Pediatric Advanced Life Support - 2020 AHA Guideline Updates

Introduction

• Recent 2020 updates from the American Heart Association (AHA) for Pediatric Advanced Life Support (PALS).
• Focus on pediatric patients for advanced life support.
• Recommendation to watch previous video on basic life support updates.

Key Guideline Changes

1. Invasive Blood Pressure Monitoring

• For CPR Quality Assessment: Use diastolic blood pressure in patients with continuous invasive arterial blood pressure monitoring.
• Study Findings: Improved survival with favorable neurological outcomes if diastolic BP is ≥25 mm Hg in infants and ≥30 mm Hg in children during CPR.

2. Early Epinephrine Administration

• 2015 Guideline: Reasonable to administer epinephrine in pediatric cardiac arrest.
• 2020 Update: Administer the initial dose of epinephrine within 5 minutes of the start of chest compressions in any setting.
• Emphasis: Early administration of epinephrine saves lives.

Algorithms

Pediatric Bradycardia with Pulse Algorithm

• Initial Assessment: Determine cardiopulmonary compromise (altered mental status, signs of shock, hypotension).
  • No compromise: Support ABCs, consider oxygen, observe, monitor 12-lead ECG, treat underlying causes.
  • With compromise: Maintain airway, assist breathing (PPV, oxygen), apply cardiac monitoring (pulse, BP, oximetry).
• CPR: Start CPR if HR < 60 BPM despite oxygenation/ventilation.
• Treatments: IV/IO access, administer epinephrine, consider atropine for increased vagal tone/AV block, transthoracic, or transvenous pacing.
• Pulse Check: Continually check every 2 minutes, transition to cardiac arrest algorithm if no pulse.

Sinus Bradycardia

• Rate: < 60 BPM
• Rhythm: Regular, initiated at the sinoatrial node.
• P Waves: Normal/upright, PR interval lengthens as HR decreases, QRS interval < 0.12s.
• Common Causes: Hypoxia, hypothermia, medications.

Epinephrine for Bradycardia

• Dosage: 0.01 mg/kg (0.1 mg/mL concentration), repeat every 3-5 minutes.
• ET Dose: 0.1 mg/kg (1 mg/mL concentration) if no IV/IO access.

Interventions & Considerations

• Epinephrine Considerations: Rising BP with increasing HR can cause angina, myocardial ischemia, increased oxygen demand.
  • High doses do not improve survival rates and may cause post-resuscitation myocardial dysfunction.
• Transcutaneous Pacing: For unstable bradycardias < 50 BPM with compromised hemodynamics.
  • Provide analgesia if patient is conscious.
  • Avoid carotid pulse to confirm capture (muscle jerks may mimic pulses).

Pediatric Tachycardia with Pulse Algorithm

• Initial Support: Maintain airway, assist breathing if necessary, administer oxygen, cardiac monitoring, IV/IO access, obtain 12-lead ECG.
• Cardiopulmonary Compromise: Evaluate QRS duration (narrow or wide).
  • Narrow QRS: Likely SVT, treat with adenosine and synchronized cardioversion if needed.
  • Wide QRS: Treat as ventricular tachycardia, move to synchronized cardioversion.
• No Compromise: Similar evaluation and treatment but include vagal maneuvers and seek expert consultation.

Supraventricular Tachycardia (SVT)

• Definition: Absence/abnormal presentation of P waves, HR not variable.
• Rates: Infants > 220 BPM, children > 180 BPM.
• Vagal Maneuvers: First-line for stable narrow complex tachycardias.
  • Techniques: Coughing, cold stimulus to face, carotid massage, gagging, bearing down.

Adenosine for Tachycardia

• Indication: First choice for stable narrow complex SVT.
• Dosage: Initial 0.1 mg/kg (max 6 mg), rapidly administered, repeat with 0.2 mg/kg (max 12 mg).
• Procedure: Use synchronized cardioversion if medications fail.
  • Settings: 0.5-1 J/kg, increase to 2 J/kg if needed.
• Considerations: Sedation prior to procedure if stable, emergency equipment prepared.

