pals pandemic module and management -200103142856.pptx

Update in pals during pandemic

1. P EDIATRIC A DVANCED L IFE S UPPORT Dr. Vinaykumar S Appannavar

2. SESSION 01 BLS pearls Introduction to PALS How to recognize the sick child – a structured approach

3. Basic life support BLS refers to care healthcare providers and public safety professionals provide to patients who are experiencing respiratory or cardiac arrest Steps of BLS: Ensure safety Assess response Activate EMS C-A-B Defibrillation Continuation or recovery from resuscitation BLS

4. CHEST COMPRESSIONS

5. AIRWAY

6. BREATHING

7. DEFIBRILLATION

8. BLS DIFFERENCES

9. CHAIN OF SURVIVAL ADULT PEDIATRIC

10. CARDIAC CARDIAC ARREST Physiological impairment pathways

11. PRINCIPLES OF PALS ALS refers to constellation of interventions needed to support the vital physiological processes during critical illness ,while we await for definite therapy Taking care of respiratory, circulatory and neurological insufficiencies is called as ADVANCED LIFE SUPPORT The format of identifying a sick child involves a structured approach .

12. HOW TO RECOGNIZE THE SICK CHILD – A STRUCTURED APPROACH 3 year old Riya, presented with fever and cough since 2 days and rapid breathing since 1 day. At presentation RR – 56 cpm Pallor + recession ++ Spo2 – 86% @RA CASE 01

13. MANTRA

14. EVALUATE – For recognition of sick child using structured approach INITIAL IMPRESSION PRIMARY ASSESSMENT SECONDARY ASSESSMENT DIAGNOSTIC TESTS EVALUATE

15. 1. INITIAL IMPRESSION EVALUATE 3 year old Riya, presented with fever and cough since 2 days and rapid breathing since 1 day. At presentation Pallor + RR – 56 cpm recession ++ Spo2 – 86% @RA

16. CONCIOUSNESS - HMF T one I nteractive C onsolable L ook S peech APPEARENCE EVALUATE INITIAL IMPRESSION

17. BRAIN DYSFUNCTION Primary hypoxia Secondary hypoxia IDENTIFY

18. EVALUATE 3 year old Riya, presented with fever and cough since 2 days and rapid breathing since 1 day. At presentation Pallor + RR – 56 cpm recession ++ Spo2 – 86% @RA BREATHING Whether the child is not breathing at all ? Whether the breathing is too fast or too slow ? Are there any audible sounds during respiration? Is breathing regular and smooth or asynchronous/ jerky / paradoxical ? Is there use of accessory muscles : flaring of ala nasi, head bobbing ? BREATHING INITIAL IMPRESSION

19. RESPIRATORY DYSFUNCTION ABNORMALITIES in any of previously mentioned parameters IDENTIFY

20. EVALUATE 3 year old Riya, presented with fever and cough since 2 days and rapid breathing since 1 day. At presentation Pallor + RR – 56 cpm recession ++ Spo2 – 86% @RA BREATING A pale child Bruises, ecchymosis or petechial rashes Mottling or dusky or blue hue Cyanosis Evidence of active bleeding COLOR INITIAL IMPRESSION COLOR

21. CIRCULATORY DYSFUNCTION ABNORMALITIES in any of previously mentioned parameters IDENTIFY

22. EVALUATE INITIAL IMPRESSION IDENTIFY

23. IDENTIFY – severity of the insufficiency and classify the types IDENTIFY

24. 6yr old Sameer, presented with early morning pain abdomen and vomiting since 2 hours, drooping of eyelids and weekness of all 4 limbs since 1 hour, At presentation RR – 16cpm, shallow Secretions ++ Ptosis + Quadriparesis + Spo2 – 86% @ RA CASE 02

25. PRIMARY ASSESSMENT EVALUATE 3 year old Riya, presented with fever and cough since 2 days and rapid breathing since 1 day. At presentation Pallor + RR – 56 cpm recession ++ Spo2 – 86% @RA 6yr old Sameer, presented with early morning pain abdomen and vomiting since 2 hours, drooping of eyelids and weakness of all 4 limbs since 1 hour, At presentation RR – 16cpm, shallow Secretions ++, Ptosis +, Quadriparesis +, Spo2 – 86% @ RA

