PALS 2020 Guideline Updates

what&#39;s going on all my healthcare brothers and sisters i hope that you are having a wonderful day the american heart association has officially come out with their 2020 guideline updates for the pediatric advanced life support certification and today we&#39;re going to be discussing what those changes are let&#39;s get started in this video we&#39;re only going to be discussing the pediatric advanced life support updates i highly recommend that you go back and check out my previous video on the american heart association 2020 guideline updates for basic life support when it comes to our pediatric patients so to begin let&#39;s take a look at some of the big changes that came with our pals update from the american heart association in 2020 to begin we have invasive blood pressure monitoring to assess cpr quality in 2020 for patients with continuous invasive arterial blood pressure monitoring in place at the time of cardiac arrest it is reasonable for providers to use diastolic blood pressure to assess cpr quality a new study showed that among the pediatric patients receiving cpr with an arterial line in place rates of survival with favor favorable neurological outcomes were improved if the diastolic blood pressure was at least 25 millimeters of mercury in infants and at least 30 millimeters of mercury in children another big update was for early epinephrine administration in 2015 is reasonable to administer epinephrine in a pediatric arrest cardiac arrest patient however in 2020 for pediatric patients in any setting it is reasonable to administer the initial dose of epinephrine within five minutes from the start of chest compressions so something that the american heart association really has emphasized in 2020 is that early administration epinephrine has been shown to save lives so let&#39;s begin by looking at the pediatric bradycardia with pulse algorithm does the pediatric patient have cardiopulmonary compromise meaning they are acutely altered mental status signs of shock and hypotensive if they are not then we continue to support the abcs we want to consider oxygenation we want to observe the patient continue to monitor them as well as perform a 12v ecg and identify and treat any underlying causes if they do have cardiopulmonary compromise then we start providing assessment and support we want to maintain the patient airway assist with breathing with positive pressure ventilation and oxygen as needed and then cardiac monitoring should be implemented if it hasn&#39;t been so already monitoring the pulse the blood pressure and the oximetry now if we have a pediatric patient we want to start cpr if the heart rate is still less less than 60 beats per minute despite us providing oxygenation and ventilation if that bradycardia persists we&#39;re going to continue cpr get that ivio access administer that epinephrine we can even look at potentially atropine for increased vagal tone or or if there&#39;s a primary av block present we want to consider transthoracic transvenous pacing but we also want to identify and treat underlying causes we&#39;re going to continuously check for that pulse every two minutes if there is a pulse presence um we go back to is the patient is the bradycardia persisting we just keep going back and forth in that algorithm supporting the abcs watching oxygen observing 12 leading treatment underlying cause if a pulse is not present then we transition over to that pediatric cardiac arrest algorithm so we start by looking at our sinus bradycardia we have a rate of less than 60 beats per minute the rhythm will be regular and it&#39;s going to be initiated in that sinoatrial node p waves will be normal and upright but the pr interval is going to be lengthening dependent on how that rate decreases and the qrs interval will be less than 0.12 seconds so the most common cause of bradycardia when it comes to children is hypoxia it can also be caused from hypothermia as well as medications but it&#39;s usually related to hypoxia and again if the child&#39;s heart rate is still less than 60 despite us providing oxygenation and ventilation we begin providing cpr immediately epinephrine is another great joke of choice when it comes to our bradycardias it&#39;s an alternative drug of choice when it comes to symptomatic sinus bradycardia pediatric dosing for this is 0.01 milligrams per kilogram or if you have a 0.1 milligrams per ml concentration you can use 0.1 ml per kilogram you&#39;re going to repeat this every three to five minutes if there is no iv or io access available and we need to get this medication to our pediatric patient we can use the endotracheal et tube and with that you can give 0.1 milligrams per kilogram or if you have a 1 milligram per ml concentration you&#39;re going to give 0.1 mls per kilogram epinephrine considerations rising blood pressure with increasing heart rate can actually cause angina myocardial ischemia as well as increase oxygen demand so you have to be very careful with the medication that we&#39;re giving high doses do not improve survival rates it may actually contribute to post-resuscitation myocardial dysfunction with poor neurological outcomes and high doses will most likely be required if we have any kind of poison or drug induced shock with our pediatric patients trans-containing spacing is another potential intervention when it comes to our bradycardias it&#39;s usually used for our unstable bradycardias that are less than 50 beats per minute but are also showing some kind of compromised hemodynamics that can include your hypotension your acute altered mental status changes shock ischemic chest discomfort as well as acute heart failure precautions when using this intervention is with our conscious patients we want to give them some analgesia because pacing can be uncomfortable you also want to avoid palpating any kind of carotid pulses to confirm capture because electrical impulses can cause muscles to jerk which will mimic which will mimic a pulse so you definitely don&#39;t want to use that as your only indicator that we&#39;re having capture um transmutation is pacing set up you want to position the pads on the chest as instructed by the packaging you&#39;re going to turn on the pacer you&#39;re usually going to set the demand to 80 beats per minute or per the physician order you&#39;re going to set the current mma output increase current starting with the minimum settings until you start to see the electrical capture being consistent that means you&#39;re going to have that wide qrs and t waves after each pacer spike also known as ventricular paste and the most common currents that you&#39;re going to see when it comes to the ma is going to be between 50 to 80. now let&#39;s take a look at the tachycardia with the pulse algorithm now i know this is a little bit confusing but bear with me as we break this down so our initial assessment support is we want to maintain patient airway and assist with breathing as necessary we can administer oxygen we want to do cardiac monitoring to identify the rhythm as well as monitor for pulse blood pressure and oximetry we want to get our iv io access and we want to obtain a 12 lead ecg if it is available if we can&#39;t obtain a 12 ecg then we&#39;re going to monitor for which rhythm it is and search and treat for the cause something else that&#39;s important to know is we also need to look if there&#39;s any kind of cardiopulmonary compromise that can consist of any kind of acutely altered mental status signs of shock and hypotension so if we obtain a 1280cg and there is cardiocompromise present we need to evaluate the cure restoration do we have a narrow qrs or do we have a wide qrs if we have a narrow qrs we&#39;re most likely dealing with a supraventricular tachycardia that&#39;s usually an infant&#39;s greater than 100 i&#39;m sorry 220 beats per minute and in children greater than 180 beats per minute if we have confirmed that we have svt and cardiopulmonary compromise we&#39;re going to give iv we&#39;re going to get that iv io access and give adenosine or if we don&#39;t have any of those available or if the adenosine is not effective we can move straight to synchronized cardioversion if we evaluate the qrs duration and it&#39;s wide we most likely have a ventricular tachycardia present so if we have a ventricular tachycardia present with cardiopulmonary compromise then we immediately move to electricity we&#39;ve always talked about this electricity when we have any kind of compromise comes first before medications so we want to give synchronized cardioversion to our vtec patients seek expert consultations and give additional direct therapies if needed if we don&#39;t have any kind of cardiopulmonary compromise we follow the same steps in evaluating the cure restoration do we have a narrow qrs or do we have a wide qrs if we have a narrow qrs again we&#39;re most likely dealing with some kind of supraventricular tachycardia if we have an svt and no cardiopulmonary compromise present and we want to consider vagal maneuvers if iv or io access is also present we can even give adenosine if we have a wide qrs we&#39;re most likely looking at a ventricular tachycardia if we have ventricular tachycardia and no cardiopulmonary compromise present then the rhythm and if the rhythm is a regular monomorphic rhythm we can consider giving adenosine and we also want to seek expert consultation for any patient within these spectrums so let&#39;s take a little bit of a closer look at these rhythms so when it comes to supraventricular tachycardia it&#39;s defined as the absence or abnormal presentation of p waves and the heart rate is not variable so when it comes to our pediatric patients if the parent is able to soothe the child and the heart rate comes down they were not dealing with a supraventricular tachycardia however if after limiting movement and providing comfort the heart rate remains elevated and consistent the rhythm is an svt and as we talked about before in our algorithm infant rates are going to be greater than 220 beats per minute and children rates are going to be greater than 180 beats per minute and our last shockable rhythm