Difference between revisions of "PALS (Main)"

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==Background==
+
==Recommendations==
hypotension is defined as a systolic blood pressure:
+
IO access is a rapid, safe, effective, and acceptable route for
�60 mm Hg in term neonates (0 to 28 days)
+
vascular access in children,172–179,181 and it is useful as the
�70 mm Hg in infants (1 month to 12 months)
+
initial vascular access in cases of cardiac arrest
�70 mm Hg � (2 age in years) in children 1 to 10 years
+
 
�90 mm Hg in children �10 years of age
+
*Use the largest paddles or self-adhering electrodes265–267 that
 +
will fit on the child’s chest without touching (when possible,
 +
leave about 3 cm between the paddles or electrodes
 +
 
 +
 
 +
Adult” size (8 to 10 cm) for children �10 kg
 +
(� approximately 1 year)
 +
● “Infant” size for infants �10 kg
  
If the infant or child is not intubated, pause after 30 chest
 
compressions (1 rescuer) or after 15 chest compressions (2
 
rescuers) to give 2 ventilations (mouth-to-mouth, mouth-tomask,
 
or bag-mask). Deliver each breath with an inspiratory
 
time of approximately 1 second. If the infant or child is
 
intubated, ventilate at a rate of about 1 breath every 6 to 8
 
seconds (8 to 10 times per minute) without interrupting chest
 
compressions
 
  
In the victim with a perfusing rhythm but absent or
+
*hypotension is defined as a systolic blood pressure:
inadequate respiratory effort, give 1 breath every 3 to 5
+
60 mm Hg in term neonates (0 to 28 days)
seconds (12 to 20 breaths per minute), using the higher rate
+
70 mm Hg in infants (1 month to 12 months)
for the younger child (Class I, LOE C). One way to achieve
+
70 mm Hg � (2 � age in years) in children 1 to 10 years
that rate with a ventilating bag is to use the mnemonic
+
90 mm Hg in children �10 years of age
“squeeze-release-release” at a normal speaking rate.
 
  
Both cuffed and uncuffed endotracheal tubes are acceptable
+
==BLS==
for intubating infants and children
+
*Compressions
 +
**Push hard (≥ 1/3 chest diameter) and fast (≥100/min)
 +
*Ventilations
 +
**NO perfusing rhythm
 +
***15:2 ratio when do not have advanced airway
 +
****Do not overventilate! (leads to decr venous return)
 +
****Deliver breath with inspiratory time of 1s
 +
***8-10 breaths per min when intubated
 +
**YES perfusing rhythm
 +
***Give rescue breaths 12-20 per min (“squeeze-release-release”)
  
 +
==Advanced Airway==
 +
*Cuffed and uncuffed ETT are acceptable
 +
**Uncuffed
 +
***<1yo - 3.5mm ETT
 +
***1-2yo - 4mm ETT
 +
***>2yo - 4 + (age/4)
 +
**Cuffed
 +
***<1yo - 3mm ETT
 +
***1-2yo - 3.5mm ETT
 +
***>2yo - 3.5 + (age/4)
  
If an uncuffed endotracheal tube is used for emergency
+
==Pulseless Arrest==
intubation, it is reasonable to select a 3.5-mm ID tube for infants
+
===Asystole and PEA===
up to one year of age and a 4.0-mm ID tube for patients between
+
*Give Epi 0.01 mg/kg (0.1 mL/kg 1:10,000) (max 1mg) q3-5min
1 and 2 years of age. After age 2, uncuffed endotracheal tube
+
*Rhythm check q2min
size can be estimated by the following formula:
+
*Consider H's and T's
Uncuffed endotracheal tube ID (mm)�4�(age/4)
+
**Hypovolemia
If a cuffed tube is used for emergency intubation of an infant
+
**Hypoxia
less than 1 year of age, it is reasonable to select a 3.0 mm ID
+
**Hydrogen ion
tube. For children between 1 and 2 years of age, it is
+
**Hypo/hyperkalemia
reasonable to use a cuffed endotracheal tube with an internal
+
**Hypothermia
diameter of 3.5 mm (Class IIa, LOE B).89,98–100 After age 2 it
+
**Tension pneumo
is reasonable to estimate tube size with the following formula
+
**Tamponade
(Class IIa, LOE B:89,98–101):
+
**Toxins
Cuffed endotracheal tube ID (mm)�3.5�(age/4)
+
**Thrombosis, pulmonary
 +
**Thrombosis, coronary
  
