PALS

Pediatric Advanced Life

Support
SAMUEL SHAN MS-RRT-NPS-ACCS
 Overview

 Pre-course Self-Assessment (PALS-core and basic knowledge)

 ECG rhythm identification
 Pharmacology
 Practical application
 Complete at eLearning.heart.org/courses
 Submit certificate of completion in iCollege
 Skills
 Performing child and infant CPR
 Focus on high quality CPR
 Using O2 delivery and airway management equipment
 Establishing intraosseous (IO) access and providing rapid flush boluses
 Using electrocardiogram (ECG) monitoring
 Providing defibrillation/cardioversion
 Overview

 Pediatric Assessment
 A systematic approach
 Evaluate
 Initial Assessment
 ABC
 Primary Assessment
 ABCDE
 Secondary Assessment
 SAMPLE
 H’s and T’s
 Focused History
 Focused Physical Exam
 Continuous Reassessment
 Diagnostic Assessments
 Identify
 Intervene
 Overview

 Medical Management
 Acute respiratory problems
 Acute circulatory problems (shock)
 Acute cardiac problems
 Team Dynamics
 Effective team work and communication
 Competency Checkoffs
 Child and infant BLS
 Airway management
 Vascular access (IO)
 Shock Management
 Approach and management of 2 cases using teamwork
 1 Cardiac case
 1 Respiratory case
 Goal

 Improve outcomes by preparing healthcare providers to effectively recognize and intervene in

patients with respiratory emergencies, shock, and cardiopulmonary arrest by using high-
performance team dynamics and high-quality individual skills.
 Learning Objectives

 Perform high-quality CPR (AHA BLS recommendations)

 Differentiate between patients who do and do not require immediate intervention
 Perform role as a high-performance team member
 Differentiate between respiratory distress and failure
 Perform early interventions for respiratory distress and failure
 Differentiate between compensated and uncompensated shock
 Perform early interventions for the treatment of shock
 Differentiate between stable and unstable patients with arrhythmias
 Demonstrate treatment of arrhythmias
 Implement post-arrest care
BLS
BLS
 High-Performance Teams

 Timing
 Time to 1st compression
 Time to 1st shock
 CCF (chest compression fraction) ideally >80%
 Perform pulse checks when there’s an organize rhythm and during pre-charge phase (discontinue compressions)
 Hover over chest
 Switch compressors every 2 minutes
 Intubate without pausing compressions
 Deliver Meds during compressions
 Consider continuous compressions (2 minutes) with asynchronous bag mask device (1 breath every 2-3 sec)
 Minimize pre-shock pause by charging 15 sec before delivering shock (generally minimize all pauses to <10 sec)
 Early response time (EMS and In-hospital-MET)
 High-Performance Teams

 Quality
 Rate (100-120 cpm), depth (1/3 of anteroposterior diameter of chest), and complete recoil
 Minimize interruptions (<10 sec)
 Switch compressors (2 min)
 Avoid excessive ventilation
 Use a feedback device
 Coordination
 Team dynamics – work together, communicate, and be proficient in roles (anticipate what’s next)
 Administration
 Leadership
 Measurement
 Cont. quality control
 Number of code team members
 Team Roles

 Team Leader
 Compressor
 Monitor/Defibrillator/CPR Coach
 Airway
 IV/IO/Medications
 Timer Recorder
 Role of the Team Leader

• Organize the group

– Be clear about role assignments
• Monitor performance of members
• Back up members
• Model team behavior
• Train/coach
– Not during a code!
• Facilitate understanding
• Focus on comprehensive patient care
– Look at the “big picture”
– Debriefings post resuscitation to improve future efforts
 Closed-Loop Communication

 Team leader gives order

 Leader looks for eye contact/verbal confirmation to ensure that message was heard
 Person who receives order repeats the order
 Confirms order once completed
 Leader listens for confirmation of task performance prior to assigning another
 Compressor