is this beautiful regular monomorphic ventricular tachycardia again we talked about the rates before the rhythm is going to be regular the pr interval will be not present because we have this beautiful ventricular beats and the qrs interval is going to be y greater than 0.12 seconds so one of the options we can perform are vagal maneuvers it&#39;s the first line management tool when it comes to tachycardias now with pediatric patients we range all the way from 28 days to the presence of puberty right so a lot of these may not work for different patient populations you&#39;re going to have to use your clinical judgment when it comes to vagal maneuvers so coughing may be difficult for young younger patients that they&#39;re unable to follow commands but if they are coughing actually creates the same physiological responses bearing down and it&#39;s easily performed the cough has to be forceful and sustained in order for it to mimic that bearing down procedure cold stimulus to the face by either providing ice packs to the face or a washcloth soaked in ice water for 10 seconds can be used because this creates a physiological response like submersion and cold water also known as diver&#39;s reflex carotid massage can be performed on the patient&#39;s neck by extending the position and turning away from the carotid and you only want to massage one carotid at a time for no more than 10 seconds it is not recommended usually i don&#39;t personally perform this even with being an open heart i see a nurse i usually allow this to be performed by the providers because there&#39;s a lot of um there&#39;s a lot of things that can&#39;t go wrong with carotid massage depending on the age group and depending on their core morbidities when it comes to gagging again not something i recommend your patients probably not going to trust you if you use this but it is an option it stimulates that vagus nerve by placing a tongue depressor in the back of the patient&#39;s throat and then lastly bearing down you instruct the patient to bear down like they&#39;re having a bowel movement or they can blow through an occluded 10ml syringe for about 15 to 20 seconds another great option when it comes to our tachycardia rhythms is adenosine if you haven&#39;t seen this it&#39;s fantastic it stops the heart restarts it it&#39;s it&#39;s incredible if you haven&#39;t seen it i really hope you get the chance to but with adenosine it&#39;s the first drug of choice for stable narrow complex supraventricular tachycardias and it can be used with our unstable narrow complex tachycardias usually in the preparation of cardioversion taking place if it&#39;s needed we don&#39;t usually use this to convert atrial fibrillation atrial flutter or ventricular tachycardia there&#39;s a different medication that they use for those specific rhythms so when it comes to adenosine um dosing patients are placed in a mild reverse trendelenburg position and for our pediatric patients that initial dose will be 0.1 milligrams per kilogram give it rapidly over three i&#39;m sorry one to three seconds with a maximum dose of six milligrams you want to immediately elevate the extremity after you give the medication just to get to the heart a little quicker if there is a second dose required that would be 0.2 milligrams per kilogram given rapidly again over one to three seconds with a maximum second dose of 12 milligrams so let&#39;s talk about synchronized cardioversion it involves the delivery of a low energy shot which is timed or synchronized to be delivered at a specific point in the qrs complex to avoid causing ventricular fibrillation so the procedure is you want to first obtain a 12 lead ecg if the patient is stable you&#39;re going to prepare proper sedation since cardioversion is painful emergency equipment should always be ready just in case there&#39;s some kind of complications such as your code card you&#39;re going to place the defibrillator pads on the patient and set the monitors to synchronized or sync mode sync mode will deliver concurrent energy with the qrs so what you&#39;ll find is when you place in the same mode and you&#39;re looking at the rhythm there&#39;ll be these little ticks above each r wave and it does this so that when it delivers the shock it doesn&#39;t send the pediatric patient into ventricular fibrillation so like i said you want to engage the sync mode before each attempt look at the sync markers above each r wave to make sure that sync mode is on so when it comes to the initial recommended voltage doses you&#39;re going to get between 0.5 to 1 joule per kilogram if that&#39;s not effective then you can increase it to 2 joules per kilogram and i highly recommend if you are able to to give sedation prior to delivering any kind of cardioversion shock because it is very uncomfortable if the patient is unstable absolutely give the shock before sedation you want to clear all personnel from the patient prior to delivering the shock you&#39;re going to press the charge button clear the patient then press press the shock button after the shock you&#39;re going to reassess the patient&#39;s rhythm for potentially any additional shocks let&#39;s take a look at the pediatric cardiac arrest algorithm we always want to start by providing cardiopulmonary resuscitation we want to make sure that we have that back mass ventilation as well as oxygenation present and attach the monitor into if we have a shockable rhythm then we&#39;re most likely looking at a ventricular fibrillation and pulseless ventricular tachycardia those rhythms we want to continue providing those shocks after giving our shots we&#39;re going to immediately begin cpr for two minutes and keep reassessing the rhythm we also want to make sure that we have our iv io access our advanced airway providing our epinephrine amiodarone or lidocaine if necessary and treating any reversible causes if we do not have a shockable rhythm we&#39;re most likely dealing with either a a sicily or pulseless electrical activity something new that came out with the 2020 american heart association guidelines for our non-choco shockable rhythms is we want to give that epinephrine as quickly as possible do not delay giving epinephrine it can save lives we&#39;re going to continuously give our two minutes of cpr rechecking if the rhythm has become shockable obtaining our iv io access giving the epinephrine like we spoke about obtaining our advanced airway as well as capenography if no signs and symptoms of spontaneous circulation are present then we&#39;re going to continuously give cpr until we make the determination of when to terminate pediatric advanced life support if rusk does return then we&#39;re going to go to the post cardiac arrest checklist and start those procedures from there so taking a closer look at our cardiac arrest rhythms we have pulseless electrical ventricular tachycardia the rate&#39;s going to be between 100 to 220 beats per minute the rhythm should be regular p waves are not going to be apparent so if they&#39;re not apparent you&#39;re not going to have a pr interval and the qrs is going to be y it&#39;s going to be greater than 0.12 the definition for this is three or more pvcs in a row is either non-sustained meaning that it&#39;s less than 30 seconds or sustained being greater than 30 seconds adequate blood pressure is difficult to sustain due to that rapid rate and it can ultimately lead to ventricular fibrillation if it&#39;s not treated appropriately ventricular fibrillation again nothing&#39;s going to be measurable uh no rate no rhythm no p was no pr intervals and when it comes to your qrs intervals the it&#39;s just going to be fibrillation waste it&#39;s going to look like artifact but it&#39;s not um the definition for this is multiple foci within the ventricle are rapidly firing repeatedly causing this disorganized ventricular contraction um this is going to be one of three ecg patterns that you&#39;re going to see with your cardiac arrest a sisley pretty obvious right we&#39;ve got no right now rhythm no p waves or periodical no qrs this is really just a cease of all heart function and electricity and lastly we have our pulseless electrical activity also known as pea you&#39;re going to look on the monitor and it&#39;s going to look like this beautiful sinus rhythm but when you check your patient they are not going to have a pulse so ultimately you&#39;re just going to have this organized cardiac electrical activity with no palpable pulse so let&#39;s talk about defibrillation it is the first intervention when it comes to ventricular fibrillation or pulseless ventricular tachycardia we always want to assess for these rhythms and if they are present we&#39;re going to continue chest compressions without interruptions and get ready to shock the patient so when it comes to pediatric defibrillation the first thing we want to do is turn on the defibrillator if we are required to leave a shock the initial shock is going to be 2 joules per kilogram if a second shock is required it&#39;s going to be four joules per kilogram and each subsequent shock to that will be equal to or greater than four joules per kilogram we never want to go above 10 joules per kilogram an easy way to remember this when you&#39;re doing your pals mega code is two four six eight that&#39;s the dose to defibrillate you&#39;re going to begin by placing the adhesive pads on the patient one of the right interior chest wall and one on the left axillary position depending on the patient and the size of the pads it&#39;s going to be a little bit different i highly recommend you check out my bls video to learn what that looks like you&#39;re going to announce the team charging defibrillator you&#39;re going to press the charge button on the defibrillator when the defibrillator is fully charged you want to verify that your team members are clear from the patient you&#39;re going to announce all clear once you have verified that nobody is touching the patient or the bed and you&#39;re going to provide the shock by pressing the shock button on the defibrillator immediately after that shock is given you&#39;re going to resume cpr for five cycles and then reassess