Pediatric Life Support

Introduction

  • Pediatric Life Support describes protocols to resuscitate critically ill pediatric patients.
  • Basic Life Support (BLS) is intended for use by both healthcare professionals and laypersons to maintain individuals in nonhospital or limited-resource settings until they can be stabilized in a healthcare facility.
  • Pediatric Advanced Life Support (PALS) is a certification that can be obtained by healthcare providers to enforce a systematic approach to evaluation, management, and resuscitation of critically ill patients.
  • Survival to discharge from in hospital cardiac arrest in pediatric patients has improved since 2001, with return of spontaneous circulation (ROSC) rates improving from 39% to 77% and survival to discharge from 24% to 43%.  
  • Prolonged cardiopulmonary resuscitation also has been shown to be favorable, with 12% of patients surviving.
    • 60% of those survivors had a favorable neurological outcome at time of discharge.
  • Guidelines were updated by the American Heart Association (AHA) in 2015
  • Unlike adults, in which most common etiologies requiring life support are generally cardiac in nature, children generally go into cardiopulmonary arrest and require life support as a result of accidents, sudden infant death syndrome, respiratory distress, and sepsis leading to shock.

 

Basic Life Support

Overview

  • Describes algorithms related to resuscitation of unresponsive children in a non-hospital or limited-resource setting, as it relates to initial assessment, activation of EMS, cardiopulmonary resuscitation and defibrillation with AED.
  • It is intended for use by both healthcare professionals and laypersons.
  • Use infant BLS under the age of 1, Child BLS through puberty (defined as thelarche in females and presence of axillary hair in males), and Adult BLS after puberty.
  • 2015 Guidelines reaffirm the C-A-B (Compression-Airway-Breathing) to increase compression time and decrease periods without blood flow.

 

Compressions

  • Rate of compressions is 100-120/minute, with depth of compression at least 1/3 the anteroposterior diameter of the chest.
  • Infants: With single rescuers, the two finger method (two fingers placed on the sternum just beneath the nipples) is recommended; with multiple rescuers, the two thumb-encircling hands is recommended.
  • Children: The one handed heel on sternum or two handed heel on sternum approach applies.

 

Rescue Breathing

  • Rescue breathing is associated with increased survival in pediatric patients as most pediatric BLS patients enter arrest as a result of some respiratory process.
  • Compression-only cardiopulmonary resuscitation (CPR) was found to have outcomes equivalent to patients receiving no bystander CPR.
  • Rescue breaths are delivered over 1 second, with volume to visible appreciate the chest wall rising

 

Two Types: Single Rescuer and Multiple Rescuers

  1. Single Rescuer
    • Breathing, Pulse intact --> activate EMS and wait for arrival
    • No breathing, pulse intact --> 1 breath every 3-5 seconds, with compressions for pulse <60.
    • No breathing, no pulse --> Cycle 30 compressions:2 breaths and activate EMS/use AED as soon as possible.
      • If the AED can shock the rhythm, allow one shock and continue CPR, otherwise continue CPR.
  2. Multiple Rescuers
    • First rescuer will stay with victim and second rescuer activates EMS and obtains AED.
    • Breathing, Pulse intact --> activate EMS and wait for arrival
    • No breathing, pulse intact --> 1 breath every 3-5 seconds, with compressions for pulse <60.
    • No breathing, no pulse --> Cycle 30 compressions:2 breaths while alone and switch to 15 compressions:2 breaths when second rescuer returns. Use AED as soon as possible.
      • If shockable rhythm, allow one shock and continue CPR, otherwise continue CPR.

 

Advanced Life Support

Evaluation

  • In general, pediatric patients that require PALS are readily identified by chief complaints, e.g., asthma exacerbation, anaphylaxis, trauma, etc.
  • Clinicians are also likely to use a once-over approach to triage patients into sick/not sick.
  • Pediatric Assessment Triangle
    • For those without historical information, use of the Pediatric Assessment Triangle (Figure 1) has been validated in a pediatric emergency setting utilizing nurses triaging all entering patients.

