Episode 93 – PALS Guidelines

This is EM Cases Episode 92 - PALS Guidelines. I remember when I started practicing emergency medicine a decade and a half ago it seemed that any kid who came to our ED in cardiac arrest died. I know, depressing thought. But, over the past 15 years, survival to discharge from pediatric cardiac arrest has markedly improved, at least for in-hospital arrests. This is probably mostly due to an emphasis on high-quality CPR and advances in post-resuscitation care; nonetheless the more comfortable, knowledgeable and prepared we are for the always scary critically ill pediatric patient, the more likely we will be able to resuscitate them successfully - which is always a huge save. With this mission in mind Dr. Allan DeCaen, a pediatric intensivist at Stollery in Edmonton and the director of the pediatric ICU transport team, as well as the writing group chair for the American heart association and heart and stroke Canada PALS guidelines, and Dr. Anthony Crocco division head and medical director of the pediatric emergency program at McMaster children’s hospital, will walk us through highlights from the recent AHA PALS guidelines including: * How to recognize pediatric shock and prevent cardiac arrest before it's too late * Key differences in pediatric anatomy and physiology to help guide management * How to maximize effective CPR * The indications for atropine and antidysrhythmics in children * How to improve post-cardiac arrest care in children Podcast produced by Anton Helman, voice editing by Richard Hoang, sound design by Anton Helman Written Summary and blog post written by Michael Kilian, edited by Anton Helman March, 2017 Cite this podcast as: Helman, A, DeCaen, A, Crocco, A. PALS Guidelines. Emergency Medicine Cases. March, 2017. https://emergencymedicinecases.com/uti-myths-misconceptions/. Accessed [date]. It's best to avoid cardiac arrest in the first place: Early identification of shock The pediatric assessment triangle, provides a valuable checklist that we should go through for every child we see in the ED to help us assess their risk of crashing. The pediatric assessment triangle is based solely on observing the child from the foot of the bed. Pediatric assessment triangle The Pediatric Early Warning Score (PEWS) isn't good enough There is little evidence that the use of PEWS (tool that is based on 5 domains: behavior, cardiovascular status, respiratory status, nebulizer use, and persistent vomiting) outside of the pediatric ICU setting reduces hospital mortality. In one observational study, PEWS use was associated with a reduction in cardiac arrest rate when used in a single hospital with an established medical emergency team system. The importance of accurate interpretation of heart rate and respiratory rate in early identification of pediatric shock One of the main reasons that we sometimes tend to under-recognize the deteriorating child is because their blood pressure often remains normal until they suddenly crash and arrest. Because of their high sympathetic tone, children can maintain a seemingly normal blood pressure longer than an adultwould, making hypotension a very late finding in a critically ill child. This can make early recognition of sepsis more challenging in children. The keys to early identification of pediatric sepsis lies in the heart rate and respiratory rate, both of which will increase disproportionately to the fever in sepsis. We must consider tachycardia an early warning sign for sepsis. While individual vital signs are sensitive but not specific, multiple abnormal vital signs taken together have an improve specificity for sepsis. Assessing whether or not a child is tachycardic ...