for a pulse and a rhythm epinephrine is another great job of choice when it comes to our cardiac arrest patients when it comes to pediatrics the dosing is going to be 0.01 milligrams per kilogram if you have a 0.1 milligram per ml concentration then you can give 0.1 ml per kilogram and you&#39;re gonna repeat this every three to five minutes with a max dose of one milligram if you do not have iv or io access but you do have an endotracheal tube in place then you can give the endotracheal tube dose which is 0.1 milligrams per kilogram or 0.1 ml per kilogram if you have a one milligram per ml concentration something important to note when it comes to epinephrine rising blood pressure with increasing heart rate can cause angina myocardial ischemia as well as increase oxygen demands high doses do not always improve survival rates and can actually contribute to myocardial dysfunction with poor neurological outcomes we have to be very careful careful with how much that we&#39;re giving and high doses could be required for poison and drug-induced shock amiodarone is another great option that can be used however it is highly toxic so that&#39;s the reason we only use it when we have life-threatening arrhythmias taking place such as ventricular fibrillation ventricular tachycardia unresponsive to cardioversion cpr as well as vasopressors and if we have any kind of hemodynamically unstable ventricular tachycardia so the first dose when it comes to our pediatric patients will be five milligrams per kilogram iv or io bolus and you may repeat it up to three doses for refractory ventricular fibrillation or pulseless b-tac lidocaine is another great option they are equal when it comes to amiodarone and lidocaine you can use either one um lidocaine doses when it comes to our pediatric patients the initial dose is going to be one milligram per kilogram iv or io loading dose as always we want to consider our h&#39;s and our t&#39;s when it comes to our pediatric patients our hs consists of hypoxia hypovolemia hydrogen ions acidosis hypo or hyperkalemia hypothermia and something that is not found in the advanced cardiac life support with adults that is found in the pediatric advanced life support for peds is hypoglycemia hypoglycemia can cause a lot of these problems in our pediatric patients so that&#39;s why it&#39;s included here teas also toxins cardiac tamponade tension pneumothorax and thrombosis of either pulmonary or coronary descent should be considered when determining what the underlying cause of the cardiac arrest is i included the pals post-cardiac arrest return of spontaneous circulation in here i&#39;m not going to go through everything but the important factors you need to know is oxygenation ventilation you want to do hemodynamic monitoring we can also consider targeted temperature management depending on what the return of spontaneous circulation is neurological monitoring electrolyte and glucose monitoring sedation absolutely and then start considering the prognosis of what the outcome is going to look like for this pediatric patient now let&#39;s start looking at our respiratory emergencies when it comes to our pediatric patients so upper airway obstruction consists of the upper airways outside of the thorax such as the nose the pharynx and the larynx so causes for this can be crube anaphylaxis form body aspiration and when you assess these patients you&#39;re going to have an increased respiratory rate strider is going to be hallmark sign when it comes to upper airway obstruction they can have a barking cough hoarseness and they can even have drooling or snoring or gurgling sounds depending on what caused the upper airway obstruction so when it comes to treatment for croup we want to give nebulized epinephrine as well as corticosteroids if it&#39;s anaphylaxis we can consider im epinephrine or an auto injector albuterol antihistamines or corticosteroids and for aspiration of foreign body we&#39;re going to allow for positioning of comfort and we want to seek a specialized consultation to see how we can remove that foreign body lower airway obstructions consists of the lower airways that&#39;s within the thorax such as the trachea bronchi and bronchioles causes for this are usually bronchitis or asthma and when you&#39;re performing an assessment you&#39;re going to have an increased respiratory rate expiratory wheezing as well as prolonged expiratory phases are seen with the lower airway obstructions when it comes to treatment for bronchiolitis we&#39;re looking at nasal suctioning bronchial dilators and for asthma we&#39;re considering albuterol plus or minus additional medications corticosteroids subcutaneous epinephrine magnesium sulfate as well as turbulene lung tissue disease is described as a disease involving a substance of the lungs such as the parakina or the tissue um the tissues become stiff due to fluid accumulation in the alveoli the interstitium or both um usually this is caused by pneumonia pneumonitis pulmonary edema or acute respiratory distress syndrome such as ours and when you&#39;re assessing these patients you&#39;re going to have an increased respiratory rate you can hear grunting as well as crackles from all that fluid buildup and decrease breath sounds depending on how much fluid is in the lungs so treatment for pneumonia pneumonitis and whether it&#39;s infectious chemical or aspiration you&#39;re going to look at albuterol antibiotics may potentially be indicated depending on the infection as well as considering maybe a cpap machine when it comes to pulmonary edema cardiogenic or non-cardiogenic i&#39;m acute respiratory distress syndrome you want to consider non-invasive or invasive ventilation support that has peep which is your positive end expiratory pressure you want to consider vasoactive support as well as consider diuretic use and lastly we have the disordered control of breathing so with this it results from a host of conditions either including neurological disorders such as seizures central nervous system infections head injury brain tumors hydrocephalus or neuromuscular disease increased intracranial pressure can also be another cause additional causes can include like metabolic abnormalities drug overdoses and poisoning when it comes to your assessment you&#39;re going to have a variable or decreased respiratory rate or effort so that&#39;s the big thing that stands out here is this decreased respiratory rate or effort but breath sounds are going to be normal so if we have an increased intracranial pressure pediatric patient we want to avoid hypoxemia hypercarbia as well as hyperthermia for poisoning and overdose we want to give the antidote if there is anything available and contact poison control and if it is a neuromuscular disease we might have to consider non-invasive or invasive ventilatory support so let&#39;s look at respiratory failure interventions if we have respiratory failure we want to provide one breath every two to three seconds that&#39;s 20 to 30 breaths per minute with or without an airway that&#39;s the big thing that came out in the 2020 guidelines was it was a little bit different depending on if you had an airway or not now it doesn&#39;t matter it&#39;s one breath every two to three seconds 20 to 30 per minute with or without that airway you want to make sure that you see chest rise or fall to confirm appropriate rescue breaths and patients should be placed in that sniffing position for optimization of rescue breaths this requires the flexion and extension of the head and neck using that ec method with the bag valve mask intubation is covered in the pal certification however this is not practiced unless that person is a respiratory therapist or has a respiratory role they do cover however to detect sutter deterioration in an intubated patient using that dope mnemonic so the d stands for displacement of the tube the two may be displaced in the trachea or advanced into the right or left main bronchus so we have to consider those if we&#39;re having any kind of intubation issues obstruction of the tube obstruction can be caused by secretions blood plus foreign body some kind of kinking of the two pneumothorax a simple pneumothorax results in a sudden deterioration and oxygenation and decreased chest expansion and loss of breath sounds on the involved side or you can have a tension pneumothorax which results in a simple pneumothorax with signs of evidence of hypotension and a decrease in cardiac output and lastly the e stands for equipment failure so you could have a disconnection of the oxygen supply from the ventilation system there could be a leak in the ventilatory circuit failure of the power supply to the ventilator or there could just be a malfunction of valves in the bag or the circuit so let&#39;s take a look at shock emergencies we have hypovolemic cardiogenic distributive and obstructive shock so the hypobulemic it can be caused by gastroenteritis burns some kind of hemorrhage and adequate fluid intake increased body fluid losses osmotic diaphoresis vomiting or diarrhea so you&#39;re going to see a low blood pressure often due to a hemorrhage or fluids shifting out of the vasculature space with cardiogenic shock causes for this are usually congenital heart failure myocarditis cardiomyopathy or some kind of arrhythmia the heart is not pumping adequately is the big thing with cardiogenic shock distributive shock can be caused from sepsis is a huge one when it comes to our pediatric patients anaphylaxis and spinal cord injuries usually there&#39;s a blood vessel dilation such as what we see with septic shock and then lastly obstructive shock causes um can be tensioned pneumothorax cardiac tamponade pulmonary embolism constriction of the ductus arteriosus ductal dependent cardio congenital heart lesions are also a potential cause this really is just a physical block of blood flow something is obstructing blood flow from taking place um signs that you may see in shock with our pediatric patients are going to be delayed capillary refill as well as weak pulses something that&#39;s important to note when it comes to our pediatric patients is when it comes to any kind of shock they are only