Paediatric advanced life support ppt for UG

Paediatric advance life support

1. TRIAGE AND PEDIATRIC ADVANCED LIFE SUPPORT (PALS) – ASSESSMENT OF PAEDIATRIC AND NEONATAL EMERGENCY DR AVINASH JHA MBBS(GOLD MEDALIST),DNB,PGPN(BOSTON) ASSISTANT PROF., PAEDIATRICS OH GOD, I MISSED MY EMERGENCY LECTURE, AB KYA KARU? AB KISE CALL KRU?

2. What is Triage? French verb “trier”, means to separate or select. Triage is the process of rapid assessment of a patient with a view to define urgency of care & priorities in treatment. It helps in rational allocation of limited resources , when demand exceeds availability. Triage is the first step in the management of a sick child admitted to a hospital.

3. STEPS IN THE MANAGEMENT OF THE SICK CHILD ADMITTED TO HOSPITAL TRIAGE Check for emergency signs Check for priority signs Emergency treatment Rapid assessment & treatment Non- urgent cases & stabilized cases History and examination Laboratory and other investigations List and consider DIFFERENTIAL DIAGNOSES Select MAIN (WORKING) DIAGNOSIS and Secondary diagnoses Plan and begin INPATIENT TREATMENT (including supportive care) YES NO NO C O U N S E L I N G

4. STEPS IN THE MANAGEMENT OF THE SICK CHILD ADMITTED TO HOSPITAL (Contd.) Monitor for Response to treatment Complications INPATIENT TREATMENT Continue treatment Plan for discharge Revise treatment Treat complications Refer if not possible IMPROVING NOT IMPROVING OR NEW PROBLEM C O U N S E L I N G

5. When should Triage take place? As soon as the sick child arrives at hospital. Before any administrative procedure such as registration. Where should Triaging be done? Can be carried out any where. At Emergency Room, at OP D queue, at ICU or at ward.

6. Who should triage? All the staff working in a health care facility should be trained to carry out rapid assessment of sick child and triage.

7. Different Triage systems WHO – ETAT ( E mergency T riage A ssessment and T reatment) guidelines Pediatric Triage according to F- IMNCI module: EPN ( E mergency, P riority & N on- urgent) system Triage of newborns according to FBNC module: EPN ( E mergency, P riority & N on- urgent) system Emergency Severity Index Canadian Triage and Acuity Scale

8. Rapid screening of the child to decide to which one of the following groups, the child belongs: Emergency treatment Rapid assessment & action Can wait Emergency cases Priority cases Non- urgent cases Check for emergency signs Check for priority signs Emergency treatment Rapid assessment & treatment Non- urgent cases & stabilized cases YES Dr Naveen Kumar Cheri S.V. Medical College, Tirupati NO NO

9. PALS Systematic Approach Algorithm 1. Check r esponsi v en e ss 2. Call for help 3. Check for a pulse 4. PALS Cardiac Arrest Algorithm 1 2 3 4 E - I -T

10. The BLS Assessment is the first step that you will take when treating any emergency situation This initial impression of consciousness, breathing, and color helps to answer the following question:

11. “Is the child unresponsive with no breathing or only gasping? ” Consciousness : Unresponsive Irritable Alert Breathing Abnormal breath sounds Abnormal breathing patterns Accessory muscle use Color Cyanosis Pallor Mottling

12. Check for a pulse Check the pulse in the infant using the brachial artery on the inside of the upper arm between the infant’s elbow and shoulder Check for pulse in child using the carotid artery on the side of the neck or femoral pulse on the inner thigh in the crease between the leg and groin.

13. Position the victim Head Tilt – Chin Lift Maneuver Jaw – Thrust Maneuver Open Airway

14. Ventilation and Oxygen

15. PALS Cardiac Arrest Algorithm

16. Start CPR 5 components of high-quality CPR Adequate depth: ≥ 1/3 diameter of chest – 6cm Adequate rate: 100-120 beats/minute Full chest recoil Minimize interuptions Avoid excess ventilation One cycle CPR: 15:2 (no advanced airway) 5 cycles = 2 minutes If advanced airway 10 breaths per minute (1 breath every 6 secs) Check rhythm every 2 minutes Rotate compressors every 2 minutes, rhythm checked

17. Give Oxygen Open the airway Provide basic ventilation Bag-mask ventilation ± Use of artificial airways (OPA and NPA) Only use an OPA in unresponsive patients with NO cough or gag reflex Avoid hyperventilation Suction to maintain a clear airway 10 seconds or less