Figure 1: Components of The Pediatric Assessment Triangle pediatricassessment.pnghttp://www.jenonline.org/article/S0099-1767(12)00004-9/abstract

 

  • The PAT allows a rapid impression of a child’s ability to be made using evaluations of 3 components: appearance, work of breathing, and circulation to skin.
    • Appearance:
      • Tone, Interactiveness, Consolability, Look/gaze, Speech/cry (TICLS)
    • Work of Breathing:
      • Stridor, grunting, wheezing, positioning, retractions, nostril flaring, accessory muscle use.
    • Circulation to Skin:
      • Pallor, cyanosis, mottling.
  • Any abnormality noted indicates the child is unstable and requires intervention, but the permutation of abnormalities can distinguish a basic etiology for the current state of the child.
  • The use of the PAT was demonstrated to have a LR of 10 for stable patients (those patients deemed stable by PAT were 10 times more likely to have a stable diagnosis).
  • Similarly, by etiology of distress the PAT was demonstrated to have an LR+ 4 for respiratory distress, LR+12 for respiratory failure, LR+4.2 for shock, and LR+49 for cardiopulmonary failure.

Table 1: Pediatric Assessment Triangle ImpressionComponents of the Pediatric Assessment Triangle and the General Impression.pnghttp://www.jenonline.org/article/S0099-1767(12)00004-9/abstract

 

  • Vitals signs: respiratory rate, heart rate, blood pressure, and pulse oximetry.
    • Weight in kilograms should be determined for purposes of drug dosage.
  • Exam should evaluate at minimum airway, breathing, circulation, disability, Glasgow coma scale/neurologic evaluation and exposure (fever, hypothermia, skin findings, trauma) systems until patient is stable to tolerate a full head to toe exam or multiple providers are available to provide a full head to toe exam.
  • History in a trauma based setting involves interview of caretakers and bystanders and can be obtained using the SAMPLE mnemonic which allows for obtainment of a rapid and focused history.
    • Signs and Symptoms
    • Allergies
    • Medications
    • Past Medical History
    • Last Meal
    • Events leading to current illness
  • Further workup is related to identified etiology, with the differential diagnosis for a patient requiring PALS:

ddxlifesupport.png

 

Stabilization of Patients with Respiratory Issues

  • Airway
    • Clear airway
    • Provide 100% FIO2
    • Consider nasal or oral airway options
    • Intubation if patient unable to protect airway
  • Breathing
    • Escalate airway options as needed, use of bag valve masks, non-rebreathers, and intubation as indicated
    • Assess oxygenation with pulse oximetry
    • Use of inhaled medications (albuterol, epinephrine) as needed
  • Circulation
    • Monitoring cardiac activity, providing compressions as necessary
    • Assess pulses and capillary refill (if pulse is lost, proceed to cardiac arrest protocol)
    • Monitor blood pressure
    • Establishing vascular access (two large bore IVs, IO catheter as necessary)
  • Further management based on etiology of respiratory distress, which can be determined using SAMPLE history.

 

Stabilization of Patients in Shock

  • Critical to care for patients in shock is early identification, signs and symptoms include
    • Diminished pulses
    • Cool, pale, mottled skin
    • Increased capillary refill time
    • Altered Mental Status
    • Vital Sign Abnormalities (importantly, individuals in shock may not display vital sign abnormalities but can display tachypnea, tachycardia, hypotension, pulse pressure abnormalities)
  • ALS protocols aim to identify the type of shock to target the therapeutic interventions. An algorithm detailing the approach to identifying type of shock is found here
  • For all patients initial management includes:
    • Identify patient in shock/treat life threatening conditions
    • High Flow oxygen
    • Intubation in individuals who cannot protect their airway or appear to be entering respiratory failure
    • Obtain Vascular access (IV/IO), infusing initial 20 mL/kg bolus of normal saline
    • Continuous HR, BP, and SpO2 monitoring
    • Identification of Type of Shock and treatment accordingly

Stabilization of Cardiac Arrest

  • Start CPR
    • Give Oxygen
    • Attach a monitor/defibrillator
    • Compressions should depress ½ of the anteroposterior of the chest at a rate of 100/min, with enough time to allow complete recoil of the chest; interruptions to compressions should be minimized
    • Individuals compressing should rotate at least every 2 minutes or sooner, if necessary.
    • If unable or not yet placed an advanced airway, maintain a compression to ventilation ratio of 15:2
      • Advanced airway = Endotracheal intubation of supraglottic advanced airway
      • With an advanced airway, 1 breath/6 seconds and continuous compressions

Figure 2: Pediatric Cardiac Arrest Algorithm 2015 Updatecardiacarrestalgo.pnghttps://circ.ahajournals.org/ content/132/18_suppl_2/S526.full.pdf

