Pediatric Advanced Life Support (PALS)

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Outline

Overview

Pediatric Advanced Life Support (PALS)
1. Structured approach to assessing and treating critically ill children.
2. Guidelines provided through the American Heart Association
3. Last updated in 2015
4. Training usually required within the first 6 months of work as a pediatric nurse

Nursing Points

General

When children become critically ill it’s usually because of…
1. Respiratory distress/failure
2. Sepsis
3. Shock
Usually the endpoint of a long process of being unwell and extreme hypoxia and acidosis are present
Outcomes are very poor if the child actually goes into cardiac arrest
Efforts focus on preventing arrest by quickly recognizing and treating hypoxia, poor perfusion, infection

Assessment

PALS uses the following assessment tools to provide structure
1. Primary assessment
  1. A.B.C.D.E.
    1. Airway
    2. Breathing
    3. Circulation
    4. Disability
    5. Exposure
Common problems to be on the lookout for
1. Upper airway obstruction
  1. Listen for…
    1. Stridor and upper airway sounds
    2. Barking cough (croup)
  2. Look for…
    1. Drooling
    2. Cyanosis
  3. Possible causes
    1. Anaphylaxis
    2. Foreign body inhalation (grapes, legos)
    3. Croup/Epiglottitis
2. Lower airway obstruction
  1. Listen for…
    1. Wheeze
    2. Silent chest
  2. Look for…
    1. Severe retractions
    2. Severe tachypnea
    3. Cyanosis
  3. Possible causes
    1. Bronchiolitis
    2. Asthma Exacerbation (severe)
    3. Status Asthmaticus (silent chest)
3. Shock
  1. Look for…
    1. Signs of dehydration
      1. Decreased wet diapers
      2. Sunken fontanelles
    2. Tachycardia and Tachypnea
    3. Lethargy decreased LOC
    4. Pale/Mottled Skin
    5. Cool peripheries
    6. Delayed capillary refill >2 seconds
    7. Hypotension
      1. This will be the last thing to drop.
      2. Don’t wait to treat until BP drops.
  2. Possible causes
    1. Infection
    2. Excessive d/v
    3. Poor intake (prolonged)
    4. DKA
    5. Head injury
    6. Congenital heart defects
    7. Poisoning/Toxic ingestion
4. Seizures
  1. Possible causes
    1. Febrile convulsions
    2. Hypoglycemia

Therapeutic Management

Common intereventions
1. Airway problems
  1. Airway positioning
  2. Elevate head of bed
  3. Suctioning
  4. Medications
    1. Steroids
    2. Nebulized epinephrine
    3. Antibiotics (epiglottitis)
  5. Airway adjuncts
  6. Ventilation
2. Breathing
  1. Oxygen (via non-rebreather)
  2. Continuous pulse-ox monitor
  3. Medications
    1. Albuterol
    2. Epinephrine
    3. Steroids
3. Circulation
  1. IV access
  2. Close monitoring
  3. Fluids
  4. Treat cause

Nursing Concepts

Oxygenation
1. Problems with oxygenation and perfusion are the most common cause of cardiopulmonary arrest in pediatric patients.
Perfusion
1. Problems with oxygenation and perfusion are the most common cause of cardiopulmonary arrest in pediatric patients.
Clinical Judgement
1. PALS provides a structured way to assess and treat acutely ill children.

Patient Education

During a pediatric resuscitation event parents should be allowed to stay in the room.
A staff member should be allocated to stay with them and talk through events as they occur.
Allowing parents to be present during the resus may help the them process the experience.

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Transcript

Today we are going to be talking about pediatric advanced life support or PALS as its usually called.

PALS guidelines are established by the American Heart Association and basically what the guidelines provide is a structured approach to assessing and treating critically ill kids. If you decide to go into pediatric nursing PALS will be essential training for you and likely part of your orientation.