Pediatric Cardiac Arrest Algorithm

• Initiate CPR: Ensure back mass ventilation and oxygenation, monitor rhythm.
• Shockable Rhythms: VFib/pulseless VTach, provide shocks, continue with CPR, administer epinephrine, amiodarone, or lidocaine.
• Non-shockable Rhythms: Asystole/PEA, provide epinephrine immediately, continue CPR, secure IV/IO access.

Cardiac Arrest Rhythm Details

• Pulseless Electrical Activity (PEA) & Asystole: Immediate epinephrine administration.
• VFib/VTach Details: No discernible rate or rhythm in VFib, three or more PVCs in a row for VTach.

Defibrillation

• First Shock: 2 J/kg
• Second Shock: 4 J/kg, subsequently ≥ 4 J/kg, max 10 J/kg.
• Consideration: Aim for consistent CPR interruptions, minimal delays.
• Epinephrine Dosage for Cardiac Arrest: 0.01 mg/kg (0.1 mg/mL), repeat every 3-5 minutes.

Medications

• Amiodarone: 5 mg/kg IV/IO, can repeat up to 3 doses.
• Lidocaine: Alternate to amiodarone, 1 mg/kg IV/IO.

Considerations for Post-Cardiac Arrest Care

• Focus: Respiratory support, Monitor hemodynamics, consider targeted temperature management, neurological surveillance, electrolyte/glucose monitoring, sedation, and prognosis evaluation.

Respiratory Emergencies in Pediatrics

• Upper Airway Obstructions: (e.g., croup, anaphylaxis, foreign body aspiration).
  • Assessment: Increased RR, stridor, barking cough, hoarseness, drooling.
  • Treatment: Nebulized epinephrine, corticosteroids, IM epinephrine for anaphylaxis, position for comfort.
• Lower Airway Obstructions: (e.g., bronchiolitis, asthma).
  • Assessment: Increased RR, expiratory wheezing, prolonged expiration.
  • Treatment: Albuterol, steroids, magnesium sulfate.
• Lung Tissue Disease: (e.g., pneumonia, pulmonary edema, ARDS).
  • Assessment: Increased RR, grunting, crackles.
  • Treatment: Ventilatory support, antibiotics if infectious, diuretics.
• Disordered Control of Breathing: (e.g., neurological conditions, metabolic abnormalities, poisoning).
  • Assessment: Variable RR/effort, normal breath sounds.
  • Treatment: Optimize respiration, administer antidotes, monitor glucose.

Respiratory Failure Interventions

• Rescue Breaths: 1 breath every 2-3 seconds (20-30 breaths per minute).
• Chest Rise: Confirm effective breaths, position patient for best airway alignment.
• DOPE Mnemonic: Detect deterioration in intubated patients.
  • D: Displacement of tube.
  • O: Obstruction of tube.
  • P: Pneumothorax.
  • E: Equipment failure.

Types of Shock in Pediatrics

1. Hypovolemic Shock:

• Causes: Gastroenteritis, burns, hemorrhage, fluid loss.
• Signs: Low BP from fluid shifts/hemorrhage.
• Treatment: Crystalloids (NS, LR) 20 ml/kg bolus, blood products if hemorrhagic shock.

2. Cardiogenic Shock:

• Causes: Congenital heart disease, myocarditis, arrhythmias.
• Signs: Heart not pumping efficiently.
• Treatment: Fluids (5-10 ml/kg), vasoactive infusions, expert consultation.

3. Distributive Shock:

• Causes: Sepsis, anaphylaxis, spinal injury.
• Signs: Blood vessel dilation (septic shock).
• Treatment: Follow septic shock algorithms, IM epinephrine for anaphylaxis, fluid boluses (10-20 ml/kg).

4. Obstructive Shock:

• Causes: Tension pneumothorax, cardiac tamponade, PE.
• Signs: Physical blood flow obstruction.
• Treatment: Needle decompression, fluid resuscitation.

Evaluate-Identify-Intervene Approach in PALS

• Initial Impression: Check ABCs (Appearance, Breathing, Circulation).
• Primary Survey: Focus on airway, breathing, circulation, disability (neurological status, AVPU score), exposure (temperature, skin).
• Secondary Survey: Use SAMPLE mnemonic (Signs/symptoms, Allergies, Medications, Past medical history, Last meal, Events leading up).
• Life-threatening Situations: Intervene immediately.