Paediatric Advanced Life Support

A Practical Guide for Nurses

Philip Jevon

• Publisher: Wiley-Blackwell
• Year: 2012
• ISBN:
  9781118274637
• Edition: 2
• Topic: Medicine
• Subtopic: Pedriatic Nursing

In the event of a paediatric cardiac arrest, it is essential to be able to respond rapidly, providing safe and effective care. The second edition of this successful text providesnurses with a practical and systematic guide to the rapid assessment and delivery of appropriate resuscitation to infants and children.

• Conforms to current European Resuscitation Council Guidelines
• Based on up-to-date research and evidence-based practice protocols
• Synoptic approach enables rapid delivery of effective treatment
• Written by experts in the field of both resuscitation and paediatrics

Paediatric Advanced Life Support is a succinct yet comprehensive guide and is an essential purchase for any health professional likely to encounter an emergency situation.

Chapter 1

An Overview of Paediatric Advanced Life Support

Introduction

Paediatric advanced life support (PALS) includes the knowledge and skills necessary to identify and effectively treat infants and children who have potential respiratory or circulatory failure, and to provide the appropriate early treatment for a paediatric cardiac arrest.

The aim of this chapter is to provide an overview of PALS.

Learning Objectives

At the end of this chapter, the reader will be able to:

• Discuss the causes of death in childhood
• Discuss survival rates following paediatric resuscitation
• Outline the pathophysiology of paediatric cardiac arrest
• Discuss the importance of treating children differently from adults
• Outline the provision of a resuscitation service in hospital

Causes of Death in Childhood

The most common causes of death in children under 6 years of age worldwide are detailed in Table 1.1.

Table 1.1 Most common causes of death worldwide in children under 6 years of age

Reproduced from Stevenson & Tedrow (2010).

According to the Office for National Statistics (2009), the highest death rates in childhood occur during the first year of life, particularly the first month (Table 1.2). Causes of death in childhood vary according to age. The most common causes are:

• Newborn period – congenital abnormalities and factors associated with prematurity

• 1 month to 1 year – cot death, infection and congenital abnormality
• From 1 year – trauma

Table 1.2 Causes of death by age in England and Wales, 2008

Reproduced from Office for National Statistics (2010).

In England and Wales, infant mortality rates (number of deaths of children under 1 year of age in one calendar year per 1000 live births in the same calendar year) have fallen by more than 50% in the last 28 years, from 12 in 1980 down to 4.5 in 2008, the lowest on record (Advanced Life Support Group, 2011).

Survival Rates Following Paediatric Resuscitation

Paediatric cardiac arrest is rarely caused by a primary cardiac problem. It is also rarely a sudden event (Klitzener, 1995), often being the end result of a progressive deterioration in respiratory and circulatory function (American Academy of Paediatrics, 2000). If cardiac arrest ensues, the prognosis is dismal (O’Rourke, 1986); the survival rate of patients in asystole has been reported to be as low as 3% (Zaritsky et al., 1987).

The early diagnosis and aggressive management of respiratory or cardiac insufficiency aimed at preventing deterioration to cardiac arrest are the key to improving survival without neurological deficit in seriously ill children (Zideman & Spearpoint, 1999). Prompt resuscitation in the event of a respiratory arrest is associated with a favourable outcome – survival rates of over 50% have been reported (Zaritsky et al., 1987; Spearpoint, 2002). Recognition of respiratory failure and shock is discussed in Chapter 3.

Pathophysiology of Cardiac Arrest

There are three basic mechanisms of paediatric cardiac arrest – asystole, pulseless electrical activity (PEA; formerly known as electromechanical dissociation) and ventricular fibrillation (VF). Pulseless ventricular tachycardia (VT) is another mechanism, but this is usually classified with VF because the causes and treatment are similar.