 Assess patient
 Pulse checks when necessary (only in-between compressions when paused)
 This duty is expected from all providers
 Perform high quality compressions
 Push hard and fast
 at least 1/3 of anteroposterior diameter of chest
 100 to 120 bpm
 Allow complete chest recoil
 Minimize interruptions (10 sec or less)
 If no advanced airway, 15 compressions/2 breaths
 Advanced airway placed to track capnography
 Intubate without interruptions or use LMA
 Rotate every 2 minutes (next compressor ready - hover)
 Monitor/Defibrillator/CPR Coach

 Bring and operate defib

 Place pads in proper position
 Defibrillation
 1st shock – 2 J/Kg, 4 J/Kg, greater than 4J/Kg for subsequent shocks up to 10 J/Kg
 Cardioversion
 Begin with 0.5 J/Kg, then 1 J/Kg, then 2 J/Kg
 Charge unit 15 sec before 2 min rhythm analysis is complete for immediate shock
 Perform pulse checks during pre-charge phase
 Management of monitoring screen for team leader to view
 Clear bed before each shock
 Double sequence defib not supported
 CPR Coach in-between shocks
 Monitor high quality compressions and ventilations
 Limit compression pauses (adopt protocol)
 Airway

 Open/position airway
 OPA/NPA
 Sniffing position
 Jaw thrust if cervical issue is suspected
 Provide ventilation
 Every 2-3 sec in resp arrest
 Every 2-3 sec when airway is placed
 Avoid excessive ventilation
 Advanced airway placement (now recommended)
 ETT is first option
 Do not pause compressions to intubate
 LMA if intubation is not possible or unsuccessful
 Place capnography (bag/mask) to monitor compression quality and ROSC
 Minimum of 10 mm Hg (ideally 20 mm Hg)
 Sustained 40 mm Hg or greater is good sign of ROSC
 IV/IO/Medication

 Initiates IV/IO
 IV is preferred
 IO if unable to run IV
 Administration of medication
 Closed loop communication
 Cross check of meds and dosage
 All administration of meds followed by a rapid push/flush of saline while raising site of IV
 Deliver drugs during compressions
 Timer/Recorder

 Records timing of interventions and medications

 Records frequency of pauses and duration of interruptions
 Keep all pauses under 10 sec
 Communication with team (mainly with team leader)
 Audio Feedback device
 Other Elements of Effective Team Dynamics

• Send clear messages

• Assign clear roles/responsibilities
– Encourage members to participate, not follow orders blindly
• Know your limitations
• If you are given a role outside your scope of practice, ask for another role
• Share knowledge
• Use constructive intervention
• Reevaluate/summarize
• Show mutual respect
 PALS - Systematic Approach

 Initial Assessment
 Appearance
 Breathing (work of breathing)
 Circulation (color)
 Primary Assessment
 Airway
 Breathing
 Circulation
 Disability
 Exposure
 Secondary Assessment
 SAMPLE
 Signs & Symptoms, Allergies, Medications, Past Medical History, Last meal, Events
 H’s and T’s
 Diagnostic Assessments
 Disability

 Check for neurologic function

 Assess
 Responsiveness
 Level of consciousness
 Pupil dilation
 AVPU
 Alert
 Voice
 Painful
 Unresponsiveness
 GCS

 The GCS measures the following functions:

 Eye Opening (E)
 4 = spontaneous
 3 = to voice
 2 = to pain
 1 = none
 Verbal Response (V)
 5 = normal conversation
 4 = disoriented conversation
 3 = words, but not coherent
 2 = no words, only sounds
 1 = none
 GCS

 Motor Response (M)

 6 = normal
 5 = localized to pain
 4 = withdraws to pain
 3 = decorticate posture (an abnormal posture that can include rigidity, clenched fists, legs held straight out, and arms bent inward toward the body
with the wrists and fingers bend and held on the chest)
 2 = decerebrate (an abnormal posture that can include rigidity, arms and legs held straight out, toes pointed downward, head and neck arched
backwards)
 1 = none
 Using the Glasgow Coma Scale Every brain injury is different, but generally, brain injury is classified as:
 Severe: GCS 3-8
 You cannot score lower than a 3
 Moderate: GCS 9-12
 Mild: GCS 13-15
 PGCS

 Here is the slightly altered grading scale for the PGCS:

