Difference between revisions of "PALS (Main)"

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==Recommendations==
 
==Recommendations==
IO access is a rapid, safe, effective, and acceptable route for
+
*Treat shock w/ initial 20cc/kg bolus
vascular access in children,172–179,181 and it is useful as the
+
*Do not routinely hyperventilate even in cases of head injury
initial vascular access in cases of cardiac arrest
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*Provide family w/ option of being present during resuscitation
 
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*IO is useful as initial vascular access
*Use the largest paddles or self-adhering electrodes265–267 that
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*Self-Adhering Electrodes
will fit on the child’s chest without touching (when possible,
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**Use largest size that will fit on child’s chest w/o touching
leave about 3 cm between the paddles or electrodes
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**When possible leave 3cm between electrodes
 
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**Adult size for >10kg; infant size for <10kg
 
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*Hypotension is defined as sys BP:
Adult” size (8 to 10 cm) for children �10 kg
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**<60 (0 to 28 days)
(� approximately 1 year)
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**<70 (1mo - 12mo)
● “Infant” size for infants �10 kg
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**<70 + (2 X age in yr) (1-10yr)
 
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**<90 (≥10yr)
 
 
*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==
 
==BLS==
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==Bradycardia==
 
==Bradycardia==
*Assumes pulse and poor perfusion (low BP, AMS, shock)
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*Algorithm assumes pulse and poor perfusion (low BP, AMS, shock)
 
**Start CPR if HR <60/min w/ poor perfusion
 
**Start CPR if HR <60/min w/ poor perfusion
 
***Recheck after 2min; if poor perfusion persists:
 
***Recheck after 2min; if poor perfusion persists:
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==Tachycardia==
 
==Tachycardia==
 
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*Algorithm assumes pulse and adequate perfusion
If pulses are palpable and the patient has adequate
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===Narrow-Complex===
perfusion:
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*Sinus tachycardia - treat underlying cause
 
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*Supraventricular
Narrow-Complex (<0.09 Second) Tachycardia
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**Vagal stimulation (if will not delay meds/cardioversion)
Supraventricular Tachycardia
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***Infants/young children: apply ice to face
 
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***Older children: Carotid sinus massage / Valsalva
Attempt vagal stimulation (Box 7) first, unless the patient
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**Synchronized cardioversion
is hemodynamically unstable or the procedure will unduly
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***Use if unstable or adenosine ineffective
delay chemical or electric cardioversion (Class IIa, LOE C).
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***Give 0.5-1 J/kg; if unsuccessful increase to 2 J/kg
In infants and young children, apply ice to the face without
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****Give 2nd shock consider amiodarone OR procainamide before 3rd shock
occluding the airway
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*****Amiodarone  5 mg/kg over 20-60min
 
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*****Procainamide 15 mg/kg over 30-60min
In older children, carotid sinus massage or Valsalva maneuvers
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**Adenosine
are safe.
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**0.1 mg/kg; immediately flush w/ 5cc NS
 
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===Wide-Complex===
Pharmacologic cardioversion with adenosine (Box 8) is
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*Adenosine for differentiating SVT from VT
very effective with minimal and transient side effects.300–304 If
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**Consider only if rhythm is regular and QRS monomorphic
IV/IO access is readily available, adenosine is the drug of
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*Synchronized cardioversion
choice (Class I, LOE C). Side effects are usually transient.
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**Give 0.5-1 J/kg; if unsuccessful increase to 2 J/kg
300–304 Administer IV/IO adenosine 0.1 mg/kg using 2
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**Give 2nd shock consider amiodarone OR procainamide before 3rd shock
syringes connected to a T-connector or stopcock; give
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***Amiodarone  5 mg/kg over 20-60min
adenosine rapidly with 1 syringe and immediately flush
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***Procainamide 15 mg/kg over 30-60min
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==
 
==Source==
 
+
AHA 2010 Guidelines for PALS
  
 
[[Category:Peds]]
 
[[Category:Peds]]

Revision as of 22:52, 24 June 2011

Recommendations

  • Treat shock w/ initial 20cc/kg bolus
  • Do not routinely hyperventilate even in cases of head injury
  • Provide family w/ option of being present during resuscitation
  • IO is useful as initial vascular access
  • Self-Adhering Electrodes
    • Use largest size that will fit on child’s chest w/o touching
    • When possible leave 3cm between electrodes
    • Adult size for >10kg; infant size for <10kg
  • Hypotension is defined as sys BP:
    • <60 (0 to 28 days)
    • <70 (1mo - 12mo)
    • <70 + (2 X age in yr) (1-10yr)
    • <90 (≥10yr)

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

  • Algorithm 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

  • Algorithm assumes pulse and adequate perfusion

Narrow-Complex

  • Sinus tachycardia - treat underlying cause
  • Supraventricular
    • Vagal stimulation (if will not delay meds/cardioversion)
      • Infants/young children: apply ice to face
      • Older children: Carotid sinus massage / Valsalva
    • Synchronized cardioversion
      • Use if unstable or adenosine ineffective
      • Give 0.5-1 J/kg; if unsuccessful increase to 2 J/kg
        • Give 2nd shock consider amiodarone OR procainamide before 3rd shock
          • Amiodarone 5 mg/kg over 20-60min
          • Procainamide 15 mg/kg over 30-60min
    • Adenosine
    • 0.1 mg/kg; immediately flush w/ 5cc NS

Wide-Complex

  • Adenosine for differentiating SVT from VT
    • Consider only if rhythm is regular and QRS monomorphic
  • Synchronized cardioversion
    • Give 0.5-1 J/kg; if unsuccessful increase to 2 J/kg
    • Give 2nd shock consider amiodarone OR procainamide before 3rd shock
      • Amiodarone 5 mg/kg over 20-60min
      • Procainamide 15 mg/kg over 30-60min

Source

AHA 2010 Guidelines for PALS