Asystole

Asystole (Fig. 1.1) is the most common presenting rhythm in paediatric cardiac arrests (Sirbaugh et al., 1999; Young & Seidel, 1999). It is the final common pathway of respiratory or circulatory failure (Zideman, 1997). Prolonged severe hypoxia and acidosis leads to progressive bradycardia and asystole (Advanced Life Support Group, 2011). The most common cause is hypoxia, and the most effective treatment is to establish a clear airway and effective ventilation (Zideman, 1997).

Fig. 1.1 Non-shockable rhythm: asystole.

Management of asystole is less commonly successful than when the rhythm is VF (Dieckmann & Vardis, 1995), but survival to discharge has been reported (Spearpoint, 2002).

Pulseless Electrical Activity

‘Pulseless electrical activity’ is a term used to signify the features of cardiac arrest associated with a normal (or near-normal) ECG (Fig. 1.2). The diagnosis is made on clinical grounds by the combination of the absence of a cardiac output with a ECG rhythm on the monitor that would normally be associated with a good cardiac output.

Fig. 1.2 Non-shockable rhythm: pulseless electrical activity.

The causes of PEA can be classified into one of two broad categories:

• Primary PEA – there is failure of excitation contraction coupling in the cardiac myocytes resulting in a profound loss of cardiac output. Causes include hypoxia, poisoning, for example due to beta-blockers, calcium channel blockers or toxins, and electrolyte disturbance (hyperkalaemia or hypocalcaemia).
• Secondary PEA – there is a mechanical barrier to ventricular filling or ejection. Causes include hypovolaemia, cardiac tamponade and tension pneumothorax.

In all cases, treatment is directed towards the cause.

Ventricular Fibrillation/Pulseless Ventricular Tachycardia

VF/pulseless VT (Fig. 1.3) is uncommon in children (Zideman, 1997; Spearpoint, 2002). However, clinical situations when it may occur include after cardiac surgery or with cardiomyopathy, congenital heart disease, hypothermia or drug intoxication.

Fig. 1.3 Shockable rhythms: ventricular fibrillation (a) and pulseless ventricular tachycardia (b).

The ECG displays a bizarre irregular waveform, apparently random in both frequency and amplitude, which reflects disorganised electrical activity in the myocardium. This is an eminently treatable arrhythmia, but the only effective treatment is early defibrillation, and the likelihood of success is crucially time-dependent (Jevon, 2009).

Conditions for defibrillation are optimal for as little as 90 seconds after the onset of the rhythm, and the chances of success fall by about 10% with every minute that treatment is delayed (Waalewijn et al., 2001). Untreated VF will inevitably deteriorate into asystole as myocardial energy reserves and oxygen are exhausted; successful cardiopulmonary resuscitation (CPR) at this late stage is almost impossible (Waalewijn et al., 2001).

Importance of Treating Children Differently from Adults

Children are not small adults. Children are a diverse group of the population. They vary dramatically in weight, size, shape, intellectual ability and emotional responses.

At birth, a child is, on average, 3.5 kg, with a small respiratory and cardiovascular reserve and an immature immune system. At this stage, children are capable of limited movement, exhibit limited emotional responses and are dependent upon adults for their needs. Fourteen or more years later, at the other end of ch...

Table of contents

• Cover
• Title page
• Copyright page
• Foreword
• Contributors
• Chapter 1 An Overview of Paediatric Advanced Life Support
• Chapter 2 Resuscitation Equipment for Paediatric Resuscitation
• Chapter 3 Recognition of the Seriously Ill Child
• Chapter 4 Paediatric Basic Life Support
• Chapter 5 Airway Management and Ventilation
• Chapter 6 ECG Recognition and Management of Cardiac Arrhythmias
• Chapter 7 Defibrillation and Electrical Cardioversion
• Chapter 8 Paediatric Advanced Life Support
• Chapter 9 Management of Anaphylaxis
• Chapter 10 Resuscitation in Special Situations
• Chapter 11 Post-resuscitation Care
• Chapter 12 Bereavement
• Chapter 13 Records, Record-keeping and Audit
• Chapter 14 Legal and Ethical Issues
• Chapter 15 Resuscitation Training
• Index