 

  • Rhythm Shockable = Ventricular Fibrillation of Ventricular Tachycardia
    • Shock Energy
      • First Shock: 2 J/kg
      • Second Shock: 4 J/kg
      • Subsequent Shocks >4 J/kg, not to exceed 10 J/kg or adult dose
    • After administering a shock, provide CPR for 2 minutes and obtain IV access
      • Depending on the patient’s peripheral perfusion and pressure, IV access may not be obtainable and an IO access should be obtained
    • If the rhythm persists and can be shocked, do so again (at 4 J/kg) and administer Epinephrine every 3-5 minutes.
      • Advanced airways should be considered if not already placed.
        • Epinephrine IO/IV dosing = 0.01mg/kg = 0.1 mL/kg at 1:10,000 concentration
    • If the rhythm persists and can be shocked, do so again (>4 J/kg) and administer amiodarone or lidocaine. Also consider reversible causes of cardiac arrest.
      • Amiodarone IO/IV dose = 5 mg/kg bolus, up to 2 times
      • Lidocaine IO/IV dose = Initial 1mg/kg loading dose, Maintenance 20-50 mcg/kg/minute infusion. Repeat the bolus if the infusion is begun 15 minutes after bolus.
    • This cycle continues until the rhythm obtained cannot be shocked or if the patient stabilizes
  • Rhythm Not Shockable = Asystole or Pulseless Electrical Activity (PEA)
    • Perform CPR for 2 minutes
      • Obtain IO/IV Access
      • Epinephrine every 3-5 minutes. 0.01mg/kg = 0.1 mL/kg at 1:10,000 concentration
      • Advanced Airway
    • Continue to reevaluate the rhythm
      • If continued to be not shockable, repeat CPR for 2 minutes and continue to give epinephrine. Consider reversible causes.
      • If shockable, proceed to shockable rhythm algorithm.
      • If organized rhythm check for a pulse
      • If pulse present (ROSC) proceed to post-cardiac arrest care.
        • ROSC = Pulse and blood pressure, with spontaneous arterial pressure waves if monitoring intraarterial pressure.
  • Reversible Causes
    • Hypovolemia
    • Hypoxia
    • Hydrogen Ion (Acidosis)
    • Hypoglycemia
    • Hypo/hyperkalemia
    • Hypothermia
    • Tension pneumothorax
    • Tamponade, cardiac
    • Toxins
    • Thrombosis, Pulmonary
    • Thrombosis, Cardiac

 

References

  1. Atkins, Dianne, Stuart Berger, Jonathan P. Duff et al. “Part 11: Pediatric Basic Life Support and Cardiopulmonary Resuscitation Quality: 2015 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.” Circulation 132[suppl. 2]:S519-25.
  2. Brierley, Joe, Joseph A Carcillo, Karen Choong et al. “Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine.” Critical Care Medicine 37 (February 2009): 666-88.
  3. de Caen, Allan R., Marc D. Berg, Leon Chameides et al. “Part 12: Pediatric Advanced Life Support: 2015 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.” Circulation 132[suppl. 2]:S526-42.
  4. Dieckmann, Ronald A., Dena Brownstein and Marianne Gausche-Hill. “The Pediatric Assessment Triangle: A Novel Approach for the Rapid Evaluation of Children.” Pediatric Emergency Care 26 (April 2010): 312-15.
  5. Fleegler, Eric and Monica Kleinman. “Pediatric advanced life support (PALS).” In UpToDate. Waltham:UpToDate, 2015.
  6. Horeczko, Timothy, Brianna Enriquez, Nancy E. McGrath, Marianne Gausche-Hill and Roger J. Lewis. “The Pediatric Assessment Triangle: Accuracy of Its Application by Nurses in the Triage of Children.” Journal of Emergency Nursing 39 (March 2013):182-189.
  7. Samuels, Martin, and Susan Wieteska, eds. “Advanced Support of the Airway and Ventilation.” Chap. 5 in Advanced Paediatric Life Support: The Practical Approach, Fifth Edition. West Sussex:John Wiley & Sons, Ltd, 2011.
  8. Tschudy, Megan, and Kristin Arcara, eds. “Emergency Management.” Chap. 1 in The Harriet Lane Handbook: A Manual for Pediatric House Officers, 19th Edition. Philadelphia:Elsevier, 2012.

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