26. AIRWAY OPEN MAINTAINABLE – Some assistance NON MAINTAINABLE – Advanced assistance EVALUATE PRIMARY ASSESSMENT AIRWAY 3 year old Riya, presented with fever and cough since 2 days and rapid breathing since 1 day. At presentation Pallor + RR – 56 cpm recession ++ Spo2 – 86% @RA 6yr old Sameer, presented with early morning pain abdomen and vomiting since 2 hours, drooping of eyelids and weakness of all 4 limbs since 1 hour, At presentation RR – 16cpm, shallow Secretions ++, Ptosis +, Quadriparesis +, Spo2 – 86% @ RA

27. BREATHING Respiratory rate Work of breathing Chest wall movements and tidal volume Auscultation for air entry and adventitious sounds Pulse oximetry EVALUATE PRIMARY ASSESSMENT BREATHING 3 year old Riya, presented with fever and cough since 2 days and rapid breathing since 1 day. At presentation Pallor + RR – 56 cpm recession ++ Spo2 – 86% @RA 6yr old Sameer, presented with early morning pain abdomen and vomiting since 2 hours, drooping of eyelids and weakness of all 4 limbs since 1 hour, At presentation RR – 16cpm, shallow Secretions ++, Ptosis +, Quadriparesis +, Spo2 – 86% @ RA

28. BREATH SOUNDS EVALUATE PRIMARY ASSESSMENT BREATHING AIRWAY ADDED SOUNDS LOCATION Snuffles Nasal Snoring Naso -pharyngeal Stridor Upper airway Wheeze Lower airway Crackles Lungs - alveoli Grunting Parenchyma

29. Severity of Respiratory insufficiency IDENTIFY

30. Type of Respiratory insufficiency IDENTIFY

31. INTERVENE TYPE EXAMPLE ER INTERVENTIONS M edical Upper airway obstruction Viral croup Humidified oxygen, nebulised budesonide or injectable steroid M echanical Upper airway obstruction Foreign body Diphtheria Black slap/ chest thrust – infant Heimlich Manoeuvre - Children ADS & Tracheostomy Lower airway obstruction Acute severe asthma Bronchiolitis Inhaled short acting beta agonist Lung parenchymal disease Bacterial Pneumonia Antibiotics Disordered control of breathing Seizures / Coma Anticonvulsants Bag-mask ventilation Advanced airway management

32. CIRCULATION Heart rate and rhythm Central and peripheral pulses Capillary refill time Skin color and temperature Blood pressure Urine output EVALUATE PRIMARY ASSESSMENT 3 year old Riya, presented with fever and cough since 2 days and rapid breathing since 1 day. At presentation Pallor + RR – 56 cpm recession ++ Spo2 – 86% @RA 6yr old Sameer, presented with early morning pain abdomen and vomiting since 2 hours, drooping of eyelids and weakness of all 4 limbs since 1 hour, At presentation RR – 16cpm, shallow Secretions ++, Ptosis +, Quadriparesis +, Spo2 – 86% @ RA CIRCULATION

33. Hypotension cut off AGE FORMULA Term neonate < 60mmHg Upto 1 year < 70 mmHg 1-10 year 70 + age (years) * 2 10 years < 90 EVALUATE PRIMARY ASSESSMENT CIRCULATION Compensated shock will have normal BP with poor perfusion Hypotension is a late sign : Shock will be decompensated once hypotension sets in Fall of systolic pressure of >10mmhg is worrisome even if hypotension is absent Recognized and must be intervened in the compensated stage

34. Severity of Circulatory insufficiency IDENTIFY

35. Type of Circulatory insufficiency IDENTIFY

36. TYPE EXAMPLE ER INTERVENTIONS HYPOVEMIC SHOCK Diarrhoea and dehydration Humidified oxygen, IO/IV access, Crystalloid bolus DISTRUTIVE SHOCK Septic shock Humidified oxygen, IO/IV access, Crystalloid bolus, ANTIBIOTICS, vasoactives CARDIOGENIC SHOCK Acute myocarditis Humidified oxygen, IO/IV access, inotropes OBSTRUCTIVE SHOCK Tension pnuemothorax Assisted ventilation, IO/IV access, needle thoracocentesis INTERVENE

