Pediatric Advanced Life Support
As in the adult, the head is tilted and either the jaw thrust or chin lift used to open the airway. In the child requiring intubation, the patient is first ventilated by bag-valve-mask with 100% oxygen. If the child is slightly breathing, gentle positive-pressure should be carefully timed with voluntary respirations. Unlike the adult where two assistants are required to adequately bag the patient, one assistant is often sufficient. In the infant, the jaw is supported with the base of the middle and 4th fingers. In older children, the fingertips of the 3rd, 4th and 5th fingers are placed on the ramus of the mandible to hold
the jaw forward and extend the head. Endotracheal intubation is always via the orotracheal route (nasotracheal intubation is not performed in children). Rapid sequence intubation (RSI) is accomplished as in the adult.
In major trauma, the c-spine is immobilized and the jaw thrust is performed. The oral cavity is inspected for foreign bodies, vomitus, broken teeth and suctioned using a hard-tipped suction catheter of appropriate size. Not only must the C-spine be cleared but the child must be cleared neurologically. If the history and physical exam indicate a possible spinal cord injury (spinal cord injury without radiographic abnormality—SCIWORA)
the C-collar is left on and the patient is cleared by the neurosurgeon.
Diagnosing a foreign body in the airway may pose a difficult problem unless complete obstruction occurs. Offenders are nuts, toy parts, round candies and aluminum “pop-tops”. Complete obstruction in an infant is treated by a variation of the Heimlich maneuver: the infant is held prone in the left hand and forearm and 5 back blows are delivered between the shoulder blades with the heel of the right hand. Then the infant is turned over, with the head lower than the body, and 5 quick chest thrusts are delivered
on the lower third of the sternum. The mouth is opened and, if visualized, the foreign body is removed. The finger sweep and rescue breathing are performed.
Nearly all larger foreign bodies are captured at this point. Smaller foreign bodies will be moved into a mainstem bronchus. In the child over 1- 2 years, the Heimlich maneuver is similar to the adult. If the patient can not be adequately bagged or intubated, a needle
cricothyrotomy is performed by inserting a 14 or 16g angiocath through the cricothyroid membrane. The needle is removed, the cannula is secured and attached to oxygen tubing using a “Y” connector, at 20 breaths per minute: 1 second inhalation, 2 seconds exhalation. A surgical cricothyrotomy is not performed in children less than 9 years old.
As in the adult, the lungs are auscultated for equal breath sounds. Breathing children receive 100% oxygen by nonrebreather mask. Comatose patients are intubated to protect the airway. Nonbreathing children are bagged with a bag-valve-mask and 100% oxygen and are intubated.
In trauma, if signs of tension pneumothorax are present (respiratory distress, distended neck veins, tracheal deviation), needle decompression is accomplished through the 2nd intercostal space above the 3rd rib at the midclavicular line, followed by chest tube placement at the 5th interspace anterior to the mid-axillary line. An open pneumothorax is treated with an occlusive dressing and a chest tube as described for the adult.
In respiratory failure, oxygen by mask should be administered to all seriously ill or injured children. A nasopharyngeal airway is placed in the conscious patient. Respiratory failure should be anticipated when the following signs are present:
1. Increased respiratory effort. Tachypnea is the first sign of respiratory distress in infants. Other signs are restlessness, use of accessory muscles with nasal flaring, inspiratory/intercostal/sternal retractions and tachycardia. Stridor is an inspiratory high-pitched sound of upper airway obstruction. Wheezing may be present. Grunting is caused by premature closure of the glottis during early expiration in an attempt to increase airway pressure.
2. Diminished level of consciousness or response to pain.
3. Poor skeletal muscle tone.
4. Cyanosis is a late sign.
Treatment of Respiratory Failure:
- 1. Open airway.
- 2. 100% oxygen by mask.
- 3. If the patient is not moving air, begin bag-mask ventilations with small volumes and prepare for endotracheal intubation.
In a child with no pulse, chest compressions are begun and an intravenous line is secured. If intravenous access cannot be obtained within 1-2 minutes, intraosseous access should be performed at the proximal medial tibia. The next step depends on the reason for the arrest. In adults it is often cardiac, but in children it is usually respiratory or traumatic. In the trauma setting, hemorrhage is identified and controlled. Hemorrhagic shock is treated
with normal saline boluses (20 cc/kg x 3) and type-specific or O-neg packed red cells (10 cc/kg) as indicated.
Ventricular fibrillation/pulseless ventricular tachycardia, asystole and pulseless electrical activity are rare occurrences in pediatrics. In the hospital, a call is made for quick-look paddles/monitor, with appropriate therapy depending on the arrhythmia.
4. DISABILITY (Level of Consciousness)
“D” for Disability is similar to the adult and represents Level of Consciousness.
Glasgow Coma Scale has been modified for infants ages 0-23 months and children ages 2-5 years (Pediatric Glasgow Coma Scale—PGCS). Since the total scores are the same as for the adult, intubation is still required for a score of 8 or less. As in the adult, AVPU is sometimes substituted for the PGCS in the field.
The PGCS is now an integral part of the Revised Trauma Score (RTS). A separate Pediatric Trauma Score (PTS) has also been developed that does not use the GCS. Children with an RTS of less than 12 or a PTS of less than 8 are at increased risk for morbidity and should be evaluated at a trauma center.
During delivery, as soon as the head is delivered, the mouth and the nose are suctioned. If meconium is present, intubation is performed and suction is applied through the endotracheal tube. The newborn is dried, warmed, positioned supine, suctioned and tactile stimulation is applied. For low Apgars, oxygen is administrated. If the heart rate is less than 100 beats per minute, the newborn is ventilated with a bag-valve-mask at 40
breaths per minute. If bag-mask ventilation cannot raise the heart-rate above 100, intubation is required. Chest compressions (90 per minute) and ventilations (30 per min) are performed if the heart rate is less than 60. If the heart-rate remains below 60 after intubation, epinephrine 0.01 mg/kg (1:10,000) is administered by way of the umbilical vein. Neonatal resuscitation is sometimes necessary because of drug ingestion, particularly crack/ cocaine, by the mother. If the history indicates drug abuse by the mother, naloxone (0.1 mg/kg) IV is given.