The management of Paediatric Advance Life Support by Jake Stanley

ALS Algorithm

stanleyjake13 — 2022-02-22 14:49:30 UTC

Advanced Life Support (ALS) is a team activity, and several interventions will be done in parallel (see above PDF from the Resusatacon council (2015))

Paediatric ALS broadly follows adult ALS, however there is emphasis on establishing the following;

ALS must not delay the transfer of the child to hospital, and that focus should be placed on good quality basic life support (BLS)on scene and only to focus on ALS on route if practical (Tijssen et al, 2015).

How old is a child?

stanleyjake13 — 2022-02-22 14:50:17 UTC

children can be split up into three different age categories;

A new-born is an infant just after birth.

An infant is under 1 year.

A child is between 1 year and 18 years of age (or puberty depending in documentation/ guidelines)

(The resuscitation council UK, 2021)

Introduction 📚

stanleyjake13 — 2022-02-25 16:03:13 UTC

After searching through the vast amount of evidence/ supporting literature I have accumulated/ condensed some of the key points and tips towards the management of paediatric advanced life support as well as a brief reminder into the management and treatment of the event.

Paediatric Cardiac arrests are uncommon consisting of 1% of all cardiac arrests each year with age ranges from 0 -15 y/o. Records show that survival rates on average are 8.2% with worsening survival rates the younger the age is. (Kämäräinen, 2010)

Reversable Casues

stanleyjake13 — 2022-02-25 16:03:58 UTC

The 4 H's and T's of reversible causes are still applicable to paediatric cardiac arrests and should be sought to be corrected in paediatric ALS.

Hypoxia is the most common cause of arrest in children, which is why 5 rescue breaths are to be given prior to BLS/ ALS starting to.

How do you work out weight?

stanleyjake13 — 2022-02-25 16:05:54 UTC

The majority of us will be aware of the formula which is nice (Age+4) x2 (if not then this is what you can use to estimate a child's weight for your calculations)

however new literature suggests there is a more accurate estimation of weight. Formulas based on age are fine, but there is huge variability in size according to age.

as Carley (2013) states that the new formula is:

Weight 0 -1 = (Age/2)+4

Weight 1 -5 = (Age x2)+8

Weight 6 -12 = (Age x3)+7

These weights are continued to be explored/ discussed throughout the article, and the evidence suggests that it is only slightly more accurate than the old.

Or you could use a page for age reference such as JRCALC.

References

stanleyjake13 — 2022-02-25 16:06:05 UTC

Carley. S. (2013) “APLS weight estimation – don’t do it (well almost never). St.Emlyn’s” Available at:https://www.stemlynsblog.org/apls-estimation-formulas-do-not-safely-predict-weight-in-uk-children-st-emlyns/ (accessed: 18/02/22)

Harless, J., Ramaiah, R., & Bhananker, S. M. (2014). Pediatric airway management. International journal of critical illness and injury science, 4(1), 65.

Joint Royal Colleges Ambulance Liaison Committee, Association of Ambulance Chief Executives (2019) JRCALC Clinical Guidelines 2019. Bridgwater: Class Professional Publishing.

Kämäräinen A. (2010). Out-of-hospital cardiac arrests in children. Journal of emergencies, trauma, and shock, 3(3), 273–276. https://doi.org/10.4103/0974-2700.66531

Resuscitation council (2015) “Paediatric advanced life support Guidelines” Available at:https://www.resus.org.uk/library/2021-resuscitation-guidelines/paediatric-advanced-life-support-guidelines (Accessed 19/02/22).

Tijssen JA, Prince DK, Morrison LJ, et al. Time on the scene and interventions are associated with improved survival in pediatric out-of-hospital cardiac arrest. Resuscitation. 2015;94:1-7. doi:10.1016/j.resuscitation.2015.06.012

Zeretzke-Bien C.M. (2018) Airway: Pediatric Anatomy, Infants and Children. In: Zeretzke-Bien C., Swan T., Allen B. (eds) Quick Hits for Pediatric Emergency Medicine. Springer, Cham. https://doi.org/10.1007/978-3-319-93830-1_1

Airway

stanleyjake13 — 2022-02-25 16:52:05 UTC

During ALS, the priority remains to deliver effective ventilation with high flow oxygen as hypoxia is a common reversible cause, supraglottic airways such as igels, may be used of bag mask ventilation is ineffective, and that intubation is rarely indicated due to the difficulties surrounding a child's airway

A brief look into a child's airways

stanleyjake13 — 2022-02-25 16:57:48 UTC

This is an excellent image of the differences with paediatric airway anatomy compared to an adult.

Sourced from Bien (2018) it highlights that children are not just small adults.

key points to remember are;

the airway is smaller in diameter and shorter in length
tounges are larger in the oropharynx than adults
the larynx in infants and you children are located more anterior compared to adults
they have a larger / narrow epiglottis which is relatively floppy
A child’s trachea is softer, consisting more of cartilage than an adult’s.

What does all this mean? the results are that children's airways are more likely to be obstructed, Even minor injuries or slight swelling can make it harder for a young child to breathe.

one final thing to mention is that the child’s occipital bone (the back and lower part of the skull) is large and round, compared to the flatter adult skull, requiring the airway management to be placed into the sniffing the "morning air position "

Harless, J., Ramaiah, R., & Bhananker, S. M. (2014)

Defibrillation ⚡

stanleyjake13 — 2022-02-25 18:10:36 UTC

Defibrillation should be delivered at 4J/kg or rounded up to the level which the defibrillator can deliver.
Paediatric defibrillation pads are to be used wherever possible. this ensures that adequate current passes through the myocardium, and pads should be placed in the sternal however adults' pads may be used when they are not available, ensure they are placed on the anterior and posterior of the heart.

When to start?

stanleyjake13 — 2022-02-25 18:43:18 UTC

If the child is displaying no signs of life then CPR should begin, these signs / symptoms include;

unresponsive, no respiratory effort / agonal breathing, no pulse palpable OR unable to locate a pulse (usually difficult in children) then CPR should be started.

Additionally, if the child is in a collapsed state with no signs of life and has a heart rate of <60 beats per minute, compressions must be commenced.