37. PRIMARY ASSESSMENT EVALUATE 3 year old Riya, presented with fever and cough since 2 days and rapid breathing since 1 day. At presentation Pallor + RR – 56 cpm recession ++ Spo2 – 86% @RA 6yr old Sameer, presented with early morning pain abdomen and vomiting since 2 hours, drooping of eyelids and weekness of all 4 limbs since 1 hour, At presentation RR – 16cpm, shallow Secretions ++, Ptosis +, Quadriparesis +, Spo2 – 86% @ RA

38. DISABILTY EVALUATE PRIMARY ASSESSMENT DISABILITY 2 STEP process Cortical assessment : By GCS and AVPU scale Brain stem assessment : Pupillary responses and movements

39. EXPOSURE EVALUATE PRIMARY ASSESSMENT EXPOSURE The child is appropriately exposed and examined for bleeds, injuries, swelling, distension, deformity and rashes

40. EVALUATE INITIAL IMPRESSION IDENTIFY INTERVENE INTERVENE IDENTIFY EVALUATE PRIMARY ASSESSMENT

41. SECONDARY ASSESSMENT EVALUATE S ings and symptoms A llergies M edication received P ast medical history L ast meal taken E vent that bought the child to ER

42. DIAGNOSTIC TESTS EVALUATE Blood glucose Hematological profile Acid – base balances CT scan MRI

43. IDENTIFY – severity of the insufficiency and classify the types IDENTIFY

44. At the end of INITIAL IMPRESSION 3 year old Riya, presented with fever and cough since 2 days and rapid breathing since 1 day. At presentation RR – 56 cpm recession ++ Spo2 – 86% @RA 6yr old Sameer, presented with early morning pain abdomen and vomiting since 2 hours, drooping of eyelids and weakness of all 4 limbs since 1 hour, At presentation RR – 16cpm, shallow Secretions ++, Ptosis +, Quadriparesis +, Spo2 – 86% @ RA SEVERITY Respiratory distress Compensated Shock Respiratory Failure Hypotensive shock TYPE UAO Hypovolemic Shock LAO Distributive Shock Lung parenchymal disease Cardiogenic shock Disordered control of breathing Obstructive shock

45. 3 year old Riya, presented with fever and cough since 2 days and rapid breathing since 1 day. At presentation RR – 56 cpm recession ++ Spo2 – 86% @RA 6yr old Sameer, presented with early morning pain abdomen and vomiting since 2 hours, drooping of eyelids and weakness of all 4 limbs since 1 hour, At presentation RR – 16cpm, shallow Secretions ++, Ptosis +, Quadriparesis +, Spo2 – 86% @ RA SEVERITY Respiratory distress Compensated Shock Respiratory Failure Hypotensive shock TYPE UAO Hypovolemic Shock LAO Distributive Shock Lung parenchymal disease Cardiogenic shock Disordered control of breathing Obstructive shock At the end of PRIMARY ASSEMENET CIRCULATION DISABILITY Cortical Brainstem Cardiogenic shock Obstructive shock Primary Secondary

46. SEVERITY CARDIOPULMONARY ARREST CARDIAC ARREST

47. 3 month old baby, brought with 1 day history of URI, Poor feeding and breathing difficulty. Previously well child. CASE 03

48. EVALUATE INITIAL IMPRESSION IDENTIFY INTERVENE RESPIRATORY AND CIRCULATORY INSUFFICENCY START OXYGEN, GATHER TEAM , ATTACH MONITORS

49. EVALUATE PRIMARY ASSESSMENT IDENTIFY INTERVENE RESPIRATORY FAILURE COMPENSATED SHOCK IO/IV ACCESS, Check ABG, Plan for bolus START HFNC 0R CPAP

50. EVALUATE SECONDARY ASSESSMENT No volume loss, No sepsis Restrict fluid boluses to 10ml/kg Cardiogenic shock, pulmonary edema INTERVENE Stop Bolus, Start Inotropes

51. EVALUATE DIAGNOSTIC TESTS VIRAL MYOCARDITIS MANAGE ACCORDINGLY INTERVENE Chest Xray 2D ECHO Cardiac biomarkers Viral studies

52. EVALUATE IDENTIFY INTERVENE INITIAL IMPRESSION PRIMARY ASSESSMENT SECONDARY ASSESSMENT DIAGNOSTIC TESTS PAT ABCDE ABCDE SAMPLE FOCUSED EXAMINATION

53. MANTRA

54. THANK YOU V S A