going to compensate for so long until they completely crash a lot of times we see with our adult patients that they compensate really well and we can kind of start to see deterioration but when it comes to our pediatric patient it&#39;s like we&#39;re good we&#39;re good we&#39;re good now we&#39;re no longer good so that&#39;s something that&#39;s really important to know in the back of your head when you&#39;re caring for a pediatric patient to begin when it comes to hypovolemic shock we&#39;ve got non-hemorrhagic and hemorrhagic shock that&#39;s something that was big in 2020 that was among infants and children with hypotensive hemorrhagic shock after trauma it&#39;s reasonable to note that we&#39;re going to be giving these patients blood products when available instead of crystalloids so it wasn&#39;t really clearly defined in the initial guidelines now it is early balanced resuscitation with plaque packed red blood cells fresh hose and plasmid platelets are also encouraged depending on that hemorrhagic shock if it is a non-hemorrhagic shock then we are going to give those crystalloids right so 20 mls per kilogram normal saline lactating or lactated ringer bolus repeat as needed if the patient&#39;s blood pressure has not improved based on three boluses we start to look at vasopressors and we can even consider crystalloids depending on the problem when it comes to our distributive shock we have sepsis we have anaphylaxis and we have neurogenic shock so we always want to follow the septic shock algorithms when it comes to anaphylaxis uh we get im epinephrine or an auto injector fluid bolus is between 10 to 20 ml per kilogram normal saline or lactated ringers with frequent assessments that is something new that came out with the 2020 guidelines um albuterol antihistamines corticosteroids epinephrine and infusion again the same fluid resuscitation when it comes to neurogenic shock as well as considerations of vasopressors depending on how severe the shock is like i said before the 20 20 guidelines have now moved from just 20 ml per kilogram to 10 to or 20 mls per kilogram fluid boluses with frequent assessment infant and children with fluid refractory septic shock it is reasonable to use either epinephrine or norepinephrine as the initial vasoactive infusion if epinephrine or norepinephrine is not available dopamine may also be considered and for instance in children with septic shock unresponsive to fluids and requiring vasoactive support it is reasonable to consider stress dose corticosteroids to help improve patient outcomes in our last two categories of shock are cardiogenic and obstructive if we have any kind of brady or tacky arrhythmia we&#39;re going to follow the appropriate algorithms that we spoke about before any other causes would um be treated with 5 to 10 ml per kilogram almost sanely lactated wearing our bolus repeat as needed we give a little bit less since the heart is not pumping appropriately we can also give vasoactive infusions and consider expert consultation when it comes to these patients with obstructive shock if we have any kind of ductal dependent outflow obstruction issues we can give prostaglandin e1 it&#39;s used to treat ductus arteriosus patent and we also want to speak expert consultations tension pneumothorax we&#39;re looking at potentially doing a needle decompression or tube thoracotomy cardiac tamponade a pair cardiocentesis and we&#39;re also going to give a little bit of fluid 10 or 20 ml per kilogram almost sailing lactate around her bolus and when it comes to pulmonary embolism we&#39;re using the same fluid resuscitation guidelines or even considering thrombolytics as well as anticoagulants and seeking expert consultation lastly we&#39;re going to finish out the systematic approach when it comes to our pediatric advanced life support it&#39;s important to note that if at any point during the systematic approach you identify a potential life-threatening emergency you stop using the systematic approach intervene and continue with your assessment so we use the evaluate identify and intervene so when it comes to this symptomatic approach for mega code we want to begin with the initial impression that&#39;s our abc so that&#39;s our appearance are there any level of consciousness issues their ability to interact with you breathing is b work of breathing any audible breath sounds wheezing grunting or strider and c is for circulation skin color and condition pallor petechiae bleeding and wounds any potential life-threatening emergencies are identified then we want to identify them and intervene if not then we move on to our primary survey our primary assessment survey consists of a b c d e a stands for airway is the airway patent is there good flow in the trachea the cricoid cartilage is the narrowest point in the pediatric airway and the circumference of the trachea is smaller than adults and is more of like a funnel shape a pediatric head and tongue and epiglottis are also larger than adults so those things can impede the airway b stands for breathing is the respiratory rate regular increased decreased is breathing effort unlabored is the chest expanding appropriately retractions and or nasal flaring present adventitious breath sounds such as wheezing or grunting grunting can result and that upper airway obstruction like we spoke about before due to secretions blood and vomit oxygen saturation and pulse oximetry are they within normal a consistent respiratory rate of less than 10 or more than 60 breaths per minute in a child of any age is considered abnormal and warrants assessment for the presence of a potentially serious condition the c in our primary survey is circulation so is the heart rate regular increased or decreased heart rate is greater than 180 beats per minute and an infant or toddler or 160 beats per minute in a child older than two warrants assessment and can be serious is the heart rhythm regular or irregular pulses both peripherally and centrally hypertensive versus hypotensive blood pressure so we have a low systolic blood pressure this is a late sign that something is wrong it can be difficult to memorize all of the normal systolic blood pressures when it comes to children regarding their age so something that was created was this beautiful calculation to help you configure what a low soft blood pressure is dependent on the child or infant or toddler or whatever so a low solid blood pressure is less than 70 plus 2 times the asian years of a child the only exception to this blood pressure rule is in neonates if they have a systolic less than 60 infants assault less than 70 and children ages 10 or older should not have a systolic less than 90. lastly for circulation skin color and temperature is their cyanosis present is their modeling capillary refill and how is the patient oxygenating the d stands for disability what are we looking at regarding our neurological status what is our level of consciousness and do they have pupillary responsiveness we also want to get an avpu score are they alert and interacting with us are they only verbal verbal to stimuli do they only respond to painful stimuli or are they completely unresponsive we also want to monitor our blood glucose monitoring with disability because it&#39;s extremely important it&#39;s one of the things that&#39;s included in the h&#39;s and t&#39;s when it comes to our pediatric population hypoglycemia and pediatrics for our neonates is going to be less than 45 and with our infant and children it&#39;s going to be less than or equal to 60. as we know children go through glucose much quicker than adults so we want to give d25w for treatment of hypoglycemia in pediatrics and lastly we&#39;re going to look at exposure we want to know what the pediatric patient&#39;s body temperature is and what their skin condition is is there any bleeding bruising or rashes at this point if we have identified any potential life-threatening emergencies we&#39;re going to identify and intervene if we haven&#39;t then we&#39;re going to move on to our last assessment which is the secondary survey our secondary survey consists of the sample mnemonic s stands for signs and symptoms signs being the objective information that we see and symptoms being the subjective information that&#39;s provided by either the pediatric patient or the caregiver when it comes to allergies are they allergic to foods medications environmental allergies medications we&#39;re looking at over-the-counter medications vitamins supplements prescribed medications or even any medication not prescribed to the pediatric that may have been ingested or used the p stands for previous medical history is there any previous illnesses hospitalizations and are there immunizations up to date l stands for last meal fluid pee poo what was their last meal or fluid intake what was the meal or fluid ingested and when was the last pea poop wet diaper and how many were there and then lastly e stands for events what led up to the current presentation of our pediatric patient i hope this video was helpful for you in passing your pediatric advanced life support certifications based on the new 2020 american heart association updated guidelines if you have any questions make sure that you leave them down below i love answering your questions follow me on my social media i&#39;m on facebook instagram as well as here on youtube make sure you subscribe and hit that bell notification to be aware of whenever i post new content head over to my website at www.nursejung.com where i&#39;ll have additional resources including all the algorithms that you&#39;ll need to know for the pediatric advanced life support certification but until next time i hope you&#39;re having a wonderful day and i&#39;ll see you all again soon bye

