PEDIATRIC

Advanced
Life
Support
Muhammad Fauzi
I 111 10 002

What is PALS all about?

Evaluating and recognizing an infant or child with

respiratory compromise, circulatory compromise,
or cardiac arrest
Giving timely and appropriate treatment or
interventions
Applying effective team dynamics, observing
individual roles and responsibilities during
pediatric resuscitation
Providing optimal post resuscitation management

Pediatric Chain of Survival

prevention

Early CPR

EMS

Rapid PALS

Intergrated
Post-cardiac
Arrest care

Berg, M. D. et al. Circulation 2010;122:S862-S875

BLS: foundation of saving lives

Fundamental aspects:
immediate recognition of sudden cardiac
arrest ( unconsciousness)
activation of emergency response system
( call 911 )
early performance of CPR (C A B steps)
rapid defibrillation (AED) when appropriate

CPR: ABC IS FOR BABIES. NOW ITS C-A-B!

NEW

OLD

High quality CPR

Chest compressions of appropriate rate and depth.

"Push fast": push at a rate of at least 100 compressions
per minute. "Push hard": push with sufficient force to
depress the chest (at least 1/3 of the AP diameter of the
chest or approximately 1 in. = 4 cm in infants and
approximately 2 in. = 5 cm in children)

allowing complete recoil of the chest after each

compression

minimizing interruptions in compressions

avoiding excessive ventilation

High quality CPR = Effective

PALS

the cornerstone of a system

of care that can optimize
outcomes beyond return of
spontaneous circulation
(ROSC).

Return to a prior quality of life

and functional state of health
is the ultimate goal of a
resuscitation system of care.

Pathway to
pediatric cardiac
arrest

AHA Pediatric Advanced Life Support. 2006

Assessment: Key to Pediatric

Management

AHA Pediatric Advanced Life Support

Manual 2006

What We
Had

General Assessment
(PAT)
Primary Assessment
Secondary Assessment
Tertiary Assessment

Assess-Categorize-Decide-Act Model
Pediatric Advanced Life Support 2006

The PAT & the Primary, Secondary & Tertiary Surveys

AHA Pediatric Advanced Life Support. 2006

What Ionni t i a l I m p r e s s i
s
Evaluate
NEW

Primary assessment
Secondary assessment
Diagnostic tests

Interve
ne

Identi
fy

Evaluate-Identify-Intervene Sequence Pediatric Advanced Life Support 2010

The Initial Impression

A

modification of the PAT, the goal of

which is to help one quickly recognize
a child at risk for deterioration and
prioritize actions and interventions

The

first quick (within seconds) from

the doorway visual and auditory
observation of the childs
consciousness, breathing and color

CB-C
Consciousness

Breathing

Color

Initial Impression
Unresponsive, irritable,
alert
Increased work of
breathing, absent or
decreased respiratory
effort, or abnormal sounds
heard without ausculation
Pallor, mottling, cyanosis

Initial Impression: DECISION & ACTION

POINTS

Unresponsive and not breathing or only gasping

Call for help

Check pulse
(-) pulse, start CPR beginning with compressions
if with ROSC
begin E-I-I sequence
(+) pulse

rescue breathing

HR<60 & poor perfusion despite adequate

oxygenation/ventilation
chest compressions
& ventilations
HR>60
begin EII sequence

Initial Impression: DECISION & ACTION

POINTS

Findings normal or non-urgent, child

breathing adequately

begin E-I-I sequence

Always be alert to a life-threatening

situation. If at any point you identify
a life-threatening problem, call for
help and begin lifesaving
interventions.

