pediatric assessment in emergency rooms , how to pass the PALS exam , part 1 search for the other 3 parts, for any comment send to sayedahmed 1900@ g mail .com

1. PEDIATRIC ADVANCED
LIFE SUPPORT 2017
GUIDELINES- PART 1
DR. SAYED ISMAIL,MD
PROFESSOR AND CONSULTANT OF PEDIATRIC
ALSALAMA HOSPITAL

2. Objectives
• Pediatric advanced life support 2017 guidelines are
presented in 4 parts presentations
• To provide up to date management of life threatening
conditions
• To help the pediatricians and emergency physicians to
pass the PALS examination

3. PART 1
PEDIATRIC
ASSESSMENT

4. Pediatric Assessment
Initial assessment
Primary assessment
Secondary assessment
Diagnostic tests

5. Initial Assessment (1st look )
aim : to detect life threatening conditions

6. Based on initial assessment
If the patient
Unresponsive ,
Critical conditions
identify
intervene
Evaluate
Activate CPR
SSS
Connect to monitors
SSS = safety ,
stimulate ,
shout

7. IF PATIENT UNRESPONSIVE
NO BREATHING , NO PULSE
START CAB
GO TO CARDIAC ARREST
ALGORITHM
YES
identify
intervene
Evaluate
No breathing ,
pulse present
OPEN AIRWAY , GIVE PPV
IF PULSE LESS THAN 60YES
NO
SSS
Safety ,stimulate , shout

8. identify
intervene
Evaluate
•Evaluate by primary , secondary ass. and diagnostic test
•Identify the problem either respiratory or circulatory
•Then intervene according to problems
Continuous process

9. Evaluate by
Primary assessment
Secondary assessment
Diagnostic tests
identify
intervene
Evaluate

10. Identify
TYPE SEVERITY
1-Respiratory Upper airway
obstruction
Lower airway
obstruction
lung tissues
Disordered control of
breathing
Respiratory distress
Respiratory failure
2-Circulatory =
Shock
Hypovolemic shock
Distributive
Cardiogenic
Obstrutctive
Compensated
Hypotensive
3-Cardiopulmonary failure e.g. SVT , VT,
4- Cardiac arrest (asystole , pulseless VT, VF)
All exam
cases

11. Intervene
• Open air way
• Suction
• intubations
• Ppv
• Iv line
• Iv bolus
• inotropes
• Cardiac Consultations
identify
intervene
Evaluate
The evalaute –identify –
intervene is continous :
process after each
intervension and when the
child condition changes
ABCD

13. Evaluate Identify Intervene
Initial assessment
• Appearance
• Breathing
• circulation
Life threatening
critical disease
SSS , CPR
Help, call team ,connect TO
cardiac monitor , PULSE O2,
assess..
Primary assessment
A: patent , maintainable
B : R rate , effort ,sounds ,
air entry, o2 sat
C : HR, PULSE( P, C) , BP,
CRT, skin T, Color , Level of
consciousness
D: AVPU , pupil , b glucose
E: skin , temperature
• RESPIRATORY :
• RD or
• RF
• CARDIAC CASE :
• STABLE
• OR UNSTABLE
(Poor perfusion,lowBP….)
• SHOCK
• compensated
• or hypotensive
Resuscitative measures :
High flow O2 for RD , but
bagging for RF
OPEN AIR WAY METHODS
intubation,
IV adenosine
Cardio version
IV LINE , Bolus Fluids
Dextrose for hypoglycemia
N.B The primary assessment
also takes place once
life‐threatening conditions have
been treated (the pulse >60 , )

14. Evaluate Identify Intervene
Secondary assessment
1. SAMPLE
• S/s ,
• Allergy,
• Medication ,
• Past h,
• Last meal
• Events
2. Reassessment Repeat Vital
signs
3. Head to toe examination
differential diagnosis.
• Type of respiratory
problems e.g
• URTO,
• LRTO
• Lung D ,
• disorderd breath
control
Type of shock
• hypovolemic ,
• cardiogenic ,
• Distrubutive
• Obstructive
To Give Emergency
Treatment
A B C D E
D-Treat the undelaying
causes
E- Expert consultation
Diagnostic tests
Blood gases
Hb concentration , blood
chemistry
CXR …..
Identify the type of problem
as respiratory or circulatory
or both , and deterimine the
severity