what&amp;#39;s going on all my healthcare brothers and sisters i hope that you are having a wonderful day the american heart association has officially come out with their 2020 guideline updates for the pediatric advanced life support certification and today we&amp;#39;re going to be discussing what those changes are let&amp;#39;s get started in this video we&amp;#39;re only going to be discussing the pediatric advanced life support updates i highly recommend that you go back and check out my previous video on the american heart association 2020 guideline updates for basic life support when it comes to our pediatric patients so to begin let&amp;#39;s take a look at some of the big changes that came with our pals update from the american heart association in 2020 to begin we have invasive blood pressure monitoring to assess cpr quality in 2020 for patients with continuous invasive arterial blood pressure monitoring in place at the time of cardiac arrest it is reasonable for providers to use diastolic blood pressure to assess cpr quality a new study showed that among the pediatric patients receiving cpr with an arterial line in place rates of survival with favor favorable neurological outcomes were improved if the diastolic blood pressure was at least 25 millimeters of mercury in infants and at least 30 millimeters of mercury in children another big update was for early epinephrine administration in 2015 is reasonable to administer epinephrine in a pediatric arrest cardiac arrest patient however in 2020 for pediatric patients in any setting it is reasonable to administer the initial dose of epinephrine within five minutes from the start of chest compressions so something that the american heart association really has emphasized in 2020 is that early administration epinephrine has been shown to save lives so let&amp;#39;s begin by looking at the pediatric bradycardia with pulse algorithm does the pediatric patient have cardiopulmonary compromise meaning they are acutely altered mental status signs of shock and hypotensive if they are not then we continue to support the abcs we want to consider oxygenation we want to observe the patient continue to monitor them as well as perform a 12v ecg and identify and treat any underlying causes if they do have cardiopulmonary compromise then we start providing assessment and support we want to maintain the patient airway assist with breathing with positive pressure ventilation and oxygen as needed and then cardiac monitoring should be implemented if it hasn&amp;#39;t been so already monitoring the pulse the blood pressure and the oximetry now if we have a pediatric patient we want to start cpr if the heart rate is still less less than 60 beats per minute despite us providing oxygenation and ventilation if that bradycardia persists we&amp;#39;re going to continue cpr get that ivio access administer that epinephrine we can even look at potentially atropine for increased vagal tone or or if there&amp;#39;s a primary av block present we want to consider transthoracic transvenous pacing but we also want to identify and treat underlying causes we&amp;#39;re going to continuously check for that pulse every two minutes if there is a pulse presence um we go back to is the patient is the bradycardia persisting we just keep going back and forth in that algorithm supporting the abcs watching oxygen observing 12 leading treatment underlying cause if a pulse is not present then we transition over to that pediatric cardiac arrest algorithm so we start by looking at our sinus bradycardia we have a rate of less than 60 beats per minute the rhythm will be regular and it&amp;#39;s going to be initiated in that sinoatrial node p waves will be normal and upright but the pr interval is going to be lengthening dependent on how that rate decreases and the qrs interval will be less than 0.12 seconds so the most common cause of bradycardia when it comes to children is hypoxia it can also be caused from hypothermia as well as medications but it&amp;#39;s usually related to hypoxia and again if the child&amp;#39;s heart rate is still less than 60 despite us providing oxygenation and ventilation we begin providing cpr immediately epinephrine is another great joke of choice when it comes to our bradycardias it&amp;#39;s an alternative drug of choice when it comes to symptomatic sinus bradycardia pediatric dosing for this is 0.01 milligrams per kilogram or if you have a 0.1 milligrams per ml concentration you can use 0.1 ml per kilogram you&amp;#39;re going to repeat this every three to five minutes if there is no iv or io access available and we need to get this medication to our pediatric patient we can use the endotracheal et tube and with that you can give 0.1 milligrams per kilogram or if you have a 1 milligram per ml concentration you&amp;#39;re going to give 0.1 mls per kilogram epinephrine considerations rising blood pressure with increasing heart rate can actually cause angina myocardial ischemia as well as increase oxygen demand so you have to be very careful with the medication that we&amp;#39;re giving high doses do not improve survival rates it may actually contribute to post-resuscitation myocardial dysfunction with poor neurological outcomes and high doses will most likely be required if we have any kind of poison or drug induced shock with our pediatric patients trans-containing spacing is another potential intervention when it comes to our bradycardias it&amp;#39;s usually used for our unstable bradycardias that are less than 50 beats per minute but are also showing some kind of compromised hemodynamics that can include your hypotension your acute altered mental status changes shock ischemic chest discomfort as well as acute heart failure precautions when using this intervention is with our conscious patients we want to give them some analgesia because pacing can be uncomfortable you also want to avoid palpating any kind of carotid pulses to confirm capture because electrical impulses can cause muscles to jerk which will mimic which will mimic a pulse so you definitely don&amp;#39;t want to use that as your only indicator that we&amp;#39;re having capture um transmutation is pacing set up you want to position the pads on the chest as instructed by the packaging you&amp;#39;re going to turn on the pacer you&amp;#39;re usually going to set the demand to 80 beats per minute or per the physician order you&amp;#39;re going to set the current mma output increase current starting with the minimum settings until you start to see the electrical capture being consistent that means you&amp;#39;re going to have that wide qrs and t waves after each pacer spike also known as ventricular paste and the most common currents that you&amp;#39;re going to see when it comes to the ma is going to be between 50 to 80. now let&amp;#39;s take a look at the tachycardia with the pulse algorithm now i know this is a little bit confusing but bear with me as we break this down so our initial assessment support is we want to maintain patient airway and assist with breathing as necessary we can administer oxygen we want to do cardiac monitoring to identify the rhythm as well as monitor for pulse blood pressure and oximetry we want to get our iv io access and we want to obtain a 12 lead ecg if it is available if we can&amp;#39;t obtain a 12 ecg then we&amp;#39;re going to monitor for which rhythm it is and search and treat for the cause something else that&amp;#39;s important to know is we also need to look if there&amp;#39;s any kind of cardiopulmonary compromise that can consist of any kind of acutely altered mental status signs of shock and hypotension so if we obtain a 1280cg and there is cardiocompromise present we need to evaluate the cure restoration do we have a narrow qrs or do we have a wide qrs if we have a narrow qrs we&amp;#39;re most likely dealing with a supraventricular tachycardia that&amp;#39;s usually an infant&amp;#39;s greater than 100 i&amp;#39;m sorry 220 beats per minute and in children greater than 180 beats per minute if we have confirmed that we have svt and cardiopulmonary compromise we&amp;#39;re going to give iv we&amp;#39;re going to get that iv io access and give adenosine or if we don&amp;#39;t have any of those available or if the adenosine is not effective we can move straight to synchronized cardioversion if we evaluate the qrs duration and it&amp;#39;s wide we most likely have a ventricular tachycardia present so if we have a ventricular tachycardia present with cardiopulmonary compromise then we immediately move to electricity we&amp;#39;ve always talked about this electricity when we have any kind of compromise comes first before medications so we want to give synchronized cardioversion to our vtec patients seek expert consultations and give additional direct therapies if needed if we don&amp;#39;t have any kind of cardiopulmonary compromise we follow the same steps in evaluating the cure restoration do we have a narrow qrs or do we have a wide qrs if we have a narrow qrs again we&amp;#39;re most likely dealing with some kind of supraventricular tachycardia if we have an svt and no cardiopulmonary compromise present and we want to consider vagal maneuvers if iv or io access is also present we can even give adenosine if we have a wide qrs we&amp;#39;re most likely looking at a ventricular tachycardia if we have ventricular tachycardia and no cardiopulmonary compromise present then the rhythm and if the rhythm is a regular monomorphic rhythm we can consider giving adenosine and we also want to seek expert consultation for any patient within these spectrums so let&amp;#39;s take a little bit of a closer look at these rhythms so when it comes to supraventricular tachycardia it&amp;#39;s defined as the absence or abnormal presentation of p waves and the heart rate is not variable so when it comes to our pediatric patients if the parent is able to soothe the child and the heart rate comes down they were not dealing with a supraventricular tachycardia however if after limiting movement and providing comfort the heart rate remains elevated and consistent the rhythm is an svt and as we talked about before in our algorithm infant rates are going to be greater than 220 beats per minute and children rates are going to be greater than 180 beats per minute and our last shockable rhythm is this beautiful regular monomorphic ventricular tachycardia again we talked about the rates before the rhythm is going to be regular the pr interval will be not present because we have this beautiful ventricular beats and the qrs interval is going to be y