18. Adrenaline Dose: IV/IO access: 0.1 mL/kg of 1:10.000 concentration Endotracheal dose: 0.1 mL/kg of 1:1.000 concentration Repeat every 3 – 5 minutes

19. Reversible Causes 5 H’s: Hypoxia Hypovolemia Hyper/Hypokalemia Hypothermia Hypoglycemia 5 T’s: Thrombosis Tension pneumothorax Tamponade Toxic Trauma

20. Part 1-Sequence: Evaluate Primary Assessment Maintainable Unmaintainable R Distress R Failure Compensated Uncompensated Alert V oi c e Pain Unreponsive

21. A - Airway Is the airway open? This means open and unobstructed If yes, proceed to B (Breathing) Can the airway be kept open manually? Jaw Lift/ Chin Thrust Nasopharygeal or oropharygeal airway In an advanced airway required? Endotracheal intubation Cricothyrotomy, if necessary

22. Management of choking in young infant Lay the infant on arm or thigh in a head down position. Give 5 blows to the infant’s back with heel of hand. (Back slaps) If obstruction persists, turn infant over and give 5 chest thrusts with 2 fingers, one finger breadth below nipple level in midline. (Chest thursts) If obstruction persists, check infant’s mouth for any obstruction which can be removed. If necessary, repeat sequence with back slaps again.

23. Management of choking in older child Give 5 blows to the child’s back with heel of hand with child sitting, kneeling or lying. (Back slaps) If the obstruction persists, go behind the child and pass your arms around the child’s body; form a fist with one hand immediately below the child’s sternum; place the other hand over the fist and pull upwards into the abdomen; repeat this Heimlich maneuver 5 times. If the obstruction persists, check the child’s mouth for any obstruction which can be removed. If necessary, repeat this sequence with back slaps again.

24. B - Breathing Respiratory Rate Respiratory Effort and Mechanics Air entry/Tidal volume Skin color Respiratory Distress: increased WOB Respiratory Failure: Inadequate gas exchange resulting in inadequate oxygenation and/or ventilation (distress ±)

25. C – Circulation Cardiovascular function Responsiveness: AVPU Heart r ate Pulse Blood pressure End-organ perfusion Brain Skin: temperature, capillary refill, color

26. Circulation - summary

27. Secondary assessment A search for underlying causes 4 H’s 4 T’s If possible a focused medical history SAMPLE: (S) Signs and symptoms Allergies (M) Medications (P) Past illnesses (L) Last Oral Intake (E) Events Leading Up To Present illness

28. Part 2-Sequence: Identify STABLE RESPIRATORY DISTRESS RESPIRATORY FAILURE SHOCK CARDIOPULMONARY FAILURE

29. Coma & Convulsion - a ssessment AVPU Scale A Is the child A lert? If not, V Is the child responding to V oice? If not, P Is the child responding to P ain? U The child who is U nresponsive to voice (or being shaken) AND to pain is U nconscious. A child with a coma scale of “P” or “U” will receive emergency treatment for coma

30. Coma & Convulsion - management

31. Coma & Convulsion - management Recovery Position: Turn the child on the side. Keep the neck slightly extended and stabilize by placing the cheek on one hand. Bend one leg to stabilize the body position.

32. Severe Dehydration - assessment Assess for severe dehydration if ABC 3 assessments are normal. If there is history of diarrhoea/vomiting look for presence of any two of the following signs: Is the child lethargic? Does the child have sunken eyes? Does the skin pinch take longer than 2 seconds to go back? Also look if the child has severe malnutrition.

33. Severe Dehydration – management (In the absence of shock and severe malnutrition) Give the child a large quantity of fluids quickly according to Plan C. Fluid of choice: Ringer Lactate For infants: 30 ml/kg in the first hour 70 ml/kg in the next 5 hours For children > 1 year of age: 30 ml/kg in the first 30 minutes 70 ml/kg in the next 2.5 hours

34. EMERGENCY SIGNS PRIORITY SIGNS NON URGENT CASES Hypothermia (temp<36 C) Apnea or gasping respiration Severe respiratory distress (rate>70, severe retractions, grunt) Central cyanosis Shock (cold periphery, CFT>3secs, weak & fast pulse) Coma, convulsions or encephalopathy Cold stress (temp 36.4 C - 36 C) Respiratory distress (rate>60, no retractions) Tiny neonate (<1800gms) Large baby Irritable/restless/jittery Refusal to feed Abdominal distension Severe jaundice Severe pallor Bleeding from any sites Major congenital malformations Jaundice Transitional stools Developmental peculiarities Minor birth trauma Posseting Superficial infections Minor malformations All cases not categorized as Emergency/Priority TRIAGE -NEONATES

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