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PALS
PALS AHA Systemic Approach
| Question | Answer |
|---|---|
| Why is it necessary to use an organized, systematic method to evaluate a child? | Because in a child respiratory failure, respiratory arrest, and or shock can quickly deteriorate to cardiopulmonary failure or cardiac arrest. Rapid recognition and intervention are required. |
| What are the most common causes of cardiac arrest in infants and children? | progressive respiratory failure or shock or both |
| What is the less common cause of cardiac arrest in infants and children? | arrhythmias such as VT and VF |
| What are the percentages of survival for infants and children in cardiac arrest in hospital and out of hospital? | in hospital only 33% survive, out of hospital only 4-13% even with optimal resuscitation effort |
| What can we do to prevent infant and child progression to cardiac arrest? | be able to readily identify the signs of respiratory failure and shock and intervene promptly |
| What are the assessments made during the initial assessment? | consciousness, breathing, color |
| What are the types of consciousness that might be assessed during the initial impression? | alert, irritable, unresponsive |
| What are some possible causes of decreased level of consciousness? | inadequate oxygen, substrate delivery, or brain trauma/dysfunction |
| What are the signs of abnormal breathing? | increased work of breathing, use of accessory muscles, absent or decreased respiratory effort, extra breath sounds, irregular breathing patterns |
| What are the signs of abnormal color? | pale, mottled, pallor (bluish/gray skin), flushing |
| What could cause cyanosis, pallor, or mottling in an infant/child? | poor perfusion, poor oxygenation or both |
| What are two possible causes of flushing of the skin in an infant/child? | fever, toxin |
| What is the next course of action if you find an infant/child is unresponsive and not breathing or only gasping? | activate emergency response system and check pulse |
| What is the next course of action if you find that an infant/child is unresponsive, not breathing or gasping and there is no pulse? | start CPR and follow the PALS cardiac arrest algorithm |
| What is the next course of action if an infant/child is not breathing or only gasping but pulse is present? | provide rescue breathing |
| What is the next course of action if an infant/child, despite adequate oxygenation and ventilation has a heart rate less than 60 with signs of poor perfusion? | compressions and ventilations, proceed with Pediatric Cardiac Arrest algorithm |
| What is the three step sequence of action that is repeated until an infant/child is stable? | Evaluate-Identify-Intervene |
| What clinical assessment tools make up the Evaluate step of the Evaluate-Identify-Intervene sequence? | Primary assessment, Secondary assessment, diagnostic tests |
| What are the components of the primary assessment? | Rapid hands on assessment of respiratory, cardiac, neurologic function, vital signs and pulse oximetry using the ABCDE approach |
| What is the secondary assessment? | a focused medical history and focused physical exam |
| What do we mean by diagnostic tests? | labs, x-rays, us, etc |
| During the identify step of the Evaluate-Identify-Intervene sequence, what are the main areas of focus? | Type and severity of Respiratory or Circulatory disorders which can quickly lead to cardiopulmonary failure and or cardiac arrest |
| List the types and severities of respiratory problems that you will assess for. | types: upper airway obstruction, lower airway obstruction, lung tissue disease, or disordered control of breathing. Severity: respiratory distress, respiratory failure |
| List the types and severities of circulatory disorders that you will assess for. | types: hypovolemic, distributive, cardiogenic, or obstructive shock. Severity: compensated or hypotensive shock |
| Positioning for patent airway, activating emergency response, CPR, attaching cardiac monitor and pulse ox, administering 02, supporting ventilation, starting medications or fluids are considered which step of the Evaluate- Identify-Intervene process? | intervention |
| What is the next course of action after every intervention or when the child’s condition changes or deteriorates? | reevaluate the child, start the Evaluate-Identify-Intervene sequence again if the problem is life threatening activate emergency response |
| List four signs that indicate Life threatening situations. | absent or agonal breathing, respiratory distress, cyanosis, decreased level of consciousness |
| What does ABCDE model stand for in the primary assessment? | Airway, Breathing, Circulation, Disability, Exposure |
