User:Cbutterflyd/Pediatric advanced life support

Assessment

PALS teaches a systematic assessment approach so that the health care provider can quickly identify any life threatening conditions and treat them. This approach begins with a quick initial assessment, then primary assessment, then secondary assessment, with regular continued assessments after that. Once primary and secondary assessments have been done, the provider may look further for causes and extent of injury. Continuous reassessments should be done to assess for life threatening conditions.

Initial Assessment

The initial assessment is meant to a very quick assessment performed within the first few seconds of interacting with a child. The provider should assess appearance (level of consciousness and responsiveness, speaking or crying), breathing (breathing or not breathing, increased work of breathing, abnormal breath sounds), and color (pale, mottled, cyanotic (blue), bleeding).

Primary Assessment - ABCDE

Airway - assess airway patency (open/patent, unobstructed vs obstructed) and if the patient will need assistance maintaining their airway

Breathing - assess respiratory rate, respiratory effort, lung sounds, airway sounds, chest movement, oxygen saturation via pulse oximetry

Circulation - assess heart rate, heart rhythm, pulses, skin color, skin temperature, capillary refill time, blood pressure

Disability - assess neurological function with AVPU pediatric response scale (alert, voice, painful, unresponsive), pediatric Glasgow coma scale (eye opening, motor response, verbal response), pupil response to light (normal, pinpoint, dilated, unilateral dilated), blood glucose test (low blood sugar/ hypoglycemia can cause altered mental status)

Exposure

Respiratory Distress and Failure

Providers must be able to identify respiratory problems that are easily treatable (eg, treated with oxygen, suctioning/ clearing airway, albuterol, etc.) and those that can rapidly progress to life threatening conditions. Respiratory distress can progress to respiratory failure which can progress to cardiac arrest. Once respiratory complaints have progressed to cardiac arrest, death and neurological damage are more likely to occur. For this reason, providers should aim to identify and treat respiratory conditions before they progress and worsen.

Recognition

Signs and symptoms

Common signs of respiratory distress

• increased work of breathing
• nasal flaring (nostrils widening during breathing)
• accessory muscle use (using muscles other than the diaphragm and intercostal muscles during breathing (eg, sternocleidomastoid))
• retractions (collapse of parts of the chest during breathing) (eg, suprasternal, substernal, sternal, intercostal, subcostal, supraclavicular)
• head bobbing (in infants)
• grunting
• tachypnea (too fast breathing)
• pallor (pale skin)
• tachycardia (fast heart rate)
• agitation and anxiety

Respiratory distress can progress and worsen to respiratory failure. Signs of respiratory failure include the following

• decreased work of breathing
• eventual pauses in or altogether stopping breathing (apnea)
• bradypnea (too slow breathing)
• decreased or absent air movement
• abnormal breath sounds
• cyanosis (blue skin)
• exhaustion and unresponsiveness
• can’t speak or cough

Types of respiratory problems

• upper airway obstruction - eg, croup, epiglottitis, foreign body aspiration, anaphylaxis, retropharyngeal abscess, tonsilar hypertrophy
• lower airway obstruction - eg, asthma, bronchiolitis
• lung tissue disease - eg, pneumonia, pneumonitis, pulmonary edema
• disordered control of breathing - often described as "breathing funny"; eg, seizure, overdose, trauma, coma, neuromuscular diseases

Management

Initial Management - ABCs

Airway

• support the airway by making sure that it is open/patent (child can do this on their own or provider may have to open airway with head tilt-chin lift or jaw thrust (if suspected cervical spine injury))
• clear the airway as needed (eg, suctioning mucus/secretions in nose and throat, removing foreign bodies, etc.)
• consider adding airway adjuncts such as nasopharyngeal airway (NPA) or oropharyngeal airway (OPA) (if no gag reflex)

Breathing

• monitor oxygen saturation with a pulse ox
• give supplemental oxygen
• give inhaled medications (eg, albuterol, epinephrine) as needed
• manually ventilate as needed (eg, bag mask ventilation)
• prepare for advanced airway

Circulation

• monitor vitals (eg, heart rate, blood pressure)
• establish vascular access (for medications and fluids) as needed

Advanced Airways

Advanced airways may be necessary if the child can’t maintain their airway on their own and isn’t responding to other methods of ventilation and oxygenation. Advanced airways use medical equipment to allow for open airways and ease of ventilation and medication delivery. Types of advanced airways include supraglottic devices (devices that lie above the glottis such as OPA, NPA, laryngeal mask airway), infraglottic devices (devices that lie below the glottis and go into the trachea such as endotracheal tube (intubation)), and surgery (incision below the glottis such as cricothyrotomy and tracheotomy). Surgical advanced airways are typically performed intubation and other less invasive methods fail or are contraindicated or when the child will need long term mechanical ventilation.

Intubation

To perform an intubation, the health care provider should be able to perform the steps of rapid sequence intubation (preparation, preoxygenation, pretreatment, paralysis and sedation, positioning, placement of tube, postintubation management).

Further Management

Further management should be based on the specific medical condition the child has. For example, if the child is experiencing respiratory distress secondary to asthma, management would include albuterol, corticosteroids, supplemental oxygen, and more depending upon the severity of the asthma.