I’m going to take the next couple of slides to cover some basic information about PALS-obviously this doesn’t cover everything and with real advanced life support, there is a lot of simulation and hands on practice. The first thing you need to keep in mind is that pediatric arrests are different than adults. The primary way they are different is in the cause. The most common causes of arrest in childhood are respiratory problems, sepsis, and shock.

When a child actually arrests it’s usually the end point of a really long process- so what i mean by this is that they have been sick for a while, they have been hypoxic and dehydrated for a long time so they are very unstable. Because of this- if cardiac arrest actually occurs and the child’s heart stops the outcomes are pretty poor. So to prevent this from happening a lot of PALS focuses on actually preventing that decline by recognizing hypoxia, dehydration, infection, and shock as early as possible and intervening.

The structure used when assessing an acutely unwell patient is ABCDE. This is true for adults as well. A stands for airway, B for breathing, C for circulation, D for disability and E for exposure. I think AB and C are pretty straight forward. For A you are checking to see if the patient has a patent airway so listening and looking at the airway. For breathing, you are looking for increased work of breathing and listening for added lung sounds like wheezing and crackles. For circulation, you want to assess for signs of dehydration and shock. Disability is when you assess their level of consciousness, so Glasgow coma scale, pupils, posturing and checking blood sugar. For exposure you want to look at the entire body, looking for rashes, bruising, signs of injury or bleeding. Sometimes we call this- everything else.

For children there are some common problems to be on the lookout for. These are upper airway obstruction, lower airway obstruction, shock and seizures.

Upper airway obstruction usually presents as stridor. Stridor is a high pitched sound that indicates decreased airflow in the upper airway. You won’t need a stethoscope to hear stridor, it’s audible without one. Most of the time, in kids this is caused by croup, epiglottitis, anaphylaxis or inhaled foreign body. Other things that may indicate a compromised airway are drooling and cyanosis.

Lower airway obstruction will make the child work hard to breathe. This will often cause retractions, nasal flaring and and an increased RR. Things to listen for are a wheeze, or possibly a silent chest. The silent chest is a really bad sign because it means no air is moving through the lungs. Common diagnoses that cause these problems are asthma and bronchiolitis.

Signs of shock are cool peripheries, mottled skin, increased HR and RR and probably the most important thing to assess is capillary refill. In kids you want capillary refill to be less than two seconds. Always keep in mind that blood pressure is the last thing to change in kids so don’t wait in the blood pressure to drop to give fluids and treat the cause of shock. Common diagnoses that may cause shock and dehydration are sepsis, severe dehydration from n/v and DKA.

Seizures are most often caused by fevers and low blood sugar. So for your D assessment remember- DEFG- don’t ever forget glucose.

There is a lot to know about how these are managed, but i’m just going to highlight some of the basics. The first thing we do is make sure the airway is in the best position. Then we apply oxygen- usually in an acute setting, this means high flow oxygen given via mask. Fluids are very important as well to correct dehydration and shock. Check out the peds lesson on dehydration for details on how we calculate fluids for kids.

Common medications used in these critical scenarios are albuterol (used to treat a wheeze), epinephrine (used to treat croup and airway obstruction), steroids (to reduce inflammation in airways) and antibiotics (to treat infection).

Okay- key points to remember for this lesson are, first that the causes of pediatric arrests are different than those that cause adult arrest. They are respiratory problems, sepsis or shock.

Efforts should focus on preventing arrest and identifying early on when a child is unwell. This early intervention provides the opportunity for the best outcomes.

The structure to use when assessing a critically unwell patient are ABCDE. That stands for airway, breathing, circulation, disability, and exposure.

Key interventions that are part of treating these sick kids are oxygen, fluids and meds are albuterol, steroids, epinephrine, and antibiotics.
Your priority nursing concepts when providing Pediatric Advanced Life Support are clinical judgment, oxygenation and perfusion.

We love you guys! Go out and be your best self today! And as always, Happy Nursing!