 Eye Opening (E)
 4 = spontaneous
 3 = to voice
 2 = to pain
 1 = none
 Verbal Response (V)
 5 = smiles, oriented to sounds, follows objects, interacts
 4 = cries but consolable, inappropriate interactions
 3 = inconsistently inconsolable, moaning
 2 = inconsolable, agitated
 1 = none
 PGCS

 Motor Response (M)

 6 = moves spontaneously or purposefully
 5 = withdraws from touch
 4 = withdraws to pain
 3 = decorticate posture (an abnormal posture that can include rigidity, clenched fists, legs held straight out, and arms bent inward toward the body
with the wrists and fingers bend and held on the chest)
 2 = decerebrate (an abnormal posture that can include rigidity, arms and legs held straight out, toes pointed downward, head and neck arched
backwards)
 1 = none

 PGCS of 8 or less require immediate intubation

Cardiac
Arrest
 Cardiac Arrest

 CPR
 Airway
 Breathing
 Drowning victims-suction and decompress stomach (OG/NG tube)
 Circulation
 Exposure
 For drowning victims
 Rewarm body temperature is <30 degrees C
Bradycardia
 Tachycardia

HR Limits for ST vs SVT

ST <220 IN INFANTS
SVT >220 IN INFANTS

ST <180 IN CHILDREN (1-5)

SVT >180 IN CHILDREN (1-5)

>5 YEARS (150)

Post
Cardiac
Arrest
Care
Shock After
ROSC
Respiratory
Distress
Failure
Managing
Respiratory
Emergencies
Opioid
Associated
Emergencies
 Managing Respiratory Distress & Failure

 Bag-Mask Ventilation
 C/E technique (1 person/2 person techniques)
 Self inflating
 Flow inflating
 Patient (airway) positioning
 Peds
 Neonates/Newborns/Infants
 Head tilt/chin lift or Jaw Thrust
 Suctioning
 OPA/NPA
 Managing Respiratory Distress & Failure

 Low flow O2 delivery devices

 Nasal cannula
 Simple mask
 Nonrebreather (Peds-older children)
 High flow O2 delivery devices
 High flow nasal cannula
 >4 LPM considered high flow in neonatal/newborn/infant/small children
 Nonrebreather
 Neonatal/newborn/infant/small children
 Venturi mask
 Self inflating and flow inflating bag-mask systems
 CPAP/BIPAP
 Managing Respiratory Distress & Failure

 Nebulizer Treatments
 SVN
 Mouthpiece
 Aerosol mask
 MDI
 Holding Chamber
 DPI
 Respimat
 Endotracheal Intubation
 Equipment
 ETT size – (Age in years + 16)/4, insertion depth is 3 times ETT size, recommend cuffed ETTs
 Procedure
Recognizing
Shock
 Pediatric Septic Shock

 Distributive Shock
 Circulatory compromise due to a response from infection (inflammatory response)
 Management
 Restore hemodynamic stability (DO2)
 Support organ function (avoid MODS)
 ID and control infection (early detection and support is critical)
 Highlights
 Rapid fluid therapy is priority for both compensated (warm phase) and decompensated (cold phase)
 In severe illness, be careful with fluid overload
 10 – 20 ml/kg, instead of always providing 20 ml/kg
 Provide 5 – 10 ml/kg slow infusion (10 – 20 min) once fluid overload is detected
 Decrease volume when there’s a cardiac condition present
 10 – 20 ml/kg
 Pediatric Septic Shock

 Managing fluid-refractory shock

 Vasoactive drugs
 Once 40 – 60 ml/kg of fluid has been administered w/o improvement
 Epi or Norepi for both warm or cold shock
 Literature demonstrates preference towards Epi (2020 Surviving Sepsis Campaign)
 Improved CO and myocardial function
 Literature demonstrates preference towards Norepi for vasopressor support (low SVR)
 Both Epi and Norepi are preferred over Dopamine in pediatric septic shock
 Typically (in practice), Epi is initially used to treat fluid-refractory septic shock patients with cold extremities
 Consider early intubation and mechanical ventilation to treat ARDS
 PEEP and lung protection strategies
 Sepsis will induce ARDS due to the inflammatory response
 Pediatric Septic Shock