CPR Guidelines for Newborns With Cardiac
+
===VF/Pulseless VT===
Arrest of Cardiac Origin
+
*Shock as quickly as possible and resume CPR immediately
Recommendations for infants differ from those for the newly
+
**First shock 2 J/kg
born (ie, in the delivery room and during the first hours after
+
**Second shock 4 J/kg
birth) and newborns (during their initial hospitalization and in
+
**Subsequent shocks ≥ 4 J/kg (max 10 J/kg)
the NICU). The compression-to-ventilation ratio differs
+
*Give Epi if (shock + 2min CPR) fails to convert rhythm
(newly born and newborns – 3:1; infant two rescuer - 15:2)
+
*Perform pulse check/shock if appropriate q2min
and how to provide ventilations in the presence of an
+
*Give antiarrhythmic if (2nd shock +2min CPR) again fails
advanced airway differs (newly born and newborns – pause
+
**1st line: Amiodarone
after 3 compressions; infants – no pauses for ventilations).
+
***5 mg/kg (max 300mg)
This presents a dilemma for healthcare providers who may
+
***May repeat twice up to 15mg/kg
also care for newborns outside the NICU. Because there are
+
**2nd line: Lidocaine
no definitive scientific data to help resolve this dilemma, for
+
***1 mg/kg
ease of training we recommend that newborns (intubated or
+
**Magnesium
not) who require CPR in the newborn nursery or NICU
+
***25-50mg/kg (max 2g) IV
receive CPR using the same technique as for the newly born
+
***Only for polymorphic V-tach
in the delivery room (ie, 3:1 compression-to-ventilation ratio
 
with a pause for ventilation). Newborns who require CPR in
 
other settings (eg, prehospital, ED, pediatric intensive care
 
unit [PICU], etc.), should receive CPR according to infant
 
guidelines: 2 rescuers provide continuous chest compressions
 
with asynchronous ventilations if an advanced airway is in
 
place and a 15:2 ventilation-to-compression ratio if no advanced
 
airway is in place (Class IIb, LOE C). It is reasonable
 
to resuscitate newborns with a primary cardiac etiology of
 
arrest, regardless of location, according to infant guidelines,
 
with emphasis on chest compressions
 
  
IO access is a rapid, safe, effective, and acceptable route for
+
==Bradycardia==
vascular access in children,172–179,181 and it is useful as the
+
*Assumes pulse and poor perfusion (low BP, AMS, shock)
initial vascular access in cases of cardiac arrest
+
**Start CPR if HR <60/min w/ poor perfusion
 +
***Recheck after 2min; if poor perfusion persists:
 +
****Give Epi 0.01 mg/kg (0.1 mL/kg 1:10,000)
 +
****Give Atropine 0.02mg/kg
 +
*****Only if due to incr vagal tone or AV block (not hypoxia)
 +
****Transcutaneous pacing
 +
*****Consider if bradycardia is due to complete heart block
 +
 
 +
==Tachycardia==
 +
 
 +
If pulses are palpable and the patient has adequate
 +
perfusion:
 +
 
 +
Narrow-Complex (<0.09 Second) Tachycardia
 +
Supraventricular Tachycardia
 +
 
 +
Attempt vagal stimulation (Box 7) first, unless the patient
 +
is hemodynamically unstable or the procedure will unduly
 +
delay chemical or electric cardioversion (Class IIa, LOE C).
 +
In infants and young children, apply ice to the face without
 +
occluding the airway
 +
 
 +
In older children, carotid sinus massage or Valsalva maneuvers
 +
are safe.
 +
 
 +
Pharmacologic cardioversion with adenosine (Box 8) is
 +
very effective with minimal and transient side effects.300–304 If
 +
IV/IO access is readily available, adenosine is the drug of
 +
choice (Class I, LOE C). Side effects are usually transient.
 +
300–304 Administer IV/IO adenosine 0.1 mg/kg using 2
 +
syringes connected to a T-connector or stopcock; give
 +
adenosine rapidly with 1 syringe and immediately flush
 +
with �5 mL of normal saline with the other
 +
 
 +
If the patient is hemodynamically unstable or if adenosine
 +
is ineffective, perform electric synchronized cardioversion
 +
(Box 8). Use sedation, if possible. Start with a dose of 0.5
 +
to 1 J/kg. If unsuccessful, increase the dose to 2 J/kg (Class
 +
IIb, LOE C). If a second shock is unsuccessful or the
 +
tachycardia recurs quickly, consider amiodarone or procainamide
 +
before a third shock
 +
 