15. Identify
TYPE SEVERITY
1-Respiratory Upper airway
obstruction
Lower airway
obstruction
lung tissues
Disordered control of
breathing
Respiratory distress
Respiratory failure
2-Circulatory =
Shock
Hypovolemic shock
Distributive
Cardiogenic
Obstrutctive
Compensated
Hypotensive
3-Cardiopulmonary failure e.g. SVT , VT,
4- Cardiac arrest
All exam
Cases will
be
one of
theses
Problems

16. Primary assessment
ABCDE
Airway
Breathing
Circulation
Disability
Exposure
Intervene
Resuscitations
MEASURES
Suction , air way ,
bag positive breathing
, intubation,
IV FLUIDS
Anticonvulsive drugs
AIM
Idetify the problems:
• Respiratory
• Cardiac
• shock
Secondary assessment

17. Airway Assessment
• The airway must be clear and patent for
successful ventilation
• Maintainable or unmaintainable
A
Evaluate

18. Measures to maintain airway
• Use head tilt , chin left
• jaw thrust In cervical injury (most useful)
• Suctions
• Use oral or nasopharyngeal airway
• Intubations
• Laryngeal mask
• Cricothyrotomy
• Remove the foreign body :
– <1 yr give 5 back slaps and 5 chest thrusts
– >1yr give 5 abdominal thrusts
– If the patient become unresponsive activate emergency , and start CPR
= Intervene

19. Breathing Assessment
1. Respiratory rate ˂ 10 or > 60 is sign of impending respiratory
failure
2. Respiratory effort ,retractions,
3. Sounds wheezing, grunting , rales
4. Air entry
5. Pulse oximetry
B

20. Respiratory distress
RD is clinical state characterized by
↑RR
Nasal flaring
Retraction
Grunting ,wheezing or stridor
Cyanosis
Change in mental status
GRUNTING
IS SIGN OF SEVERE RESP DISTRESS

21. Breathing difficulty Location of retraction
Mild to moderate Subcostal
Sub sternal
Intercostal
Severe Supraclavicular
Suprasternal sternal
HEAD BOBBING
SEESAW SAW
UPPER AIR WAY
OBSTRUCTION
Chest retractions
Stridor
LOWER AIRWAY
OBSTRUCTIONS
Chest retractions
WHEEZING

22. FOUNDATIONAL FACTS
• SEESAW BREATHING :
– Is present when chest retract and abdomen expand
– Caused by strong contraction of diaphragm that dominate the
chest wall muscles
– Seen in infant and children with neuromuscular weakness
– Is inefficient form of ventilation can quickly lead to fatigue

23. Apnea
• Apnea = cessation of breathing more than 15 seconds
• Types :
– Central apnea , no respiratory efforts
– Obstructive : there is respiratory effort without airflow
– Mixed apnea
MINUTE VENTILATION = Respiratory rate X tidal volume

24. O2 SATURATION
• Is the % of total HB that is fully saturated with O2
• IF 94 % or more in room air indicate adequate
oxygenation
• Less than 94% indicate hypoxia and need o2
administration
• Keep the o2 sat 94 - 99% to avoid hypoxia or hyperoxia
• O2 sat less than 90% while receiving 100% o2 is an
indication (RF) for further intervention

25. Respiratory failure
It Is inadequate ventilation or oxygenation, or both, that leads
to an ↑ (paco2) and/or ↓ (pao2), resulting in acidosis.
Clinical
findings
Marked ↑RR (early) or ↓RR (late)
Tachycardia early or Bradycardia late
Low O2 sat despite high
O2
Cyanosis
Decreased consciousness
+ Abnormal blood gases

26. Breathing - Primary assessment intervene
Resuscitation
● Give high‐flow oxygen (flow rate 15 l/min) through a mask with a
reservoir bag to any child with respiratory difficulty or hypoxia.
● In the child with inadequate respiratory effort, this should be
supported either with bag–valve–mask ventilation or intubation and
intermittent positive pressure ventilation