 Correct adrenal insufficiency

 Fluid-refractory and vasoactive drug resistant septic shock could induce adrenal insufficiency
 History of steroid use
 Give hydrocortisone 1 to 2 mg/kg IV bolus early
 Monitor and maintain normal levels
 Therapeutic goals
 Improve lactate concentration levels
 Normalize vitals
 Focus on normalizing HR and BP (circulation)
 Good distal pulses (<2 sec cap refill)
 Improve LOC
 Normalize UO
 Pediatric Septic Shock

 Within the first hour

 ID signs of septic shock (Immediate, 10-15 min)
 Altered mental status, HR, temperature, perfusion (cap refill, color, appearance, extremities, UO)
 Hypotension may or may not be present (compensated of uncompensated)
 Stabilization
 ABCs
 Monitor vital signs
 Establish IV/IO
 Fluid resuscitation
 Boluses – 10-20 mL/kg isotonic crystalloid (10 mL/kg for neonates and pre-existing cardiovascular compromise)
 Pediatric Septic Shock

 Remainder of first hour

 Draw blood for culture and labs
 Glucose
 Calcium
 Antibiotics – broad spectrum
 Continued hemodynamic assessments
 Antipyretics as needed
 Alternate between acetaminophen/ibuprofen?
 Do signs shock persist after 40-60 mL/kg total fluid administration or evidence of fluid overload?
 Yes
 Obtain critical care consult
 Initiate and titrate epi or norepi
 No
 Consider critical care consult
 Pediatric Septic Shock

 After the first hour

 Establish CVL and Arterial line
 Continue vasoactive drug therapy
 Continue fluid resuscitation (management)
 Maintain adequate airway, oxygenation and ventilation
 Consider stress-dose hydrocortisone if hemodynamics are uncontrolled despite fluid/vasoactive therapies
 Goals of therapy
 Improve mental status (DO2)
 Normalize HR and Temp
 Maintain adequate BP
 Improve perfusion
 Anaphylactic Shock

 Distributive shock
 Cardiopulmonary compromise from mediators released as a part of uncontrolled allergic (humoral) response
 Blood distributes out but venous return is compromised (massive vasodilatation)
 Causes edema (angioedema will compromise upper airway)
 Epinephrine is the front line treatment
 Vasoconstriction presses vessels and improves venous return
 Specific treatments
 Place in supine position, O2, and maintain airway
 Epi
 IM or autoinjector (Epi Pen)
 2nd dose or infusion after 10-15 minutes in severe cases (low dose infusion at <0.05 mcg/kg per minute)
 Isotonic crystalloid fluid boluses
 Albuterol
 When humoral response causes bronchospasm
 Anaphylactic Shock

 Adjunct treatments
 Antihistamines
 H1 blocker (Diphenhydramine (Benadryl))
 Consider H2 blocker (Famotidine (Pepcid AC))
 Corticosteroids
 Methylprednisolone (Solu-medrol)
 Neurogenic Shock

 Distributive shock
 Loss of neurological support/control/regulation of autonomic functions
 Hypotension
 Bradycardia
 Hypothermia
 Minimal response to fluid resuscitation
 Loss of vascular tone results in low DP and wide pulse pressure
 Spinal shock may require more frequent warming or cooling
 Specific treatments
 Position patient flat or in Trendelenburg
 Improves venous return
 Avoid when there is head trauma or increased cranial pressure (ICP)
 Administer fluid resuscitation and assess response
 For fluid refractory hypotension, consider vasopressors
 Norepi or Epi
 Provide warming or cooling
 Cardiogenic Shock

 Circulatory compromised from myocardial dysfunction

 Initially resembles hypovolemic shock
 Slow and small administration of fluids is required
 Pulmonary edema
 Venous congestion
 Main objectives
 Improve cardiac function/CO
 Minimize metabolic demand
 Reduce afterload of the left ventricle (SVR) to increase SV
 Inotrope agents increase contractility, but has a high metabolic demand
 Hypotensive patients may require fluids and inotropes before tolerating afterload reduction
 Cardiogenic Shock