 +
Consider amiodarone 5 mg/kg IO/IV308,309 or procainamide
 +
15 mg/kg IO/IV236 for a patient with SVT unresponsive to
 +
vagal maneuvers and adenosine and/or electric cardioversion;
 +
for hemodynamically stable patients, expert consultation
 +
is strongly recommended prior to administration
 +
(Class IIb, LOE C). Both amiodarone and procainamide
 +
must be infused slowly (amiodarone over 20 to 60 minutes
 +
and procainamide over 30 to 60 minutes), depending on the
 +
urgency, while the ECG and blood pressure are monitored.
 +
If there is no effect and there are no signs of toxicity, give
 +
additional doses (Table 1). Avoid the simultaneous use of
 +
amiodarone and procainamide without expert consultation.
 +
 
 +
Wide-Complex (>0.09 Second) Tachycardia
 +
 
 +
Adenosine may be useful in differentiating SVT from VT
 +
and converting wide-complex tachycardia of supraventricular
 +
origin (Box 12). Adenosine should be considered only
 +
if the rhythm is regular and the QRS is monomorphic
 +
Consider electric cardioversion after sedation using a
 +
starting energy dose of 0.5 to 1 J/kg. If that fails, increase
 +
the dose to 2 J/kg
  
Therefore, regardless of the
+
Consider pharmacologic conversion with either intravenous
patient’s habitus, use the actual body weight for calculating
+
amiodarone (5 mg/kg over 20 to 60 minutes) or
initial resuscitation drug doses or use a body length tape with
+
procainamide (15 mg/kg given over 30 to 60 minutes)
precalculated doses
+
while monitoring ECG and blood pressure. Stop or slow
 +
the infusion if there is a decline in blood pressure or the
 +
QRS widens
  
Amiodarone
+
Treat signs of shock with a bolus of 20 mL/kg of isotonic
Decrease the infusion rate if there is prolongation
+
crystalloid even if blood pressure is normal
of the QT interval or heart block; stop the infusion if
 
the QRS widens to �50% of baseline or hypotension develops.
 
Amiodarone should not be administered together with another
 
drug that causes QT prolongation, such as procainamide,
 
without expert consultation.
 
  
Calcium administration is not recommended for pediatric cardiopulmonary
+
Do not routinely hyperventilate even in case of head injury
arrest in the absence of documented hypocalcemia,
 
calcium channel blocker overdose, hypermagnesemia, or
 
hyperkalemia
 
  
Lidocaine decreases automaticity and suppresses ventricular
 
arrhythmias,227 but is not as effective as amiodarone for
 
improving ROSC or survival to hospital admission among adults
 
  
Procainamide
+
Whenever possible, provide family
Decrease the infusion rate if there is prolongation of the QT
+
members with the option of being present during resuscitation of
interval, or heart block; stop the infusion if the QRS widens
+
an infant or child
to �50% of baseline or hypotension develops. Do not
 
administer together with another drug causing QT prolongation,
 
such as amiodarone, without expert consultation a
 
  
  
Pulseless Arrest
 
  
  

Revision as of 22:34, 24 June 2011

Recommendations

IO access is a rapid, safe, effective, and acceptable route for vascular access in children,172–179,181 and it is useful as the initial vascular access in cases of cardiac arrest

  • Use the largest paddles or self-adhering electrodes265–267 that

will fit on the child’s chest without touching (when possible, leave about 3 cm between the paddles or electrodes


Adult” size (8 to 10 cm) for children �10 kg (� approximately 1 year) ● “Infant” size for infants �10 kg


  • hypotension is defined as a systolic blood pressure:

60 mm Hg in term neonates (0 to 28 days) 70 mm Hg in infants (1 month to 12 months) 70 mm Hg � (2 � age in years) in children 1 to 10 years 90 mm Hg in children �10 years of age

BLS

  • Compressions
    • Push hard (≥ 1/3 chest diameter) and fast (≥100/min)
  • Ventilations
    • NO perfusing rhythm
      • 15:2 ratio when do not have advanced airway
        • Do not overventilate! (leads to decr venous return)
        • Deliver breath with inspiratory time of 1s
      • 8-10 breaths per min when intubated
    • YES perfusing rhythm
      • Give rescue breaths 12-20 per min (“squeeze-release-release”)

Advanced Airway

  • Cuffed and uncuffed ETT are acceptable
    • Uncuffed
      • <1yo - 3.5mm ETT
      • 1-2yo - 4mm ETT
      • >2yo - 4 + (age/4)
    • Cuffed
      • <1yo - 3mm ETT
      • 1-2yo - 3.5mm ETT
      • >2yo - 3.5 + (age/4)