| When assessing the Airway what determinations are we making? | is the upper airway open, if not is it maintainable or not maintainable |
| How do we assess the Airway? | look for movement of the chest or abdomen, listen for air movement and breath sounds |
| What signs suggest obstruction of the upper airway? | increased respiratory effort, retractions, abnormal inspiratory sounds (stridor, snoring), no airway or breath sounds despite inspiratory effort |
| What is the definition of a maintainable airway according to PALS? | can be maintained by simple measures such as head tilt-chin lift, NPA, OPA |
| What do you do if you suspect a foreign-body airway obstruction? | If the child is still responsive and has complete airway obstruction <1 year =5 back slaps and 5 chest thrusts, >1 year = abdominal thrust |
| What are the possible advanced interventions for airway patency? | ET tube, CPAP, Removal of foreign body (may require visualization via larngoscopy), cricothyrotomy (a surgical opening into the trachea below the vocal chords) |
| What assessments are necessary to evaluate breathing? | respiratory rate and effort, chest expansion and air movement, lung and airway sounds, O2 sats |
| What are the normal respiratory rates for Infants (<1yr), toddlers (1-3), preschoolers (4-5), school age (6-12), and adolescents (13-18)? | infant 30-60, toddler 24-40, preschool 22-34, school age 18-30, adolescent 12-16 |
| What consistent respiratory rates, low and high, in a child should sound an alarm if assessed in a child of any age? | less than 10 or greater than 60 |
| How would you expect conditions that raise the metabolic demand such as fever, excitement, anxiety, exercise, pain to affect a child’s respiratory rate? | would expect respiratory rate to be higher than normal |
| What irregularity in breathing pattern during sleep is normal for infants? | periodic breathing with pauses lasting as long as 10-15 seconds |
| When is a return to a more regular rate of breathing in a child a good sign? A bad sign? | good when the child shows signs of improvement such as improving LOC, reduced work of breathing and reduced signs of air hunger, bad when LOC continues to deteriorate |
| What sound is typically a sign of severe respiratory distress or failure from lung tissue disease requiring quick identification and treatment of cause? | grunting |
| Coarse, high pitched sound typically heard on inspiration | stridor |
| Short, low pitched sound heard during expiration; occurs as the child exhales against partially closed glottis | grunting |
| Bubbling sound heard during inspiration or expiration caused by liquid upper airway obstruction | gurgling |
| What do we look at to assess a child’s circulatory status? | heart rate and rhythm, pulses (peripheral/central), cap refill, skin color/temp, blood pressure, urine output and LOC |
| Give the normal heart rates for newborn to 3months, 3 months to 2 years, 2 years to 10, and 10 and up. | 85-205, 100 to 190, 60-140, 60 -100 |
| What is the most common cause of bradycardia in a child? | hypoxia |
| If bradycardia is causing poor perfusion, what signs would you expect in the child? | decreased responsiveness, weak peripheral pulses, cool mottled skin |
| If you see signs of poor perfusion due to bradycardia what is the 1st intervention? | immediately support ventilations with a bag mask and administer 02 |
| If the child has bradycardia but no signs of poor perfusion what is your next action? | check for other causes of bradycardia such as heart block or drug overdose |
| Define pulsus paradoxus. | fluctuation in pulse volume with the respiratory cycle |
| Name a couple things that could cause pulsus paradoxus. | severe asthma and pericardial tamponade |
| What are some common causes of sluggish cap refill? | dehydration, shock , hypothermia |
| What type of shock can be present with a brisk capillary refill? | septic shock |
| Name the broad clinically significant causes of pallor. | poor perfusion due to cold stress or shock especially hypovolemic or cardiogenic, or anemia |
| What kind of pallor would be strongly indicative of pallor due to clinically significant cause? | central pallor meaning lips and mucous membranes (lining of the mouth, tongue, eyelids) and pale palms and soles |
| Patchy discoloration of the skin consisting of an uneven combination of pink, grayish, bluish skin tones | mottling |
| Describe the physiology of clinically significant mottling. | intense blood vessel constriction to compensate for irregular supply of oxygenated blood to the skin due to hypoxemia or hypovolemia |
| Define cyanosis and cause. | cyanosis is a bluish discoloration due to lack of oxygen in the blood (oxygenated blood is red) |
| Define acrocyanosis. | bluish discoloration of the hands and feet (often normal in newborn period) |