greater than 0.12 seconds so one of the options we can perform are vagal maneuvers it&amp;#39;s the first line management tool when it comes to tachycardias now with pediatric patients we range all the way from 28 days to the presence of puberty right so a lot of these may not work for different patient populations you&amp;#39;re going to have to use your clinical judgment when it comes to vagal maneuvers so coughing may be difficult for young younger patients that they&amp;#39;re unable to follow commands but if they are coughing actually creates the same physiological responses bearing down and it&amp;#39;s easily performed the cough has to be forceful and sustained in order for it to mimic that bearing down procedure cold stimulus to the face by either providing ice packs to the face or a washcloth soaked in ice water for 10 seconds can be used because this creates a physiological response like submersion and cold water also known as diver&amp;#39;s reflex carotid massage can be performed on the patient&amp;#39;s neck by extending the position and turning away from the carotid and you only want to massage one carotid at a time for no more than 10 seconds it is not recommended usually i don&amp;#39;t personally perform this even with being an open heart i see a nurse i usually allow this to be performed by the providers because there&amp;#39;s a lot of um there&amp;#39;s a lot of things that can&amp;#39;t go wrong with carotid massage depending on the age group and depending on their core morbidities when it comes to gagging again not something i recommend your patients probably not going to trust you if you use this but it is an option it stimulates that vagus nerve by placing a tongue depressor in the back of the patient&amp;#39;s throat and then lastly bearing down you instruct the patient to bear down like they&amp;#39;re having a bowel movement or they can blow through an occluded 10ml syringe for about 15 to 20 seconds another great option when it comes to our tachycardia rhythms is adenosine if you haven&amp;#39;t seen this it&amp;#39;s fantastic it stops the heart restarts it it&amp;#39;s it&amp;#39;s incredible if you haven&amp;#39;t seen it i really hope you get the chance to but with adenosine it&amp;#39;s the first drug of choice for stable narrow complex supraventricular tachycardias and it can be used with our unstable narrow complex tachycardias usually in the preparation of cardioversion taking place if it&amp;#39;s needed we don&amp;#39;t usually use this to convert atrial fibrillation atrial flutter or ventricular tachycardia there&amp;#39;s a different medication that they use for those specific rhythms so when it comes to adenosine um dosing patients are placed in a mild reverse trendelenburg position and for our pediatric patients that initial dose will be 0.1 milligrams per kilogram give it rapidly over three i&amp;#39;m sorry one to three seconds with a maximum dose of six milligrams you want to immediately elevate the extremity after you give the medication just to get to the heart a little quicker if there is a second dose required that would be 0.2 milligrams per kilogram given rapidly again over one to three seconds with a maximum second dose of 12 milligrams so let&amp;#39;s talk about synchronized cardioversion it involves the delivery of a low energy shot which is timed or synchronized to be delivered at a specific point in the qrs complex to avoid causing ventricular fibrillation so the procedure is you want to first obtain a 12 lead ecg if the patient is stable you&amp;#39;re going to prepare proper sedation since cardioversion is painful emergency equipment should always be ready just in case there&amp;#39;s some kind of complications such as your code card you&amp;#39;re going to place the defibrillator pads on the patient and set the monitors to synchronized or sync mode sync mode will deliver concurrent energy with the qrs so what you&amp;#39;ll find is when you place in the same mode and you&amp;#39;re looking at the rhythm there&amp;#39;ll be these little ticks above each r wave and it does this so that when it delivers the shock it doesn&amp;#39;t send the pediatric patient into ventricular fibrillation so like i said you want to engage the sync mode before each attempt look at the sync markers above each r wave to make sure that sync mode is on so when it comes to the initial recommended voltage doses you&amp;#39;re going to get between 0.5 to 1 joule per kilogram if that&amp;#39;s not effective then you can increase it to 2 joules per kilogram and i highly recommend if you are able to to give sedation prior to delivering any kind of cardioversion shock because it is very uncomfortable if the patient is unstable absolutely give the shock before sedation you want to clear all personnel from the patient prior to delivering the shock you&amp;#39;re going to press the charge button clear the patient then press press the shock button after the shock you&amp;#39;re going to reassess the patient&amp;#39;s rhythm for potentially any additional shocks let&amp;#39;s take a look at the pediatric cardiac arrest algorithm we always want to start by providing cardiopulmonary resuscitation we want to make sure that we have that back mass ventilation as well as oxygenation present and attach the monitor into if we have a shockable rhythm then we&amp;#39;re most likely looking at a ventricular fibrillation and pulseless ventricular tachycardia those rhythms we want to continue providing those shocks after giving our shots we&amp;#39;re going to immediately begin cpr for two minutes and keep reassessing the rhythm we also want to make sure that we have our iv io access our advanced airway providing our epinephrine amiodarone or lidocaine if necessary and treating any reversible causes if we do not have a shockable rhythm we&amp;#39;re most likely dealing with either a a sicily or pulseless electrical activity something new that came out with the 2020 american heart association guidelines for our non-choco shockable rhythms is we want to give that epinephrine as quickly as possible do not delay giving epinephrine it can save lives we&amp;#39;re going to continuously give our two minutes of cpr rechecking if the rhythm has become shockable obtaining our iv io access giving the epinephrine like we spoke about obtaining our advanced airway as well as capenography if no signs and symptoms of spontaneous circulation are present then we&amp;#39;re going to continuously give cpr until we make the determination of when to terminate pediatric advanced life support if rusk does return then we&amp;#39;re going to go to the post cardiac arrest checklist and start those procedures from there so taking a closer look at our cardiac arrest rhythms we have pulseless electrical ventricular tachycardia the rate&amp;#39;s going to be between 100 to 220 beats per minute the rhythm should be regular p waves are not going to be apparent so if they&amp;#39;re not apparent you&amp;#39;re not going to have a pr interval and the qrs is going to be y it&amp;#39;s going to be greater than 0.12 the definition for this is three or more pvcs in a row is either non-sustained meaning that it&amp;#39;s less than 30 seconds or sustained being greater than 30 seconds adequate blood pressure is difficult to sustain due to that rapid rate and it can ultimately lead to ventricular fibrillation if it&amp;#39;s not treated appropriately ventricular fibrillation again nothing&amp;#39;s going to be measurable uh no rate no rhythm no p was no pr intervals and when it comes to your qrs intervals the it&amp;#39;s just going to be fibrillation waste it&amp;#39;s going to look like artifact but it&amp;#39;s not um the definition for this is multiple foci within the ventricle are rapidly firing repeatedly causing this disorganized ventricular contraction um this is going to be one of three ecg patterns that you&amp;#39;re going to see with your cardiac arrest a sisley pretty obvious right we&amp;#39;ve got no right now rhythm no p waves or periodical no qrs this is really just a cease of all heart function and electricity and lastly we have our pulseless electrical activity also known as pea you&amp;#39;re going to look on the monitor and it&amp;#39;s going to look like this beautiful sinus rhythm but when you check your patient they are not going to have a pulse so ultimately you&amp;#39;re just going to have this organized cardiac electrical activity with no palpable pulse so let&amp;#39;s talk about defibrillation it is the first intervention when it comes to ventricular fibrillation or pulseless ventricular tachycardia we always want to assess for these rhythms and if they are present we&amp;#39;re going to continue chest compressions without interruptions and get ready to shock the patient so when it comes to pediatric defibrillation the first thing we want to do is turn on the defibrillator if we are required to leave a shock the initial shock is going to be 2 joules per kilogram if a second shock is required it&amp;#39;s going to be four joules per kilogram and each subsequent shock to that will be equal to or greater than four joules per kilogram we never want to go above 10 joules per kilogram an easy way to remember this when you&amp;#39;re doing your pals mega code is two four six eight that&amp;#39;s the dose to defibrillate you&amp;#39;re going to begin by placing the adhesive pads on the patient one of the right interior chest wall and one on the left axillary position depending on the patient and the size of the pads it&amp;#39;s going to be a little bit different i highly recommend you check out my bls video to learn what that looks like you&amp;#39;re going to announce the team charging defibrillator you&amp;#39;re going to press the charge button on the defibrillator when the defibrillator is fully charged you want to verify that your team members are clear from the patient you&amp;#39;re going to announce all clear once you have verified that nobody is touching the patient or the bed and you&amp;#39;re going to provide the shock by pressing the shock button on the defibrillator immediately after that shock is given you&amp;#39;re going to resume cpr for five cycles