The E-I-I Sequence: Evaluate

Clinical Assessment
Primary Assessment

Secondary Assessment
Diagnostic Tests

What It Is
Rapid, hands-on ABCDE
approach evaluating
respiratory, cardiac &
neurologic function; includes
vital signs & pulse oximetry
Focused medical history &
physical exam
Laboratory, radiographic &
other advanced tests that
help to identify the childs
physiologic condition &
diagnosis

Pediatric Primary Assessment

Airway, Breathing,
Circulation, Disability,
Exposure

rapid ordered, stepwise hands-on

evaluation of cardiopulmonary and
neurologic function to prioritize treatment
Includes vital signs & O2 saturation by
pulse oximetry

Pediatric Primary
Assessment

AIRWAY
open?
movement of the chest/abdomen?
air movement and breath sounds?
Decide if:
Clear open / unobstructed
Maintainable simple measures
not maintainable - advanced
interventions
AHA Pediatric Advanced Life Support.2010

Pediatric Primary Assessment

BREATHING

Respiratory rate (RR)

Normal, Irregular, Fast, Slow,
Apnea
Respiratory effort
Normal, Increased, Inadequate
Chest expansion & air movement (TV)
Normal, Decreased, Unequal,
Prolonged expiration
Lung and airway sounds
Pulse oximetry (SaO2)
Normal, Hypoxemic
AHA Pediatric Advanced Life Support.2010

Pediatric Primary Assessment

CIRCULATION

Heart Rate (HR) & rhythm

Pulses (central & peripheral)
CRT
Skin color and temperature
Blood Pressure (BP); in
children <3 yrs, attempt only
once
Level of consciousness
Urine output

Pediatric Primary Assessment

DISABILITY

AVPU Pediatric Response

Scale (cerebral cortex fxn)
GCS
Pupillary response
Blood sugar
Decreased LOC
Loss of muscle tone
Irritability, lethargy, agitation
Generalized seizures
Pupil dilatation

EXPOSURE

Hypo/hyperthermia
Evidence of trauma
or injury
Rash

Pediatric Secondary Assessment

S
Focused history
E

Signs and symptoms

Allergies
Medications
Past Medical History
Last Meal
Events

Detailed PE

A
M

P
Focused medical hx
using SAMPLE
mnemonic and a
thorough head-to-toe
AHA Pediatric Advanced Life Support. 2010
P.E.

Diagnostic Tests

Assessment of respiratory and circulatory

abnormalities
ABG, VBG, Hb, Blood sugar
Pulse oximetry, CXR
Capnography (ETC02), exhaled C02
Sv02 saturation, arterial lactate
CVP, 2DEcho, ECG, PEFR
Invasive arterial pressure monitoring

The E-I-I Sequence: IDENTIFY

Type
Respiratory

Upper Airway Obstruction

Severity
Respiratory

Distress
Lower Airway Obstruction
Lung Tissue Disease
Disordered Control of
Breathing

Circulatory

Hypovolemic Shock

Respiratory Failure

Compensated

Shock
Distributive Shock
Cardiogenic Shock

Hypotensive Shock

Obstructive Shock

Cardiopulmonary Failure
Cardiac Arrest

The E-I-I Sequence: INTERVENE

Positioning to maintain a patent airway

Activating ERS or calling a code
Starting CPR
Obtaining the code cart & monitor
Placing the pt on a cardiac monitor & pulse oximeter
Administering oxygen
Supporting ventilation
Starting medications & fluids (e.g., nebulizer
treatment, IV/IO fluid bolus)

Lets look at a scenario

You are on duty at the ER and the nurse asks
you evaluate a 10-yr-old with difficulty
breathing 15 min after eating.

