Beyond the ABCs: Implementing the Latest Guidelines for Pediatric Advanced Life Support (PALS)

Introduction:

PALS (Pediatric Advanced Life Support) is an initiative of the AHA (American Heart Association) program, which is a course designed to train healthcare providers working in emergency departments, intensive care units, critical care units, pediatric surgeons, and doctors to deal with life-threatening emergencies like cardiac arrest, respiratory failure, shock, etc., in adults and children.

What Is PALS (Pediatric Advanced Life Support)?

Pediatric advanced life support (PALS) trains a clinician to evaluate and recognize potentially life-threatening conditions like cardiac arrest or respiratory failure in an injured child and intervene immediately to restore vital signs like breathing and circulation as soon as possible, thereby preventing further progression of the crisis and death.

What Are the Steps Involved In Carrying Out the PALS(Pediatric Advanced Life Support) Technique?

• The American Heart Association (AHA), in collaboration with the American Academy of Pediatrics, has devised a strategy that equips healthcare professionals with the knowledge and skills required to treat pediatric emergencies like respiratory crises, shock, or cardiac arrest.
• The model devised is based on the principle of “assess-categorize-decide-act,” which enables the caregiver to look out for every minute detail and to carry out the procedure skillfully in an injured child.
• The first step involves adequate assessment of the condition, which includes,

General Assessment:

1. The general assessment, being the first step, involves the assessment of the injured child and is often looked for signs like breathing, circulation, and appearance.
2. The altered functioning of the above-mentioned signs gives a clue to an underlying disorder and should be intervened immediately.

Primary Assessment:

1. The primary assessment involves a hands-on assessment of cardiopulmonary and neurological signs, which is carried out by the ABCDE method.
2. The child should be checked for vitals and oxygen saturation.
3. The caregiver needs to be attentive enough while carrying out the ABCDE approach to recognize the danger signs and should direct the child for immediate intervention.

The ABCDE Approach:

1. Airway: The airway needs to be checked and evaluated for chest movements, obstruction, and abnormal or no breath sounds. In case of obstruction, the airway needs to be stabilized by conventional or advanced techniques, depending on the complexity of the case.

2. Breathing: Breathing refers to the movement of air in and out of the lungs and can be determined with the help of the following parameters:

• Airway and lung sounds.
• Tidal volume (tidal volume refers to the amount of air moving in and out of the lungs during a respiratory cycle).
• Respiratory rate (refers to the number of breaths taken per minute).
• Respiratory effort (refers to an increased amount of breaths per minute, indicating trouble in respiration, increasing the respiratory effort).
• Pulse oximetry (a non-invasive method of determining blood oxygen saturation levels).

3. Circulation: Assessment is done to check cardiovascular and end-organ function. The below-mentioned parameters are checked to evaluate the normal cardiovascular function, which include:

• Skin color and temperature.
• Heart rate.
• Heart rhythm.
• Blood pressure.
• Central and peripheral pulses.
• Capillary refill time (assess the blood circulation).
• The end-organ function is assessed by,
• Either mental status or brain perfusion.
• Skin perfusion.
• Renal perfusion.

Disability: The child is checked for disability by assessing the consciousness level and hence, immediate intervention is advised.

Exposure: The temperature changes in the patient are checked and looked for hypothermia ( fall in temperature), and necessary steps are initiated to treat the same.

Secondary Assessment: Once the primary assessment is completed, a more detailed history is elicited, which includes the past medical history, allergic history, and detailed information about the injury. Also, a thorough physical examination is carried out.

Tertiary Assessment:The tertiary assessment is carried out using laboratory and non-laboratory tests to find the causative factor behind the cardiovascular and respiratory pathology. The laboratory investigations are used to detect arterial blood gas (ABG), venous blood gas (VBG), and hemoglobin levels in the blood. The non-laboratory studies include:

• Pulse oximetry.
• Monitoring of the exhaled carbon dioxide.
• Capnography (a non-invasive method of checking the carbon dioxide levels in the blood).
• Chest X-ray.
• Peak expiratory flow rate (the amount of air expelled forcefully from the lungs during exhalation).