27. Circulation Assessment
Circulation is assessed by
1. Heart rate,
2. heart rhythm (cardiac monitor , or ECG recording )
3. Pulse ( both peripheral and central )
4. Capillary refill time
5. Blood pressure
6. Skin ,color and temperature
7. Brain ,Level of consciousness
8. Renal ,Urine output
End organ
perfusion
C

28. Bradycardia
• Hypoxia is the most common cause of bradycardia
• Bradycardia + signs of poor perfusion ( decreased
responsiveness , weak peripheral pulse ,cool mottled
skin) needs immediate support with bag ventilation
with O2 , if HR LESS THAN 60 , DO CHEST
COMPRESSION + epinephrine
• Bradycardia + no signs of poor perfusion , suggest
heart block or drug overdose

29. Tachycardia
Warrant further
assessment
HR > 180 infant or toddler
HR >160 in child older than 2 yr
Tachycardia + hypotension ,
or depressed consciousness,
or poor perfusion
= Shock require immediate
evaluation and intervention

30. PULSE
CENTRAL PULSE PERIPHERAL PULSE
• Carotid
• Axillary
• Brachial
• Femoral
• Radial
• Dorsalis pedis
• Posterior TIBIAL
Weak central pulse need rapid intervention it indicates ( shock )
DECREASED COP WEAK CENTRAL PULSE

31. Capillary refill time
• Is the time to blood takes to return to tissue blanched by
pressure
• Normal = 2 seconds
• More than 2 sec in poor tissue perfusion ( dehydration ,
shock , hypothermia )
• Brisky as in septic shock

32. Skin findings
Skin color Location Causes
Pallor Skin , mucous
membranes
• Anemia
• Poor perfusion
(cold, stress, shock)
Mottling Skin Vasoconstriction
Cyanosis Skin , mm Decreased O2 sat
Skin temperature Cool skin with decreased
perfusion

33. Blood pressure
Minimal acceptable systolic BP more than
60 in neonate , more than 70 in infant
in children = 70 + ( AGE X 2)
Hypotension indicates decompensated shock
25% of the blood volume must be lost before a drop in blood
pressure occurs.

34. Renal perfusion
Urine Output
• 1.5 To 2 ml/ Kg / Hour in infant
and young children
• 1ml/kg per hour in older
children

35. Circulation assessment followed by appropriate
intervention
Primary assessment of circulation as before
Resuscitation
In every child with an inadequate circulation:
● Give high‐flow oxygen through either a mask with a reservoir bag or
an endotracheal tube if intubation has been necessary for airway
control or inadequate breathing.
1. Provide IV or intraosseous access should be gained
2. Immediate infusion of crystalloid (20 ml/kg) given.
3. Vasoactive drugs

36. • IV access- Don’t forget intraosseous access in emergencies
• To place an intraosseous cannula: use sterile technique, identify
the tibial tuberosity, insert the intraosseous cannula 1 - 3 cm
below (distal) to the tuberosity on the medial side of the tibia,
direct the needle perpendicular to the long axis of the bone or
slightly caudal (toward the toes) to avoid the epiphysial plate,
use a firm twisting motion.
• Do NOT use an IO in a fractured bone.

37. • Stop advancing the needle when you feel a sudden
decrease in resistance as the needle enters the
marrow cavity. The needle is in the marrow cavity
if:
• You felt the decrease in resistance as you entered
the marrow cavity.
• The needle can remain upright without support.
• Marrow can be aspirated (looks red and grainy) -
not always achievable.
• Fluid flows freely without subcutaneous infiltration.

38. Disability
Cerebral cortex
function evaluation by
1- AVPU response
Or Glasgow coma score
Brain stem evaluation
by
2-Pupillary response
Equality of pupil size
3- Blood sugar
D

39. The level of
consciousness
AVPU
Alert = GCS 15
Responds to verbal stimuli = GCS 13
Responds to Painful stimuli = GCS 8
Unresponsive = GCS 6
Cause of decreased level of consciousness:
1. Traumatic brain injury
2. Hypoxia , poor cerebral perfusion , shock
3. Encephalopathy : hypoglycemia, hypercarbia , uremia..
4. Seizures : epilepsy
5. CNS infections : encephalitis , meningitis
6. Drug overdose

40. Severity of head injury :
• Severe, with GCS less than
or equal to 8
• Moderate, GCS 9 – 12
• Minor, GCS 13 or greater.