 Specific treatments
 Cautious fluid administration and monitoring
 Prevent or reduce pulmonary edema
 5 – 10 ml/kg over 10 – 20 min
 Labs and other diagnostic tests
 ID cardiac dysfunction
 ABG (oxygenation/ventilation and metabolic acidosis)
 CBC (HgB count to ensure DO2)
 Lactate and ScVO2
 Cardiac enzymes (creatine kinase, myocardial, troponin)
 Thyroid function tests
 CXR (cardiac size and pulmonary vascular markings)
 Electrocardiogram (ECG)
 Echocardiogram (Ultrasound)
 Cardiogenic Shock

 Medications
 Normotensive
 Diuretics
 Vasodilators and inodilators (cont. infusions)
 Reduce ventricular AL (Decrease SVR) which increases SV or EF
 ACE inhibitors
 Angiotensin receptor blockers
 Calcium channel blockers
 Nitrates
 Phosphodiesterase inhibitors (Milrinone) is the preferred drug

 Hypotensive
 Cautious fluid resuscitation
 Inotropes
 Norepinephrine
 Dobutamine
 Dopamine
 Cardiogenic Shock

 Reduce metabolic demands (O2 demands)

 Ventilatory support
 Antipyretics
 Analgesics
 sedatives
 Mechanical circulatory support (ECMO)
 VA ECMO
 VV ECMO
 Obstructive Shock

 Common obstructive shock

 Cardiac tamponade
 Tension pneumothorax
 Ductal-dependent congenital heart lesions
 Massive pulmonary embolism
 Main objectives
 Initial presentation similar to hypovolemic shock
 Early ID is critical (patients with OS can deteriorate quickly to cardiac failure)
 Correct obstruction to circulation/tissue perfusion
 Obstructive Shock

 Specific management
 Cardiac tamponade
 Immediate ID and removal of fluid or air in pericardial space (pericardiocentesis)
 Provide fluid resuscitation
 10 – 20 ml/kg over 10 – 20 min
 Consult cardiac specialists
 Tension pneumothorax
 Immediate ID and removal of air in pleural space (needle thoracentesis and chest tube)
 Provide fluid resuscitation
 10 – 20 ml/kg over 10 – 20 min
 Consult pulmonary specialists
 Obstructive Shock

 Specific management
 Ductal-dependent lesions
 Immediate ID and correction of congenital heart defect
 Echocardiography to direct therapy
 Provide prostaglandin E1 (PGE1) to maintain patent DA
 Provide cautious fluid resuscitation with monitoring
 10 – 20 ml/kg over 10 – 20 min
 Ventilatory support with cautious O2 usage
 Fine balance between PVR and SVR
 Increase PVR and decrease SVR
 Correct metabolic derangements
 Metabolic acidosis
 Consult cardiac specialists
 Obstructive Shock

 Specific management
 Pulmonary embolism
 Immediate ID and correction of occluded PA
 Echocardiography
 V/Q scan
 Pulmonary CT angiography (gold standard)
 Initial treatment is supportive
 O2 administration
 Ventilatory support
 Provide fluid resuscitation
 10 – 20 ml/kg over 10 – 20 m
 Anticoagulants (heparin, enoxaparin)
 Fibrinolytic therapy
 Cath lab
 Pediatric Hypovolemic Shock

 ID type of volume loss

 Non-hemorrhagic
 Dehydration - >5% volume depletion/weight loss (50 ml/kg or greater)
 Hemorrhagic
 Trauma
 Replacing volume deficit
 Preventing and replacing ongoing losses
 Restoring acid – base balance
 Correcting metabolic derangements
 Pediatric Hypovolemic Shock

 Non-Hemorrhagic
 Mild: Table 53 on page 206 in PALS manual
 Moderate: Table 53 on page 207 in PALS manual
 Severe: Table 53 on page 207 in PALS manual

 Treatment
 Rapidly infuse 20 ml/kg boluses of isotonic crystalloid
 Failure to improve after 3 boluses:
 Fluid loss is underestimated
 Type of fluid resuscitation may be altered
 Hemorrhage
 Misinterpretation of classification of shock
 Pediatric Hypovolemic Shock