| Define peripheral cyanosis. | bluish hands and feet after the newborn period |
| What could cause peripheral cyanosis? | diminished 02 delivery to the periphery possilbly due to shock, CHF, PVD, or conditions causing venous stasis |
| What is the definition of hypotension for an neonate ( 0=28 days)? | systolic BP <60 |
| What is the definition of hypotension for an infant 1-12 months? | systolic BP <70 |
| What is the definition of hypotension for children 1-10 years old? | Systolic BP <70 + age x 2 |
| What is the definition of hypotension for children older than 10? | Systolic BP <90 |
| What amount of variation from a child’s baseline BP should prompt serial assessments for shock? | decrease of 10mm Hg |
| Explain why hypotension is an ominous sign of impending arrest. | it means the body’s compensatory mechanisms for hypovolemia (tachycardia and vasoconstriction have failed) |
| Discuss bleeding in relation to loss of blood volume and hypotension. | hypotension as a result of hemorrhage is thought to be consistent with a 20-25% loss of circulating blood volume |
| What happens to circulating blood volume in septic shock? | it is decreased due to inappropriate vasodilation |
| What is required if a child goes from tachycardia and hypotension to bradycardia and hypotension? | this is an ominous sign. Management of airway, breathing and aggressive fluid resuscitation are required to prevent cardiac arrest |
| Discuss urine output as an assessment tool for shock in critically ill and injured children. | all criticall ill or injured children should have a foley catheter to monitor output as an indication of kidney perfusion, Poor perfusion is a sign of shock. Initial output is not as reliable because may be urine from before symptom onset. |
| What are we assessing during the D part of the ABCDE assessment? | Disability – neurologic function |
| When is the D assessment made? | during the primary assessment and again during the secondary assessment |
| What assessments tell us about brain perfusion? | LOC, pupillary responses and muscle tone |
| What are the signs of cerebral hypoxia or poor brain perfusion? | decreased level of consciousness, pupil dilation, loss of muscle tone, generalized seizures |
| If cerebral hypoxia occurs gradually, the signs may be more subtle. What would you look for? | decreased level of consciousness with confusion, irritability, lethargy, agitation alternating with irritability |
| Name the tools used for neurologic assessment in children. | AVPU and Glascow Comma |
| What does AVPU stand for? | Alert (typical response), Voice (responds to voice), Painful (responds to pain), or Unresponsive |
| What are some causes of decreased level of consciousness in children? | Poor cerebral confusion, traumatic brain injury, encephalitis, meningitis, hypoglycemia, drugs, hypoxemia, hypercarbia |
| What are the next 3 priority assessments if a child shows signs of decreased LOC? | oxygenation, ventilation, perfusion |
| What are we concerned about if a child’s eyes do not constrict to light? | possible brainstem injury |
| What should we record after assessing pupils? | mm, equality, shape, and reaction to light |
| What are we concerned about if a child’s eyes show irregularities in equality or response to light? | increased intracranial pressure |
| Describe the Exposure element of the ABCDE assessment. | systematically assess the child’s body from head to toe, look for irregularities, wounds, deformities, palpate extremities and watch for signs of tenderness |
| Using the ABCDE acronym, give assessment findings that would indicate a life threatening condition. | A- airway obstruction, B-increased work of breathing, apnea, bradypnea, C- absence of palpable pulse, hypotension, bradycardia, poor perfusion, D – unresponsiveness, decreased LOC, E-hypothermia, petechai or purpura (septic shock), bleeding |
| What information is collected during the secondary assessment? | focused history and physical exam |
| What acronym guides us through the focused history? | SAMPLE |
| What does SAMPLE stand for? | Signs and Symptoms (at onset), Allergies, Medications, Past Medical History, Last meal (or oral intake), Events |
| Name 10 test that might be ordered for assessment of respiratory and circulatory problems. | ABG, Venous Blood Gas, Hemoglobin concentration, Central venous 02 sat, arterial lactate, central venous pressure monitoring, invasive arterial monitoring, Chest XR, ECG, Echocardiogram, Peak expiratory flow rate |
| Explain the limitations of ABG’s to diagnose adequate oxygenation in a child. | PaO2 reflects the 02 disolved in plasma. If the child is anemic or lack hemoglobin they may not have adequate oxygenation but still have an acceptable PaO2 ABG result |
Created by:
Perseverandovercome