Initial impression: anxious, with increased

inspiratory effort and stridor, with pale skin

IDENTIFY the
problem
Respiratory distress or respiratory failure
INTERVENE
Open airway if needed, give 100% O2 via nonrebreathing mask in tolerated, attach to
monitor, apply pulse oximeter

EVALUATE Primary Assessment

Airway: inspiratory stridor

Breathing: RR 30/min, deep suprasternal retractions,
nasal flaring, poor aeration on auscultation, SP02 90%
room air
Circulation: HR 130/min, peripheral pulses normal,
CRT 2 sec, BP 115/75 mmHg
Disability: somewhat anxious
Exposure: T 37C

IDENTIF
Y
Respiratory distress vs respiratory failure;
Upper Airway Obstruction
INTERVENE
Assess response to 02; analyze cardiac rhythm

EVALUATE Secondary Assessment:

SAMPLE History

Signs and symptoms: difficulty breathing 15 min after

eating a cookie
Allergies: Peanuts
Medications: None
Past medical history: previously healthy
Last meal: had only a cookie since breakfast
Events: difficulty of breathing began within several min
of eating a cookie

EVALUATE Secondary Assessment: P.E.

Vital signs after 02: HR 120/min RR 20/min SP02 98% at 100%

02 BP 115/75 mmHg
HEENT: stridor at rest
Heart & Lungs: no murmur, breath sounds course, CRT 2 sec
Abdomen: normal
Extremities: no edema
Back: normal
Neurologic: somewhat anxious

IDENTIFY
Respiratory distress vs respiratory failure; Upper Airway Obstruction

IDENTIF
Y
Respiratory distress vs respiratory failure; Upper Airway Obstruction

INTERVENE
Allow position of comfort; consider specific interventions for
UAO (eg. Racemic epinephrine, IV/IM dexamethasone, helium02 mixture, etc.; consider vascular access IV/IO; prepare for
endotracheal intubation

EVALUATE Diagnostic Tests

ABG / VBG, electrolytes, BUN/creatinine, glucose, CBC

with differential
Imaging as appropriate

RE-EVALUATE IDENTIFY INTERVENE

after each intervention

Identification of Respiratory
Problems

By severity
1. respiratory distress
2. respiratory failure
By type
1. upper airway obstruction
2. lower airway obstruction
3. lung tissue disease
4. disordered control of breathing

Respiratory distress

Clinical state characterized by abnormal

respiratory rate (tachypnea) or effort (increased
or inadequate)

Ranges from mild to severe

Signs: tachypnea, increased/inadequate

respiratory effort, abnormal airway sounds,
tachycardia, pale cool skin, alteration in
consciousness

Respiratory Failure

Inadequate ventilation, insufficient oxygenation, or both

Signs:
- RR, signs of distress (eg, respiratory effort: nasal
flaring, retractions, seesaw breathing, or grunting)
- inadequate respiratory rate, effort, or chest excursion
(eg, diminished breath sounds or gasping), especially if
mental status is depressed
- Cyanosis with abnormal breathing despite
supplementary oxygen

Upper airway obstruction

Foreign body aspiration

Epiglottitis
Croup
Anaphylaxis
Tonsillar hypertrophy
Mass compromising the airway lumen
(abscess, tumor)
Congenital airway abnormality (congenital
subglottic stenosis)

Lower airway obstruction

Obstruction

of the lower airways (lower

trachea, bronchi, bronchioles)

Asthma,

bronchiolitis

Tachypnea,

expiratory/inspiratory/biphasic
wheezing, increased respiratory effort,
prolonged expiratory phase

Lung tissue disease

Heterogenous group of clinical conditions affecting

the lung at the level of gas exchange, characterized
by alveolar and small airway collapse or fluid-filled
alveoli

Pneumonia (bacterial, viral, chemical), pulmonary

edema (CHF, ARDS), pulmonary contusion, toxins,
vasculitis, infiltrative disease

Disordered control of breathing

Abnormal

breathing pattern producing

signs of inadequate respiratory rate, effort,
or both

Neurologic

disorders (seizures, CNS

infections, head injury, brain tumor,
hydrocephalus, neuromuscular disease)

Initial management of
respiratory distress or failure

AIRWAY
position of comfort
open airway (head tilt-chin lift, modified jaw thrust)
clear airway (suction, remove FB)
consider OPA, NPA
BREATHING
monitor Sp02, provide 02, assist ventilation
inhaled medication as needed
endotracheal intubation if needed
CIRCULATION
monitor HR, rhythm, BP
establish vascular access as indicated