 Hemorrhagic
 Acute blood loss of about 30% of blood volume
 75 – 80 ml/kg is average total blood volume; 25 ml/kg represents about 30%
 Systemic response to blood loss in peds
 Table 54 on page 208
 Treatment
 Rapidly infuse 20 ml/kg boluses of isotonic crystalloid
 Give up to 3 boluses
 Replace 3 ml of isotonic crystalloid for every 1 ml blood lost
 PRBC
 10 ml/kg boluses
 Crossmatched
 Warm and rapidly infuse
 Pediatric Hypovolemic Shock

 Medication therapy
 Consider vasoactive agents when fluid resuscitation alone is ineffective
 Acid-Base balance
 ABGS
 Avoid lactic acid buildup
 Treat and manage persistent acidosis
 Treat respiratory alkalosis
 Specific considerations-consider other lab studies
 CBC
 Blood type and cross matching
 ABGs/CBGs
 Electrolyte panels
 Lactate
 Diagnostic imaging to locate blood loss
 Shock

 “Result of widespread reduction in effective tissue perfusion leading to cellular

dysfunction and organ failure.”
 Role of clinician
 Early identification (including etiology)
 Treat the underlying cause
 Provide support to organs during treatment
 Avoid MODS

 https://www.youtube.com/watch?v=8UwKigQhdto
 https://www.youtube.com/watch?v=biSHy_nVNeo
 Shock in General

 Circulatory insufficiency
 Altered metabolism
 Multi-organ dysfunction
 Body is trying to save primary functions
 Hypoxic Sequence of Cellular Events

 Anaerobic Metabolism
 Lactic Acidosis
 Decreased energy (ATP)
 Failure of Na/K pump
 Cellular swelling
 Lysosomal rupture
 Cell death
 Organ failure; death
 Classifications of Shock

 Hypovolemic shock
 Most common in children
 Result of fluid or blood loss
 Example?
 Trauma
 Cardiogenic shock
 Result of severe reduction in cardiac function
 Congenital heart defects
 Obstructive shock
 Result of obstruction to flow in the cardiovascular circuit
 Pneumothorax or pneumomediastinum
 Distributive shock
 Result of vasodilation of peripheral vascular bed (leads to decreased preload)
 Example?
 Anaphylaxis, sepsis, and neurological disorders
 Classifications of Shock

 1.) Hypovolemic shock:

 Shock caused by inadequate circulating volume .
 2.) Distributive shock:
 Shock caused by maldistribution of the circulating volume.
 3.) Cardiogenic shock:
 Shock caused by primary pump (heart) failure.
 4.) Obstructive shock:
 Shock caused by physical obstruction of blood flow to and from the heart.
 Goal of Therapy

 To maintain adequate CO in order to supply O2 to the tissues!

 DO2!!!
 Balance tissue perfusion and metabolic demand
 Support organ function
 Prevent cardiac arrest

 Therapeutic goals that indicate treatments are effective include:

 -Improved mental status
 -Improved BP
 -Improved HR
 -Normal and equal central and peripheral pulses
 -Improved capillary refill < 2 seconds
 -Warming extremities
 -Improvement in important laboratory studies (ie. Lactate Level)
 Warning Signs

 Increasing tachycardia
 Diminishing or absent peripheral pulses
 Weakening central pulses
 Narrowing pulse pressure
 Cold distal extremities w/ prolonged cap refill
 Decreasing LOC
 Hypotension (late stage/uncompensated phase)
 Increased Lactate levels
 Definitions

 Preload
 The volume present in the heart & great vessels at rest (during diastole); measure as CVP
 Inotropy
 Describes the ability of the heart muscle to contract
 Afterload
 The resistance against which the heart must pump
 SVR
 Compensatory Mechanisms

 Cortisol release
 Increased in septic shock
 Levels spike in compensated or warm septic shock
 Stress hormone released by the adrenal glands
 Tachycardia
 Initial response of circulatory shock to maintain CO
 Vasodilation
 Initial response in distributive shock
 Vasoconstriction
 Initial response in hypovolemic, obstructive, cardiogenic shock
 Compensated vs. Uncompensated
Shock