and then reassess for a pulse and a rhythm epinephrine is another great job of choice when it comes to our cardiac arrest patients when it comes to pediatrics the dosing is going to be 0.01 milligrams per kilogram if you have a 0.1 milligram per ml concentration then you can give 0.1 ml per kilogram and you&amp;#39;re gonna repeat this every three to five minutes with a max dose of one milligram if you do not have iv or io access but you do have an endotracheal tube in place then you can give the endotracheal tube dose which is 0.1 milligrams per kilogram or 0.1 ml per kilogram if you have a one milligram per ml concentration something important to note when it comes to epinephrine rising blood pressure with increasing heart rate can cause angina myocardial ischemia as well as increase oxygen demands high doses do not always improve survival rates and can actually contribute to myocardial dysfunction with poor neurological outcomes we have to be very careful careful with how much that we&amp;#39;re giving and high doses could be required for poison and drug-induced shock amiodarone is another great option that can be used however it is highly toxic so that&amp;#39;s the reason we only use it when we have life-threatening arrhythmias taking place such as ventricular fibrillation ventricular tachycardia unresponsive to cardioversion cpr as well as vasopressors and if we have any kind of hemodynamically unstable ventricular tachycardia so the first dose when it comes to our pediatric patients will be five milligrams per kilogram iv or io bolus and you may repeat it up to three doses for refractory ventricular fibrillation or pulseless b-tac lidocaine is another great option they are equal when it comes to amiodarone and lidocaine you can use either one um lidocaine doses when it comes to our pediatric patients the initial dose is going to be one milligram per kilogram iv or io loading dose as always we want to consider our h&amp;#39;s and our t&amp;#39;s when it comes to our pediatric patients our hs consists of hypoxia hypovolemia hydrogen ions acidosis hypo or hyperkalemia hypothermia and something that is not found in the advanced cardiac life support with adults that is found in the pediatric advanced life support for peds is hypoglycemia hypoglycemia can cause a lot of these problems in our pediatric patients so that&amp;#39;s why it&amp;#39;s included here teas also toxins cardiac tamponade tension pneumothorax and thrombosis of either pulmonary or coronary descent should be considered when determining what the underlying cause of the cardiac arrest is i included the pals post-cardiac arrest return of spontaneous circulation in here i&amp;#39;m not going to go through everything but the important factors you need to know is oxygenation ventilation you want to do hemodynamic monitoring we can also consider targeted temperature management depending on what the return of spontaneous circulation is neurological monitoring electrolyte and glucose monitoring sedation absolutely and then start considering the prognosis of what the outcome is going to look like for this pediatric patient now let&amp;#39;s start looking at our respiratory emergencies when it comes to our pediatric patients so upper airway obstruction consists of the upper airways outside of the thorax such as the nose the pharynx and the larynx so causes for this can be crube anaphylaxis form body aspiration and when you assess these patients you&amp;#39;re going to have an increased respiratory rate strider is going to be hallmark sign when it comes to upper airway obstruction they can have a barking cough hoarseness and they can even have drooling or snoring or gurgling sounds depending on what caused the upper airway obstruction so when it comes to treatment for croup we want to give nebulized epinephrine as well as corticosteroids if it&amp;#39;s anaphylaxis we can consider im epinephrine or an auto injector albuterol antihistamines or corticosteroids and for aspiration of foreign body we&amp;#39;re going to allow for positioning of comfort and we want to seek a specialized consultation to see how we can remove that foreign body lower airway obstructions consists of the lower airways that&amp;#39;s within the thorax such as the trachea bronchi and bronchioles causes for this are usually bronchitis or asthma and when you&amp;#39;re performing an assessment you&amp;#39;re going to have an increased respiratory rate expiratory wheezing as well as prolonged expiratory phases are seen with the lower airway obstructions when it comes to treatment for bronchiolitis we&amp;#39;re looking at nasal suctioning bronchial dilators and for asthma we&amp;#39;re considering albuterol plus or minus additional medications corticosteroids subcutaneous epinephrine magnesium sulfate as well as turbulene lung tissue disease is described as a disease involving a substance of the lungs such as the parakina or the tissue um the tissues become stiff due to fluid accumulation in the alveoli the interstitium or both um usually this is caused by pneumonia pneumonitis pulmonary edema or acute respiratory distress syndrome such as ours and when you&amp;#39;re assessing these patients you&amp;#39;re going to have an increased respiratory rate you can hear grunting as well as crackles from all that fluid buildup and decrease breath sounds depending on how much fluid is in the lungs so treatment for pneumonia pneumonitis and whether it&amp;#39;s infectious chemical or aspiration you&amp;#39;re going to look at albuterol antibiotics may potentially be indicated depending on the infection as well as considering maybe a cpap machine when it comes to pulmonary edema cardiogenic or non-cardiogenic i&amp;#39;m acute respiratory distress syndrome you want to consider non-invasive or invasive ventilation support that has peep which is your positive end expiratory pressure you want to consider vasoactive support as well as consider diuretic use and lastly we have the disordered control of breathing so with this it results from a host of conditions either including neurological disorders such as seizures central nervous system infections head injury brain tumors hydrocephalus or neuromuscular disease increased intracranial pressure can also be another cause additional causes can include like metabolic abnormalities drug overdoses and poisoning when it comes to your assessment you&amp;#39;re going to have a variable or decreased respiratory rate or effort so that&amp;#39;s the big thing that stands out here is this decreased respiratory rate or effort but breath sounds are going to be normal so if we have an increased intracranial pressure pediatric patient we want to avoid hypoxemia hypercarbia as well as hyperthermia for poisoning and overdose we want to give the antidote if there is anything available and contact poison control and if it is a neuromuscular disease we might have to consider non-invasive or invasive ventilatory support so let&amp;#39;s look at respiratory failure interventions if we have respiratory failure we want to provide one breath every two to three seconds that&amp;#39;s 20 to 30 breaths per minute with or without an airway that&amp;#39;s the big thing that came out in the 2020 guidelines was it was a little bit different depending on if you had an airway or not now it doesn&amp;#39;t matter it&amp;#39;s one breath every two to three seconds 20 to 30 per minute with or without that airway you want to make sure that you see chest rise or fall to confirm appropriate rescue breaths and patients should be placed in that sniffing position for optimization of rescue breaths this requires the flexion and extension of the head and neck using that ec method with the bag valve mask intubation is covered in the pal certification however this is not practiced unless that person is a respiratory therapist or has a respiratory role they do cover however to detect sutter deterioration in an intubated patient using that dope mnemonic so the d stands for displacement of the tube the two may be displaced in the trachea or advanced into the right or left main bronchus so we have to consider those if we&amp;#39;re having any kind of intubation issues obstruction of the tube obstruction can be caused by secretions blood plus foreign body some kind of kinking of the two pneumothorax a simple pneumothorax results in a sudden deterioration and oxygenation and decreased chest expansion and loss of breath sounds on the involved side or you can have a tension pneumothorax which results in a simple pneumothorax with signs of evidence of hypotension and a decrease in cardiac output and lastly the e stands for equipment failure so you could have a disconnection of the oxygen supply from the ventilation system there could be a leak in the ventilatory circuit failure of the power supply to the ventilator or there could just be a malfunction of valves in the bag or the circuit so let&amp;#39;s take a look at shock emergencies we have hypovolemic cardiogenic distributive and obstructive shock so the hypobulemic it can be caused by gastroenteritis burns some kind of hemorrhage and adequate fluid intake increased body fluid losses osmotic diaphoresis vomiting or diarrhea so you&amp;#39;re going to see a low blood pressure often due to a hemorrhage or fluids shifting out of the vasculature space with cardiogenic shock causes for this are usually congenital heart failure myocarditis cardiomyopathy or some kind of arrhythmia the heart is not pumping adequately is the big thing with cardiogenic shock distributive shock can be caused from sepsis is a huge one when it comes to our pediatric patients anaphylaxis and spinal cord injuries usually there&amp;#39;s a blood vessel dilation such as what we see with septic shock and then lastly obstructive shock causes um can be tensioned pneumothorax cardiac tamponade pulmonary embolism constriction of the ductus arteriosus ductal dependent cardio congenital heart lesions are also a potential cause this really is just a physical block of blood flow something is obstructing blood flow from taking place um signs that you may see in shock with our pediatric patients are going to be delayed capillary refill as