Bag-Mask Ventilation
Appropriate

face mask (extending from

bridge of the nose to cleft of the chin)
Self inflating ventilation bag
Bag size: 400-500 ml infant/young child
1000 ml older child/adolescent
Position: neutral or sniffing
E-C clamp technique

Breathing: EC clamp
technique

Bag-Mask Ventilation

Tracheal Tube- size and depth

Uncuffed
Uncuffed tube
tube size:
size:
<1yr
3.5mm
<1yr
3.5mm ID
ID
1-2
4.0mm
1-2yr
yr
4.0mm ID
ID
>2
44++ (Age/4)
>2yr
yr
(Age/4)
Cuffed
Cuffed tube
tube size:
size:
<1yr
3.0
<1yr
3.0 mm
mm ID
ID
1-2
3.5
1-2yr
yr
3.5 mm
mm ID
ID
>2
3.5
>2yr
yr
3.5 ++(Age/4)
(Age/4)
ETT
ETTdepth
depth(lip):
(lip):
ETT
ETTsize
sizexx33
AHA, Basic Life Support Textbook,2007

Shock

Results from inadequate blood flow and oxygen

delivery to meet tissue metabolic demands

Typical signs of compensated shock include

Tachycardia
Cool and pale distal extremities
CRT >2 sec despite warm ambient temp
Weak peripheral vs central pulses
Normal systolic blood pressure

Identification of Shock

By severity (effect on BP)

Compensated shock
Hypotensive

By type
Hypovolemic (diarrhea, vomiting, hge, burns)
Distributive (septic, anaphylactic, neurogenic)
Cardiogenic (CHD, myocarditis, arrhythmias, sepsis)
Obstructive (cardiac tamponade, tension
pneumothorax, ductal-dependent lesions, massive PE)

Blood Pressure

Typical SBP 1-10 y.o. (50th percentile)

90 + (age in yrs x 2) mmHg

Hypotension (5th percentile)

term neonates
<60mmHg
up to 12 months

<70mmHg

1-10 yrs:
70 + (age in yrs x 2 ) mmHg
>10 yrs
<90mmHg
Typical MAP: 55 + (age in yrs x 1.5) mmHg

COMPENSATED SHOCK
Possibly Hours
HYPOTENSIVE SHOCK
Potentially Minutes
CARDIAC ARREST

AHA Pediatric Advanced Life Support Manual 2011

Shock management
Optimizing

02 content of the blood

Improving volume & distribution of
cardiac output
Reducing 02 demand
Correcting metabolic derangements
Identifying and reversing the underlying
cause of shock

10 steps of goal-directed
management of pediatric shock
1. Recognize shock at time of triage
2. Transfer pt immediately to shock/trauma room
and amass resuscitation team
3. Begin Oxygen and establish IV access using 90
sec for peripheral attempts
4. If unsuccessful after 2 peripheral attempts,
consider IO
5. Palpate for hepatomegaly; auscultate for rales

10 steps of goal-directed
management of pediatric shock
6. If liver is up and if no rales are present, push 20ml/kg boluses of
isotonic saline up to 60ml in 5-10min until improved perfusion or liver
comes down or patient develops crackles. Give blood if with
unresponsive hemorrhagic shock
If liver is down, beware of cardiogenic shock.
Consider inotropic support ( PGE1 to maintain ductus
arteriosus in all neonates).

7. If CRT>2 sec and/or hypotension persists during fluid resuscitation,

begin IO / peripheral Epinephrine

10 steps of goal-directed
management of pediatric shock
8. If at risk for adrenal insufficiency give hydrocortisone
as bolus (50mg/kg) and then as infusion titrating between
2-50 mg/kg/day
9. If continued shock, intubate and support ventilation
mechanically.
10. Direct therapy to goals: CRT < 3sec, normal BP for age,
improving shock index.