41. Pupil response to light
Check pupil size and reaction in each eye in any patient with ,
depressed consciousness to evaluate brain stem function
Record the size of pupil , equality of pupil and reaction to light

42. Disability (neurological evaluation)
possible intervention needed after Primary assessment
• Both hypoxia and shock can cause a decrease in conscious level. Any
problem with ABC must be addressed before assuming that a decrease in
conscious level is due to a primary neurological problem.
• any patient with a decreased conscious level or convulsions must have an
initial glucose stick test performed.
Resuscitation
1. Consider intubation to stabilize the airway in any child with a conscious level recorded as
P or U (only responding to painful stimuli or unresponsive).
2. treat hypoglycaemia with a bolus of glucose (2 ml/kg of 25% glucose) followed
by an IV infusion of glucose, after taking blood for glucose measurement in the
laboratory and a sample for further studies.
3. Intravenous lorazepam, buccal midazolam or rectal diazepam should be given
for prolonged or recurrent fits .
4. Manage raised intracranial pressure if present

43. Glucose Level
Serum glucose concentration should be determined in all
ill or injured children
In children Glucose replacement 25 % dextrose
2 to 4 mL/ kg IV over 20 to 30 minutes for hypoglycemia.
In neonates, 10 % dextrose 2ml/kg

44. Signs of increased intracranial pressure
• Tense fontanel
• Papilledema
• Depressed consciousness'
• Dilated pupil
• Abnormal breathing
• Bradycardia
• Cushing triad late
• Decelerate or decorticate posture
Management ( ABCDE)
1- ABC : maintain airway ,
ventilation to keep normaL O2
sat and CO levels
2- head in 30 degree position
3- saline 3% (3ml/kg) , keep
blood osmo. Less tha 360 or give
mannitol
4-neurosurgical consultation
D
Expert

45. Exposure
1-Temperature : fever suggests an infection
2- SKIN
Undress the seriously ill or injured child
Look for evidence of trauma, purpura , rash , bleeding ,
burn or unusual marking suggestive of abuse
Tenderness of extremities suggests injury
E

46. Summary: the primary assessment of an infant or child
• Airway and Breathing
– Effort of breathing
– Respiratory rate/rhythm
– Stridor/wheeze
– Auscultation
– Skin colour
• Circulation
– Heart rate
– Pulse volume
– BP
– Capillary refill
– Skin temperature
Disability
• Mental status/conscious level
• Pupils
• blood glucose
Exposure
• skin
• temperature
The whole P. assessment should take less than a minute.
Once airway (A), breathing (B) and circulation (C) are clearly recognised as being stable or have
been stabilised, then definitive management of the underlying condition can proceed.
During definitive management reassessment of ABCDE at frequent intervals will be necessary
to assess progress and detect deterioration.

47. Secondary Assessment
Aim : To Give Emergency Treatment
1- History / SAMPLE S For Signs And Symptoms
A – Allergy to foods or drugs
M - Medication
P - Past History
L - Last Meal
E Event Result To The Problem
2- focused Clinical
Examination
Head To Toe
Examination
Clue
3- Ongoing assessment of vital

48. Secondary assessment and emergency treatment
• The secondary assessment takes place once life‐threatening
conditions have been assessed and treated .
• It includes a focus medical history, and a clinical examination
• Time is limited and a focused approach is essential.
• At the end of secondary assessment, the practitioner should
have formulated a differential diagnosis.

49. Diagnostic tests
To asses the cardiopulmonary function and determine the cause
Blood gases
Hb concentration
Pulse oximetry
CXR
Exhaled CO2 monitoring
Echocardiography
Invasive arterial pressure monitoring
CVP monitoring
Arterial lactate