up of air in the pleural space of the lungs causing compression and collapse of the lung. common signs include