Therapeutic End Points

RESUSCITATION TO CLINICAL GOALS IS THE FIRST
PRIORITY!

Normal mental status

Normal pulses (no differential between peripheral & central)
Equal central and peripheral temperatures/warm extremities
CRT < 2 sec
Normal HR & BP for age
Urine output > 1cc/kg/hr
serum lactate (<2mmol/L)
Reduced base deficit
Central venous 02 sat (SvO2) > 70%

Hemodynamic Support
Dopamine 1st line vasopressor for fluid-refractory hypotensive
shock with low SVR (10-20mcg/k/min); increase myocardial
contractility after preload restoration.
Epinephrine 1st line inotrope for fluid refractory, dopamineresistant nonvasodilatory shock (0.02-1mcg/k/min, to as high as 2-3
mcg/kg/min in severe cases)
Norepinephrine 1st line pressor agent for fluid refractory,
dopamine-resistant vasodilatory (warm, hyperdynamic) shock
(0.03-1.5mcg/k/min)

Phosphodiesterase inhibitors
for catecholamine-refractory low cardiac output and
high SVR
milrinone 50-75 mcg/kg iv loading 60 min
0.375-0.75 mcg/kg/min continuous infusion
increases contractility & improves diastolic function
by decreased degradation of cAMP and increased
intracellular calcium release

Pediatric Critical Care Medicine 2005; 6:195-199

Phosphodiesterase inhibitors
Amiodarone (inodilator)
5 mg/kg iv 30 min
5-10 mcg/kg/min infusion
improves myocardial depression and does not
increase SVR or the metabolic demands of the
heart
Pediatric Critical Care Medicine 2001, 2:24-28

 Dobutamine (2-20mcg/kg/min)
not to be used alone in severe shock
increases cardiac contractility and decreases PVR
(afterload)

Vasodilator therapy (Nitroprusside/NTG)

for epinephrine-resistant low CO and elevated SVR,

normal blood pressure (afterload unloader)
may need simultaneous inotropic support
always augment volume (preload)

Vasopressin
Endogenous

levels decrease in
vasodilatory shock
potent vasoactive agent in the treatment
of vasodilatory shock in adults and
children
Dose:
0.0005-0.002 U/kg/min
varying doses in studies
Pediatr Crit Care Med 2008 Vol. 9, No. 4 Vasopressin in pediatric vasodilatory shock: a
multicenter randomized controlled trial. Choong K. et al., Am J Crit Care Med. 2009 Oct
1;180(7):632-9. Epub 2009 Jul 16.

PALS Pulseless Arrest Algorithm.

Kleinman M E et al. Pediatrics 2010;126:e1361-e1399

2010 by American Academy of Pediatrics

PALS Bradycardia Algorithm.

Kleinman M E et al. Pediatrics 2010;126:e1361-e1399

2010 by American Academy of Pediatrics

PALS Tachycardia Algorithm.

Kleinman M E et al. Pediatrics 2010;126:e1361-e1399

2010 by American Academy of Pediatrics

PALS means TEAMWORK

Resuscitation

= medical expertise and

mastery of skills = multiple tasks

Teamwork divides the tasks while

multiplying the chances of success
Successful

resuscitation = effective
communication and team dynamics

If you want to be on the team &

make a difference
Learn

the science of PALS and learn it

well
Understand your role and the role of
every member of your team in
resuscitation
Understand how teamwork increases the
chances of resuscitation success

The Resuscitation Team

airway

Team leader
Airway
Compressor
IV / IO meds
Monitor / Defibrillator
Observer/ Recorder

I
IV/IO
V
meds
/
comresso
r

Monitor/
defibrillat
or

Observer/
recorder

Team
leader

Elements of effective
resuscitation team dynamics

Closed-loop communication
Clear messages
Clear roles and responsibilities
Knowing limitations
Knowledge sharing
Constructive intervention
Reevaluation and summarizing
Mutual respect

THANK
YOU