What Are the Latest Guidelines to Be Followed While Carrying Out the Pediatric Advanced Life Support (PALS)?

The American Heart Association (AHA) and Heart and Stroke Foundation of Canada (HSFC) gave the updated guidelines on pediatric advanced life support (PALS) in October 2010. The important concerns and the changes made with respect to them are mentioned as follows:

End Tidal (ET) Carbon Dioxide Monitoring:

• The quality of the chest compression is assessed by ETCO2 monitoring.
• If the ETCO2 consistently falls below 10 to 15 mm Hg, steps to carry out CPR (cardiopulmonary resuscitation) have to be modified to increase the cardiac output.
• At the same time, hyperventilation should be avoided as it causes increased intrathoracic pressure, thereby decreasing preload and cardiac output.

Use Of Cuffed Endotracheal Tubes:

• Cuffed and uncuffed endotracheal tubes can be used in infants and children.
• Infants below one year are advised of the 3 mm endotracheal tube, and for children between one and two years of age, are recommended the 3.5mm endotracheal tube.

Cricoid Pressure: Cricoid pressure applications in routine procedures for infants and children are not recommended.

Post Resuscitation Care:

• Return of spontaneous circulation (ROSC) can resume following the increase in end-tidal carbon dioxide volume, which indicates the return of pulmonary circulation.
• Oxygen levels need to be titrated to the optimum levels after the return of spontaneous circulation.
• Resuscitation should be carried out with 100 percent oxygen, and this needs to be continued till normal circulation is restored.
• Once the spontaneous circulation is resumed, the fraction of inspiratory oxygen volume FiO2 is restricted between 94 percent and 99 percent.
• If it is more, reperfusion injury can result due to hyperoxia (increased oxygen level in the blood), as hyperoxia can increase reperfusion injury.
• Studies have shown higher mortality rates in patients with hyperoxia than hypoxia or normoxia following cardiac resuscitation.

Therapeutic Hypothermia Following Cardiac Arrest: Therapeutic hypothermia is a condition when the body temperature is cooled down between 32 degrees Celsius to 34 degrees Celsius for infants and children who do not recover from the coma state after cardiac arrest.

Medication to Treat Cardiac Arrest:

• When treating a child with cardiac arrest, the medication used should be according to the actual weight and not the ideal weight and should not exceed the standard dose.
• Calcium therapy during cardiac arrest is restricted only to cases like hypocalcemia (reduced calcium levels in the blood) to counteract the overdose of calcium channel blockers, hypermagnesemia (increased magnesium levels), and hyperkalemia (increased potassium levels in the blood).
• Pediatric patients undergoing tachycardia (increased heart rate) should be consulted by experts before administering the drug, as the anti-arrhythmic drugs cause serious adverse effects.
• Adenosine has been shown to be effective and safe in diagnosing and treating arrhythmias (irregular heartbeat).
• However, Adenosine is not recommended in case of irregular heart rhythm or unstable wide-complex tachycardia as it can lead to ventricular fibrillation.
• Adenosine is not advised in patients suffering from Wolff-Parkinson-White syndrome.

Evaluation of Sudden Cardiac Deaths:

• An increase in sudden cardiac death (SCD) is attributed to cardiac ion channelopathies (cardiovascular disorders) like long QT syndrome.
• When small children and young adults have sudden cardiac death, a detailed investigation, including the family and past medical history, is carried out, and ECG (electrocardiogram) reports are assessed to identify the other family members at risk.

Conclusion:

Cardiac arrest remains a major concern for pediatric surgeons and emergency care professionals when treating small children or adults. The caregiver needs to differentiate the causative factors of potential emergencies among the children and adults. One needs to be updated with the recent guidelines of pediatric advanced life support (PALS) and adopt the same when encountering such emergencies.