well as weak pulses something that&amp;#39;s important to note when it comes to our pediatric patients is when it comes to any kind of shock they are only going to compensate for so long until they completely crash a lot of times we see with our adult patients that they compensate really well and we can kind of start to see deterioration but when it comes to our pediatric patient it&amp;#39;s like we&amp;#39;re good we&amp;#39;re good we&amp;#39;re good now we&amp;#39;re no longer good so that&amp;#39;s something that&amp;#39;s really important to know in the back of your head when you&amp;#39;re caring for a pediatric patient to begin when it comes to hypovolemic shock we&amp;#39;ve got non-hemorrhagic and hemorrhagic shock that&amp;#39;s something that was big in 2020 that was among infants and children with hypotensive hemorrhagic shock after trauma it&amp;#39;s reasonable to note that we&amp;#39;re going to be giving these patients blood products when available instead of crystalloids so it wasn&amp;#39;t really clearly defined in the initial guidelines now it is early balanced resuscitation with plaque packed red blood cells fresh hose and plasmid platelets are also encouraged depending on that hemorrhagic shock if it is a non-hemorrhagic shock then we are going to give those crystalloids right so 20 mls per kilogram normal saline lactating or lactated ringer bolus repeat as needed if the patient&amp;#39;s blood pressure has not improved based on three boluses we start to look at vasopressors and we can even consider crystalloids depending on the problem when it comes to our distributive shock we have sepsis we have anaphylaxis and we have neurogenic shock so we always want to follow the septic shock algorithms when it comes to anaphylaxis uh we get im epinephrine or an auto injector fluid bolus is between 10 to 20 ml per kilogram normal saline or lactated ringers with frequent assessments that is something new that came out with the 2020 guidelines um albuterol antihistamines corticosteroids epinephrine and infusion again the same fluid resuscitation when it comes to neurogenic shock as well as considerations of vasopressors depending on how severe the shock is like i said before the 20 20 guidelines have now moved from just 20 ml per kilogram to 10 to or 20 mls per kilogram fluid boluses with frequent assessment infant and children with fluid refractory septic shock it is reasonable to use either epinephrine or norepinephrine as the initial vasoactive infusion if epinephrine or norepinephrine is not available dopamine may also be considered and for instance in children with septic shock unresponsive to fluids and requiring vasoactive support it is reasonable to consider stress dose corticosteroids to help improve patient outcomes in our last two categories of shock are cardiogenic and obstructive if we have any kind of brady or tacky arrhythmia we&amp;#39;re going to follow the appropriate algorithms that we spoke about before any other causes would um be treated with 5 to 10 ml per kilogram almost sanely lactated wearing our bolus repeat as needed we give a little bit less since the heart is not pumping appropriately we can also give vasoactive infusions and consider expert consultation when it comes to these patients with obstructive shock if we have any kind of ductal dependent outflow obstruction issues we can give prostaglandin e1 it&amp;#39;s used to treat ductus arteriosus patent and we also want to speak expert consultations tension pneumothorax we&amp;#39;re looking at potentially doing a needle decompression or tube thoracotomy cardiac tamponade a pair cardiocentesis and we&amp;#39;re also going to give a little bit of fluid 10 or 20 ml per kilogram almost sailing lactate around her bolus and when it comes to pulmonary embolism we&amp;#39;re using the same fluid resuscitation guidelines or even considering thrombolytics as well as anticoagulants and seeking expert consultation lastly we&amp;#39;re going to finish out the systematic approach when it comes to our pediatric advanced life support it&amp;#39;s important to note that if at any point during the systematic approach you identify a potential life-threatening emergency you stop using the systematic approach intervene and continue with your assessment so we use the evaluate identify and intervene so when it comes to this symptomatic approach for mega code we want to begin with the initial impression that&amp;#39;s our abc so that&amp;#39;s our appearance are there any level of consciousness issues their ability to interact with you breathing is b work of breathing any audible breath sounds wheezing grunting or strider and c is for circulation skin color and condition pallor petechiae bleeding and wounds any potential life-threatening emergencies are identified then we want to identify them and intervene if not then we move on to our primary survey our primary assessment survey consists of a b c d e a stands for airway is the airway patent is there good flow in the trachea the cricoid cartilage is the narrowest point in the pediatric airway and the circumference of the trachea is smaller than adults and is more of like a funnel shape a pediatric head and tongue and epiglottis are also larger than adults so those things can impede the airway b stands for breathing is the respiratory rate regular increased decreased is breathing effort unlabored is the chest expanding appropriately retractions and or nasal flaring present adventitious breath sounds such as wheezing or grunting grunting can result and that upper airway obstruction like we spoke about before due to secretions blood and vomit oxygen saturation and pulse oximetry are they within normal a consistent respiratory rate of less than 10 or more than 60 breaths per minute in a child of any age is considered abnormal and warrants assessment for the presence of a potentially serious condition the c in our primary survey is circulation so is the heart rate regular increased or decreased heart rate is greater than 180 beats per minute and an infant or toddler or 160 beats per minute in a child older than two warrants assessment and can be serious is the heart rhythm regular or irregular pulses both peripherally and centrally hypertensive versus hypotensive blood pressure so we have a low systolic blood pressure this is a late sign that something is wrong it can be difficult to memorize all of the normal systolic blood pressures when it comes to children regarding their age so something that was created was this beautiful calculation to help you configure what a low soft blood pressure is dependent on the child or infant or toddler or whatever so a low solid blood pressure is less than 70 plus 2 times the asian years of a child the only exception to this blood pressure rule is in neonates if they have a systolic less than 60 infants assault less than 70 and children ages 10 or older should not have a systolic less than 90. lastly for circulation skin color and temperature is their cyanosis present is their modeling capillary refill and how is the patient oxygenating the d stands for disability what are we looking at regarding our neurological status what is our level of consciousness and do they have pupillary responsiveness we also want to get an avpu score are they alert and interacting with us are they only verbal verbal to stimuli do they only respond to painful stimuli or are they completely unresponsive we also want to monitor our blood glucose monitoring with disability because it&amp;#39;s extremely important it&amp;#39;s one of the things that&amp;#39;s included in the h&amp;#39;s and t&amp;#39;s when it comes to our pediatric population hypoglycemia and pediatrics for our neonates is going to be less than 45 and with our infant and children it&amp;#39;s going to be less than or equal to 60. as we know children go through glucose much quicker than adults so we want to give d25w for treatment of hypoglycemia in pediatrics and lastly we&amp;#39;re going to look at exposure we want to know what the pediatric patient&amp;#39;s body temperature is and what their skin condition is is there any bleeding bruising or rashes at this point if we have identified any potential life-threatening emergencies we&amp;#39;re going to identify and intervene if we haven&amp;#39;t then we&amp;#39;re going to move on to our last assessment which is the secondary survey our secondary survey consists of the sample mnemonic s stands for signs and symptoms signs being the objective information that we see and symptoms being the subjective information that&amp;#39;s provided by either the pediatric patient or the caregiver when it comes to allergies are they allergic to foods medications environmental allergies medications we&amp;#39;re looking at over-the-counter medications vitamins supplements prescribed medications or even any medication not prescribed to the pediatric that may have been ingested or used the p stands for previous medical history is there any previous illnesses hospitalizations and are there immunizations up to date l stands for last meal fluid pee poo what was their last meal or fluid intake what was the meal or fluid ingested and when was the last pea poop wet diaper and how many were there and then lastly e stands for events what led up to the current presentation of our pediatric patient i hope this video was helpful for you in passing your pediatric advanced life support certifications based on the new 2020 american heart association updated guidelines if you have any questions make sure that you leave them down below i love answering your questions follow me on my social media i&amp;#39;m on facebook instagram as well as here on youtube make sure you subscribe and hit that bell notification to be aware of whenever i post new content head over to my website at www.nursejung.com where i&amp;#39;ll have additional resources including all the algorithms that you&amp;#39;ll need to know for the pediatric advanced life support certification but until next time i hope you&amp;#39;re having a wonderful day and i&amp;#39;ll see you all again soon bye

Transcript for:PALS 2020 Guideline Updates

Transcript for:
PALS 2020 Guideline Updates