Pulseless Arrest

Asystole and PEA

  • Give Epi 0.01 mg/kg (0.1 mL/kg 1:10,000) (max 1mg) q3-5min
  • Rhythm check q2min
  • Consider H's and T's
    • Hypovolemia
    • Hypoxia
    • Hydrogen ion
    • Hypo/hyperkalemia
    • Hypothermia
    • Tension pneumo
    • Tamponade
    • Toxins
    • Thrombosis, pulmonary
    • Thrombosis, coronary

VF/Pulseless VT

  • Shock as quickly as possible and resume CPR immediately
    • First shock 2 J/kg
    • Second shock 4 J/kg
    • Subsequent shocks ≥ 4 J/kg (max 10 J/kg)
  • Give Epi if (shock + 2min CPR) fails to convert rhythm
  • Perform pulse check/shock if appropriate q2min
  • Give antiarrhythmic if (2nd shock +2min CPR) again fails
    • 1st line: Amiodarone
      • 5 mg/kg (max 300mg)
      • May repeat twice up to 15mg/kg
    • 2nd line: Lidocaine
      • 1 mg/kg
    • Magnesium
      • 25-50mg/kg (max 2g) IV
      • Only for polymorphic V-tach

Bradycardia

  • Assumes pulse and poor perfusion (low BP, AMS, shock)
    • Start CPR if HR <60/min w/ poor perfusion
      • Recheck after 2min; if poor perfusion persists:
        • Give Epi 0.01 mg/kg (0.1 mL/kg 1:10,000)
        • Give Atropine 0.02mg/kg
          • Only if due to incr vagal tone or AV block (not hypoxia)
        • Transcutaneous pacing
          • Consider if bradycardia is due to complete heart block

Tachycardia

If pulses are palpable and the patient has adequate perfusion:

Narrow-Complex (<0.09 Second) Tachycardia Supraventricular Tachycardia

Attempt vagal stimulation (Box 7) first, unless the patient is hemodynamically unstable or the procedure will unduly delay chemical or electric cardioversion (Class IIa, LOE C). In infants and young children, apply ice to the face without occluding the airway

In older children, carotid sinus massage or Valsalva maneuvers are safe.

Pharmacologic cardioversion with adenosine (Box 8) is very effective with minimal and transient side effects.300–304 If IV/IO access is readily available, adenosine is the drug of choice (Class I, LOE C). Side effects are usually transient. 300–304 Administer IV/IO adenosine 0.1 mg/kg using 2 syringes connected to a T-connector or stopcock; give adenosine rapidly with 1 syringe and immediately flush with �5 mL of normal saline with the other

If the patient is hemodynamically unstable or if adenosine is ineffective, perform electric synchronized cardioversion (Box 8). Use sedation, if possible. Start with a dose of 0.5 to 1 J/kg. If unsuccessful, increase the dose to 2 J/kg (Class IIb, LOE C). If a second shock is unsuccessful or the tachycardia recurs quickly, consider amiodarone or procainamide before a third shock

Consider amiodarone 5 mg/kg IO/IV308,309 or procainamide 15 mg/kg IO/IV236 for a patient with SVT unresponsive to vagal maneuvers and adenosine and/or electric cardioversion; for hemodynamically stable patients, expert consultation is strongly recommended prior to administration (Class IIb, LOE C). Both amiodarone and procainamide must be infused slowly (amiodarone over 20 to 60 minutes and procainamide over 30 to 60 minutes), depending on the urgency, while the ECG and blood pressure are monitored. If there is no effect and there are no signs of toxicity, give additional doses (Table 1). Avoid the simultaneous use of amiodarone and procainamide without expert consultation.

Wide-Complex (>0.09 Second) Tachycardia

Adenosine may be useful in differentiating SVT from VT and converting wide-complex tachycardia of supraventricular origin (Box 12). Adenosine should be considered only if the rhythm is regular and the QRS is monomorphic Consider electric cardioversion after sedation using a starting energy dose of 0.5 to 1 J/kg. If that fails, increase the dose to 2 J/kg

Consider pharmacologic conversion with either intravenous amiodarone (5 mg/kg over 20 to 60 minutes) or procainamide (15 mg/kg given over 30 to 60 minutes) while monitoring ECG and blood pressure. Stop or slow the infusion if there is a decline in blood pressure or the QRS widens

Treat signs of shock with a bolus of 20 mL/kg of isotonic crystalloid even if blood pressure is normal

Do not routinely hyperventilate even in case of head injury


Whenever possible, provide family members with the option of being present during resuscitation of an infant or child











Diagnosis

Work-Up

DDx

Treatment

Disposition

See Also

Source