Pediatric Advanced Life

Support
Jan Bazner-Chandler
CPNP, CNS, MSN, RN
Pediatric Advanced Life Support
Guidelines established in 1983 by the American
heart Association.

Pediatric Advanced Life Support: A Review of the
AHA Recommendations, American Family
Physician, October 15, 1999.

Http://www.aafp.org/afp/991015ap/1743.html

American Heart Association
Pediatric Advanced Life Support
Published online November 28, 2005
Article can be found at:

http://circ.ahajournals.org/cgi/content/full/112/24_suppl/IV-167

JAOA
Review of guidelines for Pediatric Advanced
Life Support short version of AHA
www.jaoa.org/cgi/reprint/104/1/22.pdf
Quick review of AHA guidelines

Students Nurse Concerns
You will need to learn the basics as outlined
in the PALS article 1999 and review 2005
standards.
AHA guidelines are expected standards of a
practicing pediatric nurse.
You will need to know basic CPR guidelines
and have a current CPR card prior to starting
the clinical rotation.
Cardiopulmonary Arrest
In most infants and small children respiratory
arrest precedes cardiac arrest.

92% of children with respiratory arrest only
have no subsequent neurologic impairment.
Cardiac Arrest
Pediatric cardiac arrest is:
Uncommon
Rarely sudden cardiac arrest caused by primary
cardiac arrhythmias.
Most often asphyxial, resulting from the
progression of respiratory failure or shock or both.

Respiratory
Failure
Hypotensive
Shock
Cardiopulmonary
Failure
Asphyxial Arrest
Upper airway obstruction
Lower airway obstruction
Lung tissue disease /
infection
Disorders of breathing
Hypovolemic (most common)
Distributive: septic, anaphylactic
Cardiogenic
Obstructive
Respiratory Arrest
Early recognition and intervention prevents
deterioration to cardiopulmonary arrest and
probable death.

Only 10% of children who progress to
cardiopulmonary arrest are successfully
resuscitated.
Assessment
30 second rapid cardiopulmonary
assessment is structured around ABCs.

Airway
Breathing
Circulation
Airway
Airway must be clear and patent for
successful ventilation.

Position
Clear of foreign body
Free from injury

Intubate if needed.

Breathing
Breathing is assessed to determine the
childs ability to oxygenate.
Assessment:
Respiratory rate
Respiratory effort
Breath sounds
Skin color

Impending Respiratory Failure

Respiratory rate less than 10 or greater than
60 is an ominous sign of impending
respiratory failure.
Circulation
Circulation reflects perfusion.

Shock is a physiologic state where delivery of
oxygen and substrates are inadequate to
meet tissue metabolic needs.
Circulation Assessment
Heart rate
Pulse
Blood pressure
End organ profusion
Urine output
Level of consciousness
Muscle tone
Circulatory Assessment
Heart rate is the most sensitive parameter for
determining perfusion and oxygenation in children.

Heart rate needs to be at least 60 beats per minute to
provide adequate perfusion.

Heart rate greater than 140 beats per minute at rest needs
to be evaluated.
Circulatory Assessment
Pulse quality reflects cardiac output.

Capillary refill measures peripheral perfusion.

Temperature and color of extremities
proximal versus distal.

Circulatory Assessment
Urinary output

Adequate kidney perfusion

1- 2 ml of urine per kg / hour

Level of Consciousness / LOC
Blood Pressure

25% of blood volume must be lost before a
drop in blood pressure occurs.

Minimal changes in blood pressure in
children may indicate shock.
Management
Oxygen

Cardiac Monitoring

Pulse oximetry
May be inaccurate when peripheral perfusion is
impaired.
Airway Management
Bag-valve-mask with bradypenia or apnea
Suctioning to remove secretions
Intubation as needed

Bag-valve-mask
New Guidelines Airway Management
Failure to maintain the airway is leading
cause of preventable death in children.
New PALS focuses on basic airway
techniques.
Laryngeal mask airway.
LMA Laryngeal Mask Airway
LMA
Disadvantages:
Inability to prevent aspiration.
Inability to serve as route for administering
medications.
Endotracheal Tube Intubation
New guidelines:
Secondary confirmation of tracheal tube
placement.
Use of end-tidal carbon dioxide monitor or
colorimetric device
Vascular Access
After airway and oxygenation needs met.
Crystalloid solution

Normal saline 20mL/kg bolus over 20 minutes

Lactated ringers used more in adults


Vascular Access New Guidelines
New guidelines: in children who are six years
or younger after 90 seconds or 3 attempts at
peripheral intravenous access Intraosseous
access recommended.
Intraosseous Access
Gastric Decompression
Gastric decompression with a nasogastric or
oral gastric tube is necessary to ensure
maximum ventilation.

Air trapped in stomach can put pressure on the
diaphragm impeding adequate ventilation.

Undigested food can lead to aspiration.
Cardiopulmonary Failure
Childs response to ventilation and
oxygenation guides further interventions.

If signs of shock persists:

Inotropic agents such as epinephrine are given.
Epinephrine
Indications:

Bradycardia
Shock (cardiogenic, septic, or anaphylactic)
Hypotension

IV or ET through the endotracheal tube

New Guideline Epinephrine
Still remains primary drug for treating patients
for cardiopulmonary arrest, escalating doses
are de-emphasized.
Neurologic outcomes are worse with high-
dose epinephrine.
2 New Medications for PALS
Vasopressin causes systemic
vasoconstriction used to increase blood
flow to brain and heart during CPR.
Need to be studied further.
Amiodarone antiarrhythmic agent used in
ventricular fibrillation and ventricular
tachycardia. Given 5 mg/kg over 20 minutes.
Bradycardia
Bradycardia is the most common dysrhythmia
in the pediatric population.

Epinephrine is drug of choice dose is 0.01 to
0.03 mg/kg/dose

Sodium Bicarbonate
In instances where the child is acidotic,
sodium bicarbonate may be administered IV.
The drug is not as stable in the pediatric
population but is often used during the
resuscitative phase of CPR.
Glucose Levels
Monitor serum glucose levels

Replace with 10 % dextrose in the neonate

25% glucose in the child
Ventricular Tachycardia
Ventricular tachycardia is usually secondary
to structural cardiac disease.

Amiodarone 5 mg/kg over 20 minutes

Cardioversion

Defibrillator Guidelines
AHA recommends that automatic external
defibrillation be use in children with sudden
collapse or presumed cardiac arrest who are
older than 8 years of age or more than 25 kg
and are 50 inches long.
Electrical energy is delivered by a fixed amount
range 150 to 200. (4J/kg)
Post-resuscitation Care
Re-assessment of status is ongoing.
Laboratory and radiologic information is
obtained.
Etiology of respiratory failure or shock is
determined.
Transfer to facility where child can get
maximum care.

BLS Updates 2006
Unresponsive infant less than 1 year and
children 1 year to puberty
Open airway
Give 2 breaths (if not breathing)
Begin compressions 30 (if no pulse)
Activate EMS system
AED after 5 cycles of CPR
Tilt Head to Sniff Position
Witnessed Collapse of Child
Activate EMS
AED before CPR
Compression 30 to 2 breaths hand
placement at nipple line
2 rescue 15 to 2 if infant circle chest and
use thumbs
Choking Infant
5 back slaps
5 Chest thrusts
Heimlich for Infants
Clearing the Mouth