 Compensated
 The body is able to maintain blood flow and perfusion via vasomotor auto-regulation
mechanisms
 Warm phase in septic shock
 Uncompensated
 Body can no longer maintain adequate perfusion
 BP falls
 Organ perfusion is compromised
 Cold phase in septic shock

 Irreversible when treatment fails in uncompensated phase

 Monitoring Shock

 If child responds to fluids, then noninvasive methods may be used

 If child does not respond to fluids:
 Arterial catheter
 CVP monitoring
 Pulmonary artery catheter
 EKG
 Electronic BP cuff
 Managing Shock

 Fundamentals
 Optimize O2 content of blood
 DO2 – Hgb, CO, and O2 saturation
 Correct V/Q mismatch
 Improve CO and volume resuscitation
 Start with volume and then consider inotropes/chronotropes with vasoactive drugs
 Reduce O2 demand
 Decrease WOB
 Decrease pain and anxiety
 Reduce fever
 Correct metabolic derangements
 Hypoglycemia
 Hypocalcemia
 Hyperkalemia
 Metabolic acidosis
 Lactic acid
 Managing Shock

 Components of general management

 Positioning
 Comfortable position to reduce anxiety when stable
 Supine when hypotensive
 Support airway, oxygenation, and ventilation
 Maintain/protect airway
 High O2
 High flow devices
 Noninvasive/invasive ventilatory devices
 Vascular access
 Fluid and medication administration
 Peripheral IV is preferred, but IO in hypotensive shock or when IV is not readily established
 Central venous access in critical situations
 Managing Shock

 Fluid resuscitation
 Isotonic crystalloid bolus over 5 – 20 minutes
 20 ml/kg for all shock (unless otherwise specified)
 Septic shock: 10 – 20 ml/kg
 Cardiogenic shock: 5 – 10 ml/kg over 10 – 20 minutes
 Pulmonary edema

 For severe, hypotensive, hypovolemic shock

 Bolus over 5 – 10 minutes
 Monitoring
 SPO2: >94%
 HR: normal values
 Peripheral pulses: weak pulses get stronger and bounding pulse resolves
 Capillary refill: <2 sec
 Skin color and temp: pink/perfused skin color and warm extremities
 BP: normal w/ normal pulse pressures
 LOC
 Ongoing fluid losses: bleeding and diarrhea controlled
 UO: 1.5 – 2 ml/kg per hour (older children 1 ml/kg per hour)
 Managing Shock

 Frequent reassessment
 Evaluate trends
 Determine response to therapy
 Plan inventions
 Lab studies
 CBC
 Hemorrhagic hypovolemic shock
 Septic shock ID of infection
 Glucose
 Hypoglycemia is present in critically ill patients (AMS, Resp compromise, shock)
 Left untreated results in brain injury
 Infants have higher glucose utilization and limited glycogen sores (higher MR)
 ID and treat hypoglycemia early
 Preterm and term neonates: >40 mg/dl
 Infants, children, adolescents: >60 mg/dl
 Provide 0.5 to 1 g/kg IV
 D25W (2 to 4 ml/kg) or D10W (5 to 10 ml/kg
 Managing Shock

 Lab studies
 Potassium
 Electrolyte balance
 Heart function
 Calcium
 Electrolyte balance
 Heart function
 Lactate
 Shock
 ABG
 V/Q, DO2, metabolic disorders
 SCVO2/SVO2
 Tissue consumption
 Circulation
 Managing Shock

 Medication therapy
 Inotropes
 Epinephrine
 Dobutamine
 Dopamine
 Phosphodiesterase inhibitors
 Milrinone
 Vasodilators
 Nitroglycerine
 Nitroprusside
 Vasopressors
 Epinephrine
 Norepinephrine
 Dopamine
 Vasopressin
 Intraosseous Access

 Sites for IO access

 Proximal tibia (preferred site)
 Just below the growth plate
 Distal tibia
 Just above medial malleolus
 Distal femur
 Anterior-superior iliac spine
 Proximal humerus for older children
 Contraindications
 Fractures and crush injuries near access site
 Conditions with fragile bones
 Previous attempts to establish IO on same bone